ENT/Optho/Ethics/CYPT Flashcards
What is the criteria performing imaging for sinusitis?
-when do you start antibiotics?
- Symptoms and signs consistent with sinus inflammation: rhinorrhea, headache, facial tenderness
- Fever
- Purulent nasal discharge > 3 days
- No improvement after > 10 days after watchful waiting or worsening symptoms despite antibiotics
**Only start antibiotics at 14 days of symptoms and also start nasal decongestants at the same time so that it opens up the nose and allows the abx to absorb from the vessels
**Can start with xray or do CT sinuses
What is the order of pneumatization of sinuses?
Ethmoid at birth, then maxillary at 1 yo, then sphenoid at 4 yo, then frontal in preadolescent
What is hyphema?
- treatment?
- major possible long-term complication?
Blood in the anterior chamber of the eye from blunt or perforating trauma
- treatment: rest, NO MOVEMENT AT ALL because might increase risk of rebleeding and increased intraocular pressure
1. Bedrest
2. HOB elevated
3. May need hospitalization and sedation if kid is freaking out
4. Can use topical steroids to decrease risk of rebleeding
5. In rebleeding, may need to evacuate clot
Major complication: increased risk of glaucoma
What is amblyopia?
- types? (4)
- treatment modalities?
Lack of clear image on the retina
- Strabismus amblyopia: confusing image! Due to poor aim
- Anisometropic amblyopia: unequal need for vision correction between the eyes
- amytropic amblyopia: blurry image! high refractive error in both eyes
- Deprivation amblyopia: no image due to poor clarity and something blocking the light and affecting ability to focus (ie. cataracts)
Treatment depends on cause of amblyopia: refer to ophtho!
-opacify the good eye or do pharmacological penalization with atropine drops
What criteria warrant further evaluation in a child presenting with epistaxis?
- Prolonged epistaxis > 30 minutes despite pressure
- Refractory to acute measures
- Less than 2 yo
- More than 2 per week
- History or exam findings of bleeding disorder
What percentage of the population have different sized pupils?
25% = anisocoria
-should make sure they have normal pupillary light reflex
What is a ranula?
-treatment?
Cyst associated with a major salivary gland in the sublingual area. Bluish, fluctuant, can affect the opening of the mouth
- it is a large, soft mucus containing swelling in the floor of the mouth
- cyst should be excised
Which sport is the most common cause of eye injury?
Baseball
What is the most objective test to detect a middle ear effusion?
Tympanometry: looks at how much TM moves
-if stiff with effusion, moves less
What condition is trismus most commonly associated with?
- most common organisms?
- treatment?
- when to consider tonsillectomy? (2)
- most serious complication?
Peritonsillar abscess!!!!!
- most common in adolescents
- GAS most common cause; can also be from oral anaerobe
- treatment:
1. Surgical drainage (needle aspiration)
2. Abx against GAS and anaerobes (Amoxi-clav)
Consider tonsillectomy if:
- Recurrence
- No improvement after abx or needle aspiration
Most serious complication: aspiration pneumonia if BURSTS
What position worsens stridor in laryngomalacia/tracheomalacia?
Worsens when lying supine, improved when prone
What is a pathognomonic sign of a thyroglossal duct cyst?
Vertical motion of the mass with swallowing and tongue protrusion
When does rebound nasal congestion occur after the use of otrivin?
Use > 3 days
What are the indications for tonsillectomy?
- absolute (4)?
- relative (2)?
Absolute (4):
- OSA: AHI >1
- get the child on nasocorticosteroid sprays asap! Can decrease AHI by 50% - Suspected malignancy
- Recurrent hemorrhagic tonsillitis (usually seen in teen girls)
- Severe dysphagia
Relative (2):
- Recurrent acute tonsillitis: 3-7 episodes per year depending on different organizations
- Recurrent peritonsillar abscess
What is the differential diagnosis for esotropia? (3
- Congenital
- starts less than 6 months
- tends to have refractive errors
- refer to ophtho - Accommodative
- have difficulty focusing on object
- 3-6 yo
- amblyopia is present
- uncorrected far-sightedness - 6th nerve palsy from congenital, meningitis, increased ICP (tumor, idiopathic intracranial hypertension)
What are the features of Treacher-Collins syndrome?
- Downslanted palpebral fissures
- Malformed auricles
- Malar hypoplasia
- Mandibular hypoplasia
What are 4 indications for tympanostomy?
- Recurrent AOM with middle ear effusion
- Bilateral OM with chronic effusion > 3 months with conductive hearing loss (most common) or school problems/discomfort
What are the guidelines around swimming in a child with tympanostomy tubes?
No deep sea diving, no swimming in dirty water (lakes/oceans)
-can swim in pools/be in a bath but need ear plugs
What condition is a bifid uvula associated with?
Submucosal cleft palate
- may not be able to see it so need to palpate
- can present with hypernasal speech, eustacian tube defects, chronic middle ear disease
16 month boy has weekly episodes of falling down suddenly and refusing to get up. Remains conscious and eyes are noted to move during the episode. Recovers within a few minutes. Sometimes vomits. What is his diagnosis?
-what is one associated condition?
Benign paroxysmal vertigo = sudden attack of feeling like the room is moving around you; dizziness, little children will tend to drop to the floor, horizontal nystagmus can occur. Can have nausea and vomiting. Usually seen in children
What is an associated condition that may worsen laryngomalacia?
Reflux = may need to treat to see improvement in laryngomalacia
What is the differential diagnosis for torticollis in newborns? (5)
- Congenital muscular torticollis = uterine positioning
- Sternocleidomastoid tumor
- Klippelfeil syndrome (fusion of cervical motion segments)
- Brachial plexus injury
- Clavicle fracture
When would you refer a child with esotropia or exotropia to an ophthalmologist?
-what are SCARY causes of esotropia/exotropia?
If constant, need to refer asap!
- if intermittent, need to refer by 4 months of age
- scary causes: cranial nerve palsy, brain tumors
What is the treatment of a corneal abrasion?
- Topical cycloplegic agent to relieve pain from ciliary spasm (not for home use) = ONLY for slit lamp exam
- Topical antibiotic ointment until healed (do not use topical aminoglycosides or topical steroids as this increases risk of corneal ulceration)
**do not use semipressure patch since it can itself abrade the cornea and doesn’t help healing time
What is a hordeolum? What is a chalazion?
- usual causative organism or hordeolum?
- treatment?
- mom asks if you are going to incise her kid’s hordeolum. What do you say?
Hordeolum: stye in your eye! Blockage of Meibomian gland with an infection (glands at base of eyelid where eyelashes are
- chalazion: blockage of meibomian gland WITHOUT infection.
- usual causative organism of stye = staph aureus
- Treatment: frequent warm compresses +/- PO abx (topical abx are not useful)
- do NOT I&D stye when it is acutely infected since this will increase the risk of periorbital cellulitis
- can I&D chalazion
How can you differentiate between ptosis caused by CN3 palsy vs. Horner syndrome?
CN3 palsy = causes SEVERE ptosis Horner syndrome (sympathetic fibres) = causes mild ptosis
CN3 = think of the 3 roman columns holding up your eyelid with the sympathetics doing a tiny bit of the work on top of the columns
A 5 mo baby presents to you with ptosis. Her mother says she has been this way since birth. Her extraocular movements and pupillary light reflexes are normal. What is your diagnosis?
Congenital dystrophy of levator palpebrae superioris muscle = innervated by CN3 which is working normally but the muscle is not functioning
What is the most common source of infection for periorbital cellulitis? What about orbital cellulitis?
Periorbital cellulitis is USUALLY from an external infection (ie. scratch in the skin) whereas orbital cellulitis is USUALLY from an internal infection (ie. from sinusitis!!!)
What is blepharitis?
-what is a possible complication of blepharitis?
Swelling of the eyelid at the eyelashes= Meibomian gland blockage = see dandruff on eye lid
-possible complication: corneal ulcer
What is the management for nasolacrimal duct obstruction?
- when is ophtho consult indicated?
- what percentage self resolve?
- Warm compresses
- Pump 10x at tear duct prior to each feed (since pumping the tear duct will make baby cry, then can soothe and comfort them with feeding)
- consult ophtho if no resolution post 1 yo = then can probe through the puncta/cannicula and create an opening for tears to drain
- 80-90% self-resolve
What is the treatment for dacryocystocele?
- what age group is this most likely seen in compared to nasolacrimal duct obstruction?
- complication of untreated?
Infected and inflammed nasolacrimal duct secondary to complete blockage and bacterial trapping
- usually seen within first 2 weeks of life (whereas nasolacrimal duct obstruction that is narrowed but still draining tears, parents usually bring their babies in later on, like a few months of age)
- treatment:
1. IV abs +/- surgical drainage (needed 50% of the time) - complication: can compress nares and cause resp distress
What are the 3 parts of the uvea?
- Iris
- Choroid
- Ciliary body
- all the same tissue embryologically
What is the treatment for viral conjunctivitis? (3)
- Artificial tears
- Cold compresses
- ENCOURAGE HAND HYGIENE AS VERY CONTAGIOUS
What are 2 complications of untreated anterior uveitis?
-treatment for anterior uveitis?
- Increased IOP
- Cataracts
- treatment: - PO steroids +/- topical steroids
A healthy 3 mo boy has anisocoria. His right pupil is slightly smaller than the left. Which of the following findings would suggest Horner syndrome of the right eye?
a. Severe right upper eyelid ptosis
b. right iris appears lighter in color than the left
c. mild right proptosis
d. optic disc edema in the right eye
e. limited abduction in the right eye
B! Heterochromia can be seen in Horner syndrome if it is congenital…don’t know why…iris color can apparently be sympathetically driven
A mother brings her baby to you with concerns about vision. She reports that her baby sleeps during the day all the time and only opens his eyes in dim light. Also she notices he has “big beautiful eyes”. What is your diagnosis?
Congenital glaucoma! Increased ocular pressure secondary to impaired fluid drainage leads to expansion of the eye, cornea gets cloudy, expands and then the baby gets photophobia too
What is the approach to the treatment of strabismus?
- Check vision of both eyes. If vision is equal, then this means amblyopia has not developed secondary to the strabismus = can go straight to surgery
- If vision is unequal, then this is amblyopia and need to patch the good eye first so that the eye with the amblyopia can improve its vision first. Then can do surgery.
What is pseudoesotropia?
Excess skin at the medial canthus makes the pupils look crooked BUT if you look at the pupils using a light, the corneal light reflex will be symmetrical and cover/uncover test will be normal
What is myopia? Heteropia?
Myopia = near sighted! (MN)
Heterotrpia = far sighted (H`F)
-letters closer together
What is the management of otitis media with effusion?
See middle ear fluid without signs or symptoms of inection
- management:
1. Observation = 90% resolve after 3 months
2. Document degree of hearing loss if > 3 mo and consider myringotomy for ear tubes
What is the management of mastoiditis?
-what is a Bezold’s abscses?
- Start on IV abx asap (most of the time, there is response)
- MAY require surgical drainage IF no improvement on IV abx x 48 hrs
- Bezold’s abscess: pus from mastoiditis escapes into SCM muscles
What are risk factors for congenital sensorineural hearing loss?
ABCDS
- Affected family member
- Bilirubin (kernicterus)
- Congenital TORCH infections
- Defects of the ear, nose and throat
- Small at birth (prem, bw
What is the most common genetic cause of sensorineural hearing loss?
Connexin 26 protein defect from mutation = autosomal recessive
What is the best way to diagnose CMV as a cause of congenital hearing loss? Does it matter by age group?
Yes!
-in 3 wks of age: urine will no longer be positive so need a neonatal dry blood spot or MRI
Answer the following questions:
- Most common cause of nasal obstruction is?
- Unilateral purulent discharge in a child is most commonly due to?
- 90% of epistaxis is from the?
- Nasal obstruction = viral rhinitis
- Unilateral purulent discharge = foreign body
- 90% of epistaxis = anterior septum
In a child with recurrent severe chronic epistaxis with normal coags, what is your next step in management?
Refer to ENT for endoscopy/possible imaging = need to rule out angiofibroma!
1 mo boy presenting with progressively worsening biphasic stridor. No history of intubation. What is the most likely diagnosis? Next step in management?
-what if it was inspiratory stridor? Expiratory?
Vocal cord paralysis!! Next step: immediate ENT referral and get MRI of the brain!! Need to look at course of recurrent laryngeal nerves from Cranial nerve CN 9/10 to the nerve itself
- Insp stridor = think laryngomalacia
- exp stridor = think trachomalaceia
- biphasic stridor = think vocal cord paralysis
What is the CLASSIC feature associated with the following neck masses:
- thyroglossal duct cyst
- dermoid cyst
- branchial cleft cyst
- laryngocele
- cystic hygroma
- thyroglossal duct cyst: moves with tongue protrusion and is midline
- dermoid cyst: midline, see calcifications on plain films
- branchial cleft cyst: smooth along the SCM border (lateral)
- laryngocele: enlarges with valsalva
- cystic hygroma: transilluminates and is compressible
What are the key differentiating factors between tonsillitis and peritonsillar abscess?
hi
What is the most serious complication of peritonsillar abscess?
-what about retropharyngeal abscess?
Peritonsillar abscess: aspiration pneumonia
Retropharyngeal abscess: airway obstruction
What is the ddx for unilateral tonsillar enlargement?
pparent enlargement (tonsil is rotated) vs. true enlargement
True enlargement
- Infectious: tonsillitis, peritonsillar abscess
- Benign hypertrophy (chronic)
- Neoplastic: lymphoma
- rapid growth
- dysphagia
- cervical nodes
- night sweats
A patient has recurrent sore throats. What are indications for tonsillectomy?
- Watchful waiting should be done for recurrent sore throats UNLESS Paradise criteria are met:
- 7 episodes in preceding year or 5/yr x 2 yrs or 3/yr x 3 yrs PLUS s/s with each episode: fever, lymphadenopathy, recurrent strep infections, etc.
What are the 2 positive predictive factors on whether a T&A will cure OSA in a patient
Age
What are the indications for adenoidectomy? (7)
- Chronic nasal obstruction or obligate mouth breathing
- OSA with FTT, cor pulmonale
- Dysphagia
- Speech problems
- Severe orofacial/dental abn
- Recurrent/chronic adenoiditis/sinusitis if medical management failed (3 or more episodes/yr)
- Recurrent/chronic OME
What are the criteria for admission and overnight observation post T&A? (7)
- Poor PO intake/vomiting or hemorrhage immediately post-op
2. Age
What is the treatment for prevention of recurrent epistaxis?
Medical therapy:
- 2 weeks of ointment (polysporin ointment, rhinaris, citaris) BID snorted up the nose
- if this doesn’t work- - Transexamanic acid or cautery
- if this doesn’t work- - THEN do bloodwork to rule out coagulopathy
What is the treatment of acute epistaxis?
-adolescent male presents recurrently with epistaxis and it is always on the same side. What is the most likely diagnosis?
- Pressure first x 5 minutes.
- If that doesn’t work: then pack with vaseline strip gauze or gel foam
- If that doesn’t work: then call ENT to do nasal packing
* **cautery may not be great because it might traumatize the tissue around the bleed so if you do cauterize, need to do medical therapy x 2 wks post
Most nosebleeds originate from septal wall: Little’s area
Adolescent male: Juvenile angiofibroma = usually unilateral, always same side, may have element of nasal obstruction
What is a possible complication of nasal fracture?
Septal hematoma
2 most common causes of swollen midline neck mass?
-first step in work-up?
- Thyroglossal duct cyst = cystic mass
- Dermoid cyst = solid mass
- Lymphadenopathy
First step in work-up: ultrasound
How do you calculate specificity?
Specificity = (True negatives)/(true negatives + false positives)
What is the definition of positive predictive value?
-calculation?
Probability that a person has the disease if the test is positive
= (true positives)/(true positives + false positives)
How do you calculate sensitivity?
Sensitivity = (True positives)/(true positives + false negatives)
= ability to identify people who truly has the disease
What is the definition of negative predictive value?
-calculation?
Probability that a person does not have the disease if the test is negative
= (true negatives)/(true negatives + false negatives)
What is the definition of relative risk?
-what is the calculation for relative risk reduction?
Probability of outcome in an exposed group
= incidence in exposed/incidence in control
= (a/a+b) / (c/c+d)
-a = exposed with outcome
-b = exposed without outcome
-c = non-exposed with outcome
-d = non-exposed without outcome
-relative risk reduction = 1 - relative risk
***shortcut = a/c (risk of outcome in exposed/risk of outcome in unexposed)
What do you need for the diagnosis of AOM?
Acute onset of symptoms
Middle ear effusion
Inflammation
What is the most specific type of tympanogram for AOM?
Type B
When can you observe?
Age>6M
Non severe symptoms
FU available
Absence of additional risk factors
Indications for myringotomy tubes?
recurrent AOM with effusion
Bilateral OME >3 with HL
Unilat/bil OME >3 with other problems (Vestibular/Behaviour/School)
At risk children
What are the complications of AOM
Post-auricular abscess TM perforation Labyrinithitis Labhinthinie fistula Facial nerve paresis Mastoiditis Bezoids abscess Cholesteatoma
Chronic draining ear
Cholesteatoma
Gold standard to diagnosis CMV
3weeks: CMV PCR
EOM
ALl are CNIII except LR6SO4
What is bias?
Systematic errors or flaws in the study design that erode reliability and validity of your results
Bias in surveys
Incomplete sample frame
Inappropriate sampling method
Failed FU
Data processing
Bias in Cohort
Unanticipated confounders
Loss to FU
Change in exposure
Bias in case control studies
Choice of the control group
Quality of retrospective daa
Bias in RCTs
Inclusion/Exclusion too tight or loose Recruitment bias Allocation errors Drop outs Loss to follow up
Cohort study
Prospective
Identify a group of individuals who have a recent or ongoing intervention exposure
ID a group without disease
Sampling occurs after intervention
Cohort pro and cons
Pros: prosective data, possible confounded captured
Cons: costly, many take years, very large numbers needed, drop outs
Case control
Retrospective
Identity a group with an outcome and a group without and look back for exposure
Case control pros and cons
Pros: Cases already definied, short duration, less cost
Cons: Difficult to choose an appropriate control group, impossible to match on all confounders, incomplete or inaccurate data recall, data limited by number of identified cases
Randomized control trials
Prospective,
Cohort study but patients randomly assigned ot intervention and control arms
RCT Pro/COn
Pro: Bias reduced by equal allocation of confounders, high quality data, least biased estimate of the true effect of the intervention on this sample
Cons: Ethical concerns, complexity for patients, cost
Three components of informed consent?
- Disclosure
- Capacity
- Voluntariness
What is assent?
When one of the three components of informed consent cannot be met
Applies to children: partial decision making skills
What are the three categories of decision making capacity?
Incapable
Developing capacity (Assent, dissent)
Fully capable
Sterilization ethics
Least permanent and intrusive method of contraception consistent with the lowest risk for the developmentally delayed patient
When do you break confidentiality?
SI
HI
Abuse or neglect
Reportable STDS
Benefiance?
Action done for the benefit of others.
“DO GOOD”
Non-malefience?
“DO NO HARM”
Must refrain from providing ineffective treatments or acting with malice towards patients
Autonomy?
Person’s capacity to express freely their will, capacity and freedom for action
Veracity?
Full and honest disclosure
Truth telling
PICO
Population
Intervention
Comparison
Outcome
Selection bias:
Patients selected in a non random way to both control and exposure groups
Measurement bias
Different measurements in control and exposure
Analysis bias
If patients change groups, withdraw, lost to FU
Prevalence
Proportion of a population found to have a condition at one point in time
Incidence
A measure of risk of developing a condition in a specified period of time
Relative risk
Risk of event in the exposure vs. control group
Ratio of probability of the vent occurring in the exposed vs. non exposed group
RR>1 Higher in the treatment group
RR
Relative risk reduction
(Risk in control group-risk in intervention group)/Risk in control group
“Attending the lecture reduces the relative risk of stress by 80%”
RR= (A/A+B)/(C/C+D)
Absolute risk reduction
Difference between control groups event rate and expiermental groups event rate
“8 people were saved due to the intervention”
Precision
The ability of the test to get a consistent answer when repeated
Accuracy
The ability of the test to get the right answer
SnNOUT
WHen the sensitivity is high a Negative test rules OUT the disease
SpPIN
When the specificity is high a Positive test Rules IN the disease
Sensitivity
A/A+C
Specificity
D/B+D
Positive predictive value
Given the test is positive, the probability the disease is present
A/A+B
Negative predictive value
Given the test is negative, the probability the disease is absent
D/C+D
+LR
Sensitivity/1-specificity
-LR
1-sensivity/specificity
p value
the probability that the difference observed inthe study sample is simply due to chance
P probability that your null hypothesis is actually correct
Type 1 error
Incorrect rejection of a true null hypothesis
Type 2 error
false negative
