Eye and Upper Respiratory Disorders

Question 1

visual screening method in children (by age)

birth

Age 2

Age 3

Answer 1

birth: red reflex, corneal light reflex, pupillary response to light

Age 2: add cover/uncover test

Age 3⁺: add visual acuity (first with tumbling “E” chart→ kindergarden shape charts→ Snellen chart

Question 2

Normal red reflex= red glow with no evidence of opacitites

DDx of abnormal red reflex?

Answer 2

normal= white reflex in AA

Abnormal red/white reflex:

stellate dark lesion= congenital cararacts

difference between two eyes should alert to pathology (eg retinoblastoma→malignant eye tumor (until proven otherwise), large refractive error, strabismus

Question 3

Normal Hirshberg’s Test= equal light reflection in both eyes

DDx for abnormal Hirshberg?

Answer 3

abnormal Hirshberg test= strabismus

(unequal eye muscle weakness)

Question 4

4 types of strabismus

(direction of eye movement)

Answer 4

esotropia= turning inward

exotropia= turning outward

hypertropia= turning upward

hypotropia= turning downward

Question 5

Normal cover/uncover test= both eyes maintain conjugate gaze, even with one eye being covered

(performed 5months to 6yo)

DDx abnormal test?

Answer 5

abnormal cover/uncover= amblyopia

affected eye moves when covered and then has to return to conjugate gaze when uncovered

d/t strabismus or refractive error

Question 6

At about what age does conjugate gaze develop?

Answer 6

around 5 mo

Question 7

Normal visual acuity test= 20/20

(by age 8, with or without glasses)

What does 20/20 mean?

Answer 7

the numerator is the distance between the subject and the chart, while the denominator is the distance at which a person with 20/20 acuity would just discern the same optotype

Question 8

DDx of abnormal visual acuity test:

**visual acuity is vital sign of the eye

Answer 8

MC abnormality= refractive errors

also: astigmitism, corneal irregularities, neural issues

Question 9

why is urgent opthalmology consult required for:

congenital cateracts?

Answer 9

must be removed before 6weeks old or risk blindness

Question 10

why is urgent opthalmology consult required for:

corneal ulcer?

Answer 10

corneal abrasion has become infected

(often in contact lens wearers)

Question 11

urgent opthalmology consult is needed for ocular trauma → will need to know the % of the anterior chamber that has hyphema

what is hyphema?

Answer 11

reddish discoloration occluding the pupil and iris = hyphema

(blood in the anterior chamber)

higher % of chamber with hyphema= associated with acute angle closure glaucoma

also, trauma itself poses risk of retinal detachment

Question 12

Treatment for strabismus:

Answer 12

should be followed by opthalmologist bc at risk for developing amblyopia

mild→ patch dominant eye or use cycloplegic drops in the good eye (encourages deviant eye to strengthen)

severe→ surgery

Question 13

Treatment for amblyopia (and age for best outcomes)

Answer 13

best if treated before 6yo, but 8-9yrs may still have good outcome

any older, and Tx will not restore proper vision bc central vision will be permanently compromised

Tx: same as for strabismus (patching or cyclopegic drops)

Question 14

MC cause of purulent eye discharge in neonate

(in US)

(in developing countries)

Answer 14

in US→ purulent eye discharge in neonates likely chlamydia

in developing countries→ gonorrhea

Question 15

Common cause of watery eye(s) in infants

Answer 15

dacryostenosis= blocked tear duct

Question 16

majority of kids with red eyes (with or without discharge) have a type of this:

Answer 16

conjunctivitis

(allergic, bacterial or viral)

Question 17

What are the red flags in Hx and PE of “red eye” or “eye discharge”?

Answer 17

trauma

photophobia

eye pain

Question 18

type of conjunctivitis:

Sx: itchy eyes or nose, seasonal reoccurance, watery/stringy discharge, cobblestoning on the palpebral conjunctiva

Answer 18

allergic conjunctivitis

Question 19

type of conjuctivitis:

Sx: purulent eye discharge with significant erythema of the palpebral (and sometimes bulbar conjunctiva) without eye pain

**swelling of bulbar conjunctiva= chemosis

Answer 19

bacterial conjunctivits

Question 20

type of conjunctivitis:

Sx: red eye +/- watery discharge, likley with URI

Answer 20

Viral conjunctivitis

(still may give Abx drops bc often 2º bacterial infxn)

**herpetic conjunctivitis is viral BUT has red flags of significant eye pain and photophobia

Question 21

Eval/Tx for neonate with red eye and discharge

Answer 21

culture eye discharge, gram stain if gonorrhea is possibility

empiric IV abx until culture results returned

Question 22

Tx for infant with dacrostenosis:

Answer 22

amniotic debris can clog tear duct in neonate

Tx: **massage inner canthus of eye 3x/day **(debatable effect)

Abx needed if discharge becomes purulent

if still blocked at 6mo old→ refer to opthalmology for probing of the tear duct, which usually opens it

Question 23

Abx Tx for bacterial conjunctivitis:

Answer 23

Polytrim, Vigamox, Ocuflox

[erythromycin ointment in neonates]

Question 24

Eval/ Tx for herpetic conjunctivitis:

* pt will present with significant eye pain and photophobia

Answer 24

confirm with fluorescein stain

MUST refer to opthalmology

Question 25

Antihistamine Tx for allergic conjunctivitis:

Answer 25

responds very well to antihistamine eye drops

Patanol or Pataday (q day formula)

Naphcon or Ketotifen (OTC formulas)

Question 26

Eval for corneal abrasion:

potential complications?

Answer 26

stain with fluorescein, then use black light (Wood’s lamp)

consider in inconsolable infant, esp if facial ezcema as baby may scratch eye trying to scratch itchy skin

Document: location and % corneal involvement

Rx: Abx eye drops and Tylenol #3 (for pain)

RTC next day→ should heal overnight!

Complication= infected (corneal ulcer)→ medical emergency (to opthalmology immediately)

Question 27

Eval/ Tx for blunt eye trauma:

**hyphema= blood in the anterior chamber

(can occude iris and pupil)

Answer 27

also examine eye socket, facial bones for fractures

refer to opthalmology (know % of anterior chamber that has hyphema)

►higher % assoc with acute angle closure glaucoma

►trauma itself is risk for retinal detachment

Question 28

Exam findings for periorbital (pre-septal) and orbital (post-septal) cellulitis

exam finding that distinguishes the 2?

Answer 28

erythematous, edematous, warm eyelid, fever

distinguished by: extra-ocular eye movements INTACT with periorbital cellulitis but not with orbital

Question 29

likley cause of periorbital cellulitis?

of orbital cellulitis?

Answer 29

periorbital→ insect bite (may see bite mark) or scratched face

orbital→ eye trauma or sinusitis that has eroded the orbital bone (muscle and fat surrounding the eye are infected and post-septal area fills with pus)

Question 30

management for periorbital cellulitis (pre-septal):

Answer 30

monitor for sepsis, meningitis and check Hib and pneumococcal vaccine status

need close monitoring/RTC precautions, but can Tx outpatient with Augmentin or cephalosporins

Question 31

management for orbital cellulitis (post-septal):

Answer 31

if unsure of Extra Ocular Movement exam→ ask for help or admit pt for CT scan and IV Abx

ENT consult req’d as surgical eye orbit debridement req’d

significant risk of spread to brain, so speed/vigilance needed!

Question 32

what is retinopathy of prematurity?

why is it so important to refer to opthalmology?

Answer 32

infants born <32weeks or <1500grams at risk for retina not to develop appropirate blood vessels (in photo, note absence of blood vessels in bottom portion of retina)

stage 1= minimal change→ stage 5=retinal detachement

Retinopathy of prematurity is signif cause of blindness in US

PCP’s job: make sure NICU grads follow-up with opthalmology rechecks every 1-2 weeks. Document discussion of importance of follow-up in patient’s chart.

Question 33

Differentiate the clinical S/Sx assoc with the MCC of rhinitis:

Answer 33

MC→ viral URI (lasts 7-14 days, so rhinorrhea 1-2 weeks/month… more during winter months) *as long as brief periods of resolution, likley reoccurences of viral URIs

**Allergic rhinitis→ **no break in Sx, Hx of seasonal Sx, itchy nose, some eye involvement

2° bacterial infxn→ Sx 10⁺days (but <1mo), esp with fever after initial cold Sx, purelent discharge, Sx worsening rather than improving (**yellow-green nasal discharge is common around days 3-4 and does NOT indicate a 2° bacterial sinusitis)

**Foreign Body/ Choanal atresia **(congenital blocked nasal passage)→ persistent purulent discharge

Question 34

pathophys of common cold in young kids:

Answer 34

kids under 5yo average _~6-8 viral URIs/year (fewer as get older), each one lasts 1-2weeks

*about 1/4 of time kids have a cold

MCC are rhinoviruses (there are many rhinoviruses, so continue to get colds)

Question 35

Tx plan for child with suspected viral URI:

Answer 35

SUPPORTIVE care: nasal irrigation with normal saline using a bulb syringe q few hours. Parents can buy or make the soln.

honey helps with cough but is CONTRAINDICATED under 1yr

**cough/cough preparations NOT recommended **under 6yo and are CONTRINDICATED under 2yo

humidifiers somewhat helpful to relieve congestion

Question 36

Tx plan for child with suspected bacterial sinusitis

(including dosing indications):

Answer 36

1 MC organism= Strep pneumo

same organisms as AOM, so same treatment

first line amoxicillin (80-90mg/kg, divided BID (max 3g/day) then Augmentin (amox+clavulanic acid→ inactivates bacterial beta lactamase)

nasal steroids helpful

Question 37

Eval of child with suspected Group A strep pharyngitis:

Answer 37

90% of sore throats are caused by a virus and need no intervention

PE not always helpful in determining who to test→use scoring system

Sx of GAS often include→ obrupt onset HA, upset stomach, vomiting, sandpaper rash to trunk and groin in some

►kids with rash likley have scarlet fever (expect +rapid strep test)

Question 38

Tx of GAS pharyngitis

Answer 38

Tx GAS to avoid complications of post-streptococcal glomerulonephritis or rheumatic fever

Tx with penicillin/amoxicillin/ampicillin for 10days

expect rapid improvement

can return to school after 24hrs Abx

stress importance of completeing entire Abx regimen

Question 39

scoring system for deciding who to test for GAS

(1 point for each “yes” answer)

**all neg rapid strep test needs confirmatory culture bc test has low sensitivity

Answer 39

1. age 5-15yr
2. late fall/early spring presentation
3. pharyngeal erythema, edema or exudates on exam
4. tender, >1cm anterior cervical LAD
5. fever of 101-103
6. absence of URI Sx (cough/ rhinorrhea)

score of 5→ culture only bc rapid test only 50% chance of coming up positive (avoids dual testing)

Question 40

S/Sx of abscesses that require emergent ENT consult, hospital admission, IV abx, incision/drainage:

differentiate between peritonsillar and retropharyngeal abscess

Answer 40

severe sore throat, fever, difficulty swallowing and talking (“hot potato” voice)

►life threatening due to airway obstruction

Peritonsillar abscess is more common: begins as cellulitis, often GAS. PE→ bulging soft palate and deviated uvula

Retropharyngeal abscess→ stiff neck/lateral flexion due to presence of mass near neck muscle

Question 41

risk factors for obstructive sleep apnea in kids

Signs/Sx of OSA:

Answer 41

Risk factors: obesity (BMI > 97th %), 3-4⁺ tonsils, adenoidal hypertrophy (have to get lateral neck x-ray to see adenoids)

to a lesser degree: FHx of OSA, Down syndrome, CP

Signs/Sx: habitual snoring, episodes of arrested breathing/choking during sleep, behavior/learning problems including ADHD and nocturnal enuresis

Question 42

management of suspected OSA

Answer 42

if risk factors, or S/Sx of OSA→ can refer directly to ENT or can send for sleep study and refer if +

Tx: tonsilecotmy/ adenoidectomy, +/- CPAP machine for sleep

Question 43

differentiate between clinical signs and Sx of acute otitis media vs serous otitis media

(around 6yo, the eustachian tubes become longer and positioned at a downward slant into the throat, making AOM less common)

Answer 43

AOM: acute ear pain, bulging TM, +/- fever or otorrhea

→mastoiditis is potential complication of AOM (protruding ear, erythema over mastoid process→ emergency ENT referral

Serous otitis media= middle ear effusion: air/fluid levels, fluid behind TM may be clear or yellow (non-invasive, quick test for MEE with tympanometer)

→after AOM infxns are treated, fluid remains in the middle ear for a few days/weeks (60% of MEE resolve by 1 month, 90% by 3 months)

Question 44

Tx plan for child with AOM (including amox dosing):

Answer 44

most providers treat whether or not febrile (have the option to watch and wait→ make f/u plan and start Abx if Sx persist at day 3→ consider Safety Net Abx Prescription (SNAP) for caregiver to fill if necessary

Pts with high fever and ear pain should get Abx and acetominophen or ibuprofen for pain

RTC if Sx not improved within 2-3 days of Abx (need to change to 2nd line therapy like Augmentin)

First line Abx (use unless pt treated with amoxicillin in past 30days or has both AOM & purulent conjunctivitis). Give macrolide if PCN allergy

Amoxicillin 80-90mg/kg/day, divided BID→ max 3g/day