HEENT

Question 1

Conjunctivitis

Answer 1

inflammation of palpebral and bulbar conjunctiva. most frequently seen ocular disorder in peds. most often d/t bacteria Dec. - April, commonly H. Flu, S. Pneumonia, & Moraxella. bacterial often unilateral, viral usually bilateral. most common cause in neonates is chlamydia, and gonococcal most serious.

Question 2

Dacrostenosis

Answer 2

nasolacrimal duct obstruction. stops tears from flowing into an opening in nasal mucosa. infection can occur. maybe d/t membrane failing to break down quickly, or secondary to trauma to duct or URI. more common in craniofacial disorders/down’s. usually resolves by 6-12 months. s/s: tearing, mucoid discharge at inner cantos, blepharitis, nasal obstruction/drainage, tenderness/swelling of lacrimal duct (painful).

Question 3

Chalazion

Answer 3

chronic sterile inflammation of eyelid resulting from a lipogranuloma of meibomian glands. deeper in eyelid than hordeolum. s/s: slight redness/ swelling > inflammation to slow-growing, round, non pigmented, painless* mass. can last a while. tx: hot compresses. refer for surgical incision or steroid injections if unresolved.

Question 4

Blepharitis

Answer 4

acute or chronic inflammation of eyelash follicles. or sebaceous glands of eyelids. bilateral. anterior: d/t seborrhea/staph, or parasite. Posterior: d/t chronic inflammatory diseases. also can be d/t allergy, eczema, psoriasis. s/s: swelling/erythema eyelid margins and palpebral conjunctiva. flaky, scaly debris. gritty, burning eyes. can ulcer at base.

Question 5

Hordeolum

Answer 5

infection of sebaceous glands, eyelids, meibomian glands. usually S. aureus, sometimes pseudomonas. s/s: tender, swollen red furuncle. differential: cellulitis, sebaceous cell cancer, pyogenic granuloma. tx: rupture when large. removal of eyelash may cause rupture. warm moist compresses. 1/2 strength no tears shampoo hygiene. antistaph ointment. refer if no rupture when at a point.

Question 6

Orbital/periorbital cellulitis

Answer 6

often associated with trauma or focal infection; sometimes with lacs, stings/bites, foreign body. anterior infection to orbital septum/not involving orbit. up to 6 years old. Common bacteria: Strep, S. Aureus. swelling/erythema of tissues, deep red, orbital discomfort, proptosis. Dx: not required, but may due CBC, blood cultures, CT. Differentials: conjunctivitis, cavernous sinus thrombosis, orbital cellulitis.

Question 7

Cataracts

Answer 7

partial/complete opacity of lens; most common cause of abnormal pupillary reflex. congenital or acquired. can be spontaneous or genetic, result of infection, trauma, or metabolic disease, or d/t long term steroids, preemie, CNS problems. +history prenatal infection/drug exposure/hypocalcemia. opacity on lens. varied visual acuity defects.

Question 8

Glaucoma

Answer 8

disturbance in circulation of aqueous fluid that results in increase IOP and > damage to optic nerve. congenital at birth, infantile 1-2year, juvenile >3 years. most have no known cause and are primary = d/t congintal abnormality of structures draining aqueous humor. often seen with dominantly inherited conditions like neurofibromatosis etc. secondary d/t obstruction post infection, trauma, disease, steroids.

Question 9

Strabismus

Answer 9

defect of ocular alignment, lazy eye. if >7, diplopia, but if <7 suppression of vision in deviated eye occurs but leads to amblyopia. phobia is intermittent deviation held latent by sensory fusion and can maintain alignment on object. tropic is consistent/intermittent unable to maintain alignment on object. accommodative esotropia often goes with hyperopia. newborns can have transient exotropia that corrects by 6 months. dx: asymmetrical corneal light reflex. cover-uncover test. photo screener.

Question 10

Nystagmus

Answer 10

presence of involuntary, rhythmic movements that can be oscillations or jerky drifts. congenital between 6w and 3 months of age, acquired is later. related to albinism, CNS issues, refractive errors, low vB12, after infection, ear diseases, med toxicity. may be preemie, IVH, drug exposure, DD, hydrocephalus, gestational diabetes. note type, frequency, distance, fields of gaze with nystagmus. at newborn normal.

Question 11

Refractive disorders

Answer 11

most common eye problem. Myopia often develops 6-9 years. s/s: squinting, closing one eye, abnormal vision exam, pain in around eyes or headaches, fatigue, dizziness, DD, family hx. Myopia: nearsightedness. hyperopia = farsightedness. astigmatism=uneven curvature > blurry both ways. anisometropia=different error in each eye.

Question 12

Ambylopia

Answer 12

unilateral deficit where there is defective development of visual pathways needed to attain central vision. clear images don’t go to brain, causing permanent vision loss. labeled by different causes: derivational, obstruction of vision, strabismic, refractive.

Question 13

Corneal Abrasion

Answer 13

damage to/loss of epithelial cells of cornea d/t scratches. sensation of foreign body, redness, severe pain, photophobia, decreased vision, tearing, disrupted tear film. fluorescein staining. refer those with contact lenses. if no s/s corneal infection, topical antibiotics qid 3-5 days. patch doesn’t help. abrasion normally heals in 24-49 hours. if no improvement then, refer. elbow restraints for infants.

Question 14

Foreign Body

Answer 14

usually lodged on surface of eye or superficially in cornea. common in play/sports. sensation of foreign body, perforating wound to cornea/iris, tearing, photophobia, inflammation, irregular pupil. dx: fluorescein staining, US, CT. tx: never remove foreign body. refer immediately. topical anesthetic. irrigate eye. antibiotic ointment. f/u 24 hours.

Question 15

Hyphema

Answer 15

accumulation of visible blood in anterior chamber of eye and is result of blunt trauma to the globe without penetration or perforation. can be related to high risk sports. s/s: open globe must be excluded before increasing IOP. no red reflex, blood, history of trauma, pain, photophobia, tearing, abnormal pupillary reflex, visual acuity changes, impaired vision. tx: refer. restrict oral intake. place a shield. elevate HOB, bedrest, no strenuous activities. cycloplegia. hospital grade II/III, sickle cell, increased IOP, in compliance. Tylenol, no NSAIDs. prevent vomiting. may need surgery. second hemorrhage can occur 3-5days out.

Question 16

Microcephaly

Answer 16

head circumference >2 standard deviations below mean for age, gender, and conceptual age. abnormally small brain and s/s of any disorder impairing brain growth. Dx: family history, prenatal history, congenital anomalies, karyotyping, oligo array, amino acid screening, serologic studies for infection, skull Xray, CT, MRI.

Question 17

Macrocephaly

Answer 17

head circumference >2 standard deviations above mean for age, gender, gestation. can be d/t: hydrocephalus, mass lesions, skull enlargement, increase in brain substance. Evaluate: serial measurements, measure parents’ head circumferences/ history; developmental history, exam for evidence of increased iCP, DD, skeletal dysplasia, transilluminations, cranial bruits, organomegaly. Xray, CT/MRI.

Question 18

Hydrocephalous

Answer 18

d/t imbalance of CSF production and resorption enough to lead to net accumulation of fluid in ventricles. can be d/t obstruction of pathways of ventricles, subarachnoid space. or d/t CSF overproduction. s/s: large head, rapid growth rate, large forehead and small face, thin/glistening scalp with distended veins, large/tense anterior fontanelle. wide sutures. divergent strabismus, impaired upward gaze. sunsetting sign. DD, automatisms, spasticity/hyperreflexia of lower extremities. CT/MRI.

Question 19

Caput succedaneum

Answer 19

diffuse, superficial swelling of soft tissue with underlying bruising. crosses suture lines. d/t trauma in birth. Diff: cephalohematoma/subgaleal hemorrhage. Tx: none necessary, resolves over a few days.

Question 20

Cephalohematoma

Answer 20

deep collection of blood in subperiosteal area of scalp, does not cross suture lines. d/t trauma during delivery. diff: caput, smbgaleal hemorrhage, cranial meningocele. resolves over weeks to months. monitor for hyperbilirubinemia.

Question 21

Craniosynostosis

Answer 21

skull malformations. congenital: d/t premature fusion of sutures.can be d/t syndromes. secondary synostosis d/t outside forces putting pressure on cranium, leading to misshapen head often seen with preemies. monitor cranial symmetry for first year. Dx: CT scan or clinical exam. Differentials: frontal bossing. Tx: refer to surgeon

Question 22

Otitis (external)

Answer 22

externa: swimmer’s ear, inflammation of EAC/ pinna/ TM. simple infection, furuncles/abscesses, or superficial. Often d/t pseudomonas and s.aureus. Differential: AOM, tymponostomy, necrotizing OE, cholesteatoma, mastoiditis. Tx: acetic acid or antibiotic drops with or without steroids. should resolve in 2 weeks. no neomycin if perforated TM. no swimming during acute infection. debridement. don’t touch ear. if no improvement 72hr, reassess. refer after a week. avoid water in ear canals, use alcohol/vinegar mix post swimming, blow dryer on warm to dry EAC, don’t scratch.

Question 23

Tympanic membrane perforation

Answer 23

Often associated with AOM. pain improves with rupture, profuse otorrhea. often P. Aeruginosa, S. aureus; heal with no intervention in 1-3 months. Traumatic perf’s less likely to heal spontaneously, prone to infection and hearing loss. S/s: whistling sounds during sneezing or nose blowing, hearing loss, TM perforation seen on otoscope. otorrhea. flat tympanogram. Diff: AOM, TTO, trauma. if d/t AOM, otic drops, oral antibiotics. no swimming or water in ears, no irrigation. refer for hearing loss

Question 24

Mastoiditis

Answer 24

suppurative infection of mastoid cells that can cooccur with AOM. s/s: AOM, fever, otalgia, post auricular swelling, AOM unresponsive to antibiotic therapy. Dx: CT pro MRI, tympanocentesis with culture/gram stain. Diff: lymphadenopathy, cellulitis, mumps, tumors, perichondritis. Tx: urgent referral. hospital, IV antibiotics, surgery like tube placements, mastoidectomy.

Question 25

Cholesteoma

Answer 25

often d/t chronic ear infection and is formation of epidermal inclusion cyst of middle ear or mastoid with debris from keratinizing, squamous epithelial lining. can grow and destroy structures > otorrhea, hearing loss, ossicular erosion. Congenital pearly white mass behind TM. Primary acquired from negative middle ear pressure > retraction and erosive cyst. Secondary acquired d/t skin ingrowth from perforated TM. Diff: tympanosclerosis, OME, rhabdosarcoma. Tx: immediate referral surgery.

Question 26

Allergic Rhinitis

Answer 26

more susceptible to infectious sinusitis. s/s mimic sinusitis without source of infection. 2 pictures: nasal congestion, nighttime cough, morning throat clearing; potential nausea/emesis. No fever, purulent drainage, halitosis. itching/snezing. Dennie lines, allergic shiners, cobblestone conjunctiva. Tx: antihistamines, environmental control. second picture is vacuum headache: intense facial/frontal headache, no fever. during allergic exacerbations, after swimming, or flying. d/t blockage of sinus Ostia with mucosal edema > vacuum in sinus > negative pressure. nasal mucosa pale and swollen no discharge, tender to percussion but clear on X-ray. Tx: topical vasoconstrictor and warm compresses over face. antihistamines, decongestants.

Question 27

Sinusitis

Answer 27

infection of maxillary/ethmoid, frontal sinuses (frontal >10years old). etiology: mucosal swelling d/t URI, allergic rhinitis, or chemical irritation > obstruction of sinus Ostia > mucus plugging > bacterial growth and infection. Commonly: S. pneumonia, H. Flu, Moraxella Catararhalis, adenovirus, para-flu. s/s: prolonged URI no improvement in 7-10 days, cough prominent during day, persistent nasal discharge, halitosis, fever, discomfort, tenderness to percussion, peri orbital swelling, headache/face pain. postnasal drip.

Question 28

Epistaxis

Answer 28

d/t trauma, infection, irritation, bleeding disorders, vascular anomalies, HTN. hard to stop > HTN, acute thrombocytopenia, vascular. Mild:; mucosal infection/irritation. mild treated with antibiotics if infection, humidification, antihistamines, and lubricants used. bleeding disorder: labs, replacement of coagulopathy, topical vasoconstrictor or packing. vascular: unilateral like dilated septal vessel/plexus d/t prior inflammation. cauterization is curative. HTN: preceding headache, spontaneous/profuse bleeding. history of coarc/CKD/HTN work up.

Question 29

Nasal foreign body and polyps

Answer 29

foreign bodies: thick, purulent, foul smelling discharge, inflammation, intermittent epistaxis. unilateral. Speculum exam. use topical anesthetic and vasoconstrictor. if object anterior to turbinates, attempt removal with suction, curette, or Day hook, or forceps. consult ENT for those more posterior or not easily removed. can have significant bleeding. Polyps: end result of recurrent infection or inflammation. usually >10 years old. s/s discharge, recurrent sinusitis, intermittent epistaxis; grape like growths on inspection. CT prior to removal. Surgery needed to relieve obstruction.

Question 30

Thrush

Answer 30

infection by opportunistic pathogen Candida albicans. can happen in young kids getting antibiotics or in immunosuppressed kids. oral forms look pseudo-membranous or plaque like. scraping reveals raw red base with bleeding from capillaries. must rule out HIV when therapy resistant disease present. on buccal mucosa, tongue, palate, commissures of lips. intramural: soft, elevated, creamy white and don’t scrape off easily. diagnosis: clinical exam or KOH. Tx: apply nystatin and control underlying cause

Question 31

Cleft lip and palate

Answer 31

disruptions of face structure. most common birth defects. d/t poor development as embryo.can be genetic or from teratogens. unilateral or bilateral, soft/hard palate, bifid uvula. Tx: refer to ENT for surgery at around 3 months for lip and 8 months for palate. may need special nipple beforehand. often get ear infections.

Question 32

Cold sores and fever blisters (Herpes labialis)

Answer 32

HSV infection; transmitted by contact with secretions or mucocutaneous lesions. Incubation days to weeks. can be dormant until triggers: stress, menses, illness, sunburn, windburn, fatigue. HSV-1 most common around oral mucosa, pharynx, lips, eyes. contagious while present. may have fever, malaise, sore throat, decreased PO. cluster of small, clear, tense vesicles/red base that becomes weepy and ulcerates > crusts. Dx: Tzanck smear, viral cultures gold standard. Diff: aphthous stomatitis, coxsackie virus, hand/food/mouth. Tx: burrow solution tid, acyclovir topical, acyclovir PO to shorten course for >2 years and systemic or immunocompromised, antibiotics secondary infection, oral anesthetics, Benadryl topical. only exclude from day care during initial course.

Question 33

Hand foot and mouth disease

Answer 33

coxsackievirus or enterovirus; s/s Fever, malaise, abdominal pain, cough, lymphadenopathy. oral ulcerations (5-10), vesicles on hands/arms/feet, for about 10 days. maintain hydration. defer dental treatment until lesions resolve.

Question 34

Herpangina

Answer 34

coxsackievirus A, during summer/fall. spreads oral/fecal route. vesicles on soft palate and tonsillar pillars. often rupture, leaving shallow but painful ulcerations. malaise, fever, lymphadenopathy. self-limited disease. defer elective dental treatment.

Question 35

Pharyngitis

Answer 35

often d/t strep pyogenes. red inflammation of tonsils and pharynx, petechiae soft palate, anterior cervical lymphadenopathy. headaches, fever, vomiting, abdominal discomfort. s/s for 5-7 days. Dx: throat culture and NP if <3 years old. Tx: 10 day course of penicillin/amoxicillin for GAS infection.

Question 36

Cervical lymphangitis

Answer 36

inflammation of lymphatic channels, usually secondary to infection at distal site. S. Pyogenes common source. erythematous, irregular linear streaks are seen extending from primary site toward draining regional node. s/s systemically include fever, chills, malaise. Need culture/gram stain but broad-spectrum antibiotics immediately.

Question 37

Retropharyngeal/peritonsillar abscess

Answer 37

abscess between tonsil and constrictor muscle extending into soft palate. school age or older, had sore throat a week or two earlier that was not treated properly. initial improvement but then sudden onset severe throat pain (worse on one side), high fever, ipsilateral referred pain to ear, enlarged ipsilateral lymph node, torticollis, dysphagia, truisms, muffled speech, deviating uvula away. needs to be drained

Question 38

Refractive error management

Answer 38

refer for lenses. Annual evaluations. Moderate amblyopia responds to 2 hours daily patching or weekend atropine. toddlers need reinforcement with replacing glasses. untreated amblyopia causes irreversible vision loss.

Question 39

Strabismus management

Answer 39

misalignment >4months needs referral. unaffected eye is occluded, forcing use of bad eye. patches 2 hours a day. surgery may be needed. corrective lenses helps amblyopia.

Question 40

Nystagmus management

Answer 40

treating underlying systemic disorder, and referral. acquired is worrisome. visual acuity loss varies.

Question 41

Cataract management

Answer 41

TORCH titers, calcium/phos, urine testing, genetic testing. small cataract monitored. surgical removal; resultant aphakic refractive error corrected with implant, contact lens, or glasses. poorer prognosis congenital unilateral. UV protectant sunglasses to prevent cataracts.

Question 42

Glaucoma s/s and treatment

Answer 42

orbital size discrepancy. classic triad: tearing, photophobia, excessive blinking/blepharospasm. turns away from light. hazy corneas/edema. secondary glaucoma s/s: extreme pain, vomiting, blurred/lost/tunneled vision, pupil dilation/redness, asymmetry of eyes. Tx: prompt referral, surgery ASAP. systemic or topical carbonic anhydrase inhibitors, beta blocker drops, limit stress and straining; wear medical tag. f/u for life q3-6months; exam for all family.

Question 43

Conjunctivitis s/s

Answer 43

chemical: in first 24-48 hours. bacterial in 5-14 days. Chlamydia 5-14 days. gonorrhea 3-5 Fays. HSV first month. erythema, chemises, purulent drainage, exudate, matter in eyelashes, itching, burning. hsv often unilateral and has vesicular rash too. dx cultures, ELISA, PCR. <2 test gonorrhea.

Question 44

conjunctivitis tx

Answer 44

irrigate the eyes after culture. gonococcal: IM rocephin. nongonoccocal: topical antibiotic. chlamydia: EES systemic. prophylactic eye antibiotic recommended within 1 hour of birth. Bacterial: self resolving within 8-10 days. can do sodium sulfacetamide, trimethoprim sulfate, EES, fluoroquinolone >1 year.

Question 45

Blepharitis dx/ tx

Answer 45

Differential: Pediculosis. Tx: scrub with cotton tipped applicator with 50% no-tears shampoo. rinse well. Warm compresses 5-10 minutes 2-4x a day. massage lids. antistaph antibiotic (bacitracin, ees) daily. don’t wear contacts. use new eye makeup.

Question 46

Dacrostenosis dx/ tx

Answer 46

Fluorescein dye, WBC/cultures. Differentials: canalicular atresia, ophthalmia neonatorum, conjunctivitis, foreign body, corneal abrasion, glaucoma, dacryocele, nasal edema. tx: daily massage of lacrimal sac. clean water afterword. saline drops in nose. if persists past 2 weeks, refer.

Question 47

Cellulitis

Answer 47

moderate to severe, <1 year child, poor response to outpatient management, purulent wound near eye: hospitalization and IV antibiotics. mild, >1 year, uninvolved orbit: outpatient oral antibiotics (augmentin, cefdinir, cefpodoxime). if MRSA, clindamycin, Bactrim, amoxicillin. Warm soaks every 2-4 hours. if no rapid response seen, further eval. f/u in 24 hours

Question 48

Acute Otitis Media

Answer 48

middle ear infection. inflammation, ear pain, irritability, otorrhea, fever, MEE = bulging TM, limited mobility, air-fluid level behind it, otorrhea. kids prone d/t horizontal Eustachian tube, narrower tube, closeness to adenoids. common causes: URI, cleft palate, allergies, smoke exposure. RSV/flu. Most common bacteria: S. Pneumonia, H. flu, mortadella catararhalis, S. Pyogenes. red/yellow/purple TM. Dx: pneumatic otoscope. tx: amoxicillin. watchful waiting for 2-3 days.

Question 49

Otitis media with effusion

Answer 49

often afebrile/asymptomatic, or mild ear pain/fullness, dizziness. pneumatic otoscope dx: decreased TM mobility, dull, bulging/opaque to no retracted/translucent and air-fluid bubble. differentials: AOM, NP lesion. Tx: watchful waiting 3 month; hearing test if >3mo. reevaluate q3months until resolves or q3-6months for chronic. refer if impending damage, hearing loss, or >6months. Tubes may help.

Question 50

Sinusitis dx/tx

Answer 50

treat empirically with most symptoms. radiography, CT is gold standard. needle aspiration is conclusive but invasive. tx: amoxicillin, augmentin, clindamycin (step up q3-4 days if no improvement). 10-14day course analgesia, antihistamine, intranasal steroid, topical nasal vasoconstrictors/warm compresses for intense headache facial pain for 1-2 days.