HEENT Disorders Flashcards
1
Q
Normal birth head size
A
32-38 cm
2
Q
HC growth in first year
A
12 cm (6 cm at 0-3 mo, 3 cm at 4-6 mo, 3 cm at 6-12 mo)
3
Q
Microcephaly
A
HC < 2 SD below mean for age, sex, gestation, or HC percentiles dropping with age
4
Q
Microcephaly etiology + S/S
A
- Genetic chromosomal disorders (familial or genetic syndrome)
- Acquired from noxious causes in utero or first 2 years of life (TORCH infections, maternal substance use, fetal exposure to radiation, placental insufficiency, prenatal hypoxia, trauma, maternal hypoglycemia, degenerative diseases: Tay-Sachs, poor nutrition first 6 mo, alcohol use, inadequate prenatal care, AA)
S/S: small head in full term birth - 6 mo old; chest circumference > HC; delayed development; neurologic problems; mental retardation; family hx
5
Q
Microcephaly DDx + physical findings
A
DDx:
- Craniosynostosis
- Endocrine dx (hypothyroidism, hypopituitary)
- Severe malnutrition
- Small infant
Findings:
- early fontanel closure; prominent cranial sutures
- marked downward-sloped forehead with narrowed temporal diameter + occipital flattening (familial)
- skull asymmetries, high arched palate, dysplastic teeth (chromosomal disorders)
6
Q
Microcephaly diagnostic tests + mgmt/tx
A
Diagnostics:
- karyotyping for chromosomal disorders (fragile X)
- antibody titers for TORCH infections of mom/child
- test infant serum + urine for amino/organic acids
- CT or MRI to detect calcification, malformations, atrophy
Mgmt/Tx:
- Complete history + physical findings to find origin (hypopituitarism, severe protein-calorie malnutrition)
- Most are untreatable; appropriate genetic/family counseling
- Supportive mgmt, early placement in program for development of mental retardation
7
Q
Macrocephaly
A
HC > 2 SD from mean for age, sex, gestation or HC increasing too rapidly
8
Q
Macrocephaly etiology + S/S
A
- Hydrocephalus: > CSF
- Intracranial lesions: neoplasms, subdural effusions
- Skull enlargement: primary skeletal dysplasia
- Increased brain size (megalencephaly): r/t neurofibromatosis
Normal variants:
- Familial macrocephaly: benign family trait
- Large infant: all growth parameters high
S/S: excessive head growth, depends on cause (hydrocephalus)
9
Q
Macrocephaly DDx + physical findings
A
DDx:
- Benign macrocephaly: familial or catch-up growth in thriving premie
- Pathological macrocephaly
Findings:
- Progressive head growth > 2 SD above mean
- Skull transillumination may reveal chronic subdural effusions, hydrocephaly, or large cystic defects
- Enlarged anterior fontanel/tense with wide suture lines
- Dependent on cause: increased ICP, developmental delays, skeletal dysplasia, ocular abnormalities, skin findings (cafe au lait)
10
Q
Macrocephaly diagnostic tests + mgmt/tx
A
Diagnostics:
- CT, MRI or ultrasonography of anterior fontanel (if open) to define structural cause & assess operability
- Skull xrays provide indirect info (changes seen with increased ICP, skeletal dysplasias, or calcifications)
Mgmt/tx:
- CT, MRI, ultrasound of head if any S/S of increased ICP
- Surgical correction of underlying cause (shunt placement with hydrocephalus or tumor resection)
- Genetic counseling
11
Q
Hydrocephalus
A
Increased CSF in cerebral ventricles & ventricular enlargement
12
Q
Hydrocephalus etiology
A
CSF obstruction anywhere from ventricles (produced) to subarachnoid space (reabsorption area)
Causes:
- congenital d/t primary cerebral malformation
- acquired postnatally sec to tumor, hemorrhage, CNS infection (meningitis)
- choroid plexus papilloma: CSF overproduction (rare)
Types:
A. Obstructive or noncommunicating:
-Major cause
-Obstruction within ventricular system including Sylvius aqueduct & 4th ventricle
-Congenital defects (most common cause) – isolated in aqueductal stenosis or from syndrome Arnold-Chiari & Dandy-Walker)
-Acquired conditions – common tumor complication
B. Nonobstructive or communicating:
- Impaired CSF absorption in subarachnoid space
- Scarring from subarachnoid hemorrhage (intraventricular hemorrhage in premature infant) or meningitis
13
Q
Hydrocephalus S/S + DDx
A
0-12 mo S/S: apparent large head, sluggish feeding, vomiting, piercing cry, irritability
12 mo-teens S/S: increased ICP signs, HA post sleep, lethargy, irritability, confusion, personality changes, possible decline in academics, vision changes (papilledema), possible 6th nerve palsies
DDx:
- macrocephaly
- megalencephaly
- benign large head
- macrocrania
- meningitis
- sepsis
- tumor
14
Q
Hydrocephalus findings, diagnostics, tx
A
Infancy physical findings: bulging anterior fontanel, scalp vein distention, bossing, “setting sun sign,” separated skull sutures, slow PERRL, hypertonia, hyperreflexia, spasticity
Childhood findings: strabismus, extrapyramidal tract signs (ataxia), papilledema, optic atrophy, growth failure r/t endocrine
Diagnostic tests:
- Cranial radiography - separated sutures
- CT scan/ultrasound - impaired CSF circulation = ventricular enlargement
- Ventriculography - obstruction detection
Tx:
- Most require extracranial shunts (VP)
- Tx underlying cause (mass, lesion, inflammation, infection, vasogenic edema)
- Anticipatory guidance throughout: support group referrals, teach ICP s/s, daily HC measurements, psychomotor challenges mgmt
15
Q
Caput succedaneum
A
Diffuse soft tissue swelling of newborn’s scalp (crosses suture line with some bruising)
16
Q
Caput succedaneum etiology + S/S
A
Caused by compression or trauma to scalp during vaginal delivery (scalp edema)
S/S: non-pitting swelling of scalp (present at birth), overlies occipital bones & some parietal bones, some bruising, often molding but disappears within first few days of life
17
Q
Caput succedaneum DDx, diagnostics, mgmt
A
DDx: cephalohematoma, subgaleal hematoma
Diagnostics: NONE
Mgmt: self-limiting within few days; may require phototherapy for hyperbilirubinemia if lots of bruising
18
Q
Cephalohematoma
A
Subperiosteal collection of blood within suture lines, often around parietal bones
19
Q
Cephalohematoma etiology + S/S
A
About 2% of all deliveries secondary to trauma from difficult delivery (LGA, prolonged labor, forceps, abnormal presentation). Uncommonly d/t coagulopathy or intracranial hemorrhage
S/S: not evident at birth but presents hours-days post delivery, limited to suture margins, usually unilateral, may prolong neonatal jaundice
20
Q
Cephalohematoma DDx, findings, diagnostics, mgmt
A
DDx: caput succedaneum, cranial meningocele
Findings: nonecchymotic swelling of parietal area not crossing suture line, soft, fluctuant
Diagnostics: NONE
Mgmt: slowly self-limiting over few weeks-months
- Calcification of hematoma possible; may be felt as bony prominence
- monitor hyperbilirubinemia
21
Q
Craniosynostosis
A
Premature closure of 1+ of cranial sutures leading to skull deformity
Sutures normally remain open until 2-3 yo
22
Q
Craniosynostosis etiology + S/S
A
Primary: pathology at suture line, sometimes d/t genetic syndrome
Secondary: underlying brain pathology (microcephaly)
S/S: abnormal head shape, no s/s unless part of genetic syndrome or multiple suture closes, rarely ICP s/s
23
Q
Craniosynostosis DDx + physical findings
A
DDx: newborn molding, pseudosynostosis positional plagiocephaly
Physical findings: abnormal head shape, palpable bony ridge along affected suture line, small or large anterior fontanel depending on suture closing
24
Q
Craniosynostosis diagnostics + mgmt/tx
A
Diagnostics: plain skull XR, chromosomal analysis if needed
Tx: surgery to open for cosmetic reasons, unless neuro complications
25
Newborn conjunctivitis (ophthalmia neonatorum)
infection/inflammation of conjunctiva in first month of life
26
Ophthalmia neonatorum etiology + S/S
Chemical: silver nitrate use
s/s: mild conjunctival injection, onset following ophthalmic ointment lasting 36-48 hours; resolves spontaneously
Gonococcal: prophylactic tx with erythromycin ointment
s/s: acute purulent discharge 2-4 days post birth
Chlamydia (inclusion): most common cause
s/s: mild mucopurulent discharge (profuse) 5-14 days post
HSV: uncommon but results in vision loss (asymptomatic mother)
s/s: eye redness, watery discharge beginning within 2 weeks
27
Ophthalmia neonatorum DDx + findings
DDx: dacryostenosis, foreign body, corneal abrasion, congenital glaucoma
Chemical findings: conjunctival hyperemia, minimal lid edema, scant discharge
Gonococcal findings: SIGNIFICANT LID EDEMA, chemosis, profuse purulent discharge
Chlamydia findings: MINIMAL LID EDEMA, conjunctival hyperemia, chemosis, possible concomitant PNEUMONIA (afebrile, cough, tachypnea, rales)
Herpes findings: usually UNILATERAL, small eyelid vesicles, mild conjunctivitis, possible NEUROLOGIC or SYSTEMIC symptoms (lethargy, poor feeding)
28
Ophthalmia neonatorum diagnostics + mgmt/tx
Gonorrhea tests:
-gram stain of conjunctival scrapings & purulent discharge --> gram-negative intracellular diplococci; verify by culture (chocolate agar or Thayer Martin medium)
Chlamydia tests:
- giemsa stain --> intracytoplasmic inclusion bodies
- direct immunofluorescent antibody staning of conjunctival scrapings for chlamydial inclusions; high sensitivity + specificity
- culture using special tissue culture
HSV
- fluorescein eye staining --> ocular dendritic ulcers
- culture for virus isolation
--------------
Gonococcal conjunctiva
- ocular EMERGENCY --> blindness; hospitalize
- eye irrigation with NS until discharge gone
- systemic antibodies, IV/IM cefotaxime or ceftriaxone (avoid ceftriaxone in newborns with hyperbilirubinemia)
- topical tx ineffective & unnecessary when systemic therapy given
Chlamydia
- EES 50 mg/kg/day x14 days PO qid to treat conjunctivitis & subsequent pneumonia (GI SE)
- PO sulfonamides (trimethoprim, sulfamethoxazole) may be used after neonatal period if infant intolerant to EES
- topical tx ineffective & unnecessary
HSV
- hospitalization needed
- acyclovir first line (parenteral)
- topical ophthalmic preparations adjunct therapy; 0.1% iododeoxyuridine, 1-2% trifluridine, or 3% vidarabine
Other bacteria
- topical antibiotics (EES, polymixin-bacitracin, tobramycin)
- warm compress to remove exudate
* thorough hand washing; avoid sharing towels
* mothers + sexual partners must be treated too
29
Conjunctivitis
Inflammation/infection of palpebral & bulbar > 1 mo
30
Conjunctivitis etiology + S/S
Very contagious!
Bacterial conjunctivitis: Staph aureus, H influenzae, Strep pneumonia, Moraxella catarrhalis
s/s: purulent, glued eyes (AM)
Viral conjunctivitis: adenovirus 3, 4, 7; uncommonly HSV or varicella
s/s: watery, think/stringy mucoid
Allergic + vernal (chronic allergic): seasonly allergies
S/S: eye redness, pruritus, foreign body sensation, mild eye discomfort/burning
no pain
31
Conjunctivitis DDx + findings
DDx: nasolacrimal duct obstruction, blepharitis (older kids), keratitis (HSV or adenovirus, painful), systemic infection (rubella, rubeolla, Kawasaki), periorbital cellulitis, eye injury (foreign body, corneal abrasion, chemical damage), uveitis (if perilimbal erythema)
Findings: varying injection (one or both eyes), mild eyelid edema, mild redness, preauricular adenopathy, cobblestone-like papillary hypertrophy (inner upper lid), systemic symptoms (nasal congestion, fever, pharyngitis)
discharge may be present
32
Conjunctivitis diagnostics + mgmt/tx
Culture & sensitivities unnecessary unless pseudomonas or neisseria; Rule out corneal involvement with fluorescein stain
Bacterial mgmt/tx: topical ophthalmic antibodies (tobramycin, erythromycin, sulfacetamide, polymixin B sulfate-trimethroprim, fluoroquinolone drops/ointment
Viral mgmt/tx: artificial tears for lubrication, topical steroids if keratitis present (ophthalmologist only)
Herpes mgmt/tx: topical & systemic antivirals; ophthalmology referral in all suspected cases + any child with history of herpes ocular infection with red eye, lid vesicles, or dendritic findings on fluorescein corneal staining
Allergic mgmt/tx: avoidance, cold compress, systemic/topical antihistamines (ketorolac/acular), or topical mast cell stabilizers (cromolyn Na); ophthalmology referral if chronic
33
Conjunctivitis education + referral criteria
Contagious! Cross contamination - hand washing, avoid sharing towel, cleanse eyelashes with warm sterile water, wipe in-out, stop wearing contact lenses until resolved, discard old eye makeup
Ophthalmology referral if:
- conjunctivitis unresponsive to treatment within 2-3 days, especially if wearing contact lenses
- associated vision loss, pain, photophobia
- severe conjunctivitis, corneal involvement
34
Dacrostenosis
unilateral or bilateral blocked tear ducts -- common in 30% newborns; 90% resolves spontaneously by 12 mo
35
Dacrostenosis S/S, DDx, findings, diagnostics, mgmt/tx
S/S: onset around 1-2 weeks old (newborn-1 mo), continuous or intermittent tearing with eyelash crusting, clear conjunctiva
DDx: ophthalmia neonatorum, dacrocystitis, glaucoma, intraocular inflammation, external irritation
Findings: tearing, thin mucopurulent exudate, clear conjunctiva without swelling
Mgmt/tx: gentle massage with clean finger from brow along lateral nose, intermittent use of erythromycin ointment if purulent discharge until clear, past < 12 mo needs ophthalmologist referral for possible surgical probing or silicone tube intubation
*severe dacrocystitis - ophthalmo. referral + systemic abx
36
Chalazion + S/S
Chronic granulomatous inflammation of meibomian glands on mid upper eyelid --> well-defined, nontender cyst
S/S: slow-growing, round, painless, nonpigmented mass in mid upper eyelid; typically larger than styes
Possible slight discomfort & minimal redness at onset x few days
37
Chalazion DDx, findings, mgmt/tx
DDx: hordeolum, blepharitis, sebaceous gland carcinoma
Findings: firm, nontender, localized nodule at mid portion of li; may become secondarily infected; large cysts may apply chronic pressure --> astigmatism
Mgmt/Tx:
- most small chalazions resolve without treatment
- warm compress 2-3x daily for 20 mins x2-3 days
- treat large, recurrent, or infected cysts with LOCAL ANTIBACTERIAL DROPS/OINTMENT (sulfacetamide Na 10% qid x1 week) or systemic abx if recurrent
- opthamolo. referral if tx unresponsive (surgical excision, curettage, or corticosteroid injections)
38
Hordeolum (stye)
acute localized inflammation of 1+ sweat sebaceous glands (meibomian or zeisian) of eyelids
most common pathogen- Staph aureus; highest incidence in kids/teens
39
Hordeolum (stye) S/S + DDx
S/S: sudden onset of tender, edematous red papule typically on lid margin; occasional foreign body sensation
DDx: chalazion, blepharitis, inclusion cyst
40
Hordeolum (stye) findings + mgmt/tx
Findings: painful erythematous swelling on either eyelid side (external stye) or conjunctival (internal stye) surface
Mgmt/tx: warm, moist compress for 15 mins 3-4x daily
- antibiotic ophthalmic ointment or drops. Sulfacetamide sodium 10%, polymixin B-bacitracin, or EES ointment
- cleanse eyelids with diluted baby shampoo once daily
- refer for I&D if unresponsive to treatment
- dispose of old eye makeup; discourage makeup use until resolved; good hand/eye hygiene
41
Blepharitis
Etiology + S/S
Common acute or chronic bilateral inflammation of eyelid margins
1. Seborrheic - seborrheic dermatitis, psoriasis, eczema, allergies; worsen from chemicals, smoke, air pollution, cosmetics
2. Staphylococcal aureus - bacterial infection of eyelash follicle
3. Mixed
S/S: irritation, burning sensation, foreign body sensation, erythema of eyelid margins, itching eyelid margin, loss of eye lashes (esp with staph)
42
Blepharitis DDx, findings, mgmt/tx
DDx: chalazion, conjunctivitis, superficial keratitis, hordeolum, pediculosis of eyelash
Findings: scales on eyelid margin & eyelashes (seborrheic=greasy, staph=dry)
- erythema to lid margin & scales on eyelash (seborrheic=less red, staph=really red)
- loss of eyelash (staph)
- tiny ulcerated areas on lid margin (staph) --> could lead to eyelid margin distortion & possible ectropion
Mgmt/tx: warm, moist compress to lid margins several times daily
- daily mechanical scrubbing & cleansing of lid margins with cotton-tipped applicator or soft cloth dipped in dilute baby shampoo
- application of topical antibiotic ointment massaged into lid margins (sulfacetamide sodium 10% polymyxin B-bacitracin)
- frequent shampooing with selenium sulfide for seborrheic dermatitis
43
Peri/Orbital cellulitis
Orbital: soft tissue infection of orbit posterior to orbital septum; may involve extraocular muscles & optic nerve
Periorbital: inflammation/infection of skin & subcutaneous tissue around eye (no involvement of eye)
44
Peri/Orbital cellulitis etiology
Orbital cellulitis: older kids average age 12
- extension of bacterial sinusitis (into orbital tissues)
- life-threatening & vision-threatening complications
Periorbital cellulitis: more common than orbital; younger kids < 6 yo (average 2 yo)
- commonly assoc with skin diseases of eyelid/face (insect bites, impetigo, styes)
- Staph aureus, strep pneumoniae, H influenzae, group A strep
- Prevnar & Hib vaccines decreases annual cases
45
Peri/Orbital cellulitis S/S
Orbital cellulitis: insidious onset of unilateral eyelid swelling, orbital pain, HA, decreased vision, fever
Periorbital cellulitis: acute onset of unilateral eyelid swelling (upper eyelid), warmth, swelling, skin tenderness, eye/vision normal, maybe systemic s/s (fever 102F & rhinorrhea)
46
Peri/Orbital cellulitis DDx + physical findings
DDx: differentiate btwn orbital, periorbital, preseptal cellulitis
- edema s/t trauma
- allergic periorbital edema
- insect bite on eyelid with local allergic rxn (swellling)
- orbital malignancies (neuroblastoma, retinoblastoma vs orbital cellulitis)
Orbital cellulitis findings:
- lid edema & redness (unlike periorbital on eyebrow)
- unilateral
- chemosis
- proptosis
- decreased ocular mobility
- decreased visual acuity
- ophthalmoplegia (eye muscle paralysis) & proptosis (eyeball protrusion) -- classic findings for orbital
Periorbital cellulitis findings:
- unilateral eyelid edema
- erythema
- tenderness of overlying skin
- visual acuity & ocular mobility from periorbital cellulitis
47
Peri/Orbital cellulitis diagnostics + mgmt/tx
Diagnostics:
- visual acuity exam (orbital cellulitis = decreased vision)
- CT scan of sinuses (determine sinus involvement)
- oral contrast enhanced CT scan of orbit (determine orbital vs periorbital & any orbital complications
- CBC with diff (leukocytosis present with both; more common with orbital)
- blood/eye cultures to R/O concurrent sepsis & ID pathogen
- LP on infants for meningitis
Mgmt/tx:
1. Hospitalization for IV abx
- all pts with suspected orbital cellulitis
- pts < 1 yo
- anyone with sepsis s/s
- immunocompromised
- uncertain F/U
- no improvement post 48 h of outpatient mgmt
2. Outpatient mgmt with IM ceftriaxone --> PO abx & close F/U. 1st like abx = amoxicillin with clavulanic acid (augmentin) & cefixime
- pts > 1 yo
- early periorbital cellulitis
- not sick appearing
- adequate F/U
48
Cataracts
partial or complete opacity/blockage of lens
49
Cataracts etiology & S/S
Can be partial or bilateral
Congenital: TORCH infections, genetic anomalies, premature, drug exposure, or metabolic abnormalities
Acquired: trauma to eye (child abuse)
- systemic disease (DM, trisomy 21, hypoparathyroidism, galactosemia, atopic dermatitis, hypocalcemia, Marfan's syndrome, neurofibromatosis
- toxins, drugs, radiation, long-term systemic corticosteroid or ocular steroid drops
- about 30% hereditary, 30% syndrome/disease related
Complications: amblyopia, partial/complete blindness
S/S: possible decreased visual acuity; no associated pain but photophobia; evaluate underlying disease
50
Cataracts DDx, physical findings, mgmt/tx
DDx: retinoblastoma, glaucoma
Physical findings: decreased visual acuity, strabismus (can be initial sign in child), leukocoria (absent red reflex), black dots around red reflex, or white plaque-like opacities
Mgmt/tx: prompt opthalmologist referral; surgical or visual correction
51
Glaucoma
Increased intraocular pressure from altered aqueous fluid circulation in one or both eye = optic nerve damage with visual acuity loss or blindness if untreated
52
Glaucoma etiology, S/S, DDx
Congenital: first 3 years of life (40% at birth, 85% by 1)
Juvenile: begins btwn 3-30 yo
(2/3 are male)
Primary etiology: isolated anomaly
Secondary etiology: other ocular or systemic abnormalities (trauma, intraocular hemorrhage, intraocular tumor, cataracts, corticosteroid use, Marfan's, neurofibromatosis, congenital rubella syndrome, Pierre Robins syndrome)
S/S: classic triad (photophobia, epiphora (abnormal tear outflow), belpharospasm (eyelid spasm)
-decreased vision in periphery first, tunnel vision
DDx: cataracts
53
Glaucoma physical findings, diagnostics, mgmt/tx
Findings: corneal enlargement (corneal diameter > 12 mm), corneal haziness, edema, conjunctival injection, irregular Hirschburg/corneal light reflex
Hallmark = increased intraocular pressure
Diagnostics: glaucoma pressure test
Mgmt/tx: prompts opthalmologist referral; surgery first line then postop steroids, cycloplegic drops; topical beta blockers, adrenergic agents, carbonic anhydrase inhibitors
54
Strabismus
ocular misalignment "lazy or cross eyed"
Exotropia: outward deviation
Esotropia: inward deviation
Hypotropia: downward deviation
Hypertropia: upward deviation
Diplopia = double vision
```
constant = tropia
intermittent = phoria
```
*esotropia most common
55
Strabismus etiology, S/S, DDx
Affects
