HEENT from Book ?s Flashcards
trismus
inability to speak – aka “lockjaw”
–spasm of the jaw muscles, causing the mouth to remain tightly closed
Which of the following may cause microcephaly?
a) Hypocalcemia
b) Craniosynostosis
c) Skull fracture
d) Seizure d/o
b) Craniosynostosis
craniosynostosis
- -premature closure of one or more of the cranial sutures
- -> results in skull deformity (**may cause microcephaly)
- -usually suture line should remain open until 2-3yo
- -if severe, can lead to increased ICP
what does pulsating anterior fontanelle indicate?
–can be normal variant, or can be d/t increased ICP
what would you see with premature closing of suture lines?
AKA: craniosynostosis
–often results in a small head (microcephaly)
what may accompany a sunken fontanelle?
dehydration
How would you identify craniosynostosis?
routine skull x-ray
Why might you need to do a routine skull x-ray with a cephalohematoma or caput succedaneum?
–to identify a suspected underlying skull fracture
What test would you want to do with macrocephaly? Why s this impt?
CT scan
–necessary to identify hydrocephalus (can be one of many diff. causes of macrocephaly)
What is one commonly known risk factor for hydrocephalus?
prematurity
Is craniosynostosis assoc. w/ the development of hydrocephalus?
no! if severe, can lead to increased ICP, but not assoc. w/hydrocephalus
A conjunctivitis in a 2 day old is likely d/t…?
chemical irritation from the routine prophylactic eye medication
(seen less now that erythromycin ophthalmic ointment is used as opposed to silver nitrate, but still can occur)
when would you first start seeing conjunctivitis caused by chlamydia?
2 weeks old
how would you confirm the dx of chlamydia conjunctivitis in a newborn?
–culture one of the conjunctival scrapings
must collect and test epithelial cells, which would be included in the scrapings, but not in eye d/c
If you saw unilateral, vesicular lesions on the upper eyelid in a 3-week-old, what would it indicate? Management?
- -possible herpetic infection of the eye
- -> in 3 week old, could spread to CNS, potentially causing severe, permanent CNS damage and/or death
- -> OPHTHALMIC EMERGENCY
What is chemosis? It is often associated with what?
- -swelling on the conjunctiva
- -often assoc. w/allergies
- -not vision or life-threatening
A firm, contender nodule in the mid-upper eyelid present for 3 weeks in a 5yo is most likely what? Management?
- -chalazion
- -topical antibiotic ointment is an appropriate and recommended treatment
- ->although often resolves w/out tx, can become infected, and antibiotic ointment may prevent this from happening
- -can also use warm compresses
- -if become recurrent, then oral antibiotics may be used to prevent another reoccurrence
What is blepharitis? Management?
common acute or chronic bilateral inflammation of the eyelid margins
- -> seborrheic - -> staphylococcal (bacterial infection of eyelash follicles) - -> mixed (combination of both types) - -warm, moist compresses several times/day - -daily mechanical scrubbing & cleansing of lid margins with cotton-tipped applicator or soft cloth dipped in dilute baby shampoo - -continue tx for several weeks if necessary; recurrences are common
What condition would require daily eyelid cleansing with dilute baby shampoo and a cotton-tipped applicator as tx?
blepharitis
A 3yo has an edematous, mildly erythematous right upper eyelid for 1 day with fever of 103F. What is likely dx? Impt eye assessment to perform?
describes an early orbital or periorbital cellulitis
- -> have diff tx’s, so need to distinguish b/t the 2 by assessing for ocular mobility
- -> ocular mobility is absent or significantly decreased with orbital cellulitis
- -> ocular mobility is not affected in periorbital cellulitis
What assessment helps to distinguish b/t orbital cellulitis and periorbital cellulitis?
ocular mobility
- -> ocular mobility is absent or significantly decreased with orbital cellulitis - -> ocular mobility is not affected in periorbital cellulitis
Concurrent otitis media and conjunctivitis is likely d/t which organism?
Haemophilus influenzae
What is classic triad for glaucoma?
- -photophobia
- -epiphora
- -blepharospasm
epiphora
excessive tears
What 3 tests test for strabismus?
Hirschberg test & cover-uncover test
–> assess for a nonparalytic strabismus
EOMs
–> assess for a paralytic strabismus
Would you be concerned seeing a mild asymmetrical corneal light reflex in a 3 month old? What should you do?
- -No! a mild asymmetrical corneal light reflex can be a normal variant until 4 mos of age
- -can safely be reevaluated at next well-visit; does not need referral
Prematurity increases the risk of developing which one of the following?
a) Nystagmus
b) Astigmatism
c) Myopia
d) Glaucoma
c) Myopia
–myopia of prematurity is a known association
What is a keratitis? What can you see this with fluorescein stain?
- -inflammation of the cornea
- -> herpetic keratitis may produce ocular dendritic ulcers that can be seen with a fluorescein stain
What is a hyphema?
bleeding into the anterior chamber (behind the cornea)
–is usually visible as a blood level in the eye
Trauma to the eye increases the risk of developing all but which one of the following?
a) Strabismus
b) Glaucoma
c) Cataracts
d) Hyphema
a) Strabismus
- -cataracts & glaucoma may develop years after eye trauma
- -hyphemas, if they occur, develop soon after eye trauma and may reoccur
Corneal abrasions can be managed with topical application of what?
- -antibiotics to prevent infection (corneal abrasions are susceptible to infection)
- -pain control can be obtained with topical or oral NSAIDs
What is the greatest risk in a pt with a hyphema?
Rebleed! = greatest risk
–> often leads to more eye damage (vision loss) than the initial bleed
Secondary risks:
–> increased risk for development of glaucoma & cataracts following eye trauma (not specific to hyphemas)
With hyphemas, where does the bleeding occur?
in anterior chamber
–not as susceptible to outside organisms like a corneal abrasion would be –> infection not as imminent a problem
Intraocular pressure assesses for which eye condition?
glaucoma
A 16yo was hit in the eye 1 day ago and now has ecchymoses on the upper and lower lids with 5 out of 10 eye pain. All but which of the following would be appropriate to obtain at this time?
a) Visual acuity
b) Intraocular pressure
c) CT scan
d) Fluorescein stain
b) Intraocular pressure
- -> this is used to test for glaucoma, which, if it occurs, would be years later
- -almost all eye injuries should have a visual acuity done
- -an eye injury can produce more than 1 injury
- -> person with “black eye” could also have other injuries such as a corneal abrasion or orbital fracture
- -CT scan would be appropriate to assess for an orbital fracture
- -a fluorescein stain could be used to assess for a concurrent corneal abrasion
An ear canal that is edematous with exudate describes which condition? What is one of most common organisms? Treatment?
otitis externa (OE)
- -Pseudomonas, which is susceptible to fluoroquinolones
- -tx w/ topical antibiotics, bc antibiotic needs to be in contact with the canal
- -> oral antibiotics are not effective!
- -can combine the topical antibiotics with a topical steroid
What is one of the primary causes of OE? Management?
overhydration of the ear canal
- -keep ear canal dry to enhance healing
- -limit swimming during acute phase (earplugs don’t work!)
- -equal parts alcohol and white vinegar used at the end of the swimming day can help evaporate remaining water droplets, and prevent swimmer’s ear
- -> these drops can prevent, but are not effective tx for OE
All but which one of the following pts are at an increased risk of developing otitis media?
a) 2yo with cleft palate repair at 1 year of age
b) 15 month old w/Down syndrome
c) 9 month old w/ lactose intolerance
d) 3yo with IgA immune deficiency
c) 9 month old w/ lactose intolerance
- ->not a risk factor for otitis media
–others are known risk factors
When would it be appropriate to treat AOM with Augmentin?
Augmentin is the preferred 2nd-line tx!
–use with failed tx, or first-line of child has significant signs/sx ( –> high fever)
What is first-line management of AOM?
high-dose amoxicillin, 80-90 mg/kg/day
What is third-line tx for AOM?
ceftriaxone
How does a cholesteatoma present? Risk factor? Management?
- -typically appears as a pearly white opacity in the upper outer quadrant of the TM
- -chronic serous OM is a risk factor
- -immediate referral needed d/t risk of continued growth and potential spread into the brain
How can you distinguish tympanosclerosis from a cholesteatoma?
tympanosclerosis (scar tissue) is also whitish appearing but more cloud-like in appearance and is usually seen in the lower quadrants of the TM
–> whereas cholesteatoma typically appears as a pearly white opacity in the upper outer quadrant of the TM
–pt w/tympanosclerosis usually has a hx of PE tubes or TM perforations
How does a perforation of the ear appear? Treatment?
- -as a hole in the TM
- -pt usually has a hx of PE tubes, TM perforation, or ear injury
- -topical antibiotics may be used, but also refer to ENT with initial perforation
With a cholesteatoma, is hearing affected? Will child have sx?
Child may have no sx!
- -the child may appear to hear well bc the other ear may be compensating
- -all hearing in the affected ear is not destroyed immediately
If epistaxis does have an underlying medical cause, it is most often…? Signs?
- -usually no medical cause, but if so, is often hematologic, such as bleeding d/o’s or leukemia
- -> petechiae can be indicator of various hematologic d/o’s
Signs of allergic rhinitis?
- -pale, boggy, nasal turbinates
- -allergic shiners
- -itchy, watery eyes
- -increased eosinophils on CBC
Acceptable management options for allergic rhinitis include all of the following except:
a) Oral cetirizine
b) Oral montelukast
c) Nasal beclomethasone
d) Nasal neosynephrine
d) Nasal neosynephrine ( = OTC nasal spray such as Afrin)
- -indicated only for short-term use (3 days max) bc extended use leads to rebound chronic nasal congestion
- -nasal steroid sprays such as beclomethasone, oral cetirizine, and montelukast are recommended tx for allergic rhinitis and can be used long-term
What complication of sinusitis are adolescent males more prone to?
a) Intracranial abscess
b) Potts puffy tumor
c) Orbital cellulitis
d) Dental infection
a) Intracranial abscess
- -all are potential complications of sinusitis, but adolescent males have higher incidence of brain abscesses
- -> close f/u is essential for persistent HAs after initiating antibiotics
Patients with sinusitis should be instructed not to participate in which activity?
a) Swimming/diving
b) Boxing/wrestling
c) Weight lifting
d) Cross-country running
a) Swimming/diving
- -swimming and diving are known contributing factors to the development of sinusitis as well as exacerbating factors during tx
- -> may be d/t contaminated water entering the nasal cavities and sinuses at an increased pressure
All of the following may predispose a pt to thrush except:
a) Age
b) Steroid therapy
c) Antibiotics
d) Poor oral hygiene
d) Poor oral hygiene
- -> is risk factor for developing dental caries, not thrush
- -infants are at increased risk of developing thrush d/t age
- -antibiotics alter the balance of microbes in the mouth, allowing yeast to increase above their normal count
- -steroids can alter immune functioning as well as glucose levels
A bifid uvula is a sign of what?
a possible submucous cleft
–is not visible but can be felt by palpating the hard palate
All cleft palates increase the risk of…?
otitis media
What characterizes an aphthous ulcer? Tx?
- -tend to occur as single, ulcerated lesions most often located on the unattached gingiva (lower, inner buccal mucosa)
- -TX = triamcinolone in Orabase
What characterizes herpes simplex stomatitis? Likely age?
diffuse swelling of the gingiva and very superficial (not deeply ulcerated) lesions on the gingiva
- -tends to occur in younger children (toddlers)
- -is often assoc. w/high fevers
What characterizes herpangina? Age?
ulcerative lesions located posteriorly (usually on the anterior pillars)
- -tends to occur in older pts
- -usually accompanied by high fevers and severe sore throat (not single area of mouth soreness)
What characterizes hand, foot, and mouth syndrome? Age?
- -diffuse, small and painful blisters can occur throughout the mouth, including the tongue as well as the hard and soft palettes
- -nonpainful papules can appear on the palms and soles as well as buttocks
- -fever is usually absent or low-grade
- -usually seen in younger children (toddler and preschool age)
Initial exposure to the herpes virus may produce all of the following except:
a) Fever and dehydration
b) Submandibular lymph nodes
c) Vesicular lesions on tonsils
d) Friable and edematous gingiva
c) Vesicular lesions on tonsils
- -> if lesions seen on the anterior pillars and/or tonsils, another dx should be considered
- -with 1st exposure, child is usually quite ill
- -> intraoral lesions occur in the front of the mouth
- -> gingiva are typically painful, friable (bleed easily), and edematous (the swelling can be so severe as to nearly cover the teeth)
- -> the lesions do to extend to the tonsils
- -> fever is common and be fairly high (104F)
- -> illness can cause anorexia d/t painful mouth lesions, leading to risk of dehydration
- -> submandibular nodes drain the mouth and often become enlarged and tender with herpetic infections of the mouth and lips
–with subsequent intermittent outbreaks, see fever blisters on the lips
What is the most common organism with croup?
parainfluenza
CMV can cause…?
pharyngitis and fever
Which one of the following complications of strep pharyngitis cannot be prevented with antibiotics?
a) Peritonsillar abscess
b) Cervical adenines
c) Glomerulonephritis
d) Acute rheumatic fever
c) Glomerulonephritis
–even w/prompt and adequate tx, acute glomerulonephritis (AGN) cannot be prevented
–all other potential complications of strep can be prevented with antibiotics
In addition to penicillin, all of the following antibiotics can be used to treat strep pharyngitis except:
a) Clindamycin
b) Erythromycin
c) Bactrim
d) Ceftriaxone
c) Bactrim
- -Bactrim has no effect on strep and therefore can never be used to treat strep infections
- -the other antibiotics do provide the needed coverage
Retropharyngeal abscess is typically seen in what age group and includes what mainstay tx?
- -2 to 6 yr olds, with average age of 3
- -> bc of changes in lymphatics, do not usually occur after age 6
- -always requires ICU admission and IV antibiotics
- -> life-threatening condition bc of potential airway compromise
Findings consistent with peritonsillar (pharyngeal) abscess include:
- -muffled voice (“potato voice”)
- -trismus (difficulty opening mouth)
- -unilateral enlargement of tonsil (are typically unilateral)–> exudate would not be visible on the tonsils: although exudate would be present, it would be under the surface and not visible
What is cervical adenitis? Causes? Appropriate lab tests to obtain?
cervical adenitis = swollen cervical node or nodes
- -causes include strep pharyngitis, infectious mononucleosis, and to a lesser extent, TB
- -> appropriate to test for those conditions if indicated
- -> throat culture for strep
- -> mono spot
- -> PPD if hx is suggestive (exposure, cough), or later if enlarged lymph node did not resolve w/antibiotics
- -> appropriate to test for those conditions if indicated
- -not assoc. w/sepsis –> blood culture not useful
Incidence of epiglottitis has decreased due to which vaccine?
HIB
–Haemophilus influenzae was one of primary organisms causing epiglottitis
Patients with epiglottitis prefer to sit in which position?
–sitting up and leaning forward –> makes breathing easier
All but which one of the following conditions requires urgent inpatient admission?
a) Cervical adenitis
b) Retropharyngeal abscess
c) Epiglottitis
d) Orbital cellulitis
a) Cervical adenitis
- -> is not life-threatening, typically tx’d on outpatient basis with antibiotics and close f/u to make certain the lymph node(s) have improved
the other conditions can be life threatening:
- -retropharyngeal abscess and epiglottitis can cause airway compromise
- -orbital cellulitis can be life and vision threatening
What can cause conductive hearing loss? How?
- -a problem in the outer ear, such as impacted cerumen, or in the middle ear, such as fluid in the middle ear
- -both conditions (cerumen and fluid) impede the conduction of sound from the environment to the inner ear
What can cause sensorineural hearing loss? How?
- -stems from a problem in the inner ear and extending to the hearing center in the brain, such a a tumor on the acoustic nerve (8th cranial nerve)
- -ototoxic drugs and loud noise damage parts of the ear such as the cochlea and can result in sensorineural hearing loss
