Lecture 5 - EENT Flashcards
Strabismus
misaligned eyes
“TROPIA” - constant
“PHORIA” - intermittent
ESO - inward (adducted)
EXO - outward (abducted)
HYPO - dowards
HYPER - upward
typically unilateral
Pen light test
can help you when strabismus is a little more subtle or its psuedostrabismus
psuedostrabismus
epicanthial fold might be different between left and right eye making it appear to have strabismus
pen light test will show that this is not the case
What does a left esotropia look like?
the pts left eye is slightly deviated inward and the light from the pen light test is on the outer edge of the eye
Cover-uncover test
child fixes on object in from of them
cover 1 eye and observe the uncovered eye –if it had to move to focus on the eye then it was not initially aligned on the object –suggests tropia
then remove the cover and check the other eye, if it had to move to refocus then it drifted while covered –suggests phoria
Amylopia
loss of visual acuity due to cortical suppression of the vision of an eye
the brain suppresses the vision in the one eye –this could become permanent since the brain is trying to avoid double vision
What is the treatment for strabismus?
before visual fixation is well established, infants can have esodeviations
-expect normal alignment by 4 months of age
refer pts >4 moths of age with strabismus to ophthalmology
Ophthalmia neonatorum
infection of the eye caused by a variety of different things
red eye + discharge
Chemical conjunctivitis
onset within the 1st 24 hours of life
erythema and water discharge
reaction to topical bactericidal
less common now that we dont use silver nitrate and instead use erythromycin
What is the treatment for chemical conjunctivitis?
sys resolve within days without need for treatment
Neisseria gonorrhoeae - ophthalmia neonatorum
onset typically occurs 2 to 5 days of age
swelling of lids and conjunctivae
copious purulent discharge
gram stain
complications
-risk for corneal perforation and scar –can lead to blindness
tx:
-ceftriazone
What is the treatment for neisseria gonorrhoeae?
cerftriaxone
Chlamidia traachomatis ophthalmic presentation?
onset typically occurs 4-19 days of age
mild swelling of lids and conunvtivae
hyperemia
scant purulent discharge
complications –infants with chlamydia may develop pneumonitis
tx: erythromycin
What is the treatment for chlamidia traachomatis ophthalmic?
erythromycin
Herpes simplex virus - ophthalmic
viral conjunctivitis RARE in neonates
typically unilateral
onset within 2-4 weeks
vesicular lid lesions
complications: herpetic corneal disease can threaten vision
tx: systemic acyclovir
Dacryostenosis
nasolacrimal duct obstruction
MC cause of tearing in children
-ip to 20% of normal newborns
chronic or intermittent tearing, debris on eyelashes
conjunctival erythema not common but rubbing may result in lid redness
palpation of lacrimal sac may cause reflux of tears and/or mucoid discharge into eye through the puncta
How do pts with dacryostenosis present?
chronic or intermittent tearing, debris on eyelashes
conjunctival erythema not common but rubbing may result in lid redness
palpation of lacrimal sac may cause reflux of tears and/or mucoid discharge into eye through the puncta
How do you treat dacryostenosis?
non-surgical observation
lacrimal sac massage may be helpful
referral to ophthalmology if not resolved by 6 months for possible lacrimal duct probing or surgery
What are the complications of dacryostenosis?
acute dacrocystitis - infection of nasolacrimal system
can lead to orbital cellulitis, sepsis or meningitis
What are the risk factors for AOM?
tobacco exposure use of pacifier not breastfeeding feeding lying down daycare attendance incomplete immunizations younger age mild hereditary risk
How do you dx AOM?
these pts are typically consoled by mom
moderate to sever bulging on TM (most specific finding)
often TM will have a white or pale yellow appearance
impaired mobility of the TM with pneumatic otoscopy or tympanogram
What is a tympanogram?
look like ear thromometers
you get a reading based on the light to give you an idea of what is behind the membrane
What is the most common pathogen of AOM?
S. pneumoniae
a viral infection (RSV, parainfluenza) is typically the predisposing cause but can also be the presenting cause
How do you treat AOM?
anybody under 6 months, regardless of bilateral or otorrhea gets ABX (amoxicllin (1st line), cephalexin)
you can observe pts 6months - 2 years if unilateral without otorrhea and kids >2 years uni/bilateral without otorrhea
(observe means follow up 48-72 hours)
everyone else gets ABX
What are considered “severe sxs” for AOM?
toxic appearing child
otalgia for >48h
temp >39C in last 48 hours
uncertain access to follow up
When do you use augmentin when treating AOM?
if pt has concomitant purulent conjunctivits
children who have been treated with amoxicillin in last 30 days
fail initial ABX treatment
Allergy testing is only commercially available for ____
IgE mediation reactions to PCN and NO other ABX
How do you determine allergy vs side effect?
Hx
- timing of onset
- character of sxs (GI is probably just SE right?)
- Duration of sxs
- have they received the drug again, what happened?
Can perform skin testing for PCN
When are tympanostomy tubes recommended?
3 or more episodes of AOM within 6 month period
OR
4 episodes within a year with 1 in the last 6 months
OR
Children with AOM before 6 months –warrant a more aggressive approach to management
Why might pts with tympanostomy tubes have otorrhea?
bacterial infection post op
introduction of contaminated water from ear canal into middle ear
tx: fluoroquinolone drops (ofloxacin and ciprofloxacin dexamethasone) —> these are the only topical antimicrobials FDA approved fro treateing otorrhea with non-intact membrane
What antimicrobials are FDA approved to treat otorrhea for pts withOUT intact membranes?
ofloxacin and ciprofloxacin dexamethasone
OME
otitis media with effusion
commonly follows URI NOT an infectious process no pain/fever typically resolves without intervention <3months meds really haven't been shown to help
referral for tympanostomy tubes if no resolution in 3 months
When should you consider ENT referral for foreign body in the ear?
battery
bug
object is pressed up against the TM
object has been in the canal for >24 hours
What do you do to remove a foreign body from the ear canal?
irrigation is best unless:
- there is concern of TM perforation
- the foreign matter will swell (food, insects)
Viral Rhinitis
MC pediatric infectious disease
-children <5 typically have 6-12 episodes per year
sxs: clear or mucoid rhinorrhea nasal congestion sneezing often begin with sore throat may develop cough and fever (fever more common in <6 y/o)
What are the most common causes of URIs in children?
Rhinoviruses (MC) adenovirus parainfluenza RSV (respiratory syncytial virus) influenza
What can rhinovirus cause?
"common cold" pharyngitis OM bronchiolitis PNA act as precipitating factor in asthma
What is the treatment for viral rhinitis?
supportive
increased fluids, rest, cool mist humidifier
nasal saline spray
OTC cold and cough should NOT be used in children <4 and used with caution in children <6
What ages should not use cold and cough OTC medications?
NOT be used in children <4 and used with caution in children <6
What is the typical course of viral rhinitis?
simple URI lasts 7-9 days but can last 15 days
fever typically resolves by day 3
sxs peak on day 3
cough lasts longer than other sxs
When is the development of paranasal sinuses complete?
20 years of age
What sinuses develop when?
maxillary - rapidly expand by 4 years
sphenoid - develop in first 2 years of life, pneumatized by 5 years, permanent size by 12 years
frontal - can be seen on xray 6-8 years, don’t complete development until 14-18 years of age
How do you dx sinusitis?
acute bacterial sinusitis must have:
-sxs present for > 10 days
OR
-sxs worsen with new onset of fever or cough
OR
-be associated with temperatures >39 for more than 3 days
color of nasal discharge does NOT indicate infection
When is the earliest presentation of allergic rhinitis?
10-12 months of age
What age do seasonal allergies typically appear?
3-4 years of age
What is the presentation of allergic rhinitis?
ocular
- itching, swelling, tearing
- always bilateral (something else if unilateral)
- uncommon to have photophobia or pain
nasal
- itching, sneezing, rhinorrhea, congestion
- “shiners” are non-specific finding
What are complications of allergic rhinitis?
OM poor asthma control poor sleep sinusitis missed school missed work
What is the treatment for allergic rhinitis?
Antihistamines
- fast acting, short lasting
- not very effective for congestion, post-nasal drip (not effective for URIs)
- first gen –sedating SE (don’t use if you can avoid it)
- second gen –less sedating, last longer
Intranasal steroid spray:
- no effective when used intermittently or acutely
- best medication for congestion, post-nasal drip
Leukotriene Modifiers
- not very effective for rhinoconjunctivits
- not indicated as monotherapy or 1st line therapy
- block part of late phase allergic response, no antihistmaine properties
Immunotherapy
- indicated for refractory sxs despite optimal medical management/avoidance
- weekly build up x 6-8 months, then monthly injections x 3-5 years
- no benefit for at least 6-12 months
Which generation antihistamines are ideal for allergic rhinitis in children?
2nd generation d/t less sedative SEs
What are the pros and cons to immunotherapy for allergic rhinitis?
Pros:
effective
only disease modifying treatment
may prevent sensitization to new allergens and progression of AR to asthma
Cons:
painful (multiple shots)
risk of anaphylaxis
inconvenient (30 min monitoring pst shot)
slow onset of action
not all pts benefit
must use correct allergens and concentrations
Epistaxis treatment
sit forward
pinch nose for 5-10 min
nasal steroid spray, packing
referral to ENT for cautery
Types of pharyngitis
viral
- infectious mono
- hand, food, mouth
- herpangina
Bacterial
Fungal
-thrush
presentation of mono
tonsillar exudates
cervical lymphadenopathy (posterior chain)
fever
dx:
>10% atypical lymphocytes on blood smear
positive mono spot
EBV serology with elevated IgM is definitive
tx:
symptomatic
amoxicillin can cause RASH
Hand, Foot, Mouth
coxsackievirus
ulcerations in posterior pharynx surrounded by a halo
macular, maculopapular or vesicular rash on hands and feet
dx
clinical
tx
symptomatic
Strep pharyngitis
abrupt onset of sore throat, tender cervical lymphadenopathy, fever, erythematous posterior pharynx
N/V/HA
young children
Centor 4 point scale
fever
absence of cough
anterior cervical adenopathy
tonsilar exudates
strep pharyngitis presentation
How do you dx strep?
rapid antigen test or throat culture
Group A strep is a self-limited disease, so why do we treat?
prevent suppurative complications
reduce communicability
prevent Rheumatic fever
Actue rheumatic fever
occurs 2-4 weeks after GAS pharyngitis, may consist of:
- arthritis
- carditis and valvulitis
- CNS involvment
- erythema marginatum
- subcutaneous nodules
Brodsky grady scale
tonsillar hypertrophy grading 0-4
4 being the tonsils take up most of the orophrayngeal width
Paradise Criteria
for tonsillectomy
“sore throat episode”
-temp >38.8, or cervical lymphadenopathy, or tonsillar exudate or positive culture for group a strep
criterion definition:
-min 7 or more episodes of sore throat in the last year
OR
-5 or more episodes in each of the preceding 2 years
OR
-3 or more episodes in each of the preceding 3 years
Croup
laryngotracheitis
parainfluenza type 1 and 2
Type 1 peaks every other autumn
Type 2 has annual peaks
spread through direct contact, droplets, and fomites
incubation 2-6 days
children 6-36 months MC
rare beyond 6 years
How do pts with croup present?
onset of sxs is gradual
begins with nasal irritation, congestion, rhinorrhea
characterized by inspiratory stridor, hoarseness and distinctive “barking” cough which develop over 12-24 hours
sxs stem from inflammation of the larynx and subglottic airway
presence of cough and absence of drooling help distinguish from epiglottis
What is the treatment for croup?
mild croup may be managed with supportive care (fluids, mist therapy)
glucocorticoid
-single dose of dexamthasone shortens sxs
Nebulized racemic epi commonly used in ED
Why has the incidence of epiglottitis decreased?
H. influenzae vaccine
What is the presentation of epiglottitis?
most common children 2-6 years
sudden onset high fever, dysphagia, DROOLING and muffled voice, unable to clear secretion
inspiratory retractions, stridor, cyanosis
tripod, “sniffing dog”
“thumbprint” sign on lateral neck xray
definitive dx can be made by direct inspection of “cherry red” and swollen epiglotis
What is the treatment for epiglotitis?
endotracial intubation –typically done in OR d/t risk of respiratory arrest
blood and throat cultures should be obtained
IV abx (ceftriaxone) extubation usually 24-48 hours when direct inspection demonstrates reduction in swelling
Tx for AOM?
High dose amoxicillin = first line therapy
80-90 mg/kg/day BID
If watchful waiting —must have follow up in 48-72 hours
