Module 6 - heent

Question 1

A 17-year-old girl has a painful single 1 cm oval ulcer on the buccal mucosa. She states she has had similar sores, usually during times of stress, but not frequently. She has a normal physical appearance, blood pressure 118/65 mmHg, respiration rate is 12/min, heart rate is 70/min, and the temperature is 37.1 C. Conjunctiva is normal, teeth are without caries, and neck is without adenopathy. Which is the best method to ensure an accurate diagnosis?

1. Serum anti-endomysial antibody assay
2. Complete blood count
3. Diagnosis is based on history and clinical exam
4. Deroofing of the lesion and performing Tzanck smear test

Answer 1

3. Diagnosis is based on history and clinical exam

POINTS

• The diagnosis of aphthous ulceration is clinical, and laboratory studies are typically unnecessary. Recurrent ulcerations occur on mucous membrane surfaces, and not on keratinized mucosal surfaces where herpes simplex can occur.
• Hematinic deficiencies, such as iron, vitamin B12, and folic acid, are found in up to 20% of patients with recurrent aphthous ulcers and could be suspected in a patient with signs of anemia.
• Involvement of the eye (uveitis) or genitalia suggest other diagnoses than aphthous ulcers, such as Behçet syndrome or MAGIC syndrome (mouth and genital ulcers with inflamed cartilage).
• Serum anti-endomysial antibody and transglutaminase assay could be considered to exclude celiac disease as a cause of recurrent aphthous ulcers, though this is present in fewer than 5% of aphthous ulcer cases and could be suspected in a patient with symptoms suggestive of celiac disease.

Question 2

The absence of a red reflex on an eye exam is characteristic of which of the following?
1. Aniridia
2. Coloboma
3. Cataract
4. Keratoconus

Answer 2

3. Cataract

POINTS

The red reflex is due to the reflection of light from the retina.
Congenital cataracts usually obscure the red reflex. Therefore, the absence of a red reflex on an eye exam is characteristic of congenital cataracts.
Aniridia is the absence of the iris.
Coloboma can be a defect in the lid, iris, lens, retina, or choroid.

Question 3

A 9-month-old child is brought to the clinic for a routine checkup by her mother. Since birth, the patient has had three episodes of ear infection, which were all managed symptomatically as an outpatient. The girl was previously a happy child and liked meeting and playing with new people but has recently started crying whenever her mother is not around her. Her mother mentions that “she has also started giving her babysitter a tough time.” On further inquiry, the mother says that the girl can pull to stand up herself. She can also grasp a fork with three fingers and has recently started throwing balls as well. She has not yet started responding to her name, babble, or say ‘mama.’ She knows how to wave goodbye and smiles socially as long as her mother is around. What is the next best step in the management of this patient?

1. Hearing evaluation
2. Psychological evaluation
3. Reassurance and follow up
4. Gross motor evaluation

Answer 3

1. Hearing evaluation

POINTS

• This child’s language development is lagging behind her age.
• Further evaluation of hearing is necessary to prevent permanent language deficits.
• The history of 3 episodes of ear infection provides a clue to the etiology of this developmental disorder.
• The patient does not need to be evaluated psychologically as stranger anxiety is normal at 9 months.

Question 4

A 24 month old is seen in the clinic for the third time in 6 months with AOM. In addition, an effusion is discovered because the tympanic membrane has restricted mobility and appears opaque. Choose the correct statement below.

1. This child is at risk for tympanic membrane perforation
2. This child is not a candidate for tympanostomy because he is too young
3. A short trial of corticosteroids is appropriate
4. Myringotomy without tube placement is most appropriate

Answer 4

1. This child is at risk for tympanic membrane perforation

POINTS

• Acute otitis media that is recurrent or otitis media with effusion can predispose a child to rupture of the tympanic membrane.
• Tympanostomy tube placement would be an appropriate intervention since the AOM is recurrent. This may improve quality of life.
• A trial of corticosteroids in this age group is controversial and may provide short to term relief, but one must outweigh the risks before placing the child on steroids.
• Myringotomy without tubes may be helpful but often times the effusion will reaccumulate if tubes are not placed.

Question 5

A 17-year-old boy is brought to the emergency department due to blurred vision and pain in his left eye for the past 10 hours. His mother administered a dose of over-the-counter oral acetaminophen and tried warm compresses, but they did not bring relief. She also states that her son recently had a wisdom tooth removed from his left upper jaw. He takes a mild emollient for his eczema and is up to date on vaccinations. Vitals are temperature 103 F (39.4 C), blood pressure 105/65 mm Hg, heart rate 125 bpm, and respirations 21 breaths/min. Physical examination reveals a lethargic and restless male with proptosis, conjunctival injection, and periorbital edema of the left eye. Visual acuity is 20/60 in the left eye and 60/60 in the right. He complains of pain with extraocular movements. Ophthalmoscopy shows a normal retina. The right eye is unremarkable. The left cheek is tender to palpation, and the oropharynx shows swelling, erythema, and tenderness where the tooth was removed. Which of the following is the most appropriate initial treatment for this patient?

1. Intravenous antibiotics
2. Oral antibiotics
3. Intrravitreous antibiotics
4. Reassurance and follow-up

Answer 5

1. Intravenous antibiotics

POINTS

• Orbital cellulitis involves infection of tissues in the bony orbit behind the septum.
• CT scan is needed to delineate the spread of infection properly.
• It can also assess for abscess collection.
• Orbital cellulitis is a medical emergency and needs IV antibiotics. Surgery may be required to drain any abscess.

Question 6

n 11-year-old boy reported with a painfully bulged left eye and impaired vision for the past 2 days. Extraoral examination revealed left periorbital swelling with proptosis, severe chemosis, and non-reactive pupils. Examination of the fundus revealed a pale disc for the left eye and normal right eye. Orbital computed tomography scans reported maxillary sinusitis and cheek cellulitis on the left side that extended into the left orbit. Intraoral examination revealed carious primary upper first and second molars. Which among the following is the most probable etiology in the present case?

1. Infection in the eye
2. Infection in the maxillary sinus
3. Infection in the left cheek
4. Infection in the primary left maxillary molars

Answer 6

4. Infection in the primary left maxillary molars

POINTS

• Dental caries in the primary maxillary left molars lead to an acute periapical abscess, which secondarily involved the maxillary sinus, infraorbital region, and extended into the orbital cavity causing protrusion of the eyeball with impaired vision.
• The odontogenic infections spread through the path of least resistance, which is determined by the muscle attachments in relation to the teeth and fascial planes.
• If dental caries is left untreated for a longer period, it may lead to several complications based on the nature of the carious lesion.
• If the host immune response is weak, dental caries may result in inflammation of pulp leading to apical periodontitis, periapical abscess or periapical granuloma, periapical cyst, cellulitis, abscess, periostitis and may progress to osteomyelitis.

Question 7

A 5-year-old boy presents with decreased visual acuity in his left eye. He can read the 20/25 line on the tumbling E chart in the right eye; however, he can only see the 20/200 line with the left eye. The patient is orthophoric showing normal extraocular movements. The anterior and posterior segment exams are normal in both eyes. After cycloplegia, the provider gets a refractive error of +2.50 + 0.50 x 135 in the right eye and +1.75 + 6.75 x 50 in the left eye. After trying the new prescription, the patient still only sees 20/100 in the left eye. What is the most likely cause for continued decreased vision in the left eye despite refractive correction?

1. Strabismic amblyopia
2. Anisometropic amblyopia
3. Visual deprivation amblyopia
4. Astigmatism

Answer 7

2. Anisometropic amblyopia

POINTS

• This patient has a high amount of astigmatism in the left eye. Since the prescriptions in the two eyes are different, the right eye becomes dominant, and the left eye becomes lazy. Despite the refractive correction, the left eye still does not have the same vision as the right eye. This indicates the patient is likely amblyopic due to the different prescriptions. This is referred to as anisometropic amblyopia. When the cause of anisometropia is astigmatism, it is called meridional amblyopia.
• Lazy eye is the lay term for amblyopia. Amblyopia occurs when the brain does not develop vision in one or both eyes because of poor visual stimulation. This may be because of strabismus, anisometropia, or media opacity such as cataract or ptosis.
• If this patient had exotropia, hypotropia, hypertropia, or esotropia, then strabismus could be the cause of the patient’s amblyopia. This patient showed normal eye movements and no signs of strabism.
• Eye patching is a form of occlusion used to treat amblyopia with the intention of improving or recovering vision in a child who has worse vision in one eye compared to the other. The better eye is patched for a few hours, thus stimulating the lazy eye.

Question 8

A 12-year-old female competitive swimmer with no past medical history is brought to the clinic with a 3-day history of left ear pain, pruritus, discharge, and low-grade fever. Physical exam reveals an almost completely occluded ear canal due to edema. What is the best initial therapy for this patient?

1. Observation
2. Oral antibiotics
3. Parenteral antibiotics
4. Ear wick placement with ototopical medication

Answer 8

4. Ear wick placement with ototopical medication

POINTS

• The patient’s clinical presentation is most consistent with a diagnosis of simple otitis externa.
• Most patients diagnosed with otitis externa will receive outpatient management. The mainstay of uncomplicated otitis externa treatment usually involves topical antibiotic drops and pain control.
• Some studies have shown that topical antibiotic drops containing steroids may decrease inflammation and secretions, and hasten pain relief. Regardless of the topical antibiotic used, approximately 65% to 90% of cases will have a clinical resolution within 7 to 10 days.
• Oral or intravenous antibiotics are likely unnecessary in cases of uncomplicated otitis externa and their inappropriate use will increase the resistance among common otitis externa pathogens.

Question 9

A 5-year-old patient previously diagnosed with right otitis media is 2 days into treatment with high dose amoxicillin. He now presents to your office with complaints of worsening right-sided ear pain and continued fevers. On exam, you note proptosis of the right ear and post-auricular erythema. The most appropriate next step is which one of the following?

1. Reassurance and recommendations to finish current antibiotic course
2. Admission to hospital for further evaluation and management
3. Change current oral antibiotics to broader spectrum antibiotics
4. Outpatient referral to ENT at soonest available date

Answer 9

2. Admission to hospital for further evaluation and management

POINTS

• This patient has developed acute mastoiditis despite outpatient therapy, and admission for further testing and parenteral therapy is warranted.
• Imaging is often obtained as well to assess for further complications and to aid in confirming diagnoses, though mastoiditis is truly a clinical diagnosis.
• The first step is to obtain material for culture and sensitivity. this can be done with tympanocentesis or myringotomy.
• An audiometric evaluation must be done to check for any hearing deficits. CT scan of the temporal bone is the standard of care to assess for suppurative mastoiditis, which must be surgically treated. Plain x-rays can be obtained if CT scan is not available but the images will not provide details about staging.

Question 10

An otherwise healthy 18-month-old boy presents with right-sided, thick nasal discharge that has been present for two weeks. The parents deny fever, cough, or ear tugging. On physical examination, he appears to be breathing predominantly through his mouth. Given the likely diagnosis, what is the first-line treatment for this infant’s condition?

1. Oral amoxicillin
2. Oral amoxicillin-clavulanic acid
3. Mother’s kiss maneuver
4. Nasal oxymetazoline and fluticasone sprays

Answer 10

3. Mother’s kiss maneuver

POINTS

• The mother’s kiss (parent’s kiss) maneuver can be used to treat nasal foreign bodies, particularly in small children who often insert small objects into various orifices, such as the nose. The parent or caretaker places their mouth over their child’s mouth while holding closed the unaffected nostril, then blows into the child’s mouth. The breath may force the object out.
• Unilateral nasal discharge should always raise the question of a foreign body in a small child. While most nasal foreign bodies are benign, it is important to rule out the presence of a button battery, which can cause severe injury if left in place for a prolonged period.
• The nares may require endoscopic examination to confirm the diagnosis and extract the foreign body if conservative measures are insufficient.
• Sinusitis is rare in children of this age because of the relative lack of development of the paranasal sinuses; adenoiditis is more common.

Question 11

An 8-month-old child is brought to the ophthalmology department for an initial visit. On examination, the child has a whitish pupillary reflex and iris heterochromia. The patient’s father had an eye removed as a child. What is the most likely diagnosis?

1. Rhabdomyosarcoma
2. Persistent hyperplastic primary vitreous
3. Retinoblastoma
4. Coloboma of the choroid

Answer 11

3. Retinoblastoma

POINTS

• The most prevalent intraocular neoplasia in children is retinoblastoma. The usual age of presentation is within the first year of life.
• Retinoblastoma is the most common primary intraocular malignancy of childhood and accounts for 3% of cases of all childhood tumors. It is also the second most common malignant tumor of the eye after uveal melanoma.
• Familial retinoblastoma can be bilateral, with the second tumor occurring at a later age.
• The genetics of this condition can be autosomal dominant, a new mutation, or from an unaffected parent with the gene.

Question 12

A 9-year-old boy presents to the emergency department with his mother, complaining of discharge from his right eye. His mother states that this morning, he woke with his right eye glued together, and there has been white drainage throughout the day. He denies any associated itching or pain, fever, or decreased appetite. He has never had a similar episode previously. On examination, conjunctival erythema and thick, purulent discharge are noted. Fluorescein stain and slit lamp exam do not reveal any foreign body or corneal involvement. Which of the following is the most likely cause of this patient’s presentation?

1. Haemophilus influenzae
2. Vernal keratoconjunctivitis
3. Traumatic injury
4. Adenovirus

Answer 12

1. Haemophilus influenzae

POINTS

• Bacterial conjunctivitis is characterized by a thick, purulent discharge. The absence of previous episodes of conjunctivitis symptoms is indicative of a bacterial origin. Haemophilus influenzae is the most common organism responsible for pediatric bacterial conjunctivitis. Conjunctivitis of viral and allergic etiology is characterized by red-eye with itching and watery discharge.
• It can be difficult to ascertain the etiology of red eyes clinically, and considerable diagnostic ambiguity lends itself to over-treating with antibiotics for a bacterial etiology.
• Uncomplicated bacterial conjunctivitis can be treated with topical antibiotics or managed expectantly without antimicrobials.
• Regardless of the etiology of conjunctivitis, good hand hygiene is essential when caring for patients who are seen with conjunctivitis. This should be stressed to all providers and caregivers.

Question 13

A 6-year old boy presents to the clinician with his mother. The mother says that the child has been complaining about pain in the left ear and is unable to sleep well for eight days. He has not been febrile. Upon further questioning, the mother reveals that his younger brother and the patient recovered recently from the “flu” they had last week. He is in daycare. On examination, the child is uncooperative but oral examination reveals no dental pathology. There is no overt otorrhea, and both tympanic membranes appear erythematous. He has no history of drug allergies. Which of the following is the best choice of therapy to alleviate his condition?

1. Symptomatic management with analgesics only
2. Cephalexin
3. Amoxicillin
4. Doxycycline

Answer 13

3. Amoxicillin

POINTS

• The patient has acute otitis media. It is a painful type of ear infection that occurs when the middle ear becomes inflamed and infected. The patient’s duration of symptoms (>1 week) makes bacterial infection/superinfection more likely than isolated viral etiologies.
• Amoxicillin is considered a first-line agent for otitis media in pediatric patients. It is a beta-lactam penicillin antibiotic used in the pediatric treatment of conditions including middle ear infections, pharyngitis, sinusitis, and community-acquired pneumonia.
• If the child has had amoxicillin therapy in the past month or resistance is suspected, a beta-lactamase inhibitor plus penicillin derivative may be used.
• The other choices in the list above would either be ineffective against otitis media or be contraindicated.

Question 14

A 2-day-old male patient presents to the hospital with an eye discharge. It was noticed that both eyes are affected, and there is a profuse purulent discharge. There is no scleral icterus or jaundice. His mother had a sexually transmitted infection during her pregnancy. The eye exam shows bilateral eyelids have erythema and edema, conjunctival injection, and purulent discharge. What is the drug of choice for this patient’s condition?

1. Azithromycin
2. Ceftriaxone
3. Erythromycin
4. Topical vidarabine

Answer 14

2. Ceftriaxone

POINTS

• Ophthalmia neonatorum (neonatal conjunctivitis) presents during the first four weeks of life with eye discharge and hyperemia and is usually an acquired infection during delivery.
• At 24 to 48 hrs of life, the bacterial causes are most likely. Neisseria gonorrhoeae is the most common cause with Staphylococcus aureus being a secondary etiology.
• Bilateral conjunctivitis is seen with infection caused by N. gonorrhoeae or by the use of ocular prophylaxis.
• Gonococcal conjunctivitis is a medical emergency. Third-generation cephalosporins are first-line antibiotics like ceftriaxone. Ceftriaxone should be avoided in patients with hyperbilirubinemia. It can happen even with appropriate prophylaxis infants delivered to mothers with positive maternal gonococcal infection.

Question 15

A 17-year-old female presents with a 3-day history of itching, burning, crusting, and matting of her eyelids bilaterally which is worse in the morning when she awakens. The patient has no prior history of a similar event. On physical exam, there is crusting of the eyelashes at the bases, erythema of the eyelids, clear conjunctiva, and cornea. There are small ulcers on the eyelid margins. The meibomian glands appear normal. Which of the following is not first-line treatment?

1. Warm compresses and lid margin scrubs with a cotton swab dipped in diluted baby shampoo
2. Avoidance of eye makeup
3. Erythromycin ophthalmic ointment
4. Oral doxycycline

Answer 15

4. Oral doxycycline

POINTS

• The patient’s symptoms are acute. The likely diagnosis is acute blepharitis.
• Ulcerations of eyelid margins are indicative of an infectious cause of the symptoms. The likely causes are Staphylococcus and viral causes. Acute blepharitis should always be treated with topical antibiotics.
• All types of blepharitis should be treated with eyelid hygiene and avoidance of potential triggers.
• Oral doxycycline is reserved for the treatment of posterior blepharitis that is not responsive to eyelid hygiene.

Question 16

A 7-year-old female presents six weeks after an adenoidectomy and bilateral tympanostomy tube placement for otitis media with effusion. Her parents have noted an improvement in her hearing but are concerned about nasal discharge while eating. On examination, the tympanostomy tubes are in place, and patent and her adenoid pads have healed fully on nasopharyngeal endoscopy. When speaking she occasionally demonstrates air escape through her nose, particularly with a sustained /s/ sound. What is the most appropriate next step in management?

1. A trial of topical nasal steroids
2. A trial of a proton pump inhibitor
3. Referral to speech therapy
4. Modified barium swallow

Answer 16

3. Referral to speech therapy

POINTS

• Velopharyngeal insufficiency (VPI) is a rare but important complication of adenoidectomy.
• Risk factors include cleft palate and submucosal cleft. For this reason, palpation of the soft palate to assess for an occult submucosal cleft is essential before surgery.
• In cases where a submucosal cleft is identified, and surgery remains indicated, a limited adenoidectomy clearing the superior choanal and peritubular portion of tissue has been proposed. First-line treatment for postoperative VPI is speech therapy, which enjoys high success rates if instituted promptly.
• Long-term postoperative velopharyngeal insufficiency is very rare (less than 1/1000). Most cases are mild and can be treated with speech therapy. When significant speech and swallowing issues are persistent and refractory to speech and language therapy, further reconstructive surgery in the form of pharyngoplasty or veloplasty may be considered.

Question 17

A patient presents with outward turning of the right eyelid. The cause of the condition is determined to be scarring and shortening of the anterior lamella of the eyelid skin. Artificial tears and lubricants fail to improve the condition. Which of the following is the best next step?

1. Blepharoplasty
2. Lateral tarsal strip procedure
3. Full-thickness skin graft and a lateral tarsal strip procedure
4. Medial spindle procedure

Answer 17

3. Full-thickness skin graft and a lateral tarsal strip procedure

POINTS

• Ectropion is an outward turning of the eyelid margin, typically occurring on the lower eyelid. When the globe is not protected properly, the eye can become very dry. This dryness may lead to symptoms of redness, tearing, and foreign body sensation secondary to exposure of the ocular surface and inadequate tear film.
• In extreme cases, the cornea can develop punctate epithelial erosions, ulceration, and permanent vision loss. Management almost always begins with lubrication with artificial tears, gels, and ointments. Surgical repair is commonly needed to improve the function of the eyelid and to protect the globe permanently.
• Cicatricial ectropion commonly requires replacing the anterior lamella and horizontally tightening the lower eyelid.
• Horizontal tightening of the lower lid without correcting the cicatricial component may result in inadequate correction of the ectropion.

Question 18

A 6-month-old infant is brought to the emergency department for bilateral subconjunctival hemorrhages. She was born at 32 weeks gestation but has been developing normally until now. The mother denies any history of constipation or bleeding diathesis. The mother states she noticed the blood in her child’s eyes after a longer than usual nap. She also reports that the baby has been less alert lately. On exam, the healthcare provider notices dried blood in bilateral nares, facial petechiae, and ecchymosis behind the ear. What is the next best step in management?

1. Reassurance
2. Administer topical steroids
3. Check platelet count
4. Contact child protective services

Answer 18

4. Contact child protective services

POINTS

• Subconjunctival hemorrhages are generally benign; however, the clinical context in this situation refers to non-accidental trauma (NAT), and child protective services should be contacted.
• Subconjunctival hemorrhage, especially bilateral, may be the only sign for non-accidental trauma. The mechanism in the stem suggests traumatic asphyxia syndrome, such as strangling.
• Subconjunctival hemorrhages in neonates may be a normal occurrence with thoracic compression during delivery. However, in this scenario, there are other aspects to the physical exam, such as bruising behind the ear and facial petechiae to suggest NAT. Child protective services should be promptly contacted.
• The clinician should always be cautious when examining infants and toddlers when there are signs of trauma. Subconjunctival hemorrhages can occur, especially in infants who have constipation or bleeding disorders. In addition to contacting child protective services, skeletal surveys and other blood work should be done. A CT scan and a fundoscopy are also indicated.

Question 19

A 4-year-old boy presents with a three-month history of left otorrhea. Two courses of amoxicillin have been ineffective. He has a history of several ear infections as an infant, and he is meeting his speech and developmental milestones. On examination, his left ear canal is edematous, and the tympanic membrane is partially visible. A retraction pocket with debris is visible in the pars flaccida. What is the most appropriate next step in management?

1. Admit to the hospital for parenteral antibiotics
2. Debridement and ototopical ciprofloxacin with follow up in 1 week
3. Prompt surgical excision
4. Oral ciprofloxacin and follow up in 1 week

Answer 19

2. Debridement and ototopical ciprofloxacin with follow up in 1 week

POINTS

• Patients with cholesteatomas generally present with complaints of hearing loss and persistent otorrhea, as is seen often with chronic suppurative otitis media. On examination, a retraction pocket filled with squamous epithelial debris may be seen.
• The patient has no signs or symptoms suggestive of an intratemporal or intracranial complication of cholesteatoma. After microscopic debridement of the debris in the ear canal an ototopical antibiotic such as ciprofloxacin should be used to cover the most common infecting organism which is Pseudomonas aeruginosa. An ototopical antibiotic/steroid combination may be used to help control granulation tissue in addition to the infection.
• Parenteral antibiotics are indicated if the patient exhibits any intratemporal or intracranial complications of cholesteatoma.
  A cholesteatoma is an epithelial cyst that contains desquamated keratin.
• Cholesteatomas destroy bone. After the infection is controlled, definitive treatment is surgical excision. Recurrence is common.

Question 20

A 17-year-old female presents with decreased vision in her right eye for ten days. She denies a history of right-eye trauma or ophthalmic surgery and admits to a history of recurrent episodes of left-eye redness. On slit-lamp examination, the right eye has central circumscribed corneal edema with underlying keratic precipitates and Descemet membrane folds. There are footprint scars on examination of the left eye. What is the most likely diagnosis?

1. Herpes simplex virus (HSV) endotheliitis
2. Spontaneous Descemet membrane detachment
3. Microsporidial stromal keratitis
4. Fungal keratitis

Answer 20

1. Herpes simplex virus (HSV) endotheliitis

POINTS

• HSV endotheliitis often presents as well-circumscribed corneal edema with corresponding underlying keratic precipitates and Descemet folds.
• Lack of pain can result in delayed presentation.
• Its always necessary to rule out trauma, intraocular surgery, or toxic endotheliitis before establishing the diagnosis of HSV endotheliitis.
• The mainstay of treatment is a topical steroid plus an oral antiviral.

Question 21

A 5-year-old female presents for a follow-up after the placement of tympanostomy tubes six weeks ago. She has been doing well, but her parents state she has had intermittent clear drainage for the past week from her right ear that is occasionally blood-tinged. The patient is in no acute distress and does not have any otalgia. On exam, her left tube is in place, patent, and without otorrhea. On the right, the ear canal is dry, and a patent tube with normal middle ear mucosa without an effusion is located within the inferior anterior quadrant. However, just inferior to her tube is pink tissue with overlying vascularity. What is the next best treatment for this patient?

1. Treatment with ototopical ofloxacin with dexamethasone
2. Removal of the tissue under binocular microscopy
3. Treatment with ototopical gentamycin
4. Removal of the tube

Answer 21

1. Treatment with ototopical ofloxacin with dexamethasone

POINTS

• Postoperative granulation tissue formation occurs in about 4% of patients.
• Treatment with ototopical antibiotics, typical ciprofloxacin, or ofloxacin, along with a topical steroid, is the best treatment.
• Removal of the granulation tissue is not recommended, as this will lead to bleeding and possible occlusion of the tube with a clot. The granulation tissue will also likely recur if not treated with antibiotic-steroid drops.
• Granulation tissue should not be observed as it is likely to continue increasing in size and could lead to tube occlusion or infection.

Question 22

• Otitis media with effusion

Answer 22

does not require antibiotics, ninety percent of middle ear
effusions take 6 weeks to clear.
* Decongestants are not likely helpful
* PET tubes are not indicated

Question 23

Mastoiditis

Answer 23

• direct complication of otitis media.
• Acute mastoiditis is a disease of children but can occur at any age.
• Typical organisms include STREP, pneumoniae, group A beta-hemolytic streptococci,
  Staphylococcus aureus, Streptococcus pyogenes, Moraxella catarrhalis, Haemophilus influenzae, and Pseudomonas aeruginosa.

Question 24

AOM treatment and signs

Answer 24

The initial drug of choice for acute otitis media is amoxicillin.

If PCN allergy, consider
using oral cefdinir.

• The cardinal signs of acute otitis media are otalgia, opacification of the tympanic membrane, retraction of the tympanic membrane, and
  immobility of the tympanic membrane.
• For non-toxic appearing children, it is typically safe to watch-and-wait for 24 to 72 hours before deciding to prescribe an antibiotic

Question 25

A cause of acquired sensorineural hearing loss is

Answer 25

meningitis

Question 26

Mumps:

Answer 26

swelling and tenderness between the mandible and the mastoid with
elevation the earlobe

Question 27

Cholesteatoma

Answer 27

Cholesteatoma
* A cholesteatoma results from the benign proliferation of squamous
epithelium.
* It usually appears as a white nodular lesion near the annulus of the
tympanic membrane.
* It may be locally destructive.
* Untreated eustachian tube dysfunction with chronic otitis media is often
the underlying etiology of cholesteatomas

TREATMENT?

Question 28

Retropharyngeal abscess

Answer 28

• Retropharyngeal abscess
• Mortality from a retropharyngeal abscess occurs when there issp read to the adjacent organs.
• CT will show a large mass in the retropharynx and narrowing of the airways.
• As the retropharyngeal abscess grows in size, it results in gradual upper airway obstruction and eventually to asphyxiation if left untreated.
• Sepsis and airway compromise are other complications.
• Requires immediate trans-cervical drainage in the operating room !!

Question 29

Strep throat

Answer 29

Strep throat
* Treat with 10 days of Amoxicillin (Max 1g/day)
* Rheumatic fever is a long term nonsuppurative sequelae

Question 30

Retinoblastoma

Answer 30

may present with a white reflex in the affected eye and a red reflex in the other

Question 31

STI conjunctivitis

Answer 31

• Treatment (regular): polymyxin B/trimethoprim and several fluroquinolones
• Secondary to chlamydia or gonorrhea (systemic treatment):

o 5-14 days: Chlamydia: PO or IV erythromycin or azithromycin + 14 days topical erythromycin
 1 eye at first

o First 24-48hrs of life: Gonorrhea: IV or IM ceftriaxone x 1 dose and eye irrigation
 Bilateral

• It is recommended that babies born to mothers with untreated chlamydia trachomatis infection, be closely followed and observed for the appearance of clinical symptoms suggestive of chlamydial
  conjunctivitis.
• Routine screening for all pregnant women is the most effective way to prevent ophthalmia neonatorum. Babies born to mothers with
  untreated chlamydia trachomatis infection have up to 50% risk of transmitting the infection to the newborns.

Question 32

Dental Eruption

Answer 32

• Teeth begin to erupt at approximately age 6 months. Consider “lip habit” if teeth erupt from
  their non-functional position in the alveolar processes to its final functional position in the
  oral cavity.
• Apthous stomatitis:

Question 33

Tooth Avulsion

Answer 33

Tooth avulsion:
* If reimplanted within 30 minutes, 90% of avulsed teeth are viable.
* Ten percent of children will sustain serious dental trauma.
* Rinse debris off of the tooth with water and, without wiping, replace it in the socket,
and bring the child to the dentist urgently

Question 34

• Apthous stomatitis:

Answer 34

canker sores –
Topical steroids are first line agents for minor aphthous stomatitis !!!!!!!!!!!!!!

Other agents to consider are honey, amlexanox, coating or occlusive agents.

Question 35

Periorbital cellulitis, treatment

Answer 35

(Bactrim and augmentin)