Ophthalmology and ENT

Question 1

A 10-year-old boy has confirmed group A streptococcal pharyngitis. He is given an IM injection of penicillin G benzathine 1.2 million U.

When may he return to school?

Answer 1

The Next Day

Children become non-infectious within a few hours after penicillin therapy; therefore, if clinically improved, the child may return to school the next day.

Question 2

A healthy 16-year-old male competitive swimmer presents to your office with:

• Drainage from his right ear
• Muffled hearing
• Pain with movement of his right ear

What organisms are the likely cause of this teen’s discomfort?

Answer 2

Pseudomonas aeruginosa and Staphylococcus aureus

Otitis externa (a.k.a. swimmer’s ear) is an inflammation of the outer ear canal. It is usually caused by water remaining in the ear canal following swimming, providing a ripe environment for bacterial overgrowth. P. aeruginosa and S. aureus are the most commonly involved organisms. Symptoms include ear pain, drainage, redness, pruritis, and muffled hearing. Pain is worsened by manipulating the pinna. Treatment includes topical antibiotic drops and topical glucocorticoids.

Question 3

A healthy 3-year-old girl with tympanostomy tubes presents with:

• A 2-month history of intermittent, painless drainage from her pressure equalizer tubes
• Muffled hearing on and off
• No mass identified behind the ear drum

What is the most likely cause of this child’s ear drainage?

Answer 3

Chronic Suppurative Otitis Media (CSOM)

CSOM refers to chronic drainage through a perforated tympanic membrane lasting > 6 weeks. Common causes include recurrent acute otitis media, tympanostomy tube placement, and trauma. CSOM tends to follow the age distribution of acute otitis media, though a perforated tympanic membrane following an infection or a traumatic rupture can occur at any age. Clinically, the patient has nonpainful ear drainage with possible conductive hearing loss. The most common pathogens associated with CSOM are Pseudomonas and Proteus.

Question 4

A 4-year-old boy with a 1-day history of “acute pharyngitis” presents with:

• Abrupt fever of 104.2° F (40.1° C)
• Difficulty swallowing
• Refusing to eat
• Severe throat pain
• Drooling
• Hyperextension of the head
• “Bulge” in the posterior pharyngeal wall

What is the most likely diagnosis?

Answer 4

Retropharyngeal Abscess

Retropharyngeal abscess most commonly presents in children 2–4 years of age with an abrupt onset of high fever and difficulty swallowing. They commonly refuse to eat, have severe throat pain, and may present with head hyperextension. Drooling is common. On examination, many have a “bulge” on the posterior pharyngeal wall. A lateral x-ray would show that the mass and the retropharyngeal soft tissue is > 50% of the width of the adjacent vertebral body; however, false-positives are common. In high-suspicion cases, do a CT with contrast. This is a medical emergency requiring emergent antibiotics, and, if the mass is fluctuant, drainage.

Question 5

What is the most common cause of visual loss in children (and adults < 45 years of age)?

Answer 5

Amblyopia

Amblyopia can result from childhood refractive disorders, strabismus, cataracts, corneal opacities, or an unequal refractive error between the eyes (anisometropia). It is not correctable with glasses or contacts, but patching the better-seeing eye is recommended. The earlier treatment is started, the better the outcome.

Question 6

An 8-year-old girl presents with:

• A cough, sore throat, nasal congestion, and low-grade fever for 5 days
• Redness to her left eye for 2 days, which spread to her right eye today
• Watery eye discharge for 3 days

What is the most likely etiology of this girl’s red eyes?

Answer 6

Viral Conjunctivitis (Adenovirus)

Conjunctivitis presents as a painful, red eye. Etiologies include viral (most commonly adenovirus), bacterial (S. pneumoniae, H. influenza, M. catarrhalis), and chemical/allergic forms, with viral being the most common. School-age children are prone to infectious causes. Viral conjunctivitis generally starts in one eye, spreads to the second within 48 hours, and is accompanied by a watery discharge. Bacterial forms tend to be unilateral and produce a thick, purulent discharge. These forms are highly contagious and can affect any age group.

Question 7

A 13-month-old girl presents with:

• Coryza
• Postnasal discharge
• High fever (103.9° F [39.9° C])
• Poor appetite
• Tender cervical lymphadenitis

What is a possible bacterial diagnosis?

Answer 7

Streptococcosis

This is a classic presentation for streptococcal disease in a child < 2 years of age. Streptococcosis is a persistent illness in these younger children. Treat with penicillin. Use erythromycin, clindamycin, or azithromycin for those allergic to penicillin.

Question 8

Which type of involuntary rapid eye movement is normal in infants looking at objects moving across their visual fields?

Answer 8

Nystagmus (Optokinetic)

Nystagmus is a form of involuntary rapid eye movement (usually side-to-side). In infants, optokinetic nystagmus (nystagmus induced by looking at objects moving across the visual field) provides stability of visual images and is a normal part of visual development.

Question 9

A 5-year-old boy presents with a 2-day history of:

• Low-grade fever
• Malaise
• Runny nose
• Congestion
• Thick, copious, green nasal discharge

What is the likely diagnosis?

Answer 9

Viral Upper Respiratory Infection (URI)

This is the classic history for a common, everyday URI. Do not immediately choose sinusitis as the diagnosis on seeing “thick, copious, green nasal discharge.” Remember: A diagnosis of sinusitis requires symptoms for at least 7–10 days! The green snot is just an indication that WBCs are being called in to help fight the infection.

Question 10

What condition involves the misalignment of one or both eyes?

Answer 10

Strabismus

The misalignment can be in 1 of 4 directions:

• in (esotropia),
• out (exotropia),
• up (hypertropia), or
• down (hypotropia).

Pseudostrabismus, on the other hand, has the appearance of misalignment but is caused by a wide nasal bridge and/or epicanthal folds, which obscure the nasal sclera. With strabismus, corneal light reflex and cover/uncover tests are abnormal; they are normal in pseudostrabismus.

Question 11

A 5-year-old boy presents with:

• Fever
• Rhinitis
• Moderate-to-severe sore throat pain
• On examination, the pharynx is bright red with petechiae and erythema of the tonsils; exudates are noted on the posterior pillars.

What is the most likely etiology of his sore throat?

Answer 11

Viral Infection

Do not go right for group A Streptococcus (GAS) because of the petechiae and exudates in the throat—these are very nonspecific. The clue that this is viral, not bacterial, is the rhinitis. Viral pharyngitis is accompanied by URI symptoms and can include conjunctivitis, rhinitis, cough, hoarseness, coryza, ulcerative lesions, or viral rashes.

Question 12

A 15-year-old girl was brought to the office with:

• Acute onset of left eye pain while inserting her contact lens
• Complaint of blurred vision, tearing, and sensitivity to light
• Positive slit lamp exam after application of fluorescein dye

What is the probable cause of this patient’s eye discomfort?

Answer 12

Corneal Abrasion

Symptoms of corneal abrasions include pain, tearing, photophobia, and blurred vision. Infants may present with inconsolable crying. Diagnosis is made with a slit lamp or Wood’s lamp after the application of fluorescein dye. Treat with a topical antibiotic and oral analgesics. Use topical anesthetics acutely, but do not send them home with the patient. Eye patching is no longer considered effective. Recheck the patient in 48 hours to ensure resolution.

Question 13

A 2-year-old boy presents with:

• Unilateral nasal discharge
• The mother notes that the drainage has a bad odor.

What is the most likely diagnosis?

Answer 13

Foreign Body

Various items can end up in a child’s nostril without anyone’s knowledge of how they got there. These items may include crayons, toys, erasers, paper, beads, beans, stones, pencils, and various foods. Foreign bodies lead to unilateral, purulent, foul-smelling discharge.

Question 14

What are the indications for a radiologic evaluation of hoarseness?

Answer 14

Suspicion of a Foreign Body or a Mass

Hoarseness in children is generally benign and is typically caused by nodules, polyps, infection, papillomas, hypothyroidism, foreign bodies, congenital anomalies, and vocal fold granulomas (due to gastroesophageal reflux disease, intubation, and vocal cord overuse). Radiologic evaluation is only necessary if you suspect a foreign body or mass. Refer to an otolaryngologist if hoarseness lasts > 2 weeks.

Question 15

A playful 16-month-old boy presents with:

• A recent history of an insect bite by his right eye
• Swelling, redness, and warmth noted to his right eyelid and surrounding skin
• No pain, chemosis, or proptosis noted

What is the cause of this child’s eye findings?

Answer 15

Preseptal Cellulitis

Rare complications of sinusitis, insect bites, and eye trauma are preseptal and orbital cellulitis. Both include erythema, warmth, swelling, and tenderness to the eyelid and surrounding skin. Preceptal cellulitus is typically mild, but orbital cellulitis is much more severe and includes fever, eye pain, vision loss, diplopia, proptosis, ophthalmoplegia, and chemosis (conjunctival swelling). Besides a CBC and blood culture, get a CT scan of the sinuses/orbits if there is any possibility of orbital cellulitis. This is needed to determine orbital involvement, as patients’ eyes are often swollen shut.

Question 16

What diagnostic study is necessary for a firm diagnosis of orbital cellulitis?

Answer 16

CT Scan of Orbits

Because the patient’s eyes tend to be swollen shut, an orbital CT scan is needed for a firm diagnosis of orbital cellulitus. These children are generally ill appearing and should be admitted for IV antibiotics, CBC, and blood cultures, as well as the CT scan. If organisms are recovered, S. aureus or streptococci are usually identified, though orbital cellulitis is generally caused by multiple organisms.

Question 17

A newborn presents at 2 days of life with:

• Difficulty with breastfeeding
• The infant has difficulty extending the tongue past the alveolar ridge.

What is the diagnosis?

Answer 17

Lingual Ankyloglossia (Tongue-Tie)

This is a classic presentation for this common disorder. The lingual frenulum limits the movement of the anterior tongue tip. Most patients do well and can adjust, but some require a frenulectomy.

Question 18

A 5-year-old boy presents with:

• An initial history of abdominal pain, headache, and vomiting
• This is followed the next day by development of:
  
  • Fever
  • Moderate-to-severe sore throat pain
  • Diffuse erythema of the tonsils and tonsillar pillars
  • Petechiae of the soft palate

What is the most likely diagnosis?

Answer 18

Streptococcus pyogenes Pharyngitis

This is the classic presentation for S. pyogenes sore throat. Initially, he has abdominal pain, headache, and vomiting that is then followed by throat pain, diffuse redness of the tonsils and tonsillar pillars, and petechiae of the soft palate. He has no URI symptoms.

Question 19

Are low-birth-weight newborns farsighted, nearsighted, or have normal vision?

Answer 19

Nearsighted

The normal eye at birth, due to its size and shape, is farsighted (hyperopic). As the visual system matures, the eye elongates and becomes and less farsighted. Although most full-term infants are mildly hyperopic at birth, premature and low-birth-weight infants tend to be less hyperopic or even myopic (nearsighted), often with some degree of astigmatism. Approximately 45% of premature infants are myopic compared to 20% of full-term infants.

Question 20

What organisms are usually responsible for acute unilateral cervical lymphadenopathy (LA)?

Answer 20

Bacteria (Staphylococcus aureus or Streptococcus pyogenes)

Acute LA is common in childhood. It is usually self-limited but is sometimes a sign of a more serious disease process. Viruses generally cause acute bilateral LA, which does not require treatment, while bacteria (typically S. aureus or S. pyogenes) tend to cause unilateral LA, which generally responds well to oral antibiotics. Subacute/chronic LA can also be unilateral (usually caused by non-tuberculous Mycobacteria or Bartonella henselae) or bilateral (usually caused by EBV or CMV). Always consider malignancy in a subacute/chronic workup, which should include CBC with differential, tuberculin skin testing, and serologic tests for B. henselae, CMV, EBV, and HIV. If no etiology is found, an excisional biopsy is necessary.

Question 21

A 10-year-old girl presents with:

• Nasal stuffiness
• Mouth breathing
• A “nasal” voice
• History of recurrent pneumonia
• On physical exam, you note nasal polyps.

What illness should she be evaluated for?

Answer 21

Cystic Fibrosis (CF)

Any child < 12 years of age who presents with nasal polyps should be evaluated for CF. CF is the most common cause of nasal polyps in children. Other things that can cause nasal polyps include chronic sinusitis and allergic rhinitis. Nasal steroids are quite effective for many polyps, especially in children with CF.

Question 22

A 16-year-old female asthmatic presents with:

• A 12-week history of thick, purulent nasal discharge and cough despite multiple courses of antibiotics
• Halitosis for 1 month
• Intermittent facial pain

What is the most likely cause of this teen’s symptoms?

Answer 22

Chronic Sinusitis

Chronic sinusitis is defined as an inflammatory process affecting the paranasal sinuses that lasts at least 12 weeks despite medical therapy. Children with chronic coughs are prone to chronic sinusitis. Anatomic abnormalities and nasal polyps also predispose patients to chronic sinusitis.

Question 23

What structure is the origin of bleeding in most cases of epistaxis?

Answer 23

Kiesselbach Plexus

The Kiesselbach plexus is an area in the anterior portion of the nasal septum where 4 arteries converge. Most epistaxis (nose bleeds) come from this structure, usually caused by nose picking. Other causes include trauma, foreign bodies, neoplasms, cocaine use, and coagulopathies. Treat by pinching the nose for 5–10 minutes. If the bleeding does not stop, use vasoconstrictor nose spray or cauterize with silver nitrate. Conduct coagulation and hematologic studies when epistaxis is frequent or difficult to control.

Question 24

What common cause of midline neck masses is often associated with an ectopic thyroid gland?

Answer 24

Thyroglossal Duct Cyst

Thyroglossal duct cysts are common cystic midline masses that are often seen with ectopic thyroid glands. The cyst typically moves with swallowing. They are usually asymptomatic unless they become infected. If infection occurs, the cyst can rapidly increase in size, potentially compromising the airway. Surgically remove thyroglossal duct cysts, but if infection is involved, address that first.

Question 25

What is the most commonly prescribed 1^st line therapy for acute bacterial sinusitis?

Answer 25

Amoxicillin

Note that almost all cases of acute sinusitis are viral in origin. Bacterial causes include S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. Rarely, fungal organisms (e.g., Aspergillus, Candida, mucormycosis) can be isolated in immunocompromised patients. To treat acute bacterial sinusitis, cover the most common organisms. Most centers still recommend amoxicillin as the 1^st line of treatment; high-dose (80–90 mg/kg/day) therapy is recommended in areas with high resistance rates to S. pneumoniae. Some centers recommend amoxicillin/clavulanic acid, extended-spectrum macrolides, or 2^nd and 3^rd generation cephalosporins as the 1stline of treatment, due to increased β-lactamase production by H. influenzae and M. catarrhalis. A 10–21 day course of antibiotics is recommended.

Question 26

A child with a high BMI presents with:

• Loud, frequent, disruptive snoring
• Restless sleep
• Daytime sleepiness and drowsiness
• Increased irritability
• Anxiety

What is the most likely diagnosis?

Answer 26

Obstructive Sleep Apnea (OSA)

The prevalence of OSA documented in sleep studies is 1–3% in children. Excess weight, anatomic abnormalities, and poor pharyngeal or laryngeal tone increases the risk of OSA. The gold standard for diagnosis is an overnight polysomnogram.

Question 27

What is the most common pathogen associated with acute otitis media?

Answer 27

Virus

Acute otitis media (AOM) is an acute inflammation of the middle ear. While generally caused by both viral and bacterial pathogens, AOM is most commonly caused by viruses. Bacteria such as S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis are important causative agents as well. Note that the serotypes of bacteria responsible for AOM are generally those not included in the pneumococcal and H. influenzae vaccines. The most common age group for AOM is 6–18 months of age. A smaller peak occurs at 5–6 years of age due to school entrance.

Question 28

A 2-year-old girl with a 1-week history of sore throat presents with:

• Fever of 104.0° F (40.0° C)
• Severe neck pain/stiffness and drooling
• Difficulty opening her mouth on examination
• Erythematous bulge visible in the posterior pharyngeal wall on examination
• Mild respiratory distress

What is the 1^st step in evaluating this child’s severe throat pain?

Answer 28

CT Scan with Contrast

These symptoms suggest a retropharyngeal abscess, which is a medical emergency. Without prompt treatment, pus can extend into the fascial planes or rupture into the pharynx, causing aspiration. CT scan with contrast is the preferred imaging study because it differentiates between retropharyngeal abscess and cellulitis. It can also detect if there is extension of the infection. A lateral neck x-ray can be ordered in cases with no distress and suspicion of disease is low. A positive result shows a widened retropharyngeal space with anterior displacement of the airway. Additionally, the retropharyngeal soft tissue is > 50% of the width of the adjacent vertebral body. However, false-positives with this method are common. For patients who are in moderate-to-severe respiratory distress, forego imaging studies and go straight to the OR for evaluation.

Question 29

A 5-year-old girl presents with:

• A 12-day history of URI
• Worsening cough over the last few days, worse at night when she is supine
• Sore throat worsening the last few days
• Nasal discharge is clear.

What is the most likely diagnosis?

Answer 29

Acute Bacterial Sinusitis

For children ≤ 6 years of age who have persistent respiratory symptoms that have not improved for > 10 but < 30 days, the diagnosis of acute bacterial sinusitis can be made on clinical grounds without imaging. The nasal discharge “color” does not matter; the key is the duration of the symptoms. Cough is much more common in younger children than in adults with sinusitis. Commonly, it is worse at night in the supine position.

Question 30

A 9-month-old boy presents to your office with:

• A 5-day history of upper respiratory symptoms and low-grade fever
• Nighttime waking with daytime fussiness for 2 days
• Tugging at both ears for 3 days

What is the likely cause of this child’s fussiness?

Answer 30

Acute Otitis Media (AOM)

Usually AOM is proceeded by a URI, causing blockage of the eustachian tube. Ear pain is the most common symptom, though younger children tend to have nonspecific symptoms (e.g., fever, anorexia, irritability, ear tugging). Risk factors include 6–18 months of age, family history, day care, exposure to tobacco smoke, and lack of breastfeeding.

Question 31

A newborn presents with:

• Intermittent cyanosis, especially when being fed
• Inability to pass a firm catheter through either nostril to a depth of 3 cm

What is the diagnosis?

Answer 31

Choanal Atresia

Choanal atresia is the most common congenital anomaly of the nose. Classically, infants present with cyanosis that resolves with crying and worsens when feeding. Some infants suck in their lips when they inspire. Failure to pass a firm catheter suggests the diagnosis. CT scan confirms the abnormality and location. Due to the high association of other anomalies, cardiology and ophthalmology consultations are warranted.

Question 32

What is the most common infectious cause of congenital sensorineural hearing loss?

Answer 32

Cytomegalovirus (CMV)

Sensorineural hearing loss involves dysfunction of the sensory epithelium, cochlea, or neural pathways leading to the auditory cortex via CN 8. Severe and profound hearing loss is always sensorineural and most often affects the higher frequencies. CMV is the most common infectious cause of congenital deafness, causing sensorineural hearing loss in 60% of symptomatic and 7% of asymptomatic infants. Other causes of sensorineural hearing loss include other congenital infections (e.g., toxoplasmosis, rubella, syphilis), genetic syndromes (e.g., Jervell and Lange-Nielson syndrome), prolonged exposure to loud noise, bacterial meningitis, ototoxic drugs, and trauma.

Question 33

What is the usual age for a cleft palate repair?

Answer 33

9–12 Months of Age

Lip repairs generally occur at 10 weeks of age, while palate repairs occur between 9–12 months of age. Cleft palates can run in families, but most are not associated with a genetic syndrome. Cleft palates involve the soft palate and occasionally the hard palate as well. Often the cleft palate is connected to a cleft lip. Submucosal cleft palates are commonly not obvious until several years of age (e.g., bifid uvula, zona pellucida). Treatment involves a multifaceted approach with craniofacial teams, speech pathologists, and occupational therapists all involved. Address feeding issues first.

Question 34

An 8-year-old with a 2-day history of acute pharyngotonsillitis presents with:

• High, abrupt fever to 104.5° F (40.3° C)
• Severe sore throat pain on one side
• Trismus
• Refusing to speak or swallow
• “Hot potato” voice
• Uvula that is displaced off to one side

What is the diagnosis?

Answer 34

Peritonsillar Abscess (PTA)

PTA occurs after or with an acute pharyngotonsillitis. Fever can be very high. Severe pain, usually unilateral; trismus; and refusing to speak or swallow are common. A “hot potato” voice is classic, as is displacement of the uvula away from the swollen side of the throat—these 2 symptoms help distinguish this entity from retropharyngeal abscess or epiglottitis.

Question 35

A 10-year-old boy presents after being hit in the eye with a baseball. He is sleepy, nauseated, and complains of eye pain. You see a layer of blood obscuring the lower third of the iris, but the pupil looks normal.

What is the most likely diagnosis?

Answer 35

Hyphema

Hyphema is the presence of blood in the anterior chamber of the eye. Usually it occurs after trauma, although it can occasionally be spontaneous. In this scenario, also check for blowout fracture (diplopia, limited upward gaze, etc.) and a ruptured globe. Protect the eye with a rigid shield, control pain and nausea, and consult ophthalmology. Complications include glaucoma and rebleeding.