Otolaryngology Flashcards

Question

Pharyngitis

Answer 1

Inflammation of the mucosa- tonsils, pharynx, uvula, soft palate and nasopharynx Etiology - infectious or noninfectious: - viral: epstein barr - bacterial: beta hemolytic strep (common in school age), mycoplasma pneumonia, gonorrhea - allergic, referred pain, oncological HPI: pain, muscle or body aches, fever, dysphagia if viral- rhinorrhea, cough, haorseness, diarrhea, conjunctivitis PE: Erythema of the tonsils and pharynx Reactive, tender cervical lymph nodes Virus specific: EBV- exudate, palatal petechiae, enlarged cervical nodes Adenovirus- fever, bulbar & palpebral conjunctivitis, rhinitis, pharyngitis Enterovirus- ulcers, coryza, vomiting, diarrhea HSV- gum erythema, vesicles to the anterior mouth, adenopathy Parainfluenza & RSV- lower respiratory tract symptoms i.e wheezing, stridor Influenza- cough, fever and systemic symptoms

Answer 2

GABHS suspected: -Rapid antigen diagnostic test (RADT) -Consider throat culture if rapid is negative, unless molecular test is performed -Anti- streptolysin O (ASO) and anti-deoxyribonuclease B (anti-DNase B) Adolescents engaging in oral sex- consider gonorrhea if coming in with sore throat complaint If underimmunized, consider testing for diphtheria- grey membrane covering posterior oropharynx Infectious mononucleosis: -CBC- lymphocytosis and atypical lymphocytes -Heterophile antibody test (Mono spot)- accurate only after having symptoms for a week -Can also send for EBV titers

Answer 3

Viral: Supportive care - gargle w/ warm salt water, throat lozenges, fluids, OTC APAP or ibuprofen Beta lactam abx react w/ CMV and EBV and can cause rash Bacterial: Oral abx - shorten fever duration, decreased infectiousness, decrease risk of rheumatic fever, glomerulonephritis Supportive care Change toothrbush, sterilize retainer return to school when afebrile and on abx for minimum of 12 hrs

Answer 4

**Symptoms**: Acute onset sore throat, dysphagia No nasal symptoms Tender cervical lymphadenopathy Headache, body or muscle aches Fever, malaise Nausea, vomiting, abdominal pain Headache, abdominal pain, sore throat= strep triad **PE:** Petechiae on soft palate & pharynx Swollen and erythematous uvula Enlarged tonsillopharyngeal tissue Yellow exudate, blood tinged Malodorous breath Scarlatiniform rash (finite, papular rash on chest and back) Strawberry tongue **Diagnostics:** Rapid antigen diagnostic test (RADT) Consider throat culture if rapid is negative, unless molecular test is performed Anti- streptolysin O (ASO) and anti-deoxyribonuclease B (anti-DNase B) - Not diagnostic - Useful if suspect rheumatic fever (high fever or chest pain) or glomerulonephritis (blood in urine) -Antibody test determines recent infection (ASO 1 week) (anti-DNase B 2-3 weeks)

Answer 5

Penicillin V Potassium x 10 days <27 kg= 250 mg 2-3x/day >27kg & adolescents= 500 mg 2-3x/day Amoxicillin x 10 days 50 mg/kg/day (max 1 G) ( can do 2 divided dose) Cephalexin x 10 days 20 mg/kg/dose (max 500 mg/dose) BID Clindamycin x 10 days 7 mg/kg/dose (max 300mg/dose) TID Azithromycin x 5 days 12mg/kg/day (max 500 mg)

Answer 6

strep carrier treatment not needed unless: pending tonsillectomy, communal outbreak, history of RF, ping pong spreading in household Clindamycin x 10 days 20-30mg.kg/day in 3 doses Augmentin x 10 days 40 mg/kg/day in 3 doses (max 2000mg/day) Penicillin V x 10 days + Rifampin (day 6-10) 50 mg/kg/day in 4 doses (max 2000mg/day) + 20mg/kg/day (max 600 mg/day) -if treated and throat culture still positive, give 2nd round of abx, consider ENT referral

Answer 7

Nonsuppurative: Rheumatic fever Poststreptococcal reactive arthritis & pediatric autoimmune neuropsychiatric disorder syndrome (PANDAS) Pediatric acute onset neuropsychiatric syndrome (PANS) Sydenham chorea- movement disorder, uncoordinated Acute glomerulonephritis- inflammation of glomeruli, can lead to bloody urine, abdominal pain Suppurative: Cervical adenitis- infection in gland or lymph node Rhinosinusitis, mastoiditis AOM, retropharyngeal or peritonsillar abscess Pneumonia

Answer 8

Tonsillectomy: >/= 7 episodes of throat infection in past year, or > 5 per year for 2 yrs or > 3 per year for 3 yrs Throat infection is defined as fever >100.9, cervical lymphadenopathy with exudate or positive GABHS Adenoidectomy: Severe nasal obstruction > 1 yr or sleep apnea

Answer 9

Inflammation of the larynx, trachea, and bronchi (laryngotracheobronchitis) Etiology Typical viral: parainfluenza virus (most common), influenza, SARS/covid, measles Bacterial: M. Pneumoniae HPI: Barkly, seal like cough Hoarse voice, hoarse cry +/- URI symptoms, fever PE: Brassy sounding cough, inspiratory stridor, cough and respiratory distress General- well appearing and comfortable or fussy and ill-appearing HEENT- rhinorrhea, +/- signs of AOM, +/- pharyngeal erythema Respiratory- normal at time of exam or stridor Cardiac- tachycardia, otherwise normal GI- WNL

Answer 10

Clinical diagnosis Lateral neck x-ray: steeple or pencil point sign Differntials: Tracheitis- consider if high fever and ill appearing (pharyngeal culture) Foreign body Retropharyngeal abscess- especially w/ high fever, throat pain, unilateral swelling of tonsils Angioedema- if having allergic rx Compression from tumor or congenital airway malformation Infectious mononucleosis Psychogenic stridor- anxiety exacerbation

Answer 11

Westly croup score- used to grade severity of symptoms -Chest wall retractions (none mild, moderate, severe) -Stridor (none, w/ agitation, at rest) -Cyanosis (none, w/ agitation, at rest) -LOC (normal, disoriented) -Air entry (normal, decreased, markedly decreased) Treatment should be reserved for moderate to severe cases: Corticosteroids- dexamethasone 0.15 mg-0.6 mg/kg x 1 dose Bronchodilators- if bronchospasm present or h/o asthma Oxygen - pulse ox < 95% Nebulized epinephrine Cold night air shown to improve symtpoms d/t decreased inflamation (not humidified air)

Answer 12

Inflammation and constriction of the trachea secondary to a bacterial infection (Bacterial infection causes inflammatory cells to increase, mucus secretion and sloughing → inflammation) Etiology: Staphyloccous most common Other commonly found: staph or strep pyogenes, M. catarrhalis, non typeable H. influenzae Gram negative infections are rare Seen from 3 weeks- adolescent age Management: Medical emergency- progresses rapidly from compromsied airway to airway obstruction- will require airway stabilization and IV abx Call 911 In primary care setting- utilize crash cart

Answer 13

HPI: Sudden or gradual onset May be clear choking episode history Difficulty breathing, wheezing, cyanosis Afebrile or low grade fever Red flags: - Sudden onset of coughing w/o history of URI symptoms - Child presenting w/ recurrent PNA or unilateral wheezing Treatment: Refer to otolaryngology or pediatric surgeon for removal X-ray to confirm suspicion Endoscopy or bronchoscopy under sedation for removal

Answer 14

Inflammation of the epiglottis Bacterial etiology: GABHS, streptococcus pneumonia, klebisella, staph aureus HPI: Sudden onset of fever, irritability, muffled voice, severe sore throat, dysphagia w/ drooling, respiratory distress Older children may complain of difficulty swallowing PE: Ill appearing Drooling, aphonia, febrile Nasal flaring, retractions Hyperextension of the neck; tripod position Cherry red epiglottis (do not examine pharynx, maintain comfortable position and call 911) Treatment Emergent otolaryngology consult Establish airway Administer broad spectrum IV abx O2 therapy as needed

Answer 15

Lateral neck x-ray- thumb sign

Answer 16

Increased risk of airway compromise and infection, encourage good oral hygiene

Answer 17

Combination of upper airway obstruction which disrupts sleep and leads to abnormal breathing Affects learning (daytime sleepiness/irritability), weight gain, predispose children to obesity (can lead to leptin resistance and icnreased ghrelin levels --> increased hunger) Anatomical risk factors: enlarge adenoids & tonsils, untreated allergic rhinitis obesity craniofacial abnormalities GERD neuromuscular disorders- can cause inadequate respiratory effort HPI: snoring, mouth breathing, disrupted sleep PE: may or may not observe enlarged tonsils, ENT may observe enlarged adenoids Treatment: Adenotonsillectomy (TNA) - prior sleep study- identifies degree of sleep apnea and risk of going under sedation - risks: poor PO intake post op, dehydration, excessive bleeding, infection Non surgical: nasal steroids (flonase, fluticasone), leukotriene receptor antagonist (montelukast), normal saline rinse, weight loss, positive airway pressure therapy at night, rapid mandible expansion (RME)