Otolaryngology Flashcards
What in what order do you acquire/pneumatize your various sinuses?
Birth - ethmoid and maxillary sinuses
4 yrs - maxillary sinuses
5-6 yrs - sphenoid sinuses
7-8 yrs - frontal sinuses
Ethmoid + Maxillary (Earliest Made - at birth)
Sphenoid (SK - 5 years)
Frontal (Final)
What are the typical pathogens found in cases of sinusitis?
- morexella catarrhalis
- H. influenza (non-typable)
- strep pneumo
What are the diagnostic criteria for sinusitis?
- persistenceof nasal congestion
- rhinorrhea (of any quality)
- daytime cough ≥10 days without improvement
- severe symptomsof temperature ≥39°C (102°F) with purulent nasal discharge for 3 days or longer
- recurrence of symptoms after an initial improvement or new symptoms of fever, nasal discharge and daytime cough
What antibiotic should be used in the treatment of sinusitis?
- 45 mg/kg/day divided BID of amoxicillin
- for second-line treatment 80-90 mg/kg/day Amox-clav
What are the possible complications of sinusitis?
- Sinus venous thrombosis
- Meningitis
- Pott’s puffy tumour
- Sinus venous thrombosis
- Periorbital cellulitis, orbital cellulitis
- Subdural abscess
- Periosteal abscess
- Mucoceles
What are the most common infectious agents in bacterial tracheitis?
S. aureus
MRSA, S. pneumoniae, S. pyogenes, Moraxella catarrhalis, non-typable H. influenza, anaerobes
What are the clinical signs of Bacterial tracheitis?
○ Brassy cough
○ High fever
○ Toxic with respiratory distress
§ May be immediate or after a few days of apparent improvement
○ Able to lie flat
○ No drooling
○ Usual treatment for croup (racemic epi) is ineffective
What empiric therapy is used with bacterial tracheitis?
Clindamycin or vancomycin + 3rd generation cephalosporin
Consideration or preparation for alternative airway
What is the etiology of Obstructive Sleep Apnea?
1) Decreased upper airway patency
□ Nose, nasopharynx/oropharynx, hypopharynx narrowing
□ Chronic rhinitis, craniofacial abnormalities, hypoplasia of the maxilla/mandible, GERD with resulting pharyngeal reactive edema, septal deviation
□ Adenotonsillar hypertrophy (Note: tonsillar size does not necessarily correlate with degree of obstruction)
- Increased upper airway collapsibility (reduced pharyngeal muscle tone)
□ Hypotonic CP, muscular dystrophy - Decreased drive to breathe
□ Arnold-Chiari malformation, rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic dysregulation and meningomyelocele - Mixed picture: T21
What does the AAP suggest the work-up is in children with suspected OSA?
1) polysomnogram (gold standard) OR
2) refer the patient to a sleep specialist or otolaryngologist OR
3) perform alternative diagnostic tests i.e. Nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, ambulatory polysomnography
What treatment options are suggested for children with OSA?
○ T+A as first line treatment
○ If signs/symptoms persist, should refer to a sleep specialist, perform an objective test and/or refer for CPAP management
○ Clinicians should recommend weight loss as adjunct if the child is overweight or obese
○ Topical intranasal corticosteroids for mild OSA if whole T+A is contraindicated
What are the clinical manifestations of mastoditis?
- Acute otitis media on the affected side
- Protrusion of the ear
- Retroauricular swelling and tenderness
- Retroauricular erythema
- Fever
- Otalgia
- Hearing loss
What is empiric treatment for mastoiditis?
- IV antibiotics (3rd generation cephalosporin +/- vancomycin)
- total duration: 3-4 weeks
What are some potential complications of retropharyngeal abscess?
- Airway obstruction
- Septicemia
- Aspiration pneumonia if the abscess ruptures
- Internal jugular vein thrombosis
- Jugular vein suppurative thrombophlebitis (Lemierre’s syndrome)
- Carotid artery rupture
- Mediastinitis
How to differentiate Epiglottitis from RPA, from PTA?
Epiglottitis - drooling, stridor, toxic
RPA - no drooling, stridor, neck stiffness, no trismus, able to lie down
PTA - trismus, dyphagia, uvular deviation
A child with mastoiditis presents with ocular findings; what is their diagnosis now?
Gradenigo syndrome: triad
(1) Suppurative OM (2) Paralysis of the external rectus muscle (CN VI, no lateral eye movement, medial deviation) (3) Pain to ipsilateral orbit
What are the indications for Tonsillectomy/Adenoidectomy?
Paradise criteria: 7 episodes of pharyngitis in the past year (5 in last 2 years, or at least 3 in the preceding 3 years)
- Rhinosinusitis unresponsive to conservative management - INCS, rinses, avoidance, Singulair
- OSA
- Nasal obstruction
- Chronic adenoiditis
- Malignancy
- PFAPA
What are some post-operative complications of T/A?
- Nasal voice as a result of velopharyngeal insufficiency
- Bleeding
- Recurrence
- Insufficient pain management - first line Tylenol/NSAIDs, caution to avoidance of opioids
Which virus is responsible for the majority of cases of croup?
Human parainfluenzavirus (75% of cases)
What distinguishes a severe from a moderate case of croup?
Presence of both inspiratory and expiratory wheezes, marked lethargy and severe indrawing
When is dexamethasone not indicated in children with croup?
In cases of concurrent TB or varicella infection
What is the dose of dexamethasone for treatment of croup? Epinephrine?
0.6 mg/kg
5 mL of 1:1000 L-epinephrine or 0.5 mL of racemic 1:10000 epinephrine nebulized
What medications can cause hearing loss?
- Cisplatin
- Aminoglycosides (gent > tobra > amikacin > neomycin)
- High-dose IV loop diuretics
- Macrolides, vanco, tetracycline
- Chemo agents (5-fluorouracil, bleomycin)
- Salicylates
- Antimalarial meds (quinine and chloroquine)
What causes most cases of congenital hearing loss?
Genetic (50%)
most involving Connexin 26
What are some inherited conditions that can lead to hearing loss?
- Usher Syndrome
- T21
- Treacher Collins syndrome
- Crouzon syndrome
- Alport syndrome
- Waardenburg syndrome
- Stickler’s syndrome
- Pendred syndrome
- Jervell-Lange-Nielsen
What are some risk factors for hearing loss?
ABCDs
• Affected family member
• Bilirubin (high)
• Congenital intrauterine infection (TORCH)
• Defects of the ear, nose and throat
• Small at birth (<1500 g), low apgar, NICU stay
What is the most common cause of stridor in early childhood?
Laryngomalacia
In counselling parents, what is the natural history of laryngomalacia
begins as early as 2 weeks of life and can worsen up until 6 months of life before resolving with age
Clinically, what is the difference between tracheomalacia and bronchomalacia?
Trancheomalacia - expiratory stridor
Bronchomalacia - expiratory wheeze
Which children should be considered for supraglottoplasty?
- apnea
- failure to thrive
- respiratory distress
- persistent cyanosis
4 Causes of secondary trancheobronchomalacia?
- Post TEF repair
- External compression i.e. vascular ring
- Prolonged mechanical ventilation
- Connective tissue disorder
What are the clinical features of vocal cord paralysis?
- Variable extrathoracic upper airway obstructive pattern on respiratory curves
- Soft breathy cry (if unilateral)
- May see aspiration, choking, coughing
What are the clinical features of vocal cord dysfunction?
- Sudden, paroxysmal respiratory distress and wheezing
- Not responsive to ventolin
- Adolescent onset, usually female
- Triggered by exercise
Name 4 causes of centrally located neck masses
- Thyroglossal duct cyst
- Teratoma
- Ranula
- Vascular malformation
- Dermoid cyst
Name 4 causes of lateral neck masses
- Branchial cleft anomaly
- Vascular malformation
- Congeintal torticollis
- Thymic cyst
What is the pathognomonic sign of thyroglossal duct cysts?
Vertical motion of the mass with swallowing and tongue protrusion
Where is the most common site of bleeding in cases of epistaxis?
Kiesselbach’s plexus
What are some strategies for preventing recurrent nosebleeds?
- Room humidifier (should feel tropical in there)
- Saline drops
- Vaseline applied to the septum (alternate and occlude nares qhs)
- Antiseptic cream (e.g.: mupirocin)
- Stop nose picking
- Stop nasal steroid sprays if you can
What clinical scenario of epistaxis is particularly concerning?
Profuse unilateral epistaxis associated with a nasal mass in an adolescent boy near puberty
- Juvenile nasopharyngeal angiofibroma
How do you manage a translucent, bluish growth found beneath the tongue?
Rannula
Requires surgical management (excision)
What is the difference between Ebstein’s pearls and Bohn’s nodules?
“Ebstein pearl” - P - on the palate
“Bohn nodules” are typically seen on gingival ridges
What are some potential complications of tracheostomy tubes?
- granuloma formation
- infection
- fistulization
- decannulation
- obstruction
- pain and irritation
