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ENT > Peds ENT > Flashcards

Peds ENT Flashcards

1
Q

Palatine Tonsil vasculature?

A

Lingual aa (dorsal); facial aa (tonsillar branch); ascending pharyngeal aa; lesser palatine

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2
Q

Palatine tonsil innervation

A
  • CN IX
  • tonsillar branches of CN V2
  • lesser palatine n. via sphenopalatine ganglion
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3
Q

Anterior pillar

A

Palatoglossus

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4
Q

Posterior pillar

A

Palatopharyngeus

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5
Q

Muscle deep to the palatine tonsil

A

Superior constrictor

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6
Q

Pre-op for tonsil, what to ask?

A

Bleeding hx; family bleeding hx; anesthesia reactions or family members

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7
Q

2 main indications for T/A

A

Recurrent tonsillitis and SDB

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8
Q

PARADISE Criteria

A

♦ 7 episodes in a year OR
♦ 5 or more episodes for 2 years, in each year OR
♦ 3 or more episodes in each of the preceeding 3 years
Clinical features: sore throat + 38.3< fever, Cervical LAD, tonsillar exudate or positive Group A culture

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9
Q

SDB indications for tonsillectomy

A

somnolence, behavior issues, poor cognitive performance, enuresis + exam of adenotonsillar hypertrophy +/- witnessed apnea there’s no need to get PSG

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10
Q

rarer indications for Tonsillectomy

A
  • PTA resistant to tx
  • Rheumatic heart disease or glomerulonephritis
  • Antiobiotic allergy
  • PFAPA
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11
Q

Bursa of Luschka

A

folds of adenoid respiratory epithelium that radiate forward from a median blind recess

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12
Q

Adenoid Vasculature

A

Main: Ascending pharyngeal aa. from ECA
Minor: tonsilar branch of facial aa., pharyngeal branch of maxillary aa., artery of pterygoid canal, basisphenoid aa., ascending palatine aa.

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13
Q

Adenoid Innervation

A

Pharyngeal plexus (CN X+IX)

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14
Q

Main complications of adenoids

A

Choanal stenosis;
VPI (watch for bifid uvula–> SMCP)
ETD via torus tubularis dmg

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15
Q

Main complications of tonsillectomy

A

bleeding, bleeding, bleeding

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16
Q

Pre-op clearance for Down Syndrome

A

Check for c1-c2 subluxation w/ c-spine xray

Cardiac workup

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17
Q

Thyroglossal Duct Cyst Excision

A

Sistrunk procedure. Much lower rate of recurrence (~5% v 20%) than simple excision

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18
Q

DDX for midline neck mass in kid

A
  1. TGDC (MC, 70% of cong neck masses)
  2. Dermoid (more dense on U/S)
  3. LNs
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19
Q

Sistrunk procedure goal

A

Resect cystic mass, the associated tract, middle third of the hyoid, and part of the BOT deep to foramen cecum

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20
Q

Procedures for Recurrent TGDC

A
  • try sistrunk again

- Suture guided transhyoid pharyngotomy

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21
Q

Why surgery for TGDCs?

A

Infections and PTC risk

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22
Q

Midline neck cyst complication: rupture intra-op

A

Close wound, antibiotics, take cx

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23
Q

Midline neck cyst complication: enter pharynx

A
  • Wound closed, cx taken, start antibiotics
  • Feeding tube placed
  • MBS after 3-5 days
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24
Q

Supraglottoplasty indications for LM

A

Laryngomalacia: symptoms dictating surgical mgmt

  • cyanosis, dyspnea, feeding difficulties, recurrent PNAs
    • release the tight AE folds
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25
Q

Paranasal sinus development

A

Eat My S* F**
Ethmoid and Mastoid (3rd+4th mo gestationally–>5 years)

Sphenoid 5y
Frontal 7-15y

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26
Q

Mastoid development

A

pneumatizes and develops by 3y

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27
Q

CN7 risk in infants

A

extratemporal CN7 relatively unprotected up until 3. Puts nerve at risk esp during delivery, parotid surg and tympanomastoid. What needs to develop?

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28
Q

Eustachian tube dvlpment

A

50% length at birth. Horizontal. by 5-7 it widens and angles inferiorly

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29
Q

Larynx position in infancy

A
  • Infant position is high @ C3-4, w/ swallowing @C1-2. Neck is short.
  • High positioning overlaps w/ epiglottis and soft palate, helping to protect airway early
  • Gradually descends to C5
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30
Q

Chandler classifications

A 
I: preseptal cellulitis
II: Orbital cellulitis
III: Subperiosteal abscess
IV: Orbital abscess
V: Cavernous sinus thrombosis
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31
Q

When to operate in Chandler criteria

A

III or above. Esp w/ decrease in vision, APD, proptosis despite antibiotics. No decrease in abscess size after 48-72hrs

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32
Q

Ankyloglossia Dx

A

Palpation of genioglossus or lifting of tongue. ‘Heart shaped’
Hx: pain w/ breast feeding, ‘gulping’ air when breast feeding.
Can have speech, and feeding difficulties

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33
Q

Laryngomalacia anatomical fx’s

A

large arytenoids covering posterior glottis w/ omega shaped+furled epiglottis

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34
Q

Adenoid facies

A

2/2 chronic nasal/nasopharyngeal obstruction.

Constant mouth breathing w/ abnormal dental malocclusion and elongation of the face

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35
Q

Recurrent Respiratory Papillomas cause

A

2/2 HPV 6+11

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36
Q

Submucous cleft palate

A
  1. Notch in the hard palate, 2. bifid uvula, 3. transluscent zone in soft palate. causes incorrect positioning of palate muscles
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37
Q

Inference on anatomy based on Stridor timing in insp/exp

A

Inspiratory=think supraglottic
Biphasic=Glottis or subglottic
Expiratory=subglottic

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38
Q

Laryngeal cleft grading (Inglis)

A

Inglis classification
♣ Type I: deep interarytenoid notch w/o posterior cricoid involvement
♣ II: extend into but not through cricoid
♣ III: through the cricoid plate and into cervical trachea
♣ IV: extend into thoracic trachea or even bronchus

39
Q

Laryngeal cleft treatment: Grade I and II

A

GERD tx, thick feeds. Gelfoam injection and thickened feeds

40
Q

Laryngeal cleft treatment: Grade III+IV

A

Surgery: Endoscopic suture closure, open=anterior tracheal split and laryngofissure approach
Type IV repair requires ECMO due to post op swelling of trachea and difficulty intubating

41
Q

Glottic Webs

A 
most severe: laryngeal atresia
MC anteriorly
Tx: ranges from obs to emergent trach
Thick webs--> Laryngofissure w/ stenting to prevent scar formation
Thin--> laser or knife endoscopically
42
Q

Laryngomalacia clinical features

A

MC stridor in infancy
Most outgrow by 2
Anatomical + neuromuscular immaturity

P/w Stridor worse w/ crying, feeding, supine

  • -usually in the first weeks of life
    • a/w GERD
    • treat w/ ranitidine
43
Q

Stridor DDX in kids: Broad categories

A

Congenital: LM, Laryngocele, webs, subglottic stenosis

Infections: RPAs, angioedema, croup, tracheitis, epiglottitis

Neoplasm: RRP, hemangiomas, thyroid tumors

Other: FB, laryngeal fracture, VC immobility

44
Q

Croup=Laryngotracheabronchitis general features

A 
MC infectious source of stridor in kids
-MC from parainfluenza I
6mo-3yo
Course: 2-3d of URI prodrome w/ progressive barking cough
Insp stridor
Steeple sign on lateral neck xray

Check vaccine status, could be epiglottitis

45
Q

Croup Tx

A 
Conservatively but first think if this could be epiglottitis
if severe
-Humidification
-Racemic epi
-dexamethasone 0.5mg/kg
-Intubation rare (Heliox if severe)
46
Q

Recurrent Croup

A 
>2 episodes/year
Broaden ddx: think airway issues that would worsen with normal URI like subglottic stenosis, cysts, hemangiomas, tracheomalacia
-GERD
-Asthma
-Adenoids?
Need to be scoped
47
Q

Subglottic stenosis grading (Cotton grade)

A

I < 50%
II: 51-70%
III: 71-99%
IV: no lumen

48
Q

LM Tx

A

GERD Tx, thickened feeds, and SGP if severe

49
Q

Indications for SGP in LM

A

Cyanosis, recurrent PNA, FTT

50
Q

Vascular causes of Stridor

A

MC: aberrant R subclavian aa. (retroesophageal) Dx: w/ esophagram. Sx: R thoracotomy

  • High riding innominate aa.
    Compresses ant. tracheal wall
    look for pulsatile tracheal wall compression

-Vascular ring or pulm artery sling.
Double aortic arch, R aortic arch w/ lig arteriosum=sling
often assoc. w/ complete tracheal rings

51
Q

VC immobility causes

A

3rd MC cong cause of stridor

2/2 Chiara, hydrocephalus, trauma, birth, cardiac sx, intubation damage

52
Q

VC immobility symp, uni vs BL

A

Uni: Weak voice, abnormal cry

BL: insp stridor, abnormal cry, aspiration

DX: FFL in awake child
W/U: Imaging of entire RLN
Most cases resolve by 2

53
Q

SGS

A

Cong vs acquired (90% of vases)
Normal size=4-7mm

Acquired–> prolonged intubation, laryngeal trauma, cricothyroidotomy, high trach

54
Q

SGS symp

A

Mild: recurrent croup +/- feeding issues

Sever: biphasic sridor, resp distress, increased WOB

55
Q

General stridor mgmt

A

Assess severity and acuity

Pulse ox, humidified O2, nebulized racemic epi,steroids, IV abx.
Intubate in controlled environment w/ anesthesia
Trach

56
Q

TEFs

A

MC type is eso atresia (90%)

Often dx after birth due to severe aspiration and perinatal complications

A/W VACTERL+Down syndrome

57
Q

Pediatric Chronic Cough Time and DDX

A

Daily >4 weeks

DDX: RAD, FB, aspiration, Infxns, sinus infxn, PCD, immunodeficiencies, Eosinophilic esophagitis

58
Q

ENT role in chronic cough

A

Identify and eliminate upper aerodigestive sources of cough

59
Q

Cough receptors location

A

All over aerodigestive tract up to terminal bronchials and UGI tract.
High conc in Larynx, carina and bifurcations

60
Q

Pediatric voice evaluations:
Perception?
For QoL?

A

Perception:
Pediatric voice outcomes survey (PVOS)
Consensus auditory perceptual eval of voice CAPE-V

QoL
Ped Voice Outcomes survey (PVOS)
Ped voice related QoL (PVRQOL)
Ped voice handicap index (PVHI)

61
Q

Peds Dysphonia DDX

A 
Reflux, Eosinophilic esophagitis are MC
VF nodules, cysts, polyps
VF immobility
Laryngeal webs
Fx voice disorders (muscle tension dysphonia)
Vocal process granuloma
62
Q

GERD vs EE MGMT

A

PPI 1-2 months, 2nd line is bx to differentiate the two

63
Q

VF nodules

A

much more common that cysts and polyps

1st step voice therapy

64
Q

VF immobility mgmt

A

unilateral: obs and temporizing measures: Injections
RLN Reinnervation w/ ansa cervicalis

Bilateral: Obs, trach, post cordotomy, arytenoidectomy, posterior cricoid expansion

65
Q

Alkali caustic ingestions general info

A

Liquefactive necrosis
mucosal disintegration
More oral and upper Eso injury

Usually odorless and tasteless
pH>11 severe

Granular worse than liquid. Adheres to mucosa

66
Q

Acidic caustic ingestions general info

A

Coagulation necrosis, limits necrosis to surface until stomach
Sequelae- perfs and gastric outlet obstruction

Bitter tastes usually lowers volume ingested

67
Q

Bleach caustic ingestions general info

A

Neutral pH, eso irritants, no significant morbidity or mortality

68
Q

General caustic ingestions

A

Injury based on amount, type, food in stomach, gastric transit time, and GERD

Changes start immediately and progress over 2-3d

69
Q

Caustic ingestion sequelae

A

Strictures (w/in months over years)

Eso dysmotility

70
Q

Ingestion presentation

A

often unwitnessed: but see dysphagia, drooling, food avoidance, vomiting

Watch for: tachy w/ hypotension and retrosternal pain

71
Q

Ingestion mgmt

A 
ABCs
Hx not always helpful
Get parents to bring agent container
If severe--> emergent trach
Direct visualization 12-48h post-ingestion

If over 72h get esophagram

DONT use neutralizers, emetics, or blind NGs

72
Q

Ingestion grading

A

I: Mucosal edema+erythema, mIVF and NPO 1-2d

II: Sloughing, ulcers, noncircumferential exudate; NG or parental nutrition 7-10d followed by esophagram

III: Deep ulcers or circumferential; NG or parental nutrition 7-10d

IV:Eschar, full thickness change, perf; correct perf

73
Q

Adenoid hypertrophy symp

A

SDB, recurrent OME, ETD, rhinorrhea, mouthbreathing, hyponasal speech, adenoid facies

2/2 chronic infxns

74
Q

Tonsillar hypertrophy symp

A

dysphagia, SDB w/ apneas, voice changes, dental malocclusion

75
Q

Nasal sounds

A

/m/ /n/ /ng/

76
Q

SDB background

A

neuromuscular tone, anatomy, and AT hypertrophy

Tonsil size does NOT correlate w/ symp

77
Q

PTAs etiology

A

MC deep space infxn of neck

Can be continuous w/ tonsil or 2/2 minor salivary gland infxn.

78
Q

PTA presentation

A 
Trismus, 
muffled voice, 
dysphagia, 
sore throat, 
drooling
PE: Medial+inf displacement of tonsil; uvular deviation away from tonsil

Clinical dx
uncooperative kids may ned CT

79
Q

PTA TX

A

I&D w/ topical anesthetic or tonsillectomy

80
Q

Cleft etiology

A

one of the MC cong anomalies 0.2-2.3 cases/1000

Higher in native americans and asians

81
Q

Cleft Genetics

A

Strong Family Hx

TGFB3 and MSX genes implicated

82
Q

Clefts a/w

A

Digeorge
Velocardiofacial syndrome
Stickle syndrome
Van der woude

83
Q

Categories of VP dysfunction

A

Structural
Dynamic impairment
Other

84
Q

VP dysfx

A

more broad than ‘incompetency’

incompentency- inadequate closure 2/2 function problems

Insufficiency- Poor closure of velopharynx
can cause speaking and swallowing issues

Mislearning- articulation difficulties

85
Q

Structural VP dysfx

A

Clefts, SMCP, occult smcp (absence or deficiency of musculus uvulae, w/o bifid uvulae or grooved soft palate)
Tonsillar hypertrophy

86
Q

Dynamic VP dysfx

A

Post-A, neurologic dz

87
Q

Muscles of VP shincter

A 
Tensor veli palatine 
Levator veli palatine
Musculus uvulae
Palatoglossus
Palatapharyngeus
Superior constrictor
88
Q

Tensor veli palatine

A

♣ (CN V3): tenses soft palate and opens ET during swallowing

89
Q

Levator veli palatine:

A

(CN IX, X): major elevator of the velum

90
Q

Musculus uvulae

A

(CN IX, X) bulks up dorsal uvula

91
Q

Palatoglossus

A

(CN IX, X) lowers velum and elevates tongue upwards and backwards

92
Q

Palatopharyngeus

A

(CN IX, X) narrows VP orifice by adducting posterior pillars

93
Q

Superior constrictor

A

Superior constrictor(CN IX, X): medial movement of pharyngeal walls

ENT (9 decks)

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