Peds ENT Flashcards
1
Q
Palatine Tonsil vasculature?
A
Lingual aa (dorsal); facial aa (tonsillar branch); ascending pharyngeal aa; lesser palatine
2
Q
Palatine tonsil innervation
A
- CN IX
- tonsillar branches of CN V2
- lesser palatine n. via sphenopalatine ganglion
3
Q
Anterior pillar
A
Palatoglossus
4
Q
Posterior pillar
A
Palatopharyngeus
5
Q
Muscle deep to the palatine tonsil
A
Superior constrictor
6
Q
Pre-op for tonsil, what to ask?
A
Bleeding hx; family bleeding hx; anesthesia reactions or family members
7
Q
2 main indications for T/A
A
Recurrent tonsillitis and SDB
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
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
10
Q
rarer indications for Tonsillectomy
A
- PTA resistant to tx
- Rheumatic heart disease or glomerulonephritis
- Antiobiotic allergy
- PFAPA
11
Q
Bursa of Luschka
A
folds of adenoid respiratory epithelium that radiate forward from a median blind recess
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.
13
Q
Adenoid Innervation
A
Pharyngeal plexus (CN X+IX)
14
Q
Main complications of adenoids
A
Choanal stenosis;
VPI (watch for bifid uvula–> SMCP)
ETD via torus tubularis dmg
15
Q
Main complications of tonsillectomy
A
bleeding, bleeding, bleeding
16
Q
Pre-op clearance for Down Syndrome
A
Check for c1-c2 subluxation w/ c-spine xray
Cardiac workup
17
Q
Thyroglossal Duct Cyst Excision
A
Sistrunk procedure. Much lower rate of recurrence (~5% v 20%) than simple excision
18
Q
DDX for midline neck mass in kid
A
- TGDC (MC, 70% of cong neck masses)
- Dermoid (more dense on U/S)
- LNs
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
20
Q
Procedures for Recurrent TGDC
A
- try sistrunk again
- Suture guided transhyoid pharyngotomy
21
Q
Why surgery for TGDCs?
A
Infections and PTC risk
22
Q
Midline neck cyst complication: rupture intra-op
A
Close wound, antibiotics, take cx
23
Q
Midline neck cyst complication: enter pharynx
A
- Wound closed, cx taken, start antibiotics
- Feeding tube placed
- MBS after 3-5 days
24
Q
Supraglottoplasty indications for LM
A
Laryngomalacia: symptoms dictating surgical mgmt
- cyanosis, dyspnea, feeding difficulties, recurrent PNAs
- release the tight AE folds
25
Paranasal sinus development
Eat My S*** F****
Ethmoid and Mastoid (3rd+4th mo gestationally-->5 years)
Sphenoid 5y
Frontal 7-15y
26
Mastoid development
pneumatizes and develops by 3y
27
CN7 risk in infants
extratemporal CN7 relatively unprotected up until 3. Puts nerve at risk esp during delivery, parotid surg and tympanomastoid. What needs to develop?
28
Eustachian tube dvlpment
50% length at birth. Horizontal. by 5-7 it widens and angles inferiorly
29
Larynx position in infancy
- 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
30
Chandler classifications
```
I: preseptal cellulitis
II: Orbital cellulitis
III: Subperiosteal abscess
IV: Orbital abscess
V: Cavernous sinus thrombosis
```
31
When to operate in Chandler criteria
III or above. Esp w/ decrease in vision, APD, proptosis despite antibiotics. No decrease in abscess size after 48-72hrs
32
Ankyloglossia Dx
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
33
Laryngomalacia anatomical fx's
large arytenoids covering posterior glottis w/ omega shaped+furled epiglottis
34
Adenoid facies
2/2 chronic nasal/nasopharyngeal obstruction.
Constant mouth breathing w/ abnormal dental malocclusion and elongation of the face
35
Recurrent Respiratory Papillomas cause
2/2 HPV 6+11
36
Submucous cleft palate
1. Notch in the hard palate, 2. bifid uvula, 3. transluscent zone in soft palate. causes incorrect positioning of palate muscles
37
Inference on anatomy based on Stridor timing in insp/exp
Inspiratory=think supraglottic
Biphasic=Glottis or subglottic
Expiratory=subglottic
38
Laryngeal cleft grading (Inglis)
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
Laryngeal cleft treatment: Grade I and II
GERD tx, thick feeds. Gelfoam injection and thickened feeds
40
Laryngeal cleft treatment: Grade III+IV
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
Glottic Webs
```
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
Laryngomalacia clinical features
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
Stridor DDX in kids: Broad categories
Congenital: LM, Laryngocele, webs, subglottic stenosis
Infections: RPAs, angioedema, croup, tracheitis, epiglottitis
Neoplasm: RRP, hemangiomas, thyroid tumors
Other: FB, laryngeal fracture, VC immobility
44
Croup=Laryngotracheabronchitis general features
```
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
Croup Tx
```
Conservatively but first think if this could be epiglottitis
if severe
-Humidification
-Racemic epi
-dexamethasone 0.5mg/kg
-Intubation rare (Heliox if severe)
```
46
Recurrent Croup
```
>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
Subglottic stenosis grading (Cotton grade)
I < 50%
II: 51-70%
III: 71-99%
IV: no lumen
48
LM Tx
GERD Tx, thickened feeds, and SGP if severe
49
Indications for SGP in LM
Cyanosis, recurrent PNA, FTT
50
Vascular causes of Stridor
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
VC immobility causes
3rd MC cong cause of stridor
2/2 Chiara, hydrocephalus, trauma, birth, cardiac sx, intubation damage
52
VC immobility symp, uni vs BL
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
SGS
Cong vs acquired (90% of vases)
Normal size=4-7mm
Acquired--> prolonged intubation, laryngeal trauma, cricothyroidotomy, high trach
54
SGS symp
Mild: recurrent croup +/- feeding issues
Sever: biphasic sridor, resp distress, increased WOB
55
General stridor mgmt
Assess severity and acuity
Pulse ox, humidified O2, nebulized racemic epi,steroids, IV abx.
Intubate in controlled environment w/ anesthesia
Trach
56
TEFs
MC type is eso atresia (90%)
Often dx after birth due to severe aspiration and perinatal complications
A/W VACTERL+Down syndrome
57
Pediatric Chronic Cough Time and DDX
Daily >4 weeks
DDX: RAD, FB, aspiration, Infxns, sinus infxn, PCD, immunodeficiencies, Eosinophilic esophagitis
58
ENT role in chronic cough
Identify and eliminate upper aerodigestive sources of cough
59
Cough receptors location
All over aerodigestive tract up to terminal bronchials and UGI tract.
High conc in Larynx, carina and bifurcations
60
Pediatric voice evaluations:
Perception?
For QoL?
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
Peds Dysphonia DDX
```
Reflux, Eosinophilic esophagitis are MC
VF nodules, cysts, polyps
VF immobility
Laryngeal webs
Fx voice disorders (muscle tension dysphonia)
Vocal process granuloma
```
62
GERD vs EE MGMT
PPI 1-2 months, 2nd line is bx to differentiate the two
63
VF nodules
much more common that cysts and polyps
1st step voice therapy
64
VF immobility mgmt
unilateral: obs and temporizing measures: Injections
RLN Reinnervation w/ ansa cervicalis
Bilateral: Obs, trach, post cordotomy, arytenoidectomy, posterior cricoid expansion
65
Alkali caustic ingestions general info
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
Acidic caustic ingestions general info
Coagulation necrosis, limits necrosis to surface until stomach
Sequelae- perfs and gastric outlet obstruction
Bitter tastes usually lowers volume ingested
67
Bleach caustic ingestions general info
Neutral pH, eso irritants, no significant morbidity or mortality
68
General caustic ingestions
Injury based on amount, type, food in stomach, gastric transit time, and GERD
Changes start immediately and progress over 2-3d
69
Caustic ingestion sequelae
Strictures (w/in months over years)
Eso dysmotility
70
Ingestion presentation
often unwitnessed: but see dysphagia, drooling, food avoidance, vomiting
Watch for: tachy w/ hypotension and retrosternal pain
71
Ingestion mgmt
```
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
Ingestion grading
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
Adenoid hypertrophy symp
SDB, recurrent OME, ETD, rhinorrhea, mouthbreathing, hyponasal speech, adenoid facies
2/2 chronic infxns
74
Tonsillar hypertrophy symp
dysphagia, SDB w/ apneas, voice changes, dental malocclusion
75
Nasal sounds
/m/ /n/ /ng/
76
SDB background
neuromuscular tone, anatomy, and AT hypertrophy
Tonsil size does NOT correlate w/ symp
77
PTAs etiology
MC deep space infxn of neck
| Can be continuous w/ tonsil or 2/2 minor salivary gland infxn.
78
PTA presentation
```
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
PTA TX
I&D w/ topical anesthetic or tonsillectomy
80
Cleft etiology
one of the MC cong anomalies 0.2-2.3 cases/1000
Higher in native americans and asians
81
Cleft Genetics
Strong Family Hx
| TGFB3 and MSX genes implicated
82
Clefts a/w
Digeorge
Velocardiofacial syndrome
Stickle syndrome
Van der woude
83
Categories of VP dysfunction
Structural
Dynamic impairment
Other
84
VP dysfx
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
Structural VP dysfx
Clefts, SMCP, occult smcp (absence or deficiency of musculus uvulae, w/o bifid uvulae or grooved soft palate)
Tonsillar hypertrophy
86
Dynamic VP dysfx
Post-A, neurologic dz
87
Muscles of VP shincter
```
Tensor veli palatine
Levator veli palatine
Musculus uvulae
Palatoglossus
Palatapharyngeus
Superior constrictor
```
88
Tensor veli palatine
♣ (CN V3): tenses soft palate and opens ET during swallowing
89
Levator veli palatine:
(CN IX, X): major elevator of the velum
90
Musculus uvulae
(CN IX, X) bulks up dorsal uvula
91
Palatoglossus
(CN IX, X) lowers velum and elevates tongue upwards and backwards
92
Palatopharyngeus
(CN IX, X) narrows VP orifice by adducting posterior pillars
93
Superior constrictor
Superior constrictor(CN IX, X): medial movement of pharyngeal walls
