Respirology Nelson Flashcards
Which of the following statements is false?
a) newborns are obligate nose breathers
b) maternal estrogen stimuli can be a reason for nasal congestion with obstruction in the first year of life
c) the internal nasal airway doubles in size in the first 6 months of life
d) the anterior nasal cavity has laminar airflow
e) nasal passages contribute as much as 50% of resistance to normal breathing
d) false -
in the anterior nasal cavity, turbulent airflow and coarse hairs enhance the deposition of large particulate mater,
the remaining airways filter out particles as small as 6 um in diameter, in the turbinate region is where the airflow is laminar, and the airstream is narrowed and directed superiorly, enhancing particle deposition, warming and humidification
the rest are true
e) nasal flaring reduces the resistance to inspiratory airflow through the nose and may improve ventilation
Which of the following is not present in the nasal secretions?
a) IgM
b) IgA
c) IgG
d) IgE
a)IgM not listed, the nasal secretions contain both lysozyme and secretory IgA, (antimicrobial activity), IgG, IgE (remember as AGE) as well as albumin, histamine, bacteria, lactoferrin, cellular debris, mucous glycoproteins
replacement of mucous layers every 10-20 minutes
nasal mucosa is more vascular than the lower airways, but the surface epithelium is similar, with ciliated cells, goblet cells, submucosal glands and a covering blanket of mucus.
nasal secretions contain
Which of the following is not associated with severe narrowing of the nasal passages ?
a) hard and narrow hard palate
b) CNS anomalies
c) significant obstruction during infection
d) more susceptible to chronic or recurrent hypoventilation
e) congenital nasolacrimal duct obstruction
b) CNS abnormalities are not listed
this is taking about congenital structural nasal malformations, (less common than acquired) can be sufficiently malformed for severe narrowing of the passages, when this happen, is associated with the other
can also have inspiratory obstruction
nasal hypoplasia ->nasal bones are congenitally absent
Which is the most common congenital anomaly of the nose?
a) perforation of the septum
b) nasal polyps
c) choanal atresia
d) nasal hypoplasia
c) choanal hypoplasia - most common congenital anomaly of the nose and has a frequency of 1/7000 live births
the others are acquired problems
what it is: unilateral or bilateral bony or membranous SEPTUM between the nose and the pharynx, most cases have a combo of bony and membranous atresia (i.e. the back of the nasal passage is blocked)
50% have other associated anomalies, more frequently in bilateral cases
Which of the following is not part of CHARGE syndrome?
a) choanal atresia
b) heart anomalies
c) cataracts
d) hypogonadism
e) renal abnormalities
f) growth retardation
g) CNS anomalies
h) deafness
c) false Colobomas are part of the charge syndrome
what is a coloboma? a hole in a part of the eye, i.e.) iris, retina, choroid, or optic disc. occurs because of problems in early development. most colobomas are in the iris, effect on vision is varied.
Coloboma Heart defect Atresia choanae Retardation of growth/development and/or CNS abnormalities Genital abnormalities or hypogonadism Ear abnormalities or deafness
CHARGE is one of the most common anomalies associated with CHARGE syndrome, most patients have mutations in the CHD7 gene
A newborn infant presents with cyanosis, difficulty breathing, and sucking in their lips. The baby starts crying vigorously and the cyanosis is relieved. What diagnostic test is most likely to diagnose the problem?
a) attempt to pass a catheter through the nose
b) echo
c) CXR
d) pre and post ductal saturations
a) this is a classic presentation of how choanal atresia will present, if bilateral choanal atresia:
- if have difficulty with mouth breathing, make vigorous attempts to inspire, often suck in their lips and develop cyanosis. distressed children then cry (which lets air in) and the cyanosis is relieved. when they close their mouth again, the same thing happens again.
- those who are able to breath through their mouths often only experience difficulty when sucking and swallowing, becoming cyanotic when they attempt to feed
- babies who only have unilateral obstruction, may be asymptomatic for a long period of time until the 1st respiratory infection, when may present with unilateral nasal discharge or persistent nasal obstruction
Diagnosis: inability to pass a firm catheter through each nostril 3-4 cm into the nasopharynx, anatomy best evaluated using CT
Treatment: oral airway,
The child above’s vital signs are stable. what should be your first step in management as you try to mobilize your team?
a) nasal airway
b) oral airway
c) bag mask ventilation
d) tracheostomy
e) flexible scope
b) oral airway
initial treatment:
- standard oral airway/feeding nipple with large holes at the tip to facilitate air passage, keep the mouth open, intubation
- after oral airway is established, can do NG feeds until breathing and eating without the assistance is possible
- bilateral cases: may need intubation or tracheotomy
operative repair can either be done in neonate or later on
overal for airway in congenital nasal disorders - supportive care of the airway until diagnosis established, diagnosis is done by flex scope and imaging (i.e. CT), surgery once child is otherwise healthy.
Which of the following is not a cause of perforation of the nasal septum?
a) syphilis
b) tuberculosis
c) O2 prongs
d) birth trauma
e) developmental
c) CPAP canals are a common cause, not O2 prongs
the other causes are true:
- infection (syphillis/TB), trauma, rarely developmental
- CPAP cannulas - iatrogenic
- most common cause of septal deviation at birth - trauma from delivery , can be corrected immediately , but formal is usually postponed to not disturb mid face growth
Which of the following is the most common congenital midline nasal mass?
a) hemangiomas
b) encephaloceles
c) gliomas
d) dermoids
d) dermoids are the most common, 2nd is gliomas then encephaloceles, present intranasally or extra nasally and may have intracranial connections. nasal mermaids often have a dimple or pit on the nasal dorsum. can predispose to intracranial infection (if fistula or sinus is present), recurrent infection of the dermoid is more common.
gliomas/heterotopic brain tissue are firm, encephaloceles are soft and enlarge with crying/valsalva.
diagnosis: physical exam and imaging. CT - bone, MRI sagital views. usually need surgery.
Which of the following nasal masses is rarely present at birth?
a) hemangiomas
b) nasal polyps
c) congenital nasolacrimal duct obstruction
d) rhabdomyosarcoma
b) nasal polyps rarely present at birth, the other nasal masses listed often present at birth or early infancy
congenital nasolacrimal duct obstruction can present as a intranasal mass
poor development of paransal sinuses and a narrow nasal airway are associated with recurrent or chronic upper airway infection in Down syndrome
Which of the following is the most common presentation of a nasal foreign body?
a) clinical history of insertion
b) mucopurulent nasal discharge
c) nasal obstruction
d) epistaxis
a) history of insertion most common -86%
nasal discharge - 24$
nasal odor 9%
epistaxis 6%
nasal obstruction 3%
mouth breathing 2%
presentation most commonly unilateral nasal discharge and obstruction, exam with nasal speculum or wide otoscope, usually it is anterior but can get forced in by an unskilledd examiner
if metallic or radio opaque, lateral skull X ray can help
Which of the following is not a complication of nasal foreign bodies?
a) infection
b) septal perforation
c) retropharyngeal abscess
d) tetanus
c) not related
the other 3 are complications of nasal foreign bodies
tetanus is a rare complication of long standing nasal foreign bodies in NONimmunized children, toxic shock syndrome also rare but can occur (related to nasal packing)
disk batteries can cause local injury
saddle nose deformity is a complication of a septal hematoma (from trauma)->if untreated leads to necrosis of the septal cartilage and saddle nose deformity (don’t think this is common for nasal foreign body, more related to nasal TRAUMA
Which of the following is the most common site of bleeding in epistaxis?
a) Kiesselbach plexus
b) internal maxillary artery
c) external nose
d) posterior septum
a) Kiesselbach plexus - an area in the anterior septum where vessels rom both the internal carotid (anterior and posterior ethmoid arteries) and external carotid (sphenopalatine and terminal branches of the internal maxillary arteries) converge. thin mucosa and anterior location make it prone to exposure (dry air and trauma
kiesselbach plexus bleeding decreases in adolescence
nose bleeds are rare in infancy, common in childhood, less after puberty
internal maxillary artery causes bleeding in the posterior nasal septum, may need surgery for these bleedings
Which of the following is not a cause of severe nosebleeds?
a) hypertension
b) juvenile nasal angiofibroma
c) thrombophilia
d) renal failure
e) von willebrand disease
c) rather the opposite, its coagulopathies that can cause severe nosebleeds:
causes of severe nosebleeds:
- congenital vascular anomalies (hereditary hemorrhagive telangiectasia), varicosities, hemangiomas, tyrombocytopenia, deficiency of clotting factors (especially von willebrand disease) hypertension (go figure), renal failure, venous congestion. nasal polyps or other growths may be associated.
juvenile nasal angiofibromas - recurrent and frequentcy severe nosebleeds in adolescent males (profuse unilateral epistaxis associated with nasal mass in adolescent boy around puberty,y, usually tumour)
common causes of nosebleeds from the anterior septum: digital trauma, foreign bodies, dry air, inflammation (URTI, sinusitis, allergic rhinitis), nasal steroid sprays - chronic use, GERD can lead to epistaxis from inflammation, family history. increased during URTI/winter (dry infection etc)
Which of the following clinical features suggests a nasal lesion as the cause of epistaxis?
a) nightime
b) after physical activity
c) hematemesis
d) bilateral bleedingl
b) after physical activity suggests nasal lesion
bleeding at night - can get swallowed and become apparent only after vomiting or passing blood in the stools
posterior epistaxis - can manifest as anterior nasal bleeding or vomiting blood as the initial symptom
in general epistaxis happens without warning, blood flowing from one nostril or occasionally both
Which of the following patients does not need an ENT consult?
a) isolated bleeding from the Kiesselbach plexus
b) bilteral bleeding
c) severe epistaxis needing blood transfusions
d) recurrent epistaxis
a) ENT should be referred for bleeding NOT arising from Kiesselbach plexus
other indications:
- severe bleeding needing transfusion, bilateral bleeding
hematology (coagulopathy and anemia) and nasal endoscopy and diagnostic imaging, may need to make definitive diagnosis in cases of severe recurrent epistaxis
1)Treamtment most nosebleeds should stop spontaneously in a few minutes - compress the nares and keep the child upright with head forward, cold compresses
2) If doesn’t work: oxymetazoline or neo-synephrine local application
3)If that does work, nasal packing (anterior); if bleeding is posterior, need to pack anterior and posterior
obliterate the site of bleeding by cautery
one study looked at effect of humidity, vaseline etc and found no effect(although nelson says it may help). prevent nose picking and dryness.
Which of the following is the most common location of nasal polyps?
a) antrochoanal
b) maxillary antrum
c) ethmoidal sinus
c) most commonly nasal polyps arise from the ethmoidal sinus and present in the middle meatus
occasionally they appear within the maxillary antreum and extend to the nasopharynx - these are known as antrochoanal polyps which are not frequent in adults but more so in children (33%)
ethmoidal - not well vascularized, antrochoanal more so, antrochoanal can be in the ansopharynx - scope
prolonged presence of ethmoidal polyps can destroy adjacent tissues
antrochoanal polyps - usually NOT associated with underlying disease process so less recurrence
sitelli 932 - for picture
can lead to changes in facial growth without treatment
How many children with cystic fibrosis have nasal polyps?
a) 5%
b) 10%
c) 20%
d) 30%
d) as much as 30% of children with CF have nasal polyps
should suspect in any child with nasal polyps<12 year old, even without other symptoms
other cause so nasal polyp:
chronic sinusitis, allergic rhinitis, uncommon Samter triad (aspirin sensitivity, asthma and nasal polyps)
presentation: nasal obstruction or discharge
Which of the following treatments can be helpful in shrinking nasal polyps?
a) local decongestants
b) systemic decongestants
c) intranasal steroid sprays
d) acetaminofen
c) intranasal steroid sprays - can provide some shrinkage of nasal polyps with symptomatic relief
local/systemic decongestant - may help with symptoms but don’t shrink
indications for removal: complete obstruction, uncontrolled rhinorrhea, deformity of the nose
may return if underlying cause, steroid sprays after
endoscopic sinus surgery - more complete removal, polyps less likely to recur
antrochoanal - medical measures don’t work, need surgery
Which of the following is the most common cause of the common cold?
a) coronaviruses
b) influenza
c) RSV
d) rhinoviruses
d) rhinoviruses are the most common cause of the common cold (coronavirus is the other virus that is primarily associated with colds) the other agents are associated with other syndromes that cause cold-like symptoms (and include RSV, HMPV, influenza, par influenza, adeno, entero, rota
parainfluenzae - late fall
chilren in daycare get sick 50% more
RSV and rhino- most effectively spread through direct contact, influenza, more by small aerosols
some destroy the epithelial lining of the nose - influenza/adeno, or no damage (rhino, RSV, corona)
inflammatory response in the nasal epithelium
Which of the following is the most common complication of a cold?
a) pneumonia
b) sinusitis
c) otitis media
d) asthma
c) otitis meia - in 5-30% of children who have a cold, higher in daycare
symptomatic treatment no effect on otitis media, but treatment with oseltamivir - may reduce the incidence of OM in patients with influenza
sinusitis - another complication, no evidence that treating cold alters it
asthma exacerbations - most in children are associated with colds as a trigger
inappropriate antibiotic use
Which of the following sinuses is the last to develop?
a) frontal sinus
b) maxillary sinus
c) sphenoidal sinus
d) ethmoidal sinus
a) frontal sinus - starts to develop at age 7-8, not complete until adolescence
ethmoid and maxillary are present at birth but not pneumatized (filled with air)
maxillary gets pneumatized at age 4
sphenoidal is present by age 5
the EMS Farts Sinuses
Which of the following is not a common cause of acute bacterial sinusitis?
a) S. pneumo
b) Staph aureus
c) H influenzae
d) Moraxella
b)Staph aureus not common other non common ones include staphylococcus aureus, other strep, anaerobes
common s. pneumo, non typable h influenza, moraxella catarrhalis
lots of the S. pneumo is penicillin resistant
in chronic sinus disease: M catarrhalis, S. pneumo and coagulase -negative staph are commonly found
A 14 year old who is afebrile with cold symptoms for 5 days has an MRI done, and it shows mucosal thickening, edema and inflammation of the paranasal sinuses. Which of the following is the correct interpretation of this test?
a) the child has acute bacterial sinusitis and should be treated
b) the child has chronic bacterial sinusitis and should be treated
c) the child likely has a viral rhino sinusitis and can be watched symptomatically
d) none of the above
c) true
68% of children with an MRI during a cold have signs of sinus inflammation
likely this is the normal viral rhino sinusitis that precedes bacterial sinusitis
presentation of sinusitis
o Include nasal congestion, purulent nasal discharge (unilateral or bilateral), fever and cough
o Less common findings:
• Bad breath, decreased sense of smell and periorbital edema, maxillary tooth discomfort, pain or pressure exacerbated by bending forward hyposmia
o Acute bacterial sinusitis:
• Persistent symptoms of URTI, including nasal discharge and cough for >10-14 days without improvement
• OR
• Severe respiratory symptoms including fever >39 and purulent nasal discharge for 3-4 days
Which of the following is the appropriate first line treatment for sinusitis in a otherwise healthy 10 year old?
a) amoxicillin PO
b) ceftriaxone IV
c) amox/clav
d) clarithromycin
a) amoxicillin PO
if allergy, then do TMP/SMX, clarithroomycin, azithromycin, cefuroxime
children with risk factors should use amox clav, risk factors are:
age t respond then talk to ENT
saling washes may help but no studies, decongestants not studied enough in children
Which of the following is not a common complication of bacterial sinusitis?
a) Pott’s Puffy Tumour
b) subdural hemorrhage
c) Periorbital cellulitis
d) Brain abscess
b) subdural hemorrhage
complications include:
periorbital and orbital cellulitis, infection of the brain (including epidural abscess, meningitis, cavernous sinus thrombosis, subdural empyema, brain abscess)
osteomyelitis of the frontal bone - which is Pott’s puffy tumour, presents with edema of the forehead
mucoceles - chronic inflammation of the frontal sinus, causes displacement of the eye and diplopia
A 7 year old girl presents with sore throat. All but which of the following organisms grown from a throat swab is likely the cause?
a) Strep pneumoniae
b) Neisseria gonorrhea
c) Mycoplasma pneumonia
d) Herpes simplex virus
a) Haemophilus influenzae and streptococcus pneumo may be cultured from the throats of children with pharyngitis but their role in causing pharyngitis has not been established
the most common causes : viruses (including EBV, HSV and other common ones), Group A strep
Other organisms: group B strep, Arcanobacterium, Francisella, Mycoplasma, gonorrhoea, corynebacteria
strep usually not in below 2-3 year old HIV can present with pharyngitis and mono-like picture
How many times can you get scarlet fever?
a) 1 time
b) 3 time
c) 4 times
d) no limit
b) usually 3 times - scarlet fever is caused by exotoxins (A, B and C) which is produced by group A strep and causes the fine papular rash. each time you get immunity only to that particular exotoxin so can get scarlet fever 3 times. exotoxin A is the most associated
colonization of pharynx by GAS- either asymptomatic or acute infection
M protein is the major virulence factor,
headache and GI symptoms are common with GAS pharyngitis
