UW PEDS ENT CASES

Question 1

(1) 5 y/o boy + sudden-onset difficulty breathing. The patient developed a mild cough and sore throat yesterday; his parents gave him acetaminophen, which improved his throat pain. However, this morning the patient had difficulty breathing and was sitting in bed and leaning forward, refusing to lie down. He takes no medications and has no known allergies. The patient has had no vaccinations. Temp. 39.1 C (102.4 F), BP 100/65 , pulse is 130/min, RR 46/min. SpO2 92% on room air. The patient appears anxious, is drooling, and has inspiratory stridor. The uvula is midline, and there is no oropharyngeal or tonsillar erythema. Lung examination shows transmitted upper airway noises without wheezing or crackles. Which of the following is the most likely diagnosis?

Answer 1

EPIGLOTITIS

Question 2

(2) A 9-year-old girl is brought to the office due to “ringing in her right ear” over the past week. She also has noticed a popping sensation in the ear when she swallows and difficulty hearing soft sounds. The patient has had nasal congestion during this time but is otherwise well. She and her family flew home from a ski trip in Colorado a few days before her symptoms began. Vital signs are normal. Otoscopic examination shows a retracted right tympanic membrane with surrounding dilated blood vessels; the left side is unremarkable. Pupils are equal, round, and reactive to light and accommodation. Coordination and balance are normal. Cranial nerve testing demonstrates a mild reduction in hearing on the right side. Which of the following is the most likely diagnosis in this patient?

Answer 2

EUSTACHIAN TUBE DYSFUNCTION (zymejau tympanic membrane rupture)

Question 3

(2) EUSTACHIAN TUBE DYSFUNCTION. CP?

Answer 3

Ear fullness/discomfort
Tinnitus
Conductive hearing loss
,,Popping” sensation

Question 4

(2) EUSTACHIAN TUBE DYSFUNCTION. Mechanism?

Answer 4

Inflammation (eg infection, allergies, environmental) -> tube obstruction

Question 5

(2) EUSTACHIAN TUBE DYSFUNCTION. Mx?

Answer 5

underlying cause (eg abs for acute bacterial rhinosinusitis)

Question 6

(2) EUSTACHIAN TUBE DYSFUNCTION. vs tympanic membrane rupture.

Answer 6

TM rupture due to barotrauma (eg, flying) can cause hearing loss and tinnitus. Symptoms develop at the time of inadequate pressure equalization (eg, ascent, descent), not days later, as in this case. In addition, a perforated TM on examination with or without a history of otorrhea would be expected.

Question 7

(3) A 3-year-old girl is evaluated for hoarseness that has been getting worse over the past 2 months. The patient has had no fever, shortness of breath, or change in activity level. She is eating normally, gaining weight well, and does not seem to be in pain. Vital signs are within normal limits. On physical examination, the ears are normal appearing with no middle ear fluid. The nasal mucosa is clear with no rhinorrhea, and the turbinates are normal in size. There are no oral mucosal lesions. The tonsils are small and nonobstructive. There is no cervical lymphadenopathy. Aside from hoarseness, examination of cranial nerves is normal. Flexible laryngoscopy shows several finger-shaped lesions on both vocal cords. Which of the following is the most likely cause of this patient’s current condition

Answer 7

MATERNALLY TRANSMITTED VIRAL INFECTION

recurrent respiratory papillomatosis (RRP), HPV 6/11

Question 8

(3) respiratory papilomatosis. Mx?

Answer 8

The mainstay of treatment remains surgical debridement, and patients often require many procedures

Question 9

(4) A 3-year-old boy is brought to the office due to nasal discharge for the past 2 weeks. His mother reports clear nasal discharge that has become progressively thicker and more malodorous. The patient has had no fever, cough, or shortness of breath. He is eating normally. Medical history includes congenitally acquired HIV, and the patient has taken antiretroviral therapy since birth. Three months ago, the CD4 cell count was 520/mm3. The patient has received all age-appropriate vaccinations. He lives with his parents, 6-year-old brother, and a pet dog. The patient’s father smokes cigarettes outside of the house. Growth parameters are at the 40th percentile for age. On examination, the patient is playful and interactive. There is purulent drainage from the right nostril, and the right nasal mucosa and turbinates are erythematous and swollen. There is no discharge from the left side, and the left turbinates are pink and nonedematous. The oropharynx and tonsils are normal. There is no cervical lymphadenopathy. Which of the following is the most likely cause of this patient’s current symptoms?

Answer 9

Nasal foreign body

This toddler with unilateral, purulent rhinorrhea likely has a nasal foreign body.

!!!!Imaging is unhelpful because most objects are radiolucent.

Question 10

(4) Nasal foreign body Mx?

Answer 10

Positive pressure expulsion (eg exhalation)
Mechanical extraction

Question 11

(4) Nasal foreign body complications?

Answer 11

local irritation
Infection
Aspiration
nasal septal perforation (button battery, mulptiple magnets)

Question 12

(4) Nasal foreign body.

A visualized object can usually be safely removed in the office. However, if the object cannot be visualized because of its location or surrounding edema or if removal could cause further trauma (eg, penetrating objects), referral to otolaryngology for nasal endoscopy is appropriate. Nasal foreign bodies should not be managed expectantly because inflammation may lead to obstruction of the sinus outflow tract and cause sinusitis or periorbital cellulitis.

Question 13

(4) kiti ats. Acute bacterial sinusitis can present with purulent nasal drainage and inflamed nasal mucosa. However, nasal symptoms are typically bilateral and often accompanied by fever and cough.

Answer 13

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Question 14

(4) kiti ats. Adenoid hypertrophy, the most common cause of nasal obstruction in children, can result in mucopurulent nasal discharge; however, bilateral symptoms would be expected.

Answer 14

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Question 15

(4) kiti ats Allergic rhinosinusitis can present with rhinorrhea in a well-appearing child. Parental smoking increases this risk, and pets can be a source of antigen exposure.

Answer 15

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Question 16

(5) 18-month-old boy + two weeks ago acute otitis media of the right ear.+ amoxicillin, with resolution of symptoms. For the past few days, the patient has been tugging at both of his ears, and his parents are concerned that he may have another ear infection. Temperature is 36.8 C (98.2 F). On otoscopic examination, air-fluid levels are visible posterior to both tympanic membranes, which appear translucent and gray. Pneumatic insufflation demonstrates reduced mobility of tympanic membranes bilaterally. Both external ear canals are clear. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient? Dx?

Answer 16

Observation and followup

Dx? otitis media with effusion (OME), defined by middle ear fluid without tympanic membrane (TM) inflammation. resolves within weeks

Question 17

(6) A 12-month-old girl is brought to the office due to 3 days of fever, rhinorrhea, and nasal congestion. The patient completed a course of oral antibiotics for an ear infection 3 weeks ago and was noted to have a persistent middle ear effusion at a well-child visit last week. There is no history of additional infections or medical conditions. She has no allergies. Both parents smoke cigarettes, and both older siblings received tympanostomy tubes as infants. Temperature is 39.4 C (102.9 F). The patient is irritable but easily consoled by her mother. External ear examination is unremarkable, and external ear canals are patent. Otoscopy shows bilateral bulging and pink tympanic membranes with poor mobility on insufflation. The oropharynx appears normal without lesions or sores, and the lungs are clear to auscultation. Which of the following is the most appropriate next step in management of this patient? Dx?

Answer 17

Acute otitis media

Tx = oral antibiotics (nebuvo pamineti konkreciai kokie, bet turetu but amoxiclav, nes neseniai gere amoxicilina)

Question 18

(7) Choanal atresia typical case, asked next step?

Answer 18

PASS A CATHETER THROUGH THE NARES

Question 19

(8) A 2-hour-old boy is evaluated in the newborn nursery due to cyanosis. The boy was born at 38 weeks gestation via spontaneous vaginal delivery to a primigravida mother whose pregnancy and delivery were uncomplicated. When the mother attempted to breastfeed in the first hour of life, the patient latched and sucked well but began to appear blue around the lips and face. He began crying and turned pink when he was removed from the breast. He has voided and passed meconium. The patient’s weight is appropriate for gestational age. Heart rate and 4-extremity blood pressures are normal. Examination shows a nondysmorphic neonate with mild cyanosis at rest. Auscultation shows clear lungs and no murmurs. There are no intercostal retractions or stridor. Peripheral pulses are strong and symmetric. Which of the following is the most likely diagnosis in this patient?

Answer 19

CHOANAL ATRESIA

Obstruction may be unilateral or bilateral. Unilateral choanal atresia is mild and often undiagnosed in early childhood. However, bilateral choanal atresia presents with cyanosis in the newborn period.

Question 20

(9) A 3-year-old boy is brought to the clinic by his parents due to “inattentiveness.” Over the last few months, when the mother asks him to perform tasks at home, he often ignores her and continues to do whatever he was previously engaged in. He has also seemed more withdrawn, often preferring to race his cars or flip through books alone instead of playing with his brother. The parents state that he is an “affectionate, active little boy who loves new people and places.” The patient was born at 35 weeks gestation and had a normal hearing screening at birth. He has a history of eczema and has had several ear infections since starting preschool a year ago. Family history is significant for attention deficit hyperactivity disorder in his older brother. Height and weight are stable at the 25th percentile. During the examination, the child responds only intermittently to directions. The patient can draw a square and stand on 1 foot. He speaks in brief phrases of 2 words, similar to his speech patterns at age 2. Neurologic examination is normal. Which of the following is the best next step in management?

Answer 20

Order audiometry testing

This patient age 3 with new-onset inattention has delayed language milestones. The first step in the evaluation of young children with language delay is audiometry to assess for underlying hearing loss.

Question 21

(9) hearing loss. Hearing loss may manifest solely as delays in language (eg, plateau in speech progression) and social development (eg, inattention, disinterest in activities).

Causes?

Answer 21

Congenital (anatomic malformation, genetic syndrome, infectin)

Acquired (AOM, trauma, atotoxic drugs)

Question 22

(9) Hearing loss symptoms?

Answer 22

Young children (<4 yo): Language delay, social disinterest/delay, inattention (difficulty following instructions)

Older and adolescents: subjective change in hearing

Question 23

(9) Hearing loss Dx?

Answer 23

Formal audiometry

Question 24

(10) A 14-year-old boy comes to the office due to right ear pain, pruritus, and discharge over the past week. He has had no cold symptoms, hearing loss, dizziness, or tinnitus. The patient returned yesterday from a 2-week vacation at a lake house, where he swam and fished daily. Temperature is 37.1 C (98.8 F), blood pressure is 110/70 mm Hg, and pulse is 75/min. Manipulation of the right ear during otoscopy elicits pain. There is prominent swelling and erythema of the ear canal with purulent and crusty debris. The tympanic membrane appears normal and has normal mobility. The left ear is normal. Nasal and oropharyngeal mucosa are also normal, and no rashes or skin lesions are noted. Which of the following is the most likely causative organism of this patient’s current condition? Dx?

Answer 24

Dx = otitis externa

Mos: pseudomonas aeruginosa

Question 25

(10) otitis externa Tx?

Answer 25

Remove debris Topical abs (eg fluoroquinolones) +/- topical glucocorticoids Empiric treatment regimens for P aeruginosa should include drugs with antipseudomonal activity (eg, fluoroquinolone drops). Staphylococcus aureus is also common and is typically covered by antipseudomonal antibiotics

Question 26

(11) <...> left tympanic membrane, which is pale yellow and immobile with pneumatic insufflation. Dx?

Answer 26

ACUTE OTITIS MEDIA

Question 27

(12) A 5-year-old boy is brought to the clinic due to persistent ear discharge. The patient began to have purulent right ear drainage a month ago. Topical antibiotic drops and oral antibiotics have not improved his symptoms. He has had no fever, ear pain, dizziness, or tinnitus. The patient was born with a cleft palate that was repaired in infancy. Due to bilateral persistent middle ear effusions, tympanostomy tubes were also placed. Three years ago, the tympanostomy tubes were removed, after which audiometry was normal. He has no other medical conditions. Temperature is 37.2 C (99 F). There is scant, yellow, malodorous discharge in the right ear canal. The right tympanic membrane (TM) is immobile with insufflation and appears intact. There is retraction of the superior portion of the TM and a pearly white mass. The left TM is mobile and normal in appearance. Audiometry reveals conductive hearing loss on the right side. Gait is normal. Which of the following is most likely responsible for this patient's presentation?

Answer 27

Tympanic membrane epithelium and keratin debris accumulation Dx = cholesteatoma (zymejau kad external canal epithelial maceration and inflammation)

Question 28

(12) kitas ats: external canal epithelial maceration and inflammation). Otitis externa is characterized by external ear canal maceration and inflammation and is most commonly infectious. This patient has not responded to appropriate therapy of topical antibiotics and has a distinct mass on examination suggestive of cholesteatoma

Question 29

(12) cholesteatoma finding?

Answer 29

epithelium and keratin debris, retraction pocket, pearly mass

Question 30

(13) An 8-year-old girl is brought to the office due to a small amount of left ear discharge that has persisted for 3 months. The patient was seen twice over this period and completed 2 courses of antibiotics, but the discharge has persisted. She has no pain or fever but has hearing loss on the left side. The patient has a history of recurrent ear infections. Vaccinations are up to date. Vital signs are normal. Otoscopy shows that the left tympanic membrane is partially obscured by keratin debris. Which of the following is the most likely diagnosis in this patient?

Answer 30

CHOLESTEATOMA persistent ear drainage despite antibiotic therapy, as well as keratin debris in the external auditory canal (EAC). These findings are suggestive of cholesteatoma, or the accumulation of keratin debris and benign growth of squamous epithelium within the middle ear. is chronic, painless otorrhea due to persistent inflammation of the abnormal epithelium.

Question 31

(13) cholesteatoma - what hearing loss?

Answer 31

conductive hearing loss

Question 32

(14) A 4-year-old girl is brought to the office due to a worsening cough and nasal discharge. Two weeks ago, the patient developed nasal congestion and a runny nose, which initially improved over a few days. However, for the past 10 days she has had increasing amounts of thick, yellow-green nasal discharge. She stayed home from preschool for the past 2 days due to a worsening daytime cough and has also been waking up at night with a cough. She has no chronic medical conditions and takes no daily medications. Immunizations are up to date. Temperature is 37.2 C (99 F), pulse is 90/min, and respirations are 18/min. Pulse oximetry is 99% on room air. Examination shows an alert, active child with intermittent coughing. Thick, purulent mucus is present in the nares and visualized in the posterior oropharynx. Nasal turbinates are mildly erythematous and swollen. Bilateral tympanic membranes are translucent and mobile, and the lungs are clear on auscultation. Which of the following is the best next step in management of this patient? Dx?

Answer 32

Oral abs (observation and follow up – wrong; Oral antihistamine wrong; intranasal corticosteroids wrong. Acute bacterial rhinosinusitis. This patient has worsening daytime cough and purulent nasal discharge consistent with acute bacterial rhinosinusitis (ABRS), a common complication of viral upper respiratory infection (URI). Viral URI symptoms typically self-resolve in 7-10 days. In contrast, ABRS is diagnosed by any 1 of the following 3 criteria.

Question 33

(14) Acute bacterial rhinosinusitis. table. CP?

Answer 33

Cough, nasal discharge, fever, face pain/headache.

Question 34

(14) Acute bacterial rhinosinusitis. table. Diagnostic criteria (1 of 3).

Answer 34

Persistent symptoms >= 10 days without improvement Severe onset (fever >= 39 C) for >= 3 days Worsening symptoms following initial improvement

Question 35

(14) Acute bacterial rhinosinusitis. table. Tx?

Answer 35

with oral antibiotics (eg, amoxicillin ± clavulanate)

Question 36

(14) Acute bacterial rhinosinusitis. In contrast, in patients with persistent but not worsening symptoms and a milder course, oral antibiotics or a 3-day period of observation for clinical improvement are both acceptable treatment options

Answer 36

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Question 37

(15) <.normal vitals>. On examination of the right ear, there is exquisite tenderness to movement of the pinna during otoscopy. The canal is red and swollen. Most of the tympanic membrane can be seen, and it is clear with no fluid. The left ear is normal. Which of the following risk factors most likely contributed to this patient's condition?

Answer 37

WATER EXPOSURE

Question 38

(16) A 3-hour-old girl is being evaluated in the newborn nursery for excessive coughing. The patient was being bottle-fed by her mother and within a few minutes began coughing forcefully. The mother allowed the infant to rest, but she continued to cough. The patient was born via spontaneous vaginal delivery to a 30-year-old primigravida who had no prenatal care. Ballard score estimates the infant to be around 38 weeks gestation. Vital signs are normal. The patient is awake, and the coughing has subsided. The oropharynx is clear with an intact palate. Lung examination reveals coarse breath sounds, particularly on the right side. Abdominal examination shows no organomegaly. When a nasogastric tube is inserted, itencounters resistance at 10 cm. Chest radiograph shows that the end of the tube is at the upper esophagus. Which of the following additional evaluations is currently indicated in this patient?

Answer 38

RENAL UG and cardiac UG (vs no additional workup) VACTERL/CHARGE SYNDROMES!!!! For this reason, evaluation of all patients who have TEF with EA should include screening echocardiography and renal ultrasonography. Contrast enema (to detect anal atresia) and limb radiographs may also be performed if clinical suspicion for VACTERL association is high.

Question 39

(16) charge/VACTERL syndromes. For this reason, evaluation of all patients who have TEF with EA should include screening echocardiography and renal ultrasonography.

Answer 39

Up to 50% of patients who have TEF with EA have other congenital abnormalities, such as those included in the VACTERL association (Vertebral, Anal, Cardiac, TracheoEsophageal fistula, Renal, and/or Limb anomalies). TEF with EA is also less commonly associated with CHARGE syndrome (Coloboma, Heart defects, Atresia choanae, Retardation of growth, Genitourinary anomalies, and Ear abnormalities).

Question 40

(17) A 7-year-old boy is brought to the clinic by his mother for evaluation of rhinorrhea. Three days ago, the patient developed rhinorrhea and a cough that is worse at night. For the past day, he has had intermittent, mild pain around the upper cheeks, particularly when leaning forward. He had fever on the first day of illness but has been afebrile for 48 hours. The patient's appetite is decreased, but he is drinking fluids and voiding normally. He has no chronic medical conditions and takes no medication. Immunizations are up to date. Temperature is 37.6 C (99.7 F), pulse is 100/min, and respirations are 20/min. The patient is well-appearing and comfortable on examination. The tympanic membranes are clear. Nasal discharge is profuse and yellow-green in color. The posterior oropharynx is erythematous. Palpation over the upper cheeks bilaterally causes mild discomfort. Cardiopulmonary examination is unremarkable. The abdomen is soft with no organomegaly. Which of the following is the best next step in management of this patient?

Answer 40

SUPPORTIVE CARE (zymejau oral abs, nes galvojau apie bakterini) Dx = acute rhinosinusitis This afebrile patient with 3 days of purulent nasal discharge and mild pain with palpation of the maxillary sinuses likely has acute viral rhinosinusitis.

Question 41

(17) Rhinosinusitis is a common infection of the upper respiratory tract characterized by inflammation of the nasal passages and paranasal sinuses. Presenting symptoms include nasal congestion and/or purulent discharge in addition to facial pressure/pain that is exacerbated by leaning forward (as seen in this patient). Pain with palpation or percussion of sinuses is common. Additional symptoms may include fever, cough, headache, ear pain, and loss of smell.

Answer 41

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Question 42

(17) Viral vs bacterial rhinosinusitis. Viral rhinosinusitis can be differentiated from bacterial rhinosinusitis by the duration and severity of symptoms. History suggestive of a viral etiology includes mild symptoms (eg, no fever or early resolution of fever, mild pain) and improvement by day 5-10. In contrast, the clinical course of bacterial rhinosinusitis is one of the following: severe in onset (ie, high fever for ≥3 days), persistent (ie, symptoms lasting ≥10 days without improvement), or biphasic (ie, recurrent fever after initial improvement).

Answer 42

.

Question 43

(17) Viral vs bacterial rhinosinusitis. table. CP jau mineta kur budinga abiems, tipo congestion, purulent discharge. Viral CP?

Answer 43

no fever/early resolution of fever Mild symptoms (well-appearing, mild facial pain) Improvement and resolution by day 5-10

Question 44

(17) Viral vs bacterial rhinosinusitis. table. CP jau mineta kur budinga abiems, tipo congestion, purulent discharge. Bacterial CP?

Answer 44

Fever >= 3 days OR New/recurrent fever after initial improvement OR Persistent symptoms >= 10 days 1 of 3 criteria

Question 45

(17) Management of viral rhinosinusitis is supportive care, including intranasal saline, saline irrigation, and nonsteroidal anti-inflammatory drugs.

Answer 45

Antibiotics (eg, amoxicillin, amoxicillin-clavulanate) are indicated for acute bacterial rhinosinusitis.

Question 46

(18) Epiglotitis Cp -> intubation -> best empiric therapy?

Answer 46

best empiric antibiotic therapy for this patient? CEFTRIAXONE AND VANCOMYCIN (Zymejau ampicillin and gentamicin) Ceftriaxone (targeting H influenzae and Streptococcus species) and vancomycin (targeting S aureus, including methicillin-resistant strains) should be initiated promptly. Most commonly Haemophilus influenzae type b (Hib). Due to widespread vaccination against Hib, the incidence of epiglottitis has diminished. However, the proportion of epiglottitis caused by other pathogens, such as other strains of H influenzae, Streptococcus species (S pneumoniae, S pyogenes), and Staphylococcus aureus, has increased

Question 47

(19) Epiglotitis Cp and Xray foto.

Answer 47

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Question 48

(20) A 14-year-old boy comes to the emergency department due to sore throat and fever. He started having a mild sore throat after returning from summer camp approximately a week ago, and it has progressively worsened in the last 2 days. The patient has difficulty swallowing and an earache but no cough or shortness of breath. His voice is muffled. Temp. 38.8 C (101.8 F), BP 118/74, pulse 104/min. There is no neck pain on extension or stiffness. Enlarged and tender cervical lymph nodes are present. The patient is unable to fully open his mouth, but examination of the oral cavity shows pooling of saliva, a large right tonsil with swelling of the right soft palate, and deviation of the uvula to the left. Ear examination shows normal tympanic membranes. Which of the following is the most appropriate next step in diagnosis of this patient?

Answer 48

No additional diagnostic testing needed Dx = peritonsilar abscess zymejau CT - CT scan of the neck is indicated only if there are concerning signs that a PTA has spread to involve deep spaces of the neck (eg, retropharyngeal or parapharyngeal abscess).

Question 49

(20) Tx of peritonsilar abscess?

Answer 49

Treatment of PTA involves needle aspiration or incision and drainage plus antibiotic therapy to cover group A hemolytic Streptococcus and respiratory anaerobes.

Question 50

(20) peritonsilar CP?

Answer 50

muffled ("hot potato") voice, trismus (eg, inability to open the mouth fully, due to inflammation of the pterygoid muscles), dysphagia, and unilateral swelling of the soft palate with uvular deviation.

Question 51

(21) A 3-month-old girl undergoes flexible fiberoptic laryngoscopy for evaluation of noisy breathing. Two weeks ago, the patient began making squeaky noises when lying on her back, which have been getting progressively louder and more persistent. Her mother has been putting her to sleep on the stomach, which quiets the breathing. The patient is adequately gaining weight, is breastfeeding well, and does not appear to have labored breathing or cyanosis. Flexible fiberoptic laryngoscopy shows that both nasal cavities are patent to the nasopharynx. The adenoids are small and nonobstructive, and the palate functions well with symmetric elevation. The tonsils and base of tongue are small and not obstructive. There is intermittent collapse of the arytenoid cartilages into the airway, which worsens during crying. The vocal cords are mobile. This patient is most likely making which of the following abnormal sounds?

Answer 51

INSPIRATORY STRIDOR inspiratory collapse of the supraglottic tissues (eg, epiglottis, arytenoids), leading to partial obstruction of the airway and thus inspiratory stridor

Question 52

(22) When the patient is placed supine on the examination table, inspiratory stridor is heard, which resolves quickly when he is placed in the prone position. No cyanosis is noted. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

Answer 52

LARYNGOMALACIA

Question 53

(23) A 20-month-old girl is brought to the office due to fever and fussiness for the past 5 days. She has been less playful than usual and is not eating well today. The patient has had several episodes of acute otitis media in the last year, all of which resolved with oral antibiotics. Temperature is 38.6 C (101.5 F), blood pressure is 100/60 mm Hg, and pulse is 120/min. Examination of the right ear reveals a protruded auricle with tenderness and swelling behind the ear. Otoscopy reveals narrowing of the external ear canal; the tympanic membrane cannot be seen. Left ear examination is normal. Which of the following is the most likely diagnosis?

Answer 53

ACUTE MASTOIDITIS (zymejau perichondritis)

Question 54

(24) 5 y/o boy is brought to the clinic due to persistent ear drainage. The patient first developed drainage from his right ear 6 months ago. When the drainage did not improve with antibiotics, he was diagnosed with a cholesteatoma, which was removed. After surgery, the patient's symptoms improved but recurred following an episode of acute otitis media. Over the past 2 months, he has been treated with several oral antibiotics with only transient improvement. Examination shows copious, foul-smelling, purulent drainage from the right ear canal. The ear is suctioned, revealing a normal-appearing external canal. The tympanic membrane is heavily scarred with a large perforation and no cholesteatoma. Which of the following organisms is the most likely cause of this patient's infection?

Answer 54

PSEUDOMONAS AERUGINOSA Dx = This patient has chronic, purulent ear drainage with a tympanic membrane (TM) perforation, findings consistent with chronic suppurative otitis media (CSOM).

Question 55

(24) chronic suppurative otitis media (CSOM). Causes?

Answer 55

Often polymicrobal, most commonly with Staphylococcus aureus and/or Pseudomonas aeruginosa.

Question 56

(24) chronic suppurative otitis media (CSOM). Most common in young children due to an increased incidence of acute otitis media, a major risk factor for CSOM. Conditions that lead to negative middle ear pressure (eg, dysfunction of the eustachian tubes, cholesteatoma) also contribute to the pathogenesis because the TM can weaken over time with sustained pressure, increasing the risk of perforation, as seen in this patient. Bacteria from the external auditory canal are then introduced into the middle ear and can lead to chronic inflammation and infection

Answer 56

.

Question 57

(24) chronic suppurative otitis media (CSOM). CP?

Answer 57

chronic (>6 weeks) purulent otorrhea with TM perforation. The external ear canal typically appears normal, and ear pain is uncommon.

Question 58

(24) chronic suppurative otitis media (CSOM). Tx?

Answer 58

Diagnosis is clinical, and management is ototopical fluoroquinolone drops.

Question 59

(24) chronic suppurative otitis media (CSOM). vs cholesteatoma.

Answer 59

CSOM does not typically respond to oral antibiotics, as seen in this patient, because the middle ear is poorly vascularized due to chronic inflammation and scarring. Of note, cholesteatoma can also cause chronic ear drainage, as seen in this patient's history, and should be considered when the condition does not respond to topical therapy for presumed CSOM.

Question 60

(26) A 6-year-old boy is brought to the office for evaluation of a neck lump. His mother first noticed the mass 2 weeks ago while he was experiencing cold symptoms. His nasal congestion and fever resolved within several days with symptomatic treatment, but the mass failed to improve. The patient was born at full term without pregnancy complications and has been healthy until now. He has received all recommended vaccines and takes no medications. The patient is afebrile, and height and weight are at the 60th percentile for his age. Physical examination shows a 1.5-cm, soft, mildly tender mass in the midline upper neck. It moves up and down when the patient swallows; there are no other neck masses. The nasal turbinates are pink with no rhinorrhea, and the tonsils are normal with no erythema or exudates. The remainder of the examination shows no abnormalities. Which of the following is the most likely underlying cause of this patient's condition?

Answer 60

EMBRYOLOGIC ANOMALY This patient with a midline neck mass that moves superiorly with swallowing has a thyroglossal duct cyst (TDC). A TDC is often detected when it becomes secondarily infected after an upper respiratory tract infection, leading to erythema and tenderness. It may also be noted incidentally.

Question 61

(26) Examination shows a somewhat anxious child. There is no rhinorrhea. Physical examination of the oropharynx shows normal tonsils with no exudate or erythema. There is no cervical adenopathy. The patient cries during examination of the right ear, which reveals a tender, swollen ear canal. Although only a part of the tympanic membrane is seen, it appears normal. The left ear is normal. Which of the following is the most appropriate treatment for this patient's condition?

Answer 61

TOPICAL CIPROFLOXACIN Dx = otitis externa Topical therapy (eg, ciprofloxacin [± glucocorticoid] drops) is appropriate for uncomplicated otitis externa

Question 62

(27) . On physical examination, the patient has inspiratory stridor when he is supine that improves when he is prone. The remainder of the examination is normal. Which of the following would confirm the most likely diagnosis for this patient?

Answer 62

FLEXIBLE FIBEROPTIC LARYNGOSCOPY Dx = laryngomalacia