Ophtho / ENT

Question 1

Leukoria - white pupillary reflex that can be due to chorioretinitis, ROP, or retinoblastoma

• Should be considered retinoblastoma until proven otherwise
• Immediate referral to an ophthalmologist.

Answer 1

Leukoria - white pupillary reflex that can be due to chorioretinitis, ROP, or retinoblastoma

• Should be considered retinoblastoma until proven otherwise
• Immediate referral to an ophthalmologist.

Question 2

Congenital cataract

• 50% of congenital cataracts are idiopathic and 25% are genetic. The remainder are caused by infection, metabolic disease, and acquired causes.
  
  • Metabolic:
    
    • ______ is one of the most common metabolic causes of congenital cataracts
    • Hypoparathyroidism, hypoglycemia, diabetes mellitus
  • Infection: TORCH infections
  • Genetic: Chromosomal abnormalities, such as trisomies 13, 18, and 21
• Unilateral cataract is usually sporadic and not associated with a systemic disease. Bilateral cataracts, however, can be caused by autosomal dominant inheritance, trisomy syndromes (21, 13, 18), metabolic disorders (galactosemia), and intrauterine infections (TORCH).
• Pt:
  
  • Asymmetric retinal red reflexes that are absent, dulled, or opaque. Dark spots in the red reflex. Or leukoria (white reflex).
  • Nystagmus
• Screening: Red reflex test is the most useful assessment to detect lens opacity. If abnormal, a complete eye exam must be done by an ophthalmologist.
• Management:
  
  • Urgent referral to pediatric ophthalmologist.

Answer 2

Congenital cataract

• 50% of congenital cataracts are idiopathic and 25% are genetic. The remainder are caused by infection, metabolic disease, and acquired causes.
  
  • Metabolic:
    
    • Galactosemia is one of the most common metabolic causes of congenital cataracts
    • Hypoparathyroidism, hypoglycemia, diabetes mellitus
  • Infection: TORCH infections
  • Genetic: Chromosomal abnormalities, such as trisomies 13, 18, and 21
• Unilateral cataract is usually sporadic and not associated with a systemic disease. Bilateral cataracts, however, can be caused by autosomal dominant inheritance, trisomy syndromes (21, 13, 18), metabolic disorders (galactosemia), and intrauterine infections (TORCH).
• Pt:
  
  • Asymmetric retinal red reflexes that are absent, dulled, or opaque. Dark spots in the red reflex. Or leukoria (white reflex).
  • Nystagmus
• Screening: Red reflex test is the most useful assessment to detect lens opacity. If abnormal, a complete eye exam must be done by an ophthalmologist.
• Management:
  
  • Urgent referral to pediatric ophthalmologist.

Question 3

Glaucoma

• Pt:
  
  • Triad (<30% of patients): ____, ____, and ____
  • Enlarged cornea that becomes progressively cloudy. Corneal clouding, enlargement of eye
    
    • Corneal diameter >11mm warrants further investigation
  • On fundoscopic exam, cupping and atrophy of the optic nerve may be noted.
• Management:
  
  • Immediate referral to ophthalmologist for fundoscopic exam and measurement of intraocular pressure. Pressures >____mmHg are considered elevated, putting child at increased risk for permanent damage.

Answer 3

Glaucoma

• Pt:
  
  • Triad (<30% of patients): Excessive tearing, photophobia, and frequent blinking of eyelid due to muscle spasms
  • Enlarged cornea that becomes progressively cloudy. Corneal clouding, enlargement of eye
    
    • Corneal diameter >11mm warrants further investigation
  • On fundoscopic exam, cupping and atrophy of the optic nerve may be noted.
• Management:
  
  • Immediate referral to ophthalmologist for fundoscopic exam and measurement of intraocular pressure. Pressures >20mmHg are considered elevated, putting child at increased risk for permanent damage.

Question 4

Visual Development
- Visual fixation can be demonstrated soon after birth and achieves accuracy by 6-8 weeks.

• By 2 months, infants should track across midline.
• Due to its size and shape, the normal age at birth is often hyperopic (farsighted).
• Color discrimination occurs by 2 weeks of age and improves over the next 3 months.

Answer 4

Visual Development
- Visual fixation can be demonstrated soon after birth and achieves accuracy by 6-8 weeks.

• By 2 months, infants should track across midline.
• Due to its size and shape, the normal age at birth is often hyperopic (farsighted).
• Color discrimination occurs by 2 weeks of age and improves over the next 3 months.

Question 5

Strabismus
- Continuous or intermittent malalignment of one or both eyes, in which one or both eyes are turned in (esotropia), out (exotropia), up (hypertropia), or down (hypotropia).

• Physical exam reveals asymmetric corneal light reflex (light reflex is either nasal or temporal to the pupil) and abnormal cover/uncover test (ie movement of the uncovered eye that is fixated on a target when the other eye is covered).
• While ocular instability of infancy is frequently present in normal newborns during the first few months of life, refer for possible pathologic strabismus if it persists past ____ months.
• Tx begins with patching and should occur based on recommendations from peds ophthalmology

Answer 5

Strabismus
- Continuous or intermittent malalignment of one or both eyes, in which one or both eyes are turned in (esotropia), out (exotropia), up (hypertropia), or down (hypotropia).

• Physical exam reveals asymmetric corneal light reflex (light reflex is either nasal or temporal to the pupil) and abnormal cover/uncover test (ie movement of the uncovered eye that is fixated on a target when the other eye is covered).
• While ocular instability of infancy is frequently present in normal newborns during the first few months of life, refer for possible pathologic strabismus if it persists past 4 months.
• Tx begins with patching and should occur based on recommendations from peds ophthalmology

Question 6

Pseudostrabismus / Pseudoesotropia

• The result of wide nasal bridge, prominent epicanthal folds (which obscure the nasal sclera, particularly when the child looks to the right or left), or a narrow interpupillary distance.
• On formal testing, a _____ light reflex is demonstrated on both examination of the corneal light reflex and the cover/uncover test, thereby confirm child has pseudostrabismus.
  
  • True strabismus may be ruled out with normal examination findings of the red reflex, corneal light reflex (Hirschberg test), and cover test
• Once pseudostrabismus has been confirmed, the pts can be reassured that the child will outgrow the appearance of esotropia.

Answer 6

Pseudostrabismus / Pseudoesotropia

• The result of wide nasal bridge, prominent epicanthal folds (which obscure the nasal sclera, particularly when the child looks to the right or left), or a narrow interpupillary distance.
• On formal testing, a symmetric light reflex is demonstrated on both examination of the corneal light reflex and the cover/uncover test, thereby confirm child has pseudostrabismus.
  
  • True strabismus may be ruled out with normal examination findings of the red reflex, corneal light reflex (Hirschberg test), and cover test
• Once pseudostrabismus has been confirmed, the pts can be reassured that the child will outgrow the appearance of esotropia.

Question 7

AMBLYOPIA
- Def: Reduced visual acuity because of abnormal visual development early in life

• Path:
  
  • Often due to strabismus, refractive disorders, cataracts, corneal opacities, or anisometropia (different visual acuity / unequal refractive error in each eye)
• Early detection and tx improves outcomes. Tx is most effective when initiated before 7yo.
  
  • Have the child use the amblyopic eye by patching the better-seeing eye with a patch or cycloplegic eye drops.

Answer 7

AMBLYOPIA
- Def: Reduced visual acuity because of abnormal visual development early in life

• Path:
  
  • Often due to strabismus, refractive disorders, cataracts, corneal opacities, or anisometropia (different visual acuity / unequal refractive error in each eye)
• Early detection and tx improves outcomes. Tx is most effective when initiated before 7yo.
  
  • Have the child use the amblyopic eye by patching the better-seeing eye with a patch or cycloplegic eye drops.

Question 8

Color vision defects

• The ability to match colors is present by 2yo.
• Due to X-linked protan and deutan deficits (red-green color blindness).

Answer 8

Color vision defects

• The ability to match colors is present by 2yo.
• Due to X-linked protan and deutan deficits (red-green color blindness).

Question 9

Optic nerve hypoplasia

• Optic nerve hypoplasia is an example of a midline facial defect (other defects include a single central incisor, cleft lip/palate, male with microphallus or undescended testicle)
• Path: ____ and ____ are the most common cause of optic atrophy in children
• It is characterized by pallor of the disc, loss of substance of the nerve head, and enlargement of the disc cup

Answer 9

Optic nerve hypoplasia

• Optic nerve hypoplasia is an example of a midline facial defect (other defects include a single central incisor, cleft lip/palate, male with microphallus or undescended testicle)
• Path: Intracranial tumors and hydrocephalus are the most common cause of optic atrophy in children
• It is characterized by pallor of the disc, loss of substance of the nerve head, and enlargement of the disc cup

Question 10

NYSTAGMUS

• 1. Jerk nystagmus (more common): 2 components of slow and fast. It is further characterized by direction and appearance (downbeat, upbeat, horizontal, torsional, mixed).
     - Fast component defines the direction of the nystagmus
     - Most common in vestibular disorders but does not indicate whether the lesion is within the CNS or if it involves the cranial nerve itself.
• 2. Pendular nystagmus (like pendulum): Slow sinusoidal oscillation lacking fast component
     - Vertical pendular nystagmus is considered pathologic and always warrants further investigation.
• Drugs (antiepileptic medications) can cause horizontal and vertical gaze-evoked nystagmus (occurring when the person looks right, left, or up) - present in all directions.

Answer 10

NYSTAGMUS

• 1. Jerk nystagmus (more common): 2 components of slow and fast. It is further characterized by direction and appearance (downbeat, upbeat, horizontal, torsional, mixed).
     - Fast component defines the direction of the nystagmus
     - Most common in vestibular disorders but does not indicate whether the lesion is within the CNS or if it involves the cranial nerve itself.
• 2. Pendular nystagmus (like pendulum): Slow sinusoidal oscillation lacking fast component
     - Vertical pendular nystagmus is considered pathologic and always warrants further investigation.
• Drugs (antiepileptic medications) can cause horizontal and vertical gaze-evoked nystagmus (occurring when the person looks right, left, or up) - present in all directions.

Question 11

Spasmus Nutans
- Path: Unclear

• Pt:
  
  • Benign childhood condition characterized by a clinical triad of dysconjugate___, ___, and ___
• Typically present in the __ year, usually after ___ months of age, and resolves during childhood.
• Dx: Exclusion of secondary pathology that can mimic its presentation, including optic pathway gliomas and retinal dystrophy.

Answer 11

Spasmus Nutans
- Path: Unclear

• Pt:
  
  • Benign childhood condition characterized by a clinical triad of dysconjugate pendular nystagmus, torticollis, and head bobbing.
• Typically present in the 1st year, usually after 6 months of age, and resolves during childhood.
• Dx: Exclusion of secondary pathology that can mimic its presentation, including optic pathway gliomas and retinal dystrophy.

Question 12

Congenital or Infantile Nystagmus

• Pt:
  
  • Presents in the first ___ months after birth. Although present at birth, it is often first appreciated and diagnosed around 3 months of age as infants begin to fixate on objects.
  • Characterized by a _____ oscillation with a mixture of jerk and pendular features.
  • Close attention to visual development is important.
• Main differential is spasmus nutans. The 2 conditions can be distinguished by age of onset, appearance of nystagmus, and accompanying features.

Answer 12

Congenital or Infantile Nystagmus

• Pt:
  
  • Presents in the first 6 months after birth. Although present at birth, it is often first appreciated and diagnosed around 3 months of age as infants begin to fixate on objects.
  • Characterized by a conjugate horizontal oscillation with a mixture of jerk and pendular features.
  • Close attention to visual development is important.
• Main differential is spasmus nutans. The 2 conditions can be distinguished by age of onset, appearance of nystagmus, and accompanying features.

Question 13

Bacterial conjunctivitis

• Path: Staph aureus, Strep pneumoniae, Moraxella catarrhalis, H influenzae
  
  • 12-36 months: Conjunctivitis in this age group is nearly 2x as likely to be bacterial in origin, with the most common causative pathogens being Haemophilus influenzae, Strep pneumoniae, and Strep pyogenes
• Tx: Can allow parents to watch 1-2 days and then use prescription if not improving
  
  • Infants: ____ ointment (up until 1yo)
  • Children: ____ or bacitracin-polymycin drops q3h for 7-10 days. Azithromycin drops.
  • Preferred agent in contact lens wearers: ____ drops for pseudomonas
  • If eye infection AND ear infection, use ____

Answer 13

Bacterial conjunctivitis

• Path: Staph aureus, Strep pneumoniae, Moraxella catarrhalis, H influenzae
  
  • 12-36 months: Conjunctivitis in this age group is nearly 2x as likely to be bacterial in origin, with the most common causative pathogens being Haemophilus influenzae, Strep pneumoniae, and Strep pyogenes
• Tx: Can allow parents to watch 1-2 days and then use prescription if not improving
  
  • Infants: erythromycin ointment (up until 1yo)
  • Children: Polymyxin-trimethoprim or bacitracin-polymycin drops q3h for 7-10 days. Azithromycin drops.
  • Preferred agent in contact lens wearers: Fluoroquinolone drops for pseudomonas
  • If eye infection AND ear infection, use augmentin

Question 14

Viral conjunctivitis

• Path: ____ is the most common viral cause.
• Tx: Warm or cool compresses and artificial tears.
• The specific syndrome of pharyngoconjunctival fever is caused by ____ (throat and eye)

Answer 14

Viral conjunctivitis

• Path: Adenovirus is the most common viral cause.
• Tx: Warm or cool compresses and artificial tears.
• The specific syndrome of pharyngoconjunctival fever is caused by adenovirus (throat and eye)

Question 15

Pharyngoconjunctival fever

• Path: Caused by ____ types 3, 4, 5, or 7
• Pt:
  
  • Fever, pharyngitis, cervical and preauricular lymphadenopathy, follicular conjunctivitis
• Management:
  
  • Symptomatic care including cool compresses to the eyes, lubrication with artificial tears, analgesics, rest, and fluids

Answer 15

Pharyngoconjunctival fever

• Path: Caused by adenovirus types 3, 4, 5, or 7
• Pt:
  
  • Fever, pharyngitis, cervical and preauricular lymphadenopathy, follicular conjunctivitis
• Management:
  
  • Symptomatic care including cool compresses to the eyes, lubrication with artificial tears, analgesics, rest, and fluids

Question 16

Epidemic keratoconjunctivitis (EKC)
- \_\_\_\_\_\_\_-associated EKC outbreaks have been reported worldwide and are associated with significant morbidity.  EKC can result from direct or close contact with infected health care workers or contaminated equipment during ophthalmologic examinations. Outbreaks have been identified in various hospital settings including ophthalmology clinics, NICUs (following eye exams for ROP), as well as day-care centers with spread to local hospitals.

• Path: Adenovirus is a double-stranded, nonenveloped DNA virus that is viable for prolonged periods on environmental surfaces and fomites and is refractory to many forms of disinfection.
• Pt:
  • Severe follicular conjunctivitis with corneal inflammation (keratitis)

Answer 16

Epidemic keratoconjunctivitis (EKC)
- Adenovirus-associated EKC outbreaks have been reported worldwide and are associated with significant morbidity.  EKC can result from direct or close contact with infected health care workers or contaminated equipment during ophthalmologic examinations. Outbreaks have been identified in various hospital settings including ophthalmology clinics, NICUs (following eye exams for ROP), as well as day-care centers with spread to local hospitals.

• Path: Adenovirus is a double-stranded, nonenveloped DNA virus that is viable for prolonged periods on environmental surfaces and fomites and is refractory to many forms of disinfection.
• Pt:
  • Severe follicular conjunctivitis with corneal inflammation (keratitis)

Question 17

Allergic Conjunctivitis

• Tx:
  
  • Topical or systemic _____ are 1st line therapies and are effective in reducing symptoms in most patients.
    
    • Ketotifen eye drops, an H1-antihistamine and mast cell stabilizer

Answer 17

Allergc Conjunctivitis

• Tx:
  
  • Topical or systemic antihistamines are 1st line therapies and are effective in reducing symptoms in most patients.
    
    • Ketotifen eye drops, an H1-antihistamine and mast cell stabilizer

Question 18

OPHTHALMIA NEONATORUM

• Eye discharge within _ hours of delivery - almost always the result of chemical reaction to the prophylaxis
• Eye discharge within - days of birth - ____
• Eye discharge within - days of birth - ____

Answer 18

OPHTHALMIA NEONATORUM

• Eye discharge within 48 hours of delivery - almost always the result of chemical reaction to the prophylaxis
• Eye discharge within 2-7 days of birth - N gonorrhoeae
• Eye discharge within 7-14 days of birth - C trachomatis

Question 19

Gonorrhea conjunctivitis
- Pt: Most commonly presents in 1-7 days, most commonly within 24-48 hours, after birth with severe bilateral conjunctivitis with a markedly swollen eye and copious purulent discharge- bloody, green, or serosanguineous. There is significant eyelid swelling and chemosis. There is diffuse corneal edema and ulceration

• Tx: Medical emergency bc it can progress to involve the cornea and ulceration/perforation can occur if untreated.
  
  • Hospitalization and IM/IV _______ x1 (3rd generation) or cefotaxime, started prior to cultures.
• Ppx: topical 0.5% _______ at birth

Answer 19

Gonorrhea conjunctivitis
- Pt: Most commonly presents in 1-7 days, most commonly within 24-48 hours, after birth with severe bilateral conjunctivitis with a markedly swollen eye and copious purulent discharge- bloody, green, or serosanguineous. There is significant eyelid swelling and chemosis. There is diffuse corneal edema and ulceration

• Tx: Medical emergency bc it can progress to involve the cornea and ulceration/perforation can occur if untreated.
  
  • Hospitalization and IM/IV ceftriaxone x1 (3rd generation) or cefotaxime, started prior to cultures.
• Ppx: topical 0.5% erythromycin at birth

Question 20

Chlamydia conjunctivitis
- Pt: Onset: 5-14 days of life after with birth (about 1 week age) with mild unilateral or bilateral watery discharge that becomes purulent

• Tx: Oral ______ 50mg/kg per day in four divided doses for 14 days
• Follow-up: Extraocular infection: Risk for chlamydial ____, which presents between ____ weeks of life, usually afebrile/minimal fever with ____ cough.
  • Pt:
    
    • Common infection in the first 4 months of life
    • Most present with afebrile pneumonia, persistent staccato cough, and lab findings of peripheral _____. They do well.
    • Rhinorrhea, congestion, tachypnea, pertussis-like cough (nonproductive and staccato).
  • CXR: Hyperinflation with bilateral symmetrical interstitial infiltrates
  • Tx: Oral _____ or ethylsuccinate for 14 days. Azithromycin may be given.

Answer 20

Chlamydia conjunctivitis
- Pt: Onset: 5-14 days of life after with birth (about 1 week age) with mild unilateral or bilateral watery discharge that becomes purulent

• Tx: Oral erythromycin 50mg/kg per day in four divided doses for 14 days
• Follow-up: Extraocular infection: Risk for chlamydial pneumonia, which presents between 4-12 weeks of life, usually afebrile/minimal fever with staccato cough.
  • Pt:
    
    • Common infection in the first 4 months of life
    • Most present with afebrile pneumonia, persistent staccato cough, and lab findings of peripheral eosinophilia. They do well.
    • Rhinorrhea, congestion, tachypnea, pertussis-like cough (nonproductive and staccato).
  • CXR: Hyperinflation with bilateral symmetrical interstitial infiltrates
  • Tx: Oral erythromycin or ethylsuccinate for 14 days. Azithromycin may be given.

Question 21

Herpes simplex virus (HSV)

• Pt:
  
  • Generalized HSV infection with classic herpetic lesions on the skin surrounding eye and on corneal epithelium
  • ____ ulcer, vesicles in cornea. Pain, photophobia, decreased vision
• Tx:
  
  • Hospital admission for antiviral therapy IV acyclovir for systemic infection and investigation for disseminated or CNS involvement

Answer 21

Herpes simplex virus (HSV)

• Pt:
  
  • Generalized HSV infection with classic herpetic lesions on the skin surrounding eye and on corneal epithelium
  • Dendritic ulcer, vesicles in cornea. Pain, photophobia, decreased vision
• Tx:
  
  • Hospital admission for antiviral therapy IV acyclovir for systemic infection and investigation for disseminated or CNS involvement

Question 22

Parinaud oculoglandular syndrome is an uncommon systemic condition that includes unilateral granulomatous conjunctivitis with preauricular and submandibular lymphadenopathy.

• The most common causative organism is _____, which can also cause neuroretinitis in association with cat-scratch disease. Additional causes include Chlamydia, Francisella, Mycobacterium tuberculosis, Sporothrix, Coccidioides, Actinomyces, and Treponema pallidum.

Answer 22

Parinaud oculoglandular syndrome is an uncommon systemic condition that includes unilateral granulomatous conjunctivitis with preauricular and submandibular lymphadenopathy.

• The most common causative organism is Bartonella henselae, which can also cause neuroretinitis in association with cat-scratch disease. Additional causes include Chlamydia, Francisella, Mycobacterium tuberculosis, Sporothrix, Coccidioides, Actinomyces, and Treponema pallidum.

Question 23

PRESEPTAL / PERIORBITAL CELLULITIS

• Path:
  
  • 1) Secondary to localized infection or inflammation of the conjunctiva, eyelid, or adjacent structures.
    
    • Typically caused by contiguous spread of infection from surrounding soft tissue due to trauma or from sinusitis
  • 2) Hematogenous dissemination of nasopharyngeal pathogens to the periorbital tissue
  • 3) Manifestation of inflammatory edema in pts with acute sinusitis
• Causes:
  
  • Most common etiologic agents include ______ and group A Strep.
• Dx:
  
  • Clinical. ___ to rule out orbital cellulitis
• Tx:
  
  • Oral antibiotics that treat Staph aureus (including MRSA) and group A strep. 10-days course of therapy generally results in successful outcome.
    
    • ___ OR ____
    • In combination with ____ or a____ or cefpodoxime or cefdinir or linezolid
  • Hospitalize patients who are <1yo

Answer 23

PRESEPTAL / PERIORBITAL CELLULITIS

• Path:
  
  • 1) Secondary to localized infection or inflammation of the conjunctiva, eyelid, or adjacent structures.
    
    • Typically caused by contiguous spread of infection from surrounding soft tissue due to trauma or from sinusitis
  • 2) Hematogenous dissemination of nasopharyngeal pathogens to the periorbital tissue
  • 3) Manifestation of inflammatory edema in pts with acute sinusitis
• Causes:
  
  • Most common etiologic agents include Staph aureus (including MRSA) and group A Strep.
• Dx:
  
  • Clinical. CT to rule out orbital cellulitis
• Tx:
  
  • Oral antibiotics that treat Staph aureus (including MRSA) and group A strep. 10-days course of therapy generally results in successful outcome.
    
    • Clindamycin OR TMP-SMX
    • In combination with amoxicillin or amoxicillin/clavulanic acid or cefpodoxime or cefdinir or linezolid
  • Hospitalize patients who are <1yo

Question 24

POSTSEPTAL / ORBITAL CELLULITIS
- Serious infection of orbital tissue posterior to the orbital septum, usually complicating sinusitis (especially ethmoid sinus) and classically occurs following a URI.

• Pt:
  
  • Preseptal cellulitis sx PLUS _____ , ____, papilledema, +/- proptosis
• Dx:
  
  • All patients with a suspected diagnosis of orbital cellulitis should undergo _____ with contrast to confirm the diagnosis and exclude orbital complications including subperiosteal abscess and orbital abscess.
• Tx:
  
  • Empiric antimicrobial therapy of orbital cellulitis should be rapidly initiated with IV ____ and ____ to treat MRSA and other microorganisms associated with sinusitis.
  • A 5-7 day course of parenteral antibiotic therapy (until the eye examination results are greatly improved), followed by 2 weeks of oral antibiotics, is recommended.

Answer 24

POSTSEPTAL / ORBITAL CELLULITIS
- Serious infection of orbital tissue posterior to the orbital septum, usually complicating sinusitis (especially ethmoid sinus) and classically occurs following a URI.

• Pt:
  
  • Preseptal cellulitis sx PLUS ophthalmologia (diplopia/double vision), pain with extraocular movements, papilledema, +/- proptosis
• Dx:
  
  • All patients with a suspected diagnosis of orbital cellulitis should undergo orbital CT with contrast to confirm the diagnosis and exclude orbital complications including subperiosteal abscess and orbital abscess.
• Tx:
  
  • Empiric antimicrobial therapy of orbital cellulitis should be rapidly initiated with IV ampicillin-sulbactam and vancomycin to treat MRSA and other microorganisms associated with sinusitis.
  • A 5-7 day course of parenteral antibiotic therapy (until the eye examination results are greatly improved), followed by 2 weeks of oral antibiotics, is recommended.

Question 25

Keratitis

- Infection of layer of ___

Answer 25

Keratitis

- Infection of layer of cornea

Question 26

Ultraviolet keratitis - ultraviolet UV light exposure to unprotected eye

• Normal daylight does not produce enough UV light to cause burns. However, when normal daylight is reflected from snow or water, enough UV light can reflect into the eye to cause injury. This can also happen during mountain climbing, in the thin atmosphere. Injury may also occur when the eye is exposed to an artificial source, such as tanning or welding
• Pt: Ocular pain, often very severe, foreign body sensation, photophobia, tearing, conjunctival erythema, chemosis, and eyelid swelling. Visual acuity changes are very common. Symptoms may appear in 1 hour if the injury is severe, but generally appear 6-12 hours after exposure
• If fluorescein staining is done, will reveal superficial punctate epithelial surface irregularities that typically cover entire surface of cornea.
• Tx:
  
  • Self-limiting. Remove patient from offending situation to resolve symptoms. Once removed, symptoms start to resolve in 24 hours and are typically resolved within 72 hours.
  • ______, commonly need oral narcotics to tolerate their pain until symptoms resolve.

Answer 26

Ultraviolet keratitis - ultraviolet UV light exposure to unprotected eye

• Normal daylight does not produce enough UV light to cause burns. However, when normal daylight is reflected from snow or water, enough UV light can reflect into the eye to cause injury. This can also happen during mountain climbing, in the thin atmosphere. Injury may also occur when the eye is exposed to an artificial source, such as tanning or welding
• Pt: Ocular pain, often very severe, foreign body sensation, photophobia, tearing, conjunctival erythema, chemosis, and eyelid swelling. Visual acuity changes are very common. Symptoms may appear in 1 hour if the injury is severe, but generally appear 6-12 hours after exposure
• If fluorescein staining is done, will reveal superficial punctate epithelial surface irregularities that typically cover entire surface of cornea.
• Tx:
  
  • Self-limiting. Remove patient from offending situation to resolve symptoms. Once removed, symptoms start to resolve in 24 hours and are typically resolved within 72 hours.
  • Systemic analgesic, commonly need oral narcotics to tolerate their pain until symptoms resolve.

Question 27

Corneal Abrasion
- Dx: Fluorescein dye and either Wood’s lamp or blue light of a slit lamp

• Management
  
  • Pain control
  • Copious irrigation of the eye, including flipping upper eyelid to clear debris or foreign bodies. If foreign body is present, removal of foreign bodies with sterile gauze.
  • Ophthalmic antibiotic are indicated for infection prevention
    
    • ___ ointment or ____ (polymyxin-trimethoprine) drops q4h
    • With abrasions associated with contact lenses, ___ should be used to cover for risk of Pseudomonas keratitis.

Answer 27

Corneal Abrasion
- Dx: Fluorescein dye and either Wood’s lamp or blue light of a slit lamp

• Management
  
  • Pain control
  • Copious irrigation of the eye, including flipping upper eyelid to clear debris or foreign bodies. If foreign body is present, removal of foreign bodies with sterile gauze.
  • Ophthalmic antibiotic are indicated for infection prevention
    
    • Erythromycin ointment or polytrim (polymyxin-trimethoprine) drops q4h
    • With abrasions associated with contact lenses, ciprofloxacin should be used to cover for risk of Pseudomonas keratitis.

Question 28

Corneal Ulcer / Keratitis (inflammation of cornea)

• Path:
  
  • Can be due to variety of organisms, bacteria/viruses/fungi/parasites.
  • Commonly occurs in pts who wear contact lenses improperly or have decreased immunity
  • For hyperacute presentation, watch out for N gonorrhea or N meningitidis
• Pt: photophobia, blurred vision, foreign body sensation w difficulty opening affected eye
  
  • In severe corneal ulcers, there can be a _____, or dense collection of white blood cells in the anterior chamber. A white haze
  • Watch for severe extremely purulent discharge with a ____ formation
• Dx: slit-lamp examination shows corneal ulceration w fluorescein. Cultures of corneal scraping to help abx therapy.
• Tx: See ophthalmologist urgently to confirm dx and tx. Empiric therapy should be topical, combined abx therapy that has broad-spectrum activity against gram+ and gram- including pseudomonas.

Answer 28

Corneal Ulcer / Keratitis (inflammation of cornea)

• Path:
  
  • Can be due to variety of organisms, bacteria/viruses/fungi/parasites.
  • Commonly occurs in pts who wear contact lenses improperly or have decreased immunity
  • For hyperacute presentation, watch out for N gonorrhea or N meningitidis
• Pt: photophobia, blurred vision, foreign body sensation w difficulty opening affected eye
  
  • In severe corneal ulcers, there can be a hypopyon, or dense collection of white blood cells in the anterior chamber. A white haze
  • Watch for severe extremely purulent discharge with a pseudomembranous formation
• Dx: slit-lamp examination shows corneal ulceration w fluorescein. Cultures of corneal scraping to help abx therapy.
• Tx: See ophthalmologist urgently to confirm dx and tx. Empiric therapy should be topical, combined abx therapy that has broad-spectrum activity against gram+ and gram- including pseudomonas.

Question 29

Chalazion
- Localized bump at the edge of the eyelid caused by blockage of the meibomian glands, which produce oil.

• Tx:
  
  • Typically resolve without treatment within a few months. If still persistent, refer to an ophthalmologist for incision and curettage.
  • Warm compresses to the eyelid for 15 mins 4x times a day.
  • If still persistent and fails to resolve after _____ weeks of conservative management, refer to ophthalmologist for incision and curettage.
• “Cool as a clamazion”

Answer 29

Chalazion
- Localized bump at the edge of the eyelid caused by blockage of the meibomian glands, which produce oil.

• Tx:
  
  • Typically resolve without treatment within a few months. If still persistent, refer to an ophthalmologist for incision and curettage.
  • Warm compresses to the eyelid for 15 mins 4x times a day.
  • If still persistent and fails to resolve after 4-6 weeks of conservative management, refer to ophthalmologist for incision and curettage.
• “Cool as a clamazion”

Question 30

Hordoleum / Stye
- If chalazion becomes infected, it is a stye or hordeolum

• Tx:
  
  • Red and painful for 3-5 days before they rupture, and then they heal in about ___ week. Hasten rupture with warm compresses.
• “Hordoleum hurts”

Answer 30

Hordoleum / Stye
- If chalazion becomes infected, it is a stye or hordeolum

• Tx:
  
  • Red and painful for 3-5 days before they rupture, and then they heal in about a week. Hasten rupture with warm compresses.
• “Hordoleum hurts”

Question 31

Nasolacrimal duct obstruction/stenosis (Dacryostenosis)

• Tx:
  
  • Nasolacrimal duct massage 2-3x/day (clean finger to place firm pressure over lacrimal sac, stroke downward for 2-3 sec).
  • Resolution without surgical tx occurs in 90% of infants by 6mo.
  • Dacrostenosis that persists after ___mo can be tx by an ophthalmologist with in-office lacrimal duct probing

Answer 31

Nasolacrimal duct obstruction/stenosis (Dacryostenosis)

• Tx:
  
  • Nasolacrimal duct massage 2-3x/day (clean finger to place firm pressure over lacrimal sac, stroke downward for 2-3 sec).
  • Resolution without surgical tx occurs in 90% of infants by 6mo.
  • Dacrostenosis that persists after 6mo can be tx by an ophthalmologist with in-office lacrimal duct probing

Question 32

Dacryocystocele

• Pt:
  
  • These trap tears and present as bluish mass overlying the lacrimal sac, causing upward displacement of the medial epicanthus on that side.
• Tx:
  
  • Nasolacrimal duct massage with compresses and topical ______ TID. If does not resolve or worsens, may need surgical repair and/or IV antibiotics.
  • Referral to ophthalmology for decompression of dacrocystoceles

Answer 32

Dacryocystocele

• Pt:
  
  • These trap tears and present as bluish mass overlying the lacrimal sac, causing upward displacement of the medial epicanthus on that side.
• Tx:
  
  • Nasolacrimal duct massage with compresses and topical erythromycin TID. If does not resolve or worsens, may need surgical repair and/or IV antibiotics.
  • Referral to ophthalmology for decompression of dacrocystoceles

Question 33

Acute dacryocystitis
- Complication of dacrostenosis

• Pt: Erythema over lacrimal sac w associated cellulitis, tenderness of the lacrimal sac located inferior to the medial canthus. Purulent drainage may be present.
• Tx: Medical emergency, requiring systemic antibiotics to cover MRSA and involvement of ophthalmologist.

Answer 33

Acute dacryocystitis
- Complication of dacrostenosis

• Pt: Erythema over lacrimal sac w associated cellulitis, tenderness of the lacrimal sac located inferior to the medial canthus. Purulent drainage may be present.
• Tx: Medical emergency, requiring systemic antibiotics to cover MRSA and involvement of ophthalmologist.

Question 34

Hyphema
- Presence of blood in the anterior chamber of the eye

• Pt: Bright or dark red fluid level between the cornea and iris
• Dx: Clinically with visualization of blood in the anterior chamber
• Tx:
  
  • Urgent ophthalmologic evaluation as it carries the risk of additional bleeding and can result in corneal staining or glaucoma, both of which affect visual acuity.
  • Most hyphemas can be safely managed on an outpatient basis; however, hyphemas associated with increased intraocular pressure or high-grade hyphemas warrant admission to the hospital.
  • Eye rest and cycloplegic medications
    
    • Topical ____ and ____ drops.
  • Although most children with minor hyphemas do well, they are at risk of rebleeding (usually in the 1st week after initial injury); this increases the risk for long-term complications such as _____.
  • Protect any serious eye injury from further trauma with a rigid shield.

Answer 34

Hyphema
- Presence of blood in the anterior chamber of the eye

• Pt: Bright or dark red fluid level between the cornea and iris
• Dx: Clinically with visualization of blood in the anterior chamber
• Tx:
  
  • Urgent ophthalmologic evaluation as it carries the risk of additional bleeding and can result in corneal staining or glaucoma, both of which affect visual acuity.
  • Most hyphemas can be safely managed on an outpatient basis; however, hyphemas associated with increased intraocular pressure or high-grade hyphemas warrant admission to the hospital.
  • Eye rest and cycloplegic medications
    
    • Topical steroid and cycloplegic drops.
  • Although most children with minor hyphemas do well, they are at risk of rebleeding (usually in the 1st week after initial injury); this increases the risk for long-term complications such as glaucoma.
  • Protect any serious eye injury from further trauma with a rigid shield.

Question 35

Orbital Blowout Fracture
- Orbital floor fractures are the most common.

• Pt:
  
  • Vertical diplopia, cheek numbness, and limited upward gaze.
    
    • Other findings can include circumferential ecchymosis, subconjunctival hemorrhage, hyphema, and enophthalmos (eye appears sunken in).
• Get CT scan
• Tx:
  
  • Consult ophthalmology
  • Advise pts to avoid blowing their nose, and prescribe antibiotics to prevent infection

Answer 35

Orbital Blowout Fracture
- Orbital floor fractures are the most common.

• Pt:
  
  • Vertical diplopia, cheek numbness, and limited upward gaze.
    
    • Other findings can include circumferential ecchymosis, subconjunctival hemorrhage, hyphema, and enophthalmos (eye appears sunken in).
• Get CT scan
• Tx:
  
  • Consult ophthalmology
  • Advise pts to avoid blowing their nose, and prescribe antibiotics to prevent infection

Question 36

Preauricular ear pits

• Management
  
  • Increased risk of hearing impairment, so all affected pts need an audiologic examinations.
  • There is NO increased risk of renal abnormalities with isolated preauricular sinus/pit.
• In newborns with external ear anomalies who have other congenital anomalies or dysmorphic features, a family hx of deafness, ear, or renal anomalies, or a maternal hx of _______, the likelihood of clinically significant structural renal anomalies is higher, and renal US is warranted.

Answer 36

Preauricular ear pits

• Management
  
  • Increased risk of hearing impairment, so all affected pts need an audiologic examinations.
  • There is NO increased risk of renal abnormalities with isolated preauricular sinus/pit.
• In newborns with external ear anomalies who have other congenital anomalies or dysmorphic features, a family hx of deafness, ear, or renal anomalies, or a maternal hx of gestational diabetes, the likelihood of clinically significant structural renal anomalies is higher, and renal US is warranted.

Question 37

Otitis Externa

• Inflammation of the outer ear canal.
• Common infection among swimmers
• Path:
  
  • Most commonly due to _____ (38%), Staph epidermidis (9%), and Staph aureus (8%).
• Pt: Unilateral ear pain worse with manipulation of pinna (most helpful factor to distinguish from ruptured AOM).
• Tx:
  
  • Initial tx includes pain management and appropriate abx Ciprodex (but not commonly covered) or Ofloxacin (can do otic or ocular)
    
    • ________, ofloxacin and ciprofloxacin, are preferable bc they provide excellent coverage against both common pathogens.
    • Aminoglycosides and polymyxin B are alternatives
  • 2010 Cochrane review found there was insufficient evidence to add corticosteroids to topical antibiotic preparations
• For cases of otitis externa with Perforated Tympanic Membrane where TM is not intact
  
  • Tx: ____ (neomycin and gentamicin) should be avoided in the tx of otitis externa with nonintact TM bc of ototoxicity

Answer 37

Otitis Externa

• Inflammation of the outer ear canal.
• Common infection among swimmers
• Path:
  
  • Most commonly due to Pseudomonas aeruginosa (38%), Staph epidermidis (9%), and Staph aureus (8%).
• Pt: Unilateral ear pain worse with manipulation of pinna (most helpful factor to distinguish from ruptured AOM).
• Tx:
  
  • Initial tx includes pain management and appropriate abx Ciprodex (but not commonly covered) or Ofloxacin (can do otic or ocular)
    
    • Fluoroquinolones, ofloxacin and ciprofloxacin, are preferable bc they provide excellent coverage against both common pathogens.
    • Aminoglycosides and polymyxin B are alternatives
  • 2010 Cochrane review found there was insufficient evidence to add corticosteroids to topical antibiotic preparations
• For cases of otitis externa with Perforated Tympanic Membrane where TM is not intact
  
  • Tx: Aminoglycosides (neomycin and gentamicin) should be avoided in the tx of otitis externa with nonintact TM bc of ototoxicity

Question 38

Suppurative auricular perichondritis

• Piercings of upper ear helix may cause suppurative perichondritis, frequently caused by _____
• Tx: ____ to cover pseudomonas and penetrate into cartilage

Answer 38

Suppurative auricular perichondritis

• Piercings of upper ear helix may cause suppurative perichondritis, frequently caused by Pseudomonas aeruginosa
• Tx: Fluoroquinolone to cover pseudomonas and penetrate into cartilage

Question 39

Persistent purulent otorrhea for >___ weeks despite treatment is an indication for referral to otolaryngology.

Answer 39

Persistent purulent otorrhea for >2 weeks despite treatment is an indication for referral to otolaryngology.

Question 40

Acute Otitis Media
- Path: URI bugs of middle ear, most commonly 1) ___, 2) ___, 3) ____

- Concurrent otitis media and purulent conjunctivitis (otitis-conjunctivitis syndrome) is typically caused by \_\_\_\_\_\_.

• RFs:
  
  • Age (6-18 mo), family hx, day care attendance, lack of breastfeeding, and tobacco smoke exposure
  • Bottle propping is one of the known RFs
  • Chronic sinusitis
  • Ciliary dysfunction
  • Cleft palate and craniofacial anomalies
  • Daycare attendance
  • Down syndrome and other genetic abnormalities
  • 1st episode of AOM at <6 months
  • Primary immunodeficiency diseases
• Dx:
  
  • Moderate to severe bulging of TM OR
  • New onset of otorrhea not due to acute otitis externa OR
  • Mild bulging of the TM AND
    
    • Recent (<48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) OR
    • Intense erythema of the TM
  • Confirm diagnosis: Clinicians should not diagnose AOM in children who do not have middle ear effusion (based on pneumatic otoscopy and/or tympanometry)
• Tx:
  
  • AAP recommends
    
    • Observation and pain control.
      
      • For children ____
      • For >_____
    • Antimicrobials
      
      • For Infants less than ___
      • Children less than __ months with bilateral AOM
      • Children of all ages with severe AOM
        
        • _____
        • _____
        • ______
  • 1st line therapy is _____ high dose 80-90mg/kg/day in 2 doses q12 hrs (max 4000mg)
    
    • Children with penicillin allergies can be tx with 2nd or 3rd generation cephalosporin (including cefdinir).
  • Use a Beta-lactam antibiotic (amoxicillin/clavulanate or cefdinir) if:
    
    • Received ____
    • History of ____
      
      • For those who recur or have received amoxicillin 90mg/kg in last 30 days, do amoxicillin-clavulanate
    • Concurrent ____
      
      • If eye infection AND ear infection, use Augmentin as likely H influenza
      • If the child has allergy to penicillins, an oral cephalosporin or azithromycin are recommended.
  • Return to physical activity as tolerated
  • Treatment failure: On amoxicillin and there is no clinical improvement (fevers, irritability) after 48 hours in the symptoms AND ear looks the same. Broaden therapy to amoxicillin-clavulanic acid or a 2nd or 3rd generation cephalosporin.
• Recurrent otitis media = ___ episodes in __ months OR ___ episodes in ___ months with 1 episode in the preceding 6 months
  
  • Myringotomy and placement of tympanostomy tubes is considered after persistent effusion for >__ mo, or has >3 episodes of AOM in 6 mo (or >4 in a year)
• Most tympanostomy tubes are designed to remain in place for a short time, typically 12-18 months.
  
  • Indications for surgical tympanostomy tube removal include:
    
    • Failure of the tube to extrude >___ years after insertion
    • Migration of the tube into the middle ear
    • Tube-associated granulation tissue that does not respond to tx
    • Chronic otorrhea that does not respond to tx
    • Resolution of the condition that prompted insertion (eg repair of cleft palate), esp in an older child

Answer 40

Acute Otitis Media
- Path: URI bugs of middle ear, most commonly 1) Strep pneumo, 2) H influenza (w concurrent conjunctivitis and milder clinical features), 3) M catarrhalis

- Concurrent otitis media and purulent conjunctivitis (otitis-conjunctivitis syndrome) is typically caused by nontypeable h influenzae.

• RFs:
  
  • Age (6-18 mo), family hx, day care attendance, lack of breastfeeding, and tobacco smoke exposure
  • Bottle propping is one of the known RFs
  • Chronic sinusitis
  • Ciliary dysfunction
  • Cleft palate and craniofacial anomalies
  • Daycare attendance
  • Down syndrome and other genetic abnormalities
  • 1st episode of AOM at <6 months
  • Primary immunodeficiency diseases
• Dx:
  
  • Moderate to severe bulging of TM OR
  • New onset of otorrhea not due to acute otitis externa OR
  • Mild bulging of the TM AND
    
    • Recent (<48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) OR
    • Intense erythema of the TM
  • Confirm diagnosis: Clinicians should not diagnose AOM in children who do not have middle ear effusion (based on pneumatic otoscopy and/or tympanometry)
• Tx:
  
  • AAP recommends
    
    • Observation and pain control.
      
      • For children 6-24mo with unilateral nonsevere disease (without otorrhea)
      • For >24mo with unilateral or bilateral nonsevere disease (without otorrhea)
    • Antimicrobials
      
      • For Infants <6 months
      • Children <24 months with bilateral AOM
      • Children of all ages with severe AOM
        
        • Moderate-to-severe otalgia
        • Otalgia >48 hours
        • Temperature >102.2 / 39
  • 1st line therapy is amoxicillin high dose 80-90mg/kg/day in 2 doses q12 hrs (max 4000mg)
    
    • Children with penicillin allergies can be tx with 2nd or 3rd generation cephalosporin (including cefdinir).
  • Use a Beta-lactam antibiotic (amoxicillin/clavulanate or cefdinir) if:
    
    • Received amoxicillin within past 30 days
    • History of recurrent AOM
      
      • For those who recur or have received amoxicillin 90mg/kg in last 30 days, do amoxicillin-clavulanate
    • Concurrent purulent conjunctivitis
      
      • If eye infection AND ear infection, use Augmentin as likely H influenza
      • If the child has allergy to penicillins, an oral cephalosporin or azithromycin are recommended.
  • Return to physical activity as tolerated
  • Treatment failure: On amoxicillin and there is no clinical improvement (fevers, irritability) after 48 hours in the symptoms AND ear looks the same. Broaden therapy to amoxicillin-clavulanic acid or a 2nd or 3rd generation cephalosporin.
• Recurrent otitis media = 3 episodes in 6 months OR 4 episodes in 12 months with 1 episode in the preceding 6 months
  
  • Myringotomy and placement of tympanostomy tubes is considered after persistent effusion for >3 mo, or has >3 episodes of AOM in 6 mo (or >4 in a year)
• Most tympanostomy tubes are designed to remain in place for a short time, typically 12-18 months.
  
  • Indications for surgical tympanostomy tube removal include:
    
    • Failure of the tube to extrude >3 years after insertion
    • Migration of the tube into the middle ear
    • Tube-associated granulation tissue that does not respond to tx
    • Chronic otorrhea that does not respond to tx
    • Resolution of the condition that prompted insertion (eg repair of cleft palate), esp in an older child

Question 41

Chronic Suppurative Otitis Media (CSOM)

• ____ tympanic membrane with chronic drainage lasting >___ weeks
• Chronic inflammation of the middle ear and mastoid cavity which presents with recurrent ear discharge or otorrhea through a tympanic perforation.
• Path: Although CSOM often follows an episode of AOM, the bacteriology of the 2 conditions is distinct. In contrast to the usual respiratory pathogens ass with AOM (pneumococcus, H influenza, Moraxella), CSOM is caused by biofilm-producing organisms, most often ____ or ____ (like organisms for otitis externa).
• Exam: Perforated tympanic membrane and discharge that can range from “cheese-like” to purulent.
• Tx: Goal is to eradicate infection and close tympanic perforation
  
  • The most efficient tx is aural cleaning followed by otic antibiotic drops for about 2 weeks.
    
    • Topical therapy with a ____ (5 drops 3x/day for 2 weeks).

Answer 41

Chronic Suppurative Otitis Media (CSOM)

• Perforated tympanic membrane with chronic drainage lasting >6 weeks
• Chronic inflammation of the middle ear and mastoid cavity which presents with recurrent ear discharge or otorrhea through a tympanic perforation.
• Path: Although CSOM often follows an episode of AOM, the bacteriology of the 2 conditions is distinct. In contrast to the usual respiratory pathogens ass with AOM (pneumococcus, H influenza, Moraxella), CSOM is caused by biofilm-producing organisms, most often Pseudomonas aeruginosa or Staph aureus (like organisms for otitis externa).
• Exam: Perforated tympanic membrane and discharge that can range from “cheese-like” to purulent.
• Tx: Goal is to eradicate infection and close tympanic perforation
  
  • The most efficient tx is aural cleaning followed by otic antibiotic drops for about 2 weeks.
    
    • Topical therapy with a quinolone (5 drops 3x/day for 2 weeks).

Question 42

Otitis Media with Effusion (OME) (serous otitis media)

• Middle ear effusion behind a normal-appearing TM without clinical signs of infection.
  
  • Typically seen during the resolution of AOM or with eustachian tube dysfunction.
• Pt: Asymptomatic middle ear effusion WITHOUT acute signs of infection and inflammation.
• Tx:
  
  • Spontaneous resolution usually occurs within 6(-12) weeks. Most episodes of OME resolve without intervention
  • The most important potential sequelae of OME are ______ and associated language delay.
  • For children with OME who are not at increased risk for language delay, guidelines recommend watchful waiting and reevaluation in 3 months (12-week intervals) bc most OMEs resolve spontaneously.
    
    • If OME persists >___ months, or if the clinician suspects hearing loss, language delay, or learning problems, watchful waiting is not appropriate and the child should undergo hearing testing.
      
      • Children with OME >3 mo who have normal hearing testing → routine f/u every 3-6 mo
  • Children at increased risk for speech or language delay warrant a hearing test, speech evaluation, and referral to ENT for tympanostomy tube placement (to reduce the risk of permanent hearing loss) more promptly

Answer 42

Otitis Media with Effusion (OME) (serous otitis media)

• Middle ear effusion behind a normal-appearing TM without clinical signs of infection.
  
  • Typically seen during the resolution of AOM or with eustachian tube dysfunction.
• Pt: Asymptomatic middle ear effusion WITHOUT acute signs of infection and inflammation.
• Tx:
  
  • Spontaneous resolution usually occurs within 6(-12) weeks. Most episodes of OME resolve without intervention
  • The most important potential sequelae of OME are conductive hearing loss and associated language delay.
  • For children with OME who are not at increased risk for language delay, guidelines recommend watchful waiting and reevaluation in 3 months (12-week intervals) bc most OMEs resolve spontaneously.
    
    • If OME persists >3 months, or if the clinician suspects hearing loss, language delay, or learning problems, watchful waiting is not appropriate and the child should undergo hearing testing.
      
      • Children with OME >3 mo who have normal hearing testing → routine f/u every 3-6 mo
  • Children at increased risk for speech or language delay warrant a hearing test, speech evaluation, and referral to ENT for tympanostomy tube placement (to reduce the risk of permanent hearing loss) more promptly

Question 43

Cholesteatoma
- Benign skin growth (abnormal accumulation of squamous epithelial cells) typically located in the middle ear or mastoid space.

• Complication of chronic suppurative otitis media (CSOM), persistent middle ear effusion, and persistent inflammation in the middle ear.
• Pt: Painless. Can present with new-onset hearing loss or persistent/recurrent otorrhea ear drainage.
• Several warning signs for cholesteatoma:
  
  • Presence of white round mass behind an intact tympanic membrane
  • Focal granulation on the surface of the tympanic membrane
  • A deep retraction pocket with or without granulation tissue
  • New-onset hearing loss in a previously operated ear
  • Persistent drainage from an ear for >2 weeks despite treatment
• Dx:
  
  • Otoscopy exam with a vague irregular white mass behind the TM. On exam, a retraction pocket filled with squamous epithelial debris and keratin may be seen.
• Management: Persistent otorrhea and/or white mass behind TM should be referred to ENT
  
  • Because cholesteatomas typically continue to enlarge, can become infected, and can lead to hearing loss, cranial nerve palsies, vertigo, and rarely, venous thrombosis, meningitis, or brain abscess, referral to an otolaryngologist urgently for removal is necessary.
    
    • Consultation with ENT as surgical removal is usually indicated.

Answer 43

Cholesteatoma
- Benign skin growth (abnormal accumulation of squamous epithelial cells) typically located in the middle ear or mastoid space.

• Complication of chronic suppurative otitis media (CSOM), persistent middle ear effusion, and persistent inflammation in the middle ear.
• Pt: Painless. Can present with new-onset hearing loss or persistent/recurrent otorrhea ear drainage.
• Several warning signs for cholesteatoma:
  
  • Presence of white round mass behind an intact tympanic membrane
  • Focal granulation on the surface of the tympanic membrane
  • A deep retraction pocket with or without granulation tissue
  • New-onset hearing loss in a previously operated ear
  • Persistent drainage from an ear for >2 weeks despite treatment
• Dx:
  
  • Otoscopy exam with a vague irregular white mass behind the TM. On exam, a retraction pocket filled with squamous epithelial debris and keratin may be seen.
• Management: Persistent otorrhea and/or white mass behind TM should be referred to ENT
  
  • Because cholesteatomas typically continue to enlarge, can become infected, and can lead to hearing loss, cranial nerve palsies, vertigo, and rarely, venous thrombosis, meningitis, or brain abscess, referral to an otolaryngologist urgently for removal is necessary.
    
    • Consultation with ENT as surgical removal is usually indicated.

Question 44

Myringosclerosis

• Calcium and phosphate crystal deposits within the TM that appear as whitish plaques on otoscopy and may demonstrate decreased mobility on pneumatic otoscopy.
• According to meta-analysis, 32% of pts developed myringosclerosis after ____

Answer 44

Myringosclerosis

• Calcium and phosphate crystal deposits within the TM that appear as whitish plaques on otoscopy and may demonstrate decreased mobility on pneumatic otoscopy.
• According to meta-analysis, 32% of pts developed myringosclerosis after tympanostomy tube extrusion.

Question 45

Acute Mastoiditis
- Path: Bacterial infection of mastoid air cells. complication of acute otitis media. Most commonly due to _____.

• Pt:
  
  • Inflammation of mastoid/postauricular swelling/tenderness/erythema. Protruding pinna of ear.
• Tx:
  
  • IV abx: ____ PLUS ____ or (in setting of recurrent AOM and recent antibiotic use) 3rd generation cephalosporin ceftazidime or cefepime
    
    • A 4-7 day course of parenteral antibiotic therapy followed by an oral antibiotic regimen for a total of ______days is recommended for uncomplicated cases.
    • Switch to PO antibiotics once improvement is seen and sensitivities are known.
  • Treat complicated cases with arrangement for mastoidectomy to remove the infected mastoid cortical bone.

Answer 45

Acute Mastoiditis
- Path: Bacterial infection of mastoid air cells. complication of acute otitis media. Most commonly due to Strep pneumoniae.

• Pt:
  
  • Inflammation of mastoid/postauricular swelling/tenderness/erythema. Protruding pinna of ear.
• Tx:
  
  • IV abx: Vancomycin PLUS ampicillin-sulbactam or (in setting of recurrent AOM and recent antibiotic use) 3rd generation cephalosporin ceftazidime or cefepime
    
    • A 4-7 day course of parenteral antibiotic therapy followed by an oral antibiotic regimen for a total of 14-21 days is recommended for uncomplicated cases.
    • Switch to PO antibiotics once improvement is seen and sensitivities are known.
  • Treat complicated cases with arrangement for mastoidectomy to remove the infected mastoid cortical bone.

Question 46

Tympanostomy tube otorrhea
- Path: Certain pathogens, including ____ and___, must be considered as the causative agents of tympanostomy tube in older children when water penetration could have contributed to developing otorrhea.

• Tx:
  
  • For tympanostomy tube otorrhea, topical therapy is more efficacious than systemic therapy.
  • Topical ____.

Answer 46

Tympanostomy tube otorrhea
- Path: Certain pathogens, including Pseudomonas aeruginosa and Staph aureus, must be considered as the causative agents of tympanostomy tube in older children when water penetration could have contributed to developing otorrhea.

• Tx:
  
  • For tympanostomy tube otorrhea, topical therapy is more efficacious than systemic therapy.
  • Topical ofloxacin.

Question 47

Deafness
- Deafness is hearing loss at >___ dB, which results in the inability to distinguish between elements of spoken language.

• “Mild” hearing loss = ___-dB loss
• Deafness is inherited in ~50% of cases. Of these, 80% are inherited as ______, 18% as autosomal dominant, and 2% as X-linked recessive.

Answer 47

Deafness
- Deafness is hearing loss at >90 dB, which results in the inability to distinguish between elements of spoken language.

• “Mild” hearing loss = 25-dB loss
• Deafness is inherited in ~50% of cases. Of these, 80% are inherited as autosomal recessive, 18% as autosomal dominant, and 2% as X-linked recessive.

Question 48

Conductive hearing loss (disruption of sound traveling to cochlea or middle ear due to disruption of mechanical components required for the transduction of sound wave energy):

• Usually acquired and most commonly caused by middle-ear fluid.
• Cerumen impaction, ossicular chain fixation, and fluid in the middle ear - due either to acute suppurative otitis media or otitis media with effusion - are the most common causes of conductive hearing loss.

Answer 48

Conductive hearing loss (disruption of sound traveling to cochlea or middle ear due to disruption of mechanical components required for the transduction of sound wave energy):

• Usually acquired and most commonly caused by middle-ear fluid.
• Cerumen impaction, ossicular chain fixation, and fluid in the middle ear - due either to acute suppurative otitis media or otitis media with effusion - are the most common causes of conductive hearing loss.

Question 49

Sensorineural hearing loss (dysfunction of sensory epithelium, cochlea, inner ear, or neural pathways leading to the auditory cortex via CN 8 or other connections):
- Most common infectious cause of congenital deafness is ______

- Other congenital infections that can cause sensorineural hearing loss include toxoplasmosis, rubella, and syphilis. - Acquired infections: EBV, measles, mumps, Neisseria meningitidis, Borrelia burgdorferi - Genetic: Waardenburg, Pendred, Jervell and Lange-Nielsen - Other causes of acquired sensorineural hearing loss include prolonged exposure to loud noise (a typical cause of high-pitched hearing loss in adolescents), ototoxic drugs (eg aminoglycosides, salicylates, loop diuretics), and trauma.

Answer 49

Sensorineural hearing loss (dysfunction of sensory epithelium, cochlea, inner ear, or neural pathways leading to the auditory cortex via CN 8 or other connections):
- Most common infectious cause of congenital deafness is CMV

- Other congenital infections that can cause sensorineural hearing loss include toxoplasmosis, rubella, and syphilis. - Acquired infections: EBV, measles, mumps, Neisseria meningitidis, Borrelia burgdorferi - Genetic: Waardenburg, Pendred, Jervell and Lange-Nielsen - Other causes of acquired sensorineural hearing loss include prolonged exposure to loud noise (a typical cause of high-pitched hearing loss in adolescents), ototoxic drugs (eg aminoglycosides, salicylates, loop diuretics), and trauma.

Question 50

Congenital hearing loss (hearing loss within first 28 days of life)

• Up to 60% of cases of congenital and early-onset hearing loss are caused by genetic factors.
• The majority of genetic, non-syndromic, congenital hearing loss is due to any number of ____inheritance? mutations (25% if both parents are carriers)
• Exposure to ototoxic drugs (loop diuretics, aminoglycosides (gentamicin, tobramycin))

Answer 50

Congenital hearing loss (hearing loss within first 28 days of life)

• Up to 60% of cases of congenital and early-onset hearing loss are caused by genetic factors.
• The majority of genetic, non-syndromic, congenital hearing loss is due to any number of Autosomal Recessive mutations (25% if both parents are carriers)
• Exposure to ototoxic drugs (loop diuretics, aminoglycosides (gentamicin, tobramycin))

Question 51

Acquired hearing loss

• ____ is most common nongenetic cause of hearing loss in children
• Meningitis is another leading cause

Answer 51

Acquired hearing loss

• CMV is most common nongenetic cause of hearing loss in children
• Meningitis is another leading cause

Question 52

AAP recommends hearing screen by 1mo, definitive diagnosis by 3 months, tx by 6 months. If fail newborn hearing screen, confirmatory hearing tests must be done by __mo.
- The goal is for 100% screening of all infants by ____ months of age.

Answer 52

AAP recommends hearing screen by 1mo, definitive diagnosis by 3 months, tx by 6 months. If fail newborn hearing screen, confirmatory hearing tests must be done by 3mo.
- The goal is for 100% screening of all infants by 3 months of age.

Question 53

In addition to newborn screen, hearing screen is recommended in following circumstances:

• Parent expresses concern regarding hearing or language development of child
• As part of workup for speech and language delays
• Child has a hx of bacterial meningitis, significant head trauma (esp basilar skull fracture or injury to temporal bones), or any neurodegenerative disorder (Bacterial meningitis is the most common cause of postnatally acquired deafness in childhood.)
• Child has a syndrome ass with hearing loss (eg Treacher-Collins’, Waardenburg’s, Alport’s)
• Exposure to ototoxic medications (eg gentamicin, chemotherapy)
• Anatomical malformations of the head and neck esp of the auricle and/or ear canal
• Preauricular skin tags/dimpling
• Abnormal pigmentation of the skin, hair, or eyes and/or heterochromia of the irises (Waardenburg syndrome)
• Family hx of childhood hearing impairment
• Confirmed hx of infectious diseases, such as congenital CMV, HSV, rubella, toxoplasmosis, syphilis, mumps, or measles
• Recurrent or persistent otitis media with effusion for >3 months

Answer 53

In addition to newborn screen, hearing screen is recommended in following circumstances:

• Parent expresses concern regarding hearing or language development of child
• As part of workup for speech and language delays
• Child has a hx of bacterial meningitis, significant head trauma (esp basilar skull fracture or injury to temporal bones), or any neurodegenerative disorder (Bacterial meningitis is the most common cause of postnatally acquired deafness in childhood.)
• Child has a syndrome ass with hearing loss (eg Treacher-Collins’, Waardenburg’s, Alport’s)
• Exposure to ototoxic medications (eg gentamicin, chemotherapy)
• Anatomical malformations of the head and neck esp of the auricle and/or ear canal
• Preauricular skin tags/dimpling
• Abnormal pigmentation of the skin, hair, or eyes and/or heterochromia of the irises (Waardenburg syndrome)
• Family hx of childhood hearing impairment
• Confirmed hx of infectious diseases, such as congenital CMV, HSV, rubella, toxoplasmosis, syphilis, mumps, or measles
• Recurrent or persistent otitis media with effusion for >3 months

Question 54

Beyond the newborn period, children with risk factors for hearing loss should have ongoing screening as well as a formal diagnostic audiology assessment by 24-30 months of age

• Risk factors for birth - 28 days
  
  • Family hx of congenital or early-onset hearing loss
  • Congenital infection known to be associated with hearings (eg CMV, rubella, herpes, syphilis, toxoplasmosis, varicella)
  • Craniofacial abnormality (microtia, ear tags/pits)
  • Birth weight <1,500g
  • Hyperbilirubinemia requiring exchange transfusion
  • Exposure to ototoxic medications (eg gentamicin, furosemide)
  • Bacterial meningitis (neonatal or any age)
  • Low apgar scores at birth (<3 at 5 minutes, <6 at 10 minutes)
  • Prolonged mechanical ventilation (>10 days)
  • Findings consistent with a syndrome with known hearing loss

Answer 54

Beyond the newborn period, children with risk factors for hearing loss should have ongoing screening as well as a formal diagnostic audiology assessment by 24-30 months of age

• Risk factors for birth - 28 days
  
  • Family hx of congenital or early-onset hearing loss
  • Congenital infection known to be associated with hearings (eg CMV, rubella, herpes, syphilis, toxoplasmosis, varicella)
  • Craniofacial abnormality (microtia, ear tags/pits)
  • Birth weight <1,500g
  • Hyperbilirubinemia requiring exchange transfusion
  • Exposure to ototoxic medications (eg gentamicin, furosemide)
  • Bacterial meningitis (neonatal or any age)
  • Low apgar scores at birth (<3 at 5 minutes, <6 at 10 minutes)
  • Prolonged mechanical ventilation (>10 days)
  • Findings consistent with a syndrome with known hearing loss

Question 55

• Universal newborn hearing screening (UNHS) programs use otoacoustic emission (OAE) testing or auditory brainstem response testing.
  
  • OAE screening is recommended for all children 0-3yo and is part of well child health maintenance.
    
    • A normal test results requires a patent outer ear, functioning middle ear, and normal cochlea.
  • Auditory brainstem response (ABR, sometimes called auditory evoked potential) is ordered if there is suspicion of hearing loss related to the cochlea or brain pathways
    
    • Measures the response of the auditory nerve (CN 8) to a variety of sound waves at varying intensities to determine the child’s hearing level in that frequency range.

Answer 55

• Universal newborn hearing screening (UNHS) programs use otoacoustic emission (OAE) testing or auditory brainstem response testing.
  
  • OAE screening is recommended for all children 0-3yo and is part of well child health maintenance.
    
    • A normal test results requires a patent outer ear, functioning middle ear, and normal cochlea.
  • Auditory brainstem response (ABR, sometimes called auditory evoked potential) is ordered if there is suspicion of hearing loss related to the cochlea or brain pathways
    
    • Measures the response of the auditory nerve (CN 8) to a variety of sound waves at varying intensities to determine the child’s hearing level in that frequency range.

Question 56

• Definitive tests to confirm normal hearing require audiograms.
  
  • Behavioral audiometry- Observe for behavioral changes (blinking, pauses in sucking) (for 6-9mo)
  • Visual reinforcement audiometry- Infants are rewarded with visual stimuli for turning to a sound; child is conditioned to associate sound with specific stimuli (for 6-9mo)
  • Play audiometry- Children are conditioned to perform task in response to sound (for >2yo)
  • Conventional audiometry (Pure-tone, Speech)- Child asked to raise his/her hand in response to sound (for 4yo)
• Recognize the signs of possible hearing loss in the infant: delayed vocalization, not orienting to voice or loud sounds, lack of startle to loud sounds, and being unusually quiet.

Answer 56

• Definitive tests to confirm normal hearing require audiograms.
  
  • Behavioral audiometry- Observe for behavioral changes (blinking, pauses in sucking) (for 6-9mo)
  • Visual reinforcement audiometry- Infants are rewarded with visual stimuli for turning to a sound; child is conditioned to associate sound with specific stimuli (for 6-9mo)
  • Play audiometry- Children are conditioned to perform task in response to sound (for >2yo)
  • Conventional audiometry (Pure-tone, Speech)- Child asked to raise his/her hand in response to sound (for 4yo)
• Recognize the signs of possible hearing loss in the infant: delayed vocalization, not orienting to voice or loud sounds, lack of startle to loud sounds, and being unusually quiet.

Question 57

• Management
  
  • Congenital deafness is an isolated clinical finding that would warrant a referral to a geneticist.
  • Hearing aids can be fitted as early at ____mo and is the next step in management for those with confirmed hearing loss.
  • Early intervention is effective in promoting speech and language acquisition in deaf and hard-of-hearing children, should commence as early as possible, no later than ____mo
  • Criteria for cochlear implants: Severe to profound bilateral sensorineural hearing loss and little-no benefit from the use of hearing aids after ___ months.
    
    • For most infants with bilateral severe to profound sensorineural hearing loss (most who will not meet language milestones), cochlear implants placed at approx ___mo of age are the best way to achieve optimal spoken language skills.
• 3 educational/communication methods are commonly used
  
  • Oral communication method- uses the child’s residual hearing, speech, and lipreading to develop spoken language
  • Manual communication method- uses signing and fingerspelling.
  • Total language communication- allows communication with the child by any means available

Answer 57

• Management
  
  • Congenital deafness is an isolated clinical finding that would warrant a referral to a geneticist.
  • Hearing aids can be fitted as early at 3mo and is the next step in management for those with confirmed hearing loss.
  • Early intervention is effective in promoting speech and language acquisition in deaf and hard-of-hearing children, should commence as early as possible, no later than 6mo
  • Criteria for cochlear implants: Severe to profound bilateral sensorineural hearing loss and little-no benefit from the use of hearing aids after 6 months.
    
    • For most infants with bilateral severe to profound sensorineural hearing loss (most who will not meet language milestones), cochlear implants placed at approx 12mo of age are the best way to achieve optimal spoken language skills.
• 3 educational/communication methods are commonly used
  
  • Oral communication method- uses the child’s residual hearing, speech, and lipreading to develop spoken language
  • Manual communication method- uses signing and fingerspelling.
  • Total language communication- allows communication with the child by any means available

Question 58

Choanal Atresia
- Look for _____ syndrome (coloboma, heart disease, atresia of choanae, retarded growth and development, genital anomalies, and ear anomalies/deafness)

• Dx:
  
  • Inability to pass a firm catheter tube through each nostril past a depth of about 3-4 cm suggests diagnosis
  • Definitively diagnosed by ____ with intranasal contrast showing the nasal obstruction

Answer 58

Choanal Atresia
- Look for CHARGE syndrome (coloboma, heart disease, atresia of choanae, retarded growth and development, genital anomalies, and ear anomalies/deafness)

• Dx:
  
  • Inability to pass a firm catheter tube through each nostril past a depth of about 3-4 cm suggests diagnosis
  • Definitively diagnosed by CT scan with intranasal contrast showing the nasal obstruction

Question 59

Epistaxis

• Local causes (most common): Trauma, irritation, inflammation, infection
  
  • Trauma / Nose picking is the most common cause
  • Nasal foreign body (evaluate for in children with recurrent episodes of unilateral epistaxis associated with mucopurulent nasal drainage and/or foul-smelling breath)
• Tx:
  
  • No nose picking
  • 1) Direct pressure w nostril pinching to compress plexus usually controls after 5-10 mins. Usually people do not apply enough direct pressure.
  • 2) However, if anterior epistaxis does not cease, ____ is indicated
  • 3) If fail, _____ (bacitracin-covered sponge)
  • 4) ENT consultation for ____ packing

Answer 59

Epistaxis

• Local causes (most common): Trauma, irritation, inflammation, infection
  
  • Trauma / Nose picking is the most common cause
  • Nasal foreign body (evaluate for in children with recurrent episodes of unilateral epistaxis associated with mucopurulent nasal drainage and/or foul-smelling breath)
• Tx:
  
  • No nose picking
  • 1) Direct pressure w nostril pinching to compress plexus usually controls after 5-10 mins. Usually people do not apply enough direct pressure.
  • 2) However, if anterior epistaxis does not cease, topical vasoconstriction is indicated
  • 3) If fail, anterior nasal packing (bacitracin-covered sponge)
  • 4) ENT consultation for posterior nasal packing

Question 60

Nasal polyps
- Nasal polyps are benign pedunculated tumors that form in the nasal passages that originate from nasal mucosa or paranasal sinus tissue. Are usually due to chronically inflamed nasal mucosa.

• Associations
  
  • One of the most common causes in children is _____ With any child <12yo who has nasal polyps, evaluate for CF - even in the absence of other findings for CF.
    
    • Cystic fibrosis is the most common cause of nasal polyposis in childhood and should be suspected
  • In Samter triad (Aspirin-exacerbated respiratory disease or AERD), a rare condition, nasal polyps are associated with aspirin sensitivity and asthma
    
    • AERD is diagnosed in pts who have 1) Asthma and chronic sinusitis with nasal polyposis and 2) Acute respiratory tract reactions to ingestion of aspirin and other COX-1 inhibitors
• Polyps look like gray, grape-like masses found squeezed between the nasal turbinates and septum
• Any child with nasal polyposis should be screened for CF.
• Tx and prevention:
  
  • 1st line is ____ sprays; oral tx reserved for severe or refractory disease.

Answer 60

Nasal polyps
- Nasal polyps are benign pedunculated tumors that form in the nasal passages that originate from nasal mucosa or paranasal sinus tissue. Are usually due to chronically inflamed nasal mucosa.

• Associations
  
  • One of the most common causes in children is cystic fibrosis. With any child <12yo who has nasal polyps, evaluate for CF - even in the absence of other findings for CF.
    
    • Cystic fibrosis is the most common cause of nasal polyposis in childhood and should be suspected
  • In Samter triad (Aspirin-exacerbated respiratory disease or AERD), a rare condition, nasal polyps are associated with aspirin sensitivity and asthma
    
    • AERD is diagnosed in pts who have 1) Asthma and chronic sinusitis with nasal polyposis and 2) Acute respiratory tract reactions to ingestion of aspirin and other COX-1 inhibitors
• Polyps look like gray, grape-like masses found squeezed between the nasal turbinates and septum
• Any child with nasal polyposis should be screened for CF.
• Tx and prevention:
  
  • 1st line is IN corticosteroid sprays; oral tx reserved for severe or refractory disease.

Question 61

Cleft Problems

• Inheritance
  
  • “Rule of 4”
  • One parent/child affected: 4% recurrence
  • Parent and child affected: 17% recurrence (4x4)
  • 2 children: 9% (4+4)
  • Each person is 4. Same generation = Add. Different generation = Multiply
• Associated syndromes
  
  • The majority of cases are not associated with any genetic syndrome.
• Management
  
  • *Pre-surgical: Nasoalveolar molding (NAM)
  • *Lip repair at ____ months
    
    • Reconstruction of cleft lip is generally performed at approx 3 mo of age acc to rule of 10: 10 lbs weight, 10 WEEKS of age, 10g hgb
  • *Palate repair at ____ months
  • *Optional “kindergarten” rhinoplasty at 6 yo
  • *Alveolar bone graft at 7-10 yo. Involve ortho, dentistry, speech
  • *Septo-rhinoplasty at 16-18 yo
  • *Orthognathic surgery at 16-21 yo

Answer 61

Cleft Problems

• Inheritance
  
  • “Rule of 4”
  • One parent/child affected: 4% recurrence
  • Parent and child affected: 17% recurrence (4x4)
  • 2 children: 9% (4+4)
  • Each person is 4. Same generation = Add. Different generation = Multiply
• Associated syndromes
  
  • The majority of cases are not associated with any genetic syndrome.
• Management
  
  • *Pre-surgical: Nasoalveolar molding (NAM)
  • *Lip repair at 3-6 months
    
    • Reconstruction of cleft lip is generally performed at approx 3 mo of age acc to rule of 10: 10 lbs weight, 10 WEEKS of age, 10g hgb
  • *Palate repair at 9-13 months
  • *Optional “kindergarten” rhinoplasty at 6 yo
  • *Alveolar bone graft at 7-10 yo. Involve ortho, dentistry, speech
  • *Septo-rhinoplasty at 16-18 yo
  • *Orthognathic surgery at 16-21 yo

Question 62

Lingual thyroid

• Most common location for an ectopic thyroid (90% of cases).
• Path: Thyroid tissue fails to descend into the neck from its site of origin in the tongue base.

Answer 62

Lingual thyroid

• Most common location for an ectopic thyroid (90% of cases).
• Path: Thyroid tissue fails to descend into the neck from its site of origin in the tongue base.

Question 63

Cleft tongue
- Part of X-linked oral-facial-digital syndrome Type 1.

- Pt: Cleft tongue, hypoplasia of the nasal alar cartilages, medial cleft of the upper lip, asymmetric cleft of the palate, digital malformations, and mild intellectual disability. ½ of patients have hamartoma between the lobes of the divided tongue. - Mohr disease is an autosomal recessive disorder with lobulated nodular tongue, conductive hearing loss, cleft lip, high-arched palate, hypoplasia of the mandible, polydactyly, and syndactyly.

Answer 63

Cleft tongue
- Part of X-linked oral-facial-digital syndrome Type 1.

- Pt: Cleft tongue, hypoplasia of the nasal alar cartilages, medial cleft of the upper lip, asymmetric cleft of the palate, digital malformations, and mild intellectual disability. ½ of patients have hamartoma between the lobes of the divided tongue. - Mohr disease is an autosomal recessive disorder with lobulated nodular tongue, conductive hearing loss, cleft lip, high-arched palate, hypoplasia of the mandible, polydactyly, and syndactyly.

Question 64

Sinusitis

• Path:
  
  • Most common bacterial causes: ___, ___, ___
    
    • SHiMusitis - Strep pneumo, H influenza, Moraxella
  • Mucormycosis is another fungal disease that can be life-threatening. It occurs in poorly controlled diabetes and can present as a black eschar on the nasal turbinate. It is dangerous bc it frequently “grows backward” into the bone and brain.
• RFs: Exposure to cigarette smoke and air pollution
• Pt:
  
  • Viral sinusitis is almost indistinguishable from bacterial sinusitis. One clue is the duration of symptoms. Most URIs improve in 7-10 days.
  • Suspect bacterial sinusitis if
    
    • Sinus symptoms last >10 days
    • Sinus symptoms worsen during the course of a resolving URI.
    • Severe onset (concurrent fever >38.9) and purulent nasal discharge for at least 3 consecutive days
• Dx:
  
  • Clinical based on 1 of the following 3 findings:
    
    • 1) Nasal discharge or daytime cough for >___ days without improvement
    • 2) Ill appearing child with fever >38.5C with associated purulent rhinorrhea for at least 3 consecutive days
    • 3) Worsening symptoms of nasal congestion or rhinorrhea, cough, and fever after initial 3-4 day period of improvement
  • Obtain valid bacterial cultures by aspirating the sinus by direct maxillary antral puncture or endoscopic middle meatal aspiration; however, reserve these only for those who have life-threatening illness, as immunocompromised, or have illness that is unresponsive to empiric therapy.
• Tx:
  
  • Most still recommend Amoxicillin. However, many use ____ 90mg/kg/day for __ days or 7 days past symptom resolution, or extended-spectrum macrolides, or oral 2nd or 3rd cephalosporins (cefdinir, cefixime, cefpodoxime, cefuroxime)
  • Complications of sinusitis
    • Preseptal (periorbital) cellulitis
    • Orbital cellulitis
    • Septic cavernous sinus thrombosis
    • Meningitis
    • Osteomyelitis of the frontal bone with a subperiosteal abscess (Pott’s puffy tumor)
    • Epidural abscess
    • Subdural abscess
    • Brain abscess

Answer 64

Sinusitis

• Path:
  
  • Most common bacterial causes: S pneumo, M catarrhalis, H influenza
    
    • SHiMusitis - Strep pneumo, H influenza, Moraxella
  • Mucormycosis is another fungal disease that can be life-threatening. It occurs in poorly controlled diabetes and can present as a black eschar on the nasal turbinate. It is dangerous bc it frequently “grows backward” into the bone and brain.
• RFs: Exposure to cigarette smoke and air pollution
• Pt:
  
  • Viral sinusitis is almost indistinguishable from bacterial sinusitis. One clue is the duration of symptoms. Most URIs improve in 7-10 days.
  • Suspect bacterial sinusitis if
    
    • Sinus symptoms last >10 days
    • Sinus symptoms worsen during the course of a resolving URI.
    • Severe onset (concurrent fever >38.9) and purulent nasal discharge for at least 3 consecutive days
• Dx:
  
  • Clinical based on 1 of the following 3 findings:
    
    • 1) Nasal discharge or daytime cough for >10 days without improvement
    • 2) Ill appearing child with fever >38.5C with associated purulent rhinorrhea for at least 3 consecutive days
    • 3) Worsening symptoms of nasal congestion or rhinorrhea, cough, and fever after initial 3-4 day period of improvement
  • Obtain valid bacterial cultures by aspirating the sinus by direct maxillary antral puncture or endoscopic middle meatal aspiration; however, reserve these only for those who have life-threatening illness, as immunocompromised, or have illness that is unresponsive to empiric therapy.
• Tx:
  
  • Most still recommend Amoxicillin. However, many use amoxicillin-clavulanate high dose Augmentin 90mg/kg/day for 10 days or 7 days past symptom resolution, or extended-spectrum macrolides, or oral 2nd or 3rd cephalosporins (cefdinir, cefixime, cefpodoxime, cefuroxime)
  • Complications of sinusitis
    • Preseptal (periorbital) cellulitis
    • Orbital cellulitis
    • Septic cavernous sinus thrombosis
    • Meningitis
    • Osteomyelitis of the frontal bone with a subperiosteal abscess (Pott’s puffy tumor)
    • Epidural abscess
    • Subdural abscess
    • Brain abscess

Question 65

Chronic Sinusitis
- Inflammatory process affecting the paranasal sinuses that lasts at least __ weeks despite medical therapy.

• Path:
  
  • Often it is continuation of acute sinusitis but can also be caused by mechanical obstruction or allergic edema.
  • Frequently seen in children with chronic cough
• Pt:
  
  • Mucopurulent discharge (anterior and/or posterior nasal), congestion, and facial pain/pressure, in addition to cough
  • Often have received multiple short courses (5-7 days) of oral antibiotics that improve symptoms, but the symptoms return upon discontinuation.
  • Clue to diagnosis is cough that worsens upon lying down and upon awakening due to postnasal drainage of secretions. Halitosis is also frequently noted.
• Dx:
  
  • Diagnosis requires at least 2 of the following findings:
    
    • Cough
    • Mucopurulent drainage
    • Congestion
    • Facial pain/pressure
  • Evidence of inflammation can be obtained by CT scan or nasal endoscopy.
• Tx: Reducing inflammation, promoting sinus drainage, and clearing infection.
  
  • Requires a combination of nasal or oral steroids, sinus irrigation, and antibiotic therapy.
    
    • Most cases of chronic sinusitis are polymicrobial and include anaerobes, so 1st line therapy for most pts is _____.
      
      • For penicillin-allergic pts or cases in which methicillin resistance is a concern, clindamycin is used.
      • Antimicrobial therapy is given for 3-10 weeks.
      • Pts who worsen or fail to show improvement within 1 week of therapy need referral to ENT for culture and evaluation.

Answer 65

Chronic Sinusitis
- Inflammatory process affecting the paranasal sinuses that lasts at least 12 weeks despite medical therapy.

• Path:
  
  • Often it is continuation of acute sinusitis but can also be caused by mechanical obstruction or allergic edema.
  • Frequently seen in children with chronic cough
• Pt:
  
  • Mucopurulent discharge (anterior and/or posterior nasal), congestion, and facial pain/pressure, in addition to cough
  • Often have received multiple short courses (5-7 days) of oral antibiotics that improve symptoms, but the symptoms return upon discontinuation.
  • Clue to diagnosis is cough that worsens upon lying down and upon awakening due to postnasal drainage of secretions. Halitosis is also frequently noted.
• Dx:
  
  • Diagnosis requires at least 2 of the following findings:
    
    • Cough
    • Mucopurulent drainage
    • Congestion
    • Facial pain/pressure
  • Evidence of inflammation can be obtained by CT scan or nasal endoscopy.
• Tx: Reducing inflammation, promoting sinus drainage, and clearing infection.
  
  • Requires a combination of nasal or oral steroids, sinus irrigation, and antibiotic therapy.
    
    • Most cases of chronic sinusitis are polymicrobial and include anaerobes, so 1st line therapy for most pts is amoxicillin/clavulanate.
      
      • For penicillin-allergic pts or cases in which methicillin resistance is a concern, clindamycin is used.
      • Antimicrobial therapy is given for 3-10 weeks.
      • Pts who worsen or fail to show improvement within 1 week of therapy need referral to ENT for culture and evaluation.

Question 66

Lemierre Syndrome

• Jugular vein septic thrombophlebitis
• Path: _____ is the most commonly associated organism

Answer 66

Lemierre Syndrome

• Jugular vein septic thrombophlebitis
• Path: Fusobacterium necrophorum is the most commonly associated organism

Question 67

Ludwig Angina

• Aggressive, rapidly spreading, bilateral polymicrobial (oral flora including anaerobes) cellulitis of the submandibular and sublingual spaces.
• Most often a complication of an infection of the 2nd and/or 3rd mandibular molar teeth.
• Pt:
  
  • Appear very ill, with fever, severe dysphagia, difficulty opening the mouth (trismus), and stiff neck.
  • As the infection progresses, pts often purposefully lean forward in an attempt to maximize airway space and improve, at least temporarily, their respiratory status.
  • Cellulitis has a characteristic “brawny” or “woody” texture and is often associated with palpable crepitus within the submandibular and sublingual spaces.
• CT is the imaging modality of choice in pts with deep neck-space infections
• Tx:
  
  • Monitor closely for evidence of airway compromise such as cyanosis and increasing stridor.
  • Tx immunocompetent pts with IV _____, or a combination of penicillin G plus metronidazole or clindamycin.
  • Pts who do not improve with appropriate antimicrobial therapy, or in whom fluctuance is identified, require surgical intervention and drainage.
  • Additionally, extract any tooth implicated as the source of infection.

Answer 67

Ludwig Angina

• Aggressive, rapidly spreading, bilateral polymicrobial (oral flora including anaerobes) cellulitis of the submandibular and sublingual spaces.
• Most often a complication of an infection of the 2nd and/or 3rd mandibular molar teeth.
• Pt:
  
  • Appear very ill, with fever, severe dysphagia, difficulty opening the mouth (trismus), and stiff neck.
  • As the infection progresses, pts often purposefully lean forward in an attempt to maximize airway space and improve, at least temporarily, their respiratory status.
  • Cellulitis has a characteristic “brawny” or “woody” texture and is often associated with palpable crepitus within the submandibular and sublingual spaces.
• CT is the imaging modality of choice in pts with deep neck-space infections
• Tx:
  
  • Monitor closely for evidence of airway compromise such as cyanosis and increasing stridor.
  • Tx immunocompetent pts with IV ampicillin-sulbactam, or a combination of penicillin G plus metronidazole or clindamycin.
  • Pts who do not improve with appropriate antimicrobial therapy, or in whom fluctuance is identified, require surgical intervention and drainage.
  • Additionally, extract any tooth implicated as the source of infection.

Question 68

Non Strep Pharyngitis

• Path: ___ is the most frequent cause of nonstreptoccal pharyngitis
• The specific syndrome of pharyngoconjunctival fever is caused by ____ (sore throat and eye infection).

Answer 68

Non Strep Pharyngitis

• Path: Adenovirus is the most frequent cause of nonstreptoccal pharyngitis
• The specific syndrome of pharyngoconjunctival fever is caused by adenovirus (sore throat and eye infection).

Question 69

Pharyngitis (Strep Throat)
- Group A strep (GAS) is the most frequent bacterial cause

• Centor criteria
  
  • C___
  • E___
  • N___
  • T___
  • OR____
• Dx: <1 = ___, 2-3 = ____, >4 = ___
• Do not do strep throat test or treatment if less than ___yo (unless had sick strep contact)
• Tx: IM Penicillin G benzathine (Bicillin) once 600,000 U for less than ___kg OR ____ for ___ days to help prevent rheumatic heart.
  
  • If penicillin skin allergy/non anaphylactic reaction, can use cephalexin, cefadroxil, or oral cephalosporin for 10 days
    
    • If anaphylaxis or child allergic to both PCNs and cephalosporins, use macrolide (erythromycin, azithromycin) over clindamycin
  • Child is considered noninfectious after completing ___ hours of antibiotic therapy and can return to school at that point.
• Nonsuppurative Complications:
  
  • 1) ____: Can be prevented if antibiotic treatment is given within ____ days after onset of symptoms. (Remember that occurs only after ____ )
  • 2) _____ - can occur regardless of therapy and regardless of source of primary infection (pharynx or skin)

Answer 69

Pharyngitis (Strep Throat)
- Group A strep (GAS) is the most frequent bacterial cause

• Centor criteria
  
  • No Cough
  • Exudates
  • Nodes
  • Temp >38C
  • OR <14 +1, >44 -1;; for modified, +1 for age 3-15yo
• Dx: <1 = do nothing, 2-3 = rapid strep (90% sensitive), >4 = tx with antibiotics (should not do this)
• Do not do strep throat test or treatment if <3yo (unless had sick strep contact)
• Tx: IM Penicillin G benzathine (Bicillin) once 600,000 U for <27kg or 1.2 million U for >27kg OR amoxicillin for 10 days to help prevent rheumatic heart.
  
  • If penicillin skin allergy/non anaphylactic reaction, can use cephalexin, cefadroxil, or oral cephalosporin for 10 days
    
    • If anaphylaxis or child allergic to both PCNs and cephalosporins, use macrolide (erythromycin, azithromycin) over clindamycin
  • Child is considered noninfectious after completing 24 hours of antibiotic therapy and can return to school at that point.
• Nonsuppurative Complications:
  
  • 1) Rheumatic fever: Can be prevented if antibiotic treatment is given within 9 days after onset of symptoms. (Remember that rheumatic fever occurs only after pharyngitis - not skin infections)
  • 2) Poststreptococcal glomerulonephritis - can occur regardless of therapy and regardless of source of primary infection (pharynx or skin)

Question 70

Paradise criteria for tonsillectomy

• Minimum frequency of sore throat episodes
  
  • > =___ in the preceding year, or
  • > =___ in each of the preceding 2 years, or
  • > =__ in each of the preceding 3 years

Answer 70

Paradise criteria for tonsillectomy

• Minimum frequency of sore throat episodes
  
  • > =7 in the preceding year, or
  • > =5 in each of the preceding 2 years, or
  • > =3 in each of the preceding 3 years

Question 71

Scarlet fever

• Rash has “sandpaper-like” texture
• Rash is especially present on flexural surfaces of the antecubital fossae and produces Pastia lines
• Strawberry tongue.
• Tx: penicillin is DOC

Answer 71

Scarlet fever

• Rash has “sandpaper-like” texture
• Rash is especially present on flexural surfaces of the antecubital fossae and produces Pastia lines
• Strawberry tongue.
• Tx: penicillin is DOC

Question 72

Arcanobacterium Haemolyticum

• Arcanobacterium haemolyticum (formerly known as Corynebacterium haemolyticum) is a rare cause of pharyngitis in young adults and adolescents.
  
  • Gram ______ that Causes acute pharyngitis similar to S pyogenes
  • Should not be overlooked when pts are not responding to conventional tx for pharyngitis (or fever/lymphadenopathy) and have a negative workup for EBV.
• Pt:
  
  • Presents in the same manner as Group A strep pharyngitis, and is often indistinguishable from S pyogenes infection.
  • Fever, pharyngeal exudate, and desquamative maculopapular or scarlatiniform rash
• Should be considered in adolescent and adult patients with persistent pharyngitis or fever/lymphadenopathy and a negative workup for group A strep, EBV, and other common viruses.
• Dx: Throat swab culture with special request to the lab to look for AH (gram positive rod).
• Tx: ______ are drugs of choice.
  
  • Also susceptible to clindamycin in vitro.

Answer 72

Arcanobacterium Haemolyticum

• Arcanobacterium haemolyticum (formerly known as Corynebacterium haemolyticum) is a rare cause of pharyngitis in young adults and adolescents.
  
  • Gram positive rod that Causes acute pharyngitis similar to S pyogenes
  • Should not be overlooked when pts are not responding to conventional tx for pharyngitis (or fever/lymphadenopathy) and have a negative workup for EBV.
• Pt:
  
  • Presents in the same manner as Group A strep pharyngitis, and is often indistinguishable from S pyogenes infection.
  • Fever, pharyngeal exudate, and desquamative maculopapular or scarlatiniform rash
• Should be considered in adolescent and adult patients with persistent pharyngitis or fever/lymphadenopathy and a negative workup for group A strep, EBV, and other common viruses.
• Dx: Throat swab culture with special request to the lab to look for AH (gram positive rod).
• Tx: Erythromycin/macrolides are drugs of choice.
  
  • Also susceptible to clindamycin in vitro.

Question 73

Retropharyngeal abscess
- Path: Polymicrobial, often Group A Strep pyogenes, Staph aureus, and oral anaerobes (most commonly Fusobacterium or Prevotella)

• Pt:
  
  • Toddlers and children present with abrupt onset of high fevers and difficulty swallowing. Then develop refusal to eat, severe throat pain, neck stiffness, hyperextension of the head, and gurgling respirations. Drooling soon develops. Pts might not want to open their mouths bc of pain (trismus); however, if they do, an erythematous bulge is sometimes visible in the posterior pharyngeal wall.
  • PE may reveal enlarged and/or tender cervical lymph nodes, retropharyngeal mass
• Dx: Lateral neck radiographs is the initial study. Can show a widened retropharyngeal space with anterior displacement of the airway;
  
  • Assess paravertebral space for >__mm in children and adults at C__, or >___mm in children or >22mm in adults at C___, is considered pathologically widened.
    
    • Retropharyngeal space at C2 is twice the diameter of the vertebral body or > ½ the width of C4.
• Tx:
  
  • Medical emergency
  • In the prefluctuant phase, prevent suppuration by treating with ___ for S aureus and ____ for anaerobic coverage. Single agent therapy with _____is an alternative. Continue IV antibiotic therapy until pt is afebrile and clinically improved, and then complete therapy with oral amoxicillin/clavulanate or clindamycin to provide a total of 14 days of therapy.
    
    • IV ampicillin-sulbactam or IV clindamycin for early antimicrobial therapy is imperative
  • If abscess is fluctuant, drainage is necessary.

Answer 73

Retropharyngeal abscess
- Path: Polymicrobial, often Group A Strep pyogenes, Staph aureus, and oral anaerobes (most commonly Fusobacterium or Prevotella)

• Pt:
  
  • Toddlers and children present with abrupt onset of high fevers and difficulty swallowing. Then develop refusal to eat, severe throat pain, neck stiffness, hyperextension of the head, and gurgling respirations. Drooling soon develops. Pts might not want to open their mouths bc of pain (trismus); however, if they do, an erythematous bulge is sometimes visible in the posterior pharyngeal wall.
  • PE may reveal enlarged and/or tender cervical lymph nodes, retropharyngeal mass
• Dx: Lateral neck radiographs is the initial study. Can show a widened retropharyngeal space with anterior displacement of the airway;
  
  • Assess paravertebral space for >7mm in children and adults at C2, or >14mm in children or >22mm in adults at C6, is considered pathologically widened.
    
    • Retropharyngeal space at C2 is twice the diameter of the vertebral body or > ½ the width of C4.
• Tx:
  
  • Medical emergency
  • In the prefluctuant phase, prevent suppuration by treating with nafcillin for S aureus and clindamycin for anaerobic coverage. Single agent therapy with ampicillin-sulbactam is an alternative. Continue IV antibiotic therapy until pt is afebrile and clinically improved, and then complete therapy with oral amoxicillin/clavulanate or clindamycin to provide a total of 14 days of therapy.
    
    • IV ampicillin-sulbactam or IV clindamycin for early antimicrobial therapy is imperative
  • If abscess is fluctuant, drainage is necessary.

Question 74

Peritonsillar abscess (PTA)
- Path: Typically polymicrobial with the predominant species being Strep pyogenes, staph aureus (including MRSA), and respiratory anaerobes (including Fusobacterium, Prevotella, and Veillonella species).

• Pt:
  
  • Fever, severe throat pain (usually unilateral reflected affected tonsil), muffled or “hot potato” voice, trismus, and odynophagia (leading to decreased oral intake/drooling or pooling of saliva in the mouth).
  • Medial displacement of tonsil and deviation of uvula to the opposite side
• Dx:
  
  • Use CT scan with IV contrast to distinguish peritonsillar abscess from peritonsillar cellulitis and to evaluate for the spread of infection to contiguous deep neck spaces.
  • Do NOT order CT scanning in children with mod-severe resp distress, particularly when sedation is necessary; evaluate these children in the OR, where an artificial airway can be established if needed.
• Tx:
  
  • Probably peritonsillar abscess:
    
    • Drainage by needle aspiration is diagnostic and therapeutic if abscess is present
    • AND antibiotic therapy for 10-14 days to cover aerobes and anaerobes (same abx as retropharyngeal abscess)
  • -For most pts without a hx of sore throat or recurrent pharyngitis, simple I&D is best done in OR.
  • -If there is a hx of previous recurrent pharyngitis or a prior PTA, then a ____ is recommended. Tx with same abx as for RTA.

Answer 74

Peritonsillar abscess (PTA)
- Path: Typically polymicrobial with the predominant species being Strep pyogenes, staph aureus (including MRSA), and respiratory anaerobes (including Fusobacterium, Prevotella, and Veillonella species).

• Pt:
  
  • Fever, severe throat pain (usually unilateral reflected affected tonsil), muffled or “hot potato” voice, trismus, and odynophagia (leading to decreased oral intake/drooling or pooling of saliva in the mouth).
  • Medial displacement of tonsil and deviation of uvula to the opposite side
• Dx:
  
  • Use CT scan with IV contrast to distinguish peritonsillar abscess from peritonsillar cellulitis and to evaluate for the spread of infection to contiguous deep neck spaces.
  • Do NOT order CT scanning in children with mod-severe resp distress, particularly when sedation is necessary; evaluate these children in the OR, where an artificial airway can be established if needed.
• Tx:
  
  • Probably peritonsillar abscess:
    
    • Drainage by needle aspiration is diagnostic and therapeutic if abscess is present
    • AND antibiotic therapy for 10-14 days to cover aerobes and anaerobes (same abx as retropharyngeal abscess)
  • -For most pts without a hx of sore throat or recurrent pharyngitis, simple I&D is best done in OR.
  • -If there is a hx of previous recurrent pharyngitis or a prior PTA, then a tonsillectomy is recommended. Tx with same abx as for RTA.

Question 75

Indications for tonsillectomy:

• Recurrent pharyngitis: __ episodes in the past year, __ in each of the last 2 years, or __ in each of the past 3 years
• Marked/severe adenotonsillar hypertrophy (exclude tumor)
• Severe sleep apnea (adenotonsillectomy is the 1st line tx in children with OSA)

Tonsillectomy does not help prevent or treat acute or chronic sinusitis or chronic otitis media. Tonsillectomy does not help prevent URIs.

Answer 75

Indications for tonsillectomy:

• Recurrent pharyngitis: 7 episodes in the past year, 5 in each of the last 2 years, or 3 in each of the past 3 years
• Marked/severe adenotonsillar hypertrophy (exclude tumor)
• Severe sleep apnea (adenotonsillectomy is the 1st line tx in children with OSA)

Tonsillectomy does not help prevent or treat acute or chronic sinusitis or chronic otitis media. Tonsillectomy does not help prevent URIs.

Question 76

Indications for adenoidectomy:

• Persistent mouth breathing
• Repeated or chronic OME (otitis media with effusion)
• Hyponasal speech
• Adenoid facies
• Persistent or recurrent nasopharyngitis when it seems to be temporally related to hypertrophied adenoid tissue.

Do not perform tonsillectomy for these problems

Answer 76

Indications for adenoidectomy:

• Persistent mouth breathing
• Repeated or chronic OME (otitis media with effusion)
• Hyponasal speech
• Adenoid facies
• Persistent or recurrent nasopharyngitis when it seems to be temporally related to hypertrophied adenoid tissue.

Do not perform tonsillectomy for these problems

Question 77

Velopharyngeal insufficiency (VPI)

• Incomplete closure between soft palate and the pharyngeal wall during speech
• Path:
  
  • Is a known complication of adenoidectomy that occurs because removal of the adenoids increases the size of the nasopharyngeal airway. Individuals with preexisting palatal defects (ie bifid uvula) are at a much higher risk for post adenoidectomy VPI.
• Pt: Leads to a hypernasal voice and in severe cases, nasal regurgitation of fluids.

Answer 77

Velopharyngeal insufficiency (VPI)

• Incomplete closure between soft palate and the pharyngeal wall during speech
• Path:
  
  • Is a known complication of adenoidectomy that occurs because removal of the adenoids increases the size of the nasopharyngeal airway. Individuals with preexisting palatal defects (ie bifid uvula) are at a much higher risk for post adenoidectomy VPI.
• Pt: Leads to a hypernasal voice and in severe cases, nasal regurgitation of fluids.

Question 78

Laryngitis / Hoarseness

• Acute causes:
  
  • The most common cause of acute hoarseness is viral infection.
  • Trauma and other causes of inflammation may also cause acute hoarseness
• Chronic causes:
  
  • One of the most common causes of chronic hoarseness in children is benign lesions of the vocal cord (eg nodules), usually from voice abuse.
  • Structural anomaly, allergy, GERD, hx of airway intubation or other local trauma (caustic and inhalation injuries)
• Indications for laryngoscopy:
  
  • Hoarseness for >2 weeks
  • Unexplained hoarseness
  • Progressive hoarseness
  • Socially unacceptable hoarseness
• Management
  
  • For nodules:
    
    • Tend to resolve in 3-6 months without treatment, but children with relapse or highly dysfunctional nodules may require surgical intervention.
  • For voice abuse:
    
    • In an otherwise healthy child with no somatic symptoms and no abnormal findings on physical examination, there is no indication for any diagnostic testing or specialty consultation. Counsel.
  • Refer to ENT if hoarseness lasts >____ weeks.

Answer 78

Laryngitis / Hoarseness

• Acute causes:
  
  • The most common cause of acute hoarseness is viral infection.
  • Trauma and other causes of inflammation may also cause acute hoarseness
• Chronic causes:
  
  • One of the most common causes of chronic hoarseness in children is benign lesions of the vocal cord (eg nodules), usually from voice abuse.
  • Structural anomaly, allergy, GERD, hx of airway intubation or other local trauma (caustic and inhalation injuries)
• Indications for laryngoscopy:
  
  • Hoarseness for >2 weeks
  • Unexplained hoarseness
  • Progressive hoarseness
  • Socially unacceptable hoarseness
• Management
  
  • For nodules:
    
    • Tend to resolve in 3-6 months without treatment, but children with relapse or highly dysfunctional nodules may require surgical intervention.
  • For voice abuse:
    
    • In an otherwise healthy child with no somatic symptoms and no abnormal findings on physical examination, there is no indication for any diagnostic testing or specialty consultation. Counsel.
  • Refer to ENT if hoarseness lasts >2 weeks.

Question 79

Thyroglossal Duct Cyst (TGDC) (most common)- Midline. Can extend to the base of the tongue and move vertically with swallowing and tongue protrusion.

• Cystic masses in the midline of the neck. Cysts typically move with swallowing or movement of the tongue.
• Pt:
  
  • Asymptomatic unless they become infected.
  • If infection occurs, a cyst can rapidly increase in size and cause respiratory compromise.
• Dx: Clinical. US often performed to confirm diagnosis
• Tx: If the pt has recurrent infections, removal of the cyst is warranted.

Answer 79

Thyroglossal Duct Cyst (TGDC) (most common)- Midline. Can extend to the base of the tongue and move vertically with swallowing and tongue protrusion.

• Cystic masses in the midline of the neck. Cysts typically move with swallowing or movement of the tongue.
• Pt:
  
  • Asymptomatic unless they become infected.
  • If infection occurs, a cyst can rapidly increase in size and cause respiratory compromise.
• Dx: Clinical. US often performed to confirm diagnosis
• Tx: If the pt has recurrent infections, removal of the cyst is warranted.

Question 80

Dermoid cysts are usually recognized in infancy and often grow during puberty. They are firm, mobile, subcutaneous cysts found most commonly in the ______

Answer 80

Dermoid cysts are usually recognized in infancy and often grow during puberty. They are firm, mobile, subcutaneous cysts found most commonly in the lateral brow or upper eyelid region

Question 81

Branchial Cleft Cyst/Sinus- lateral (anterior to SCM)
- Embryonic epithelial remnant.

• Pt:
  
  • Usually presents in childhood or young adulthood when the cyst becomes infected during a URI.
  • Presents as solitary mass along the anterior margin of the SCM muscle (along the 1st to 4th branchial clefts)
• Dx and tx same as with thyroglossal duct cysts.
• Tx: Surgical excision following resolution of acute infection

Answer 81

Branchial Cleft Cyst/Sinus- lateral (anterior to SCM)
- Embryonic epithelial remnant.

• Pt:
  
  • Usually presents in childhood or young adulthood when the cyst becomes infected during a URI.
  • Presents as solitary mass along the anterior margin of the SCM muscle (along the 1st to 4th branchial clefts)
• Dx and tx same as with thyroglossal duct cysts.
• Tx: Surgical excision following resolution of acute infection

Question 82

Congenital cervical cartilaginous remnants (Cervical auricles)
- Skin covered proturances in the neck. Large and bilateral. No sinuses, no drainage, do not get infected

• Reassurance

Answer 82

Congenital cervical cartilaginous remnants (Cervical auricles)
- Skin covered proturances in the neck. Large and bilateral. No sinuses, no drainage, do not get infected

• Reassurance

Question 83

Parotitis

- The most likely cause of parotitis in a fully vaccinated pt with classic viral symptoms is ____

Answer 83

Parotitis

- The most likely cause of parotitis in a fully vaccinated pt with classic viral symptoms is parainfluenza virus.