ENT cases Flashcards by Meghan May

What is the general anatomy of the respiratory epithelium and what disease is closely related?

has cilia or hair fibers = whisk broom to clear mucus out of the sinus

has mucociliary clearance ability

Asthma, sinus disease is closely related

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Common cold symptoms and what are common causes?

benign, self limited, w/ symptoms hours to days post infection:

sore throat/nasal congestions/rhinorrhea/sneeze/cough

Almost always viral

Rhionvirus = 50%

Corona virus, influenza, RSV or parainfluenza

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Common cold transmission

Direct contact
Aerosolized droplets
Virus enters nose
Mucociliary clearance to nasopharynx

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Mechanism of infection in common cold

Virus enters epithelial cells
– Via intercellular adhesion molecule-1
• Virus replicates once enters cell
– 75% of patients become symptomatic
– Viral shedding peaks by day 2
– Virus can be present for several weeks
• Vasodilation, increase mucus secretion, extensive respiratory epithelium damage

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Otitis Media
• Very commonly diagnosed childhood illness
• 2.2 million episodes diagnosed yearly
• Risk factors:

– Daycare, smoke exposure, l_ack of breast-feedin_g, ethnicity, family history, older siblings, low socioeconomic status, other health conditions (e.g. Downs’)

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Most common cause for Acute otitis media

Streptococcus pneumoniae– 40%
Haemophilus influenza– Nontypeable– 25%
Moraxella catarhalis– 12%

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Causes of Chronic otitis media

Haemophilus influenza– Nontypeable– 15%
Moraxella catarhalis– 10%
Streptococcus pneumoniae– 7%

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What does a normal tympanic membrane look like?

Don’t need to memorize, just appreciate

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What is our first line tx for otitis media?

AMOXICILLIN

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What type of ear tubes are placed in child and why do they help?

How long do they last?

– Pressure equalizing (PE) tubes
– Myringotomy tubes
– Tympanostomy tubes
• Allows the middle ear to ventilate until the eustachian tube is mature

Ventilate middle ear space
• Usually last 6-18 months

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What are three indications for ear tubes?

• Chronic middle ear effusion ± conductive hearing loss
• Recurrent suppurative otitis media
• Atelectasis of middle ear
– Inadequate ventilation by auditory tube
– Retraction/deformation of tympanic membrane

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What are paranasal sinuses and how many do we have?

– Air filled cavities that are found in the bones of the face/head.

– Immature at birth, develop with age
• Named for the bone in which they form; 4 sets of sinuses
• Ethmoid
• Maxillary
• Sphenoid
• Frontal

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What is sinus disease?

Called Rhino-Sinusitis
– Inflammation/infection of the nasal passage and paranasal sinuses
• Several different types:

Acute bacterial/ recurrent acute rhinosinusitis and chronic rhinosinusitis

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What are causes of acute rhinosinusitis?

– Acute Rhinosinusitis
• Acute Bacterial
– Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarhalis
• Acute Viral

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What is the mechanism that leads to a sinus infection?

disease causes swelling–> narrows sinus ostia–> impedes draining

==> mucus fills sinus–> bacteria grow–> Sinus infection

(can also start right from ‘narrows sinus ostia’)

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What causes inflammation of the sinuses?

Viral infections
Environmental allergens
Environmental irritants
Mucus
Medications
Bacterial Infections
Fungus

guy has pain in mouth when eating spicy or acidic food. PMH of AIDs, not on meds, no temp and erythema of hard palate; flat, smooth areas of dorsal tongue but no white patches. Dx

Erythematous candidiasis!

Has candida infection even though no white plaques (thrush or pseudomembranous candidiasis)

• Adherent white plaques
– Tongue, buccal mucosa, hard palate
– Plaques wipe off and underlying mucosa is erythematous
• Most common in infants and immunocompromised
• Can affect oropharynx and esophagus
• 2nd most common AIDS-defining opportunistic
infection (Pneumocystis carinii pneumonia is #1)

Psuedomembranous candidiasis = thrush

HIV, poorly controlled diabetes, Sjorgens disease, steoid inhalers, broad spectrum antibiotics, head adn neck radiation predispose you to:

oral candidiasis

What is the most common form of oral candidiasis?

Erythematous (atrophic) candidiasis

What is this a picture of?

What agents are generally responsible?

Angular chelitis = subtype of oral candidiasis

Combination of bacterial and fungal infections
Most caused by C. albicans and S. aureus
Soreness, erythema, and fissuring at commissures
Seen in patients who wear dentures (pooling of saliva at commissures)

How do we Dx candidiasis?

Typically based on clinical signs/symptoms Cytology Mucosal biopsy Culture

– Acute atrophic – Chronic atrophic – Angular chelitis – Median rhomboid glossitis – Chronic multifocal Are all subtypes of:

Oral candidiasis

What is stomatitis and what are causes?

broad term for infection/inflammation of mouth laundry list for: bacterial/ viral/ fungal

Case: 14 yo boy, hurts to swallow, fever, chills, temperature. Has aches and headache and stomach ache. Diffuse rash, lungs clear, bilater anterior cervical lymph adenopathy throat injected, bilateral tonsillar hypertorphy + exudate, ill appearing How would you make a correct Dx before kid leaves clinic?

Obtain rapid antigen detection test

Pt has sore throat.. dx as strep. How does organism adhere to the epithelial cells on surface of oropharnyx?

Via pili on the surface of the organism

How does streptococcus (in strep throat) evade phagocytosis?

via hyaluronic acid in capsule of organism and via antiphagocytic proteins made and secreated by organism

What causes constitutional illness we see associated with strep?

from exotoxins made by organism

How is strep throat transmitted?

via large droplets containing organism; coughing, sneezing, conversation with sick individual or asymptomatic colonization of other students in John's class

What is waldyers ring?

• Waldeyer’s ring: aggregate lymphoid tissue upper aerodigestive tract

What are indicatiosn of adenotonsillectomy?

Upper airway obstruction (most common) • Recurrent/chronic infection – Tonsillitis from ß hemolytic strep Group A or Peritonsillitis / peri-tonsillar abscess • Neoplasia (lymphoma/carcinoma): see unilateral hypertrophy

You are deciding whether or not your pt has strep throat as it seems highly likely he has strep. What do you do next?

Rapid strep test or empiric antibiotics

Pt you are seeing has a moderate probability of having strep.. what are your next steps?

Order rapid strep test if positive treat if negative consider other diagnosis

If your patient is 10 - 25 years of age, what special considerations do we take into account when we suspect strep throat?

if rapid strep comes back negative, order a throat culture. Test for mononucleosis

How do you obtain a good throat culture?

Culture each tonsil + posterior pharngeal wall twist, rotate swab into tissue to get good specimen avoid touching the tongue and immediately transfer to tranpsort medium

A kid comes in with a huge swelling on the side of his neck and when it is drained it's full of pus. Dx?

Cervical abscess; kids with URI can get abcess in their cervicle lymph nodes

A concerened father brings high son in. The son is **drooling**, has a **fever** and appears very **sick**. The boy as an inspiratory stridor and sitting upright in bed. Dad says this happened very quickly. What are you suspicious of right now?

Supraglottitis rapid onset/ drooling/sitting up/fever/inspiratory stirdor

What is the etiology and tx for supraglottis?

H. flu (type B) Tx is antibiotics and secure airway

A mother brings in her son because of his cough. She states this happened gradually and he had low grade fevers so she thought it was just a cold. He recently has had loud, barking like coughs. You note he has a biphasic stridor. What is a likely dx at this point?

Croup; subglottic infection gradual onset/low fevers/barking cough/biphasic stridor

What is the cause and tx for croup?

cause of croup is viral tx with racemic epi, steroids and humidifier

What do you notice on xray? This is typical of what illness?

Steeple sign seen in Croup

What is the xray pointing to? When do we see this?

Thumb sign in Epiglottitis

Young girl comes in with a _bad cough, stridor, fever and toxic_ looking. Your attending does a physical and orders a PA and lateral chest xray as he suspects **bacterial tracheitis** What would you see if this Dx was correct?

Tracheal air column ragged and irregular on PA and lateral

Common cause for bacterial trachetis and treatement

S. Aureus IV antibiotics, hydration and rigid bronchoscopy with debridement of tracheal crusts and exudate (may need to intubate to prevent obstruction)