ENT/Ophtho/Gen Surg Flashcards
(77 cards)
1
Q
Describe your approach to a child presenting with confirmed hearing loss.
A
- Detailed family history
- Medical evaluation (history, physical examination for associated comorbidities and/or syndromic/nonsyndromic hearing loss)
- Consultations
- Paediatric otolaryngologist
- Paediatric ophthalmology
- Geneticist
- Prompt vision assessment to maximize sensory input (and r/o Usher syndrome)
2
Q
List 4 risk factors for positional plagiocephaly
A
- Male sex
- Firstborn
- Congenital Torticollis
- Supeine sleeping position at birth and at six weeks
- Exclusive bottle feeding
- Awake “tummy time” < 3 X per day
- Lower activity level with slower achievement of milestones
3
Q
Name 2 instances where imaging (x-rays) would be advised in an infant with flattening of his head
A
- Craniosynostosis is suspected
- Worsening of head shape between 4mo-2yo (when positional plagiocephaly would be expected to improve)
4
Q
What features would you look for to differentiate craniosynostosis from positional plagiocephaly?
List 3 management strategies for positional plagiocephaly
A
- Ipsilateral occipitomastoid bossing
- Posterior displacement of ipsilateral ear
Management strategies
- Positioning
- Head to foot of bed on alternating days
- Encourage lying on each side in supine position
- Tummy time (minimum 3 x 10-15min)
- Physiotherapy
- Moulding therapy
5
Q
When is moulding therapy considered for the treatment of positional plagiocephaly?
List 3 barriers to use of moulding therapy
A
Severe asymmetry + ≤8 months
- Side effects: contact dermatitis, pressure sores, local skin irritation
- Cost
- Accessibility - only available in select areas
- Time: treatment plan usually includes wearing for 23h/day
6
Q
What vision tests should you ensure you complete to screen vision in these age groups?:
≤3 months
6-12 months
3-18 years
A
-
≤3 months:
- Red reflex
- Complete examination of skin and external eye structures
-
6-12 months
- As above AND:
- Corneal light reflex
- Cover-uncover test
- As above AND:
-
3-18 years:
- As above AND:
- Visual acuity examination with age-appropriate tool
- Snellen ≥6yo
- HOTV ≥3yo
- Visual acuity examination with age-appropriate tool
- As above AND:
7
Q
At what age would a child be expected to obtain these milestones?
Face follow
Visual follow
Visual acuity measurable
A
- Face follow: Birth until 4 weeks
- Visual follow: 3mo
- Visual acuity measurable: 3.5y
8
Q
List 2 causes of amblyopia and their respective management
(reduced vision in the absence of ocular disease)
A
- Difference in refractive error (inability to focus the image)
- Corrective lenses
- Strabismus (confusing image = poor aim)
- Penalization therapy
- Occlusion (patching)
- Pharmacologic (cycloplegic drops)
- Penalization therapy
- Media opacities (no image = poor clarity)
- Clear the media - surgery for cataract etc.
9
Q
List 4 risk factors for acute otitis externa
A
- Trauma
- Foreign body in the ear
- Use of hearing aid
- Dermatological conditions
- Wearing tight head scarves
- Immunocompromise
- Chronic otorrhea
10
Q
What are the elements one needs to consider in order to diagnose acute otitis externa?
A
- Rapid onset (usually ≤48h) in the past 3 weeks
- Symptoms of ear canal inflammation
- Otalgia (often severe), itching or fullness
- +/- hearing loss or jaw pain (TMJ/in ear canal worsened with jaw motion)
- Signs of ear canal inflammation (tender tragus, pinna or both) OR diffuse ear canal edema, erythema or both +/- otorrhea, regional lymphadenitis, TM erythema or cellulitis of pinna and adjacent skin
11
Q
What are the 2 most common pathogens of acute otitis externa?
A
- Pseudomonas aeruginosa
- Staphylococcus aureus
Other bacteria: gram negative bacteria, Aspergillus, Candida
12
Q
Describe the management of acute otitis external for both mild-moderate and severe presentations.
What should you consider if there is a lack of response to the management?
A
-
Mild-moderate
-
1st line: topical antibiotic +/- topical steroids (7-10d) AND tylenol/NSIDS or oral opioid for analgesia
- No low pH, corticosporin, gentamicin or neomycin with TM tubes or perforated membranes d/t ototoxicity risk
- If canal not visualized, an expandable wick can be placed to decrease canal edema and facilitate medication delivery
- Agents:
- Polymyxin B-gramicidin (Polysporin) 1-2 drops QID
- Ciprodex 4 drops QID x 7 days
- Buro-Sol 2-3 drops TID-QID
-
1st line: topical antibiotic +/- topical steroids (7-10d) AND tylenol/NSIDS or oral opioid for analgesia
-
Severe
-
PO antibiotics that cover S aureus and P aeruginosa
- Ciprofloxacin is a good option
-
PO antibiotics that cover S aureus and P aeruginosa
Not responding to treatment
- Foreign body
- Non-adherence
- Alternative diagnosis?
- Nickel dermatitis (allergic contact dermatitis)
- viral or fungal infection
- antimicrobial resistance
13
Q
What 2 populations are at increased risk for malignant otitis externa?
What are prominent symptoms of malignant otitis externa?
What is the recommended management?
A
- Immunodeficiency
- Type 1 DM
Prominent symptoms
- Facial nerve palsy
- Pain
Risk of invasive infection of cartilage and bone of canal. May require CT/MRI to confirm diagnosis
Treatment
- Aggressive debridement with systemic antibiotics for Pseudomonas +/- Aspergillus
14
Q
List 2 recommended preventative measures for acute otitis externa
A
- Keep water out of ears (plugs vs positioning, shaking head or hair dryer on low setting)
- Avoid cotton swabs (can impact cerumen)
- Daily prophylaxis with alcohol or acidic drops durign at-risk activities (not studied)
- Hard earplugs shoudl be avoided (can cause trauma)
15
Q
- Orofacial abnormalities (e.g cleft palate)
- Indigenous
- Frequent contact with other children
- FMHx AOM
- Prolonged bottle-feeding while lying down
- Shorter duration of breastfeeding
- Pacifier use
- Exposure to cigarette smoke
- Household crowding
A
List 4 risk factors for acute otitis media
16
Q
List 5 extracranial complications associated with acute otitis media
List 5 intracranial complications associated with acute otitis media.
A
Extracranial (local/temporal bone)
- Mastoiditis
- Meningitis
- Labyrinthitis
- TM Perforation
- usually heals in 6wks (repair at 9-10yo if not [when eustachian function improves)
- Cholesteatoma
- Bezold’s abscess (deep neck abscess)
Intracranial
- Meningitis
- Gradenigo’s syndrome (CNVII palsy, CNVI palsy can’t move ipsilateral eye outwards - due to petrous bone inflammation/infection)
- Cerebral sinus venous thrombosis (transverse, lateral or sigmoid sinuses)
- Brain abscess (subdural/epidural)
- Otic hydrocephalus
- CSF leak
17
Q
List the 3 most common pathogens of acute otitis media
A
- Streptococcus pneumoniae
- Moraxella cattarhalis
- Haemophilus influenzae
Other common pathogens: Group A Streptococcus
18
Q
What is a necessary minimal diagnostic criterion for the diagnosis of acute otitis media?
A
A middle ear effusion (MEE)
- Signs of MEE:
- Little or no mobility of TM when both positive and negative pressure is applied with pneumatic otoscope)
- Loss of bony landmarks
- Presence of air-fluid level
19
Q
Desribe the management for acute otitis media
What would you prescribe if there had been a recent treatment with amoxcillin within the past month?
A
- >6 months of age, generally healthy (no craniofacial abnormalities, tubes, recurrent AOM or immunocompromised)
-
NO MEE/MEE (mild erythematous TM or non-buldging TM)
- R/A in 24-48h
- If worsens or no improvement, verify presence of effusion and signs of inflammation
-
MEE present AND bulging TM
- Mildly ill
- Symptoms
- Alert, responsive, no rigors, responding to antipyretics, mild otalgia but able to sleep
- <39˚C in absence of antipyretics
- <48h illness
- Observe for 24-48h
- Either:
- Reassess in 24-48h to document course
- Have return in 24-48h if no improvement or worsens
- Provide antimicrobial prescription if no improvement
- Either:
- Analgesia
- If not improved or worsening clinically, PO Amoxicillin
- <2yo: 10 days
- ≥2yo: 5 days
- Symptoms
- Moderate-severely ill
- Either (≥1) of:
- Irritable, trouble sleeping, poor response to antipyretics, severe otalgia
- ≥39˚C in absence of antipyretics
- >48h of symptoms
- Treat with PO Amoxicililn
- <2yo: 10 days
- ≥2yo: 5 days
- Either (≥1) of:
- Mildly ill
-
TM perforated with purulent trainage
- PO Amoxicillin x 10 days
Antibiotic choice
- Amoxicillin 75-90mg/kg/day divided BID
- If allergy: 2nd gen (cefuroxime-axetil) or 3rd gen cephalosporin (cefotaxime)
- Other considerations: Macrolide (clarithromycin/azithromycin)
Previous Amoxicillin <30 days or relapse of recent infection
- Clavulin (Amoxicillin/clavulanate)
Failure of oral drugs or Clavulin failed
- IM Ceftriaxone 50mg/kg/day x 3 days
- Referral to ENT for tympanocentesis (sample of middle ear fluid)
20
Q
What should you recommend for the management of a 7mo patient with acute otitis media and purulent conjunctivitis?
A
Otitis-conjunctivitis syndrome
- PO Antibiotic management
- Clavulin (Amoxicillin/Clavulanate), or
- 2nd generation cephalosporin (Cefuroxime-axetil)
- Obtain bacterial cultures of conjunctival discharge
21
Q
At what age should childre have a dental home by?
A
12 months
22
Q
What is the most common causative organism of dental caries?
List 2 ways that topical fluoride prevents caries.
What are risk factors for dental caries?
When should topical fluoride be administered?
A
Streptococcus mutans
Prevention
- Inhibits plaque
- Inhibits demineralization
- Enhances remineralization of enamel
Risk factors for dental caries
- Populations at risk
- Indigenous
- Low-income families
- Children with special health care needs
- New immigrants
- Prolonged use of bottle or training cups with sugar-containing drinks
- High frequency of sugary snacks per day
- Environmental tobacco smoke
- Maternal smoking status
Supplementation Indications
- Concentration in municipal water supply is <0.3ppm
- Teeth not brushed at least 2 times a day
- Dentist/HCP feel child is susceptible to cavities
23
Q
How much fluoride is in a pea-sized amount of toothpaste?
How much supplemental fluoride should be provided?
What are signs of fluorosis? List 2.
Which teeth are at the greatest risk for fluorosis at 15-24mo?
A
Pea-sized amount = ~0.4mg
- Supplemental fluoride amount (daily)
- >6mo-3y = 0.25mg
- 3-6y = 0.5mg
- >6y = 1mg
Fluorosis
- Mottling and pitting of teeth
- Enamel striations
- “Snow capped cusps”
- Chalky-white teeth
Secondary teeth are at greatest risk for fluorosis at 15-24mo
24
Q
List 4 strategies to decrease incidence of dental caries in Indigenous communities
List 3 examples of primary prevention of dental caries.
A
- Promote supervised use of fluoridated toothpaste in all Indigenous (and high-risk children) after 1st tooth erupts twice daily (infants - grain sized; child - pea-sized)
- HCPs should perform oral health screening during health assessments and provide referrals PRN to dental health providers
- Use motivational interviewing and anticipatory guidance for parents and caregivers of infants and children on oral hygiene and diet
- Provide women with preconception and prenatal screening for oral health, anticipatory guidance and referral to dental care PRN
- Ensure access to series of fluoride varnish and an assessment to determine need for sealant placement on deep grooves and fissures
Primary prevention
- Water fluoridation
- Topical fluoride if no fluoridation
- Oral health promotion
25
List 4 indications for tympanostomy tube insertion.
1. Bilateral OME with conductive hearing loss if persisting ≥3mo
2. Prior to chemotherapy for at-risk AOM groups (*most common reason)*
3. Unilateral OME with conductive hearing loss AND concern (behavioural issues, school performance, vestibular symptoms, discomfort)
4. Recurrent AOM with middle ear effusion *(least common reason)*
5. Mastoiditis
6. Chronic retraction of TM
7. Lack of response to medical management (i.e. continuous Abx)
26
What rare condition should you consider with severe unilateral epistaxis?
List 4 management options for epistaxis.
Juvenile nasopharyngeal angiofibroma
**Management**
* Humidify
* Lubricate - vaseline
* Cauterize - silver nitrate
* Pack
* Treat underlying coagulopathy
27
List 3 indications for tonsillectomy
What is Paradise criteria?
* Absolute
1. OSA (AHI \>5) and large tonsils
2. Cor pulmonale
3. Suspected malignancy
4. Hemorrhagic tonsillitis
5. Severe dysphagia
* Relative
1. Tonsillar hypertrophy
2. Recurrent tonsillitis (Paradise criteria)
3. Complications of tonsillitis
4. Tonsilloliths and halitosis
**Paradise Criteria**
* Requirements for an episode (≥1 of):
* Fever \>38.3˚C
* Cervical lymphadenopathy (tender or enlarged [\>2cm])
* Tonsillar or pharyngeal exudates
* GAS+ Throat Cx
* ≥7 in 1 year
* ≥5 in 2 years
* ≥3 in each of last 3 years
28
What are the criteria of the Centor score?
When is treatment indicated for acute pharyngitis vs investigations vs reassurance?
* CENTOR (≤3 days of acute pharyngitis)
* **C**ough absent
* **E**xudate
* **N**odes
* **T**emperature
* **OR -** young (≥3 to \<15yo) OR old (lose a point)
* Scoring
* 0-1: reassurance
* 2-3: throat swab - treat if positive
* ≥4: throat swab and consider treating
29
Describe the signs and symptoms of a child with a peritonsillar abscess
* Unilateral tonsil bulge
* Uvular deviation
* Trismus
* Presents in older children/teenagers
Treated with antibiotics and surgical drainage
30
Describe signs and symptoms in keeping with a retropharyngeal abscess
* Midline bulge in retropharynx
* Posterior to palate
* Occurs in younger children
Treatment: antibiotics +/- drainage (if not improving)
31
Provide 3 possible diagnoses each for inspiratory, expiratory and biphasic stridor
* **Inspiratory** (Supraglottis)
* ****Laryngomalacia
* Foreign body
* Epiglottitis
* Vallecular cyst
* Saccular cyst
* **Expiratory** (Trachea/Bronchi)
* Tracheomalacia
* Foreign body
* Tracheoesophageal fistula
* Complete tracheal rings
* **Biphasic** (Vocal cords/Subglottis)
* Subglottic stenosis
* Croup
* Bilateral vocal cord paresis
* Subglottic hemangioma
* Laryngeal cleft
* Croup
* Foreign body
32
Provide counselling to the parents of a child with laryngomalacia regarding expected prognosis
* Will worsen until about 6 months
* Plateaus between 6-12 months
* Improves 12-18 months (Hamilton Review says 18-24 months)
33
What is a differential diagnosis for Neck Masses?
"COIN"
* **C**ongenital
* midline vs lateral
* **O**ther
* Inflammatory: Kawasaki, Sarcoidosis
* **I**nfectious
* _Acute:_ viral (EBV, CMV), bacterial (GAS/Staph), PFAPA, Lemierre's syndrome
* *_Chronic:_* HIV lymphadenitis, bacterial (bartonella, TB, atypical mycobacterium, tularemia, syphilis, brucellosis, actinomycosis)
* **N**eoplastic
* Benign
* Midline
* Thyroglossal cyst (moves w/tongue protrusion)
* Dermoid cyst (calcification on plain films)
* Teratoma
* Vascular malformation
* Cervical cleft
* Ranula
* Foregut duplication cyst
* Lateral
* Branchial cleft cyst (along SCM border)
* Hemangioma
* Thymic cyst
* Laryngocele (enlarges with Valsalva)
* Vascular malformation
* Malignant
* Thyroid
* Lymphoma
* Ewing sarcoma
* Rhabdomyosarcoma
* Neuroblastoma
* Salivary gland tumours
34
**In regards to orbital cellulitis:**
1. Where does it usually originate from?
2. What are 2 features unique it?
3. What are the 2 most common causal organisms?
4. What are 2 ophthalmologic complications
1. Usually originates from:
* Ethmoidal sinusitis
2. Features unique to it:
* Proptosis
* Pain with extraocular movements
* Restricted ocular motility
3. Common causal pathogens?
* Staph aureus
* Streptococcus pneumoniae
* GAS
* Haemophilus influenzae
4. Ophthalmologic Complications
* Loss of vision/Blindness
* Orbital abscess
Treatment: Cefuroxime IV
35
List 4 causes of ptosis
1. Isolated congenital dystrophy of levator palpebrae superioris muscle
2. Hemangioma (mechanical ptosis)
3. Trauma
4. Muscular dystrophy
5. Myasthenia gravis
6. CNIII palsy
7. Idiopathic
36
When would you consider referral to ophthalmology for a chalazion?
Persistance for \>3mo
Aesthetic issue
37
Why is a dacrocystocele concerning?
* Area for bacteria to proliferate → mucocele
* Tears go in but can't get out → expanding → obstruction of respiratory passage → feeding difficulties
= Indications for surgical management
38
What is a classic finding in congenital Horner's syndrome?
The affected eye's iris appears lighter in colour than the opposite side
39
List 4 causes of anisocoria (asymmetric pupils)
1. Physiologic
2. Pharmacologic
3. Mechanical (trauma, inflammation)
4. Horner's syndrome
5. CNIII palsy ("down and out")
40
List 4 possible diagnosis of a child presenting with leukocoria
1. Retinoblastoma
2. Cataract
3. Persistent hyperplastic primary vitreous
4. Retinopathy of prematurity
5. Retinal detachment
6. Retinoschisis
7. Larval granulomatosis
41
What cranial nerve palsies are associated with a head tilt?
CNIV - usually congenital
CNVI - concern for increased ICP
42
Retinoblastoma
43
Left CN III palsy with ptosis and inability to elevate and adduct the eye
44
Limbal dermoid cyst
=
Goldenhar syndrome
45
Dacrocystocele
46
HSV keratitis
47
**Congenital glaucoma**
Rt eye hazy and opaque 2˚ corneal edema
48
**Coloboma**
Associated with CHARGE syndrome
49
Chorioretinitis
Photo of toxoplasmosis
Also see retinitis with rubella, syphilis, zika, CMV
50
Multiple retinal hemorrhages
Non-accidental trauma
51
Acute otitis media
52
Cholesteatoma
53
What is this?
What test should you consider in this child?
What are sequelae of this condition?
Nasal polyps
Sweat chloride
Facial changes → broadened nasal root, prominence of malar areas
54
What is this diagnosis?
What is the most common cause of this?
Pott puffy tumour (osteomyelitis of frontal bone)
Sinusitis
55
Bifid uvula - concern for submucosal cleft
56
Peritonsillar abscess
57
Retropharyngeal abscess
58
You see an 18mo boy in the clinic due to concerns his eye "didn't look right" - on examination you note corneal clouding.
What are 3 possible diagoses?
**STUMPED**
* **S**clerocornea
* **T**ears in membrane (d/t trauma or congenital glaucoma)
* **U**lcers (infection)
* **M**etabolic (e.g MPS)
* **P**eters anomaly
* **E**dema
* **D**ermoid
59
How should you manage otorrhea associated with tympanostomy tubes?
Which topical drops are safe for use with tympanostomy tubes?
* Uncomplicated acute otorrhea (\<4wks)
* Topical antibiotics x 7-10 days
* Systemic antibiotics are indicated when:
* Cellulitis of pinna or adjacent skin present
* Concurrent bacterial infection present
* Signs of severe infection exist (high fever, severe otalgia, toxic appearance)
* Acute otorrhea persists or worsens, despite topical tx
* Administration of eardrops not possible due to local discomfort or lack of tolerance by child
* Immunocompromised patient
**Topical drops = safe**
* Ofloxacin
* Ciprofloxacin-dexamethasone
60
What is the diagnostic crtieria for acute sinusitis?
* **Acute sinusitis**
* Either:
* Persistent symptoms of URTI, including:
* Nasal discharge AND
* Cough for ≥10 days without improvement
* Severe respiratory symptoms, including:
* Fever ≥39˚C
* Purulent nasal discharge for 3-4 consecutive days
* **Chronic**
* Persistent respiratory symptoms ≤90 days (cough, nasal discharge or nasal congestion)
**Management**
* 1st line: Amoxicillin 45mg/kg/day divided BID x 7-10 days for acute, 14 days for chronic
* If no improvement in 72h or severe sinusitis → high-dose Clavulin
* If vomiting or poor compliance → IV Ceftriaxone
TMP/SMX + Azithromycin have high rates of resistance
61
List 4 possible complications following tonsillectomy.
1. Throat pain
2. Postoperative nausea and vomiting
3. Dehydration
4. Hemorrhage (↑ if acutely infected at time of surgery)
5. Speech disorders (velopharyngeal insufficiency [hypernasal voice])
6. Postobstructive pulmonary edema (seen with severe OSA +/- obesity - treated with PPV/diuresis)
7. Nasopharyngeal stenosis
62
What is the most common organisms responsible for acute lymphadenitis?
List 4 other infectious causes of this
Most common
* *Staphylococcus aureus*
* Group A streptococcus (*Streptococcus pyogenes)*
* Anaerobic bacteria
Other infectious causes
* Unilateral
* Acute
* Group B *Streptococcus* (neonates)
* *Pasturella multocida*
* Gram-negative bacilli
* *Yersinia pestis*
* Tularemia
* Chronic
* Nontuberculous mycobacteria
* *Bartonella henselae*
* Toxoplasmosis
* Tuberculosis
* Actinomycosis
63
List 2 x-ray findings compatible with retropharyngeal abscess
How do you tell if the lateral film is an adequate view?
* Thickening of prevertebral tissues (greater than half the width of the C2 vertebral body, or \>7-mm diameter at C2, or \>14-mm diameter at C6)
* Locules of gas within the prevertebral tissues
Adequate view = neck should be in extension with image captured during inspiration with visualization of the C7/T1 junction
64
List 4 differences between gastroschisis and omphalocele
1. Gastroschisis occurs to the right of umbilicus/omphaocele occurs through umbilicus
2. Gastroschisis doesn't involve the peritoneal sac
3. The bowel is often inflamed with gastroschisis; whereas it is normal in omphaloceles (not exposed to amniotic fluid)
4. Gastroschisis is not associated with any other system anomalies
5. Gastroschisis often has prolonged ileus and GI dysfunction, whereas omphalocele has prompt recovery of bowel function
65
What is the most common type of anomaly associated with omphaloceles?
Which is most common of that type of anomaly?
Cardiac anomalies
Tetralogy of Fallot
66
What is the most common type of anomaly associated with gastroschisis?
What is the most common complication post-operatively after gastroschisis repair?
Intestinal atresia
67
Where is the most common location of intussusception?
Name 2 situations where air reduction (air enema) for intussusception would be unsuccessful
List 2 contraindications to air enema.
What is the success rate for this procedure? What is the perforation rate? What is the recurrence rate?
Ileocolic (upper invaginates into lower)
1. Infants \<3mo
2. \>5yo (often have pathological lead point)
3. When AXR shows signs of intestinal obstruction
4. Small bowel intussusception
**Contraindications**
1. Prolonged intussusception
2. Signs of shock
3. Peritoneal irritation
4. Intestinal perforation or pneumatosis intestinalis
**Success rate:** 80-95%
**Perforation rate**: 0.1-0.2%
**Recurrence rate:** 10%
68
List 2 risk factors for pyloric stenosis
AND 2 associated genetic disorders
What is the characteristic laboratory finding associated with this diagnosis?
**Risk factors**
* Maternal macrolide administration during pregnancy/breastfeeding
* First born children
* Family medical history
* Male sex
* B and O blood groups
**Genetic disorders**
* Zellweger
* Cornelia de Lange syndrome
* Trisomy 18
* Apert syndrome
* Smith-Lemli-Opitz syndrome
**Lab finding:** Hypochloremic metabolic acidosis 2˚ volume contraction from aldosterone; hypokalemia with prolonged emesis
69
What is the most common pathological lead point seen with intussusception?
What is are 2 predisposing factors to intussusception?
Meckel's diverticulum
1. Recent URTI (adenovirus)
2. Recent diarrheal illness (enterovirus)
3. Rotavirus vaccine (1-3 per 100,000) - highest in first week after receiving vaccine (must report all cases occurring within 21 days to Public Health Agency of Canada)
70
Which major anomaly occurs most frequently with esophageal atresia/tracheoesophageal fistula?
What are the main surgical complications seen with this type of repair?
Cardiovascular anomalies
(do VACTERL assessment)
1. Anastomotic leak
2. Recurrent fistula
71
List 3 possible diagnoses for patient presenting with bilious emesis.
What investigation should you do to work this up?
1. Malrotation
2. Midgut volvulus
3. Hirschsprung's disease
4. Ileus
5. Duodenal atresia
Upper GI series with small bowel follow-through
72
In regards to vomiting:
List 4 diagnoses that present with abdominal distension
List 4 diagnoses that DO NOT present with abdominal distension
**Abdominal Distension**
1. Hirschsprung's
2. Volvulus
3. Meconium ileus
4. Imperforate anus
5. Meconium plug
6. Colonic atresia
7. Jejunal/ileal atresia
8. NEC stricture
**NO Distension (think proximal obstruction)**
1. Hypertrophic pyloric stenosis
2. Malrotation
3. Duodenal atresia
4. Annular pancreas
5. Preduodenal portal vein
6. Antral stenosis
73
Describe the intial management for Hirschsprung's disease
1. Rectal decompression with saline irrigations
2. Antibiotics if enterocolitis is present
74
When are inguinal hernias most common?
What side do they more commonly occur on?
What population is more likely to have bilateral inguinal hernias?
When is the risk of incarceration highest?
When should repair occur?
**Most common:** \< 1 year
**Most common side:** Right (60%)
**More likely bilateral?:** Premature infants
**Risk of incarceration highest?**: Newborns (8.8%)
**When should repair occur?**
* "Soon after diagnosis" median 2 weeks (doubled risk of incarceration if \>30 days)
* If incarcerated (24-48h after reduced)
75
When should you consider referring a hydrocele for repair?
If remains present at 1 year
76
When should you refer to Ophtho for bacterial conjunctivitis?
* Not better in 48hr on topic drops
* Vision loss
* Severe purulent discharge
* Corneal involvement
* Conjunctival scarring
* SJS
* HSV
* Severe photophobia or pain
* Contact lens involvement
77
**Ectopia lentis**: displacement of the lens from where it is suspended
* Associated with Marfan syndrome (occurs in about 80% of pts and usually present in about 50% by age 5)
* Usually displaced superiorly and temporally, usually bilateral and symmetric
* Associated with homocystinuria (displaced inferiorly and nasally)
* Also associated with Weill-Marchesani syndrome, Ehlers-Danlos, Sturge-Weber, Crouzon, Klippel-Feil syndromes
