Lecture 5 - EENT

Question 1

Strabismus

Answer 1

misaligned eyes

“TROPIA” - constant

“PHORIA” - intermittent

ESO - inward (adducted)

EXO - outward (abducted)

HYPO - dowards

HYPER - upward

typically unilateral

Question 2

Pen light test

Answer 2

can help you when strabismus is a little more subtle or its psuedostrabismus

Question 3

psuedostrabismus

Answer 3

epicanthial fold might be different between left and right eye making it appear to have strabismus

pen light test will show that this is not the case

Question 4

What does a left esotropia look like?

Answer 4

the pts left eye is slightly deviated inward and the light from the pen light test is on the outer edge of the eye

Question 5

Cover-uncover test

Answer 5

child fixes on object in from of them
cover 1 eye and observe the uncovered eye –if it had to move to focus on the eye then it was not initially aligned on the object –suggests tropia

then remove the cover and check the other eye, if it had to move to refocus then it drifted while covered –suggests phoria

Question 6

Amylopia

Answer 6

loss of visual acuity due to cortical suppression of the vision of an eye

the brain suppresses the vision in the one eye –this could become permanent since the brain is trying to avoid double vision

Question 7

What is the treatment for strabismus?

Answer 7

before visual fixation is well established, infants can have esodeviations
-expect normal alignment by 4 months of age

refer pts >4 moths of age with strabismus to ophthalmology

Question 8

Ophthalmia neonatorum

Answer 8

infection of the eye caused by a variety of different things
red eye + discharge

Question 9

Chemical conjunctivitis

Answer 9

onset within the 1st 24 hours of life
erythema and water discharge
reaction to topical bactericidal

less common now that we dont use silver nitrate and instead use erythromycin

Question 10

What is the treatment for chemical conjunctivitis?

Answer 10

sys resolve within days without need for treatment

Question 11

Neisseria gonorrhoeae - ophthalmia neonatorum

Answer 11

onset typically occurs 2 to 5 days of age
swelling of lids and conjunctivae
copious purulent discharge
gram stain

complications
-risk for corneal perforation and scar –can lead to blindness

tx:
-ceftriazone

Question 12

What is the treatment for neisseria gonorrhoeae?

Answer 12

cerftriaxone

Question 13

Chlamidia traachomatis ophthalmic presentation?

Answer 13

onset typically occurs 4-19 days of age
mild swelling of lids and conunvtivae
hyperemia
scant purulent discharge

complications –infants with chlamydia may develop pneumonitis

tx: erythromycin

Question 14

What is the treatment for chlamidia traachomatis ophthalmic?

Answer 14

erythromycin

Question 15

Herpes simplex virus - ophthalmic

Answer 15

viral conjunctivitis RARE in neonates

typically unilateral
onset within 2-4 weeks
vesicular lid lesions

complications: herpetic corneal disease can threaten vision
tx: systemic acyclovir

Question 16

Dacryostenosis

Answer 16

nasolacrimal duct obstruction

MC cause of tearing in children
-ip to 20% of normal newborns

chronic or intermittent tearing, debris on eyelashes
conjunctival erythema not common but rubbing may result in lid redness
palpation of lacrimal sac may cause reflux of tears and/or mucoid discharge into eye through the puncta

Question 17

How do pts with dacryostenosis present?

Answer 17

chronic or intermittent tearing, debris on eyelashes
conjunctival erythema not common but rubbing may result in lid redness
palpation of lacrimal sac may cause reflux of tears and/or mucoid discharge into eye through the puncta

Question 18

How do you treat dacryostenosis?

Answer 18

non-surgical observation
lacrimal sac massage may be helpful
referral to ophthalmology if not resolved by 6 months for possible lacrimal duct probing or surgery

Question 19

What are the complications of dacryostenosis?

Answer 19

acute dacrocystitis - infection of nasolacrimal system

can lead to orbital cellulitis, sepsis or meningitis

Question 20

What are the risk factors for AOM?

Answer 20

tobacco exposure 
use of pacifier
not breastfeeding 
feeding lying down
daycare attendance 
incomplete immunizations
younger age
mild hereditary risk

Question 21

How do you dx AOM?

Answer 21

these pts are typically consoled by mom

moderate to sever bulging on TM (most specific finding)
often TM will have a white or pale yellow appearance
impaired mobility of the TM with pneumatic otoscopy or tympanogram

Question 22

What is a tympanogram?

Answer 22

look like ear thromometers

you get a reading based on the light to give you an idea of what is behind the membrane

Question 23

What is the most common pathogen of AOM?

Answer 23

S. pneumoniae

a viral infection (RSV, parainfluenza) is typically the predisposing cause but can also be the presenting cause

Question 24

How do you treat AOM?

Answer 24

anybody under 6 months, regardless of bilateral or otorrhea gets ABX (amoxicllin (1st line), cephalexin)

you can observe pts 6months - 2 years if unilateral without otorrhea and kids >2 years uni/bilateral without otorrhea
(observe means follow up 48-72 hours)
everyone else gets ABX

Question 25

What are considered "severe sxs" for AOM?

Answer 25

toxic appearing child otalgia for >48h temp >39C in last 48 hours uncertain access to follow up

Question 26

When do you use augmentin when treating AOM?

Answer 26

if pt has concomitant purulent conjunctivits children who have been treated with amoxicillin in last 30 days fail initial ABX treatment

Question 27

Allergy testing is only commercially available for ____

Answer 27

IgE mediation reactions to PCN and NO other ABX

Question 28

How do you determine allergy vs side effect?

Answer 28

Hx - timing of onset - character of sxs (GI is probably just SE right?) - Duration of sxs - have they received the drug again, what happened? Can perform skin testing for PCN

Question 29

When are tympanostomy tubes recommended?

Answer 29

3 or more episodes of AOM within 6 month period OR 4 episodes within a year with 1 in the last 6 months OR Children with AOM before 6 months --warrant a more aggressive approach to management

Question 30

Why might pts with tympanostomy tubes have otorrhea?

Answer 30

bacterial infection post op introduction of contaminated water from ear canal into middle ear tx: fluoroquinolone drops (ofloxacin and ciprofloxacin dexamethasone) ---> these are the only topical antimicrobials FDA approved fro treateing otorrhea with non-intact membrane

Question 31

What antimicrobials are FDA approved to treat otorrhea for pts withOUT intact membranes?

Answer 31

ofloxacin and ciprofloxacin dexamethasone

Question 32

OME

Answer 32

otitis media with effusion ``` commonly follows URI NOT an infectious process no pain/fever typically resolves without intervention <3months meds really haven't been shown to help ``` referral for tympanostomy tubes if no resolution in 3 months

Question 33

When should you consider ENT referral for foreign body in the ear?

Answer 33

battery bug object is pressed up against the TM object has been in the canal for >24 hours

Question 34

What do you do to remove a foreign body from the ear canal?

Answer 34

irrigation is best unless: - there is concern of TM perforation - the foreign matter will swell (food, insects)

Question 35

Viral Rhinitis

Answer 35

MC pediatric infectious disease -children <5 typically have 6-12 episodes per year ``` sxs: clear or mucoid rhinorrhea nasal congestion sneezing often begin with sore throat may develop cough and fever (fever more common in <6 y/o) ```

Question 36

What are the most common causes of URIs in children?

Answer 36

``` Rhinoviruses (MC) adenovirus parainfluenza RSV (respiratory syncytial virus) influenza ```

Question 37

What can rhinovirus cause?

Answer 37

``` "common cold" pharyngitis OM bronchiolitis PNA act as precipitating factor in asthma ```

Question 38

What is the treatment for viral rhinitis?

Answer 38

supportive increased fluids, rest, cool mist humidifier nasal saline spray OTC cold and cough should NOT be used in children <4 and used with caution in children <6

Question 39

What ages should not use cold and cough OTC medications?

Answer 39

NOT be used in children <4 and used with caution in children <6

Question 40

What is the typical course of viral rhinitis?

Answer 40

simple URI lasts 7-9 days but can last 15 days fever typically resolves by day 3 sxs peak on day 3 cough lasts longer than other sxs

Question 41

When is the development of paranasal sinuses complete?

Answer 41

20 years of age

Question 42

What sinuses develop when?

Answer 42

maxillary - rapidly expand by 4 years sphenoid - develop in first 2 years of life, pneumatized by 5 years, permanent size by 12 years frontal - can be seen on xray 6-8 years, don't complete development until 14-18 years of age

Question 43

How do you dx sinusitis?

Answer 43

acute bacterial sinusitis must have: -sxs present for > 10 days OR -sxs worsen with new onset of fever or cough OR -be associated with temperatures >39 for more than 3 days color of nasal discharge does NOT indicate infection

Question 44

When is the earliest presentation of allergic rhinitis?

Answer 44

10-12 months of age

Question 45

What age do seasonal allergies typically appear?

Answer 45

3-4 years of age

Question 46

What is the presentation of allergic rhinitis?

Answer 46

ocular - itching, swelling, tearing - always bilateral (something else if unilateral) - uncommon to have photophobia or pain nasal - itching, sneezing, rhinorrhea, congestion - "shiners" are non-specific finding

Question 47

What are complications of allergic rhinitis?

Answer 47

``` OM poor asthma control poor sleep sinusitis missed school missed work ```

Question 48

What is the treatment for allergic rhinitis?

Answer 48

Antihistamines - fast acting, short lasting - not very effective for congestion, post-nasal drip (not effective for URIs) - first gen --sedating SE (don't use if you can avoid it) - second gen --less sedating, last longer Intranasal steroid spray: - no effective when used intermittently or acutely - best medication for congestion, post-nasal drip Leukotriene Modifiers - not very effective for rhinoconjunctivits - not indicated as monotherapy or 1st line therapy - block part of late phase allergic response, no antihistmaine properties Immunotherapy - indicated for refractory sxs despite optimal medical management/avoidance - weekly build up x 6-8 months, then monthly injections x 3-5 years - no benefit for at least 6-12 months

Question 49

Which generation antihistamines are ideal for allergic rhinitis in children?

Answer 49

2nd generation d/t less sedative SEs

Question 50

What are the pros and cons to immunotherapy for allergic rhinitis?

Answer 50

Pros: effective only disease modifying treatment may prevent sensitization to new allergens and progression of AR to asthma Cons: painful (multiple shots) risk of anaphylaxis inconvenient (30 min monitoring pst shot) slow onset of action not all pts benefit must use correct allergens and concentrations

Question 51

Epistaxis treatment

Answer 51

sit forward pinch nose for 5-10 min nasal steroid spray, packing referral to ENT for cautery

Question 52

Types of pharyngitis

Answer 52

viral - infectious mono - hand, food, mouth - herpangina Bacterial Fungal -thrush

Question 53

presentation of mono

Answer 53

tonsillar exudates cervical lymphadenopathy (posterior chain) fever dx: >10% atypical lymphocytes on blood smear positive mono spot EBV serology with elevated IgM is definitive tx: symptomatic amoxicillin can cause RASH

Question 54

Hand, Foot, Mouth

Answer 54

coxsackievirus ulcerations in posterior pharynx surrounded by a halo macular, maculopapular or vesicular rash on hands and feet dx clinical tx symptomatic

Question 55

Strep pharyngitis

Answer 55

abrupt onset of sore throat, tender cervical lymphadenopathy, fever, erythematous posterior pharynx N/V/HA young children

Question 56

Centor 4 point scale

Answer 56

fever absence of cough anterior cervical adenopathy tonsilar exudates strep pharyngitis presentation

Question 57

How do you dx strep?

Answer 57

rapid antigen test or throat culture

Question 58

Group A strep is a self-limited disease, so why do we treat?

Answer 58

prevent suppurative complications reduce communicability prevent Rheumatic fever

Question 59

Actue rheumatic fever

Answer 59

occurs 2-4 weeks after GAS pharyngitis, may consist of: - arthritis - carditis and valvulitis - CNS involvment - erythema marginatum - subcutaneous nodules

Question 60

Brodsky grady scale

Answer 60

tonsillar hypertrophy grading 0-4 | 4 being the tonsils take up most of the orophrayngeal width

Question 61

Paradise Criteria

Answer 61

for tonsillectomy "sore throat episode" -temp >38.8, or cervical lymphadenopathy, or tonsillar exudate or positive culture for group a strep criterion definition: -min 7 or more episodes of sore throat in the last year OR -5 or more episodes in each of the preceding 2 years OR -3 or more episodes in each of the preceding 3 years

Question 62

Croup

Answer 62

laryngotracheitis parainfluenza type 1 and 2 Type 1 peaks every other autumn Type 2 has annual peaks spread through direct contact, droplets, and fomites incubation 2-6 days children 6-36 months MC rare beyond 6 years

Question 63

How do pts with croup present?

Answer 63

onset of sxs is gradual begins with nasal irritation, congestion, rhinorrhea characterized by inspiratory stridor, hoarseness and distinctive "barking" cough which develop over 12-24 hours sxs stem from inflammation of the larynx and subglottic airway presence of cough and absence of drooling help distinguish from epiglottis

Question 64

What is the treatment for croup?

Answer 64

mild croup may be managed with supportive care (fluids, mist therapy) glucocorticoid -single dose of dexamthasone shortens sxs Nebulized racemic epi commonly used in ED

Question 65

Why has the incidence of epiglottitis decreased?

Answer 65

H. influenzae vaccine

Question 66

What is the presentation of epiglottitis?

Answer 66

most common children 2-6 years sudden onset high fever, dysphagia, DROOLING and muffled voice, unable to clear secretion inspiratory retractions, stridor, cyanosis tripod, "sniffing dog" "thumbprint" sign on lateral neck xray definitive dx can be made by direct inspection of "cherry red" and swollen epiglotis

Question 67

What is the treatment for epiglotitis?

Answer 67

endotracial intubation --typically done in OR d/t risk of respiratory arrest blood and throat cultures should be obtained ``` IV abx (ceftriaxone) extubation usually 24-48 hours when direct inspection demonstrates reduction in swelling ```

Question 68

Tx for AOM?

Answer 68

High dose amoxicillin = first line therapy 80-90 mg/kg/day BID If watchful waiting —must have follow up in 48-72 hours