Lecture 6: pediatric surgery, ophthalmology ENT Flashcards Preview

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Flashcards in Lecture 6: pediatric surgery, ophthalmology ENT Deck (35)
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1
Q

common pediatric surgical problems

A
  • Acute Appendicitis
  • Intussusception
  • Malrotation and Volvulus
  • Pyloric Stenosis
  • Umbilical Hernia
  • Inguinal Hernia
  • Abdominal wall defects:
    • Diaphragmatic Hernia
    • Omphalocele
    • Gastroschesis
2
Q

acute appendicitis

A
  • Most common indication for emergency abdominal surgery in children
    • frequency increases with age
    • unusual in infants and small children
    • 5% of all pediatric cases are in age <5 years
  • Incidence of perforation is high in infants and children
    • lots of other reasons for similar symptoms
    • small children do not localize pain well
  • Etiology: Assumed that outlet of appendix becomes blocked by fecalith and causes inflammation.
3
Q

acute appendicitis signs and symptoms

A
  • Signs & Symptoms
    • short history of worsening symptoms (a few days)
    • anorexia +/- vomiting
    • +/- fever
    • classical abdominal pain
      • begins as periumbilical & diffuse pain (visceral)
      • McBurney’s Point Pain
      • often difficult to localize well in children
    • Classic signs of peritonitis:
      • rebound tenderness
      • involuntary guarding
      • tenderness to percussion
      • shaking the bed
      • jumping up and down
      • Pain going over curbs and speed bumps in the car
    • Physical Exam Findings:
      • Psoas
      • Obturator
      • Rosving’s-Palpating LLQ elicits pain in RLQ
    • Perforation
      • immediate relief of symptoms, followed by worsening of overall abdominal pain, distress, and toxicity (vomiting, signs of sepsis, etc.)
    • Obturator Sign: Pain with pain with passive internal rotation of the flexed hip. Caused from irritation of inflamed tissues that are disturbed from movement of obturator muscle.
    • Psoas Sign: Passive extension of the the hip causes stretching of the psoas muscle that irritates inflamed tissue around the appendix and results in pain.
4
Q

workup of acute appendicitis

A
  • CBC: leukocytosis increases suspicion, but a normal WBC does not rule out appendicitis
    • WBC >10k in 89% of those with appendicitis and 93% of those with perforation
    • WBC > 10k in 62% of those without appendicitis!
  • CMP: Looking for other causes of abdominal pain.
  • Ultrasound- Must note if appendix is seen. Means nothing if the appendix is not found on exam.
    • unperforated – noncompressible (diagnostic), large (>6mm, nondiagostic) appendix
    • perforated – phlegmon in RLQ
  • CT
    • Most sensitive, but often avoided due to concern for radiation.
    • a contrast-filled appendix rules out appendicitis
    • peri-appendiceal fat stranding is often not evident in thin children, who have very little intra-abdominal fat
  • KUB: appendicolith (lucky!) or if perforated, possibly free air
  • Urinalysis: +/- pyuria (peritonitis near bladder may create pyuria)
5
Q

pediatric appendicits score (PAS)

A
  • Scores/Management:
    • Score ≤2 or 3: Low risk, can discharge home with strict return precautions.
    • Score ≥7 or 8: Appendicitis likely. Urgent imaging or surgical consult.
6
Q

Treatment of acute appendicitis

A
  • laparoscopic vs. open appendectomy
  • perforated appendicitis typically first treated with antibiotics for days or weeks before operative intervention
7
Q

intususception

A
  • Telescoping of bowel to produce obstruction
    • Ileocolic is most common
  • Clinical findings
    • Episodic cramping abdominal pain
    • Emesis/diarrhea
    • Blood in stool
    • Classic “currant jelly” stool is a late finding
    • May appear lethargic between bouts of pain
  • Diagnosis:
    • Abdominal Film: Target sign (next slide), crescent sign, signs of bowel obstruction. (Great case review: https://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.html)
    • Ultrasound
    • Air/contrast enema: Diagnostic and Therapeutic
  • Treatment – the longer this exists, the more likely you will be dealing with necrotic bowel
    • Initial:
      • Air enema: 70-85% effective
    • If complicated (ex. Unstable vitals, signs of perforation) then open reduction of intussusception
    • Recurrence
      • 10% in children who underwent non-opperative reduction. Half of recurrences occur in the first 72 hours after reduction.
8
Q

malrotation and volvulus

A
  • During embryonic development the growing intestines come out of the fetus to perform a complex set of rotations to achieve the proper orientation of the normal gut.
  • If the rotations do not occur (nonrotation) or occur incompletely
    (malrotation) then the final orientation of the gut wil be compromised.
  • Patients with malrotation and non rotation can present with signs of obstruction. 75% present befor 5 yo.
    • Vomiting
    • Abdominal Distention
    • Abdominal Pain
    • Hemodynamic Instability
    • Peritonitis
    • Hematochezia
  • In malrotation the small intestine has a narrow mesenteric base that allows for the mesentery to twist and cause an obstruction. This twisting is called volvulus.
  • Most common presentation is vomiting. May not be bilious.
  • >90% of patients who present with malrotation in infancy present with volvulus.
9
Q

pyloric stenosis

A
  • diagnosed mainly on history THERE WILL BE A QUESTION ON THE EXAM
    • Gastric outlet obstruction resulting from hypertrophy of muscle around the pylorus
    • Epidemiology
      • 3 out of 1000 live births
      • Hereditary component
      • Common in first born
      • Increased risk with bottle feeding
      • Macrolide antibiotics (erythromycin, azithromycin) in the first 2 weeks of life (systemic)
    • Presentation
      • Symptoms usually start in the first 3-4 weeks of life.
      • Regurgitation of feeds that progressively worsens
      • Nonbilious vomiting that may become projectile (>3 feet)
      • Chronic emesis can lead to an emaciated and dehydrated infant with electrolyte abnormalities and hemodynamic instability.
      • Classic triad
        • hypochloremia
        • hypokalemia
        • metabolic alkalosis
      • Infrequent finding of abdominal “olive” when palpating the stomach
      • Diagnosis
        • Ultrasonography
        • Upper GI contrast study
      • Treatment
        • Correction of electrolyte abnormality
        • Hydration
        • Pyloromyotomy
10
Q

umbilical hernia

A
  • Etiology
    • weakness in the midline fascia surrounding the umbilical area
    • herniation of abdominal contents
    • incarceration is a surgical emergency
  • Treatment
    • observation with education for signs of incarceration
    • rarely causes incarceration
    • Surgical correction considered around age 3 yo
11
Q

inguinal hernia

A
  • will need surgical correction unlike the umbilical hernia which can go away on its own
    • Weakness in lower abdominal wall often where the processus vaginalis remains open
    • abdominal contents (intestine, ovary, etc.) can slip down towards the scrotum or labium
    • common in pre-term infants
    • much less common in girls
    • Presentation:
      • “fullness”
      • evidence of swelling during crying or Valsalva
      • thick or full spermatic cord
      • incarceration is a surgical emergency
    • Management:
      • Referral should be made to surgery when hernia is detected. Surgical repair will be done to prevent further complications.
12
Q

diaphragmatic hernia

A
  • Extrusion of the abdominal contents into the pleural cavity through a hole in the diaphragm.
  • Predominantly on left
  • Contraindication to positive-pressure ventilation
13
Q

omphalocele

A
  • Extrusion of abdominal contents through umbilical defect, typically encased in a membrane
  • Often associated with other malformations as part of a syndrome.
14
Q

gastroschisis

A
  • Extrusion of abdominal contents through non-umbilical defect, typically without a membrane
15
Q

vision screening

A
  • 5-10% of children have vision problems
  • Objectively screened up to 3 years of age
    • red reflex – used to assess for cataracts and intraglobular tumors. (refer to neonatology lectures)
    • fixation and tracking
    • test of pupillary reflex
    • corneal light reflex
    • blink to threat
  • Subjectively screened when older and able.
16
Q

corneal light reflex

A
  • Looking at the eyes through an ophthalmoscope at a distance should produce a symmetric reflex.
  • Asymmetry can manifest as:
    • Esotropia- Inward deviation
    • Exotropia-Outward deviation
    • Hypertropia- Upward deviation
    • Hypotropia- Downward deviation
17
Q

cover uncover test

A
  • As 1 eye is covered, the examiner watches carefully for any movement in the opposite, noncovered eye; such movement indicates the presence of a heterotropia. With movement of the noncovered eye assumed to be absent, movement of the covered eye in one direction just after the cover is applied and a movement in the opposite direction (a fusional movement) as the cover is removed indicate a heterophoria that becomes manifest only when binocularity is interrupted. If the patient has a heterophoria, the eyes will be straight before and after the cover-uncover test; the deviation that appears during the test is a result of interruption of binocular vision. A patient with a heterotropia, however, starts out with a deviated eye and ends up (after the test) with either the same or the opposite eye deviated (if the opposite eye is the deviated one, the condition is termed alternating heterotropia). Some patients may have straight eyes and start out with a heterophoria prior to the cover-uncover test; however, after prolonged testing—and therefore prolonged interruption of binocular vision—dissociation into a manifest heterotropia can occur.
18
Q

abnormal vision screen

A
  • Defects always present are called tropias
  • Defects found on provocative testing only are called phorias
  • Majority of cases develop between 18 months and 6 years of age
  • If the developing brain is receiving poor-quality visual information from one side (because of strabismus, cataract, etc.), it will quickly learn to suppress the information from the abnormal side.
  • Amblyopia is a chronic visual loss related to disease of visual pathways.
  • Reduction in central visual acuity
  • Accounts for 20-70% of visual loss in adults
  • 40% of children with strabismus will develop amblyopia
19
Q

vision screening 3 yr and up

A
  • Subjective testing starts at 3 years
    • Visual acuity testing
    • Allen object recognition
    • E test
    • Snellen chart (letters) – when developmentally able
  • Typical visual acuity
    • 6 months: 20/60
    • 3 years: 20/20-20/30
    • 3 ½ years: 20/20-20/25
20
Q

normal vision results

A
  • Vision testing is difficult in younger children due to their attention span and ability to cooperate. The following are accepted as normal values for younger children.
21
Q

referral to ophthalmology

A
  • Abnormal red reflex
  • Esotropia after two months
  • Exotropia after six months
  • Failed subjective vision screening
22
Q

corneal abrasion

A
  • Clinical Features
  • Painful (foreign body sensation)
  • History of foreign body or trauma (may be absent in newborn or young child who could have scratched themselves)
  • Testing: Fluorescein
  • Treatment
    • Antibiotic ointment
    • Patching
    • Cycloplegics
23
Q

hyphema

A
  • Bleeding in the anterior chamber
  • Usually result of direct trauma
  • Bleeding causes increase in intraocular pressure raises risk of vision loss
  • Immediate referral to ophthalmologist
  • Serial anterior chamber pressure measurements
  • Therapies include steroids, operative evacuation
24
Q

retinal hemorrhages

A
  • Most concerning for shaken baby syndrome
  • Also occur in coagulopathies, cardiopulmonary resuscitation, sudden changes in intracranial pressure
  • Occur in healthy newborns directly after delivery because of changes in intracranial pressure
  • In cases concerning for non-accidental trauma (abuse), ophthalmology should be consulted to look for retinal henorrahges.
25
Q

conjunctival hemorrhages

A
  • Common in newborns that were born by vaginal delivery or had a prolonged birthing process.
  • Can also occur in teenagers who weightlift.
26
Q

hordeolum

A
  • Acute, painful, localized infection of the eyelash follicles or glands
  • Staphylocococus aureus
  • Treatment
    • Warm compresses
    • Referral to ophthalmologist if not improving in 1 week for drainage
    • Oral antibiotics if inflammation appears to be spreading or with pre-auricular adenopathy or signs of bacteremia
27
Q

chalazion

A
  • Painless and chronic inflammation (granuloma) of the lid involving tarsal sebaceous gland (meibomian gland)
  • Typically starts as hordeolum
  • Treatment
    • warm compresses for at least six weeks
    • referral to ophthalmologist after six weeks for removal
28
Q

disorders of the nasolacrimal system

A
  • Nasolacrimal duct obstruction
    • frequent – 6% of infants
    • may open spontaneously
    • refer to ophthalmology if persistent to one year of age, or with constant eye tearing and drainage –
  • Dacryostenosis is a closed duct
  • Dacryocystocele
    • blue nodule inferior and medial to inner canthus
  • Dacryocystitis
    • infected lacrimal sac
29
Q

keratitis

A
  • Keratitis
    • Inflammation of the cornea
      • Bacterial (Staph)
      • Viral (HSV, adenovirus)
  • Presentation:
    • Pain
    • Photophobia
    • Foreign body sensation
30
Q

corneal ulcer

A
  • Symptoms
    • decreased vision
    • pain
    • scleral injection
    • white corneal infiltrate
  • Referral to ophthalmologist
  • Greater chance for scarring
31
Q

ENT Basics

A
  • Covered elsewhere: Basic otitis media, obstructive sleep apnea, hearing screening
  • Covered Here: Epistaxis, TE Fistula, Hearing Loss
32
Q

epistaxis

A
  • Features
    • Common childhood issue
    • Often due to digital trauma (nose picking)
    • For new episodes evaluate history for bleeding disorders and other types of bleeding.
    • In normal cases bleeding should last 15 in or less.
  • Treatment:
    • Vaseline
    • Humidification
    • Cautery by ENT if frequent or severe
33
Q

TE fistula

A
  • 1 in 3500-4500 live births
  • Presents with:
    • Coughing
    • Choking
    • Respiratory distress
    • Feeding difficultues
  • Diagnosis:
    • Passing NG tube
    • CXR
    • Bronchoscopy and Endoscopy
  • Treatment: Surgical repair.
34
Q

hearing loss

A
  • Conductive hearing loss vs. Sensorineural hearing loss
  • Conductive hearing loss:
    • Middle ear effusion
    • Atresia or stenosis of the ear canal
    • Foreign body or cerumen
  • Senorineural hearing loss:
    • Hair cell damage from noise, disease or drugs
  • Central hearing loss:
    • 8th nerve or cerebral cortex issues
35
Q

management of conductive and sensorineural hearing loss

A
  • Conductive
    • Tympanostomy (tubes) to remove effusion
    • Surgical correction of atresia
    • Removal of obstruction
  • Sensorineural:
    • Hearing aid
    • Cochlear implant