Otolaryngology

Question 1

Acute Otitis Media

Answer 1

Sudden onset of inflammation in the middle ear space accompanied by local (otalgia) and often systemic (fever) findings

Question 2

Otitis media with effusion (OME) or serous otitis media

Answer 2

presence of non purulent inflammatory fluid in the middle ear space

may follow an episode of AOM or accompany a URI

Question 3

Recurrent Otitis Media

Answer 3

3 or more episodes of AOM in 6 months or

4 episodes in 1 year, with 1 in the last 6 months

with each infection there is a complete clearing of the prior infection

Question 4

Chronic otitis media with effusion

Answer 4

OME that lasts longer than 3 months –> increased risk for hearing problems, speech delay

Question 5

Chronic suppurative otitis media

Answer 5

6 weeks of middle ear drainage form a non-intact TM (tympanostomy tubes, perforated TM)

Question 6

Etiology of AOM

Answer 6

Bacterial:

1. streptococcus pneumoniae
2. non typable haemophilus influenzae type B
3. Moraxella catarrhalis

Viral: RSV, adenovirus, coronavirus

Question 7

AOM diagnosis

Answer 7

-moderate to severe bulging TM

-otorrhea not due to another cause

-mild bulging TM and recent onset of ear pain (48 hrs) or intense erythema of the TM

Question 8

Otalgia treatment

Answer 8

• acetaminophen 10-15 mg/kg/dose q 4hr

-ibuprofen 5-10 mg/kg/dose q6-8 hrs

-topical agents: benzocaine, procaine, lidocaine

Question 9

First line treatment for AOM

Answer 9

Amoxicillin 80-90mg/kg/day in 2 divided doses x 10 days

or

Amoxicillin-Clavulanate (Augmentin) 90mg/kg/day - 6.4mg/kg/day in 2 divided doses x 10 days

Question 10

AOM Abx for treatment failure

Answer 10

Augmentin if started with Amoxicillin

or

Ceftriaxone (rocephin) 50mg IM or IV for 3 days

Question 11

AOM w/ tympanostomy tubes treatment

Answer 11

Treatment w/ fluoroquinolone w/ or w/o corticosteroid topical drops:

-Ofloxacin (floxin) 5 drops BID x 10 days

-Ciprofloxacin w/ dexamethasone (ciprodex) 4 drops BID x 7 days

Question 12

Mastoiditis

Answer 12

Complication of otitis media:

Inflammation/infection of the mastoid bone

Clinical presentation: tenderness & edema of the mastoid process, post auricular edema may displace ear, fever, may involve CN VI, VII, VII

Plan of care: hospital admission, blood cultures, LP, CT, IV abx

Question 13

Cholesteatoma

Answer 13

Lesions arising from the temporal bone in the middle ear or mastoid

Non neoplastic, destructive cystic structure composed of desquamated keratin and squamous debris surrounded by fibrous matrix

Clinical presentation:

-purulent otorrhea that is chronic or recurring
-pain, hearing loss, tinnitus

Physical exam:

-smooth, round, white, compressible lesion behind TM
(compared to tympanosclerosis (scarring) which will be white w/ irregular shape)
-may note retraction of TM

Plan of care:

• collaborate w/ otolaryngology: CT or MRI, surgery, hearing eval w/ audiology s/p surgery

Question 14

Otitis Externa

Answer 14

Inflammatory process involving external auditory canal

Focal- staph aureus
Diffuse- pseudomonas aeruginosa

Clinical Presentation: ear pain, pain with chewing, difficulty hearing (edema can close canal)

Physical Exam findings:
pain with manipulation of pinna and/or tragus, pain with insertion of otoscope, focal or diffuse erythema and edema of canal, presence of debris, difficulty visualizing TM (not affected)

Management = application of ototopical antimicrobial steroid solution with or without a wick x 7-10 days

Polymyxin B, neomycin, and hydrocortisone (cortisporin) 3-4 drops to affected ear QID

Ofloxacin (Floxin) 5 drops to affected ear BID

Ciprofloxacin w/ hydrocortisone (Ciprodex) 3 drops to affected ear BID

Question 15

Conductive hearing loss

Answer 15

Abnormality from the pinna to the middle-ear ossicles

Interference with the conduction of sound

Question 16

Sensorineural hearing loss (SNHL)

Answer 16

Abnormality affecting the cochlea, inner ear, or auditory nerve

Question 17

Auditory neuropathy spectrum disorder

Answer 17

Sound enters the ear normally but damage to the inner ear or nerve means sound is not organized in a way that the brain understands

Question 18

Hearing loss categories

Answer 18

Mild- 26-40 dB loss
Moderate- 40-70 dB loss
Severe- 71-90 dB loss
Profound- >90 dB loss

Question 19

Newborn hearing screening

Answer 19

Should be completed by 1 month of age

If fails:
- refer to audiologist by 3 months of age
-interventions should begin by 6 months of age

If passes but has risk factors:
-assess communication at every well visit
-refer to audiologist by 24-30 months of age

Question 20

Risk factors for hearing impairment

Answer 20

Family history of congenital or early SNHL
Congenital infection known to be associated with SNHL - CMV
Craniofacial anomalies
Birthweight < 1500g (3.3lb)
Hyperbilirubinemia over the exchange level
Infectious dx associated w/ SNHL
Exposure to ototoxic meds
Bacterial meningitis
Low APGAR scores at birth
Prolonged mechanical ventilation in neonatal period
Findings of a syndrome associated with SNHL
Any parental concern about haring, speech, language, or developmental delay
Head trauma, fracture of temporal bone
Neurodegenerative disorders

Persistent otitis media w/ effusion
Bacterial meningitis
Neurological syndromes associated w/ hearing loss
NICU stay
Parental consanguinity
Exposure to chemotherapy

Question 21

Sinusitis diagnostic criteria/ clinical presentation

Answer 21

Acute upper respiratory tract infection with persistent illness (i.e nasal discharge or daytime cough or both) lasting more than 10 days;

worsening cough, worsening or new nasal discharge or daytime cough or fever after initial improvement;

or severe onset of fever and **purulent nasal discharge **for at least 3 consecutive days

Persistent symptoms
Nasal discharge/congestion and/or cough for ≥ 10 days w/o improvement

Severe symptoms
Temperature ≥38.5oC with purulent rhinorrhea for at least 3 days

Worsening symptoms
Worsening of nasal congestion or rhinorrhea, cough, and fever after a 3- to 4-day period of improved symptoms

Question 22

Sinusitis PE

Answer 22

Pediatric findings:
Infants- not typically diagnosed
Toddler- daytime cough, worse nighttime cough, vomiting, runny nose
School age- prolonged congestion, fever, malodorous breath, sore throat
Adolescent- more classic symptoms- facial pain, tooth pain, nose pain
Other findings:
Erythematous posterior oropharynx
Mucoid discharge draining posteriorly
Fluid bubbles in ear

Question 23

Sinusitis treatment

Answer 23

Treatment
- Oral antibiotics
- Saline nasal rinse -loosen secretions, easier to evacuate nose

Choosing wisely
M. Catarrhalis, Strep. Pneumoniae and H. influenzae top bacterial causes

Uncomplicated sinusitis
Amoxicillin- clavulanate 45mg/kg/day or Amoxicillin 90 mg/kg/day
Severe sinusitis
Amoxicillin-clavulanate 90 mg/kg/day

Alternatives: cefpodoxime 10mg/kg/day (max dose = 400mg/day) or cefdinir 14mg/kg/day (max= 600mg/day)
Can be divided into 2 doses

PCN allergy: Levofloxacin 10-20mg/kg/day (daily or BID) (max 500 mg/day)

If child can not tolerate PO, consider ceftriaxone at 50mg/kg/day (max 1 gram/day)

advise against: use of antihistamine (unless atopic history) and use of oral or topical decongestants

Question 24

URI

Answer 24

Etiology: most often caused by virus- rhinovirus, parainfluenza, RSV, adenovirus, COVID, human metapneumovirus

Typical symptoms: sore throat, hoarseness, nasal congestion (rhinorrhea, sneezing), cough, fever

PE: mild conjunctival injection, erythematous nasal mucosa + nasal secretions, injection of posterior oropharynx, anterior cervical lymphadenopathy

Rapid antigen diagnostic testing- rapid flu, covid, strep

Differntials:
Allergic rhinitis
Sinusitis
Strep pharyngitis

Treatment (supportive):
Antipyretics as needed (ibuprofen only above 6 mts)
Nasal saline rinses
Fluids

Question 25

Pharyngitis

Answer 25

Inflammation of the mucosa- tonsils, pharynx, uvula, soft palate and nasopharynx
Etiology - infectious or noninfectious:
- viral: epstein barr
- bacterial: beta hemolytic strep (common in school age), mycoplasma pneumonia, gonorrhea
- allergic, referred pain, oncological

HPI:
pain, muscle or body aches, fever, dysphagia
if viral- rhinorrhea, cough, haorseness, diarrhea, conjunctivitis

PE:
Erythema of the tonsils and pharynx
Reactive, tender cervical lymph nodes
Virus specific:
EBV- exudate, palatal petechiae, enlarged cervical nodes
Adenovirus- fever, bulbar & palpebral conjunctivitis, rhinitis, pharyngitis
Enterovirus- ulcers, coryza, vomiting, diarrhea
HSV- gum erythema, vesicles to the anterior mouth, adenopathy
Parainfluenza & RSV- lower respiratory tract symptoms i.e wheezing, stridor
Influenza- cough, fever and systemic symptoms

Question 26

Pharyngitis Diagnostics

Answer 26

GABHS suspected:
-Rapid antigen diagnostic test (RADT)
-Consider throat culture if rapid is negative, unless molecular test is performed
-Anti- streptolysin O (ASO) and anti-deoxyribonuclease B (anti-DNase B)

Adolescents engaging in oral sex- consider gonorrhea if coming in with sore throat complaint

If underimmunized, consider testing for diphtheria- grey membrane covering posterior oropharynx

Infectious mononucleosis:
-CBC- lymphocytosis and atypical lymphocytes
-Heterophile antibody test (Mono spot)- accurate only after having symptoms for a week
-Can also send for EBV titers

Question 27

Pharyngitis Treatment

Answer 27

Viral:
Supportive care - gargle w/ warm salt water, throat lozenges, fluids, OTC APAP or ibuprofen
Beta lactam abx react w/ CMV and EBV and can cause rash

Bacterial:
Oral abx - shorten fever duration, decreased infectiousness, decrease risk of rheumatic fever, glomerulonephritis
Supportive care
Change toothrbush, sterilize retainer
return to school when afebrile and on abx for minimum of 12 hrs

Question 28

Group A Beta Hemolytic Strep (GABHS)

Answer 28

Symptoms:
Acute onset sore throat, dysphagia
No nasal symptoms
Tender cervical lymphadenopathy
Headache, body or muscle aches
Fever, malaise
Nausea, vomiting, abdominal pain
Headache, abdominal pain, sore throat= strep triad

PE:
Petechiae on soft palate & pharynx
Swollen and erythematous uvula
Enlarged tonsillopharyngeal tissue
Yellow exudate, blood tinged
Malodorous breath
Scarlatiniform rash (finite, papular rash on chest and back)
Strawberry tongue

Diagnostics:
Rapid antigen diagnostic test (RADT)

Consider throat culture if rapid is negative, unless molecular test is performed

Anti- streptolysin O (ASO) and anti-deoxyribonuclease B (anti-DNase B)
- Not diagnostic
- Useful if suspect rheumatic fever (high fever or chest pain) or glomerulonephritis (blood in urine)
-Antibody test determines recent infection
(ASO 1 week) (anti-DNase B 2-3 weeks)

Question 29

GABHS treatment

Answer 29

Penicillin V Potassium x 10 days
<27 kg= 250 mg 2-3x/day
>27kg & adolescents= 500 mg 2-3x/day
Amoxicillin x 10 days
50 mg/kg/day (max 1 G) ( can do 2 divided dose)
Cephalexin x 10 days
20 mg/kg/dose (max 500 mg/dose) BID
Clindamycin x 10 days
7 mg/kg/dose (max 300mg/dose) TID
Azithromycin x 5 days
12mg/kg/day (max 500 mg)

Question 30

GABHS carrier treatment

Answer 30

strep carrier treatment not needed unless:
pending tonsillectomy, communal outbreak, history of RF, ping pong spreading in household

Clindamycin x 10 days
20-30mg.kg/day in 3 doses
Augmentin x 10 days
40 mg/kg/day in 3 doses (max 2000mg/day)
Penicillin V x 10 days + Rifampin (day 6-10)
50 mg/kg/day in 4 doses (max 2000mg/day) + 20mg/kg/day (max 600 mg/day)

-if treated and throat culture still positive, give 2nd round of abx, consider ENT referral

Question 31

Complications of GABHS

Answer 31

Nonsuppurative:
Rheumatic fever
Poststreptococcal reactive arthritis & pediatric autoimmune neuropsychiatric disorder syndrome (PANDAS)
Pediatric acute onset neuropsychiatric syndrome (PANS)
Sydenham chorea- movement disorder, uncoordinated
Acute glomerulonephritis- inflammation of glomeruli, can lead to bloody urine, abdominal pain

Suppurative:
Cervical adenitis- infection in gland or lymph node
Rhinosinusitis, mastoiditis
AOM, retropharyngeal or peritonsillar abscess
Pneumonia

Question 32

Tonsillectomy & Adenoidectomy Guidelines

Answer 32

Tonsillectomy:
>/= 7 episodes of throat infection in past year, or > 5 per year for 2 yrs or > 3 per year for 3 yrs
Throat infection is defined as fever >100.9, cervical lymphadenopathy with exudate or positive GABHS

Adenoidectomy:
Severe nasal obstruction > 1 yr or sleep apnea

Question 33

Croup etiology, HPI, PE

Answer 33

Inflammation of the larynx, trachea, and bronchi (laryngotracheobronchitis)

Etiology
Typical viral: parainfluenza virus (most common), influenza, SARS/covid, measles
Bacterial: M. Pneumoniae

HPI:
Barkly, seal like cough
Hoarse voice, hoarse cry
+/- URI symptoms, fever

PE:
Brassy sounding cough, inspiratory stridor, cough and respiratory distress
General- well appearing and comfortable or fussy and ill-appearing
HEENT- rhinorrhea, +/- signs of AOM, +/- pharyngeal erythema
Respiratory- normal at time of exam or stridor
Cardiac- tachycardia, otherwise normal
GI- WNL

Question 34

Croup diagnostics/ differentials

Answer 34

Clinical diagnosis
Lateral neck x-ray: steeple or pencil point sign

Differntials:
Tracheitis- consider if high fever and ill appearing (pharyngeal culture)
Foreign body
Retropharyngeal abscess- especially w/ high fever, throat pain, unilateral swelling of tonsils
Angioedema- if having allergic rx
Compression from tumor or congenital airway malformation
Infectious mononucleosis
Psychogenic stridor- anxiety exacerbation

Question 35

Croup scoring/ treatment

Answer 35

Westly croup score- used to grade severity of symptoms
-Chest wall retractions (none mild, moderate, severe)
-Stridor (none, w/ agitation, at rest)
-Cyanosis (none, w/ agitation, at rest)
-LOC (normal, disoriented)
-Air entry (normal, decreased, markedly decreased)

Treatment should be reserved for moderate to severe cases:

Corticosteroids- dexamethasone 0.15 mg-0.6 mg/kg x 1 dose
Bronchodilators- if bronchospasm present or h/o asthma
Oxygen - pulse ox < 95%
Nebulized epinephrine
Cold night air shown to improve symtpoms d/t decreased inflamation (not humidified air)

Question 36

Tracheitis

Answer 36

Inflammation and constriction of the trachea secondary to a bacterial infection (Bacterial infection causes inflammatory cells to increase, mucus secretion and sloughing → inflammation)

Etiology:
Staphyloccous most common
Other commonly found: staph or strep pyogenes, M. catarrhalis, non typeable H. influenzae
Gram negative infections are rare
Seen from 3 weeks- adolescent age

Management:
Medical emergency- progresses rapidly from compromsied airway to airway obstruction- will require airway stabilization and IV abx
Call 911
In primary care setting- utilize crash cart

Question 37

Foreign Body

Answer 37

HPI:
Sudden or gradual onset
May be clear choking episode history
Difficulty breathing, wheezing, cyanosis
Afebrile or low grade fever
Red flags:
- Sudden onset of coughing w/o history of URI symptoms
- Child presenting w/ recurrent PNA or unilateral wheezing

Treatment:
Refer to otolaryngology or pediatric surgeon for removal
X-ray to confirm suspicion
Endoscopy or bronchoscopy under sedation for removal

Question 38

Epiglottitis

Answer 38

Inflammation of the epiglottis

Bacterial etiology:
GABHS, streptococcus pneumonia, klebisella, staph aureus

HPI:
Sudden onset of fever, irritability, muffled voice, severe sore throat, dysphagia w/ drooling, respiratory distress
Older children may complain of difficulty swallowing

PE:
Ill appearing
Drooling, aphonia, febrile
Nasal flaring, retractions
Hyperextension of the neck; tripod position
Cherry red epiglottis
(do not examine pharynx, maintain comfortable position and call 911)

Treatment
Emergent otolaryngology consult
Establish airway
Administer broad spectrum IV abx
O2 therapy as needed

Question 39

Epiglottitis diagnostics

Answer 39

Lateral neck x-ray- thumb sign

Question 40

Cleft lip/palate associated risks

Answer 40

Increased risk of airway compromise and infection, encourage good oral hygiene

Question 41

Obstructive sleep apnea (OSA)

Answer 41

Combination of upper airway obstruction which disrupts sleep and leads to abnormal breathing
Affects learning (daytime sleepiness/irritability), weight gain, predispose children to obesity (can lead to leptin resistance and icnreased ghrelin levels –> increased hunger)

Anatomical risk factors:
enlarge adenoids & tonsils, untreated allergic rhinitis
obesity
craniofacial abnormalities
GERD
neuromuscular disorders- can cause inadequate respiratory effort

HPI: snoring, mouth breathing, disrupted sleep

PE: may or may not observe enlarged tonsils, ENT may observe enlarged adenoids

Treatment:
Adenotonsillectomy (TNA)
- prior sleep study- identifies degree of sleep apnea and risk of going under sedation
- risks: poor PO intake post op, dehydration, excessive bleeding, infection

Non surgical: nasal steroids (flonase, fluticasone), leukotriene receptor antagonist (montelukast), normal saline rinse, weight loss, positive airway pressure therapy at night, rapid mandible expansion (RME)