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Unit 1 568
EENT, Fever, Antimicrobials
| Question | Answer |
|---|---|
| 2 causes of tearing in the eyes of newborns | Nasolacrimal obstruction but may be associated with congenital glaucoma |
| Watery eye discharge is associated with | viral infection, iritis, superficial foreign body, nasolacrimal obstruction |
| Mucoid discharge due to allergy typically contain | Eosinophils |
| Leukocoria | White pupil - Causes: retinoblastoma, retinopathy of prematurity, papillary membrane, cataract, vitreous opacities, retinal detachment, Toxocara infection, retinal dysplasia |
| Myopia | Nearsightedness - objects that are close are clear, Distant objects are blurred |
| Hyperopia | Farsighted - Distant objects - close; Close objects - blurred |
| Astigmatism | Cornea curved unevenly; distant and close objects are blurred |
| Referral to opthalmology : 3-5 years - 6 years - | 3-5 years = visual acuity less than 20/40 6 years - visual acuity less than 20/30 |
| Herpes simplex lesions of the corneal epithelium | dendrite or branchlike pattern |
| Contact lens wear produce | central staining pattern |
| Viral keratitis or medication toxicity in stained eye exam | fine, scatter punctuate pattern |
| Children have ______ pupils than adults or infants | larger |
| Infants and adults have ______ pupils | Miotic (constricted) |
| What medications can cause pupillary dilation | Atropine and antihistamine |
| What is aniscoria? What causes it? | Size difference btwn two pupils; horner syndrome, third nerve palsy, Adie tonic pupil, iritis, trauma |
| Findings with corneal abrasions: | eyelid edema, tearing, injection of the conjunctiva, and poor cooperation with ocular exam due to the pain. |
| Treatment for corneal abrasion: | erythromycin ointment or 1% cyclopenlate if brow ache is present. |
| Signs of ruptured globe | shallow anterior chamber with hyphema, traumatic cataract, irregular pupil |
| Which penetrates deeper the eye? Acids or alkali | Alkali |
| Immediate first aid for burns to the eyes | Copious irrigation and removal of precipitates; topical antibiotics, and patching the injured eye closed; Cyclopentolate 1% can be given if corneal involvement is present to reduce pain. |
| Treatment for hyphema (layer of blood in the anterior chamber) | eye shield, head elevated, and referral |
| Treatment of blepharitis | Lid scrubs with a non burning baby shampoo several times a week, warm compresses to the eyelids, and application of topical antibiotic ointment - erythromycin |
| Amblyopia | Lazy eye |
| Otorrhea | Ear discharge |
| First line antibiotic for OM | Amoxicillin (90mg/kg) |
| Amoxicillin, max dose | up to 4g/d |
| A situation where low dose antibiotic prophylaxis may be recommended - Part 1 of 2 | child being considered for tympanostomy tube placement for recurrent infections who presents in late spring. A 1-2 month course of amoxicilin might prevent infection until the low risk summer season when AOM is uncommon . |
| Another situation would be | the child with patent tympanostomy tubes who experiences recurrent AOM and has been found to have an immune deficiency on more than one occasion. |
| Antibiotic prophylaxis is not recommended for | children with OME. |
| The seven valent pneumococcal conjugate vaccine (PCV7) was designed to | prevent meningitis and sepsis, not AOM. However it did produce a 55% reduction in AOM resulting from the seven serotypes found in the vaccine. |
| Intranasal influenza vaccine reduced the # of influenza associated AOM by | 92% |
| What is mastoiditis? | occurs when infection spreads from the middle ear space to the mastoid portion of the temporal bone, which lies behind the ear. |
| What should be concerned with when a patient has mastoiditis? | Meningitis and brain abscess |
| Common pathogens of mastoiditis | S pneumoniae and S progenies with S aureus and H influenze occasionally seen |
| What may be the cause of the rising numbers of mastoiditis? | S pneumoniae |
| Hallmark of Mastoiditis | postauricular tenderness and ear protrusion |
| Mastoiditis can progress to | sigmoid sinus thrombosis, epidural abscess, or intraparenchymal brain abscess |
| Treatment for mastoiditis 1. | myringotomy with or without tube for mastoiditis without a subperiosteal abscess, followed by IV abc plus ofloxacin or ciprofloxacin ear gtts |
| Treatment for mastoiditis 2. | surgical drainage of mastoid if no clinical improvement in 24-48 hrs |
| Treatment for mastoiditis 3. | Cortical mastoidectomy is usual primary mgt for coalescent mastoid its (with abscess formation and breakdown of the mastoid air cells) |
| Treatment for mastoiditis 4. | after clinical improvement is achieved with parental therapy, oral abx are begun and should be continued for 3 weeks. |
| Emergency condition for FB in ear: | disk-type battery; An electric current is generated in the moist canal, and a severe burn with resultant scarring can occur in less than 4 hrs. |
| Children exhibiting pre auricular tags, ectopic cartilage, fistulas, sinuses, and cysts should have what checked? | Hearing and renal US because external ear anomalies may be associated with renal anomalies as both form during the same period of embryogenesis. |
| What should children with rXn to amocillin get when treating acute otitis media? | Cephalosporin: Cefuroxime, Cefpdoxime, Cefdinir |
| What is not recommended as a second line agent in AOM? | Macrolides such as Azithromycin and Clarithromycin because S pneumonia is resistant and all strains of H influenza have an intrinsic macrolide efflux pump pumping this ABX out of the cell. |
| When should tubes be placed for persistent effusions? | after effusion has persisted for 4 months and accompanied by bilateral hearing impairment of 20 dB or greater |
| What is the earliest finding in mastoiditis? | severe tenderness on mastoid palpation |
| Most common pathogens in mastoiditis? | S pneumoniae and S pyogens, |
| Hallmark of mastoiditis | postauricular tenderness and ear protrusion |
| OE is commonly caused by | Staph Aureus, Pseudomonas aeurginos |
| Most common causes of OM | RSV and influenza; 3rd most common M. Catarrhalis, 4th Streptococcus pyogenes |
| What is a cause of OM seen more commonly in school aged than infants | Strep pyogenes |
| Most likely cause of mastoiditis | S. pneumoniae |
| Common causes of bacterial conjunctivitis | Haemophilus species, S. pneumonia, M. Catarrhalis, S.Aurues |
| Treatment for bacterial conjunctivitis | topical antibiotics such as erythromycin, polymysin-bacitracin, sulfacetamide, tobrmycin, and fluroquinolones. |
| Systemic therapy for treatment of bacterial conjunctivitis if patient has | chlamydia trachomatis, N gonorrhoae, and neisseria meningtides |
| Observation option in AOM: | older than 2 with non severe disease for first 48-72 hours after onset of symptoms. ALWAYS ABX IN YOUNGER THAN 6 MONTHS. YOUNGER THAN 2 YEARS AND OLDER CHILDREN WITH SEVERE PAIN OR FEVER GET ABX. |
| Characteristics of OE | External canal edema, thick drainage, severe pain worsened by manipulation of pinna, often unable to visualize the TM; hearing is normal |
| What is not advised for corneal abrasion caused by contact lens or other potentially contaminated surfaces? | patching the affected eye |
| Follow up after corneal abrasion | daily follow up is required until treatment is complete |
| If pain from corneal abrasion is referred to the ipsilateral brow it may be treated with? | topical cycloplegic agent such as cyclopentolate. |
| pulling down on the lower eye lid provides visualization of | inferior cul-de-sac (palpebral conjunctiva) |
| Visualizing the upper cul-de-sac and superior bulbar conjunctiva is possible by having the patient | look inferiorly while the upper lid is pulled away from the globe and the examiner peers into the upper recess. |
| Upper lid should be everted to evaluate the | superior tarsal conjunctiva |
| How do you inspect the anterior segment of the globe and its adnexa? | adequate illumination and often magnification |
| After applying flouroscein you must have? | woods lamp or blue filter cap |
| Where do you instill fluorescein soln? | the lower cul-de-sac |
| Blue light stains defects _________? | yellow green |
| Herpes simplex stains? | lesions of the corneal epithelium produce a dendrite or branchlike pattern. |
| FB stains> | beneath the upper lid shows one or more vertical lines of stain on the cornea due to the constant movement of the FB over the cornea |
| Contact lens overwear produces | a central staining pattern |
| A fine, scattered punctuate pattern may be a sign of | Viral keratitis or medication toxicity |
| What is the swinging flashlight test used for? | pupillary defect |
| Ways to test corneal light reflex? | observation (educated guess), Hirschberg test, cover test |
| Antibiotics and steroids are no longer recommended for | Otitis media with effusion |
| Evaluation with OME | Evaluate monthly by pneumatic otoscopy or tympanometry |
| With acute trauma to the middle ear; how long until hearing returns to normal? | 6-8 weeks |
| When would you refer acute trauma to the middle ear to otolaryngologist? | Traumatic perforation of the TM; hearing loss |
| Treatment of middle ear hematomas consists mainly of? | Watchful waiting |
| Are antibiotics given to traumas to the middle ear? | Not unless signs of infection appear |
| Why should hematomas of the pinna be treated by otolargynologist and how? | It can result in a cauliflower ear due to pressure necrosis; OTO will drain the hematoma and apply a carefully molded pressure dressing |
| A low set ear is associated with? | Renal malformations (Potter syndrome). |
| Conductive hearing loss occurs when? | blockage of sound transmission from external canal to cochlear receptor cells |
| Most common cause of conductive hearing loss? | fluid in middle ear |
| Can conductive hearing loss be treated with surgery> | Yes |
| Hearing and language skills should be assessed in children who have recurrent acute otitis media or MEE longer than | 3 months |
| Sensorineural hearing loss occurs | defect in neural transmission of sound, arising from a defect in the cochlear hair cells or the auditory nerve (CN 8-Vestibulocochlear) |
| The most common congenital sensory impairment? | Sensorineural hearing loss |
| Nonhereditary causes of congenital sensorineural hearing loss? | prenatal infections, tertogenic drugs, and perinatal injuries. |
| Acquired heredity hearing loss can be delayed: T or F | True |
| Causes of Acquired hearing loss that is non genetic and has delayed onset ? | exposure to ototoxic meds, meningitis, autoimmune or neoplastic conditions, noise exposure, trauma, syphilis or Lyme disease, CMV, pulmonary htn, extracorporeal membrane oxygenation therapy. |
| What is the threshold, or 0 dB r/t hearing measurement? | the level at which a sound is perceived in normal subjects 50% of the time. |
| Hearing is considered normal if an individual's thresholds are within? | 0-15 dB |
| profound hearing loss is how many dB? | over 91dB |
| Goal of hearing loss identification | 3 months |
| Appropriate intervention with hearing loss is by age | 6 months |
| T or F : A parents report of infant behavior is reliable for hearing loss identification. | False |
| Birth - 4 months: suspect a hearing loss if: | infant does not show the startle reflex or blink eyes in response to a sudden loud sound (>70 dB) |
| Normal response if hearing is intact in a 4 month old when a noisemaker is sounded out of the vision at the child's waist level? | widening of eyes, interruption of other activity, and perhaps a slight turning of the head in the direction of the sound. |
| Normal response if hearing is intact in a 6 month old when a noisemaker is sounded out of the vision at the child's waist level | head turns toward sound |
| Normal response if hearing is intact in a 9 month old and older child when a noisemaker is sounded out of the vision at the child's waist level | the child is usually able to locate a sound originating from below as well as turn to the appropriate side. |
| Normal response if hearing is intact in a child above 1 year when a noisemaker is sounded out of the vision at the child's waist level | child can locate sound and whether its below or above |
| What can the clinician do to rule out deafness in a child? | loud horn or clacker and watch for eye blink or startle reflex |
| mama, dada, baba should be present in speech by age | 11 months |
| Conditions that warrant hearing test: | hearing loss, developmental delay, bacterial meningitis, ototoxic med exposure, neurodegenerative disorders, hx of mumps, measles, or infections |
| Emergent referral to otolaryngoloist is warranted for a diagnosis of? | bacterial meningitis; cochlear ossification can occur, necessitating urgent cochlear implantation |
| High risk children should receive audiologic monitoring even if no deficits are found until the age of ? | 3 and appropriate intervals. |
| What drugs are ototoxic? | Aminoglycosides and diuretics, particularly in combination. |
| What can possible reverse sudden onset of SNHL? | steroid therapy by OTO |
| True or False? conductive hearing loss is reversible? | True |
| True or False? SNHL is reversible? | False |
| Most common pediatric infectious disease? | Acute Viral Rhinitis |
| Under 5 yrs: how many colds per year? | 6-12 |
| What causes approximately 30-40% of Acute Viral Rhinitis (common cold)? | Rhinoviruses |
| S/S of acute viral rhinitis (common cold): | sore throat, rhinorrhea (clear or mucoid), sneezing, nasal congestion, possibly fever |
| At what point should the clinician consider bacterial rhino sinusitis? | s/s of acute viral rhinitis beyond 10-14 days. |
| How many does does it take acute viral rhinitis (common cold) to resolve? | 7-10 days |
| What is the treatment for Acute Viral Rhinitis (common cold)? | symptomatic tx (ibuprofen, tylenol, humidification, nasal saline gtts), topical decongestant (afrin, neo spray) x 3 days, Oral decongestants for adults |
| OTC could and cough meds: | Not effective in children, don't use in children under 4 yrs |
| If the patient has been s/s nasal congestion and rhino-sinusitis (sinusitis) less than 10 days what is the treatment? | pain meds, humidified air, saline nose gtts, cough suppressants? |
| If the patient has been s/s nasal congestion and rhino-sinusitis (sinusitis) less than 10 days what is the likely diagnosis? | Upper respiratory infection (URI) (viral sinusitis) |
| If the patient has been s/s nasal congestion and rhino-sinusitis (sinusitis) greater than 10 days without improvement what is the likely diagnosis? | Bacterial sinusitis |
| If the patient with nasal congestion and rhino-sinusitis (sinusitis) any duration and has focal signs such as periorbital edema, sinus tenderness, or severe headache what is the likely diagnosis? | bacterial sinusitis |
| If you determine the patient has bacterial sinusitis with mild symptoms what is the treatment? | High dose amoxicillin = 90mg/kg/d in 2 divided doses . |
| If in daycare, have severe symptoms, or have been on antibiotics in the past 1-3 months for ABRS what is the treatment? | High dose amox/clav = 90 mg/k/d amox; 6.4 mg/kg/d clav in two divided doses. |
| If the patient has a non-type 1 hypersensitivity to PCN what should he get instead of Amox or Augmentin? | Cefuroxime, Cefpodixime, Cefdinir, or other cephalosporin |
| What meds are reserved for patients with anaphylactic reaction to PCN? | Macrolide - Clarithromycin or Azithromycin |
| Clindamycin is not effective against? | Gram negative organisms such as H influenzae |
| If there is poor response with first line ABX when treating ABRS, what should the clinician do? | Prescribe second line antibiotic ( Amox-Clav or Cephalosporin). If patient is already on a second line...give IV ABX |
| If bacterial sinusitis symptoms are severe or immunosuppressed what is the treatment? | naficillin or clindamycin IV with a third generation cephalosporin such as cefotaxime. |
| Bacterial infection of the paranasal sinuses that last less than 30 days and symptoms resolve completely | Acute Bacterial Rhinosinusitis |
| What almost always precedes bacterial rhino sinusitis? | viral URI (cold); allergies and trauma can also predispose |
| S/S of ARBS: | cold that doesn't improve by 10-14 days or worsens after 5-7 days in a child; nasal congestion, nasal drainage, postnasal drainage, |
| What sinuses are most commonly involved in ARBS | Maxillary and ethmoid |
| What sinuses are present at birth? | Maxillary and ethmoid |
| Sphenoid sinuses form by age | 5 |
| Frontal sinuses form by age | 7-8 |
| True or false? Gram stain or culture of nasal discharge correlates with sinus aspirates? | False |
| What complications occur withARBS | when infection spreads to adjacent structures (overlying tissues, eyes, or brain), streptococcus anginosus (milleri) , orbital, pot's puffy tumor |
| What bacterial pathogens cause acute rhinosinusitis | S pneumoniae, H influenzae (non typeable), M. Catarrhalis, B hemolytic strep |
| Treatment for ARBS for children? | no improvement by 10 days or severe symptoms with fever at least 102.2 and purulent nasal drainage for 3-4 consecutive days, ABX recommended to decrease duration and severity |
| When do you NOT prescribe penicllins? | with diagnosis of MONO |
| First line of therapy in ABRS | Amoxicillin 90mg/kg/d in 2 divided doses |
| Severe symptoms in ABRS | Amox/Clav 90mg/kg/d amox with 6.4 mg/kg/d of clav in two divided doses |
| If in daycare or prescribed ABX in the past 1-3 months and treating ABRS prescribe: | Amox/Clav 90mg/kg/d amox with 6.4 mg/kg/d of clav in two divided doses |
| Side effect of Amox/Clav ? | Diarrhea - Clav causes diarrhea |
| 2nd line therapy is indicated in ABRS when? | 48-72 hrs with no improvement ; if already on amox/clav or cephalosporin - IV ABX should be considered |
| Chronic rhinosinusitis is diagnosed when? | A child has not cleared the infection in the expected time but no acute complications have developed. |
| What would prompt a workup for cystic fibrosis? | allergic polyps |
| treatment for chronic rhinosinusitis | ABX therapy same as for ABRS, but for 3-4 wks total |
| What are you treating if you prescribe intranasal corticosteroids, oral and intranasal antihistamines, leukotriene antagonists, and decongestants, Ipratropium nasal spray, nasal saline rinses | recurrent rhinitis |
| Difference in allergic and nonallergic rhinitis | both have rhinorrhea and nasal congestion but no immunologic rxn with nonallergic . |
| Epistaxis arises from | anterior portion of the nasal spectrum (kiesselbach area) |
| What could manifest as recurrent epistaxis? | Nasopharyngeal angiofibroma |
| Tx for epistaxis | one time application of oxymetazoline, gel foam, surgicel |
| Nasal infection treatment | dicloxacillin or cephalexin x 5 days; I&D; bacitracin topical; follow patient closely until healing is complete because the lesion is draining into the cavernous sinus. |
| Following a nasal trauma of nasal furnace, if a nasal septum infection occurs: | hospitalize and I&D by OTO because of possible spread to CNS |
| See OTO with nasal bone fractures within? | 48-72 hours |
| What meds are effective against allergic rhinitis? | intranasal corticosteroids, oral and intranasal antihistamines, leukotrienes antagonists, and decongestants. Ipratroprium nasal spray may also be used as an adjunctive therapy. Nasal saline rinses are helpful to wash away allergens. |
| Triggers of nonallergic rhinitis | sudden changes in environmental temperature, air pollution, and other irritants such as tobacco smoke |
| What antibiotics for epistaxis with packing? | cephalexin 250-500 mg QID and amoxicillin/clavulanate 250-500 mg TID. Second choices include clindamycin 150-300 mg QID or trimethoprim/sulfamethoxazole DS BID.10 also beneficial to coat packing with antibiotic prior to placing in nose |
| Treatment of aphthous ulcers (canker sores) | coating lesion with corticosteroid ointment such as triamcinolone dental paste BID, bland diet, ibuprofen and actaminophen |
| Treatment of thrush | nystatin, if not cured then systemic antifungal |
| Herpes Simplex Gingivostomatitis treatment | symptomatic; acyclovir |
| Over 90% of sore throats and fever are due to | viral infection |
| What is contraindicated in patients with mono and why? | Amoxicillin because it causes a rash |
| S/S Mono | exudative tonsillitis, generalized cervical adenitis, and fever (usually over 5); palpable spleen or axillary adenopathy increases the likelihood of the diagnosis |
| Herpangina ulcers: | classically 3 mm in size, surrounded by a halo, and are found on the anterior tonsillar pillars, soft palate, and uvula. |
| What causes Herpangina? | coxsackie A group of viruses |
| Hand foot mouth disease: where are lesions found | palms, soles, interdigital area, and buttocks; younger children may be seen on the distal extremities and even face |
| Pharyngoconjunctival fever is caused by | adenovirus |
| main findings in pharyngoconjunctival fever | exudative tonsillitis, conjunctivitis, lymphadenopathy, and fever |
| Most common cause of acute bacterial phayrngitis | group A streptococcus |
| Untreated streptococcal pharyngitis can result in: | acute rheumatic fever, glomerulonephritis, and suppurative complications (cervical adenitis, peritonsillar abscess, oM, cellulitis, septicemia). |
| What symptoms suggest acute bacterial pharyngitis | sudden onset of sore throat, odynophagia, fever, headache, anterior cervical nodes, palatal petechiae, beefy red uvula, tonsillar exudate |
| When trying to decipher viral/bacterial pharyngitis; what would raise suspicion for viral cause? | cough, hoarseness, URI symptoms, anterior stomatitis, discrete ulcerative lesions, viral rash, and diarrhea |
| What is scarlet fever?? | Develops occasionally with a child with group A streptococcal infection after the onset of symptoms. Diffuse, finely papular, erythematous eruption producing a blanch able bright red discoloration of skin |
| Suspected or proven group A streptococcal infection should be treated with | Oral Penicillin VK, a cephalosporin, or IM penicillin G benzathine LA |
| How many times daily should Pen VK given to adolescents | 3 doses |
| What is contraindicated in treating Herpes Simplex Gingivostomatitis? | Corticosteroids |
| Presentation with Acute Bacterial Pharyngitis? | sudden onset of sore throat, odynophagia (painful swallowing), fever, HA, anterior cervical nodes, petechiae on palate, beefy red uvula, tonsillar exudate. |
| What is the % of strep in children with fever and sore throat? | 10% |
| Positive rapid antigen test for bacterial pharyngitis indicates | S pyogenes infection |
| Children who fail to respond to to PenVK, cephalosporin, or IM treatment are treated with | Amoxicillin/Clav or azithromycin |
| What is not recommended in treating bacterial pharyngitis? | Trimethoprim-sulfamethoxale (Bactrim, Sulfa) |
| To eradicate the carrier state of frequent strep infections give? | Clindamycin x 10 days or Rifampin for 5 days or tonsillectomy |
| Most common pathogen of peritonsillar cellulits or abscess | B-hemolytic strep |
| Severe sore throat, unilateral tonsillar swelling, deviation of the uvula, limited mouth open: | Peritonsillar cellulitis or abscess (quinsy) |
| S/S retropharyngeal abscess | fever, respiratory symptoms, neck hyperextension. dysphagia, drooling, dyspnea, and gurgling respirations are also found and are due to impingement by the abscess |
| Most common pathogen of retropharyngeal abscess | B hemolytic strep and S aureus |
| Treatment for retropharygeal abscess | immediate hospitalization and IV abx. {Semisynthetic penicillin or clindamycin}. Drainage when definite abscess is seen or airway is compromised |
| What is a rapidly progressive cellulits of the submandibular space that can cause airway obstruction and death? | Ludwig Angina |
| Treatment of Ludwig Angina | Clindamycin or Ampicillin plus Nafcillin |
| 70% of these cases are due to B-hemolytic streptococcal infection | ACUTE CERVICAL ADENITIS |
| Typical case of Acute Cervical Adenitis | Unilateral, solitary, anterior cervical node |
| Tests for acute cervical adenitis | Rapid group A strep, cbc(looking for atypical lymphocytes), and a PPD test (looking for nontuberculous mycobacteria; rapid mono test if multiple enlarged nodes are present in addition to the sentinel node. |
| Where is the typical node involved in acute cervical adenitis | anterior cervical node |
| What gives a positive PPD skin test with reactions less than 10 mm | Cervical lymphadenitis |
| Common malignancies in the neck | Hodgkin disease, non-Hodgkin lymphoma, rhabdomyosarcoma, thyroid carcinoma |
| Gold standard for diagnosis of OSA | Polysomnogram |
| Fever is defined as | 38 degrees C and higher - Rectally |
| Petechial skin rash with fever | meningeal toxemia |
| First line treatment for pediatric fever | after cultures- Rocephin 50mg/kg/day |
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