Peds - Heent

Front 1

Differential Dx: Corneal Abrasion

Back 1

Ocular/adnexal foreign bodies
Corneal Ulcer
Corneal laceration

Front 2

Differential Dx: Blepharitis

Back 2

Chalazion

Hordeolum

Rosacea Blepharitis

Front 3

Differential Dx and Symptoms: Viral Eyelid Disease

Back 3

Diff: Impetigo

vesicular lesions with an erythematous base

Fluorescein dye and cobalt blue light

Front 4

Differential Dx: Eyelid Ptosis

Back 4

Congenital v. traumatic v. neurogenic ptosis, Horner Syndrome

Front 5

Differential Dx: Ophthalmia Neonatorum

Back 5

May be bacterial, or viral or due to tx w/silver nitrate prophylaxis at birth, Chlamydia - most common,

Gonorrhea - threatens vision
HSV - possibly systemic

Front 6

Buphthalmos

Back 6

Abnormal enlargement of eye

Seen in Congenital Glaucoma; buphthalmos is glaucoma until proven otherwise

Front 7

Nasolacrimal Duct Obstruction Treatment, Outcomes, and Risks

Back 7

Massage to remove debris (debatable),

Topical antibiotics,
Surgical tx - probing, effectiveness decreases after 1 year of age

90% spontaneously resolve in 1 year

Monitor for possible glaucoma

If light sensitivity and blepharospasm present - urgent referral to ophthalmologist

(Risks of Superinfection,
Dacryocystitis, preseptal cellulitis,
orbital cellulitis)

Front 8

Retinopathy of Prematurity Tx

Back 8

Follow up every 1-2 wks
Surgical tx necessary within 72 hours to reduce bad visual outcome if disease progressed. However, often cases don’t require tx and ROP doesn’t progress to retinal detachment.

Front 9

Amblyopia - 3 types

Back 9

kinds: 1. Strabismic 2. Refractive 3. Deprivation (causes worst visual loss)
Sequalae (leads to)- permanent blurry vision, vision loss,

Front 10

Retinoblastoma

Back 10

the most common primary intraocular malignancy of childhood
-usually presents before age 3

Front 11

Periorbital Cellulitis

Back 11

often present with erythematous and edematous eyelids, pain, and mild fever. The vision, eye movements, and eye itself are normal (unlike orbital cellulitis)
Perform H test to R/o orbital cellulitis
IV Abx

Front 12

Orbital cellulitis

Back 12

Decreased vision, restricted eye movements, and an afferent papillary defect suggest orbital cellulitis.
Orbital cellulitis presents with signs of periorbital disease as well as proptosis (a protruding eye), restricted eye movement, and pain with eye movement. Fever is usually hig

Front 13

Orbital Tumors

Back 13

Both benign and malignant orbital lesions occur in children.
-The most common benign tumor is capillary hemangioma
-The most common primary malignant tumor of the orbit is rhabdomyosarcoma.

Front 14

Symptoms of Orbital Tumors

Back 14

proptosis,
orbital ecchymosis (raccoon eyes), displacement of the globe

Front 15

Tx of Orbital Tumors

Back 15

- Treatment is indicated if the lesion is large enough to cause amblyopia
-Induced astigmatism or amblyopia (or both) are treated with glasses and patching, respectively. -Treatment of orbital dermoids is by excision
-Treatment of metastatic disease requires management by an oncologist

Front 16

Nystagmus

Back 16

Oscillation of eyes

Front 17

Recurrent Aphthous

Back 17

small ulcers (3-10mm) on inner aspect of lips or tongue, rarely on tonsils or palate. No fever or cervical adenopathy. Painful and lasts 1-2 weeks. May recur several times throughout life. PFAPA = episodes last 5 days without other URI symptoms

Recurrent = canker sores

Front 18

Herpes Simplex Gingivostomatitis

Back 18

10+ ulcers, fevers, cervical adenopathy, and inflammation

<3 y/o, lasts 7-10 days
If caught early, tx w/Acyclovir
Usually pain --> dehydration --> hospitalization required

Front 19

tx of Acute Stomatitis

Back 19

coat leasons with corticosteroid ointment (triamcinolone). Reduce pain by bland diet (no acidic, salty food or juice) or acetaminophen/ibuprofen. PFAPA = cimetidine treatoment or tonsillectomy.

Refer to otolaryngologist - if PFAPA suspected

Front 20

Acute Stomatitis: Herpes Simpex

Back 20

initially: 10+ small ulcers of buccal mucosa, anterior tonsillar pillars, inner lips, tongue, gingival. Posterior pharynx usually spared. Associated with fever, tender cervical adenopathy, generalized oral inflammation preceding the ulcers

Front 21

Acute Stomatitis: Thrush

Back 21

white curdlike plaques, predominantly on buccal mucosa (can’t wash away

Front 22

Hx of Thrush

Back 22

affects infants or older children in debilitated state. Use of broad-spectrum abx, systemic/inhaled corticosteroids, HIV + (erythematous candidiasis, producing red patches on palate and dorsum of tongue usually assoc with abx use, corticosteroids and HIV)

Front 23

Acute stomatitis: traumatic ulcers

Back 23

trauma due to biting by molars (mechanical), thermal trauma (hot food), chemical trauma (contact with aspirin). Leukemia or cyclic neutropenia

Front 24

Pharyngitis: acute viral and tonsillitis (can’t often distinguish causative viral agent):

Back 24

all: sore throat, fever (90% of sore throats and fever due to viral infection). Some have ulcers (see PhysEx)

Types:
1. infectious mono - palpable speen, increased IgM's, >5 y/o, axillary adenopathy, dx with EBV serology

2. Herpangina - 3mm ulcers surr. by halos, Coxsackie A grp. viruses, self-limiting

3. Hand Foot Mouth Disease - enteroviruses, rarely causes Encephalitis, ulcers in mouth, vesicles/papules on palms, soles, fingers, and buttocks

4. Pharyngoconjunctival Fever - Adenovirus - epidemic in kids, exudative tonsillitis, conjunctivitis, lymphadenopathy, fever, Tx is symptomatic.

Front 25

Patho of Pharyngitis

Back 25

all: sore throat, fever (90% of sore throats and fever due to viral infection). Some have ulcers (see PhysEx)

Front 26

Phys Exam of Pharyngitis

Back 26

M: exudative tonsillitis, cervical adenitis, fever, palpable spleen or axillary adenopathy. H: ulcers (3mm) surrounded by halo on anterior tonsillar pillars, soft palate and uvula. HFMD: ulcers anywhere on mouth; vesicles, pustules or papules on palms, soles, interdigital areas and buttocks. PCF: exudative tonsillitis, conjunctivitis, lymphadenopathy, fever

Front 27

Tx of Pharyngitis

Back 27

all tx is symptomatic IM: no amoxicillin bc produces rash.
HFMD - can lead to encephalitis

Front 28

Pharyngitis: bacterial

Back 28

Pharyngitis: bacterial

Front 29

Recurrent Rhinitis Allergic

Back 29

intranasal corticosteroids, oral and intranasal antihistamines, leukotriene antagonists, decongestants, nasal saline rinses

Front 30

Rhinsosinusitis: Recurrent/Chronic

Back 30

ABRS clears bur recurs with each or most URI = recurrent. Child does not clear infection in expected time, but acquires no acute complications = chronic. Allergies, anatomic variations (causing obstruction, eg septum deviation) and disorders in host immunity. Gastroesophageal reflux could contribute to chronic ABRS

If allergic polyps found in child<10 --> cystic fibrosis workup

Front 31

Acute Bacterial Rhinosinusitis

Back 31

Bacterial infection of paranasal sinuses; almost always preceded by viral URI

gradual or sudden onset of symptoms that last less than 30 days: nasal drainage, nasal congestion, facial pressure or pain, postnasal drainage, hyposmia or anosmia, fever, cough, fatigue, maxillary dental pain, ear pressure or fullness

Front 32

Acute Viral Rhinitis

Back 32

Common Cold

clear or mucoid rhinorrea, nasal congestion, sore throat, possible fever. Symptoms resolves within 7-10 days. Nose, throat and TM may appear red and inflamed. Nasal secrections more purulent after day 2 (color change should not be assumed to indicate bacterial rhinosinusitus)

Front 33

Acute trauma to middle ear - Tx

Back 33

1. Mainly watchful waiting.
2. Antibiotics are not necessary unless there are visual signs of infection.
3. If accompanied with vertigo, refer to otolaryngologist and should be attended to more urgently.

Refer !

Front 34

Mastoiditis

Back 34

1. postauricular pain
2. ear protrusion with outwardly displaced pinna.
3. fever present
4. Mastoid is swollen and red.
5. AOM is almost always present (acute otitis media).

Can have brain abscess, persistent headaches, recurring fever.

Front 35

Mastoiditis Presentation

Back 35

If acute: diffuse inflammatory clouding of mastoid cells occurs in an uncomplicated AOM.
Postauricular pain and swelling (ddx external otitis)
Body destruction and resorption of mastoid air cells occurs in severe AOM cases.

Front 36

Mastoiditis

Back 36

If acute: diffuse inflammatory clouding of mastoid cells occurs in an uncomplicated AOM.
Body destruction and resorption of mastoid air cells occurs in severe AOM cases.

Front 37

Mastoiditis Complications

Back 37

Meningitis is a complication of acute mastoiditis. Meningitis Sx are high fever, stiff neck, severe headache...diagnosis found by lumbar puncture.
Can progress to sigmoid sinus thrombosis, epidural abscess, or intaparenchymal brain absess

Front 38

Mastoiditis Complications

Back 38

Meningitis is a complication of acute mastoiditis. Meningitis Sx are high fever, stiff neck, severe headache...diagnosis found by lumbar puncture.
Can progress to sigmoid sinus thrombosis, epidural abscess, or intaparenchymal brain absess

Front 39

Snoring, mouth breathing and upper airway obstruction

Back 39

Nightly snoring or mouth breathing. Unrefreshed sleep, behavioral problems, daytime fatigue.

- Enlarged (4+) tonsils
Recurrent tonsillitis

tonsillectomy or polysomnography

Front 40

Dacryostenosis

Back 40

Obstructed nasolacrimal duct
tears build up on eye
Usually since birth
Recurrent conjunctivitis
Tx: duct massage, moist heat, eyelid cleaning, topical ABX prn if persistent, ophthalmology referral, tube placement to open up adhesed duct

Front 41

Blepharitis Peds Tx

Back 41

• management
o antibiotics
o gentle cleaning with gentle soap
o conservative approach

Monitor for corneal changes associated with dry eye

Front 42

Chalazion Tx

Back 42

 conservative management
• warm compress few times day
• time to go away
• significant red/pus – topical antibiotics prn (NOT oral)
• 2 months doesn’t go away – opthalmologist can remove them

Front 43

Ophthalmia Neonatorum

Back 43

o Newborn conjunctivitis
• 1st month of life
• contracted at birth from mother (vaginally)
o Chlamydia (CT) – most common
• Prophylaxis is NOT effective
 need oral antibiotics
• culture from eye d/c and nasopharynx
• 1-2 wks post-natal presentation
 subtle
• 50% acquisition rate if mom infected (vaginal birth)
• long term effects - scarring blindness

Front 44

Tx - Ophthalmia Neonatorum

Back 44

• management
 screen pregnant patients before delivery
• regular prenatal care?
o vaginal swabs screening for infection – less likely to have undiagnosed infection
 oral macrolide antibiotics -azithromcyin, e-mucin
• has to be ORAL antibiotics
• would progress over time if untreated

Front 45

Gonorrheal Conjunctivitis

Back 45

• More rare
 Prophylaxis is usually effective
• Typical age 1-7 days (EARLIER – more acute/severe)
• corneal perforation and scarring
• dissmeinated gonococcal dz
• management - hospitalize, IV antibiotics

Front 46

HSV Keratoconjunctivitis

Back 46

• Rare
• onset 3 days - 3 weeks
• corneal lesions, scarring, recurrent outbreaks
• management – topical or oral antivirals, no steroids (may make it worse)

Front 47

Pt presents with: Pain/Foreign Body Sensation

Back 47

i. Foreign body
ii. Corneal abrasion
iii. Laceration
iv. Acute infections of globe/ocular adnexa
v. Iritis
vi. Angle-closure glaucoma
vii. Trichiasis
viii. Contact Lens Misuse

Front 48

Pt presents with: Photophobia

Back 48

1. Corneal abrasions
2. Foreign bodies
3. Iritis
4. Squinting of one eye in bright light → intermittent exotropia

Front 49

Pt presents with: no ocular pathology

Back 49

a. Migraines
b. Meningitis
c. Retrobulbar optic neuritis

Front 50

Pt presents with: leukocoria

Back 50

1. Retinoblastoma
2. Retinopathy of prematurity
3. pupillary membrane
4. cataract
5. vitreous opacities
6. retinal detachment
7. Toxocara infection
8. Retinal Dysplasia

Front 51

Peds Ophthalmic Exam

Back 51

i. Hx of poor vision/misalignment of eyes
ii. Visual acuity outside expected level
iii. Abnormal red reflex (Infants)
1. Cataracts
2. Intraocular tumors
iv. Abnorm pupil reactivity
v. → refer to ophtalmologist
vi. prompt tx
vii. birth – 3 y/o
1. hx, vision assessment, inspection of lids and eyes, pupil exam, ocular motility, and red reflex check
viii. 3 y/o +
1. everything PLUS visual acuity testing
ix. Visual acuity
1. The MOST important test of visual fx

Front 52

Pathogens in Preseptal Infections

Back 52

S. aureus and S. pyogens

Front 53

Retinoblastoma

Back 53

• The most common primary intraocular malignancy of childhood
o Age at presentation
o DO: Red Reflex Check – white pupil, reflex absent
• Etiology
o Retinal cell mutation
o Hereditary or sporadic
• Sx
o Single or multiple tumors
o Unilateral or bilateral
o leukocoria, strabismus, glaucoma, blindness, proptosis, red eye, pus in anterior chamber

Front 54

AOM Pathogens

Back 54

• S pneumo – PCN drug resistance common
 Most invasive pathogen
 May be decreasing
• H influenzae – on the rise, but less invasive
• M. catarrhalis
• S. pyogenes

Front 55

Prevnar

Back 55

pneumococcal vaccine (Prevnar) – to prevent certain strains of strep pneumo in ear infections in kids

Front 56

1st line med for AOM

Back 56

– HD Amox (not if “allergic)
• (high dose - HD – 90 mg per kg per day)
• HD because S pneumo is becoming more resistance and the y need to bypass it

Front 57

2nd line med for AOM

Back 57

HD Augmentin ES-600mg (can’t use another formula – causes severe diarrhea)
• clinical failure of 1st line tx OR
• recurrence within 4 wks of prior antibiotic
• broadens the coverage to cover more of the pathogens than Amox alone

Front 58

3rd line med for AOM

Back 58

Rocephin IM (2 or 3 doses (based on severity), 48 hours apart) OR ENT referral (will culture fluid)
• clinical failure of 2nd line tx
• broad spectrum cephalosporin – more broad coverage

Front 59

AOM tx - if allergic to PCN or AMOX

Back 59

• Omnicef, Ceftin, Or Zantin (rash rxn to PCN/AMOX)
• Bactrim or Zithromax (severe rxn) – don’t give any cephalosporins to these pts --- don’t cover the pathogens as well.
o May give Rocephin IM 1st Line w/compelling reason and no h/o SEVERE allergies (1 injection)
• Uncommon
• VERY expensive, but great drug, does well w/infections
• Compelling – going out of country, can’t do 10 days of tx

Front 60

Neonatal Risk Factors for SN Hearing Loss

Back 60

-NICU admission > 48 hrs
-Craniofacial anomalies
-In utero infections (from mom)
-Severe neonatal jaundice
Other risk factors:
-Meningitis
-Head trauma
-Medications
-Loud Noises
-Hypoxia

Front 61

Signs of SN Hearing Loss

Back 61

-No startle, reflex, language delay, in attention, psychosocial problems
-Consider reassessment for high risk patients
Parents would usually complain of child not being able to hear. After 6 months should be able to babble.

Front 62

Newborn Hearing Screening

Back 62

-Universal screening at birth
-Otoacoustic emission test (OAE) (simple and quick)
- If OAE fails, auditory brain stems response (ABR)
(Wears headphones..Use of electrodes to measure the nerve response from cranial nerve VIII )..may need to sedate the child if moving too much.
If ABR fails, referral goes to Audiologist
-Early detection critical (very important)
-Tx: hering aids, cochlear implants, sign language, lip reading, gestures
-Refer: ENT opthamology, geneticist

Front 63

Mastoiditis

Back 63

-Infection of the periosteum of the mastoid bone
-More common under age of two
-Fever, severe pain behind the ear, redness behind the ear, displacement of the ear (pinna)
-From acute otitis media most of the time
-Pathogens: (same one) haemo, step neumo, etc
-Complications: meningitis, abscess in the brain
-Treatment: STAT (immediate) consult with ENT
-Direct admit for myringotomy, culture, IV antibiotics

Front 64

ACUTE VIRAL RHINITIS (URI/ COMMON COLD)

Back 64

Incidence and Frequency
-SX:
-Runny nose, congestion, fever, sore throat, cough, seezing
-Purulent/ thick nasal mucus after 2 days
-Cough and runny nose last longest


-Management if < 2 y/o—Usually treatment is not recommended if kids have issues with upper respiratory problems. Also, lot of young babies coming in ER with overdose of meds because parents giving combination of meds
-Saline nose drops with bulb suctioning
-1/4 tsp salt in 1 c water
-Humidifier/ vaporizer
-Tylenol or ibuprofen
-(Benadryl may be okay if > 12 months of age)
-Nighttime secretions
-Management for ages 2-6yrs:
-Use of cough, suppressants, decongestants, antihistamines, expectorants or any combination thereof are still under investigations…
-OTC meds are not recommended in kids < 4 y/o
-Management for children > 6 y/o

Front 65

Influenza

Back 65

“worse than the common cold”
-URI sx + significant amount of;
-fever, myalgias, headache, chills, fatigue
-Sometimes AGE (abdominal…) sx in younger kids
-Most common complications:
-secondary bacterial infections
-Croup
-Wheezing
-High risk children: those with immunodeficiency, like kids with diabetes, with lungs, with hearts etc
-Prevention:
-Seasonal flu shot
-H1N1 flu shot
-Relenza ((antiviral med)

Front 66

RHINOSINUSITIS:

Back 66

Inflammation in the sinuses or pathways
Diagnosis: if you have URI for ten days and not getting any better. It is Rhinosinusitis IF URI is also 5 to 7 days and conditions getting worse then it is also RHINOSINUSITIS
-Pathology is often secondary post URI or AR
-Mucosal injury/ swelling
-Increased mucus
-Obstruction
-Decreased ciliary action
Sinus development=
-Maxillary and Ethmoid infection
Younger children
Rarely infected before 1 yr old
Just sinusitis usually doesn’t occur with the child less than 1 yr old but rhoinosinutis does
Frontal sinuses
-- Form by approx 7 – 8yrs
-- Rarely infected before age 10 yrs

Front 67

Rhinosinusitis

Back 67

Major pathogens:
-the usual
-Complications
-Cellutitis, bone infection or intracranial complications

Rhinosinusitis-symptoms
Common:
Nasal congestion, purulent nasal d/c, cough
Other:
Post nasal drip, bad breath, anosmia, toothache, earache, fever, facial pain
o Signs:
Often minimal in younger children
X ray
-Best for children > 6 y/o
CT scans
-For severe disease or surgical candidates

Front 68

Mgmt/Tx of Rhinosinusitis

Back 68

X ray
-Best for children > 6 y/o
CT scans
-For severe disease or surgical candidates
Management (Figure 17-8, pg 456)
First line therapy –Amoxicillin HD (not in day care, mild moderate sx, no recent antibiotics)
First line therapy- Augmentil HD
Secondary options: same as Acute otitis Media (omnicef, septin…if hx of allergic reactic to
Zithromax, Biacyn (if severe allergic reaction) or Bactrim (doesn’t cover H influenza)
-Consider nasal corticosteroids or decongestants
-Consider pain management
-Rx antibiotics for at least 10 days.
-Look for improvement with 48-72 hrs

Front 69

Allergic Facies

Back 69

Elongated Relaxed facial, dry eyes, exaggerated skin lines, usually dark circles or red circles under the eye,
o Allergic Rhinitis
Exam:
-Pale and boggy turbinates
-red turbinates
-Cobblestoning
o Symtoms: sneexing, runny nose, itchy eyes, itchy throat
Daytime sleepiness common

Front 70

Allergic P/E

Back 70

-Pale and boggy turbinates
-red turbinates
-Cobblestoning
o Symptoms: sneezing, runny nose, itchy eyes, itchy throat
Daytime sleepiness common
o Complications:
-OM
-Sinusitis
-Obstructive sleep apnea
-Misalignment of the jaw

Front 71

Allergic Tx

Back 71

-Non sedating antihistamines
-Claritin
-Zyrtec
-Nasal corticosteroids
-Nasonex
-Flonase
-Singulair (leukotreiene antagonist)

Front 72

Epistaxis

Back 72

Common causes in children-
-trauma
-dry air/ mucosa
-Nasal sprays
-Most common site: front of the nasal septum
-Exam findings-
Raw nasal mucosa, crusting, blood
Usually benign, work-up if:
Fam hx of bleeding disorder (like hemophilia)
H/O easy bleeding
Bleeding > 30 mins
Abnormal Hgb
Onset < 2yrs of age
Initial labs
-CBC, PT, PPTT
-TX- pressure, keep mucosa moist

Front 73

ORAL CANDIDIASIS (Thrush)

Back 73

White curd like plaques
Mild mouth discomfort
Adherent (may come off with vigorous rubbing)
Usually mild sources
Can occur after use of antibiotics, cause of inhaled corticosteroids like treating asthma, doesn’t come off usually

Front 74

Thrush Tx

Back 74

-Nystatin suspension X 1 week
-Consider Fluconazole (Diflucan) oral suspension
-Wash bottles, pacifiers
-Apply to breast if breastfeeding

Front 75

HERPES GINGIVOSTOMATITIS

Back 75

SVI
-Generalized- can be on the tongue, around the mouth, looks like bunch of canker sores
-More common < 3 yrs of age
Source: somebody shedding the virus HSVI
o Symptoms/ signs include:
Lots of PAN, bleeding gums, decreases appetite, drooling, fever, ulcerations, cervial Lymphadenopathy (LAD)

HSV can also affect other place

Front 76

HERPES GINGIVOSTOMATITIS
Tx

Back 76

-Motrin or Tylenol
-Acyclovir Susp- 200 mg/5 cc
-No Corticosteroids
-Magic Mouthwash-various combos
-Benadryl, Maaloxm Viscous Lidocaine 2% (20 cc each)
-Education
-Prevent dehydration, decrease infectivity

Front 77

Apthous Ulcers

Back 77

Anterior
Pain
Self limited
Recurrent
Unknown cause

Front 78

Apthous Ulcers Tx

Back 78

-Betamethasone ointment BID
-Bland foods
-Mortin or Tylenol
-Warm H20 gargles

Front 79

Herpangina

Back 79

Coxsackie virus
Summer/ fall
Ulcers, runny nose, low fever
Anterior pillars, soft palate, uvula Recurrent self-limited

Front 80

Herpangina Tx

Back 80

-Motrin or Tylenol
-Magic Mouthwash
Pharyngitis (Viral)
-90% are viral origin
-Signs/ Symptoms
-Lab-rapid strep or throat c/s
+ treat it … (-) then culture it

Front 81

Strep Throat

Back 81

-GAS/ SABHS/ Strep pyogenes
-Signs and Symptoms
-Acute onset of fever and sore throatBeef red throat, exudate, petechiae (small red dots on soft palate) cervical LAD

Front 82

Tx of Strep Throat

Back 82

LABS: order rapid strep screening/ culture sensitivity
TxL oral PCN TID
o Alternatives-
IM PCN, Amox, Cepthalosporin
Zithromax, E mycin
-NO Bactrim (doesn’t prevent rheumatic fever and doesn’t deal with strep..)
-Can give PCN injection (once)
o Complications
-Scarlet Fever (benign…rash on stomach and tongue)…so always check the throat carefully with non specific rashes
-Rheumatic Fever (can occur in skin, cardiac problems, joint problems---need to be careful..This is due to toxins of strep)
-Acute glomerulonepthritis (can affect kidneys)
-Abscess

Front 83

Complications of Strep Throat

Back 83

-Scarlet Fever (benign…rash on stomach and tongue)…so always check the throat carefully with non specific rashes
-Rheumatic Fever (can occur in skin, cardiac problems, joint problems---need to be careful..This is due to toxins of strep)
-Acute glomerulonepthritis (can affect kidneys)
-Abscess

Front 84

Peritonsillar cellulitis or abscess

Back 84

-Source: same as step throat.
Sx:
-Severe sore throat-often unilateral
-Fever
-Dysphagia
-Hot Potato voice (gargles type of sound)
Exam:
Uvula and soft palate
LAD
Muffled voice
Tx:

Front 85

Peritonsillar cellulitis or abscess Tx

Back 85

Tx:
Admit for IV antibiotics, possible I & D

Front 86

Management of bacterial conjunctivitis

Back 86

o topical
• Erythromycin, ocuflox, polymyxin-bacitracin, sulfacetamide (topical)
• Ocuflox – flouroquinolone
 Only use topical flouroquinolones on eye or ears (not IV or oral w/kids)
• Some may burn – sulfacetamide

Front 87

Viral Conjunctivitis Tx

Back 87

o Very contagious, usually self limited
• Secondary bacterial infections DO occur
• Avoid corticosteroids, esp if it pertains to Herpes

Front 88

Allergic Conjunctivitis Tx

Back 88

o Acular (anti-inflam eye drop), Patanol (anti-histamine eye drop), Naphcon-A (anti-histamine and vasoconstrictor)

Front 89

Pink Eye Education and Tx

Back 89

o Infectivity, no improvement, return to school
• Viral – contagious at least a week
• Bacterial – after on abx for a couple of days can go back to school, redness will be better by then, not contagious
• General – if no improvement after being on abx for a couple days
o May be resistant, misdiagnosis, follow up

Front 90

Periorbital/Preseptal Cellulitis

Back 90

• Orbital septum separates eyelid from orbit
• Preseptal infection - of eyelid only and some surrounding skin around lid (eyelid infection)
o Sx
• LID edema, LID redness, LID pain, mild fever
o Source
• Eyelid abrasions, insect bites, or nearby infections
o Common Pathogens
• Staph aureus, Strep pyogenes
o Tx: Oral Abx w/ close follow up
o IV or IM abx if severe

Front 91

Orbital Cellulitis

Back 91

• Infection in the orbit of eye, surrounding the eye
• Sx:
o Same as periorbital PLUS:
• Restricted eye movement (do H Test)
• Proptosis
• Usually a HIGH fever, may appear toxic
• Source
o Contiguous sinus infection
o May be a secondary preseptal infection
• Pathogens
o Strep pneumo, H Influenzae, M Catt, Staph aureus
o Also consistent w/otitis media/HEENT disorders
o When treating – make sure rx will cover all of these

Front 92

Orbital Cellulitis Tx

Back 92

: IV ABX, surgical drainage
o Watch for orbital compression of optic nerve → vision loss

• CT Scan – check for pus in orbit to differentiate
o Difficult to tell apart by the visual appearance

Front 93

Corneal Abrasion

Back 93

• Sx
o Infants – usually scratched cornea w/ their own hand
o Older children – hx of eye trauma
• Exam
o Check visual acuity first
o Evert the upper lid,
o Check lower lid well
o Checking for foreign body
o Stain the eye to see uptake of dye in the abrasion
• Management
o Watchful waiting
o Time
o DAILY follow ups to observe improvement/watch for infections
• Prognosis
o Great, unless significant scratch/scarring

Front 94

Retinopathy of Prematurity

Back 94

• Common risk factors
o First check to see if they are under the care of an ophthalmologist already
o Retina is not completely vascularized/ not fully mature
o Vessels predisposed to hemorrhage
o If retina not getting a full blood supply → it will detach

Front 95

Retinoblastoma

Back 95

• The most common primary intraocular malignancy of childhood
o Age at presentation
o DO: Red Reflex Check – white pupil, reflex absent
• Etiology
o Retinal cell mutation
o Hereditary or sporadic
• Sx
o Single or multiple tumors
o Unilateral or bilateral
o leukocoria, strabismus, glaucoma, blindness, proptosis, red eye, pus in anterior chamber
• Management
o Detect and refer
• Prognosis
o Depends on characteristics of the specific tumor

Front 96

Leukocoria

Back 96

cataract is more diffuse, hazy cornea, retinoblastoma is intraocular, so it’s not hazy, it’s a sharp margin of a white pupil in the light

Front 97

The most appropriate test for assessing vision in a newborn infant:

Back 97

looking for blepharospastic response to bright light

Front 98

Infant Ears

Back 98

50% of time won’t see eardrum well
• Flat eardrum in infants
• Angulate speculum down

Front 99

AOM Risk Factors

Back 99

o Flat eustachian tube
o Age – bottle feeding
• Young – haven’t been exposed to many viruses/coughs/less immune than older
• Colonization – predisposed to bacterial infections, more likely to have bacterial infection
• URI’s
• Daycare – pathogen exposure
• Impaired immune system
• Smoking – inflammation to middle ear, blockage of ear, higher risk for middle ear infection
• Bottle feeding – fluids don’t drain well in recumbent position

Front 100

AOM Key Features

Back 100

o Key Features
• Fever, ear pain, inflammation, effusion
• Other
 Recent URI, decreased sleep, increasing crying, ear tugging, decreased appetite, vomiting
 Decreased TM mobility, decreased light reflex
• Special Considerations
 Fever, (fever can cause a red eardrum – may not be AOM),crying (can cause red eardrum), cerumen (can obstruct view of TM – may need to dig out wax to see)
 Decreased incidence with increasing age

Front 101

AOM Pathogens

Back 101

• S pneumo – PCN drug resistance common
 Most invasive pathogen
 May be decreasing
• H influenzae – on the rise, but less invasive
• M. catarrhalis
• S. pyogenes

Front 102

AOM Vaccine

Back 102

– pneumococcal vaccine (Prevnar) – to prevent certain strains of strep pneumo in ear infections in kids
o Now with the vaccine, the other strains are on the rise, and the strep pneumo decreasing

Front 103

Recurrent Aphthous Stomatitis

Back 103

Small (3-10 mm) ulcers; lips/tongue
No fever/LAD
Painful - last 1-2 wks
Tx: CTSD paste: Triamcinolone/Betamethasone Bid
Bland Diet
Acetaminopen/Motrin
Assoc. w/Behcet disease/Med. fever adn PFAPA

Front 104

Thrush

Back 104

C. albicans
Patho: vertically passed at birth; ABX/ICS use predisposition; immunocompromised

Tx: Nystatin, supsension x1 wk, apply 4x/day, stop when gone (3-4 days)
Systemic antifungal if no response

Replace infected pacifiers, and tx mother (breast feeding)

Front 105

Acute stomatitis:
Herpes Simplex Gingivostomatitis

Back 105

HSV1
Sx: Painful/bleeding gums/decreased appetite/HIGH fever (7-10 days)
Ulcerations (>10)
Cervical LAD, Halitosis;
diffuse mouth infxn preceding ulcer appearance
MC <3 y/o
-Herpetic Whitlow - spread to fingers --> can then spread to eyes
Tx: Pain mgmt (if >6mos/o)
Magic Mouthwash: Combo: Benadry, Maalox, +/- viscous lido (20 cc each)
-older swish + spit
-younger - wipe mouth w/Qtip
-Acyclovir - if tx early
Comp: dehydration; herpetic laryngotracheitis

Front 106

Infectious Mononucleosis (EBV)

Back 106

Gray exudative tonsillitis
Cervical Adenitis
Splenomegaly
Fever
usually >5 y/o
R/o strep: strep test first, then Mono spot (2-3 days)
(+) supports; (-) doesn't R/o Mono --> false (-) if < 5 y/o
EBV Ab Titer (IgM) - Elevated IgM capsid = DEFINITIVE

CBC = abnormal shape
Blood Smear > 10% atypical lymphocytes --> falsey (-) if <5 y/o

NO AMOX --> Rash
Tx: Symptomatic

Front 107

Herpangina

Back 107

Ulcers 3mm w/halos: anterior pillars, soft palate, uvula
Benign Glossitis (geographic tongue)
Coxsackie A Virus - summer/fall
Enteroviral PCR available, but usually unnecessary --> Self-limited
Symptomatic Tx

(Possible several episodes)

Front 108

Pharyngoconjunctival Fever

Back 108

Adenovirus
Often = epidemic; URI Sxs:
Exudative tonsillitis
Conjunctivitis
Lymphadenopathy
Fever
Tx = symptomatic

Front 109

Hand Foot Mouth Disease

Back 109

Several Enteroviruses cause it
Enterovirus 71: can cause encephalitis
Ulcers: anywhere in mouth
Vesicles; pustules; papules: palms, soles, interdigital; buttocks
Younger - distal extremities; face

Front 110

Acute Bacterial Pharyngitis
Dx

Back 110

Dx: Sore Throat +
@ least one of the following
-Cervical LAD (tender or >2 cm)
-Tonsillar exudates
-Fever >38.3C
(+) culture for group A B-hemolytic Strep

Do a rapid Antigen test, but confirm (-) rapid w/a Culture

10% of kids w/sore throat+fever = group A Strep
(sudden onset, beefy-red uvula, sore throat/odynophagia, palatal petechiae

Front 111

Acute Bacterial Pharyngitis
Tx

Back 111

1) PCN V, tid, PO, 10d course
--> beware of increasing PCN resistance and ABX failure after max dose for 10d.
--> fail to respond --> AUG or Azith

Alt: IM PCN, AMOX, Erythromycin/Azith, Ceph
(NO bactrim --> doesn't prevent Rheumatic Fever/doesn't cover Strep)

Comp: Scarlet Fever, acute glomerulonephritis, Rheumatic Fever (nodular rash/movement d/o's/Chronic Heart Dz/Hematuria)
Consider anti-streptolysin-o titers if elevated & pt wasn't tx'ed

Front 112

Peritonsilar Cellulitis or Abscess

Back 112

M/C is B-hemolytic Streptococcus
-tonsillar infxn that penetrates tonsillar capsule and spreads to surrounding tissue
- Unilateral sore throat (severe!)/dysphagia/trismus/drooling
-Hot Potatoe voice/ gargling/gutterall
-High Fever
-Tonsils bulge medially
-Soft palate swelling
-LAD; drooling
PE: Observe uvula/soft palate --> locate abscess
Difficult to differentiate cellulitis from abscess
-Admit 12-24 hrs w/IV ABX - aggressive tx prevents suppuration
- PCN or Clindamycin
-DC on oral ABX if fever cleared > 24 hrs and improved dysphagia
OR closely followed by ENT
**HIGH suspicion for abscess if failure to respond to ABX in 12-24 hrs

Front 113

Retropharyngeal Abscess

Back 113

Retropharyngeal Nodes: drain adenoids, nasopharynx, paranasal sinuses
--> become infected --> pyogenic adenitis --> Untx'ed = Abscess formation
M/C B-hemolytic Strep or S. aureus
Suspect in infants w/:
fever, RESPIRATORY SXS, Neck HYPEREXTENSION, Dysphagia, Drooling, Dyspnea, Gurgling, prominent unilateral swelling of posterior pharyngeal wall --> stops at midline --> confirms Dx
Difficult to differentiate abscess from Cervical Adenitis
--> Immediate Hospitalization + IV ABX (PCN or Clinda)
12-24 hrs of ABX helps ddx based on tx response
If abscess (+): surg. drainage

Front 114

Ludwig Angina

Back 114

Rapidly progressive
Cellulitis of submandibular space
- M/C d/t dental DZ or lacerations/injuries
Group A Strep
-Fever
-Tenderness w/swelling to floor of mouth
-Enlarged tongue - tender/red
Upwardly displaced tongue - dysphagia/drooling
--TX: ICU; IV Clindamycin; monitor airway closely for obstruction
-->Refer to otolaryngologist for drainage procedure

Front 115

Acute Cervical Adenitis

Back 115

M/C B-hemolytic Strep (also S. aureus, viral)
Local ENT infxns that involve a reginal node --> develop abscess
-Typically a unilateral, solitary, anterior Cervical Node
-Isolated, tender LAD w/fluctuance
-Fever
LABS:
CBC w/diff
Rapid A group Strep test
Monospot - if multiple nodes
PPD - Anti-TB Mycobacterium
-TX: ABX and aspiration culture/I&D if fluctuance
R/o neoplasm
Also Cat Scratch DZ - papule @ scratch site
Cervical Lymphadenitis - NonTB Myco - unilateral, w/several matted nodes (+ PPD)