Cranial/facial abnormalities
A 5 year old previously healthy girl presents to the outpatient clinic with a history of snoring and snorting respirations in sleep. The child sleeps in her own room and her mother is not sure if the girl stops breathing. on exam, it is noted that she is a mouth breather and has 3+ tonsils. BMI is at the 50th percentile for age. The remainder of the examination is noncontributory. What is the most common reason for development of OSA in this child?
Tonsillar and adenoid hypertrophy
On routine exam, a 2 month old term infant is found to have a white pupillary light reflex. The mother received prenatal care throughout pregnancy and had no perinatal or prenatal complications of infections. The infant has an unremarkable birth history and has been healthy. What is the most likely cause of these findings and what is this light reflex exam finding called?
Retinoblastoma and the white pupillary light reflex is called leukocoria
An acutely ill 4-year old boy with fever, inspiratory stridor, and torticollis is found to have markedly increased depth of the prevertebral space on a lateral soft tissue radiograph of the neck while held in extension. What diagnosis are these findings most consistent with?
Retropharyngeal abscess
What is the most common cause of bilateral sensorineural hearing loss?
CMV infection
A 9-year old boy presents with a history of right ear pain, specifically with movement of his pinna and tragus, which has continued to worsen over the previous 24 hours. The right TM is not visualized due to obstruction of the external canal by mucoid drainage in associated with edematous, tender swelling of the canal. What is the most likely cause of his symptoms (i.e. the bug)?
Pseudomonas aeruginosa
- This is a typical presentation for 'swimmers ear' or acute otitis externa
A prenatal ultrasound at 24 weeks of gestation is noted to be positive for several anomalies which include microcephaly, increased nuchal thickness, scalp defects, cleft lip and palate, a neural tube defect, and a large VSD. What syndrome is the likely cause of the patients findings?
Trisomy 13 (Patau syndrome)
You are seeing a 9 year old boy who was hit in the eye with a baseball. On exam he has blood in the anterior chamber of his left eye. What is a potential complication for this patient?
- Due to distorted RBCs clogging the trabecular meshwork and causing increased ICP
- Consultation with ophthalmologist is required
A 2 year old presents for evaluation in the emergency room after 3 days of URI symptoms now with a musical sound on inspiration per parents. She appears in acute respiratory distress. What would her CXR look like?
Steeple sign would be present consistent with narrowing of the subglottic trachea (this child has croup)
How many cases of AOM do you need in a single calendar year to refer to ENT?
4 in 1 year (3 in 6 months)
A 5 year old boy with trisomy 21 presents with a history of cough and nasal discharge for several weeks. The physical is normal with the exception of obvious halitosis and copious amounts of purulent, foul-smelling discharge from the right naris. What is the most likely diagnosis in this patient?
Nasal foreign body
A 36 hour old infant is evaluated in the nursery because of cranialfacial abnormalities. He has periorbital fullness and full lips. His iris has a stellate pattern. Further workup shows an elevated calcium level. An echocardiogram reveals supravalvular aortic stenosis. What are the expected personality traits of this infant later on in life?
Friendly, socially engaging, often perceived as charming
- This is describing Williams syndrome (77q11.23 deletion)
A healthy 6-year-old girl presents with right eye pain, redness, tearing, photophobia, and blurry vision. She has not had any fever or recent illness. How is the diagnosis made for this patient?
Diagnose using fluorescein dye and a wood lamp or slitlamp
- This patient has a corneal abrasion
- Treatment is with topical antibiotic ointment
You are seeing a patient who sustained a nose injury. Physical exam reveals a swollen, fluctuant and tender septum. You diagnose him with nasal septal hematoma. What is the most appropriate management for this patient?
Drain the hematoma, pack the nasal cavity to prevent recurrent of hematoma and administer prophylactic antibiotics to cover staph infections given the nasal packing
A CT scan in a 3 year old boy reveals clouding of the left middle ear and mastoid, loss of definition of the bony septae, coalescence of the mastoid air cells, and irregularity of the mastoid cortex. What physical exam findings are most likely seen in this patient?
This is acute mastoiditis:
- Postauricular tenderness, erythema and swelling
- Displacement of the auricle
- Evidence of AOM.
A 37 week of gestation 1.84kg infant is born via NSVD and found to be cyanotic. Several attempts have been made to pass a small NG tube are unsuccessful. Additionally, a harsh 3/6 systolic murmur localized along the left lower sternal border and B/L cryptorchidism are noted. What are the most common exam findings of this patient's eye?
A keyhole like defect in the pupil and iris associated with nystagmus (A.K.A. Coloboma of the eye)
- This is an infant with C.H.A.R.G.E. syndrome
A 12 year old girl presents to your office with nasal discharge for 12 days. It has worsened over the past 3 days. She complains of facial tenderness. She has no vomiting but has had a fever up to 102.2F over the past 2 days. What does the proper treatment look like for the diagnosis of this patient?
Amoxicillin or Augmentin for 10-21 days
- Treatment for acute bacterial sinusitis
- Most common pathogens include S. pneumoniae, M. catarrhalis, and nontypeable H. influenzae
A 15 year old boy presents to the ED complaining of left eye swelling and pain with blurry vision. The prior evening he was apart of a 'gang initiation' where he was hit in the face with a lead pip. On exam, there is evidence of left-sided periorbital edema with prominent ecchymosis. What additional PE finding would suggest an orbital floor blowout fracture?
Restricted upward gaze during testing of EOM
- This is due to entrapment of the inferior rectus muscle in the maxillary sinus after fracture of orbital floor
An 18 year old boy presents to the ER with a 3 day history of fever, sore throat, and rapidly worsenign dysphagia. On exam, he is febrile and appears acutely ill. Range of motion of his neck is painful and limited and his voice is muffled. The left tonsil is enlarged and just touches the uvula which remains midline. The right tonsil is normal. Thrombosis of the left internal jugular vein is identified on CT of the neck. What is the likely diagnosis?
Suppurative thrombophlebitis of the jugular vein (Lemierre disease)
- Extension of oropharyngeal infection to the lateral pharyngeal space
- A complication of this diagnosis is septic emboli to the lungs
A 3-year old boy, recently removed from his home due to medical neglect, presents with a history of a "draining ear" for an indeterminate time. After cleaning the external ear canal of purulent material, a spherical whitish-gray, cystic mass is identified behind the left TM along the edge of the posterior-superior quadrant of the drum. What is the most likely diagnosis? (BONUS: What is the treatment for this diagnosis?)
Cholesteatoma
BONUS: Surgical removal
What are the 7 components to a chicago style hot dog?
Yellow mustard, bright green relish, fresh chopped onions, juicy red tomato wedges, a kosher-style pickel spear, a couple of spicy short peppers, and a dash of celery salt
A plain radiograph of the skull of a 4 month old boy with a cleft palate and dysmorphic facial features reveals hypoplasia of several facial bones and paranasal sinuses. Facial features include malformed pinaae, short downward slanting palpebral fissues, micrognathia, and colobomata along lateral lower lid which also lacks eyelashes medically from the lower lid. What is a necessary component of this patient's treatment?
Bone-conducting hearing aids!
- This patient has treacher collins syndrome (aka mandibulofacial dysostosis
- Craniofacial tissues such as cartilage, bone, and connective tissue fail to develop
- Most patients will have conductive hearing loss
A mother brings her 9-month old daughter for evaluation of "weird eye movements" that have occurred off and on during the past month. She is healthy with no recent illness. On PE, you note horizontal nystagmus, torticollis, and slow head nodding. The vital signs are normal. Brain CT is negative. What is the likely diagnosis?
Spasmus nutans
- Acquired nystagmus of unknown etiology
- Usually presents at 6-24 months of life
- Spontaneous resolution occurs within months to several years
A 17 year old complains of a stiff neck and difficulty breathing and swallowing. On exam he is febrile, tachypneic with inspiratory stridor, and is drooling. His oropharynx is difficult to visualize and he is unable to open his mouth. He has symmetrical, indurated, tender, and tense submandibular swelling with overlying crepitus. What is the diagnosis of this patient and what is the appropriate treatment?
Submandibular space infection (a.k.a. Ludwig angina) which needs to be treated initially with Ampicillin-sulbactam (Unasyn)
- Complication of an infection mandibular molar roots
- Rapidly spreading bilateral polymicrobial cellulitis (oral flora including anaerobes)
A 10-year old boy presents to the emergency department with an ear injury after falling at a skate park and scraping his left ear on the concrete slab. No other injuries are noted and he had no LOC. There is a 1 cm linear laceration over the helix. The wound is hemostatic and there is minimal gaping. There is no hematoma or visible cartilage. What is the next best course of action?
Perform otoscopy to examine the tympanic membrane
A 17 year old with history of asthma presents with 2 days of increased temperature, facial pain, cough, and nasal discharge. During the preceding 4 months, he has received repeated courses of antibiotics for sinusitis with only partial resolution of symptoms despite compliance with therapy. On exam, his temp is 101.8F and there is tenderness to bilateral maxillary sinuses. Bilateral thick, yellow nasal discharge is noted. What organism is most often associated with chronic rhinosinusitis?
Staphylococcus aureus