Pediatric Examination and Board Review (94 page)

17.
(C)
In addition to those listed, complications of tonsillectomy include risks of anesthesia, infection, and atlantoaxial subluxation. Velopharyngeal insufficiency may occur because tonsillectomy increases the space in the nasopharynx leading to inability of the nasopharyngeal sphincter to close properly, causing hypernasal speech and regurgitation. The incidence of these complications is increased in children with craniofacial abnormalities or orofacial problems, such as those with Down, Treacher-Collins, and Pierre-Robin syndromes.

18.
(C)
Hyponasal speech is an indication for adenoidectomy, not hypernasal. Children with cleft palate and submucous cleft palate should have preventive adenoidectomy performed. Excessive snoring is a likely sign of chronic adenoid hypertrophy. A patient with excessive snoring should undergo further evaluation to determine whether adenoidectomy may be beneficial.

S
UGGESTED
R
EADING

Behrman RE, Kliegman RM, Jenson HB, et al.
Nelson Textbook of Pediatrics
. Philadelphia, PA: WB Saunders; 2007.

Discolo CM. Infectious indications for tonsillectomy.
Pediatr Clin North Am.
2003;50(2):445-458.

Gross CW, Harrison SE. Tonsils and adenoids.
Pediatr Rev.
2000;21(3):75-78.

Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds.
Red Book: 2009 Report of the Committee on Infectious Diseases.
28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

CASE 58: A 5-YEAR-OLD WITH NOSEBLEEDS

A 5-year-old boy is brought for evaluation during winter by his mother because of recurrent nosebleeds. They happen 1-3 times a week, last 10 minutes, and are difficult to stop. This has been going on for about 6 weeks.

SELECT THE ONE BEST ANSWER

1.
All of the following would prompt you to explore the etiology of this boy’s nosebleeds except

(A) duration of 10 minutes or longer

(B) family history of bleeding disorder

(C) age younger than 2 years

(D) low hematocrit on screening

(E) gum bleeding

2.
The differential diagnosis for recurrent epistaxis in an adolescent includes which of the following malignancies?

(A) squamous cell carcinoma

(B) adenocarcinoma

(C) nasopharyngeal angiofibroma

(D) malignant melanoma

(E) nasal lymphoma

3.
An 8-year-old girl with a history of seasonal allergic rhinitis comes in during autumn because she is “always congested.” Her regular OTC allergy medicine is not working. She feels the congestion is getting worse each week and is worse on the left side.

On examination you note allergic shiners, an allergic salute sign, mild conjunctival injection bilaterally, and a 0.75-cm soft gray bulge in the left nare, adjacent to the septum. There is some clear rhinorrhea, no foul smell, and no bleeding. What is her most likely diagnosis?

(A) foreign body

(B) nasal polyp

(C) sinusitis

(D) juvenile nasopharyngeal angiofibroma

(E) hematoma

4.
With which chronic disease(s) is/are the problem(s) in question 3 associated?

(A) chronic sinusitis

(B) asthma

(C) cystic fibrosis

(D) aspirin sensitivity

(E) all of the above

5.
What are possible treatments used for nasal polyps?

(A) intranasal steroids

(B) antihistamines and decongestants

(C) surgical removal

(D) oral steroids

(E) A, C, and D

6.
A 6-year-old boy comes to your office in August with a “runny nose.” His mother states that it has been going on for approximately 3 weeks and is not improving. He has been afebrile but has a nonproductive cough each night. What finding is not consistent with a diagnosis of allergic rhinitis?

(A) cobblestoning of the posterior pharynx

(B) dark circles under both eyes

(C) edematous, erythematous nasal turbinates

(D) a horizontal indentation across the bridge of the nose

(E) nighttime cough

7.
Which of the following is
not
a comorbid disorder of allergic rhinitis?

(A) speech impairment

(B) eczema

(C) failure to thrive

(D) otitis externa

(E) pharyngitis

8.
Which of the following is
false
regarding allergic rhinitis?

(A) prevalence peaks in adolescents

(B) its incidence is increasing

(C) higher socioeconomic status is a risk factor

(D) serum IgE more than 100 IU/mL in childhood is a risk factor

(E) early introduction to solid foods in infancy is a risk factor

9.
Which treatment for allergic rhinitis most successfully diminishes nasal symptoms?

(A) leukotriene inhibitor

(B) antihistamine

(C) allergen injection immunotherapy

(D) intranasal steroid

(E) decongestant

10.
You see a new patient in your office who is 1 week old. He is there for his preventive 1-week visit. His medical history is significant for a cleft lip and palate, and no other known conditions. All of the following are true regarding cleft lip and palate except

(A) cleft lip is more common in males

(B) cleft lip alone is more common than cleft palate alone

(C) cleft lip and palate can be inherited in an autosomal dominant pattern

(D) sensorineural hearing loss is common with cleft palate

(E) no exceptions; all of the above are true

11.
Which of the following statements is
false
?

(A) the most immediate problem facing a child with an uncomplicated cleft lip is feeding difficulty

(B) surgical closure of a cleft lip is usually performed in the first 3 months of life

(C) surgical closure of a cleft palate is usually performed by age 1 year

(D) children with uncomplicated cleft lip do not require subspecialist involvement with the exception of the surgical repair

(E) children with cleft palate often require prophylactic tympanostomy tubes

12.
Which of the following syndromes are associated with cleft lip and/or palate?

(A) histiocytosis

(B) thrombocytopenia and absent radius (TAR) syndrome

(C) cardiac abnormality, abnormal facies, thymic hypoplasia, cleft palate, hypocalcemia (CATCH-22) syndrome

(D) Waardenburg syndrome

(E) all of the above

13.
You see a 1-month-old child in your office for a preventive visit. You note on examination that the infant is at the 80th percentile for height and weight and developing well. She is breast-fed and her mother reports that it is going “well.” You note, on examination, that she has a very short lingual frenulum. What will you recommend to her mother be done?

(A) nothing

(B) surgical correction

(C) cease breastfeeding

(D) early speech therapy

(E) oral motor physical therapy

14.
The mother from question 13 asks you about when her 1-month-old might start to develop teeth. What can you tell her?

(A) most often by 2 months

(B) most often by 3 months

(C) most often by 4 months

(D) most often between 4 and 5 months

(E) most often between 6 and 12 months

15.
At a child’s 2-year routine visit, the mother asks how she can help prevent dental cavities in her child. You recommend

(A) using fluoride-containing toothpaste

(B) flossing regularly and a low-sugar diet

(C) discontinuing sleeping with the bottle

(D) B and C

(E) A, B, and C