exam 1 - ent and eyes Flashcards
(27 cards)
acute otitis externa (AOE)
-Cellulitis of the soft tissues of the EAC, which can extend to surrounding structures, such as the pinna, tragus, and lymph nodes
-Humidity, moisture, heat known to contribute
-Trauma to ear canal, which breaks skin-cerumen barrier (inhibiting bacterial/fungal growth) is first step in infection -> Cotton swab use, earbuds, scratching, ear plugs
-MC organisms: S. aureus, S. epidermidis, P. aeruginosa; fungal infections in 2-10% of patients
-Acute onset of pain, aural fullness, decreased hearing, and pruritis (peak within 3 days)
-Manipulation of tragus/pinna causes considerable pain
-Discharge may be clear/purulent
-EAC narrowed/swollen (may be difficult to visualize entire TM)
-Complications:
-Cellulitis of neck and face
-Malignant OE: Spread of infection to skull base with resultant osteomyelitis
-Treatment:
-Pain control, removal of debris from canal, topical antimicrobial therapy, avoidance of causative factors
-Fluoroquinolone ear drops first line; combination with a steroid may be necessary (ciprofloxacin/dexamethasone) -> Ensure no TM perforation before steroids!
-PO antibiotics for any invasive infection signs (fever, cellulitis, cervical lymphadenopathy)
acute otitis media
-MC reason antibiotics are prescribed for children in US
-Microbiology: S. pneumoniae > H. influenzae > M. catarrhalis > S. pyogenes
-Two critical findings: Bulging TM AND a MEE
-Otoscopic findings specific to AOM: Bulging TM, impaired visibility of ossicular landmarks, yellow or white effusion, opacified/inflamed TM, squamous exudate/bullae on TM
acute otitis media: risk factors
-Season (winter > summer)
-Ages 1-3
-Eustachian tube dysfunction
-Infants and young children more prone due to shorter, more compliant, horizontal ET
-Trisomy 21, cleft palate risk factors
-Bacterial colonization of nasopharynx: S. pneumoniae, H. influenzae, M. catarrhalis
-Smoke exposure: Increases risk of persistent MEE, prolonging inflammatory response, impeding drainage of fluid through ET
-Impaired host immune defenses
-Bottle feeding: Bottle propping in the crib or car seat > aspiration of contaminated secretions into the middle ear
-Daycare attendance (exposure to viral infections/URIs)
-Genetic susceptibility
acute otitis media tx
-Pain control (may take 1-3 days before antibiotic relieves pain)
-Wait and see approach:
-Observe episode without treatment
-Option for healthy children (typically > 2 years) with mild-moderate OM and without underlying conditions
-Decision made in conjunction with parents to begin antibiotics therapy if worsening of symptoms or lack of improvement within 48-72 hours
-Antibiotic therapy: (know this)
-First-line: High dose amoxicillin (80-90 mg/kg divided BID)
-Augmentin if child has had amoxicillin within last 30 days or clinically failing x 48-72 hours on amoxicillin
-Cephalosporins (cefuroxime, cefpodoxime, cefdinir) for those with rash to PCN – risk of cross-sensitivity is less than 0.1%
-Macrolide (azithromycin) only if history of type 1 hypersensitivity to PCN -> Resistance of S. pneumoniae and H. influenzae (macrolide efflux pump)
-Second-line antibiotics indicated when child experiences symptomatic infection within 1 month of finishing amoxicillin
acute otitis media tx: drug failure
-Failure to eradicate: Drug noncompliance, poor drug absorption, vomiting of drug
-Child remains symptomatic for > 3 days with second line antibiotics
-Tympanocentesis or IM ceftriaxone at 50 mg/kg/dose x 3 consecutive days
-Patients with tympanostomy tubes
-First-line: Ototopical antibiotics (fluoroquinolones)
-Treat infection and rinse drainage from tube
-Tympanostomy tubes considered (AAP):
-Three episodes in 6 months, 4 episodes in 1 year, last episode within past 6 months (not on test)
middle ear effusions
-Presence of fluid within middle ear without signs or symptoms of acute inflammation
-TM may be opacified/thickened, fluid can be clear/amber/or opaque, typically in neutral/retracted position
-Pneumatic otoscopy and/or tympanometry for confirmation
-Management:
-Abx, anti-histamines, and steroids have not been shown to be useful in treatment
-Audiology evaluation after 3 months of continuous B/L effusion
-Hearing loss/speech delay > referral to ENT for possible T-tube placement
-Uncomplicated cases, observed for 3 months with follow-up every 3-6 months to evaluate for effusion clearance
-T-tube indications:
-Hearing loss > 40 dB, TM retraction pockets, ossicular erosion, adhesive atelectasis, and cholesteatoma
tympanic membrane perforation
-Episode of AOM may result in rupture of TM
-Discharge from ear seen with rapid relief of pain
-Treatment: Ototopical antibiotics x 10-14 days with ENT follow-up for examination/hearing evaluation
-Failure to heal may require surgery (typically deferred until age 7, when ET has reached adult orientation)
mastoiditis
-Infection from middle ear space spreads to mastoid portion of temporal bone
-Inflammation of periosteum to bony destruction of mastoid air cells with abscess development
-Occurs at any age, most < 2 years old
-Clinical diagnosis
-Postauricular pain, fever, and outwardly displaced pinna
-Examination: Mastoid area appears indurated, red, swollen, fluctuant with severe tenderness (earliest symptom)
-AOM is almost always present
-Imaging Studies:
-CT scan to determine extent of disease
-Progressed disease: Coalescence of mastoid air cells with bone destruction
-Complications:
-Meningitis (high fever, stiff neck, severe headache)
-Brain abscess (fever, headache, changes in sensorium)
-Facial palsy, sigmoid sinus thrombosis, epidural abscess, cavernous sinus thrombosis, thrombophlebitis
acute pharyngotonsillitis: viral pharyngitis: Infectious Mononucleosis (Epstein-Barr Virus)
-Infectious Mononucleosis (Epstein-Barr Virus)
-Usually, patients > 5 years of age
-Exudative tonsillitis!, generalized cervical adenitis, fever; palpable spleen or axillary lymphadenopathy increases likelihood of diagnosis
-Presence of > 10% atypical lymphocytes on peripheral blood smear or positive Monospot supports diagnosis (though falsely negative in children < 5 years)
-Epstein-Barr virus serology showing elevated IgM antibody is definitive
-Treatment: Supportive, avoiding contact sports, 4-6-week follow-up (LFTs)
acute pharyngotonsillitis: bacterial pharyngitis
-Approx 20-30% of children with pharyngitis have a group A streptococcal (GAS) infection
-Other causes: Mycoplasma pneumoniae, Chlamydia pneumoniae, groups C/G streptococci, and Arcanobacterium hemolyticum
-MC in children 5-15 years, winter/early spring
-Sudden onset sore throat, fever, tender cervical adenopathy, palatal petechiae!, beefy-red uvula, and a tonsillar exudate
-Headache, stomachache, nausea/vomiting
-Scarlet fever!: 1-2 days into symptoms > sandpapery rash (diffuse, finely papular, erythematous, blanchable) with strawberry tongue appearance
-Modified Centor Score
-Definitive diagnosis with throat culture or rapid antigen test -> RAT specific but only 85%-95% sensitive
-KNOW THE CHART
bacterial pharyngitis: complications (untreated)
-Acute rheumatic fever**
-Glomerulonephritis
-Suppurative complications: Cervical adenitis, peritonsillar abscess, AOM, cellulitis, septicemia
-Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS)
-Sudden onset of OCD and/or tics (or worsening of such symptoms) following a strep infection
bacterial pharyngitis: tx
-First-line: PCN/Amoxicillin (50 mg/kg divided BID x 10 days)
-Alternatives: Cephalosporin (cephalexin), macrolide (azithromycin), clindamycin
-Avoid tetracyclines, sulfonamides, and quinolones
-Repeat culture following treatment is not recommended; indicated only for patients who remain symptomatic, have recurrence of symptoms, or have had rheumatic fever
-RF patients may require long-term antibiotic prophylaxis (sometimes life-long)
-Carrier state may last 2-6 months and is not contagious
-Treated with clindamycin (x 10 days) or rifampin (x 5 days) only if patient or another family member has frequent strep infections or if family member/patient has history of RF or glomerulonephritis
-Recurrent infections: Tonsillectomy is now preferred for those with recurrent strep tonsillitis (Paradise criteria):
-7 tonsillitis episodes/year, 5 episodes/year for 2 consecutive years, 3 episodes/year for at least 3 years (dont memorize)
acute pharyngotonsillitis: diptheria
-Acute infection of URT or skin caused by exotoxin-producing Corynebacterium diphtheriae (3 cases reported between 2010 and 2019)
-Gram-positive, club-shaped rods on gram stain
-Toxin absorbed into mucous membranes > destruction of epithelium > inflammatory response > embedded in fibrin with WBCs/RBCs > grayish pseudomembrane forms over tonsil, pharynx, larynx
-Pharyngeal diphtheria:
-Mild sore throat, moderate fever, and malaise > rapid decompensation
-Pharyngeal membrane forms (tenacious, gray, border of erythema/edema) and may spread to nasopharynx or trachea > obstruction
-Cervical lymph node swelling > “bull neck”
-Diagnosis: Culture of C. diphtheriae from infected tissue(s)
-Treatment:
-Reported to CDC to acquire anti-toxin (administered within 48 hours of symptom onset)
-Antibiotics (erythromycin IM/PO or procaine PCN G IM, q12hrs) x 14 days
-Vaccination during convalescence, observation in hospital setting 10-14 days (isolated for at least 1-7 days, until respiratory secretions are noncontagious)
peritonsillar cellulitis/abscess (quinsy)
-Cellulitis (tonsillar infection extending to the surrounding tissues) > cellulitis untreated > necrosis occurs > peritonsillar abscess forms
-Usually unilateral with fever and severe sore throat
-Affected tonsil bulges medially, anterior tonsillar pillar is prominent, uvula deviates to unaffected side
-Progression: Trismus (limited mouth opening/muffled voice), ear pain, dysphagia, and drooling
-Jugular vein thrombosis, septic thrombi into lungs
-Treatment:
-Cellulitis responds to parenteral antibiotics (PCN, cephalosporin, or clindamycin)
-Abscess typically requires drainage (needle aspiration or I&D)
retropharyngeal abscess
-Infection of lymph nodes draining oropharynx, nasopharynx, and paranasal sinuses
-Fever, respiratory symptoms, restriction in neck ROM (extension) -> Dysphagia, drooling, dyspnea, and gurgling respirations
-hot potato voice
-may not be able to see it
-Prominent swelling on one side of posterior pharynx (stops at midline)
-Imaging: Lateral neck x-ray (tissues wider than C4)
-CT scan w/ contrast distinguishes between soft tissue swelling versus abscess
-Treatment:
-Immediate hospitalization and IV antibiotics (PCN or clindamycin)
-If only adenitis > improvement within 12-24 hours; if not, more likely abscess
-Surgical emergency! I&D under general anesthesia
ludwigs angina
-Rapidly progressive cellulitis of both submandibular spaces that pushes the tongue posteriorly against the pharyngeal wall > life-threatening airway obstruction
-Fever and tender swelling of the tongue and floor of mouth
-Treatment:
-High-dose IV clindamycin or ampicillin + nafcillin until C&S available
-Airway obstruction: Tracheotomy versus ICU admission with intubation
tonsillectomy/adenoidectomy
-Tonsillectomy
-MC indication is hypertrophy or recurrent infections
-Second MC cause is recurrent tonsillitis (Paradise criteria)
-Adenotonsillectomy
-MC indication is hypertrophy associated with an obstructive breathing pattern during sleep (may also cause dysphagia or dental malocclusion)
-Adenoidectomy
-Indications: Upper airway obstruction, orofacial conditions (mandibular growth abnormalities, dental malocclusion), speech abnormalities, persistent MEE, and recurrent OM/sinusitis
Modified Centor’s Criteria Scoring
know this
bacterial conjunctivitis
-MCC: Haemophilus species, S. pneumoniae, M. catarrhalis, and S. aureus
-Injected conjunctiva with significant discharge (purulent), typically unilateral > bilateral
-very contagious
-Treatment:
-Topical antibiotics: Polymyxin/trimethoprim sulfate or fluoroquinolones
-Systemic therapy for conjunctivitis associated with C. trachomatis, N. gonorrhoeae and N. meningitidis
viral conjunctivitis
-MCC is adenovirus
-Injected conjunctiva with watery discharge, typically unilateral > bilateral
-Enlarged preauricular lymphadenopathy can be present
-red w/ no purulent discharge
-Treatment:
-Supportive
-Contagious 10-21 days from day of onset or as long as the eyes are red/tearing persists
-Herpes conjunctivitis: Topical versus PO antivirals
-when can you go back to school -> until you stop seeing discharge and at least 24hrs on the antibiotic
allergic conjunctivitis
-Itchy, watery eyes with injected conjunctiva, usually bilateral!
-Allergic shiners may be present -> nasal congestion causes venous congestion
-may be a hx of asthma or other allergies
-chemosis if severe- bubbling, swelling of conjunctiva
-Treatment:
-Topical solutions that combine antihistamine and mast cell stabilizer
-Systemic anti-histamines
-Limitation of exposure to allergen
-if not old enough for drops -> cool packs
corneal abrasion
-Sudden, severe eye pain
-Decreased vision, tearing, conjunctival injection, poor cooperation with ocular exam
-Diagnosis: Fluorescein dye > illumination with Wood lamp
-Evert upper/lower eyelids to evaluate for FBs
-Treatment:
-Ophthalmic ointment, follow-up until healing complete
-preventative antibiotics
-refer to specialist 2-3 days later to make sure healing
-if the pt cant tolerate drops for staining -> empiric tx and f/u with specialist who can sedate and view the eye
foreign bodies eye
-Cause discomfort, tearing, and a red eye
-Pain with blinking suggests FB trapped under eyelid/corneal surface
-every time you blink can be scratching the cornea
-Treatment:
-Eyelid eversion!
-Removal with irrigation or cotton applicator
-Referral to specialist for failed attempt/corneal FB
-Topical antibiotics typically prescribed for several days following FB removal
-corneal FB / rust ring (photo) -> specialist
blunt ocular trauma
-Blunt trauma can lead to orbital fractures, retrobulbar hemorrhage can lead to orbital compartment syndrome > permanent vision loss
-Orbital blowout fracture: Diplopia, pain with eye movements, restriction of EOM
-CT scan! useful in dx extent of injuries
-Orbital compartment syndrome: Severe eyelid edema and proptosis (can progress to this)
-Neuroimaging will show retrobulbar hemorrhage and proptosis
-Treatment:
-OBF: Nonurgent repair to prevent enophthalmos, advise not to blow nose (orbital emphysema/proptosis)
-OCS: Emergent lateral eyelid canthotomy and cantholysis to decompress orbit
