Exam 4, Treatments only Flashcards
(83 cards)
1
Q
URI (upper respiratory tract infection)
A
NO ANTIBIOTICS !!!
Symptomatic tx:
* NSAIDS/Acetaminophen
* Fluids
* Nasal saline irrigation
* Oral decongestants
* Nasal decongestants - limited to a few days
2
Q
Acute Bacterial Rhinosinusitis - general
A
- Careful observation is acceptable “treatment”
- Observation is recommended for 7-10 days in uncomplicated cases for people who are immune competent with reliable follow up
Symptomatic tx:
* NSAIDS, nasal saline sprays and intranasal decongestants have shown to help with symptom reduction
* Oxymetazoline 1-2 sprays q6-8h for 3 days (Afrin) .Watch for rebound congestion (rhinitis medicamentosa)
* Intranasal steroids have shown benefit in reducing symptoms (Flonase)
(Antibiotic treatment controversial in uncomplicated cases of ABRS) because only 5% experience shortening of symptoms
Complicated:
* May be considered complicated when symptoms last more than 7-10 days
* Or when symptoms including fever, facial pain, or swelling are severe
* Immunodeficiency, complicated (spreading to other places/tissues)
3
Q
Acute Bacterial Rhinosinusitis Risk factors?
A
- 65+
- hospitalized in last 5 d
- antibiotic use in previous month
- ICP
- multiple comorbit (diabetes, cardiac, hepatic, renal)
- severe infection
- living in a geographic area with rate of S. pneumonia exceeding 10%
4
Q
Medications for Acute Bacterial Rhinosinusitis
what meds to give if risk factors or no risk factors
A
If no risk factors- Amox-Clavulanate (augmentin). Clavulanate covers H flu M cat esp in kids.
if risk factors- Augmentin high dose 2 g PO dose is BIG
For both
Antibiotics for 7 - 10 days
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
5
Q
Acute Bacterial Rhinosinusitis - If PCN allergy anaphylaxis
A
Doxycycline
Levofloxacin (Levaquin)
Moxifloxacin (Avelox)
Azithromycin (Zithromax)
Antibiotics for 7 - 10 days
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
D ANA MAL
Doxy Anaphylaxis MAL
Sounds like dranamal
6
Q
Acute Bacterial Rhinosinusitis - if can tolerate cephalosporins and allergic
A
Clindamycin or 300 mg PO PLUS
* 3rd generation Cephalosporin
Cefixime (Suprax) -
Cefpodoxime (Vantin)
Antibiotics for 7 - 10 days
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
Clean and Fix
Well give you a clean fixing
7
Q
ABR - Orbital cellulitis and abscess - ethmoid
A
CT scan or MRI
Drainage of abscess
IV antibiotics
Vancomycin plus Ceftriaxone (Rocephin)
Drain Ivy using a Axe in the Van
8
Q
ABR -
Frontal subperiosteal abscess -
Pott’s Puffy Tumor -
frontal bone osteomyelitis
A
- Tender, doughy swelling over forehead
- Treatment
- Drainage of abscess and frontal sinus
- IV antibiotics for 6 weeks - culture sensitive
First drain then eat the
Doughy IVY green cookies for 6 weeks
9
Q
ABR - Intracranial complications
A
are as follows: Epidural abscess, subdural empyema, meningitis, dural-vein thrombophlebitis - frontal or sphenoid
Cavernous sinus thrombophlebitis - blood clot within cavernous sinus (base of brain)
Drains deoxygenated blood from brain back to heart
10
Q
Invasive Fungal Sinusitis
A
- Surgical debridement
- IV Amphotericin B
- Can switch to oral Itraconazole for 3-6 months after improvement
Mushroom surgeon vs me in amphitheater, then military gives me a blue uniform and discharges me for 6 months
11
Q
Chronic Sinusitis
A
- Refer to ENT
Antibiotics - culture guided, prolonged courses 3 - 4 weeks - Augmentin empirically
- Clindamycin for penicillin allergic
Intranasal corticosteroids
Nasal saline irrigation
Sinus surgery
* Failure of medical tx
* Restoration of ventilation
* Improve penetration of topical medications
* Opens pathways, clears blockages
Old Augmented empire, cleans allergies for 3 to 4 weeks
12
Q
Chronic Fungal Sinusitis
A
- Difficult to cure
- Overall survival poor, long-term survivors may have significant sinonasal complications
- IV Amphotericin B initial
- Switch to Itraconazole for at least 3-6 months, some possibly lifelong
Old Fungal IVY amphitheater
Then step into a blue suit
for the rest of your life or 6 months
13
Q
Chronic Fungal Sinusitis allergic subtype
A
- Endoscopic sinus surgery to remove mucin and debris, created drainage
- Post-op systemic steroids mainstay
- Tapering course over 3 month period
Old allergic mushroom surgeon
On steroids 3 months
14
Q
Wegeners Granulomatosis
A
Steroids
Immunosuppressants (for maintenance as well)
15
Q
Allergic Rhinitis - general management
A
Correct Diagnosis
Patient Education
Allergen Avoidance
Pharmacotherapy
Immunotherapy
16
Q
Allergic Rhinitis - Prevention
A
- Removal of pets
- Air filtration devices
- Travel to non-pollinating areas
- Elimination of cockroaches
- Plastic-lined covers for mattresses, pillows
- Wash bedding weekly
- Dust frequently
- Elimination of carpets and drapes
- Avoid cigarette smoking
17
Q
Allergic Rhinitis Classifications
A
- Sleep disturbance
- Impairment of daily activities, leisure, and/or sport (impair funct)
- Impairment of school or work
- Troublesome symptoms
- Mild = none
- intermittent = less than 4 d/week or for less than 4 weeks
- Moderate-severe = means 1 or more present
- persistent = more than 4 d/week, and more than 4 weeks
18
Q
Allergic Rhinitis Medications Treatment
A
Intranasal Glucocorticoids - most effective and mainstay of treatment:
-FOR classifications: persistent/ moderate to severe ONLY
intranasal glucocorticoids down regulates inflammatory response - decreases swelling of nasal mucosa
Topical nasal sprays - safe, effective
Fluticasone, mometasone, beclomethasone (1-2 sprays QD or BID)
- Side effects - local irritation, epistaxis, nasal septum perforation, Candida overgrowth (rare) nasal Perf due to vasoconstrictive activity of steroid
- Seasonal, perennial, vasomotor rhinitis
- Start with maximum dose for age and then step down at one week intervals once symptoms controlled
- May take up to 2 weeks for full benefit
Not a prn medication
19
Q
Intranasal glucocorticoids directions & education
A
Directions for intranasal glucocorticoids - Tilt head forward, point bottle to ipsilateral ear (away from septum) - very important to give proper usage to avoid dangerous SE
Pt Ed: make sure to immediately report any increasing or bothersome bleeding or crusting
Work best when administered properly and med remains in nose and not draining down back of throat
IF nose is crusted or has thick mucus
Should first clean or do nasal rinse
Once symptoms are controlled, daily dose can be reduced to lowest that maintains control
20
Q
H1 antagonist indications
A
Allergic Rhinitis
Allergic Conjunctivitis
Urticaria
Angioedema
Pruritus
21
Q
Allergic Rhinitis mild symptoms or intermittent classifications
A
H1 1st gen: diphenhydramine, hydroxyzine, chlorpheniramine, bromopheniramine. SE: sedate, dry mouth, wt gain
H1 2nd gen: 1st line - for mild or intermittent.
Cetirizine (Zyrtec), Loratadine (Claritin)
Cetirizine is sedating in 10% of patients.
Fexofenadine (Allegra), Desloratadine (Clarinex), Levocetirizine (Xyzal)
SE: dry mouth, antihistamine tolerance
Can “rotate” medications
22
Q
Nasal Antihistamines
A
Nasal Antihistamines
Azelastine (Astelin), Olopatadine (Patanase)
Rapid onset
Can improve nasal congestion
O is one nare, o is the other nare, l is the septum
Azelastine sounds like the lion. Picture his nose
23
Q
Decongestants - oral
A
Oral - Pseudoephedrine (Sudafed)
Contraindications - narrow angle glaucoma, urinary retention, uncontrolled HTN, marked CAD or CVD, hyperthyroidism
SE: Insomnia, tremor, tachycardia, hypertension
24
Q
Decongestants - Topical
A
Phenylephrine (Sudafed), Oxymetazoline (Zicam/Afrin))
Rebound vasodilation, rhinitis medicamentosa
25
Oral antihistamine/decongestant combinations
* Allegra D / Claritin D
* Non-sedating antihistamines combined with Pseudoephedrine
* Phenylephrine substituted now in OTC preparation due to substance abuse of pseudoephedrine* Not as effective
| the fake one left, now the real one is here
26
Mast cell stabilizer
Cromolyn sodium (NasalCrom): mast cell stabilizer
* Topical nasal spray
* Mast cell stabilizer
* Prophylactic
* 3 - 4 times / day
* Less potent, very few side effects
27
Leukotriene antagonist
Leukotrienes - inflammatory mediators produced by **mast** cells, **basophils**, and **eosinophils**, that are *accompanied* by the production of *histamines* and *prostaglandins*
* Trigger smooth muscle contraction
* Neuropsychiatric changes - dreams, insomnia, anxiety, depression, suicidal thinking
Used as monotherapy or combination therapy
Montelukast can also treat asthma
28
Anticholinergics topical
Ipratropium bromide -
* Useful for post nasal drip and rhinorrhea & perennial symptoms
* Combined with intranasal **steroids**
* Useful in vasomotor rhinitis
Adjunctive: +/- nasal saline irrigation
29
Allergic Rhinitis Referral?
Patient with prolonged and severe AR and any of the following:
* Comorbidity
* Symptoms affecting quality of life
* Pharmacological treatment that is ineffective or that causes adverse reactions
30
Allergic Rhinitis - Allergist Treatments?
Subcutaneous immunotherapy - “allergy shots”
Indications - **Severe allergic rhinitis**
Procedure:
Each shot contains a tiny amount of specific substance(s) that trigger your allergic reactions. Just enough to stimulate immune system, but not enough to cause full blown reaction
Over time, the dose of allergens increases, which helps your body get used to the allergens (desensitization), building up a tolerance
* 3 - 5 years long. Discontinuation - minimal symptoms over 2 consecutive years of seasonal exposure
Adverse effects-
* Localized or systemic - adjust dose
* Patient monitored for 20 min after injection
* * Contraindications
Significant **CVD**, uncontrolled **asthma**
Caution if on **Beta Blockers****
31
Vasomotor Rhinitis
Intranasal steroid or antihistamine
Ipratropium
Daily nasal saline lavage
| viridian city
32
Rhinitis Medicamentosa
* Discontinue use of nasal decongestant
* Start intranasal corticosteroids
don't use afrin once a day. use for three days max. patient education.
| Chronic nasal obstruction due to overuse of nasal decongestants
33
Epistaxis - anterior
Pressure on site
Firmly compress for 15 minutes
Sit, leaning forward
Short acting topical nasal decongestants (Vasoconstrictors - phenylephrine)
if bleeding doesn’t stop
Topical anesthetic vasoconstrictor
4% topical cocaine solution OR
4% lidocaine and epinephrine (1:10,000)
If bleeding point identified, chemical cauterization with silver nitrate stick
Thermal cauterization for more aggressive bleeding and done under anesthesia
Continued bleeding -->
Nasal packing
* Sponge or Balloon OR
* Absorbable material - oxidized cellulose, gelatin foam, gelatin and thrombin combination
34
Epistaxis - Posterior
Common association with hypertension and atherosclerotic disease.
* ENT consultation
* Packing
* Narcotic analgesics
* Ligation of nasal arterial supply (internal maxillary artery and ethmoid arteries)
* Endovascular embolization of the internal maxillary artery
Antibiotic prophylaxis, antistaphylococcal abx for Toxic Shock Syndrome
Augmentin, clindamycin, or Keflex. Follow up in 48 - 72 hours
(Augmented clean kleenex )
After control:
* Avoidance of vigorous exercises for several days
* Avoidance of hot or spicy foods and tobacco
* Avoid nasal trauma
* Lubrication with petrolatum or Bacitracin ointment
* Increase home humidity
35
Nasal Polyps
Topical nasal steroids for 1 - 3 months
Short course of oral steroids
Surgical removal if medication unsuccessful
36
Nasal Foreign Body
If no deformity, ice, analgesics, OTC decongestants. Maintain long-term airway patency and cosmesis
If deformity:
* ENT referral
* Radiographs helpful but not necessary. No clear recommendation exists regarding type of surgery or timing (open vs. closed, acute vs. waiting)
Fracture of **cribriform plate**
* May violate the subarachnoid space and cause CSF rhinorrhea
* CT and neurosurgical consultation
* Antibiotics
37
Acute Otitis Externa
Thoroughly clean ear canal to remove debris. Hypertonic saline solution
Topical antibiotics
* Ofloxacin (Floxin) otic soln or Ciprofloxacin
* Cortisporin Otic soln or susp (Neomycin, Polymyxin B, Hydrocortisone)
* Cipro HC or CiproDex otic soln
* Pain relief
* Avoid promoting factors
* Culture if severe, or no resolution
* Ear wick - Placed in swollen canal. Helps distribute medicine and keep medicine in canal. Expands as its moistened
Flush acute lady outside her window, court her top, wick her, and culture severely
38
AOE in ICP adults
For any patient with diabetes or immunocompromise, unilateral ear pain, and inflammation in the external ear canal, malignant otitis externa should be considered. Antibiotic dosing is standard for adults with normal kidney function.
If TM ruptured, Topical fluroquinolone if can't tolerate, Refer to ENT, cx, and empiric treatment w Cefuroxine or amox-clavulanate
Intact - topical acetic acid/hydrocortisone for 7 d. cx.
If intact and moderate, add cipro-hydrocortisone, or neomycin/polymixin B
Always refer to ENT if it doesn't get better in 7 days
39
Otomycosis
Cleaning of canal
Cotrimazole 1% solution BID 10-14 days
Trim and water(soln) the mushrooms by the window
40
Chronic Otitis Externa - Noninfective
Topical Hydrocortisone cream/otic drops
41
Chronic Otitis Externa - Malignant Necrotizing
* Aggressive glycemic control
* IV and oral Antibiotics 6 - 8 weeks typically required
Antipseudomonal antibiotics: ciproffloxacin, penicillin, or cephalosporin
* **Ciprofloxacin** 200-400mg BID 1st line
* Piperacillin, Cefepime (Maxipime). Treat until clinical improvement seen
Selected patients may be graduated to oral ciprofloxacin
* Aminoglycoside or Fluoroquinolone
* Ciprofloxacin 500 - 1000 mg BID
* Treat until gallium (nuclear) scan is clear of inflammation (generally 6-8 weeks)
Surgical debridement
* In severe, refractory cases only, not usually needed
42
Chronic Otitis Externa - Herpes Zoster Oticus
* Steroids and antivirals
* Prednisone and Famciclovir (Famvir) or Valacyclovir (Valtrex)
Valor presents for family
43
Auricle Hematoma
Evacuate subperichondrial blood
Prevent its reaccumulation
44
Auricle Hematoma
* Within 7 days, otherwise refer. Prevents significant cosmetic deformity
* Lidocaine 1%: auricle block
* I&D
* Irrigate pocket with NS
* Compression dressing. Leave on for 7 days
* Re-examine for recurrence every 24 hours for several days
* Avoid NSAIDS
* Antibiotic prophylaxis +/-
45
Auricular Laceration
Tetanus vaccine if indicated
Antibiotics if contaminated wound
Bite injuries
Signs of inflammation
Think dog bite augmentin
46
Auricular Laceration
Refer to surgery IF:
Large skin avulsions (5 mm or >)
Severe crush injuries
Complete or near complete avulsion
Auricular hematoma
Large cartilage defect (> 5 mm)
Wounds that require removal of > 5 mm tissue
Involvement of auditory canal
Tissue devitalization
47
Auricular Cellulitis
Treatment against Staph aureus and Streptococci
Oral antibiotics
* Cephalexin
* Trimethoprim-Sulfamethoxazole (MRSA)
* Clindamycin (MRSA)
IV antibiotics - IV vancomycin
* Tachycardia
* Rapid progression of erythema
* Progression despite oral abx
* Systemic toxicity (fever over 100.5)
Warm compresses
NSAIDS for pain management
In my cell i watch CBC news, get warm and comfy (nsaid), wait for uber ivy van to arrive at 100.5 (rhymes)
48
Perichondritis
* Want to start within 5 days. Risks of hospitalization and deformity
* Oral or IV Ciprofloxacin
* I&D
49
Acute Otitis Media pharm mild to moderate
* **Amoxicillin**
* Cefdinir
* Cefuroxime,
* Azithromycin
If exposure to antibiotics - within 30 d or tx failure after 72 hours:
*** Amox+Clavulanate (Augmentin) PO
* Cefdinir**
* Ceftriaxone OR Clindamycin
| amox lacks activity agaisnt H flu and 1/2 pneumococcal
50
Acute Otitis Media allergic to penicillins
Cephalosporins are recommended to penicillin allergic patients who do **not** have **anaphylaxis**
* Cefdinir
* Ceftriaxone
Zithromax or Doxycycline are recommended to patients with immediate PCN hypersensitivity reactions, such as anaphylaxis.
DANA Z
51
Acute OM severe
Severe = Significant hearing loss, severe pain, fever > 102⁰F, immunocompromised, under 6 months of age and or marked TM erythema
Initial therapy or with associated bacterial conjunctivitis (Likely H. Influenza)
* Augmentin ES, OR
* Ceftriaxone (Rocephin)
If exposure to antibiotics within 30 days or recent treatment failure
* Ceftriaxone (Rocephin), OR
* Clindamycin, OR
* Consider tympanocentesis
Duration of all tx= 10 days for patients <6 years old and /or patients with severe disease, TM perforation or recurrent AOM
Duration of 5 - 7 days for patients ≥6 years old
Failure to improve and/or clinical worsening in 48 - 72 hours needs re-evaluated
52
AOM Referral, when?
| acute otitis media
ENT - Tympanostomy Tubes
3+ AOM within 6 months OR
4+ AOM within 12 months OR
Unresponsive to pharmacological treatment regime
53
AOM Prevention
IMMUNIZATIONS
* Encourage breastfeeding
* Immunoglobulin IgA is secreted through breastmilk
* Offers protective qualities
* Upright for bottle feedings
* Avoid passive smoke exposure
* Limit exposure to groups of children
* Careful hand washing
* Avoid pacifier use >10 months old
* Constant sucking action exacerbates eustachian tube dysfunction
* Causes auditory tubes to become abnormally open
* Allows secretions from the throat to seep into middle ear
* This transmission of bacteria in the secretions can lead to middle ear infections
54
Bullous Myringitis
Same as AOM
May need to cover for atypicals. Mycoplasma - Zithromax
55
AOM - Tympanic Membrane Rupture
Audiogram to check hearing
* Now and repeat in 3 months
Oral and Topical antibiotics
Oral same as AOM: Amoxicillin. Augmentin. Cefdinir
Low ototoxicity topical Ab
* Ofloxacin
* Ciprodex
Earplugs
* Swimming and bath
56
Tympanic Membrane Rupture
Spontaneous resolution
Weeks to months
Tympanoplasty if no resolution
57
AOM complications - Tx
Topical Ab: Ofloxacin or Cipro with dexamethasone for exacerbations
Oral: Ciprofloxacin 500 mg BID X 1-6 weeks
Removal of debris, use earplugs to protect against water exposure
DEFINITIVE management is surgical in most cases
* TM repair may be accomplished with the temporalis muscle fascia
* Successful reconstruction of the TM may be achieved in about 90% of cases. Often with elimination of infection and improvement in hearing
58
Cholesteatoma
Refer - surgery
Surgical marsupialization or removal
59
Mastoiditis
IV antibiotics 7-10 days
* Empiric until culture results available
* Ceftriaxane (Rocephin)
* Cefazolin (Ancef)
Followed by oral antibiotics
* Amoxicillin/Clavulanate acid
* Cefdnir
Myringotomy
* Surgical drainage of TM to allow drainage of middle ear fluid
Surgery if failure of conservative treatment: mastoidectomy and debridement of infected and necrotic bone
Man on a ship carrying an axe made of IV for 10 d. Then he shoots someone for some dinner.
If it fails he will sink his ship by making a hole in it and suicide
60
Auditory Eustachian Tube Dysfunction
* Systemic and intranasal decongestants
* Autoinflation by forced exhalation against closed nostrils
* Allergies - Intranasal steroids
* Avoid air travel and altitude change, underwater diving
61
Barotrauma treatment
* Oral decongestants taken several hours before arrival time or topical decongestant 1 hr before
* Attempt autoinflation
* Myringotomy
* VT tubes if patient flies often and has severe symptoms
62
Barotrauma prevention
* Do not dive with conditions that can lead to ET dysfunction: viral URI
* Swallow, yawn, and auto inflate often during descent
* Systemic decongestants several hours before arrival
* Topical decongestants 1 hour before arrival
* No diving with URI or allergies
No diving with TM perforation
63
Viral Pharyngitis
Supportive care for all viruses - Fever reducers/pain relievers, magic mouthwash, cold food
Influenza
Tamiflu - Within 48 hours of symptoms onset
HSV
Acyclovir / Valacyclovir (Valtrex)
EBV / mono
* Avoid contact sports for 4 weeks - Risk of splenic rupture
* Can use oral Prednisone taper if tonsillar swelling is significant
* Antivirals and Steroids not recommended in regular treatment; does not reduce duration
64
Group A strep throat 1st line treatments
Pen VK first line
* Pen G benzathine (Bicillin) IM as a single dose
* Amoxicillin
* Cephalexin (Keflex)/ Cefdinir /
*Use Cephalosporins - if Penicillin allergic reaction of rash
* Use Azithromycin / Clindamycin - if Anaphylaxis reaction
65
Group A Strep throat - if tx failure
Augmentin
Erythromycin
Clindamycin
Azithromycin (Zithromax)
Big red clean Z
66
Group A strep throat patient education
* Have pt change toothbrush after 24 hours
* Not contagious any longer after 24 hours of treatment
* Strep will “go away” on it’s own without antibiotics
* However, a patient will remain contagious for 2-3 weeks after symptoms abate
67
Peritonsillar Abscess
Airway
Consult ENT
Needle aspiration or I&D
Antibiotics
Initially IV - until improved and afebrile
* Ampicillin-sulbactam (Unasyn) or Clindamycin
* Add Vancomycin if patient doesn’t respond promptly
One clean seal, van comes promptly
Switch to oral - for 14 total
* Augmentin or Clindamycin
* MRSA - Clindamycin or Linezolid (Zyvox)
Done? Augment clean.
If we are fucked, go to clean line for help
68
Retropharyngeal Abscess
Airway first
Empiric IV antibiotics
* Ampicillin / Sulbactam (Unasyn) or
* Ceftriaxone plus Metronidazole or
* Clindamycin plus Levofloxacin
Surgical drainage of abscess with ultrasound guided needle aspiration or open drainage
Clinical improvement should be seen within 24 - 48 hours
* Consider new antibiotics and / or surgery if not
* Otolaryngologist consult
: Continue IV treatment until afebrile and able to tolerate oral antibiotics
* Metronidazole or Levofloxacin
* Total of 2-3 weeks
IVy dream - Rewind aircraft, one clean levitating aircraft, or maybe axe subway.
When stable, choose metro or levitating for 2 to 4 weeks but not both
69
Acute Laryngitis
Viral- Voice rest & Hydration
Bacterial - Antibiotics & Supportive care
* PCN
* Erythromycin
Actors/singers-
Can be given oral steroids or erythromycin to help speed up recovery for performances
Vocal strain -Vocal therapy, Vocal hygiene
Vocal polyps - Surgical removal
GERD
* PPI
* ENT referral
* pH monitoring
70
What's important about acute laryngitis?
***Laryngitis (hoarseness) lasting > 2 weeks in the absence of URI symptoms or specifically in a pt who uses tobacco or drinks alcohol requires ENT or otolaryngology referral
71
Croup - general guidelines
Depends on severity.
1a mild at home
1b mild outpatient
2 moderate in ER
3 severe in ER
72
Croup 1A & 1B mild
1A
No stridor at rest
Barky cough
Hoarse cry
No /mild chest wall retractions
1B
If brought into outpatient setting, can do dexamethasone (decadron) single dose (.15 to .6 mg/kg)
Or oral Prednisolone 1mg/kg single dose
**Minimal handling of child, make sure they are comfortable
**supportive treatment including mist, antipyretics, fluid intake, exposure to cold air
**also instruct parents to watch for difficulty breathing, stridor at rest, worsening course, prolonged symptoms >7 day
73
Croup 2 moderate and 3 severe
moderate:
Stridor at rest
Mild to moderate retractions
****should be evaluated in ER***
severe:
Stridor at rest
Marked retractions with agitations
Lethargy, cyanosis
***Evaluated in ER****
All patients receive
* Dexamethasone
* Nebulized Epinephrine
* Supportive care including humidified air or oxygen, antipyretics, fluid intake, nebulized saline
74
When to discharge croup
Observe for 3-4 hours after pharmacologic intervention
Croup symptoms usually improve within 30 minutes of administration of nebulized epinephrine
Additional epinephrine should be given if children have recurrence/worsening of symptoms during observation period, including admittance to hospital
After 3-4 hours, children can be discharge if they meet following criteria
No stridor at rest
Normal pulse ox
Good air exchange
Normal color and level of consciousness
Ability to tolerate fluids
Caregiver understanding of indications to return when needed
75
Epiglottitis
VACCINATE
Airway emergency in children
Caused by Haemophilus influenzae type B
Initial Intervention
Because of the rapid progression to airway obstruction, the threshold for epiglottitis should be low
Maintenance of airway is mainstay of treatment
In patients with total or near-total airway obstruction, airway control precedes diagnostic evaluation
Tx:
Empiric IV antibiotic treatment should begin after blood and epiglottic cultures are obtained
**3rd Generation Cephalosporin (Ceftriaxone) plus Vancomycin first line
3rd Generation Cephalosporin (Ceftriaxone) plus Clindamycin also accepted as first line**
If anaphylaxis occurs with penicillin, can use Vancomycin plus fluoroquinolone
Most will treat for 7-10 days
Antipyretics
+ / - steroids
Clean axe, or van axe chase the apple
76
Ludwig's Angina
Admit to hospital
CT with IV contrast imaging of choice
Close monitoring of airway and possible intubation
Empiric IV antibiotic
* Ampicillin-sulbactam (Unasyn) alone
* Ceftriaxone plus metronidazole
* For penicillin allergic: Clindamycin plus levofloxacin
Obtain culture via needle aspiration if possible
May need surgical drainage
However, this is not a typical abscess, so there is usually nothing to drain initially
One owl alone or metroaxe ,
Allergy owl cleanly levitates
77
Tumors of the Larynx
nodules - Voice habit modification
+/- surgical excision
polyps - Lifestyle change
Inhaled steroid spray
Removal
squamous cell carcinoma - MC in larynx
Surgery
Radiation and / or chemotherapy
78
Vocal Cord Paralysis
Determine cause
* Laryngoscopy, bronchoscopy, esophagoscopy
* Neurologic examination
* Enhanced CT of head, neck and chest
* Thyroid gland scan
* Upper GI series
Maintain airway
Unilateral is occasionally temporary, may resolve spontaneously
* May take at least a year
* Surgery may be needed
79
Hypertrophic Tonsils
Recommendation for removal-
1. Obstructive sleep apnea
2. Recurrent throat infection
* ≥ 3 episodes in each of 3 years, ≥ 5 episodes in each of 2 years, or ≥ 7 episodes in 1 year
* &Each episode characterized by at least ONE of the following:
Oral temp ≥ 101℉ (38.3℃)
Enlarged (> 2 cm) or tender anterior cervical lymph nodes
Tonsillar exudate
Positive culture for group A beta-hemolytic Streptococcus
80
TMJ - when to refer?
* Symptoms do not improve after 6 months of joint rest
* Progressive difficulty in opening the mouth
* Inability to eat a normal diet
* Recurrent dislocation of the temporomandibular joint
81
TMJ
Joint rest
* To allow muscles of mastication to relax
* Reduce mandibular condyle movement
Avoid chewing gum, biting nails, excessive talking
Eat a soft diet
Reduce stress
Physical therapy - Exercises include mouth opening and closing in a straight line
Intra-oral devices - Splints, night guards, bite guards
Botox injections
* Muscle relaxation
* Only temporary relief
* 3-4 months
82
Head and neck masses
Squamous Cell Carcinomas - TREATMENT
Localized disease (early stage: I and II)
Surgery (removal of tumor/cancerous lesion) or Radiation Therapy
Locoregionally advanced disease (stage III/IV)
high risk of recurrence and metastasis
Combined modalities
Surgery, Radiation Therapy and or chemotherapy
Metastatic
Palliative chemotherapy, supportive care
83
HPV
vaccinate- 90% strains of HPV
9 to 14 y, 2 dose
15 to 26 y, 3 dose
