Flashcards in HEENT Deck (137):
what is otitis media
suppurative infection of the middle ear
How does an otitis media develop?
-bacteria gains access to the middle ear when the normal patency of the eustachian tube is blocked by upper airway infection or hypertrophied adenoids
-air trapped in middle ear is resorbed, creating neg. pressure in this cavity and facilitating reflux of nasopharyngeal bacteria
what are the most common organism that cause AOM
-Group A strep
who is most at risk for AOM (and MEE after AOM)
-Low socioeconomic status
-Native Americans and Alaskan Natives
Major risk factors for AOM
-Lack of breastfeeding
-Passive exposure to tobacco smoke
-increased exposure to infectious agents (ie. in day care)
what is considered recurrent OM
the presence of 6 or more AOM episodes in the first 6 years of life
Sx of AOM
-Otalgia (ear pain)
-Abnormal eye movement
Otorrhea (ear drainage)
Documenting ear exam for AOM
-TM is erythematous
-No visualization of bony landmarks
-Bulding TM with no light reflex present (or less than 90 degrees)
-Purulent fluid behind TM
DDX for AOM
-OM with effusion (aka chronic OM)
how do you tx AOM
*if younger than 2 or have fever greater than 39C or otalgia--> amoxicillin (80-90mg/kg/day divided in 2 doses)
failure of initial therapy w/ amoxicillin for AOM at 3 days suggest infection w/ ____
B-lactamase-producing H. influenza, M. catarrhalis or resistant S. pneumoniae
-Tx: high-dose amoicillin-clavulante, cerfuroxime, axetil, cefdinir, or cefriaxone
*decongestants or antihistamines are NOT effective
complications of AOM
1. chronic effusion
2. hearing loss
3. cholesteatoma (mass-like keratinized epithelial growth)
5. intracranial extension (brain abscess, subdural empyema or venous thrombus)
Sx of acute mastoiditis
-sx of AOM
-posterior auricular tenderness
-pinna is displaced downward and outward
precautions to prevent AOM
-avoid taking bottle to bed or bottle propping
-S. pneumo conjugate vaccine and yearly influenza vaccine
what visual screening should be done at different age groups?
-Birth: red reflex, corneal light reflex, pupillary response to light
-2: cover/uncover test (until age 6)
-3: Visual acuity w/ tumbling "E" chart
-Kindergarten (4-5): visual acuity w/ shape chart
-FINALLY, typically snellen chart
what should a red reflex look like?
-red glow w/ no opacities
-different ethnicities have different appearance of RR (African ancestry has white "red" reflex)
how can you test for strabismus?
w/ corneal light reflex or Hirschberg test
-the "stars" in the eyes should be exactly in same position
*(might appear cross-eyed but that is because the nasal bridge is so wide that they appear not to have any sclera along the medial portion of the eye)
what does the cover/uncover test screen for?
ambylopia "aka lazy eye"
(when the vision in one of the eyes is reduced because the eye and the brain are not working together properly. The eye itself looks normal, but it is not being used normally because the brain is favoring the other eye)
how often should you check a child's vision and why?
-in preschool and annually in elementary
-its important to realize that the visual cortex of the brain is developing until about the age of 9 years, so any visual deficit, whatever the cause, could cause the visual cortex to not develop properly which is an uncorrectable condition beyond the age of 9 years, even if the underlying disorder is identified and treated
when should you start referring a child for their vision
20/20 not until age 6-- so no reason to refer unless they are 20/40 or a 2-line chart difference between eyes
what is a red reflex w/ a stellate dark lesion located centrally and what do you do?
congenital cataract-needs immediate referral as it needs to be removed before the age of 6 weeks to avoid blindness
if you see a white "red" reflex in just one eye, you have to assume it is ___ until proven otherwise
-retinoblastoma (malignant eye tumor)
Causes of unequal RR intensity
-large refractive error
*needs referral to ophthalmology
what are the different types of strabismus
1. esotropia (turning inward)
2. exotropia (turning outward)
3. hypertropia (turning upward)
4. hypotropia (turning downward)
what are straismus due to and what are they at risk for if not treated
-unequal strengths of eye muscles
-risk for amblyopia
how are strabismus treated
(surgery, eye patching of dominant eye, cycloplegic drops in good eye to blurr vision)
how is amblyopia treated?
-treat underlying cause by age 8-9 to preserve central vision
*ideally treat underlying before 6 and then treat tx amblyopia w/ patching or cycloplegic drops
when does conjugate gaze develop
other causes of a wandering eye
what is internal hordeolum and how to do you treat it
acute inflammation of meibomian gland
-warm compresses to unplug the gland and antibiotic eye drops for the infection.
* Expect resolution within 2-3 days.
what is chalazions and how do you treat it
chronic inflammation of meibomian gland
-steriod eye drops, possible surgery-- refer to ophthalmology
when is it bad to use steroid drops in the eye
-w/ herpetic eye infection-- can lead to destruction of the globe of the eye w/in 24 hrs
what is external hordeolum and how do you treat it
-acute inflammation of the glands of zeis
-warm compresses to unplug the gland and antibiotic eye drops for the infection.
* Expect resolution within 2-3 days.
what do you need to consider if a neonate presents with purulent eye discharge
-chlamydia (in US) and gonorrhea (in developing countries)
*Women in this country do receive vaginal cultures in the final month of pregnancy, but may have contracted the infection between the cultures and the delivery time
how do you treat chlamydia and gonorrhea in neonates eyes
-erythromycin ointment at delivery
-culture eye discharge and consider gram stain (if thinking gonorrhea)- bc IV treatment needs to begin immediately and culture takes 2-3 days
most likely cause of a watery eye in a neonate
blocked tear duct- dacryostenosis
*usually caused by amniotic debris clogging the tear duct
how do you treat dacryostenosis
-massage of the inner canthus of the eye several times a day will usually resolve the problem by the age of 4-6 months
-Antibiotic eye drops are sometimes necessary when the discharge becomes purulent due to the stagnation of normal tear flow.
*If not resolved by age 6 months, refer to ophthalmology for probing of the tear duct which usually opens it
what should you also ask about if a child presents for red eyes w/ or w/o discharge
*could be more serious eye disorders
**Also always test visual acuity
signs and sx of allergic conjunctivitis
-allergies: itchy eyes or nose, seasonal recurrence
-Severe allergies: chemosis, edema of the bulbar conjunctiva
-water or stringy discharge
-presence of cobblestoning on palepbral conjunctiva
how to tx Allergic conjunctivitis, even chemosis
antihistamine eye drops such as Patanol or Pataday (QD formula), or Naphcon and Ketotifen which are OTC
sx of bacterial conjunctiva
-purulent eye discharge
-significant erythema of palbebral
-sometimes bulbar conjunctiva
-w/o significant eye pain
tx of bacterial conjunctivitis
Polytrim, Vigamox or Ocuflox, and erythromycin ointment in infants
when is viral conjunctivitis common
w/ hx of recurrent URIs
tx of viral conjunctiviits
-often prescribe antibiotic eye drops because they often will develop secondary bacterial conjunctivitis
sx of herpetic conjunctivitis
-significnat eye pain
*Do a fluorescein stain if in doubt. This patient needs an ophthalmologist.
presents w/ red eye, pain, associated hx of trauma, inconsolable crying (esp. w/ facial eczeza)
*visible w/ a black light (Wood's lamp) after fluorescein stain
how do you tx corneal abrasion
-documented for location and % of corneal involvement,
-are painful enough to consider Cylogel for pain or Tylenol #3
-antibiotic eye drops
*F/u in 1 day as it should heal overnight, if not refer for a slit lamp exam in case a foreign body or more extensive damage is present
how do you exam and tx a corneal ulcer?
-You can see these with tangential lighting, somewhat less with fluorescein stain and very well with a slit lamp.
*These occur almost exclusively in contact lens wearers, and are an eye emergency. Contact an ophthalmologist immediately.
-often from a corneal abrasion that got infected
what is a hyphema
blood in the anterior chamber of the eye from blunt trauma
*higher percentages are associated with acute angle closure glaucoma, and the trauma itself presents a risk of retinal detachment
presents w/ red eye, pain, hx of rheumatoid arthritis
serious eye infections
include periorbital or pre-septal cellulitis, and orbital or post-septal cellulitis
EVERY patient with red, swollen eyelids must have an ___ exam to rule out limited gaze in any of the 4 fields which is indicative of ___
Periorbital cellulitis is usually secondary to ___ and the organism is usually ____
skin disruption such as from an insect bite, scratch, etc. and the organism is usually staph or strep.
If you look carefully, you will note a small trauma to their lower eyelids at the lateral edge. The skin around the eye is in that facial area for serious complications.
how do you treat periorbital cellulitis
-If less than 1y/o, monitor for sepsis, meningitis and check vaccine status for Hib and pneumococcal vaccines.
-May treat outpatient with Augmentin or cephalosporins, and need close monitoring/return precautions.
what is the difference btwn periorbital cellulitis and orbital cellulitis
-cellulitis don’t look really different from the ones with periorbital cellulitis. -They have a fever, periorbital erythema, edema and warmth. **Because the post-septal area is filling with pus, though, there will be limitation of their field of gaze, so the EOM exam is critical
-if unsure of PE, ask for help or admit the patient for CT scan and possible IV antibiotics
tx for orbital cellulitis
-need to have the eye orbit debrided surgically, so an ENT consult is in order
-are treated with cefotaxime or ceftriaxone and clindamycin
*there is a significant risk of infectious spread to the brain, so speed and vigilance are important.
how does one typically get an orbital cellulitis
infections are usually a spread from sinusitis which has eroded through the orbital bone or sometimes from eye trauma
____ is a significant cause of blindness in the U.S
Who is at risk?
Retinopathy of prematurity
*Premature infants born at less than 32 wks gestation or less than 1500 gm are at risk for the retina to not develop appropriate blood vessels
-initial exam at 4-6 weeks after delivery, and repeat screening every 1-2 weeks
what are the stages of retinopathy
Stage 1 being minimal changes to stage 5 being retinal detachment and will be documented with the zone(s) involved
why are young children at risk for AOM
due to their short and horizontally-positioned eustachian tubes-This allows nasopharyngeal secretions to easily enter the middle ear and become infected with viruses and bacteria
*Around age 6 years, the eustachian tubes become longer and positioned at a downward slant into the throat, making AOM less common.
Guideline of diagnosing AOM
based on evidence of
-acute ear pain for more than 48 hrs,
- new onset of otorrhea which is presumptive evidence of a ruptured TM secondary to AOM in pediatric patients
how to distinguish AOM from serious otitis media
reveals air/fluid levels consistent with serous otitis media
what is middle ear effusion?
the fluid behind the TM may be white or yellow, and without the criteria of AOM (mod-severe TM bulging, new onset otorrhea, or mild TM bulging + less than 48hrs of ear pain)
who should you treat for AOM based on age groups
6months+: mod-sever otalgia + fever (39C)- unilateral or bilateral
-6-23months: maybe tx-mild otalgia + fever-bilateral (unless unilateral ---tx!)
-24months+: mild otalgia + fever-bilateral or unilateral
when should F/U with AOM occur
4 weeks (or 2)
*it is important to give time for the middle ear effusion, which always follows AOM, to have a chance to resolve before the next exam.
-if patients are not improving in their symptoms after 2-3 days of antibiotics, a follow-up visit is indicated usually with a change of antibiotics.
what is the number one pathogen that causes AOM and what is the 1st line tx?
S. Pneumoniae, which is generally susceptible to penicillin. However, up to 20% of S. Pneumo is resistant due to mutations which have resulted in cell wall resistance to PCN. This can be overcome by more PCN, which is the reason for the high dose of Amoxicillin in 1st line therapy.
Amox. 80-90mg/kg divided into 2 doses
2 reasons why S. pneumo may be resistant to PCN and its tx to overcome in AOM
1. due to mutations which have resulted in cell wall resistance to PCN-- overcome by higher PCN dose
2. the ability to produce beta-lactamase, an enzyme which inactivates PCN-- use augmentin (high dose PCN + clavulanic acid)- neutralizes the beta-lactamase enzyme
how to dose 2nd line treatments for AOM
Augmentin (Amox/Clav)- Dose based Amox @ 80-90mg/kg/day divided BID
Omnicef (cefdinir)- 1x day / taste +
Vantin (cefpodoxime)-1 x day / taste -
Ceftin (cefuroxime)- 2x day / taste -
how should you tx AOM caused by mophilus influenzae or moraxella catarrhalis
2nd line therapy tends to be more effective against these other 2 bacteria, as they often produce beta-lactamase
how do you treat AOM in someone w/ PCN allergy
-PCN-allergic patients w/o a hx of urticaria or anaphylactic reaction can take cephalosporins.
- If they have this hx, there is a 20% risk of cross-reactivity and they need to take a MACROLIDE.
-If a patient has taken Amox in the past 30d, you should move to 2nd line therapy, also if they have a history of recurrent AOM resistant to Amox
presents w/ purulent conjunctivitis and AOM
-most likely culprit is beta-lactamase H. flu, and you should prescribe 2nd line therapy
why is it important to F/u with kids with AOM at 4 week intervals until 3 months have passed or MEE has resolved?
-young children are acquiring language and the MEE results in a conductive hearing loss
when does MEE resolve
-60% of MEE will resolve at 1 mo,
-80% at 2 mo,
- 90% by 3 mo
*follow at 4 week intervals w/ pneumatic otoscopy or tympanograms
*normal light reflex also means normal middle ear pressure and no MEE
how to interpret a tympanogram
-shows a flat line, consistent with significant MEE,
- as the “line” is beginning to form a peak in the box- Resolving MEE,
-normal sharp peak in the box, indicating full mobility of the TM which will occur when the MEE is resolved
what kids should be referred to ENT for MEE
Children who do not resolve their MEE by 3 months, those who have MEE and are losing language/not gaining language, or have a hx of speech delay/learning issues should be referred to ENT for consideration of myringotomy and pressure-equalization (PE) tubes.
protruding ear, exquisite tenderness/maybe erythema over the posterior auricle, fever, and sometimes otorrhea if the TM has ruptured
*concern for meningitis/brain abscess
-need to be referred ASAP to ENT or possible direct admit
Kids less than 5y/o average about ___ viral URI per year, especially if they have exposure to other children
*tapers down as they get closer to school age
-10-15% of children have at least 12 colds each year
-this often brings parents into the office with concerns about their immune status, whether or not they have bacterial sinusitis
how long do URIs typically last?
The average URI lasts about 7-14 days, so these children have rhinorrhea about 1-2 weeks/month with closer spacing during winter months
sx of URIs
-presence of yellow-green nasal discharge around day 3-4 ( not indicative of secondary bacterial sinusitis)
sx of allergic rhinitis
1. rhinorrhea (clear and thin) w/ less breaks in their sx
2. seasons sx w/ itchy (prutitis) nose and sometimes eye
3. often use their hand to push their nose up to open their nasal airway and develop a crease across their nasal bridge
4. red eyes
5. post nasal drip- cough and hoarseness
6. nasal congestions- (pale pink or bluish gray swollen, boggy nasal turbinantes with clear, water secretions)
7. allergic shiners
8. "clucking" sounds
when do the facial sinuses develop?
The maxillary sinuses aren’t fully developed until age 4 years and sphenoid and frontal are developing from age 5 into adolescence,
*this makes bacterial sinusitis unlikely in these very young children.
when should you consider a secondary bacterial infection w/ rhinorrhea
If you see symptoms longer than 10d, but less than a month, especially if fever has set in after the initial cold symptoms and purulent discharge is worsening instead of improving
*Sinus x-rays are unreliable and sinus transillumination not helpful.
In young children, persistent purulent discharge from the nose should cause you to consider ___ or __
foreign body or choanal atresia
tx for viral URIs
-nasal irrigation w/ NS using a bulb syringe every few hours (Parents can buy the solution or gel or can make it at home)
-honey for cough (contraindicated in children less than 1)
*Cough/cold preparations are contraindicated in children less than 2y/o and not recommended in those less than 6 y/o
tx for allergic rhinitis
-intranasal steroids- if tolerated
(Mometasone: older than 2 years
Fluticasone: older than 4 years)
-If they can’t or you need to treat nasal and eye symptoms, systemic treatment with oral non-sedating antihistamines
(Cetrizine: older than 6 months
Loratadine: older than 2 years)
what is the recipe for normal saline?
1/4 tsp salt in 8oz water
tx for sinusitis
supportive-- nasal steroids are helpful
Cefdinir, Cefuroxime, Cefpodoxime
(same as for AOM and MEE)
When children present with sore throat, ___ are caused by viruses and will resolve without intervention.
why do you treat GAS pharyngitis?
children to avoid the complication of post-streptococcal glomerulonephritis or rheumatic fever
*prevented if started 1/in 9 days of illness
what is the scoring system to determine who should be tested for GAS?
1 point for each of the following that are present:
1. Age 5-15y,
2. late fall to early spring presentation,
3. pharyngeal erythema, edema or exudates on exam,
4. tender, greater than 1cm anterior cervical LAD,
5. fever 101-103,
6. absence of URI symptoms such as cough and rhinorrhea
*Patients with scores 5 (50%) or 6+ (85%) are more likely to have a positive rapid strep and/or throat culture
-All negative rapid strep tests need a ____ due to low sensitivity (as much as 30% false negative).
-It is therefore recommended that the patients with a score of 5 be tested by ___ only as they have a higher likelihood of being negative, and this will prevent doing unnecessary dual testing.
-Patients with scores of 6+ should be tested with ___
-rapid strep tests, as they are very likely to be positive and a follow-up culture is not necessary.
Sx of GAS besides sore throat
-abrupt onset HA
- upset stomach/vomiting
-sandpaper rash to their trunk and groin (likely have scarlet fever)
tx of GAS infection
-PCN, including amoxicillin, ampicillin, cephalosporins and macrolides for 10 d
*Expect rapid improvement and patients can return to school once they complete 24 hours of treatment.
**Stress the importance of completing the entire regimen
____% of school-age kids harbor GAS in their oropharynx, even when well.
Up to 20%
*usually within the pits and crypts of their tonsils, from previous GAS pharyngitis episodes.
*This erroneously leads parents to believe that their child “gets strep throat” every time they get a cold
how do you determine if someone is GAS carrier?
-often don’t have fever,
-their exam is unimpressive,
-the season is off.
-will not develop GAS complications,
-will not pass along their infection, (and don’t require treatment)
-culture their throat during a well visit to verify
how do you treat suspected GAS carriers?
Augmentin or clindamycin as they are associated with a higher rate of GAS eradication.
when do you consider pharyngeal abscess
sx: severe sore throat, fever, difficulty swallowing and talking
PE: bulging soft palate and a deviated uvula if an abscess has formed, but just unilateral edema and erythema if still in the cellulitis phase
*BC the abscess limits the mobility of their tongue, they often talk as if they just took a bite of hot food and they are trying to manage it- the “hot potato” voice
most common pharyngeal abscess
-which begins as a cellulitis due usually to GAS and then walls off into an abscess
how do you differentiate between a peritonsillar abscess and a retropharyngeal abscess
-has similar symptoms but retropharyngeal will have stiff neck and lateral neck flexion due to the position of the mass near their neck muscles
tx of pharyngeal abscess
potentially life-threatening due to airway obstruction and need emergent ENT consult, usually with admission, IV antibiotics and incision and drainage.
when do you screen a child for OSA?
all children w/ risk factors and sx of OSA at well child care visits
what is OSA
patients occlude their upper airway during sleep and have multiple oxygen desaturations per night.
-These episodes of low oxygen saturation put strain on the cardiorespiratory system and can lead to PHTN and right heart failure over time
risk factors for OSA
-are obesity (BMI greater than 97th percentile)
- tonsillar (3-4+)/adenoidal hypertrophy,
- to a lesser degree: a +FH of OSA, Down’s syndrome and cerebral palsy
sx of OSA
-episodes of arrested breathing/choking during sleep,
-behavior/learning problems including ADHD,
*Children often have larger tonsils until adolescence, and unless they are having recurrent tonsillitis or OSA, watchful waiting is appropriate
how do you determine the size of adenoidal tissue in a child
soft tissue xray of lateral neck
what is the tx for someone who screens positive for OSA and has positive PE
-send for sleep study/refer to ENT
-CPAP machine -- provides positive pressure to keep their airway open while they sleep
what is otitis externa
-aka swimmers ear
-inflammation and exudation in the external auditory canal in the absence of other disorders (ie. AOM, mastoiditis)
what organism most commonly causes otitis externa
Pseudomonas aeruginosa (pools and lakes)
20% of children w/ ___ also develop otitis externa
*associated w/ S. aureus, Streptococcus pneumoniae, Moraxella catarrhalis, proteus, Klebsiella
malignant otitis externa is cuased by what
P. aeruginosa in immunocompromised people or adults with diabetes
when does otitis externa occur mostly
-in summer (not like AOM which is in winter)
*cleaning auidotry canal, swimming and diving disrupt the integrity of the cutaneous lining of the ear canal and local defenses such as cerumen
sx of otitis externa
-pain and tenderness (esp. w/ moving pinna or tragus or chewing)
-canal is erythematous and inflammed
-Malignant OE: facial nerve palsy
*fever is notably absent and hearing is unaffected
DDX of otitis externa
-AOM with tympanic perforation
-Malignancies or cholesteatoma
tx of otitis externa
-topical antimicrobial/corticosteroid otic preparations (ex. ofloxacin, ciprofloxacin w/ hydrocortisone or dexamethasone)
-Tympanostomy tube otorrhea- tx w/ quinolone otic drugs
*avoid swimming or diving until resolved
tx of malignant otitis externa
parenteral antimicrobial, expended spectrum PCN (mezlocillin, cephalosporin)
-complications and prognosis of otitis externa
-resolves 1-2 days after treatment starts
-malignant otitis externa: insavison of the bone of the base of the skull--> cranial nerve palsies
-relapses in 1st year are common
how to prevent otitis externa
-avoid overvigorous cleaning of an asymptomatic auditory canal
-drying auditory canals w/ acetic acid (2%), burow solution, or diuted isopropyl (rubbing) alcohol after swimming
-avoid underwater gear (ear plugs/diving equipment)
what exam do you do for corneal abrasion
-slit lamp or inspect w/ tangential lighting
-fluorescien stain w/ Woods lamp
Abx used for corneal abrasion
polytrim (same Abx as conjunctivits– trying to prevent infection)
if a corneal abrasion is resolving but now has brown discoloration around it
Rust ring-- must be sanded out at opthomology
what test do you do for acute uveitis
indications to refer to ENT for recurrent AOM
-3 or more episodes of GAS in 6 months
-4 in 12 months w/ previous episodes in prior years
where is the lympadenopathy for mono vs GAS
Mono- posterior cervical
GAS- anterior cervical
indications to refer to ENT for GAS carrier
-6 episode of tonsillitis in 1 yr
-3-4 episodes recurring in consecutive yrs
another name for stye
IgE mediated allergic responses or Non-allergic rhinitis with no evidence of allergic etiology
types of allergic rhinitis
1. seasonal allergic- aireborn pollens w/ seasonal patterns
2. Perennial allergic-primarily caused by indoor allergens
3. Episodic allergic-intermittent exposure to allergen
-Intermittent exposure like visiting a friends house who has a dog
ex. Tobacco smoke
episodic allergic rhinitis
allergic rhinitis response due to House dust mites, animal dander, mold, or cockroaches
perennial allergic rhinitis
what are common allergens that cause seasonl allergic rhinitis in the different seasons?
1.Trees pollinate in spring
2.Grasses pollinate in late spring to summer
3. Weeds in the summer and fall
types of non-allergic rhinitis
1. infectious rhinitis (acute or chronic), usually viral
2. Sinusitis (not common in young children)
3. non-allergic, non-infectious
1. Sore throat
3. Poor appetite
infectious non-allergic rhinitis
*if infectious may have ear infection as well
1. Mucopurulent nasal discharge
2. Symptoms beyond 10 days (symptoms typically in older children)
3. Facial tenderness
4. Tooth pain
-Viral infection of nasal epithelial causes and acute inflammatory response with mucosal infiltration by inaflammatory cells and release of cytokines
-Inflammatory response is partly responsible for many of the symptoms
peak incidence of common cold
early fall through late spring
what are typical cold sx and when do they usually develop
develop 1-3 days after viral infection
-Occasional nonproductive cough
-Yellow/green nasal discharge (common around day 3-4 of the URI, not indicative of secondary bacterial sinusitis)
*Persist about 1 week, but 10% up to 2 weeks