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Clin Phase II Lecture > Week 1 Reading > Flashcards

Week 1 Reading Flashcards

1
Q

What are the two types of otitis media?

A

Acute otitis media - middle ear effusion with signs and symptoms of an acute infection

Otitis media with effusion - middle ear effusions without the signs of an acute infection. Can follow AOM.

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2
Q

What management method is used in most AOM and OME scenarios?

A

Watchful waiting. These conditions are often self-limited

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3
Q

What treatment is suggested for severe cases of AOM?

A

Antibiotics and or surgery

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4
Q

What are some concerns with cases of OME?

A

Can become a chronic condition that requires weeks or months of monitoring to avoid hearing loss or learning disabilities

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5
Q

What are some risk factors implicated in otitis media?

A

Eustachian tube dysfunction, chronic upper respiratory infections, food sensitivities, environmental/social risk factors

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6
Q

What group is most affected by otitis media?

A

Children under 6

May affect all ages

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7
Q

AOM is most common in _____ and preceded by ______

A

Children, upper respiratory infection

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8
Q

Presence of infection in AOM can only be diagnosed by what?

A

Aspirated fluid of the middle ear. However it is too invasive to be used for diagnostic purposes.

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9
Q

What happens in the first stage of Acute Otitis Media

A

The insulating pathogen causes local vasodilation that results in a greater than normal red reflex on inspection. Entire tympanic membrane may become red and inflamed.

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10
Q

What happens in the second stage of Acute Otitis Media

A

Bacterial toxins cause the vascular elements to increase in permeability.
Middle ear begins to fill with exudates and WBCs flow into the middle ear
Tympanic membrane may rupture

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11
Q

What are the likely sequelae of AOM?

____, ____, ____, ____, ____, ____, ____, ____

A

Mucosal edema of adenoid and lymphoid tissue
Blockage of eustachian tube
Bacterial infiltration into nasopharynx
Sneezing/coughing/sniffing forces bacteria up Eustachian tube
Spreading of bacteria or inflammation
Accumulation of exudate leading to Middle Ear Effusion

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12
Q

Rate of incidence of otitis media by the first birthday? by the third?
By age three __% have had three or more episodes

A

62%, 83%

46%

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13
Q

What are two causes of OME?

A

May occur along with upper respiratory infections or is the sequelae of AOM

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14
Q

__% of children will experience OME before their first birthday. By the time they reach school __% have had OME

A

50%, 90%

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15
Q

Recurrence of AOM

A

high rate of recurrence. when rates equal or exceed 3 in 6 months or 4 in a year the conditions is classified as recurrent.

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16
Q

Most common complications of AOM from most to least common

A

Eardrum perforation, cholesteatoma, mastoiditis, and atelectasis (collapse) of eardrum

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17
Q

Most serious complications of AOM

A

Meningitis, sigmoid sinus thrombosis, brain abscesses

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18
Q

Acute, subacute, and chronic timelines for OME

A

less than 3 weeks, 3 weeks to 3 months, longer than 3 months

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19
Q

80% of OME clear within _ months, 30-40% have recurrent problems and 5-10% last ___ __ ____

A

2, one year or more

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20
Q

Risk factors that increase OME

A 
Bottle fed or pacifier use
Secondary smoke
Attending day care
Low S/E status
Winter
Craniofacial distortions
Dairy
Allergies or family hx of allergies
Diet deficiencies
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21
Q

3 clues for a certain diagnosis of AOM

A

Rapid onset of signs and symptoms
Middle ear effusion
Signs and symptoms of middle ear inflammation

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22
Q

The only isolated symptoms useful in diagnosing AOM is what?

A 
ear pain (specific 82-92%, LR 3-7.3)
Ear tugging in an infant
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23
Q

Useful clues for OME

A

Patient appears normal
Little or no pain
Slower onset (<48 hours), more chronic in nature
No fever

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24
Q

What are the steps for evaluation of Otitis Media

A 
Appropriate history
Check for facial distortion
Check for signs of infection
Check for signs of hearing loss
Evaluate external ear
Evaluate middle ear
Evaluate neck biomechanics
If there is no evidence of otitis media or other ear pathology check for other sources of pain
If necessary ancillary studies (acoustic tympanometry, audiometric evaluation, CBC)
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25
Co-factors placing children at greater risk for developmental difficulties
``` Permanent hearing loss apart from OME Speech and language disorder or delay Autism-spectrum syndromes or craniofacial disorders Blindness or uncorrected visual impairment ```
26
In cases where there is an acute change in hearing is suspected how long should a patient be monitored?
3 months
27
Because evaluating bacterial presence in AOM is invasive what two tests are often employed?
The ear is first evaluated with otoscopy | Pneumatic endoscopy can be used to differentiate AOM from OME and diagnose OM
28
What joint should be evaluated in cases of ear pain and dysfunction?
TMJ | and look for MFTP in lateral and medial pterygoid, masseter and SCM
29
What is tympanometry used for?
indirect measure of mobility of tympanic membrane and may be used as a confirmatory test for OME Negative predictive value for normal test is between 64 and 93%
30
What is acoustic reflectometry used for?
Diagnosis of MEE and does not require a full seal so it can be used with an uncooperative patient
31
What is tympanocentesis?
Surgical puncture of the tympanic membrane to drain the middle ear and is similar to myringotomy where tunes are inserted both can be used for diagnosis
32
Mastoiditis from AOM
Follows several weeks of untreated AOM Post-auricular pain with reddening and a spiking fever X-ray reveals destroyed mastoid air cells
33
Petrous apicitis from AOM
Medial portion of the petrous bone becomes a site of infection when drainage of pneumatic cells is blocked May cause foul discharge, deep ear and retro-orbital pain and 6th nerve palsey
34
Facial palsey from AOM
associated with either acute or chronic otitis media | inflammation of the 7th cranial nerve
35
Sigmoid sinus thrombosis from AOM
Trapped infection within mastoid air cells Systemic sepsis and increased intracranial pressure (HA, lethargy, nausea, vomiting, papilledema)
36
CNS infection from OM
Otogenic meniongitis is the most common intracranial complication from ear infection AOM - from hematogenous spread of bacteria chronic otitis media - passage of bacteria along certain pathways or from extension through dural plates of petrous pyramid
37
Epidural abscesses from OM
From direct extension of the disease from chronic infection | usually asymptomatic but may present with pain, HA and low grade fever
38
Definition of rhinosinusitis
Symptomatic inflammation of paranasal sinuses and nasal cavity
39
Rhinitis definition
Inflammation of the nasal mucous membrane | infection can then spread to the sinuses causing RS
40
Types of rhinosinusitis
Acute RS and Chronic RS | both can be bacterial or nonbacterial
41
Acute rhinosinusitis duration
longer than 7 days but less than 4 weeks | Less than 7 days is rhinitis
42
Chronic rhinosinusitis duration
Longer than 12 weeks with or without acute exacerbations
43
Chronic rhinosinusitis (polyps)
In addition to bacterial or viral there can be the addition definition of with/without polyps With polyps responds poorly to treatment and has a higher rate of recurrence
44
Possible origins of RS
bacterial, fungal, viral, allergic, environmental | Ethmoid and sphenoid are most often affected. Isolated sphenoid is serious.
45
Diagnosis of acute RS
ARS is clinical in nature, based on a combination of symptoms and signs, and does not require ancillary studies.
46
Diagnosis of chronic RS
By symptoms and due to low specificity may require endoscopy or CT imaging for confirmation
47
Cardinal diagnosis of RS
Nasal discharge OR nasal obstruction AND Facial pain-pressure-fullness OR reduction/loss of smell.
48
Clinical pneumonic for RS
PODS | (Pain or facial pressure, nasal Obstruction, discolored Discharge, loss of Smell.
49
Presence of discharge in RS
May or may not be purulent and if clear should be congested
50
RS discharge locations
If nasal it implicates frontal or maxillary sinuses | if pharyngeal
51
VIral pattern of RS
Viral RS symptoms generally peak days 2 to 3 after onset and then begin to improve. Symptoms may persist 14 days or longer, but a key differentiating feature (from bacterial) is that they are mild and continue to decrease in severity
52
Bacterial pattern of RS
Duration is a key factor Significant symptoms persisting beyond 10 days indicate a possible bacterial infection. Suspect bacterial if symptoms initially improve and then get worse
53
AAO-HNS criteria for bacterial RS
symptoms or signs of acute rhinosinusitis persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms.
54
Three Cardinal Symptoms of Bacterial RS
Purulent (infected, colored, or oozing) nasal drainage. Patient complaints of nasal obstruction Facial or dental pain (unilateral over teeth or maxilla) (double sickening), presence or absence of discharge is not enough to rule it out
55
Fokken's criteria for RS
In addition to typical signs there is also at least 2 of the following Symptoms last longer than 7 to 10 days or worsens again after initial improvement; Symptoms, particularly pain over teeth and maxilla, are severe (7 to 10 cm VAS); Purulent secretions on rhinoscopy; Increased ESR or elevated CRP; Fever >38°C; 100.4°F
56
Complication due to RS most frequently occur in _____ and ______
In children with acute RS | Adults with chronic RS
57
Indicators for infectious spread of RS
``` Orbital pain High fever (102°) Painful edema (possible preseptal cellulitis) Limited and painful ocular movement Visible swelling of the conjunctiva Exophthalmos (post-septal inflammation) Alerted mental status with high fever Frontal or retro-orbital migraine ```
58
Clues for allergic rhinitis
Thin watery discharge History of allergic response Consistently positive skin-prick test Absence of fever, chills, myalgia, lymphadenopathy, productive cough, and sore throat.
59
DDX for ARS
Viral and allergic rhinitis, dental disease, and various | headaches and facial pain syndromes
60
Use of ancillary studies for acute RS
Neither nasal endoscopy, radiographs, blood work, nor any other ancillary study is required to make the initial diagnosis of uncomplicated acute RS. CT scan and/or endoscopy are the most common tests of choice to increase the accuracy of the diagnosis in the case of chronic or recurrent RS.
61
Treatment failure of RS for ___ should result in | a referral for CT or endoscopy without first performing plain film radiography
2-3 months
62
Radiographs for RS
not indicated unless there is a complication
63
INDICATIONS FOR CT for RS
CT without contrast, not plain radiography or MRI, is the modality of choice to confirm chronic RS One approach is to order CT initially in cases of suspected chronic RS to confirm the diagnosis Another approach is to limit the use of CT to patients 1) who have not responded to maximum medical therapy, 2) to plan for sinus surgery, or 3) to clarify the diagnosis in patients with symptoms of chronic RS, but who lack any objective evidence from anterior rhinoscopy or endoscopy.
64
INDICATION FOR MRI for RS
Usually is reserved for differential diagnoses of more serious conditions already identified by CT, such as intracranial and intraorbital complications of sinusitis, neoplasms, and fungal disease
65
Basic blood tests in diagnosis for RS
not required to make a diagnosis of acute RS. Useful for diffferentiation CRP and /or ESR have some limited value in supporting a diagnosis of acute RS. An ESR >30 has a reported +LR of 4.1 and if >40 a +LR of 7.40. A positive CRP had a +LR of 2.9.
66
Assessment strategy for RS
1. Differentiate RS vs rhinitis vs other causes of the symptoms 2. If the patient has RS, differentiate acute, chronic, or recurrent. (If chronic, record as chronic with or without polyps). 3. If the patient has RS, differentiate viral vs bacterial (or allergic/irritant). 4. Screen for severe complications resulting from infectious spread beyond the sinuses and refer as needed. 5. Establish a baseline to monitor improvement especially for chronic or recurrent RS. 6. Assess patients who have chronic rhinosinusitis or recurrent acute rhinosinusitis for co-morbidities such as asthma, cystic fibrosis, ciliary dyskinesia* and any immunocompromised state.
67
Pain location of RS by affected sinus
Maxillary sinusitis: pain in the maxillary area, toothache and frontal headache. Frontal sinusitis: pain over the sinuses or frontal headache, severe pain to the temple or sometimes to the occiput. Ethmoid sinusitis: pain behind and between the eyes, and a frontal headache that is often described as “splitting.” Isolated sphenoid sinusitis (rare). Pain is less well localized and is referred to the frontal or occipital area.
68
Predisposing factors for RS
Recent upper respiratory infection dental procedures, exposure to smoke, physical or chemical irritants, household molds, and forceful nose blowing. Frequent participation in swimming and diving, immuno-suppressive therapy, chronic diseases such as diabetes or renal disease. History of allergies
69
Where to palpate and percuss for RS
``` Medial angle of the eye (ethmoid sinus) Roof of the orbit (beneath the frontal ridge) (frontal sinus) The bony prominence at the cheek (maxillary) Anterior frontal wall (frontal sinus) The palate (intraoral) (maxillary sinus) ```
70
Transillumination
opaque transillumination ruled in sinusitis and normal | transillumination ruled it out
71
If polyps are seen on a rhinoscopic exam
patient is under the age of 16, arrange for a sweat test to rule out cystic fibrosis patient is an adult, consider referral for an ENT evaluation.
72
Nasal tumors are more common in ___ ____ years
men > 60 | Malignant nasal tumors are rare (3% of all head and neck cancers) but can present as chronic RS
73
If there are crusty patches on a rhinoscopic exam
fungal infection should be highly suspected
74
If the patient has nasal discharge that is watery without pus on a rhinoscopic exam
Suspect allergic or vasomotor rhinitis
75
If discharge is cloudy but colorless on a rhinoscopic exam
Suspect nonbacterial or viral sinusitis.
76
If there is drainage of pus from ostia of the | nasal meatus
Suspect acute sinusitis.
77
Sinusitis may lead to and perpetuate myofascial trigger points (MFTPs) in the ___
SCM
78
Reduced _____ ___ _____ | of the neck could be associated with extraspinal spread of an infection
Active range of motion
79
In children an ____ ______ should be performed to assess possibility of OM in children
Otoscopic exam
80
Red flags for poorer prognosis with RS
Fever of 102F and/or chills may indicate an extension of the bacterial infection Yellow, brown or green discharge, positive culture, or positive ESR/CRP may indicate bacterial infection and may warrant referral for possible antibiotic therapy Stiff neck and/or disorientation are signs of extension of infection to the central nervous system Changes in visual acuity or deficits in cranial nerve III
81
Immediate referral for antibiotic therapy
include orbital pain, periorbital swelling/ | erythema, or facial swelling/erythema

Clin Phase II Lecture (6 decks)

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