Acute Respiratory Flashcards
What is rhinosinusitis?
flammation of the paranasal sinus and sinus cavity
Viral inoculation by contact with conjunctiva and or nasal mucosa
Spread by systemic and direct route
1in 7 adults per year resulting in 7 million individuals diagnosed each year
1 in 5 antibiotics are for sinusitis
Spectrum of infection that includes
Acute Viral Rhinosinusitis (AVRS)> Acute Bacterial Rhinosinusitis (ABRS)
Most cases ABRS preceded by viral infection
Define acute rhinosinusitis
1-4 weeks
Define subacute rhinosinusitis
4-12 weeks
Define chronic rhinosinusitis
> 12 weeks, may occur with/without acute exacerbations
What are viral etiologies associated with “common cold”
200 different viruses associated with the common cold
Rhinovirus 30-40% Coronovirus 20% Respiratory syncytial virus Influenza virus A B C 10-15% Parainfluenza virus Enterovirus, Echovirus, Coxsackie
what percent of viral infections progress to bacterial infection?
2%; most AVRS resolve in 7 days
Name some predisposing conditions for increased risk to get AVRS
Cold season Decreased humidity Decreased immunity NH residents Allergic disorders *smoking increases symptoms/ duration Not frequency
How does AVRS and ABRS present initially
Nasal congestion , discharge sometimes purulent
Ear pain , sinus pain pressure
Mild sore throat generally resolves 1-3 days
Low grade fever may be present with onset
Cough
Headache
What are some differentials?
Dental infections-gingival swelling, trismus
Foreign body/Sinus tumors- history of recurrent infections , incomplete resolution, localization
CNS etiology ( migraine, meningitis, trigeminal neuralgia-phono-photophobia, EOM pain, headache, fever, Kernig and Brudzinski, nuchal rigidity
Allergic rhinitis –rhinorrhea
Rare: rhinosporidiosis, leismaniasis, blastomyocosis,histoplamosis
what is trismus?
not being able to open mouth more than the size of a quarter
associated with dental infection
What should you treat AVRS with that has good evidence?
Symptomatic relief of nasal obstruction
Rhinorrhea
Analgesics
Saline Nasal Spray
Intranasal steroids +-
Topical decongestants ( don’t affect duration of symptoms) caution rhinitis medicamentosa
Mucolytics (Guaifenesin) +_ published reports
should you suggest antihistamines to manage AVRS?
no- over drying effect
What should you suggest for eustachian tube dysfunction management?
Short course of oral decongestants may be used
people with which conditions should take caution when using oral decongestants?
CV, DM, BPH
what are three conditions under which you should prescribe ABX for ABRS?
- Onset with PERSISTANT symptoms
lasting >10 days - Onset with SEVERE symptoms
fever (102), purulent nasal discharge, or facial pain for at least 3-4 days at beginning of illness
3.Onset with WORSENING symptoms (fevers, HA, increased purulence) following typical viral infection (5-6 days)
What are the most likely bacterial causes for ABRS?
Streptococcus Pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Conjugated vaccines for S.Pneumonia / emergence of non-vaccine serotypes associated with ABRS
what is the recommended initial treatment for ABRS when abx are indicated (include PCN allergic, first and second line, pregnancy)
Augmentin 875 mg BID 5-10 days Pcn allergy: Doxycyline 100mg po BID 5-10 days Levoquin 750 q 24 x 5 days Moxifloxicin 400mg q 24 x 5 days
Pregnancy: macrolide Zpack
Clindamycin 300 mg po TID-QID x 10-14 days
may require additional drug such as
Cefpodoxime 200mg po BID or
Cefixime 400mg daily for 10 days
what should you use to manage symptoms in ABRS?
Analgesics
Saline nasal spray
Topical steroids ( 5 days to effectiveness)
Flunisolide fluticasone budesonide, triamcinolone, mometasone –most effective with allergy overlap
Decongesants –
In combination with anti-histimine shown to be more effective than anti-histimine alone
Afrin bid 3 days only
no affect on duration of illness
what would indicate lack of response to abx in ABRS?
Worsening symptoms 48-72 hours or
failure to improve 3-5 days
why would abx treatment fail to treat ABRS?
Consider
RESISTANCE
NON INFECTIOUS ETIOLOGY
STRUCTURAL ABNORMALITY- CT scan with contrast
What should you treat with when Abx failed in situation of mild/moderate disease ABRS?
Mild – Moderate Disease
(Endoscopic culture ideal but not real)
Respiratory fluoroquinolone , levoquin, moxifloxacin
2nd /Cefprozil 250-500 mg BID
Treatment course 7-10 days
3rd/Cefpodoxime 200mg po BIDWhat should you treat with when Abx failed in situation of severe disease ABRS?
May require hospitalization immediate referral
Unasyn 1.5 – 3 gram every 6 hour
Ceftriaxone 1-2 grams every 24 hours
What is an ABRS/AVRS treatment relapse?
How should you treat this?
Recurrence of s/s within 2 weeks of response to treatment indicates inadequate eradication
Good response with mild relapse
Treat with longer course of same antibiotic
Minimum symptom response with moderate to severe relapse
Change antibiotic , duration of treatment depends on response (7-10 days)
Incomplete response Refer to ENT
When should you refer someone to ENT?
Failed treatment
CT sinus with contrast , CBC
? Immune compromise
Less urgent
Multiple recurrent episodes 3-4 / year
Chronic RS w/wo polyps with recurrent ABRS
Allergic candidates eligible for immune therapy
Urgent : serious complications Immediate referral to ED High persistent fever Orbital edema Severe headache Altered mental status, meningeal signs
name some serious sinusitis complications and how you might rule them out.
Osteomylitis Pott puffy tumor Peri orbital cellulitis, swelling pain , diplopia Seizures CNS palsies – pressure on optic nerve Meningitis- headache, fever, photophobia, +Kernig and Brudzinski Subdural infections Epidural abscess Cavernous sinus thrombosis Brain abscess
What is rhinocerebral mucurmycosis?
Mucorales spores inhalation extending to the orbit (sino-orbital) or brain (rhinocerebral),.
Immune compromise with profound neutropenia
Diabetic ketoacidosis
Black eschar mucous membrane
Rare fungal infection
How would you diagnose someone with chronic rhinosinusitis (CRS)
> 12 weeks duration
Not really considered infectious process but inflammatory , remodeling occurs
At least (2) criteria anterior/ posterior mucopurulent drainage nasal obstruction focal pain, pressure, fullness decreased sense of smell
what are CRS treatment plans and goals of treatment?
Control mucosal inflammation
Maintain adequate sinus drainage
Treatment of colonized organism ( treat exacerbations as acute)
Reduce number of acute infections
Modalities include:
saline washes , topical and systemic steroids( ENT)
anti leukotrines, antifungals
Mainstay: intranasal steroids
intranasal steroid instillations – middle meatus
Caution increased ocular pressure
nebulized antibiotics after surgery
what is Otitis media (OM)
Most common disease that leads to antibiotic treatment
Fluid in middle ear
Inflammatory or infective process
Viral , bacterial, fungal
Associated with upper respiratory infection (in adults)
what might you see on a tympanic membrane that is abnormal vs normal?
Position
Retracted , full, bulging
Translucency
obscured , cloudy, opaque
Mobility
normal, decreased, absent
Color
grey, red, white
Presence of fluid
Discharge/ Perforation
What is acute otitis media, what are risk factors, and what are common pathogens?
Rapid onset, short duration
Middle ear fluid
Inflammation of mucosa that lines middle ear
Obstruction of eustachian tube
URI, allergies, smoking
Common pathogens: S.Pneumonia, H influenza,M.Catarrhalis
2/3 caused by both viral and bacterial
Biofilm- antibiotic resistant cases
Discuss ROS/OLDCART for AOM
Recent illness, uri symptoms , trauma, prior infections, hearing changes, drainage from ear, allergy history
What are associated symptoms with AOM?
Otalgia
Worsens with prone position
Imbalance
Popping , fullness
describe potential physical assessment findings with AOM
+_fevers, adenopathy , Pain with retraction of outer ear, Conductive hearing loss >Weber louder infected ear Bulging tympanic membrane ,erythema, opacification ,poor mobility with pneumatic pressure,rupture associated with purulent otorrhea
discuss potential diagnostic testing when evaluating AOM
Otoscopy
Tympanometry
Acoustic reflectometry ( not used often)
Weber and Rinne conduction testing
Labs: Acute not usually indicated
Recurrent or chronic OM or Immune compromise
Cbc with diff
Sinus CT with contrast esp with intracranial complications
Temporal CT with contrast
Allergy testing
Tympanocentesis> recurrent to identify organism(ENT)
What are some DDx for AOM?
Transient Middle ear effusion Mastoiditis- fevers, ill appearance, IC,DM TMJ disorder Mumps Dental pain Foreign body Trauma Otitis externa Eustachian tube dysfunction Herpes zoster > Ramsay Hunt syndrome Facial paralysis, ear pain, vesicles canal, +-vertigo
What are recommendations for treatment of AOM?
Recommendations for withholding antibiotic therapy in children x 48 hours > 2 years of age with uncertain diagnosis , without severe disease
(moderate to severe otalgia with fever >39 degrees C)
No specific data about withholding treatment in adults with AOM
what is the breakdown of causes/sources of infection in middle ear fluid?
No pathogen 4%
Virus 70%
Bacteria + virus 66%
Bacteria 92%
How likely is AOM to spontaneously resolve based on causative bacteria?
M. Catarrhalis 90%
H. Influenza 50%
Strep. Pneumoniae 10%
Overall 80% resolve within 2-14 days
Middle ear respiratory mucosal membrane forms a barrier rich in lysozyme- defensive immunologic antibacterial activity
What are the recommended treatments for AOM for someone who hasn’t had abx in previous month and failed 48-72 hours observation?
No antibiotics in prior month
Amox HD 1000mg TID
for high resistance prevalence
Mild to moderate : Amox 500 mg bid or 250mg TID Severe Amox 875 mg q 12 or 500mg TID Amox-clav ER 875/125mg po bid
Alternatives with PCN allergy Cefdinir 300mg q12 or 600mg q 24 or Cefpodoxime proxetil 200mg bid or Cefprozil 250-500mg BID **duration 5-10 days, except levo which is 5 days
What are the recommended treatments for AOM for someone who has had abx in previous month and failed 48-72 hours observation?
Amox-Clav ER 875/125 BID
Levofloxacin 750 mg q 24 x 5 days
Moxifloxicin 400 mg q 24
what are indications of definitive abx treatment failure in a person treated for AOM?
Def failure: No change in fever, pain, bulging or otorrhea p 3 days tx
how do you treat a person with AOM if they have a beta lactam allergy?
B-Lactam allergy:
History unclear or rash cephalosporin OK
Avoid cephalosporin if Ig-E mediated allergy> anaphylaxis
Flouroquinolones (DRSP)
Macrolides >limited efficacy for H. Influenza and S. Pneumoniae( 50% resistant)
Clindamycin lacks efficacy against H. influenza or
M. Catarrhalis
what would be causes of treatment failure in AOM?
B- Lactam resistance
Inadequate medical management
Failure
Within 14 days of completion
Recurrent
> 1 month of antibiotic completion
Consider referral to ENT
> 3 or more episodes in 6 months
> 4 in 12 months
How do you treat AOM caused by drug-resistant S. Pneumoniae
High failure rate with TMP-SMX
High dose amoxicillin is generally superior to cephalosporins for penicillin intermediate
If treatment failure with Amox HD , treat with appropriate broad spectrum another 10 day course: Augmentin, trial of 2nd 3rd gen Cephalosporin, Flouroquinolone.
Symptom manage for AOM
Nsaids
Tylenol
Auralgan q 1-2 hours as needed
Antihistimines, decongestants, steroids not proven of benefit for AOM
How would you manage acute ruptured tympanic membrane?
Acute rupture
Treat with oral and topical antibiotics
Avoid water entry
Floxin Otic Choose low acidity and low ototoxicity
Oflox gtts 10 gtts daily esp use with tympanostomy tubes
AVOID aminoglycosides , alcohol , acids, antiseptic agents
AVOID Cortisporin otic suspension ( neomycin polymyxin)
Recheck in 3-4 weeks
consider audiogram and otolaryngolic consultation with persistant subjective hearing loss
Refer for chronic suppurative OM /recurrent persistant purulent drainage
would you give corticosporin otic suspension (neomycin polymyxin) for ruptured TM?
NO! You can use to treat external infection
what is a cholesteatoma
complication associated with perforation
pearly mass behind TM
What are potential complications of AOM and factors to consider?
Host factors, Immune status, individual anatomy
Mastoiditis
fluid often seen in mastoid CT , fever, posterior ear pain , local erythema over mastoid
Labrynthitis
Petrositis vascular neurologic complication lateral rectus palsy
Epidural , subdural, brain abscess
Hearing loss
Meningitis
Lateral sinus thrombosis
what is malignant otitis media?
Invasive osteomylitis extends to cartilage and bone
Pseudomonas 95%
what are risk factors for malignant otitis media?
age, DM, IC
what are s/s of malignant otitis media?
Fever Ulcerations Necrotic granulation tissue Foul aural d/c Granulation Deep otalgia Cranial nerve palsy VI,VII,IX, X,XI
what diagnostic tests should be used to evaluate potential malignant otitis media?
CBC with diff Sed rate very high Glucose Basic chemistry CT temporal bone with contrast/ or MRI ( osseous erosion)
What should f/u and management for malignant otitis media include?
Early onset may initiate antibiotic treatment po and refer
REFER TO ED FOR ENT EVALUATION
CIPRO, PIP-TAZ + TOBRA
