Aquifer - HEENT Flashcards
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DDx - child with congestion, cough, and fever?
- AOM
- Pneumonia
- Sinusitis
- URI
Presentation of AOM?
3-5 days after onset of URI symptoms
Otalgia (ear pain, tugging at ears)
Fever, irritability, cough, anorexia, less commonly vomiting and diarrhea
What are the 5 important components of describing the TM in an ear exam?
- Color
- Other
- Mobility*
- Position*
- Translucency
*More reliable than color for predicting the presence or absence of middle ear disease
Possible descriptors of the color of the TM?
(Pearly) gray, white, red, yellow(/amber)
Possible descriptors of “other”?
Bubbles, air-fluid interface, scarring, perforation
Possible descriptors of TM mobility?
Absent, reduced, normal, or hypermobile
Possible descriptors of TM position?
Normal, retracted, or bulging
Possible descriptors of TM translucency?
Opaque or translucent
Describe a normal ear.
Translucent TM that is neutral or retracted with normal mobility
Describe the findings in OM with effusion.
Fluid in the middle ear space without signs and symptoms of acute inflammation (aka no bulging or fullness of the tympanic membrane, fever, and/or otalgia)
(Fluid is not purulent, TM may or may not be erythematous)
Describe the findings in otitis externa.
Edematous external canal and pain with traction on the ear lobe. Can occasionally follow perforation of the TM in AOM
(Caused by Pseudomonas, S. aureus, Aspergillis)
Describe the findings in AOM.
Moderate or severe bulging of the TM or mild bulging in the context of recent onset of pain or intense erythema of the TM. Should not be diagnosed in the absence of middle ear effusion, as determined by pneumatic otoscopy or tympanometry
Risk factors for AOM?
Day care Tobacco exposure Allergies Bottle propping at bedtime Pacifier use Drinking formula from a bottle rather than breastfeeding Significant family history Male gender Lower SES Respiratory allergies Children with conditions affecting craniofacial structure (cleft palate, Down syndrome) Genetic predisposition (Native Americans)
(Age <2 y/o because immune response against bacterial polysaccharides is not as fully developed, eustachian tube is shorter/more horizontal, less functional)
(Older siblings)
(Immune deficiency)
(Onset of first AOM before 6 months)
List the most common causes of bacterial AOM.
- S. pneumoniae (25-50%)
- H. influenza non-typeable (15-52%)
- Moraxella catarrhalis (3-20%)
- S. pyogenes (<5%)
How can viruses be involved in the pathogenesis of AOM?
Either alter the mucosal lining, thereby increasing bacterial colonization of the nasopharynx, or act as the sole pathogen. When a virus is a co-pathogen, the acute infection may be less responsive to antibiotics
List 3 viruses known to be associated with AOM.
RSV, influenza, rhinovirus
First-line treatment for AOM?
Amoxicillin (effective against susceptible and intermediately resistant S. pneumonia due to alternations in their penicillin-binding proteins) - inexpensive, tastes good, relatively good safety profile, narrow spectrum
Benefits are greatest in children under 2 and those with bilateral AOM
All children 6 months-2 years with bilateral acute otitis media should be treated
(High dose amox - 80-90 mg/kg, divided bid; max 1 g per dose, standard 10 day course, 5-7 days may suffice if low risk)
(Second line - augmention, cephalosporins, azithromycin)
Prognosis of AOM?
Majority of cases resolve spontaneously. Treatment has been shown to shorten the duration of symptoms (otalgia).
Complications of AOM?
Intratemporal complications occur rarely due to the extension of infection into adjacent structures. Most common - mastoiditis, occurs most commonly in children under 2
Additional complications may include facial nerve palsy, labrynthitis, cholesteatoma formation, and CNS infection
How should children age 6 months-2 years with unilateral AOM or children over 2 years with unilateral or bilateral AOM be treated?
Antibiotics: AOM with severe symptoms (toxic-appearing OR persistent ear pain for 48 hours OR fever >39 C within the past 48 housr)
Discuss antibiotics vs. additional observation and close-follow up in those with severe symptoms defined as mild ear pain and temperature <39 C in the past 48 hours
Rates of persistent middle ear effusions after AOM?
1 month (30-50% of children) 2 months (15-25%) 3 months (8-15%)
How should persistent OME be treated?
- Distinguish the child with OME who is at risk for speech, language, or learning problems from other children
- Persistent effusion for 3 months + normal speech and language + no other risk factors for hearing loss should have a hearing assessment. If normal, follow at 3-6 month intervals until effusion resolves.
- Tympanostomy tube placement in children with OME persisting 4 months or longer + hearing loss, documented language or developmental delay, risk of developmental delay, or structural abnormality of TM or middle ear.
Presentation of conjunctivitis?
Conjunctiva appears red and swollen, with some mild lid edema
Depending on the type, there is also either watery or purulent drainage
Causes of conjunctivitis?
Allergies
Chemical irritation
Infection
Presentation of allergic conjunctivitis?
Bilateral red, watery eyes, itchiness and irritation, discharge tends to be mucoid and ropey
Hx of hypersensitive reactions to seasonal allergens, such as pollens and molds, or to perennials such as dust mites and animal dander
Presentation of infectious conjunctivitis (viral vs. bacterial)?
<6 years: bacterial > viral
Both: conjunctival redness and itching, tend to begin in one eye, may spread to the other eye
Bacterial: more likely to cause a purulent exudate with eyelids crusted closed upon awakening
Adenovirus conjunctivitis presentation?
Frequently becomes bilateral, may be associated with pharyngitis and pre-auricular lymphadenopathy
DDx - periorbital swelling
- URI
- Season/perennial allergic rhinitis and conjunctivitis
- Sinusitis (ethmoid, frontal, maxillary)
- Acute allergic reaction
- Periorbital cellulitis
Presentation of periorbital swelling due to a URI?
Concurrent nasal congestion, cough, and/or pharyngitis
Presentation of periorbital swelling due to allergic rhinitis and conjunctivitis?
Pruritis and mucoid discharge, sneezing, itchy nose, and/or clear rhinorrhea
Allergic shiners (darkening/swelling of lower eyelids as a result of venous stasis and sinus congestion) Allergic salute (transverse nasal crease alone lower 1/3 of nose due to pushing nose up/back to relieve itching and obstruction) Dennies-Morgan lines (infraorbital transverse creases due to mild chronic inflammation and intermittent edema of the conjunctivae) Cobblestoning (fine granular appearance of palpebral conjunctivae resulting from edema and hyperplasia of the papillae)
Presentation of periorbital swelling due to sinusitis?
Swelling with or without redness can result from inflammatory edema, which can also occur with URI or allergic rhinitis (usually painless swelling thought to result from the obstruction of venous drainage from periorbital structures into veins that pass through the sinuses because the veins are partially blocked by inflamed tissue in the sinuses)
Associated nasal congestion, headache, and cough
Presentation of periorbital swelling due to an acute allergic reaction?
Abrupt in onset
Urticarial rash
Possible swelling of other parts of the face
Presentation of periorbital cellulitis?
Unilateral, erythematous edema
Often accompanied by a history of local insect bite, trauma, or infection
May also extend from another infection site, such as sinusitis
Periorbital cellulitis most often caused by?
Pneumococci
M. catarrhalis
Non-typable H. influenzae
DDx - Fatigue, Periorbital Edema, and Increasing Abdominal Girth
- Acute glomerulonephritis
- CHF
- Hepatic failure
- Nephrotic syndrome
Why are mildly enlarged tonsils seen in children normally?
Peak growth of lymphoid tissue occurs at 4-6 years of age + because of frequent viral URIs in children of this age
Where can generalized edema be seen in male and female patients?
Male - scrotal region
Female - labia
DDx - absent red reflex or presence of leukocoria (white pupil)?
Cataract Glaucoma Opacified cornea (as in mucopolysaccharidosis) Inflammation of the anterior chamber Chorioretinitis Developmental anomalies of the eye Retinoblastoma
What is strabismus?
Misalignment of the eyes that can lead to amblyopia (poor visual development)
Two methods to assess presence and degree of strabismus in toddlers?
Hirschberg light reflex
Cover/uncover test
