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clinical med exam 2 > ear infections, allergic rhinitis > Flashcards

ear infections, allergic rhinitis Flashcards

1
Q

heat and moisture lead to swelling and maceration of the skin in the EAC; breakdown of skin allows bacteria to enter

Clinical presentation:

  • ear pain, worse with movement of the external ear; pruritis; discharge
  • EAC may be erythematous and edematous
  • may have decreased hearing
  • TM may or may not be intact
A

otitis externa : “swimmer’s ear”

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2
Q

etiology of otitis externa

A
  • psueomonas (38%)
  • step epidermidis (9%)
  • staph aureus (8%)
  • fungal: asperigillus or candida albicans (2-10%)
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3
Q

treatment of fungal otitis externa

A
  • clotrimazole 1% solution BID x 14 days
  • acidifying solution (acetic acid)
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4
Q

treatment of bacteria otitis externa

A
  • cortisporin otic suspension (polymixin B; Neomycin; Hydrocortisone) ** avoid is suspected TM perforation
  • Floxin otic: indicated for perforated TM
  • Use ear wick: if marked swelling of EAC; remove wick after 2-3 days and continue meds as directed
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5
Q

management of otitis externa (things to do other than medication)

A
  • pain control
  • keep canal dry (no swimming 7-10 days)
  • most cases resolve within 5-7 days: if not, consider fungal infection
  • prevention: 2% acetic acid to acidify the EAC
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6
Q

what population is susceptible to malignant otitis externa? what organism causes it?

A
  • seen in diabetics and immunocompromised
  • pseudomonas in 95% of cases

* complications: osteomyelitis; meningitis; mortality

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7
Q

clinical presentation

  • intense ear pain and otorrhea (discharge)
  • red, granulation tissue in EAC
  • possible periauricular lymphadenopathy, edema and trismus (spasm of jaw muscle)
  • elevated ESR or CRP
A

malignant otitis externa

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8
Q

treatment for malignant otitis externa

A
  • admit
  • IV Ciprofloxacin
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9
Q

peak incidence of acute otitis media. Why?

A
  • 6-18 months old
  • usually precipitated by a viral URI; eustachian tube becomes obstructed with fluid and mucus; accumulated fluid become sedentary
  • horizontal eustachian tube allows for migration of organisms from nasopharynx
  • enlarged adenoids prevent adequate drainage
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10
Q

most common pathogens of acute otitis media

A
  • streptococcus pneumoniae (40-50%)
  • haemophilus influenzae (45%)
  • moraxella catarrhalis (10%)
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11
Q

predisposing risk factors of acute otitis media

A
  • age and immature anatomy in children
  • secondhand smoke
  • day care
  • use of pacifier
  • season (fall/winter)
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12
Q

clinical presentation for pediatric patient

  • irritability
  • decreased appetite
  • +/- fever
  • tugging on ear
  • hearing loss
  • may also see conjunctivitis, rhinorrhea, ear dx, vomiting, and diarrhea
A

acute otitis media

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13
Q

clinical presentation in adult

  • otalgia
  • rare to have fever
  • opaque or reddened TM
  • bulging TM
  • decreased TM mobility
A

acute otitis media

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14
Q

otitis media: criteria for diagnosis of children 6 mo -12 years

A
  • moderate to severe bulging of the TM OR
  • new onset of otorrhea not due to acute OE OR
  • mild bulging of TM and recent ear pain ( <48 hr) or intense erythema of the TM
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15
Q

tympanometry

A

quantitative measure of acoustic impedance

  • compliance or resistance of the middle ear in response to changes in air pressure
  • probe inserted into ear canal to deliver positive and negative pressure
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16
Q

type of tympanogram. what conditions will cause this

A
  • type B: little or no mobility
  • fluid or TM perf
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17
Q

type of tympanogram. what conditions will cause this

A
  • type C: retracted
  • eustachian tuve dysfunction
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18
Q

you should trea of Acute otitis media with Abx under what conditions

A
  • < 6 months
  • 6-23 months: severe signs/symptoms or bilat AOM
  • >24 months: if diagnosis is certain and illness is severe

** severe: moderate or severe otalgia, otalgia for > 48 hrs; temperature above 102.2F

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19
Q

you can treat acute otitis media with abx or observation with close follow up (48-72 hrs) if?

A
  • 6-23 months: non severe unilateral AOM
  • > 24 months: non-severe unilateral or bilat AOM
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20
Q

treatment of acute otitis media

A

amoxicillin 80-90 mg/kg/day (q 12 hrs) x 7-10 days

**should not be used in kids who are at high risk of AOM caused by resistant organism

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21
Q

what puts a kid at high risk of AOM caused by resistant organism

A
  • abx in last 30 days
  • concurrent purulent conjunctivitis
  • hx of recurrent AOM resistant to amoxicillin
22
Q

treatment for high risk of AOM caused by resistant organism

A
  1. amoxicillin/clavulanate = Augmentin
  • 90mg/kf amoxicillin and 6.4 mg/kg clavulanate
  • do not use if PCN allergy
  1. omnicef
23
Q

should OTC cold preparations be used in children under 4 yo

A

no

24
Q

how should you treat a recurrent acute otitis media

A
  1. IM rocephin (ceftriaxone)
  2. augmentin
  3. consider need for tympanostomy tubes if 3 or more episodes in 6 months
25
Q

when does otitis media become Chronic

A
  • drainage from middle ear > 2 weeks
  • associated with TM perforation that is usually painless (conductive hearing loss)
26
Q

clinical presentation

  • +/- pain, otorrhea
  • associated with acute or chronic OM
  • conductive hearing loss
  • no movement with pneumatic otoscopy
  • vertigo
A

TM perforation

** most heal spontaneously

27
Q

clinical presentation

  • extension of OE or AOM into mastoid air cells
  • postauricular pain, edema and erythema
  • protrusion of pinna
  • fever
  • deep temporal pain
A

mastoiditis

tx: IV abx; ENT consult

28
Q

etiolofy of otitis media with effusion (OME)

A
  • middle ear effusion secondary to inflammation or eustachian tube dysfunction
  • following a viral URI; AOM; or in association with allergic rhinitis
29
Q

clinical presentation

  • afebrile
  • amber-colored (straw) fluid behind TM
  • may see air fluid level and bubbles
  • neutral or retracted TM
  • conductive hearing loss
  • tympanogram type B
A

otitis media with effusion (OME

30
Q

if you have an adult patient with persistent unilateral otitis media with effusion, what must you do

A

refer to ENT to r/o nasopharyngeal carcinoma

31
Q

management of otitis media with effusion (OME)

A
  • “watchful waiting”; reevaluate 4-6 weeks
  • intranasal steroids in underlying allergic rhinitis
32
Q

when would you present a patient with otitis media with effusion (OME) to ENT for T-tubes

A
  • persistent fluid and/or hearing loss > 3 months duration
33
Q

clinical presentation

  • inflammation or blockage resulting in negative middle ear pressure
  • ear fullness, hearing loss
  • retracted TM; prominent bony landmarks
  • type C tympanogram
A

eustachian tube dysfunction

34
Q

treatment of eustachian tube dysfunction

A
  1. steroid nasal spray; decongestant
  2. topical nasal decongestant
  • phenylephrine (neo-synephrine) or oxymetazoline (Afrin)
  • limit therapy to 3 days to avoid rebound congestion
35
Q

clinical presentation

  • discomfort or damage to ear due to pressure differences (associated with altitude changes)
  • ear fullness; pain; tinnitus
  • bloody otorrhea if TM perforation
A

ear barotrauma

36
Q

treatment for barotrauma

A

supportive

37
Q

what is labyrinthitis

A
  • benign, acute infection or inflammation of vestibular system
  • most commonly associated with viral infection
  • seen commonly in 30-60 yo
38
Q

clinical presentation

  • acute onset of severe vertigo, 1-2 days duration
  • N/V
  • tinnitus and/or unilateral hearing loss. No CNS deficits
  • (+) head thrust: cannot maintain visual fixation
  • horizontal nystagmus
A

labyrinthitis

39
Q

treatment of labyrinthitis

A

symptomatic

  • bed rest; hydration
  • treatment of N/V: meclizine (antivert) 25 mg TID
  • benzodiazepines
40
Q

perennial rhinitis

A

occurs year round: usually due to dust mites, mold, animal dander

41
Q

clinical presentation: exam finding

  • nasal speculum exam: pale, blue mucosa, boggy; clear discharge
  • eyes and periorbital: palpebral conjunctiva may be pale, swollen
  • allergic shiners
  • denie morgan lines: skin folds under eyes
A

allergic rhinitis

42
Q

treatment for allergic rhinitis

A

topical intranasal corticosteroids

  • beclomethasone (beconase)
  • Triamcinolone (Nasacort): OTC
43
Q

treatment for allergic rhinitis: specific symptoms of sneezing, rhinorrhea, and itching

A

antihistamines: first generation

  • chlorpheniramine 4mg q4-6 hr or 8-12 mg BID for sustained release
  • Diphenhydramine (Benadryl) 25-50 mg BID-TID

**side effects: dry mouth, constipation, sedation

44
Q

benefit of second generation antihistamines for treatment of allergic rhinitis

A

less sedating

  • claratin 10 mg daily
  • Allegra 60 mg BID
  • Zyrtex 5-10 mg daily
45
Q

treatment for allergic rhinitis: specifically nasal congestion

A

decongestant: causes vasoconstriction

pseudoephredrine (sudafed) 30-60 q 6-8 hr or 120 mg BID for SR

*** caution flag: HTN, cardiac disease

46
Q

last resort treatment for allergic rhinitis

A

immunotherapy: hyposensitization

  • stimulates production of IgG against allergens
  • success rate 85%
47
Q
  • abnormal autonomic responsiveness triggered by stress, sexual arousal, ciggs, temp changes or anti-HTN medication
  • nasal congestion and rhinorrhea
  • no itching or sneezing
  • nasal mucosa is normal; IgE normal
A

perennial non-allergic (vasomotor) rhinitis

48
Q

treatment of perennial non-allergic (vasomotor) rhinitis

A
  • avoid triggers
  • topical steroids
  • topical antihistamines (azelastine)
  • topical anticholinergics
49
Q

treatment of nasal polyps

** commonly seen with allergic rhinitis, vasomotor rhinitis

A

intranasal glucocorticoids

refer to ENT for obstruction

50
Q
  • see tachyphylaxis (diminished response of drug) with overuse of topical decongestants
  • what is the condition when you see severe rebound congestion after stopping topical decongestant?
  • nasal mucosa is erythematous
A

rhinitis medicamentosa

**treatment: stop medication and treat with intranasal glucocorticoid

51
Q

treatment of otitis media after treatment failure

A

IM rocephin (ceftriaxone) 50 mg IM or IV once daily for 3 days

clinical med exam 2 (6 decks)

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