EENT Flashcards
Acute Rhinosinusitis
Inflammation of the nasal mucosal and paranasal sinuses lasting up to 4 weeks casued by allergens, environmental irritants, and or infection (virus [majority], bacteria, and fungi).
Acute Bacterial Rhinosinusitis
Secondary bacerial infection of paranasal sinuses
* usually following viral URI
* relatively uncommon Less than 2%
* Majority will resolve without Abx
Most common bacterial causes of ABRS
- S. pneumoniae (gram+)
- H. influenzae (gram -)
- M. catarrhalis (gram -)
Diseases cuased by S. pnemoniae
- COMPS
- Conjunctivitis
- Otitis media
- menengitis
- pneumonia
- sinusitis (#1 cause)
- gram+ diplococci
- > 25% drug-resistant
Diseases caused by H. Influenzae
- COMPS
1. Conjunctivitis
2. otiits media
3. menengitis (B)
4. Pneumonia
5. Sinusitis (#2 cause) - Gram - baccillus
- > 30% penicillin resistant via production of beta lactamase - breaks up the beta-lactam ring in most penicillians including amoxicillin, ampicillin
- most ceplasporins are stable in the presents of beta-lactamase
Diseases Casued by M. catarrhalis
- less common pathogen in ABRS (#3 cause), AOM, uncommon cause of CAP
- gram- coccus
- > 90% penicillin resistant via beta lactamase production.
Most common fetures of Acute Bacterial Rhiniosinusitis
- fever and symptom durration more than 10 days
- maxillary toothache
- Initial symptom improvement and then worsening of symptoms
- Cacosmia - sense of bad odor in the nose
- Unilateral facial pain
Treatment of ABRS
- any prior systemic abx use in last month
- risk for resistance? (use 2nd line ABX)
- Initiate first line abx
- If improvement in 3-5 days continue therapy for 5-7 days
- Worsening or no improvement in 3-5 days, broaden coverage or switch to different abx class
Initial ABX regimens for ABRS
- Macrolide abx (azithromycin, clarithromycin, erythromycin, and TMP-SMX{bactrim}) are not reccomended in ARBS due to resistance rates and resulting tx failure
- fluroqinolones (cipro, levo, moxifloxacin) risks outweigh the benifits and should not be used for ARBS, Bronchitis, and uncomplicated UTI, were other treatments are available
- Amoxicillin 500mg TID or 875mg BID
- Amoxicillin-clavulante 875/125 PO BID (augmentin)
- addition of clavulante is a beta-lactamase inhibitor increasing drug effectiveness against h. influinzae and m. catarrhalis
ABRS in penicillin allergy
- usually casue by an allergry to beta-lactam found in penicillins
- without anaphyaxis hx (cephalosporins)
1. cefdinir
2. cefpodoxime
3. cefuroxime - With anaphylaxis Hx (respiratory fluroquinolones)
1. Levofloxacin (preg risk c)
2. Moxifloxacin (pre risk C)
3. Doxycycline (pregnancy risk D)
ARBS treatment failure in 3-5 days
- Amoxicillin-clavulante
- 2/3rd gen cephaloporin (cefpodoxime. cefprozil. cefdinir)
- Levo or moxifloxacin
Medication Substrate
a medication that is metabolized/biotransformed by the isoenzyme (CYP450 34A) usually found in the liver, inorder for the drug to reach site of action and be eliminated
Ex: sildenafil, atorvostatin, simvastatin, alprazolam
Inhibitor
a drug or substance that blocks the activity of the isoenyme (CYP450 34A), limiting substrate excretion, allowing increase in substrate levels, with possible risk of substrate-induced toxicity
* ex: erythromycin, clarithromycin = CYP450 inhibitor
* concomitant use of one of these abx plus drugs that are CYP450 34A substrates will result in increase in substrate levels by decresing iotransformation and elimination.
* ex: Clrithromycin + simvastatin = statin induced rhabdomyolisis risk
* ex: clarithromycin + alprazolam = increased sedation and fall risk
Inducer
Accelerates the activity of the isoenzyme (CYP450 34A) so that the substrate is pushed out the exit pathway, leading to a reduction in substrate level causing dimished therapudic effect, possible treatment failure
* Ex: St john’s wort + COC = off loading estrogen/progestin= spotting and potential contraceptive failure
Conductive hearing loss
- Location: outter or middle ear
- Cause: sound is being blocked ( earwax, forien body, damaged eardrum, serous otits media, bone abnormality)
- Weber result: sound lateralizes to affected ear - buzzing sound louder in affected ear due to increased tissue denisty
- Rinne result: abnormal - bone conduction better than air conduction
- Tx: often self resolves after cerumen removal, post URI or AOM
Sensorineural hearing loss
- Location: inner ear vestibulocochlear nerv CNV111V
- Cause: inner ear or nerve becomes damaged-advanced age, ototoxic meds, immune disorders, trauma
- Weber result - sound lateralizes to the unaffected ear
- Rinne result: normal air conduction > bone conduction
- Tx: hearing aids, cochlear implant possible
Common cold Vs. Flu/COVID
- Cold: primary symptoms are sneez, achs and pain. runny/stuffy nose, and sore throat
- Flu Same as above without sneeze, and the addition of fever, diarhhea, and headache
- Covid: similar to flu with the addition of loss of taste/smell and SOB
Allergic rhinitis treatment
inflammatory, IgE-mediated, characterized by nasal congestion, rhinorrhea, sneezing, intraocular and/or nasal itching.
1. Allergen avoidance
2. Controller therapy - prevent symptoms by preventing formation of or inactivating inflammatory mediators
* Intranasal corticosteroids 1st line (fluticasone, triamcinolone) - up to a week for relief
* Intranasal antihistamine - azelastine - rapid symptom relief
3. Reliver therapy - to relieve acute symptoms by blocking histamine
* 2nd gen oral antihistamine - loratadine, certirazine, levocetirazine
* ocular antihistamine
Therapies not reccomended: Leukotrine modifier (montelukast) or systemic corticosteroids
Oral Cancer
Sqamous Cell Carcinoma 95% cases, HPV16 contributing factor
Risks Factors: Longstanding HPV infection, Tabacco use, alcohol misuse
Presentation: painless, ulcerating oral lesion, usually present many months prior to presenting clincally. Adjacent lymphadenopathy = imobile, nontender node usually >1cm
Dx: referral for bx
angle -closure glaucoma
- sudden increase in intraoccular pressure
- Usually unilateral, acutely red, painful eye with vision change including halos. eyeball firm when compared to other
Macular degeneration
- painless gradual central vision loss
- risks: advanced age, hx of smoking, light eye color, sun exposure, family hx
- test: amsler grid test
- fundoscopic: drusden - soft yellow deposits in macular region
open angle glaucoma
- gradual peripheral vision loss
- avoidable with treatment
- Risks: older adult, African american, long standing DM
- test: abnormal tonometry
Bacterial Vs. Viral Pharyngitis
Bacterial
* significant anterior cervicle lymphadenopathy
* frontal headaches without body aches
* patchy exudates in posterior pharynx - bad breath
* sudden onset
Viral
* Clear nasal drainage
* horseness
* scattered small vessicles on soft palate and tonsils
* generalized body aches
* sore throat preceeded by nasal drainage
Exudative pharygitis treatment
- only with documented group a beta-hemolytic strep infction using positive strep screen or throat culture
- Abx therapy:
1. Penicillin V PO x10 days or amoxicillin 500 PO BID
2. alterantive 1st or 2nd gen cephalosporin x4-6 days
3. beta lactam allergry (penicillan allergry) - azithromycin, clarithromycin, clindamycin (macrolides)
Suppurative conjunctivitis treatment
Common pathogen - S. Aureus, s. pneumoniae, h. influenzae (outbreaks coused by s. pneumoniae)
1. cipro ocular solution, or polymixin B with trimethoprim opthalmic solution
2. alternative axithromycin opthalmic solution
Otitis Externa
Common pathogen: Psudomonas spp., S. aureus, rarely fungi
1. mild: acedic acid with propylene glycol and hydrocortosone drops
2. Mod-severe: otic cipro, with hydrocortisone or dexamethasone
- decrease risk of infection by using 1:2 white vinegar and rubbing alcohol
- do not use neomycin - containing product if TM rupture suspected.
Malignant Otitis externa (necrotizing)
- persons with DM,HIV/AIDS or on chemo
- Pseudomonas
- Treatment oral Cipro
- risk for osteomylitis of skull or TMJ
Otitis media with effusion
- Hx: sensation of fullness or pressure, itch and/or otalgia, conductive hearing loss, no fever or otorrhea
- Exam: air fluid level visable, often with bubbles, opaque yellow or blue, cone of light or bony landmarks diminished. TM mobility limited
- Tx undrlying cause usually allergic rhininitis. usually resolves 1-3 weeks without special intervention.
Acute otitis media
- Hx: sensation of ear fullness, pressure and otalgia, conductive hearing loss, fever common
- Exam: TM redness, bulging, cone of ligt and bone landmarks absent, TM mobility absent, otoorrhea possible with TM rupture.
- Tx: analgesia, abx typically given
AOM ABx
if no abx in prior month
* amoxicillin high dose or
* amoxicillin-clavulante ER or
* cefdinir
If Abx in last month
* amoxicillin-clavulante or
* ceftriaxone
If allergy to beta-lactam (options are less effective)
* TMP-SMX
* or macrolide
