1
Q
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A
conjunctivitis
2
Q
What is conjunctivitis?
A
- Inflammation of the conjunctiva
3
Q
What are the types/causes of conjunctivitis?
A
- Three organisms: non-typeable H. influenza, Strep. Pneumonia, S. aureus
- Highly contagious, outbreaks can occur
- Transmission is via direct contact or via fomites. Autoinoculation, from one eye to the other, usually via the fingers is typical.
4
Q
What are the signs and symptoms of bacterial conjunctivitis?
A
- Include a acute onset of mucopurulent discharge from both eyes, red eyes, and edema of the conjunctiva
- Patients may have mild decrease in visual acuity and mild discomfort. The eyes may be “glued” shut on awakening.
5
Q
How is bacterial conjunctivitis diagnosed?
A
• Common pathogens: Gram stain should show the presence of polymorphonuclear cells (PMNs) and a predominant organism, although this is not routinely done
6
Q
How is bacterial conjunctivitis treated?
A
- Attention to hygiene, including hand washing and avoidance of contamination, should be stressed
- Topical antibiotics: sulfonamides, fluroquinolones, and aminoglycosides (drops are more effective than ointment)
- For rare pathogens treatment may also require concurrent systemic antibiotics
7
Q
What are the types/causes of viral conjunctivitis?
A
- Adenovirus type 3, 8 or 19 and coxsackievirus are typical causes. Adenovirus is the most common viral cause of conjunctivitis.
- Highly contagious, transmitted by direct contact, usually via the fingers, with the contralateral eye or with the other persons
- It can be transmitted via swimming pools
- Adenovirus: pharyngoconjunctival fever- triad: pharyngitis, fever, and conjunctivitis
8
Q
What are the signs and symptoms of viral conjunctivitis?
A
• Include watery, red eyes with pre-auricular lymph nodes. Conjunctivitis with lymph nodes: think viral etiology.
9
Q
How is viral conjunctivitis treated?
A
- Eye lavage with normal saline twice a day for 7-14 day; vasoconstrictor-antihistamine drops may also have beneficial effects
- Warm and cool compress reduces discomfort
- Includes supportive treatment with constant hand washing to prevent transmission.
10
Q
What is the cause of allergic conjunctivitis?
A
- Immunoglobulin E (IgE)- mediated reaction caused by triggers such as pollen or dust
11
Q
What are the signs and symptoms of allergic conjunctivitis?
A
- Include watery, itchy, red eyes with edema to the conjunctiva and lids
- Pruritus and chemosis are common
12
Q
What is the treatment for allergic conjunctivitis?
A
- Includes removal of the trigger, cold compress, and anti-histamines
13
Q
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A
Orbital cellulitis
14
Q
What is orbital cellulitis?
A
- Inflammation of the orbital tissues behind the septum
- Orbital cellulitis is postseptal
15
Q
What causes orbital cellulitis?
A
- Less commonly it results from trauma
- The most common organisms are H. influenza, S. aureus, and S. pneumonia
- Most common site: medial orbital wall
16
Q
What are the signs and symptoms of orbital cellulitis?
A
- Orbital cellulitis presents with ptosis, eyelid edema, exophthalmos, purulent discharge and conjunctivitis.
- Examination will reveal fever, restricted range of motion of eye muscles, edema and erythema of the lids and surrounding skin and a sluggish pupillary response
- Proptosis, ophthalmoplegia (painful extraocular motion), and decreased vision differentiate it from preseptal cellulitis
17
Q
How is orbital cellulitis diagnosed?
A
- Workup includes CBC blood cultures, and cultures of any drainage. WBC will be elevated
- CT is recommended to determining the extent of disease. CT will show broad inflammation of the orbital soft tissue.
18
Q
What is the treatment of orbital cellulitis?
A
- Medical emergency requiring hospitalization, IV antibiotics, and surgical drainage if recalcitrant or recurrent.
- Continue IV antibiotics until the fever subsides, then complete with 2-3 weeks of oral antibiotics
- Recommended regimens include nafcillin and metronidazole or clindamycin, second or third generation cephalosporin, and fluroquinolones. If MRSA is suspected treat with vancomycin.
19
Q
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A
periorbital cellulitis
20
Q
What is periorbital cellulitis?
A
- Inflammation of the eyelids and periorbital tissue anterior to the septum
- Periorbital cellulitis is preseptal cellulitis
21
Q
What causes periorbital cellulitis?
A
- Extension of local infections including upper respiratory infection (URI), sinusitis, facial cellulitis, or eyelid infections.
- Trauma: skin trauma is the most likely etiology
22
Q
What are the signs and symptoms of periorbital cellulitis?
A
- Erythema
- Edema
- No pain with extraocular movements
23
Q
How is periorbital cellulitis treated?
A
- Oral or IV antibiotics (e.g., ceftriaxone, clindamycin)
24
Q
xx
A
Strabismus
25
What is strabismus?
- Deviation or misalignment of the eye
- Condition in which binocular fixation is not present
- Strabismus can lead to vision loss (amblyopia)
26
How do we diagnose strabismus?
- Corneal light reflex: the child looks directly into a light source and the doctor observes where the reflex lies in both eyes; if the light is off center in one pupil or asymmetric, then strabismus exists.
- Alternative cover test: the child stares at an object in the distance and the doctor covers one of the child’s eyes; if there is movement of the uncovered eye once the other eye is covered, then strabismus exists. Reveals latent strabismus
27
What is the treatment for strabismus?
- Strabismus may be corrected with eye exercises (patch therapy)
- Prescription glasses may help if the strabismus is secondary to refraction
- Eye muscle surgery may be necessary
28
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Otitis Media
29
What is otitis media?
- Inflammation of the middle ear
30
What causes otitis media?
Etiology:
- S. pneumoniae
- H. influenza
- M. catarrhalis
31
Why are kids more likely to get otitis media than adults?
- The incidence of infection is higher in children because of their Eustachian tube anatomy:
• Horizontal
• Short in length
• Decreased tone
32
What are the risk factors for otitis media?
- The incidence of otitis media is higher in: boys, children in day care, children exposed to secondhand smoke, non-breast fed infants, immunocompromised children, children with craniofacial defects like cleft palate, and children with a strong family history of otitis media.
33
What is acute otitis media?
- Eustachian tube dysfunction is the most important factor
- A red eardrum in a crying child is normal; the most specific sign of acute otitis media is decreased mobility of the tympanic membrane.
- The typical scenario involves a viral URI that leads to Eustachian tube dysfunction or blockage. A bacterial infection occurs with the subsequent build up of fluid and mucus.
34
What are the signs and symptoms of AOM?
Signs and Symptoms:
- Ear tugging
- Ear pain
- Fever
- Malaise
- Irritability
- Hearing loss
- Nausea and vomiting
35
How is AOM diagnosed?
- Diagnosis is made with a pneumatic otoscope- the tympanic membrane will have decreased mobility and will appear hyperemic and bulging with loss of landmarks. The ear canal and eardrum will also be erythematous.
36
How is AOM treated?
- Typically, the first line treatment antibiotic is Amoxicillin. Can also use Augmentin or Azithromycin. High dose can be used for cases most likely to be resistant.
- Anti-pyretics: ibuprofen and/or acetaminophen
- Topical anesthetic eardrops (e.g., benzocaine)
- For healthy children > 2 years old with milder cases, watchful waiting for 24-48 hours is an option
- Pneumococcal vaccine has reduced the incidence of AOM.
37
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Allergic Rhinitis
38
What is Allergic Rhinitis?
- An IgE-mediated response to an allergen causing inflammation of the nasal mucosal membranes
39
What causes allergic rhinitis?
- It commonly occurs in children with other atopic disease (asthma, eczema, atopic dermatitis) and those with a family history
- Allergic rhinitis in children may be a precursor for the development of asthma
40
What are the signs and symptoms of allergic rhinitis?
- Generally do not develop until 2-3 years of age
- Symptoms may be confused with the common cold
- Allergic Shiners
- Allergic salute
- Sneezing
- Watery nasal discharge
- Red, watery eyes
- Itchy ears, eyes, nose and throat
- Nasal obstruction secondary to edema
41
How is allergic rhinitis diagnosed?
- Characteristic findings on physical examination including:
• Boggy, bluish mucous membranes of the nose
• Dark circles under the lower eyelids (“allergic shiners”)
• Allergic salute- horizontal crease on the nose that occurs from constant rubbing
• Rabbit nose- children with allergic rhinitis may exhibit rabbit-like nose wrinkling because of pruritus
- A smear of nasal secretions will show a high number of eosinophils
42
How is allergic rhinitis treated?
- Avoid triggers
- Antihistamines
- Decongestants
- Cromolyn nasal solution
- Topical steroids
43
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Hearing impairment
44
What is the most common cause of hearing impairment in children?
- The most common causes of hearing impairment in children are cerumen impaction and eustachian tube dysfunction
- Infancy and childhood hearing loss:
• Congenital causes include asphyxia, erythroblastosis, and maternal rubella
• Acquired causes include measles, mumps, pertussis, meningitis, influenza and Labyrinthitis
45
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Mastoiditis
46
What is mastoiditis?
- Inflammation of the mastoid air cells in the temporal bone
47
What causes mastoiditis?
- Mostly seen in children after/with an acute otitis media
- If resolution does not occur, may lead to acute mastoiditis with periosteitis, acute mastoid osteitis, or chronic mastoiditis
- Most common pathogen: S. pneumoniae
48
What are the signs and symptoms of mastoiditis?
* Spiking Fever
* Pain behind the ear (post auricular pain)
* Erythema and tenderness over the mastoid area
49
How do we diagnose mastoiditis?
- CT is helpful with the diagnosis
50
What is the treatment for mastoiditis?
- Treatment is IV antibiotics -> oral antibiotics and myringotomy (for culture as well as drainage). If ineffective a mastoidectomy is necessary.
51
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Otitis Externa
52
What is otitis externa?
- Inflammation of the external auditory canal
- Known as swimmers ear
- Occurs when trauma introduces bacteria into an area that is excessively wet to dry
53
What causes otitis externa?
- Bacterial: P. aeruginosa, S. aureus, Proteus mirabilis, Klebsiella pneumonia
- Viral: Herpes
- Fungal: Candida
54
What are the signs and symptoms of otitis externa?
- Ear pain with movement of the pinna
- Pruritus of the ear canal
- Edema of the ear canal
- Otorrhea: usually white in color
- Palpable lymph nodes: Peri- and preauricular
- Normal tympanic membrane
55
How do we diagnose otitis externa?
- Diagnosis is made by otoscopic examination
56
How do we treat otitis externa?
- Topical antibiotics and steroids to reduce edema – aminoglycoside or fluroquinolones +/- corticosteroids (e.g., Cortisporin suspension [hydrocortisone-polymyxin-neomycin-bacitracin])
57
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TM Perforatation
58
What causes a TM perforation?
- Rupture can occur from infection (acute otitis media) or trauma (i.e., barotrauma, direct impact, or explosion)
59
What are the signs and symptoms of a TM perforation?
- Ear pain
- Hearing loss
- Nausea and vomiting
- Facial weakness
- Vertigo
- New onset Otorrhea or clear, particularly unilateral rhinorrhea that is worse with straining
60
How do we treat a TM perforation?
- Most cases will resolve on their own; however, surgical repair of the tympanic membrane as well as the ossicular chain (with persistent hearing loss) may be necessary
- Water/moisture should be avoided to prevent secondary infection that can impede closure
61
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Epistaxis
62
What is an epistaxis?
- Nosebleed
63
What causes an epistaxis?
- The most common location for a nosebleed in children is the anterior septum, because Kiesselbach’s plexus is located there.
- The most common cause is trauma secondary to a finger nail
64
What are the signs and symptoms of an epistaxis?
- Bleeding may occur from one or both nostrils
65
How do we treat nose bleeds?
- Compression for 10-15 min with head tilted forward
- Cold compression to the nose
- Topical vasoconstrictors mat allow visualization of the bleeding site
- Cauterization using silver nitrite
- Packing the nose
66
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Peritonsillar abscess
67
What is a peritonsillar abscess?
- Walled off infection occurring in the space between the superior pharyngeal constrictor muscle and tonsils
- Results from penetration through the tonsillar capsule and involvement of the neighboring tissue
68
What causes a peritonsillar abscess?
- GABHS
| - Anaerobes
69
What are the signs and symptoms of a peritonsillar abscess?
- Preceded by acute tonsillopharyngitis
- Severe throat pain
- Trismus- limited opening of the mouth
- Refusal to swallow or speak
- “Hot potato voice”
- Markedly swollen and inflamed tonsils
- Deviation of soft palate and uvula displaced to opposite side are highly suggestive of tonsillar abscess
70
How do we treat a peritonsillar abscess?
- Aspiration, Incision and drainage
| - Antibiotics covering staph and strep. Typically, amoxicillin, clindamycin or ampicillin – sulbactam
