EENT Flashcards
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conjunctivitis
What is conjunctivitis?
- Inflammation of the conjunctiva
What are the types/causes of conjunctivitis?
- 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.
What are the signs and symptoms of bacterial conjunctivitis?
- 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.
How is bacterial conjunctivitis diagnosed?
• Common pathogens: Gram stain should show the presence of polymorphonuclear cells (PMNs) and a predominant organism, although this is not routinely done
How is bacterial conjunctivitis treated?
- 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
What are the types/causes of viral conjunctivitis?
- 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
What are the signs and symptoms of viral conjunctivitis?
• Include watery, red eyes with pre-auricular lymph nodes. Conjunctivitis with lymph nodes: think viral etiology.
How is viral conjunctivitis treated?
- 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.
What is the cause of allergic conjunctivitis?
- Immunoglobulin E (IgE)- mediated reaction caused by triggers such as pollen or dust
What are the signs and symptoms of allergic conjunctivitis?
- Include watery, itchy, red eyes with edema to the conjunctiva and lids
- Pruritus and chemosis are common
What is the treatment for allergic conjunctivitis?
- Includes removal of the trigger, cold compress, and anti-histamines
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Orbital cellulitis
What is orbital cellulitis?
- Inflammation of the orbital tissues behind the septum
- Orbital cellulitis is postseptal
What causes orbital cellulitis?
- Less commonly it results from trauma
- The most common organisms are H. influenza, S. aureus, and S. pneumonia
- Most common site: medial orbital wall
What are the signs and symptoms of orbital cellulitis?
- 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
How is orbital cellulitis diagnosed?
- 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.
What is the treatment of orbital cellulitis?
- 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.
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periorbital cellulitis
What is periorbital cellulitis?
- Inflammation of the eyelids and periorbital tissue anterior to the septum
- Periorbital cellulitis is preseptal cellulitis
What causes periorbital cellulitis?
- Extension of local infections including upper respiratory infection (URI), sinusitis, facial cellulitis, or eyelid infections.
- Trauma: skin trauma is the most likely etiology
What are the signs and symptoms of periorbital cellulitis?
- Erythema
- Edema
- No pain with extraocular movements
How is periorbital cellulitis treated?
- Oral or IV antibiotics (e.g., ceftriaxone, clindamycin)
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Strabismus
What is strabismus?
- Deviation or misalignment of the eye
- Condition in which binocular fixation is not present
- Strabismus can lead to vision loss (amblyopia)
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
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
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Otitis Media
What is otitis media?
- Inflammation of the middle ear
What causes otitis media?
Etiology:
- S. pneumoniae
- H. influenza
- M. catarrhalis
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
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.
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.
What are the signs and symptoms of AOM?
Signs and Symptoms:
- Ear tugging
- Ear pain
- Fever
- Malaise
- Irritability
- Hearing loss
- Nausea and vomiting
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.
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.
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Allergic Rhinitis
What is Allergic Rhinitis?
- An IgE-mediated response to an allergen causing inflammation of the nasal mucosal membranes
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
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
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
How is allergic rhinitis treated?
- Avoid triggers
- Antihistamines
- Decongestants
- Cromolyn nasal solution
- Topical steroids
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Hearing impairment
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
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Mastoiditis
What is mastoiditis?
- Inflammation of the mastoid air cells in the temporal bone
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
What are the signs and symptoms of mastoiditis?
- Spiking Fever
- Pain behind the ear (post auricular pain)
- Erythema and tenderness over the mastoid area
How do we diagnose mastoiditis?
- CT is helpful with the diagnosis
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.
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Otitis Externa
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
What causes otitis externa?
- Bacterial: P. aeruginosa, S. aureus, Proteus mirabilis, Klebsiella pneumonia
- Viral: Herpes
- Fungal: Candida
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
How do we diagnose otitis externa?
- Diagnosis is made by otoscopic examination
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])
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TM Perforatation
What causes a TM perforation?
- Rupture can occur from infection (acute otitis media) or trauma (i.e., barotrauma, direct impact, or explosion)
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
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
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Epistaxis
What is an epistaxis?
- Nosebleed
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
What are the signs and symptoms of an epistaxis?
- Bleeding may occur from one or both nostrils
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
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Peritonsillar abscess
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
What causes a peritonsillar abscess?
- GABHS
- Anaerobes
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
How do we treat a peritonsillar abscess?
- Aspiration, Incision and drainage
- Antibiotics covering staph and strep. Typically, amoxicillin, clindamycin or ampicillin – sulbactam
