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Pediatric Primary Care Exam 2 > Eye and Ear > Flashcards

Eye and Ear Flashcards

1
Q

Conjunctivitis Newborn Incidence (5)

A
  1. Newborn Incidence is 1.5-12%
  2. Vertical transmission from mom to baby - Usually will occur within first 28 days of life
  3. Ophthalmia neonatorum
  4. Vertical transmission
  5. Gonorrhea and Chlamydia
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2
Q

Conjunctivitis in Infants- School Age

A

Twice as likely to be bacterial

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3
Q

Conjunctivitis in School Age and Older

A

Likely to be viral

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4
Q

Conjunctivitis Pathology (5)

A
  1. The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as streptococci, staphylococci
  2. The primary defense against infection is the epithelial layer covering the conjunctiva.
    - Disruption of this barrier can lead to infection.
    - Rubbing eye, etc.
    - Little children’s hands go all over the place and then touch eye
  3. Secondary defenses include hematologic immune mechanisms carried by the conjunctival vasculature; tear film immunoglobulins and lysozyme; and the rinsing action of lacrimation and blinking.
  4. Any alteration in this defense allows the bacteria to get through and leads to the clinical presentation of conjunctivitis
  5. Alterations in the host defense or in the species of bacteria can lead to clinical infection.
    - External contamination: contact lens wear, swimming
    - Spread from adjacent infections: rubbing of the eyes
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5
Q

Bacterial Conjunctivitis Incidence (2)

A
  1. 50-75% of acute infectious conjunctivitis → suppurative, non-neonatal infections (it’s not maternal/vertical transmission)
  2. 50-75% of infectious conjunctivitis is bacterial
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6
Q

Common Bacterial Conjunctivitis Pathogens (5)

A
  1. Haemophilus (decreased with Hib immunization)
  2. Streptococcus pneumoniae (Most common)
  3. Staphylococcus aureus ( also most common)
  4. Moraxella catarrhalis
  5. Pseudomonas
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7
Q

Bacterial Conjunctivitis Clinical Presentations

A

Caps lock = main manifestations

  1. Unilateral or bilateral CONJUNCTIVAL HYPEREMIA
  2. Mild to moderate PURULENT DISCHARGE
  3. EARLY MORNING CRUSTING – A BIG ONE!
    - Wake up in the morning or from nap and their eyes are stuck together; have to pry the eyelashes apart or use a warm compress; more indicative of bacterial than viral
  4. Red eyes
  5. Eyelid edema
  6. Erythema surrounding the eye
  7. Excessive tearing
    - Tearing usually more common with viral, but the patient may feel like they have something in their eye continually
  8. Itching
  9. PAPILLAE: Vascular reaction – red cobblestone appearance when flipping lid over (do thorough eye exam)
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8
Q

Bacterial Conjunctivitis vs. Cellulitis

A

With bacterial conjunctivitis, watch for cellulitis – very erythematous
*Abnormal ocular movements, loss of visual acuity, may signal spread of infection beyond the orbital septum (orbital cellulitis)

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9
Q

Bacterial Conjunctivitis: When to stay out of daycare

A

Any time discharge is present!

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10
Q

Bacterial Conjunctivitis Diagnosis (3)

A
  1. Clinical suspicion
  2. Gram stain and culture if severe
  3. Refer to ophthalmologist if not resolving
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11
Q

Bacterial Conjunctivitis Management (7)

A
  1. Culture NOT usually required outside of the neonatal period because it is a self limiting disease
  2. Chest X-ray in neonates to rule out pneumonia with conjunctivitis and respiratory symptoms
  3. No school until discharge has resolved
  4. If persists > 7-10 days - culture!
  5. Hygiene
  6. For Staph etiology – daily lid cleaning baby shampoo, warm compress
  7. Do not try to pry the eyes open – can be very painful
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12
Q

General Info about Bacterial Conjunctivitis Treatment (4)

A
  1. Topical antibiotics = first line agent
    * Shortens time and prevents secondary cases by eradicating the organism
  2. Broad spectrum without culture for routine, mild to moderate conjunctivitis
  3. Treat - 5-10 day range
    - Continue it because improvement will occur within 3 days but it isn’t fully eradicated
    - Do it for at least 2 more days until it is cleared; try and do 5-7 days
  4. If not cleared by 10 days, see the patient again
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13
Q

Eye drops for conjunctivitis treatment (2)

A
  1. Do not interfere with vision

2. May sting – hard to put in alone

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14
Q

Ointments for conjunctivitis treatment (3)

A
  1. Advantage of prolonged contact with ocular surface
  2. Soothing effect
  3. Blurs vision
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15
Q

Conjunctivitis treatment for younger vs. older child

A
  1. Younger: If you want broad spectrum coverage for mild conjunctivitis in younger child use Erythromycin in ointment form
  2. If older child → go with a drop, Maybe tobramycin
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16
Q

Polytrim (trimethoprim-and polymixin B sulfate) (4)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. Effective against MRSA
  3. For > 2 months of age
  4. 1 drop every 3-4 hours (max 6 doses/24 hours) for 7-10 days
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17
Q

Garamycin/Gentak (gentamicin) (5)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. Effective against MRSA
  3. Gram negative coverage-Pseudomonas, staph aureus, Strep, H. Influ
  4. Ointment 0.3%: 0.5 inch ribbon q 8-12h
  5. Drops 0.3%: 1-2 drops q 4h
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18
Q

Tobrex (tobramycin) (4)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. Ointment -0.5 inch ribbon TID (BID)
  3. Drops – 1-2 drops every 4 hours (4-5 times/day)
  4. NOT tobradex routinely – only for severe infections with swelling (Because it contains a steroid)
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19
Q

Vigamox (moxifloxacin) (4)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. It stings!!
  3. 1 year or older
  4. 1 drop TID (3 times/day) for 7 days
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20
Q

Aza Site (azithromycin) (4)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. 1 year or older
  3. Macrolide - 7 day treat
  4. Easier dosing – 1 drop BID x 2 days…followed by 1 drop DAILY x 5 days
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21
Q

Besifloxacin (Besivance) (4)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. > 1 year of age
  3. 1 drop to affected eyes TID for 7 days
  4. 4th generation fluoroquinolone – broad spectrum +/-
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22
Q

Erythromycin (4)

A
  1. Antibiotic topical therapy for conjunctivitis
  2. SAFE for infants
  3. Ointment only: 0.5 inch ribbon to affected eye BID—QID
  4. Macrolide
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23
Q

Conjunctivitis Incubation

A

Contagious period ends when course of antibiotics started OR when symptoms/discharge no longer present

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24
Q

Viral Conjunctivitis (3)

A
  1. Common, self-limiting
  2. ADENOVIRUS most common cause – will see fever, sore throat, respiratory symptoms
  3. If only presentation is eye and not the above then they can go back to school
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25
Q

Viral Conjunctivitis Course (2)

A
  1. Highly contagious/incubation 10-12 days from onset

2. Duration – usually resolves spontaneously within 2-4wks

26
Q

Viral Conjunctivitis Transmission (2)

A
  1. Accidental inoculation of viral particles from hand to eye
  2. Contact with infected upper respiratory droplets
27
Q

Viral Conjunctivitis Presentation (5)

A
  1. Pink
  2. Swollen
  3. Watery discharge
  4. Follicles - Lymph reaction
  5. Unilateral more frequent***
28
Q

Viral Conjunctivitis Management (4)

A
  1. Treat the symptoms
  2. No antibiotics
  3. Supportive
  4. No school/daycare until fever free – observe symptoms
29
Q

Bacterial and Viral Conjunctivitis Prevention (7)

A
  1. Hand washing
  2. Washing toys and surfaces
  3. No sharing towels/linens
  4. Staying home! Until drainage is gone
  5. Covering mouth and nose
  6. Making daycare and schools aware
  7. Education
30
Q

Allergic Conjunctivitis Presentation (3)

A
  1. Itching, redness, excessive tearing
  2. Usually bilateral
  3. Papillae may be present
31
Q

Allergic Conjunctivitis Management (2)

A
  1. Remove allergen – occurs in response to contact with the agent
  2. Not contagious!
32
Q

Allergic Conjunctivitis Season

A

Spring and fall are high seasons when this occurs

33
Q

Allergic Conjunctivitis Education

A

Educate family, child and setting so they can go back to school- Because not contagious

34
Q

Chemical Conjunctivitis Presentation (2) and Management (2)

A

Presentation:

  1. Red, watery eyes, may burn or sting
  2. Usually bilateral

Management

  1. Find the cause - ex: Swimming pool with chlorine
  2. Not Contagious!
35
Q

Acute Otitis Media (3)

A
  1. Also known as- acute suppurative or purulent OM
  2. AOM is the 2nd most common reason for visits to provider next to well child visits.
  3. AOM is the most common reason antibiotics are prescribed for children
36
Q

5 categories of acute otitis media

A
  1. AOM
  2. Otitis media with effusion (OME)
  3. Recurrent AOM
  4. Chronic AOM
  5. Chronic suppurative AOM (CSOM)
37
Q

Acute otitis media clinical presentation (2)

A
  1. Sudden onset of inflammation of the middle ear

2. Often accompanied by fever, and otalgia

38
Q

Diagnosis of acute otitis media (3)

A
  1. History of acute onset of symptoms
  2. Presence of middle ear effusion (MEE)
  3. AAP, 2013 states “presents with recent onset of ear pain and marked erythema of the TM as the only findings on otoscope exam”
39
Q

Acute otitis media can be indicated by….(4)

A
  1. Bulging tympanic membrane (TM)
  2. Limited or absent TM mobility
  3. Air fluid level behind the TM
  4. Otorrhea not due to otitis externa
40
Q

Recurrent AOM definition

A

frequent AOM with complete clearing between (3 new within 6 months OR 4 documented infections in 1 year)

41
Q

Otitis Media Effusion (OME) definition

A

OME-presence of middle ear fluid after antimicrobial treatment- fluid may persist for 2-3 months (60%- in 3-4 weeks)

42
Q

Chronic OME definition

A

(serous OM) glue ear- persistence of fluid in the middle ear for >3months, TM retracted, impaired mobility

43
Q

CSOM definition

A

non intact TM, perforation or tympanostomy tube with >6 weeks of ME drainage

44
Q

AOM pathogenesis (3)

A
  1. Eustachian tube occluded- fluid accumulation- infected with bacteria
  2. Anatomy may play a part- ET is shorter, wider and straighter in children
  3. In young children it may not drain as well due to these anatomical differences (half size of the adult length and is short & stubby & straighter)
45
Q

AOM Microbiology (3)

A
  1. Strep. Pneumoniae – Prevnar13 has significantly decreased this incidence
  2. H. Influenza
  3. Moraxella catarrhalis
46
Q

AOM Risk Factors (8)

A
  1. Age; Younger = higher risk
  2. Sex; Male > Female
  3. Race
  4. Feeding practices
    * Infant population with bottle prop or breastmilk reflux up and sit’s in pocket and is unable to drain
  5. Anatomy
  6. Smoke exposure
  7. Daycare
  8. Trisomy 21
47
Q

AOM Management

Current Guidelines

A

Current guidelines for treatment of AOM consist of the use of antibiotics or observation without antibiotics for children 6 months to 2 years of age.

48
Q

Non-traditional AOM Treatments (2)

A
  1. Olive oil drops
  2. Xylitol syrup (sugar alcohol)
    * Has antibacterial properties – suppressing growth of Strep mutans, Strep pneumoniae & H. Influenza (75% of all AOM cases)
    * Give 5 times a day as a gum or syrup to reduce AOM
    * Prolonged effect contact with pharyngeal mucosa
    * For otitis prone 6 months to 5 year olds
    * Not proven to be effective – but some still use
49
Q

AOM First Line Treatment Info (6)

A
  1. Amoxicillin for non-penicillin allergic children
  2. Supplied as suspension 200mg/5ml, 400mg/5ml
  3. 80-90mg/kg/d divided BID for 10 days
  4. Refrigerate
  5. Pink – flavored, tasty
  6. If they vomit it, do not readminister at that time
50
Q

AOM Second Line Treatment Info (3)

A
  1. Augmentin (amoxicillin/clavulanate)
  2. 80-90mg/kg/d of Amox and 6.4 mg of Clavulanate comp
  3. Indicated for those that “fail” Amoxicillin or have been on Amoxil in past 30 days
51
Q

1st and 2nd line treatment for AOM if PCN allergic (2)

A

1st line: Macrolide option- Azithromycin

  • Suspension supplied 100mg/5ml
  • Dose 500mg day 1 – once a day
  • Dose 250mg days 2-5 – once a day

2nd: Cephalosporin – Omnicef/Cefdinir
- 10-15% cross-reactivity
- Reported failures and resistance
- 125mg/5ml oral suspension or 250mg/5ml
- 6m-12y age = 14 mg/kg/day divided q 12-24h
- Max dose: 600mg/24h

52
Q

AAP Guidelines for Diagnosing AOM (3)

A
  1. Clinicians should diagnose AOM in children who present with moderate to severe bulging of the TM or NEW onset otorrhea not due to otitis externa
  2. Clinicians should dx AOM in children with mild bulging of the TM and recent (less than 48 hrs) onset of ear pain, holding, tugging, rubbing of the ear in nonverbal child. Or intense erythema of TM
  3. Clinicians should NOT dx AOM in children who do not have middle ear effusion (MEE) on pneumatic otoscopy and or tympanometry
53
Q

AAP Guidelines for Managing AOM

A

The management of AOM should include and assessment of PAIN. If present should recommended tx to reduce pain.

54
Q

AAP Guidelines for Treating AOM (3)

A
  1. Severe AOM- Clinicians should prescribe abx therapy for AOM (uni/bilateral) in children 6 months and older with severe signs or symptoms – moderate or severe otalgia, otalgia for at least 48 hours, temperature of 39C, (102.2F) or higher
  2. Non-severe bilateral AOM in young children- clinician should prescribe abx therapy for bilateral AOM in children 6 – 23 months of age without severe signs or symptoms (mild otalgia, <48hrs, temperature less than 39C)
  3. Nonsevere AOM- in older children- prescribe OR observe with close follow up based on Joint decision making - =/>24 months of age –without severe s/s (mild otalgia <48hrs and temp < 39C)- WHEN observation is used – mechanism MUST BE in place to ensure f/u & begin abx therapy if worsens within 48-72hrs of onset of symptoms
55
Q

AAP Guidelines for AOM Amoxicillin Tx (4)

A
  1. Prescribe Amoxicillin for AOM when decision to tx is made and child has not received Amoxicillin in past 30 days OR does not have concurrent purulent conjunctivitis OR is not allergic to PCN
  2. Prescribe abx with additional beta lactamase coverage for AOM – if received Amox in past 30 days, OR has concurrent purulent conjunctivitis, OR hx unresponsive to Amox
  3. Should reassess the patient if the caregiver reports that the child symptoms are WORSE or FAILED to respond to abx tx within 48-72 hours – to determine if a change is needed
  4. Should NOT prescribe prophylactic abx to reduce freq of episodes of AOM in recurrent AOM
56
Q

AAP Recommendation for recurrent AOM

A

Offer tubes for recurrent AOM- 3/6mths-4/1yr- one episode in first 6 mths

57
Q

AAP Recommendation for Preventing AOM (3)

A
  1. Should recommend pneumococcal conjugate vaccine for all according to the ACIP schedule
  2. Should recommend annual Influenza vaccine to all children according to the schedule ACIP
  3. Should encourage Exclusive BF for at least 6 months
58
Q

AOM Highlights (9)

A
  1. AOM management should include pain evaluation and treatment
  2. Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for nonsevere, bilateral AOM in children aged 6-23 months
  3. On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6 -23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding antibiotics unless the child worsens or does not improve within 48-72 hours of symptom onset
  4. Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should prescribe an antibiotic with additional β-lactamase coverage
  5. Clinicians should reevaluate a child whose symptoms have worsened or not responded to the initial antibiotic treatment within 48-72 hours and change treatment if indicated
  6. In children with recurrent AOM, tympanostomy tubes but not prophylactic antibiotics may be indicated to reduce the frequency of AOM episodes
  7. Clinicians should recommend pneumococcal conjugate vaccine and annual influenza vaccine to all children according to updated schedules
  8. Clinicians should encourage exclusive breastfeeding for 6 months or longer
  9. Avoid tobacco and smoke exposure
59
Q

AOM Referral (3)

A
  1. Pediatric Otolaryngologist (ENT)
  2. Infants and children with complicated infections that may require surgery involving the ear such as OME and hearing changes, recurrent adenotonsillitis, recurrent AOM
  3. Refer to ENT and evaluate for tubes
60
Q

Conjunctivitis Otitis Syndrome Epidemiology (2)

A
  1. 20-73% of children with conjunctivitis have concurrent otitis media (even in absence of ear pain!)
  2. Younger children and those with Multiple OM (recurrent OM) are at higher risk of developing Conjunctivitis-Otitis syndrome
61
Q

Conjunctivitis Otitis Syndrome Evaluation (3)

A
  1. Every child with conjunctivitis MUST have an exam of TMs with otoscope
  2. Can perform conjunctival scraping (better then swab) but not necessary unless no improvement on antibiotics
    * Will scrape conjunctival epithelial cells to detect the pathogen and treat correctly
  3. Pathogens are seen in both MEE & purulent conjuntival discharge
    * H. influenzae most common pathogen
62
Q

Conjunctivitis Otitis Syndrome Treatment (2)

A
  1. Systemic Abx are needed- Topical Opth are NOT

2. Beta-lactamase coverage

Pediatric Primary Care Exam 2 (12 decks)

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