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Head and Neck Infections Flashcards

1
Q

What is ciliary flush

A

red ring around the iris

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2
Q

What is Hyphema

A

layering of red blood cells in the anterior chamber.

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3
Q

What is Iridocyclitis

A

inflammation of the anterior uveal tract including the ciliary body.

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4
Q

What is keratitis?

A

inflammation of the cornea, usually very painful

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5
Q

What is the uvea?

A

Includes the iris, ciliary body, and choroid. Very vascular.

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6
Q

What are the common viral causes of conjunctivitis? [6]

A 
Adenovirus
HSV
Rubella
Rubeola
Influenza
EBV
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7
Q

What is epidemic keratoconjunctivitis? What causes this?

A

More fulminant and involves the cornea. It is very contagious and due to adenovirus 8, 19, 37. Self limited

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8
Q

What are the common bacterial causes of conjunctivitis? [5]

A

Chlamydia, Neisseria, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae.

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9
Q

Presentation of conjunctivitis?

A

Usually a watery, itchy, red eye. Typically is not painful, nor does it include significant vision loss. Gritty feeling or feeling of sand in eye

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10
Q

With conjunctivitis what does Preauricular lymphadenopathy indicate about the cause of the infection? [3]

A

Viral
Gonorrhea
Chlamydia

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11
Q

What is trachoma?

A

Starts as conjunctivitis and progresses to eyelid scarring resulting in the eyelid turning inward (entropion). The eyelashes turn inward (trichiasis) and ulceration of the cornea by abrasions can eventually lead to blindness.

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12
Q

What is Arlt’s line?

A

the horizontal line of conjunctival scarring found on the superior eyelid. In trachoma

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13
Q

Diagnosis of trachoma?

A

PCR

Clinical

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14
Q

Treatment of trachoma?

A

Surgery for trichiasis.
Antibiotics for active infection.
Facial cleanliness.
Environmental improvement.

Systemic erythromycin or tetracycline for 3–4 weeks and subsequent topical erythromycin or tetracycline for 6 months.

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15
Q

What is adult inclusion conjunctivitis?

A

Chronic follicular conjunctivitis.
Acquired sexually or via inoculation from contaminated secretions.
Due to D-K chlamydia serotypes

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16
Q

Presentation of adult inclusion conjunctivitis

A

red eye with purulent discharge, preauricular lymphadenopathy, and frequently has a urethritis/cervicitis present.

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17
Q

Treatment of adult inclusion conjunctivitis?

A

Treat underlying chlamydia infection

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18
Q

Presentation of gonorrhea conjunctivitis?

A

Marked purulent discharge, red eye, swollen eyelid, preauricular lymphadenopathy, and chemosis, rapidly progressive if untreated.

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19
Q

Treatment of gonorrhea conjunctivitis?

A

IM ceftriaxone if only conjunctivitis.

If cornea involved, longer treatment course of ceftriaxone.

Concomitant treatment for Chlamydia with azithro.

Requires frequent flushing of eye to remove inflammation and enzymes harmful to the eye.

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20
Q

Empiric treatment for bacterial conjunctivitis

A
  1. Topical trimethoprim/polymyxin B

2. bacitracin/polymyxin B.

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21
Q

Treatment of HSV conjunctivitis

A

Refer to ophthalmology.
If just conjunctivitis, usually no antiviral is necessary.
Need to rule out corneal involvement.

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22
Q

Risk factors for keratitis [cornea inflammation]

A
  1. Contact lens use (particularly overnight use or extended-wear lenses).
  2. Trauma: may be surgical or nonsurgical.
  3. Diabetes mellitus.
  4. Immunosuppression.
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23
Q

What organisms invade an intact cornea?

A

Neisseria, Listeria, and Corynebacterium

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24
Q

Presentation of keratitis?

A
  1. Exquisitely painful eye
  2. Decreased vision, tearing, and corneal edema.
  3. Foreign body sensation.
  4. +/- purulent discharge
  5. Bacterial keratitis frequently has a white infiltrate or “spot” on the cornea.
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25
Work up of keratitis
1. Fluorescein used to visualize ulcer or infiltrates. | 2. Corneal scrapings and culture should be done with PCR as indicated for viral etiology.
26
Exam findings in HSV keratitis? [5]
``` Dendritic lesions Ciliary flush Decreased sensation of the cornea. May have vesicles on the eyelid. Typically unilateral. ```
27
Diagnosis of HSV keratitis?
Clinical | PCR scrapings
28
Treatment of HSV keratitis [3]
Trifluridine, aciclovir, valaciclovir | --> Topical or PO
29
Presentation of VZV keratitis
Complete loss of sensation of cornea Dendritic lesions as well Hutchinson’s sign.
30
Mgmt of VZV keratitis
ophthalmic exam Trifluridine, aciclovir, valaciclovir --> Topical or PO
31
Bacteria a/w infection following LASIK? [2]
1. Nocardia 2. Mycobacterium - -> M. chelonae is most common of the atypical mycobacteria
32
Common causes of fungal keratitis? [3]
Fusarium [most common], Aspergillus, Candida.
33
Risk factors for fungal keratitis? [4]
Trauma immunosuppression contact lens use topical steroid use in eye.
34
Treatment of fungal keratitis due to a mold? [3]
Combination of topical and systemic treatment. | Natamycin, voriconazole, or amphotericin for molds.
35
Treatment of fungal keratitis due to candida?
Azoles | Combination of topical and systemic treatment.
36
Risk factors for Acanthamoeba keratitis?
contact lens use (wearing for prolonged periods) trauma historically associated with the tablets used to make contact solution at home
37
Presentation of acanthamoeba keratitis?
Unilateral. Red eye, pain, and photophobia. Can have a dendritic lesion, so may be mistaken for HSV. May have a ring lesion later in course
38
Diagnosis of Acanthamoeba keratitis?
Calcofluor white stains the trophozoite and the cyst. | plate the scraping on an E. coli lawn.
39
Treatment of Acanthamoeba keratitis?
Topical polyhexamethylene guanide or chlor-hexidine. Plus topical propamidine isethionate or hexamidine. May require keratoplasty
40
What is uveitis
Inflammation of the iris, ciliary body, choroid, or retina
41
What is anterior uveitis?
Inflammation of iris, ciliary body, or both called iritis, cyclitis, iridocyclitis respectively.
42
What is intermediate uveitis?
Inflammation of the viterous and retina
43
What is posterior uveitis?
Inflammation of the choroid, retina, or both.
44
Ocular findings in anterior uveitis?
WBCs in aqueous, keratic precipitates, iris nodules, synechiae
45
Ocular findings in intermediate uveitis?
WBCs or snowballs in the vitreous, pars plana snow bank
46
Ocular findings in posterior uveitis?
Lesions in choroid, retina, or both; vitritis in some
47
Ocular findings in panuveitis?
WBCs in aqueous and vitreous
48
Infectious etiology of anterior uveitis [5]
``` Herpes simplex (10%) Syphilis (<1%) TB (<1%) Lyme disease (<1%) Leprosy (<1%) ```
49
Infectious etiology of intermediate uveitis [1]
Lyme disease (<1%)
50
Infectious etiology of posterior uveitis [6]
``` Toxoplasma (25%) CMV (12%) ARN (6%) Toxocara (3%) syphilis (2%) Candida (<1%) ```
51
Infectious etiology of panuveitis [3]
Syphilis (6%) TB (2%) Candida(2%)
52
Presentation of anterior uveitis?
Presents as painful red eye with loss of vision.
53
Presentation of intermediate uveitis
Loss of vision with floaters Typically painless --> Usually NOT infectious
54
Presentation of posterior uveitis?
Usually painless loss of vision.
55
Presentation of HSV anterior uveitis?
usually a preceding keratitis unilateral red, painful eye with impaired vision but absence of vesicles. Decreased sensation of cornea
56
Treatment of HSV anterior uveitis?
Oral aciclovir, followed by oral suppression. | Topical steroids.
57
Presentation of VZV anterior uveitis?
Similar to HSV No preceding keratitis Cause of acute retinal necrosis and leading cause of progressive outer retinal necrosis
58
Diagnosis of HSV and VZV anterior uveitis?
PCR of aqueous humor
59
Treatment of VZV anterior uveitis?
Retinitis present: IV aciclovir followed by oral aciclovir or valaciclovir Systemic steroids May require vitrectomy or laser therapy.
60
Presentation of CMV on eye exam?
Retinitis with hemorrhages and flares of inflammation
61
Diagnosis of CMV retinits?
clinical appearance but also with PCR of aqueous humor.
62
Treatment of CMV retinitis? [3]
IV ganciclovir Intravitreal antiviral. Oral secondary suppression.
63
What is acute retinal necrosis? [5]
1. Well demarcated retinal necrosis on peripheral retina. 2. Rapid progression of necrosis. 3. Circumferential spread. 4. Occlusive vasculopathy. 5. Vitreal and aqueous inflammation.
64
Etiology of acute retinal necrosis? [2]
HSV/VZV
65
Presentation of acute retinal necrosis?
Occurs in immunocompetent patients. Presents as anterior uveitis that progresses to necrosis. Very high risk for retinal detachment and blindness.
66
Treatment of acute retinal necrosis?
IV aciclovir followed by oral aciclovir or valaciclovir Systemic steroids May require vitrectomy or laser therapy.
67
What is progressive outer retinal necrosis?
1. Well demarcated retinal necrosis on outer retina. 2. Rapid progression of necrosis. 3. Circumferential spread. 4. No Vitreal and aqueous inflammation.
68
Who gets progressive outer retinal necrosis?
Exclusively in immunocompromised patients. | Typically persons with HIV and CD4 <100/μL.
69
Etiology of progressive outer retinal necrosis?
VZV HSV CMV
70
Treatment of progressive outer retinal necrosis? [4]
1. IV antivirals (aciclovir or ganciclovir). 2. Intravitreal antiviral Systemic steroids usually not needed (unless concerns for IRIS) given lack of inflammation. 3. May require laser therapy and/or vitrectomy. 4. Secondary oral suppression.
71
Describe syphlitic uveitis?
Frequently presents as vision loss. Occurs at any stage of syphilis. Can involve any segment of the eye, but posterior disease and panuveitis predominate. Case definition is ocular disease (uveitis, panuveitis, diminished visual acuity, blindness, optic neuropathy, interstitial keratitis, anterior uveitis, and retinal vasculitis) with syphilis of any stage.
72
Work up of syphlitic uveitis? [2]
LP | HIV testing
73
Treatment of syphlitic uveitis?
Same as neurosyphilis | IV Penicillin G
74
What is Parinaud’s oculoglandular syndrome
Result of cat scratch near the eye or self-inoculation near eye. Lymphadenopathy of preauricular, submandibular, and cervical nodes along with involvement of lid or conjunctiva. Has red eye with watering.
75
Treatment on parinaud's oculoglandular syndrome
Supportive vs azithromycin
76
Treatment of Bartonella henselae optic neuritis?
Prolonged doxycycline and rifampin.
77
Most common effect of lyme in the eye?
Conjunctivitis in early lyme disease
78
How does TB effect the eye?
Uncommon | If it does effect it is most commonly panuveitis
79
Diagnosis of ocular TB?
difficult to establish as it is paucibacillary, so unlikely to have positive tissue cultures or acid-fast stains. Relies on appropriate clinical setting and a positive PPD or interferon-gamma release assay.
80
Treatment of ocular TB?
Rifampin, isoniazid, ethambutol, and pyrazinamide May require systemic steroids. --> Same as TB meningitis
81
Presentation of toxoplasmosis in the eye?
Vision loss, unilateral or bilateral [unilateral is primary, bilateral is reactivation. +/- pain. Posterior uveitis or chorioretinitis.
82
Dilated eye exam findings in toxoplasmosis?
White focal lesion with surrounding inflammation. Can have black pigmentation in areas that are healing. May have satellite lesions.
83
Diagnosis of ocular toxoplasmosis?
Clinical PCR of vitreous humor Plasma serology.
84
Treatment of ocular toxoplasmosis?
Pyrimethamine and sulfadiazine with leucovorin. | Systemic steroids.
85
What is Endophthalmitis
Infection within the globe
86
Risk factors for endopthalmitis? [4]
Instrumentation or trauma of eye. Diabetes mellitus. Injection drug use. Risk factors associated with bacteremia or fungemia.
87
Diagnosis of endopthalmitis [2]
Vitreal Gram stain and cultures. | Blood cultures.
88
Common causes of endopthalmitis due to trauma? [4]
Bacillus, coagulase-negative staphylococci, | Pseudomonas, mold
89
Causes of endopthalmitis s/p cataract surgery? [5]
Coagulase-negative staphylococci, Staphylococcus aureus, streptococci, gram-negatives
90
Empiric treatment of endopthalmitis s/p cataract surgery?
Intravitreal vancomycin and ceftazidime
91
Common causes of endopthalmitis with Pseudophakic(Chronic disease post-cataract surgery).
Cutibacterium acnes
92
Treatment of Pseudophakic(Chronic disease post-cataract surgery) endopthalmitis? [2]
Intravitreal vancomycin | Vitrectomy, likely to require lens removal
93
Most likely cause of Intravitreal injection related endopthalmitis [2]
Coagulase-negative staphylococci and streptococci
94
Treatment of Intravitreal injection related endopthalmitis
Intravitreal vancomycin and ceftazidime
95
Most likely cause of Bleb-related(Surgical treatment for glaucoma that creates scleral defect) endopthalmitis? [3]
Streptococci, Moraxella, H. influenzae
96
Treatment of Bleb-related(Surgical treatment for glaucoma that creates scleral defect) endopthalmitis?
Intravitreal vancomycin, ceftazidime
97
Most likely cause of endogenous endopthalmitis?
``` Streptococci coagulase-negative staphylococci S. aureus Bacillus Candida Aspergillus ```
98
Treatment principles for endogenous endopthalmitis?
Both systemic and intravitreal antimicrobials. Fulminant cases of bacterial will require vitrectomy Most or all fungal will require vitrectomy.
99
What antifungal should be avoided in fungal class endopthalmitis due to poor penetration?
echinocandins
100
Treatment of resistant candida in the eye?
voriconazole | amphotericin
101
Treatment of sensitive candida in the eye?
Fluconazole
102
What is Malignant otitis externa
otitis externa that invades skull base.
103
What is Chronic otitis media
otitis media lasting >3 months.
104
Most common cause of otitis externa? [2]
Staphylococcus aureus, Pseudomonas
105
Presentation of otitis externa?
Ear pain with drainage in canal | May be pruritic
106
Treatment of otitis externa? [2]
Neomycin/polymyxin/hydrocortisone or Fluoroquinolone/hydrocortisone
107
Presentation of malignant otitis externa?
Severe pain of ear and mastoid with purulent drainage in canal May have cranial nerve palsy
108
Treatment of malignant otitis externa?
Systemic antipseudomonal | Surgical debridement
109
Treatment of otitis media? [4]
1. Amoxicillin 2. Amoxicillin/clavulanic acid if not improving 3. Cephalosporin if PCN allergy [alt] 4. Respiratory fluoroquinolone if severe PCN allergy
110
Who gets parotitis?
Elderly Diabetics Those on anticholinergics due to decreased saliva production
111
MCC of supporative vs nonsupportative parotitis?
Staph aureus | Mumps, sarcoid, sjogrens
112
Presentation of suppurative parotitis?
unilateral. Fever with severe pain and swelling of parotid gland. May be able to “milk” purulence from Stenson’s duct. May have obstructing stone.
113
Presentation of nonsuppurative parotitis?
Typically bilateral. Less fulminant presentation. Prodrome was present prior to the parotitis
114
Diagnosis of parotitis? [3]
1. (CT vs. ultrasound) to see if drainable abscess. 2. Presence of purulence from Stenson’s duct. Culture and Gram stain of any purulence. 3. Serology for viral etiology as indicated.
115
Treatment of suppurative parotitis? [4]
1. Vancomycin (or antistaphylococcal beta-lactam if MRSA not suspected) AND clindamycin. 2. May require removal of obstructing stone. 3. Warm compresses. 4. Sialagogues.
116
What is a quinsy abscess?
Peritonsillar Abscess
117
Etiology of peritonsillar abscess? [3]
Streptococci, staphylococci, and anaerobes
118
Presentation of peritonsillar abscess?
Unilateral sore throat with edematous palatine tonsil that may be causing deviation of the uvula. Fever. Abrupt onset. May have drooling or trismus. Can also lead to a suppurative thrombophlebitis (Lemierre’s syndrome).
119
Diagnosis of peritonsillar abscess? [3]
Clinical with a swollen tonsil and uvula that deviates Aspiration for Gram stain and culture May need imaging (ultrasound vs. contrast CT) if diagnosis is ambiguous.
120
Treatment of peritonsillar abscess? [4]
I+D Unasyn Clinda as alt +/- Tonsillectomy
121
What is Ludwig’s Angina?
Bilateral sublingual and submylohyoid space infection.
122
Etiology of ludwig's angina?
Polymicrobial oral flora including anaerobes. Streptococci including Group A Streptococcus. --> Extension of tooth infection, particularly molar tooth
123
Presentation of ludwig's angina?
Rapidly progressing infection of floor of the mouth that is bilateral. Fever present and may be toxic. Tongue may be markedly swollen and patient may have difficulty swallowing leading to drooling
124
Diagnosis of ludwig's angina?
Clinical | CT
125
Treatment of ludwig's angina? [3]
Unasyn Penicillin + Flagyl [alt] Clinda [alt]
126
What is Vincent’s Angina?
Acute necrotizing ulcerative gingivitis.
127
Risk factors for Vincent angina? [4]
Gingivitis Smoking Poor oral care Malnutrition
128
Etiology of vincent angina? [2]
Polymicrobial oral flora | Anaerobes
129
Presentation of vincent angina?
Pain with fetid breath. Fevers. Typically does have regional lymphadenopathy. Pseudomembranes with ulcerative gingival lesions
130
Diagnosis of vincent angina?
Clinical
131
Treatment of vincent angina?
1. Penicillin 2. Augmentin 3. Flagyl
132
Presentation of Septic Cavernous Sinus Thrombosis
``` Headache with fever. Cranial nerve III–VI palsy. May have diplopia. Proptosis. Ptosis. Periorbital edema. Can lead to vision loss ```
133
Diagnosis of Septic Cavernous Sinus Thrombosis?
MRI or MR venography. | CT if unable to do MRI.
134
Treatment of septic cavernous sinus thrombosis?
Vancomycin + Cefepime +/- Flagyl | +/- Debridement
135
What is the lateral pharyngeal space?
Base of skull to hyoid. | Medial border is the carotid sheath.
136
What is the pretracheal space?
Esophagus and trachea. | Contiguous with mediastinum and carotid sheath
137
What is the retropharyngeal space?
Posterior to hypopharynx and esophagus. | Extends to mediastinum inferiorly.
138
What is the danger space?
Between alar fascia and prevertebral fascia | Communicates with posterior mediastinum.
139
What is the prevertebral space?
Spinous process to prevertebral fascia.
140
Etiology of deep neck space infection?
Polymicrobial Staph Strep Oral anaerobes
141
Presentation of a deep neck space infection
Fever and Toxic. Can have dysphagia (particularly with pretracheal). Dyspnea. Concern is for possible extension into mediastinum.
142
Diagnosis of a deep neck space infection?
CT imaging is paramount
143
Mgmt of deep neck space infection?
Surgery Unasyn Add vanco if known colonization or recent trauma
144
Risk factors for osteomyelitis of the jaw [5]
``` DM steroids radiation trauma (dental procedure) necrosis from medication. ```
145
Etiology of osteomyelitis of the jaw [3]
Streptococci, Actinomyces, S. aureus
146
Presentation of osteomyelitis of the jaw
Jaw pain. | Exposed bone.
147
Most likely area osteomyelitis of the jaw will occur?
Mandible much more common than maxilla given better vascular supply to maxilla.
148
Treatment of osteomyelitis of the jaw?
Surgical debridement of necrotic tissue. Unasyn +/- vancomycin +/- hyperbaric oxygen

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