HEENT Flashcards
Bacterial conjunctivitis etiology
strep pneumo, H influenza, Moraxella cat
Clinical presentation of bacterial conjunctivitis
unilateral injection, thick purulent discharge, eye “stuck shut”
Tx for bacterial conjunctivitis
EES ointment, trimethoprim-polymyxin B drops
Neonatal conjunctivitis
presents 5-14 days of life; watery to mucopurulent to bloody d/c, chemosis, pseudomembrane
Neonatal conjunctivitis etiology
Chlamydia trachomatis
Dx for neonatal conjunctivitis
CULTURE
Tx for neonatal conjunctivitis
Oral erythromycin (50 mg/kg per day in 4 doses x 14 days)
Hyperacute bacterial conjunctivitis etiology
N. gonorrhoeae
Hyperacute bacterial conjunctivitis
severe & sightpthreatening; keratitis and perforation can occur; 2-5 days after birth, profuse, purulent discharge, chemosis, urethritis
Tx for hyperacute bacterial conjunctivitis
REFER TO OPTHAMOLOGY, HOSPITILIZE
Contact lens wear
high risk of pseudomonal keratitis, can lead to ulcerative keratitis (perforation)
Keratitis features
foreign body snesation, blepharospasm, typically visible corneal opacity with penligh
Tx for keratitis
URGENT REFERRAL; discontinue contacts, abx (anti-psuedomonal)
Viral conjunctivitis etiology
Adenovirus
Viral conjunctivitis presentation
+/- prodrome; injection (burning, gritty sensation), watery d/c
Tx for viral conjunctivitis
self-limited; warm or cool compresses, topical antihistamines/decongestants (Naphcon-A), lubricant eye drops
Education for infectious conjunctivitis
stay home from school until there is no longer any discharge (@ least 24 hrs topical therapy); sports: non-contact when they feel okay, contact: once daytime d/c has stopped (usually 5 days)
Allergic conjunctivitis
bilateral injection, edema, d/c (stringy), ocular pruritus
Tx for allergic conjunctivitis
symptomatic (cool compress, avoid allergens, lubricants), pharm:
topical vasoconstrictor + antihistamine (<2 weeks) (Naphcon-A, Visine-A), ANTIHISTAMINE W/ MAST-CELL STABILIZING (olopatadine, azelastine), mast-cell stabilizer (cromolyn), NSAIDs, glucocorticoids by opthamology (don’t prescribe)
Kawasaki disease
mucocutaneous lymph node syndrom; small and medium vessel vasculitis
Kawasaki disease Sx.
(crash)
Conjunctivitis (bilateral, nonexudative)
Rash (morbilliform)
Adenopathy (cervical)
Strawberry tongue (cracked, red lips, fissuring)
Hands (red, swollen w/ subsequent desquamation)
Unexplained fever longer than 5 days
Consider KD
Dx for KD
fever >5 days plus 4/5:
- Bilateral conjunctivitis
- Oral mucous membrane changes, fissured lips, strawberry tongue
- peripheral extremity changes (erythema, edema, desquamation)
- Polymorphous rash
- Cervical LAD
KD complications
cardiovascular complications (coronary aneurysms, carditis); manifestations: tachycardia, gallop, muffled heart tones Young infants: fusiform aneurysms of brachial arteries: palpable/visible in axillae; cold pale, cyanotic digits
Dx for KD
ECHOCARDIOGRAM
Tx for KD
ID and CV consults (long-term cardio f/u); Intravenous immunoglobin (IVIG)- provides extra antibodies, reduces prevalence of carotid artery aneurysms; high dose aspirin, delay vaccines
Strabismus
misalignment of eyes; potential to cause amblyopia (decreased acuity)
Dx of strabismus
abnormal corneal light reflection, cover/uncover test
Tx of stabismus
refer to opthamology
Dacryostenosis
nasolacrimal duct obstruction
Most common cause of tearing & ocular d/c in infants/young children
Dacryostenosis
Etiology of dacryostenosis
congenital
Presentation of dacrystenosis
chronic, intermittent tearing; mucoid d/c, debris on lashes, mild redness of lower lid from rubbing
Tx for dacryostenosis
most resolve spontaneously by 6 mo; lacrimal sac massage (1st line); refer to opthamology for sx >6-7 mo, complications; Surgical management for definitive treatment (surgical probe)
Dacryocystitis
inflammation or infection of lacrimal sac; rare complication of dacryostenosis
complication of dacryostenosis
dacryocystitis
Etiology of dacryocystitis
Staph epidermis and staph aureus
Clinical presentation of dacryocystitis
erythema, swelling, warmth, tenderness of lacrimal sac, purulent d/c
Tx of dacryocystitis
C&S, treat promptly with empiric abx (x7-10 days) (Clindamycin PO (mild), IV vanco (severe) + 3rd generation cephalosporin), Opthamology referral
AOM etiology
strep pneumonia, haemophilus influenza, moraxella catarrhalis
Risk factors for AOM
peak @ 6-18 mo, then 5-6 yo; family hx, day care, lack of breastfeeding, tobacco smoke or air polluiton, pacifier use
AOM Sx.
otalgia, irritability, fever, anorexia, vomiting, diarrhea
AOM PE findings
bulging, erythematous TM; TM with decreased mobility, otorrhea, hearing loss
Complications of AOM
perforation, hearing loss, cholesteatoma, facial nerve palcy, mastoiditis
Dx for AOM
bulging TM (or other signs of inflammation) AND middle ear effusion (decreased Tm mobility, otorrhea)
Tx for AOM
amoxicillin (90mg/kg/day divided by 12 hrs) (<2 yo = 10 days, >2 yo = 5-7 days)
AOM tx <2
amoxicillin x 10 days
AOM tx >2
amoxicillin x 5-7 days
Tx for AOM when resistance suspected
Amoxicillin-Clavulanate (Augmentin)
Resistance risk for AOM
recent beta-lactam, purulent conjunctivitis and recurrent AOM
AOM tx for PCN allergy
cefdinir (2nd line if not Type I allergic response) or azithromycin (3rd line), clindamycin, TMP-SMX
Tx for AOM
abx + follow up 48-72 hours
When are Abx given for AOM
- all children < 6 mo
- all children w/ severe sx (moderate/severe ear pain, ear pain >48 hrs, temp >102)
- bilateral AOM <2 yrs
- unilateral AOM <2 yrs
Recurrent AOM
> 3 episodes in 6 months; >4 episodes per year
Tx for recurrent AOM
daily abx (amoxicillin 40mg/kd or sulfisoxazole 50 mg/kg); myringotomy and tympanostomy tubes if prophylactic abx doesn’t work
OME
amber, gray or blue, cloudy, opague, RETRACTED TM; decreased mobility of TM, hearing loss
OME tx
symptomatic; eval and heart test q 3-6 months (until resolved or tubes
Otitis externa etiology
P. aeruginosa, s. aureus, s. epidermis
OE Sx.
otalgia, pruritus, d/c
OE PE findings
hearing loss, tragus tenderness, erythema and/or edema of ear canal
OE Tx
Floxin Otic solution (ofloxacin)
cortisporin otic suspension (not with perforated TM)
ciprodex
Allergic rhinitis patterns
intermittent: Sx <4 day/week or <4 weeks
Persistent: Sx >4days/week AND >4 weeks
Sx of allergic rhinitis
shiners, dennie-morgan lines, tears, allergic salute, pale/bluish boddy nasal mucosa, edematous turbinates; cobblestoning in pharynx
Dx for allergic rhinitis
clinica; IgE levels, skin testing, serum testing; imaging for chronic
Tx for allergic rhinitis
allergen avoidance, pharmacotherapy, allergen immunotherapy
Pharm tx for allergic rhinitis
intranasal steroids (Flonase), antihistamines, decongestants (pseudophedrine), anticholinergics (ipratropium), Mast cell stabilizer (cromolyn), LTR antagonist (montelukast)
Immunotherapy for allergic rhinitis
patient has maximized environmental control measure and optimal medication regimen; subq injections 1-2/week
Nasal polyps
benign pedunculated tumors, “pealed grape” appearance; formed from chronically inflamed nasal mucosa
Nasal polyps are associated with
CF (child <12 w/ polyps), chronic sinusitis, allergic rhinits
SAMTER’s TRIAD
nasal polyps, ASA sensitivity & asthma
Nasal polyps PE findings
obstruction of nasal passages (hyponasal speech and mouth breathing), inflamed nasal mucosa, profuse unilateral mucoid/mucopurluent rhinorrhea
Tx for nasal polyps
decongestants, intranasal steroid, systemic steroids, surgical removal
Viral URI
“common cold”
Duration of viral URI
14 days
Etiology of viral URI
rhinovirus
Complications of viral URI
AOM, asthma exacerbation, acute bacterial sinustitis, lower respiratory tract disease (PNA)
Viral URI tx
avoid OTC without direction, Do not use <6 YO, avoid in 6-12 YO; use antitussive, expectorant
acute rhinosinusitis
preceding viral URI
Etiology of rhinosinusitis
viral infection; s. pneumoniae, h.influenzae, m. catarrhalis
Acute bacterial rhinosinusitis
nasal sx, cough worse at night, fever, HA, facial pain; mild erythema of turbinates, mucopurulent d/c, postnasal drainage in pharynx
Bacterial rhinosinusitis
sx >10 dyas, <30 days, not improving; severe sx or double sickening
Chronic rhinosinusitis
> 12 weeks and 2 of the following: d/c, nasal obstruction, facial pain, decreased sense of smell
Dx for acute rhinosinusitis
XR/CT
Dx for chronic rhinosiusitis
XR, CT, MR, maybe culture
Tx for acute sinusitis
saline irrigation, decongestant, antihistamine; Abx if bacterial: Augmentin 45 mg/kg
Med for bacterial sinusitisi
augmentin 45 mg/kg/day
Etiology of pharyngitis
usually viral (adenovirus, coxsackie), bacterial (GAS)
Sx of pharyngitis
sore throat, fever; tonsillopharyngeal erythema, enlarged tonsils, LAD
Tx for viral pharyngitis
supportive, miracle mouth wash
Mono etiology
EBV
Sx of mono
fevere, sore throat, FATIGUE, malaise, LAD, SPLENOMEGALY
Dx of mono
CBC w/ differential, HETEROPHILE ANTIBODY TEST (monospot), strep test (RADT, culture)
Tx for mono
may persist 7-21 days; supportive; activity restriction for 4 weeks
Bacterial pharyngitis etiology
GAS; peak incidence winter/early spring (5-15 YO)
Grading system for strep
Age: 5-15 YO Season: late fall, winter, early spring pharyngitis (erythema, edema, exudates) LAD Fever (101-103) Absence of cough
Scoring: 6 = likelihood 85%
scoring: 5: likelihood falls to 50%
GAS Sx
abrupt onset, sore throat, odynophagia; exudate, palatal petechiae, tender LAD, scarlet fever
Centor criteria
Tonsillar exudates
tender LAD
fever by hx
Absence of cough
0-2 score: unlikely GAS
>3 score: reform RADT
If clinical suspicion is high with negative RADT for strep what do you do next
Throat culture
Dx of strep
RADT; throat culture if RADT is negative
Tx for strep
abx in first 48 hours (penicillin, amoxicillin; 1st gen cephalosporin); Azithromycin for PCN allergy
GAS complications
Acute rheumatic fever (ARF)- 2-4 weeks after infection;
Post-streptococal glumerulonephritis (PSGN)
5 manifestations of Acute Rheumatic fever
migratory arthritis carditis (valve damage) CNS involvement Subcutaneous nodules (firm, painless) erythema marginatum (pink/non-pruritic rash to trunk and limbs, not face)
post-streptococcal glomerulonephritis (PSGN) sx
asymptomatic, microscopic hematuria; full blown = brown urine;
Common sx: generalized edema, gross hematuria, hypertension
Dx of PSGN
Urinalysis: hematuria
complement
positive streptozyme test
Tx for PSGN
supportive; treat volume overload (sodium and water restriction, diuretics), dialysis if renal failure
Tonsillectomy indications
Paradise criteria:
7 episodes in last year OR 5 episodes in each of the past 2 years OR 3 episodes in each of the past 3 years
Thrush
occurs often after abx; caused by candida albicans; adherent white plaque that brushes off
Tx for thrush
nystatin oral suspension
Mumps
late winter/early spring; incubation 16-18 days; infectious 3 days prior and 9 days after sx
Sx of mumps
within 48 hrs parotitis develops (fever, HA, myalgia, etc)
Complications of mumps
orchitis or oophoritis, neuro (meningitis, encepahlitis, deafness), arthritis, pancreatitis, etc.
Parotitis
cause: Mumps; bacterial (purulent d/c from stenson;s), noninfectious; ages 2-9
Sx of partotitis
salivary gland swelling for up to 10 days; orifice of stensen’s duct is erythematous and enlarged
Tx for Mumps/partotitis
supportive (acetaminophen, cold/warm packs)
