HEENT and ABX

Question 1

What is Acute Otitis Media and its cause?

Answer 1

Infection of the middle ear, temporal bone, & or mastoid air cells.
—Rapid onset + S/Sx of inflammation
—RF: Peak age is 6-18 months old, day care, pacifier/bottle use, second hand smoke, and not being breastfed.
—Patho: most commonly preceded by viral URI that blocks Eustachian tube

4 most common organisms:
—STREP PNEUMO most common
— H flu
—Moraxella Catarrhalis
—Group A Strep (same as acute sinusitis)

Question 2

Clinical Manifestations and physical exam of AOM?

Answer 2

— Fever
—Otalgia
—ear tugging in infants
—stuffiness
—conductive hearing loss

PE:
—Bulging and erythematous tympanic membrane with effusion
— Tympanic membrane rupture provides rapid pain relief + otorrhea (usually heals in 1-2 days)
—Otoscope: Decreased TM mobility (most sensitive)

Question 3

Management of Acute Otitis Media?

Answer 3

—Observation depending on age and severity: Consider observation and analgesia if >6 months old with low fever, mild pain, and unilateral ds.

Children over the age of 2 should receive abx if diagnosis is certain and infection severe:
—Amoxicillin is 1st line DOC
—2nd line: Augmentin, Cefuroxime, Cefdenir, Cefpodoxime
—PCN Allx: Azithromycin, Clarithromycin, TMPSMX

Severe or recurrent:
—Effusion >3 months, >3 episodes in 6months or >4 in a year
—Myringotomy (surgical drainage) with tympanostomy tube insertion

**Children with recurrent otitis media may need iron deficiency anemia workup and CT scan

Question 4

What is Otitis Externa caused by?

Answer 4

Inflammation of the external auditory canal “swimmers ear”
—Water immersion/excess moisture raises the pH from normal acidic pH which facilitates bacterial growth

PSEUDOMONAS AERUGINOSA most commonly. Also, staph aureus.

Question 5

Otitis Externa Clinical Manifestations and Diagnosis?

Answer 5

—Ear pain
—Pruritis in ear canal
—Recent swimming
—Auricular discharge
—ear pressure or fullness
—hearing loss

PE:
—Pain on traction of ear canal or Tragus
—prurulent auricular discharge

Diagnosis:
—Clinical + Otoscopy
—edema of external auditory canal with erythema, debris, discharge

Question 6

Otitis Externa Treatment

Answer 6

—Protect the ear against moisture: drying agents are isopropyl alcohol and acetic acid
—Removal of debris and cerumen

Topical Abx that cover pseudomonas aeruginosa:
—Ciprofloxacin+ dexamethasone, Ofloxacin. (Topical glucocorticoid can be added for inflammation)
—Aminoglycoside combinations (but NOT used if tympanic perforation suspected/TM cannot be visualized- aminoglycosides are ototoxic): Neomycin/Polymixin B/ Hydrocortisone otic

Question 7

Fluoroquinolones— Cipro, Levo, and Moxi MOA and coverage

Answer 7

MOA: inhibition of DNA topoisomerases. Broad spectrum.

Ciprofloxacin:
—Aerobic enteric gram (-) rods: PSEUDOMONAS, E. Coli, Proteus, Klebsiella
—Uses: gastroenteritis, cystitis, prostatitis, otitis externa

Levo and Moxi— Respiratory Quinolones— more gram (+) activity—> PNA, and 2nd line for bacterial sinusitis when PCN allx present

Question 8

Fluoroquinolones ADRs and Contraindications

Answer 8

ADRs:
—Encephalopathy, tendinitis, tendon rupture, neuropathy, gastritis, C diff, photosensitivity, aortic dissection/rupture, heptatotoxicity, and retinal detachment

Contraindications:
—Pregnancy/BF
—<18 yrs old
—QT prolongation
—Seizures
—Renal failure
—Aortic aneurysm

Question 9

What is bacterial sinusitis caused by and what are the criteria to be bacterial?

Answer 9

Mostly Viral.
If bacterial:
— H Flu, Strep pneumo, or M Catarrhalis.

Fever, cough, nasal congestion, HA, facial pain, and sinuses TTP

Must meet 1 of 3 diagnostic criteria to be bacterial:

1. Persistent sx >10 days
2. Severe onset (fever + drainage) >3 days
3. Initial improvement followed by worsening sx “second sickening”

Question 10

Bacterial Sinusitis Treatment

Answer 10

Amoxicillin or Augmentin

If PCN allx: Respiratory FQN or Doxycycline

Question 11

What is the Centor Criteria for Strep Pharyngitis?

Answer 11

—Fever
—Tender Anterior Cervical Lymphadenopathy
—Tonsillar exudate
—No Cough

0-1= no test
2-3= Rapid strep
4= Empiric Tx

Question 12

Strep Pharyngitis Treatment

Answer 12

Penicillin V or Amoxicillin

PCN allx: Macrolide (Azithromycin), Clindamycin, or Cephalosporins

Question 13

Cause and Clinical Manifestations of Strep Pharyngitis

Answer 13

Cause: Group A Strep (Strep Pyogenes)

—Dysphagia and fever
—Not usually associated with symptoms of viral infections: cough, hoarseness, coryza, conjunctivitis, diarrhea

Question 14

What age group has the highest incidence of rheumatic fever if strep throat goes untreated?

Answer 14

Children ages 5-15

Rheumatic fever IS preventable with abx

Question 15

Complication of strep throat that is NOT preventable with antibiotics

Answer 15

Acute Glomerulonephritis

Question 16

Is peritonsillar abscess a complication of strep throat?

Answer 16

Yes

Question 17

What is a peritonsillar abscess and what causes it?

Answer 17

An abscess between the palatine tonsil and the pharyngeal muscles resulting from a complication of tonsillitis or pharyngitis. Most common in adolescents and young adults 15-30yo.

It’s often polymicrobial. The predominant species tho are GROUP A STREP (Pyogenes), Staph aureus, and respiratory anaerobes.

Question 18

Clinical Manifestations and PE of peritonsillar abscess

Answer 18

—Dysphagia
—Severe unilateral pharyngitis
—High fever
—MUFFLED HOT POTATO VOICE
—DIFFICULTY W ORAL SECRETIONS/DROOLING
—TRISMUS

PE:
—Swollen or fluctuant tonsil causing UVULA DEVIATION TO CONTRALATERAL SIDE
—Bulging of the posterior soft palate
—Anterior Cervical LAD

Question 19

Diagnosis of Peritonsillar abscess

Answer 19

—Primarily a clinical diagnosis without need for imaging or labs if classic case
—US
—CT is imaging of choice if imaging is needed to differentiate cellulitis vs abscess

Question 20

Management of Peritonsillar abscess

Answer 20

Drainage:
— Needle aspiration (preferred), or Incision and Drainage

ABX:
—PO Augmentin or clindamycin
—Parenteral Ampicillin-Sulbactam or clindamycin

Tonsillectomy usually reserved for pts who fail to respond to drainage, Peritonsillar abscess w complications, prior episodes, or recurrent severe pharyngitis