HEENT-Ear Flashcards
AOM- acute otitis media
1- Viral
#1 office vistis PEDS < 1 middle ear inf. Pn due to enclosed pressure of fluid Factors- smoke, daycare, supine drinking(anatomic tube structure), M, anatomic
#2. Strep. pneumoniae 30-40%
3. H influenza 21%
4. Moraxella Catarrhalis 12%
S/s- irritable, fever, ea, otorrhea or vertigo. TM: bulging, retract, perforate (holes), dec. hearing. Purlent-yellow section, red, no/displaced cone of light, dull vs shiny
PE- pneumaic otoscopy #1 sign- dec. mobility w/ air puff
Pinna pain w/ movement
AOM TX & complications
TX #1 Abx Amoxicillin (peniclin) esp <2yo Mryingotomy Tympanostomy tubes-drainage NEVER steroid drops
Comps
Perforations, Chronic OM- chronic s/s, w. drainage in canal. Itch #1 sx
Cholesteoma-keratinized, desquamous cell d/t TM perforation. ASX or hearing loss, dizzy
AOM serous
clear fluid in middle ear- VIRAL
Otiis Externa
Infection and inflammation of the external auditory canal #1 sx: local pain (severe-tragus) and itching, erythema, heat, crust Assoc sx- Associated periauricular adenopathy >5yo
TX #1 Staph aureus-crusty
Diffuse OE
“Swimmer’s ear”, P aeruginosa
Hot, humid climate, hot tubs
SX-Canal is erythematous, edematous, some hemorrhagic
white flakes,
TX- topical antibiotic drops w/ steroid. DRY out.
Neo
Malignant OE
Severe necrotizing bacteria infection external auditory canal with invasion into the surrounding tissues including blood vessels, cartilage, and bone.
SX-Immunocompromised, elderly, HIV, DM
Osteomyelitis at base of skull, TMJ, Elevated ESR, CRP typical, local heat, erythmetous
TX- P aeruginosa in >95% of cases
MOE TX complications
TX
Topical ABX don’t work, need systemic
Systemic Cipro treatment of choice
IV until improving, then switch to oral (6-8wks)
Levofloxacin probably acceptable, no data
Vertigo
vestibular disease-Sense motion when there is no motion, or exaggerated sense of motion in response to body movements
ETI-labyrinthitis, BPPV, Meniere’s syndrome, migraine
triggers (salt, stress, bright lights)
DX:-Asso sx, Duration is key DX, CN exam, cerebeller
eyes (nystagmus), ears, Dix-Hallpike maneuver Gold
Peripheral: sudden onset, hearing loss and tinnitus, nausea, no fever, no other neuro
Central: gradual onset, no auditory sx
BPPV TX & complications
TX- ENT or Neurology if vertigo persists or CNS lesion suspected
D-H: quickly lowering supine with head extending over edge of bed 30 degrees lower than body, turned either to left or right; elicit delayed nystagmus in BPPV; nonfatigable nystagmus indicates CNS etiology
Conductive Hearing Loss
Eti:
dysfunction of external or middle ear
Acute: cerumen impaction, middle ear effusion (URI), otosclerosis
Chronic: chronic ear infection, trauma, otosclerosis
Sensioneural Hearing Loss
deterioration of the cochlea, loss of hair cells
Progressive, high frequency loss related to aging
Noise, head trauma, DM or other systemic diseases
Surfer’s ear.
Neural: CN 8 or auditory tract/cortex lesions; least common, Acoustic neuroma, MS, cerebrovascular disease
DX-Perform thorough PE including CN 8 testing, Weber/Rinne tests
TX- Refer unless cause is easily treated
Cold-Viral
Common Cold- 200 viruses cause
Mild, self-limited syndrome caused by infection of the upper respiratory tract mucosa
S/S-one or more: nasal discharge, obstruction; sneezing; sore throat; cough; hoarseness
Clinical: mild malaise, rhinorrhea, sneezing, sore throat, variable loss of taste or smell, 2nd-4th day max sx
< 99° F, Cough and hoarseness (worse in smokers)
1-2 weeks.
Sx- 6-8wks (cough or hoarsness)
Cold TX, complications
TX-Symptomatic, ASA/APAP, NSAIDs
Nasal congestion topical sprays- Gold <5d d/t rebound, humidifier, fluids, rest, netti pot w. saline
Oral decongestants / combination antihistamine-decongestants
Expectorants and ABX not useful
Influenza
S/S: sudden onset, > 106°F (41°C) 3 days,HA, myalgias (back, arms, legs), nonproductive cough, nasal discharge, hoarseness, sore throat, Flushed face, hot skin, red watery eyes, clear nasal discharge, cervical LAD.
Mild neutropenia with lymphocytosis
Duration 3-14d. Recover 1-4wks.
aerosolized particles; incub. 18-72 hours
Viral shedding 5-10 days; highest titer in secretions first 48 hours. Infectious 24h after fever breaks
ETI: influenza v., other parainfluens, RSV (kids) andenovirus
TX-Antiviral agents: amantadine (Symmetrel); rimantadine (Flumadine), oseltamivir (Tamiflu)
reducing fever and shortening the course of illness by 1-2 days. effective 24-48 hours of onset of illness
Treat all high risk pts: chronic disease; pts with associated pneumonia
OTC supportive therapy
Mononucleosis
ETI-Epstein-Barr virus
S/S- Malaise, fever, sore throat (sometimes exudates)
Palatal petechiae, LAD, splenomegaly, sometimes maculopapular rash. Kids stomach pain.
Contagious prior, Recovery 2-8mo. No sharing saliva, drinks, towels etc.
US athletes
PE- HEENT, Abdomen (kids), Cardio (kids fever murmurs)
Labs- Monospot, lymphocytes and lymphocytosis on CBC and peripheral blood smear
Secondary strep infection
TX-Supportive, APAP
Allergic Rhinitis
ETI- 3yrs after moving,
S/S- persistent, seasonal, Sneezing, itching, rhinorrhea or congestion; ocular irritation, itching, watering, erythema. HX of eczema, asthma, Nasal turbinates pale (atrophy) or violaceous; polyps in chronic AR
Labs- IgE
TX- #1 Nasal steroids, antihistamines, Leukotriene antagonists, avoidance (new cat bird), netti pot,
Allergy testing.
Acute sinusitis- Viral
sinus cavities produce mucus, propelled by cilia, through the ostia/duct of turbinates/chocha. If cilia damage, fluid sits, bacteria grows. Maxillary common
ETI- viral or bacterial of one or more sinuses when drainage is blocked, Viral URI’s block drainage, 0.5% develop bacteria.
PE- HEENT, sinus, teeth palpate
10% dental abscess
S/S- Pts fewer than 10d sx, no high fever, complicated illness, should be managed with supportive care.
dull ache, cought inc sx. re
Bacterial-Purulent dc, nasal congestion, and facial pain lasting > 7 days, sx improve and then worsen; nasal decongestants don’t help
Ddx: dental abscess, cluster HA, trigeminal neuralgia, migraine
Acute sinusitis-TX
TX- w/o culturing
60% Strep pneumoniae or H influenza
Less common: anaerobes, S pyogenes, M catarrhalis, β-hemolytic Strep, Mycoplasma pneumoniae, Staph aureus
Topical decongestants and/or topical steroids; irrigation saline. Oral decongestants and antihistamines complicate sinusitis
Oral antibiotics
Amoxicillin or Augmentin, Bactrim, macrolides (azithromycin)
Toxic patients (esp ethmoid sinusitis) require hospitailization, IV abx, drainage and culture
Complication of noninfectious rhinosinusitis, polyps, foreign bodies, swimming/diving, anatomic nasal obstruction, nasogastric tubes
Chronic Sinusitis
loss of normal ciliated epithelial lining of the sinus cavity
anaerobic and aerobic bacteria - Strep pneumoniae orH influenza
S/S-facial pain, purulent drain, relapsing pattern >3 mo. Persistent through entire day, cough (post nasal drip)
Lab: CT prn,
Comps-periorbital cellulitis: proptosis, erythematous,
Intracranial extension, meningitis.
TX- Topical steroids. Otolaryngologist- surgical drain, ABX only for acute, Anithistamine or decongestants
Pharyngitis
1 identify and treat group A Strep (10%);
Eti- bacterial and viral pathogens
β-hemolytic Strep groups A and G, Mycoplasma pneumoniae, Chlamydia pneumoniae, (Corynebacterium diphtheriae, Neisseria gonorrhea, RSV, influenza A;B, parainfluenza, HSV, adenovirus, Epstein-Barr virus, coronavirus, rhinovirus, adenovirus, enterovirus, HIV
Strepococcal Pharyngitis
Shedding, Incubation 2-4 days
Abrupt onset of sore throat, malaise, fever, HA
Only 10% have classic syndrome.
hoarseness, rhinorrhea are absent
scarlitinaform rash: blanches, w/in one week
*Clinical Predictive Criteria Tonsillar exudate Tender anterior LAD Fever NO cough
If 3-4 of these criteria met, positive predictive value is 40%-60%
Strepococcal Pharyngitis-TX/ Complications
TX: Treat all patients w/ h/o rheumatic fever
#1 relief of sx, prevention of spread
PRN do not wait for culture results in very sx Pts.
Preferred tx: 1.2 million units benzathine PCN given IM;
or Pen VK 500mg PO QID x 10 days
Amoxicillin, or macrolides (PCN allergy)
Complications of Strep Throat
Nonsuppurative -Rheumatic fever
Suppurative -Pharyngeal abscess, Otitis media
Sinusitis
Acute Rheumatic Fever (scarlet fever)
inflammatory lesions of the heart, joints, and CNS w/ group A Strep pharyngeal infection, ages 6-15 years
2-4 weeks, Latent period between strep and ARF
TX- PCN x 10d
Jones Criteria-
Major- carditis, polyarthralgis, chorea (movement), nodules, erythema marginatum
Minor- fever, arthralgia, Prev hx RF or RHD
DX- 2 major sx OR 1 major and 2 minor.
Pharyngeal Abscess
Complication of URI
Peritonsillar most common: severe odynophagia (drool)
Unable to swallow, Muffled voice, trismus(jaw tight), fever, malaise, systemic toxicity
Swelling of the superior anterior tonsillar pillar; tonsil is displaced medially
Sialolithiasis
*stone in submandibular glands, Wharton’s duct
ETI- dehydration, anticholinergic meds, trauma
S/S-intermittent pain, swelling, tender, erythema
purulent dc if infected (parotitis)
Sialolithiasis- TX/Complications
TX-Hydration, “milk” the gland, hard candy
NSAIDs, ABX if purulent, Dicloxacillin or cephalexin
Refer to ENT lon or recurrent
Cold Transmission
Rhinoviruses: 25-30% with seasonal peaks in early fall and mid to late spring
Coronaviruses: 10-15% with seasonal peak in mid winter
Influenza, parainfluenza, respiratory syncytial virus and adenovirus : 10-15%; typical influenza syndrome
Bacterial etiology associated with pharyngitis, sinusitis, or otitis accounts for less than 10% of all colds
Incidence
Decreases with age
Adults have 2-4/y
Children have 6-8/y
Transmission: Direct contact Aerosolized particles Fomites Incubation -24-72 hours
AS S/S
Sinus pain caused by periosteal reaction due to purulent inflammation behind an obstructed ostium
Initially pain described as
Labyrinthitis:
acute, severe vertigo lasting days to a week with hearing loss, idiopathic, maybe viral
BPPV:
benign paroxysmal positional vertigo; changes in head position cause vertigo after 10-15 sec delay, vertigo gone 10-60 sec, but pt feels “imbalanced;”
ETI- theory, otoconia (crystals) floating in the semiciruclar canal become dislodged and irritate inner ear during head position changes
Meniere’s:
endolymphatic hydrops, distention of endolymphatic inner ear;
ETI- Migraine, syphilis and head trauma, largely unknown in
SX-episodic vertigo, fluctuating low frequency hearing loss, tinnitus, and aural pressure; low salt diet and diuretics, HA w/o hearing loss or tinnitus
Pharyngitis Clinical Variations- Pathogens
Corynebacterium haemolyticum: exudative, scarlitinaform rash, fever, and adenopathy
Mononucleosis: sore throat, fever, LAD, hepatosplenomegaly, maculopapular rash
Adenovirus: conjunctivitis and influenza-like symptoms
Coxsackie A, herpes simplex: mucosal vesicles or ulcers
Pharyngitis Culture
Exudate AND LAD w/ >100
43% + culutre and TX
Exudate OR LAD w/ >100
14% + culture DEFER ABX until results
Kids Rapid strep
