Lecture 10/15 Flashcards
inflammation of the lid margins may be associated with conjunctivitis. Presents with burning, irritation, photophobia. Looks greasy and oily around eyelid/ lashes.
Blepharitis
What are three causes of blepharitis?
meibomian gland dysfunction
Staphylococcus infection
Seborrhea (seen in people w/ long eyelashes)
How do you treat blepharitis?
Local steroid and antibiotic ointment applied at night (depending on cause). This may be needed long term as the condition tends to recur.
What is the most common source of blepharitis?
Staphylococcus infection
What is the main cause of a hordeolum?
Staph infection
What glands are infected in an external hordeolum?
glands of Zeis in lid
What gland are infection with an internal style (can lead to a chalazion)?
meibormian glands
How do you treat a hordeolum?
Warm compresses
Local antibiotics to prevent recurrence/ secondary infection
Drainage
Often self limiting
Is a hordeolum painful?
Yes- usually red and painful
what type antibiotics do you use for eye problems?
Topical antibiotic (oral antibiotics don’t accumulate in conjuntiva as well)
Obstruction / Inflammation in a Meibomian glad. It may develop acute suppuration infection. A lump is seen over the tarsal plate
Chalazion
Therapy for chalazion?
Warm compresses
Antibiotics to reduce cellulitis
chronic cysts may need incision and curette
Tear overflow and secondary infection may result from this obstruction resulting from lack of closure of the nasolacrimal ducts.
Nasolacrimal Duct obstruction
Clinical findings with nasolacrimal duct obstruction.
watery, discharging eyes in first few months of life- can be mucoid
+/- conjunctival redness
Erythema of lids
What organisms will cause infection with a nasolacrimal duct osbstruction?
Strep and Staph
Tx for nasolacrimal duct obstruction if it persists past 1st year of life.
Open the ducts surgically via probing
when do most nasolacrimal duct obstructions clear by
1st year of life
How do you treat nasolacrimal duct obstruction?
massage over lacrimal sac
local antibiotics drops for secondary infection
Watery discharge Tender preauricular lymph node Can present with pharyngitis, cold sxs injected eyes, usually unilateral initially and spreads to other eye 1-3 days later Dry or burning sensation/ itching
Conjunctivitis - Viral
How do you treat viral conjunctivitis?
Supportive- eye drops, antihistamiens
Most common cause of viral conjunctivitis?
Adenovirus
Red eyes, sore but not painful
In just one eye or both together at same time
Muco-purulent discharge
Usually really itching/ sore but not painful
usually not with cold symptoms
conjunctivitis- bacterial
most common causes of bacterial conjunctivitis. (from most to least common)
Staph aureus (skin infection)
Strep pneumo
H. flu
Tx for bacterial conjunctivitis.
Topical erythromicin
polymixin-bacitracin
sulfacetamide
fluoroquinolones
Why are you not as concerned for choosing a specific type of antibiotic for bacterial conjunctivitis?
Since it is right on the eye it will usually kill it not matter what
What is the name for neonatal conjunctivitis?
Opthalmia Neonatorum
What is the big concern with ophthalmia neonatorum?
Gonorrhea or chlamydia from birth canal
how do you treat ophthalmia neonatorum?
systemic antibiotic tx (Erythromycin)
For conjunctivitis are labs common?
No, except for chlamydia (want direct culture)
Presents with itchy eye, rubbing of eyes, watery discharge and no injection. Often have lid edema, nasal congestion, sneezing.
Allergic conjuntivitis
Allergic conjunctivitis often presents with ______________ on tarsal conjunctiva.
cobblestone papillae
What indicates corneal involvement and possible serious loss of vision with allergic conjunctivitis.
Photophobia or reduced vision (suggest vernal conjunctivitis)
How do you diagnose vernal conjunctivitis (chronic form of allergic conjunctivitis)?
Eosinophils in conjunctival scraping
How do you treat allergic conjunctivitis?
Topical solutions (antihistamines) - usually older than 6 combing antihistamine and mast cell stabilizers
Inflammation of the cornea- not common with conjunctivitis
Keratitis
Causes of keratitis
HSV
N. gonorrhea
adenovirus
Treatment for HSV keratitis?
Ocular acyclovir and ophthalmology referral
complications of keartitis?
Corenal scarring
iritis and deep keratitis
Do you want to put steroids in the eye?
Never because they cause rapid progression and can lead to corneal perf
Physical scratch over cornea
Usually d/t trauma or FB
Corenal abrasion
Tx for corneal abrasion
Antibiotics to avoid secondary infections (common)
patching for comfort if symptoms severe
Presents with pain, blurred vision and photophobia.
Corneal abrasion
What do you use to revel a corneal abrasion.
Fluorescein exam
What is similar to a corneal abrasion but often related to rheumatologic dz (RA, sjorgen, SLE (lupus), polyarteritis nodosa)
Corneal Ulcer
How do you treat corneal ulcers?
Tx underlying dz, usually by rheumatology
How long are antibiotics for eye infections usually?
5-7 days
Blood in anterior chamber. Usually due to trauma, glaucoma, vascular abnormalities.
Hyphema
How do you treat hyphema?
Treat underlying dz is applicable, pain management
referral to ophthalmology
may need surgical correction
Presents with dilated pupil, hazy white color, possibly white reflex. Can be painful. Will have tunnel vision
Glaucoma
Tx for glaucoma
Refer to ophthalmology
Opacity of the lens. Unilateral or bilateral.
Cataract
infective causes for cataract
CMV
Varicella
Rubella
(congenital)
Symptoms of a cataract
Leukocoria, strabismus, nystagmus, poor fixation
How do you diagnose a cataract?
altered red reflex on opthalmoscopic
workup for infection, metabolic, chormosome
How do you manage catarcts?
Surgery
decrease in the child’s vision that can happen even when there is no problem with the structure of the eye.
Amblyopia
how do you treat amblyopia?
Patching the good eye to train the bad eye
What are types of amyblyopia
Strabismic amblyopia,
deprivation amblyopia
refractive amblyopia
Most strabismus is the result of an abnormality of the poorly understood _________ (including brain) control of eye movement
neuromuscular
what is hypotropia
eye is rotated down
what is hypertropia
eye is rotated up
what nerve palsys can cause strabismus?
3rd cranial nerve superior oblique (4th CN- trochlear)
What disorders are more likely to cause strabismus?
cerebral palsy
down syndrome
hydrocephalus
brain tumor
Oscillatory movement of eyes, may be horizontal, vertical or torsional/rotational
Nystagmus
Potential treatments for strabismus
eye glasses
eye exercises
prism
eye muscle surgery.
What are some congenital causes of nystagmus?
neurologic dysfunction
decreased visual acuity
idiopathic
rarely glioma
Acquired causes of nystagmus
Vestibular lesions/inflammation/infection
brain lesions/ malformations
muscle spasms
medications
Neovascularization of immature vasculature seen in preemies (< 1500g)
Retinopathy of Prematurity (ROP)
What can induce ROP?
excess O2 supplementation
hypoxemia
illness
What does ROP result in?
Retinal detachment and vision loss
How do you treat ROP?
medical or surgical ablation vessels by optho
Inflammation of skin lining in the ear canal
Otitis externa
Risk factors for otitis externa
Water trapper “swimmers ear”
Trauma to canal from q tip
main pathogens for otitis externa
Pseudomonas aeurginosa (most common) staph aureus
symptoms of otitis externa?
Pain and itching, +/- purulent discharge,
pain elicited with traction on pinna or tragus
Treatment for otitis externa
Topical –2% acetic acid to restore ph …. Or antibiotic / corticosteroid drops . Cipro HC (flouroquinolones)
what should you never use in the ear?
Aminoglycosides
Grey/ translucent TM Air fluid levels Bubbles Little to no movement of TM TM may be retracted
Otitis media with effusion
What are some symptoms of otitis medial with effusion?
Hearing loss
fullness or ear
may have vertigo
What are some contributing factors for otitis media with effusion?
allergic rhinitis
tonsilar/ adenoid hypertrophy
sinusitis
eustachian dysfunction
What is the effusion like with otitis media with effusion?
Mucoid or serous but not puss
Tx for OME
watchful waiting
put tubes in ear
Results from post nasal drainage, URI/allergies
inflammation leads to poor regulation in middle early. because the tube i horizontal
Eustachian dysfunction
Symptoms of eustachian dysfunction.
Ear pain/ fullness/ popping sensation
decreased hearing
What is one cause of ear infection in infants?
Drinking bottle on back
When does acute otitis media peak?
6-24 months
what is recurrent OM?
> 4 episodes in 6 months or failed tx twice
Symptoms of acute otitis media?
poor reeding fever pain/ irritability pulling on ear vomiting
what is the highest predictive value of acute otitis media.
bulging tympanic membrane
What is the triad of AOM?
recent onset of illness (URI common)
signs/ symptoms of middle ear inflammation
otoscopic findings (evidence of effusion)
Predisposing factors of AOM?
Nasopharygneal colonization cigarette smoke unfavorable eustachian tubes allergies under-immunization anatomic abnormalities
What organisms cause of AOM?
S. pneumo (biggest one)
H. influenza
Moraxella catarrhalis
What are some viral causes of AOM?
RSV
influenza
If a kids is <2 years old and has AOM when do you treat them?
with a fever
If a child is <6 months old how do you treat AOM?
antibiotics
when do you not treat with antibiotics for AOM?
not febrile
supportive therapy helps enough
no ruptured ear drum
only one ear
What is the first line treatment for AOM?
amoxicillin 90 mg/kg/day for 10 days
If a child is allergic to amoxicillin what do you treat for AOM?
cefdinir cefpodoxime cefuroxime azithromycin clarithromycin
What is the second line tx for AOM? (also first line for those with severe illness- moderate to severe otalgia or fever, both ears)
amoxicillin-clavulanate 90 mg/kg/day
ceftriaxone (50 mg/kg) parenterally for 1-3 days (usually for recurrent or failed 2nd line)
how can you reduce risk of AOM?
breastfeeding for at least first 6 months
avoid supine bottle feeding
eliminate pacifier use after 6 months
eliminate tobacco smoke
what gets the higher dose of amoxicillin?
ear infections (less blow flow)
what children are at more risk for AOM?
boy, LBW, premature
childcare
cleft palate
When are PE tubes indicated?
Chronic OME with conductive hearing loss
failed tx for AOM
Do PE tubes prevent ear infections?
No, allows drainage of fluid that comes with ear infections. Prevents progression of those infections to hearing loss
when do TE tubes usually fall out?
6 months- 2 years
What does scar tissue from TM perf cause?
Hearing loss
With a TM perf that is almost complete what happens?
only have bone conduction, not air conduction
can lead to hearing loss
What are some complications of OME/AOM
tympanosclerosis= white palques on TM scars
Perf
Mastoiditis
is there any evidence to support prophylactic ABX of OME?
no (some for recurrent AOM)
Complication of masoiditis
Brain abscess
Surgical emergency!
what causes mastoiditis?
complication of AOM
what are the most common bacteria that cause mastoiditis?
Strep penumoniae
Strep pyogenes
symptoms of mastoiditis
postauricular pain, fever, displacement of pinna.
what is a complication of mastoiditis
meningitis
brain abscess
How do you treat mastoiditis?
Myringotomy to obtain culture
hospitalize with IV ABX
corticalmastoidectomy if severe
Growing mass of epithelial tissue within middle ear and temporal bone.
Cholesteatoma
Complications of cholesteatoma
Damaging hear anatomy
pemanent hearing loss
invasion into bone and brain (abscess)
How do you get a cholesteatoma?
congenital
acquired (chronic AOM, perf ear drum)
what is the main thing you’ll see first with cholesteatoma?
hearing loss
How do you treat cholesteatoma?
Surgical removal
what is the most common cause of conductive hearing loss in children?
OM
What is sensorineural hearing loss due to?
due to defect in cochlear receptor cells or auditory nerve (CN VIII)
What are some risk factors for sensorineural hearing loss (SNHL)?
LBW 50 days)
What are acquired reasons for SNHL?
ototoxic med- gentamicin
infection- meningitis, syph, lyme dz, CMV
autoimmune or neoplastic conditions
How do you test hearing at birth to 4 months?
startle to sounds
BAER or ABR
How do you test hearing at 4 month to 2 years?
using soft soundmaker outside child’s field of vision
what do you do for natal teeth?
Dental eval, possible extraction
often no roots and have an aspiration risk
What is considered late tooth development?
no teeth by age 15 months or single tooth eruption missing mirror pair
10+ small mouth ulcers on buccal mucosa, anterior pillars, inner lips, tongue, gingiva (not posterior pharynx)
Herpes Simplex Virus (HSV)
What are symptoms of HSV?
Fever
cervical adenopathy
How long does a flare of HSV occur for?
7-10 days
Most common cause of dental caries.
Strep viridans
what age are children more at risk for HSV?
<3 years old
Tx for HSV.
Acyclovir
What can HSV cause, especially in newoborns
Optic neuritis
meningitis
encephalitis
Should you give corticosteroids with HSV?
No- it will spread the infection
White curd-like plaques on the inner checks or tongue that doesn’t scrape off.
Thrush/ candida albicans
Symptoms for thursh.
refusal of feeding
in pain
how do you treat thursh?
Nystatin
Erosions to oral mucosa that has an unknown etiology. Increases with stress, recent illness, irritants (spicy food), vitamin deficiency.
Oral aphthae
what can oral aphthae be a sign of if recurrent or there are a lot of them?
Systemic illness (HIV, celiac, IBD, SLE, etc)
Treatment for oral aphthae
Dietary avoidance, mucosal protectants, pain mgmt
Where is the cone of light on the ear?
Always angled toward the front of their face
What is a good guideline for failed treatment for AOM?
If they have another ear infection within 12 months
