Lecture 3: Otitis Sinusitis Pneumonia Flashcards
2 year old female becomes irritable and cries a lot. Refuses to eat and when picked up is noted to be warm. Eyes had discharge when child awoke in morning (associated with H. influenzae)
Physical Exam
- Temperature is 38.2oC
- Lungs are clear. Abdomen soft. No adenopathy
- Conjunctivae are noted to be reddened
- Tympanic membranes are examined and both show erythema, bulging and do not move with insufflation.
Upper Respiratory Infections Involving S. pneumoniae and H. influenzae Otitis media
URI: Risk factors
- Most common in children between ages 6 to 18 months and is uncommon after age of three years
- More common if family history of otitis media exists
- Day care, smoking, lack of breast feeding increase risk
- First Nations persons in North America, Australia have higher rates than Caucasians
URI: Micro
Combined viral and bacterial etiology in about 2/3 of cases
– Bacterial pathogens most commonly encountered include S. pneumoniae, non-typable H. influenzae, Moraxella catarrhalis.
– Pneumococcal serotypes and incidence of pneumococcus have changed following conjugate vaccine introduction
Fewer vaccine associated serotype isolates (34% reduction)
Overall otitis media incidence reduced 6-7%
– S. aureus account for less than 3 % of isolates, S. pyogenes up to 5%
URI: Management
If diagnosis certain treat regardless of age
- Rapid onset
- Signs and symptoms of middle ear inflammation
- Signs of middle ear effusion
If uncertain
- Treat under 6 months age
- Watch between 6 months and 2 years old only if mild symptoms (Fever less than 39oC, mild otalgia) and reliable parents with access to care
- ≥ 2 years therapy optional if adequate follow-up
25 year old school teacher has onset of upper respiratory tract infection with sore throat, runny nose.
After 1 week and initial resolution of symptoms develops facial pain, purulent nasal discharge, fever of 38.7oC
Dx: Upper Respiratory Infections Involving S. pneumoniae and H. influenzae Sinusitis
Sinusitis 4 Categories
- Acute (less than 4 weeks)
- Subacute (4 to 12 weeks)
- Chronic (greater than 12 weeks)
- Recurrent acute. 4 or more episodes acute rhinosinusitis per year with resolution between episodes
Dx:
- Persistent
- Severe
- Worsening
Sinusitis: Etiology
- Vast majority are due to viral infection
- 0.5 – 2.0 % adult infection and 6 to 13% in children develop bacterial infection
- Respiratory droplets or direct contact with conjunctival or nasal mucosa
- Most common viral pathogens by sinus puncture are rhinovirus, influenza virus or parainfluenza virus
- Entry to sinuses by viremic spread or direct invasion (nose blowing may contribute)
- Bacteria may secondarily invade sinus
- S. pneumoniae, non-typable H. influenzae and M. catarrhalis
Sinusitis: Risk Factors
- Allergic rhinitis
- Obstruction
- Odontogenic infection
- Intranasal cocaine
- Impaired mucociliary clearance (cystic fibrosis, viral effect, smoking)
- Swimming
- Immunodeficiency
- Children in day care
Sinusitis: Presentation in Children
- Uncomplicated URI resolves in 5 to 10 days. Fever if present is in first 3 days.
- Sinusitis complicated by bacterial infection has
- – Persistent symptoms after 10 but less than 30 days
- – Severe symptoms with fever > 39o, purulent nasal discharge for 3 - 4 consecutive days
- – Worsening of symptoms after initial improvement
Sinusitis Presentation in Adults
- Similar pattern of worsening symptoms after 10 days
- Purulent nasal discharge, maxillary pain with bending forward, fever
- Bacterial infection in 60% if symptoms (persistent, severe, worsening) at 7 days
Sinusitis: complications
- include periorbital cellulitis,
- osteomyelitis of frontal bone,
- meningitis, cavernous sinus thrombosis, epidural abscess, brain abscess,
- deep neck infection.
- Need urgent referral if
- Diplopia
- – Decreased level of consciousness
- – Proptosis or periorbital edema
- – Meningismus
- – High fever (>39o, severe headache)
Sinusitis: common pathogens
- Viruses predominate in acute sinusitis
- Bacterial pathogens
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- S. aureus, anaerobes, other streptococci remainder
Sinusitis: Dx
- No gold standard test or culture
- Constellation of history and physical findings; Key features are
- purulent nasal discharge,
- nasal congestion and or facial pain or pressure
- bacterial infection suspected after 7 days if symptoms of purulent discharge, maxillary pain persist >10 days, are severe > 3-4 days after onset or symptoms worsen after initial improvement in viral URI lasting 5-6 days. (2012 IDSA Guidelines)
- P, S, W
Physical findings
- Examine respiratory tract including lungs and ears to avoid missing other complications
- Inspect pharynx
- Inspect nose looking for edema of mucosa and purulent discharge from ostia if possible
- Transillumination of sinuses not helpful in distinguishing viral from bacterial infection
Sinusitis: management
- Goal of therapy is to hasten recovery and prevent complications
- Viral infection suspected
- Pain relief
- Oral decongestants, antihistamines, mucolytics lack proven evidence of benefit
- Bacterial infection suspected based on duration and history
- Adults: watchful waiting if temperature less than 38C and mild pain. If no improvement after 7 days treat with antibiotics
- Children: Few good studies on effect of therapy. Best results when using stringent diagnostic criteria on duration and symptoms and weight based dosing.
- Antibiotic therapy
- Chose agents effective against Pneumococcus, H. influenzae and M. catarrhalis
- Duration of therapy 10 to 14 days or until symptom free and another 7 days.
- Treatment failure try another agent with better activity against possible resistant pathogen
- Aspirate or endoscopically guided culture may be required to guide therapy
- Consider IV Ceftriaxone in adults once a day
- Admission to hospital for seriously ill children or adult should be treated with 3rd generation cephalosporin (Ceftriaxone)
54 YO acute onset shortness of breath, fever and cough
He has been unwell for two days and has stayed home from work. His wife called the ambulance when he was unable to get out of the bed to come for the evening meal.
Background medical history is positive for smoking 30 pack year history, diabetes on oral hypoglycemics and ramipril (ACE inhibitor), His alcohol consumption is 2 to 3 beer a night
When asked he has been at a new construction site where they are digging a foundation. It has been very rainy lately.
Dx: Pneumonia
