Module 6: HEENT Part 1-edited Flashcards
What is the care of the patient treated for anaphylaxis?
- Mild and transient effects such as pallor, tremor, anxiety, palpitations, headache and dizziness occur within minutes after injection of a recommended dose of epinephrine. These effects confirm that a therapeutic dose has been given.
- Ensure the person lies down. Fatality can occur within seconds if the person stands or sits suddenly after epinephrine.
- People should remain in a recumbent position following receipt of an epinephrine injection and be monitored closely.
When do you refer to opthalmology for conjuctivitis?
- corneal ulceration
- keratoconjunctivitis
- ocular allergy
- viral keratitis
What considerations does NP need to take into account when prescribing Zanamivir?
Patients with asthma or COPD can have bronchospasm (wheezing) or serious breathing problems when using zanamivir.
What are the non-pharmacological interventions of viral conjunctivitis?
- Advise regarding self-limiting nature of condition (viral conjunctivitis)
- Pt is highly contagious for 48-72hrs; restrict contact with others 24-48hrs after tx initiated
- Avoid sharing personal items & ensure good hand hygiene
- Cleanse affected eye(s) by wiping from the inner canthus outward using a single tissue/cotton ball
- Clean eyes several times a day with weak
solution of no-tear baby shampoo & warm water - Stop wearing contact lenses until the problem is resolved
- Avoid makeup, smoke, wind and other irritants
- Apply cold compresses several times a day to
reduce discomfort of lid edema
What is acute otitis media?
- Rapid onset of symptoms of inflammation of the middle ear (2-3 days)
- Can be viral or bacterial
- Often preceded by viral URTI which alters respiratory tract defenses by disturbing the epithelium and impairing mucociliary clearance. This may lead to eustachian tube dysfunction
What are the side effects of corticosteroid spray?
- Epistaxis
- Nasal irritation
- Rarely, septal perforation
What must never be prescribed for conjunctivitis?
Topical anesthetic eye drops should never be prescribed for self-administration by the patient
What is uncomplicated acute otitis media?
AOM without otorrhea
What are natural remedies for colds/rhinitis?
- North America gingseng extract
- Vitamin C
- Echinacea
- Zinc
- These have been shown to reduce the frequency, duration, and severity of colds (MUMS guidelines)
What are non-pharmacological interventions for otitis externa?
- Instruct patients to remove moisture from ear after swimming (tilting the head, use warm air from hairdryer), or use earplugs while in the water
- Avoid use of cotton swabs to clean ears
- Avoid long term use of items that occlude the ear canal (e.g. headphones) if possible
- Clean external ear canal, consider flushing ear canal if cerumen impaction is present
- Use mineral oil x7 days then once a week prophylactically for cerumen impaction
What are contraindications in administering epinephrine in treating anaphylaxis?
There are no absolute contraindications to
epinephrine in the setting of anaphylaxis; but delay or absence of epi administrations can result in death
What are pharmacological interventions for bacterial conjunctivitis?
- First line- OTC drops gramicidin-polymyxin B drops (Polysporin) 1drop q3-4h. If lots of tearing present use ointment instead- bacitracin-polymixin B ointment
- RX- Erythromycin 0.5% ointment 0.5-1 inch QID (lots of other choices too like gentamycin and tobramycin-
however these options can damage cornea with prolonged use) - If infection is severe or complicated (contact lenses, corneal involvement, Tx failure): Besifloxacin 0.6% drops 1 drop TID x7 days (many other “floxacin” options as well)
usual course is 5-7 days
What are some management interventions for acute rhinitis?
- Drink plenty of water (6-8 glasses)
- Saline (nasal drops/spray/rinse/gargles)
- Analgesics
- Decongestions
Under what conditions should NP refer a child with AOM to ENT?
- for treatment failures or recurrences unresponsive to therapy
- recurrent episodes (≥3 episodes in 6 months or ≥4 episodes in 12 months) for consideration of myringotomy and tympanostomy tubes
- children with recurrent episodes of AOM should also have audiology assessment to determine any conductive hearing loss
What is nonsevere acute otitis media?
AOM with presence of mild to moderate otalgia and fever >39
What are non-pharmacologic interventions for bacterial conjunctivitis?
- Infection usually self-limited -65%
- Proper hand hygiene to stop spread and re-infection
- Warm compress to remove crusts etc wipe from inner canthus outward using single use cloth or cotton.
- Can clean lashes several time a day with weak solution of no-tears baby shampoo and water
What is the first line treatment for AOM
Amoxicillin is considered first-line therapy in the treatment of AOM.
Amox 80mg/kg/day divided BID or TID (MUMs)
What are non-pharmacological interventions for acute conjunctivitis?
- Advise about self-limiting nature of condition
- Restrict contact with others 24-48hrs
- Avoid sharing personal items
- Hand hygiene
- Clean affected eye by wiping from inner canthus outward using a single tissue/cotton ball
- Clean eyelashes several times a day with weak solution of no-tear baby shampoo and warm water
What are the pharmacological interventions of viral onjunctivitis?
- To distinguish bacterial from adenoviral conjunctivitis, a point-of- care adenoviral test is available for healthcare
practitioners to use in office - MUMS: No antibiotics or antiviral indicated for viral conjunctivitis. Can use artificial tears depending on symptoms. E.g. Refresh for dry eyes, exposure, lid malpositions, blepharitis, minor irritations. 1–2 drops TID-QID. A/E: Preservative toxicity, gels cause filmy/blurry
vision.
What is aqueous tear-deficient keratoconjunctivitis sicca?
- Sjörgen syndrome (autoimmune etiology e.g. RA, SLE)
- Non-Sjörgen syndrome (idiopathic age-related disease; lacrimal gland scarring e.g. trachoma; decreased secretion e.g. contact lenses, CN VII palsy, anticholinergics, antihistamines, diuretics, b-blockers)
What are children <6 weeks old with acute otitis media at risk for?
Bacteremia/sepsis
Refer to ER
What is the next step when antigen test is negative for strep in a child?
Throat swab culture is required for children
What is the criteria for prophylaxis treatment of influenza-like illness in LTC
When at least two residents develop acute flu-like illness within 72hrs of each other and have laboratory confirmation
What topics should the NP counsel parents on as non-pharmcologic interventions for acute otitis media?
- Breastfeed for at least 6 months
- Avoid supine bottle feeding
- Then, reduce and eliminate pacifier use in second 6 months
- Eliminate 2nd hand smoke
What are the adverse effects associated with 1st gen antihistamines when used to treat allergic rhinitis?
- 1 st gen antihistamines have many S/E - drowsiness, impaired performance,dry mouth, urinary retention, constipation
What is keratoconjunctivitis sicca?
- Bilateral desiccation (dryness) of the conjunctiva and cornea due to inadequate tear film production
- There are two main types: aqueous tear-deficient & evaporative
When do you prescribe corticosteriods and/or antibiotics for conjunctivitis?
Generally, there is no role for use of steriod or antibiotic/steriod combination in primary care
What are the non-pharmacologic interventions of keratoconjunctivitis sicca?
- Punctal occlusion (punctal plug insertion)
- Lid taping
- Tarsorrhaphy (sew lids together) if severe
Under what circumstances are antibiotics indicated in acute otitis media?
- Infants <6 months
- Severe illness (moderate to severe ear pain w/fever ≥39, bil AOM, systemic features, and severe local signs (perforation w/purulent discharge)
What is the primary purpose of treatment in pharyngitis?
The primary purpose of treatment in pharyngitis is prevention of acute rheumatic fever?
What are the sore throat score criteria for phargitis?
- Temp >38C = 1
- Absence of cough = 1
- Swollen, tender anterior cervical nodes = 1
- Tonsillar swelling or exudate = 1
- Age 3-14 yr = 1
- Age 15-44 = 0
- Age ≥45 = - 1
What is a common side effects with intranasal antihistamine spray when used to treat allergic rhinitis?
Sedation
What are non-pharma interventions for vasovagal syncope?
- Reassure the patient that vasovagal syncope is not life threatening and that it is a physical problem, not a psychiatric disorder.
- Encourage increased dietary salt (3–5 g daily) and fluid (up to 2.5 litres daily) in the absence of contraindications such as hypertension or heart failure.
- Teach pt physical counterpressure manoeuvres at the onset of presyncope (e.g. squatting, crossing the legs with isometric contraction if standing, and vigorous hand clenching with upper girdle isometric contraction).
- Pacemaker therapy
What are preventative education measures for otitis externa?
- Instruct patients to remove moisture from ear after swimming (tilting the head, warm air from hairdryer), or use earplugs while in the water
- Avoid use of cotton swabs to clean ears
- Avoid long term use of items that occlude the ear canal (e.g. headphones) if possible
- Treat underlying predisposing skin conditions (e.g. eczema, psoriasis)
- Clean external ear canal, consider flushing ear canal in cases of near occlusion with cerumen
What is blepharitis?
- Chronic bilateral inflammatory condition involving the lashes and lid margins
- Most often due to colonization of eyelash follicles and the Meibomian glands
- S. aureus is believed to be the underlying causes in most cases
- Generally classified according to the predominant anatomic location as either anterior blepharitis (AB) or posterior blepharitis (PB). PB is more common
- Both types are characterized by the common signs that the eyes are “red-rimmed” with granular matter clinging to the lashes.
- Frequent symptoms are irritation, dryness, and itching of the eyes
Which antibiotics must be avoided or given under controlled conditions due to the risk of carrying a risk of cross-reactivity with penicillin allergy?
- Cefazolin
- Cephalexin
- Cefadroxil
- Cefprozil
When do you treat GAS that is asymptomatic?
- GAS is found in 20% of population and causes no symptoms
-
Only treat if there is:
- Family hx of rheumatic fever
- Outbreak of rheumatic fever
- Outbreak of pharyngtis in a closed community
- Repeat transmission within family (≥3 culture confirmed episodes of symptomatic pharyngitis)
What are the non-pharm/pharm interventions for viral conjunctivitis?
- Antibacterials are used rarely in viral conjunctivitis & only to prevent secondary bacterial infection
- Some patients may react to preservatives in artificial tears. Lubricants without preservatives may be preferable for pts who require drops more than 4-5 times daily and who experience eye irritation
- Valtrex dosage adjustment may be required in renal impairment.
- Also, advise on safer sex practices with suppressive therapy
What are non-pharm interventions for candidiasis?
- Keep affected skin area clean & dry
- Avoid sharing personal items & towels.
- Avoid wearing tight or occlusive clothing. Wash linens & clothing in hot water & hot dryer
- If patient on inhaled steroid, use aerochamber, rinse mouth & spit after each use
- Clean dentures daily
- Expose diaper area to air
- Wear loose clothing
What are the ocular red flags?
- Diminished vision
- Ocular pain (differentiate discomfort of conjunctivitis from pain)
- Severe purulent discharge
- Conjunctivitis associated with sexual activity
What is the significance of ototoxicity in acute otitis media?
- Topical aminoglycosides increases the risk of ototoxicity in the presence of a TM defect or when placed into dry middle ear spaces.
- Health Canada advises that gentamicin containing ear drops SHOULD NOT BE USED in pts w/broken, perforated, or absent eardrum or w/surgical ear tubes.
- Advise pts to stop treatment immediately if hearing loss, tinnitus, vertigo, or imbalance is noted
What consideration does NP need to take into account when prescribing ear drops containing gentamicin?
Health Canada warns that gentamicin SHOULD NOT BE USED in patients with non-intact TM
What are the non-pharmacologic interventions for anaphylaxis?
● Avoid exposure to allergens
● If a bug sting: apply cold compresses to the site of the sting
● Patient should be placed in the Trendelenburg position
● Legs should be elevated to maintain blood pressure
What are non-pharm interventions for sinusitis?
- saline nasal irrigation to liquefy and soften crusting of nasal secretions and facilitate their removal, and to moisturize dry, inflamed nasal mucosae
- adequate rest and hydration
- warm facial packs/compresses
- sleeping with the head of the bed elevated
- Endoscopic sinus surgery for recurrent sinusitis not responding to pharmacological treatment
What are the pharmacologic interventions of otitis externa?
- Buro-sol otic solution 2-3 drops TID or QID
- Contains 0.5% aluminum acetate and 0.03% benzethonium chloride in dilute acetic acid
- Preferred over topical abx because of lower toxicity, avoids resistance, and is less expensive
- In instances of tympanic perforation (or inability toconfirm intact tympanic membrane), do NOT use gentamicin containing-drops (due to risk of ototoxicity)
- Caution should also be used with other aminoglycosides
- Ciprodex is first line in these cases
How is otitis media with effusion different from ottitis media?
- Otitis media with effusion is the presence of fluid in the middle ear without signs or symptoms of acute ear infection
- On exam, TM appears cloudy, immobile and bubbles may be visible
What should you suspect if patient is having difficulty swallowing, especially if associated with drooping, presence of alter voice ‘hot potato’ voice or airway obstruction (e.g. stridor)?
- Epiglottitis
- Peritonsillar abscess
What is chronic suppurative otitis media?
- Recurrent or persistent bacterial infection of the middle ear cleft.
- Hallmark features: presence of a TM perforation, conductive hearing loss, and presence of malodorous aural discharge. Divided in to “SAFE” (due to chronic mucosal disease) or “DANGEROUS” due to the ingrowth of stratified squamous epithelium into the middle ear (cholesteatoma)
What is otitis media with effusion?
- Otitis media with effusion (OME): inflammation of
middle ear with presence of fluid, S&S of acute
infection are absent. Avoiding exposure to passive
smoking is the single most effective modifiable risk
factor in preventing OME in children
What is the management of bacterial blepharitis?
- Tid hygiene BID-TID unitl improved then once daily
- Tear supplememts PRN
- Antiobiotic ointment
- Corticosteriod drops or ointment if infiltrates
What is a problem associated with restasis in the treatment of keratoconjunctivitis sicca?
- Restasis is an ophthalmic immunomodulator and should be prescribed on the advice of an eye care professional or rheumatologist
- Restasis has adverse effects →ocular burning sensation
What are the pharmacological interventions for anaphlaxis?
- Epinephrine 0.01 mg/kg body weight of a 1:1000 (1 mg/mL) solution should be administered into the mid-anterolateral aspect of the thigh
- Adults
- Moderate reaction: generalized urticaria, angioedema, wheezing, tachycardia
- ■ epinephrine (1:1000) 0.3-0.5 mg IM
- ■ antihistamines: diphenhydramine (Benadryl) 25-50 mg IM
- ■ salbutamol (Ventolin) 1 cc via MDI
- Severe reaction/evolution: severe wheezing, laryngeal/pulmonary edema, shock
- ■ ABCs, may need ETT due to airway edema
- ■ epinephrine (1:1000) 0.1-0.3 mg IV (or via ETT if no IV access) to start, repeat as needed
- ■ antihistamines: diphenhydramine (Benadryl®) 50 mg IV (~1 mg/kg)
- ■ steroids: hydrocortisone (Solucortef®) 100 mg IV (~1.5 mg/kg) or methylprednisolone
- (Solumedrol®) 1 mg/kg IV q6h x 24 h
- ■ large volumes of crystalloid may be required
What are comorbidity/modifying factors for CAP?
hospitalization in past 3 months and/or chronic heart, lung, liver or renal disease, diabetes mellitus, alcoholism, malignancies, asplenia, immunosuppression
When would you treat Group A strep that is symptomatic in pharyngitis?
- Family history of rheumatic fever
- An outbreak of rheumatic fever
- An outbreak of pharyngitis in a closed community
- Repeated transmission within families (≤ 3 culture confirmed episodes of symptomatic pharyngitis)
- 20% of population may carry Group A Strep asymptomatically, therefore, no need to treat everyone if asymptomatic
What is recurrent acute otitis media?
≥3 episodes in 6 months; or 4 episodes in
last year with 1 epiode in last 6 months
What is the treatment of croup?
One dose of dexamethasone 0.6mg/kg is effective against mild to moderate croup
What is bacterial conjunctivitis?
- Inflammation of the conjunctiva
- 32-50% of conjunctivitis is bacterial
- Commonly- S.aureus, S.pneumoniae, H. influenzae, M.
catarrhalis. More rarely, but more severe- N.
gonorrhoeae (can progress to keratitis, corneal
ulceration, endophthalmitis and blindness very quickly) - Rapid onset (24hr) uni or bilat. Conjunctival redness.
Gluey/sticky eyes worse in the morning, with occasional
crusting, copious thick mucopurulent discharge at lid
margins that persists throughout the day. Eyelid
erythema. Discomfort with possible foreign body
sensation - Can be mild to severe with sever infections running the risk of periorbital cellulitis (accompanying systemic
symptoms) - Photophobia is a sign that cornea in infiltrated (see tx
options) - Gonococcal infections produce copious discharge and
pre-auricular lymphadenopathy (rapid onset <24hr)
What is the management of patient with acute rhinitis having purulent secretions from the nares or throat?
- Purulent secretions are common and do not predict bacterial infection
- Antibiotics are not recommended in previously healthy individuals with acute rhinitis as they do not enhance disease resolution
What is severe acute otitis media?
AOM with presence of moderate to severe otalgia (ear pain) or fever ≥39
Watchful waiting is recommended in AOM when what conditions are met?
- When child is over 6 months of age,
- Illness is mild and uncomplicated, and;
- Parent/caregiver can monitor the child for 48-72hrs & easily access the physician for communication/re-evaluation
What is a differentiating factor between otitis externa and otitis media?
Pulling on the pinna may be extremely painful in otitis externa but not in otitis media
