Test five (weeks 8 + 9) Flashcards
First line therapy for group a strep pharyngitis
Penicillin V (B lactam antibiotic)
First line therapy for AOM, bacterial rhinosinusitis, GAS
Amoxicillin and amoxicillin / clavulanate
When might a cephalosporin be prescribed instead?
More resistant to b lactamases and have a broader spectrum of activity than penicillins, with more efficacy against gram neg species
Why might a non-lactam be prescribed instead?
Those with severe penicillin / b lactam allergies
What are some physiologic features of EENT that might affect drug absorption and distribution?
TM impermeable to most drugs, but if ruptured then drugs administered to cancel can damage middle/inner ear.
Drugs topically to eye will drain into nose where they’re systemically absorbed.
Blood-ocular barrier comparable to blood-brai barrier; drugs administered systemically don’t easily enter the eye
Adverse effects of antibiotic use
Hypersensitivity reactions
Organ toxicity
CYP450 induction or inhibition
Teratogenicity (penicillins are safest)
Disruption of microbiome
When is it appropriate to prescribe antibiotics for EENT conditions?
Infections threatening deeper structures
Cases not responding to treatment
Specific populations (Immunocompromised pts) or circumstances (pts w strep pharyngitis who have had RF)
What determines the choice of specific antibiotic for a given condition?
Microbes sensitivity to a drug
Current resistance to drug
Safety profile for individual pt
Cost/availability
Which classes of oral antibiotics are not recommended for children?
Tetracyclines
Fluoroquinolones
Which class of antibiotics should be used in the ear if there is TM rupture?
Topical fluoroquinolones
What class of antibiotics is so ototoxic its used for inner ear ablation in severe meniere disease?
Aminoglycosides (gentamicin)
What class of antivirals is helpful with the herpes virus conditions?
Nucleoside analogues such as acyclovir
What molecule is the target of most anti fungal medications?
Ergosterol, part of the fungal cell membrane
What are possible adverse effects of oral antifungals?
Oral: GI disturbance, hepatotoxicity, drug interactions
Topical: local hypersensitivity reactions
What ENT conditions are treated with antifungals?
Otitis externa
Oropharyngeal thrush
Rhinosinusitis
What routes of administration of glucocorticoids can cause HPA axis suppression?
Systemic absorption
Why might an atopic patient have particularly high plasma levels of glucocorticoids, even using topicals?
Combined effects of topical for atopic dermatitis, inhaled for asthma, intranasal for allergic rhinitis
What conditions might be treated with intranasal glucocorticoids?
All forms of rhinitis and rhinosinusitis
What conditions might be treated with otic glucocorticoids?
Ear conditions such as otitis externa and inflammatory conditions of the outer ear
What conditions might be treated with opthalmic glucocorticoids?
Inflammatory conditions of the eyes
Post op inflammation for ophthalmic surgery
To minimize damage of ocular injuries
Why are 2nd general IN glucocorticoids preferred?
Less systemic absorption
What are local adverse effects of IN glucocorticoids?
Local irritation, epistaxis, nasal ulceration
What are systemic effects of IN glucocorticoids?
Adrenal suppression, growth delays in children, increased intraocular pressure, increase risk of nasal and pharyngeal candida
Why is it reccomended that ophthalmic glucocorticoids be managed under the guidance of an ophthalmologist?
Inc risk cataracts and glaucoma
Infection
Delayed healing
Systemic absorption
What is a “cholinergic” med?
Meds that act via Ach, either by binding to its receptors or changing its concentration
Why are muscarinic agonists also called “parasympathomimetic” meds?
Muscarinic agonists mimic PNS stimulation
For what EENT conditions are muscarinic agonists used?
Acute angle-closure glaucoma
Maintenance med in primary open angle glaucoma
Dry mouth and dry eyes in Sjogrens
For what EENT conditions are muscarinic antagonists used?
Topically for pupil dilation during ophthalmic procedures
As cycloplegics for uveitis, iritis, UV keratitis
What patient population should avoid muscarinic antagonists?
Elderly due to risk of confusion, dry mouth and eyes, constipation, urinary retention
Pts with glaucoma and those at risk of acute angle-closure glaucoma
What are “adrenergic” medications?
Act by binding to adrenergic receptors or changing the concentration of epi and norepi
what do andrenergic agonists mimic?
SNS stimulation
For what EENT conditions are alpha 1 agonists used?
Nasal congestion and red eyes
For what EENT conditions are alpha 2 agonists used/
Glaucoma
For what EENT conditions are beta blockers used?
Glaucoma
Which pt populations should avoid alpha 1 agonists
HTN/CVD
Angle closure glaucoma
Urinary retention
Bowel obstruction
Which pt populations should avoid beta blockers
Asthma
Obstructive airway disease
What is the effect of histamine in the allergic response?
Vasodilation
Inc vascular permeability (edema, redness, inc mucus)
Stimulation of afferent neurons (pruritis, pain)
Contraction of bronchial smooth muscle (bronchoconstriction)
What types of histamine receptors are involved in the allergic response?
H1 receptors for allergic response
(H2 = reg of acid in gastric mucosa)
NT in CNS - several types of receptors
What EENT conditions are treated with H1 antagonists?
Reduces itching sneezing, rhinorrha, congestion of allergic rhinitis
Itching, redness, and watery eyes of allergic onjunctivitis
Which pt population should avoid antihistamines?
Children <2
How does the mechanisms of antihistamines differ from that of mast cell stabilizers?
Antihistamines block histamine receptors, mast cell stabilizers prevent the release of histamine from mast cells
What EENT conditions are treated with mast cell stabilizers?
IN for allergic rhinitis
Eye drops for allergic conjunctivitis
Topically for allergic conjunctivitis
What are the 2 eicosanoid pathways? Which eicosanoids are made by each?
Cyclooxygenase (COX) > prostaglandins and thromboxane
Lipoxygenase (LOX) > leukotrienes
How are NSAIDS and acetaminophen used in EENT conditions
Fever and pain
How are prostaglandins used in EENT conditions
Glaucoma
How are leukotrinee antagonists used in EENT conditions
Allergic rhinitis
Chronic rhinosinusitis
What types of ddxs are there for a sore throat other than pharyngitis?
Systemic disease (arthritis, HIV, TSS, hepatitis)
Head/neck disorders (cervical pain, sinusitis, mumps, thyroiditis)
Lesions (herpes, candida, mono, canker sores)
What is a red flag with sore throats?
Sudden severe throat pain, esp in older pts > aortic dissection, pneumothorax
Signs/sx of mono
Teens with sore throats > 1 week
Post cervical tender nodes
Adenopathy in groin + axilla
Functional impairment w myalgia
Tonsil exudate
Petechiae on pharynx
How do you confirm a mono infection with lab tests?
Peripheral smear (atypical lymphocytes)
Monospot (more sens 2 weeks after contraction)
Mildly elevated transaminase levels
Liver transaminases to assess for EBV hepatitis
Centor criteria points
+1
Temp > 38/100.4
Absence of cough
Swollen tender ant cervical nodes
Tonsillar swelling or exudate
3-14
0 points: 15-44
-1 points: 45+
Centor criteria meanings
<1 risk of GABHS 1-2%
No further testing/tx
1: 5-19%, no further testing/tx
2: 11-17%, culture/RADT, antibiotics if pos
3: 28-35%, same as 2
4+: 51-53%, can treat empirically with antibiotics
are strep carriers at risk for non-suppurativa complications of strep like RF?
No, they dont mount an antibody response
Antibiotics effect on sequela of strep
Prevents:
RF
Probably don’t prevent:
Guttate psoriasis
Erythema nodosum
Don’t prevent:
Glomerulonephritis
Botanicals for strep
HEMP - hydrastis, echinacea, myrrh, phytolacca
Synergism’s like belladonna, Bryonia, aconite, gelsemium
Repertories for strep
Throat, inflammation, erysipelatous
Mouth, papillae, erect, red
When should you do repeat cultures on a sore throat?
In most cases, NOT indicated
Indicated in pts who:
Have a hx of ARF
Have pharyngitis during outbreaks of ARF or glomerulonephritis
In families/daycares with ping pong spread
What is trismus
Lockjaw; muscle spasm, unable to open mouth fully
How is peritonsillar abscess diagnosed?
Needle aspiration
What are the suppurativa complications of poorly treated/untreated pharyngitis?
Peritonsillar abscess (quinsy)
Retropharyngeal abscess
What is Ludwig’s angina?
Infection to sub mental space, severe trismus, drooling, airway compromise
Ddx of chronic sore thraot
Infectious
Irritative (reflux, post nasal drip, toxins, vocal bad hygiene/abuse)
Neoplastic
Causes of globus
GERD
Abnormal UES function
Motor disorders
Thyroid disease
Hypertrophy of tongue base
Cervical osteophytes
Stress/psych
How to work up hoarseness? When is referral needed?
HEENT, lymph node exam, laryngoscopy
Referral to voice therapy to reduce laryngeal trauma
Naturopathic tx options rhinosinusitis
Prevention - treat URIs/hay fever sufficiently
Maintain open drainage of sinus ostia
Dec inflammation
Improve tissue integrity
Address known RFs
Keep bowels using, alteratives
When and why would you use N-acetyl cysteine in your tx of ENT conditions?
Tx of hay fever allergic rhinitis; potent antioxidant and mucolytic
Chronic rhinosinusitis - immune support and protection
When should imaging be ordered in cases of rhinosinusitis?
For pts who have persistent sx, CT may show an anatomical reason why there is recurrent or chronic sinusitis
Order CT if your pt develops dec visual acuity, diploplia, peri orbital edema, severe headache, or altered mental status.
LIMITED SINUS CT.
Are antibiotics indicated for the tx of acute sinusitis?
For bacterial yes; not effective or recommended for acute VIRAL rhinosinusitis
How to assess epistaxis
Assess for hemodynamic stability
Look for bleeding site
Wear gloves + eye protection
Use topical neo-synephrine if needed
Tx epistaxis
Cold application
Topical anesthetic and topical silver nitrate
Vit C
Bioflavinoids
Homeopathy
Pharm
When is epistaxis potentially dangerous?
Post epistaxis
RF rhinosinusitis
Polyps
Septal deviation
Viral URI (most imp RF for acute bacterial rhinosinusitis)
Dairy/food allergy
Pathogenesis rhinosinusitis
Viral rhinitis > blocked Ostia > O2 absorbed > neg pressure (pain=vacuum sinusitis) > transudate > bacteria invade > ciliary dyskinesia > pos pressure > pain
Indications for urgent referral with rhinosinusitis
Abnormal vision
Change in mental status
Periorbital edema
CN abnormalities (2, 3, 4, 6)
How do children’s sinuses develop?
Maxillary and ethmoid present at birth
Sphenoid develops from ethmoid at 9 yrs
Frontal develops from ethmoid at 5-7 years
How is rhinosinusitis diagnosed in children?
A presumptive dx is made if there is a persistent cough and nasal rhinorrhea > 10 days (cough usually due to postnasal drip)
What classes are included in the B lactam antibiotics?
Penicillins
Cephalosporins
Ex of penicillins
Penicillin G, V (natural penicillins)
Amino penicillins - Amoxicillin
Amplicillin
Ex of cephalosporins
Cephalexin
Cefuroxime
Ceftriaxone
Cefdinir
Drug type/Ex of tetracyclines
antibiotic
Tetracycline, doxycycline, minocycline
Drug type/Ex of Macrolides
Antibiotics
Azithromycin, clarithromycin, erythromycin
Drug type/Ex of Fluoroquinolones
Antibiotics
Ciprofloxacin, levofloxacin, oflocaxin
Drug type/Ex of Lincosamides
Antibiotics
Clindamycin, lincomycin
Drug type/Ex of Aminoglycosides
Antibiotics
Gentamicin, neomycin, tobramycin, streptomysin
Antibiotic classes used for ENT conditions
B lactams
Tetracyclines
Macrolides
Fluoroquinolones
Lincosamides
Aminoglycosides
Mupirocin
penicillin G vs V administration and use
G - IV / IM, syphilis
V - oral, first line for group A strep pharyngitis
Amino penicillins are first line therapies for
AOM
Bacterial rhinosinusitis
first line alternative for GAS
Cephalosporins uses
Alternatives for penicillins for AOM, bacterial rhinosinusiits, GAS
Ceftriaxone (IM) for gonococcal pharyngitis and conjunctivitis
Tetracycline uses
Alternative for penicillin allergic patients in tx of bacterial sinusitis
Macrolides uses
Topical erythromycin ointment for bacterial conjunctivitis, and in newborns for prophylaxis against chlamydial and gonorrheal conjunctivitis
Oral used as alternative for b lactam allergies in GAS and for bacterial conjunctivitis caused by gonorrhea and chlamydia and for gonococcal pharyngitis; long term low dose for chronic rhinosinusitis
Not used as empiric for acute bacterial rhinosinusitis bc they are resistance to S pneumonia
Fluoroquinolones uses
topical for otitis externa with TM rupture, chronic suppurativa otitis media
Oral for otitis externa in Immunocompromised patients or has extension of infection beyond the ear canal (pseudomonas)
Lincosamides (clindamycin, lincomycin) uses
Alternative in b-lactam allergies for GAS and rhinosinusitis (preferred over fluoroquinolones in kids for this purpose)
Aminoglycoside uses
Oral/IV Reserved for serious multi-drug resistant conditions or are used topically
Topical for otitis externa with intact TM, bacterial keratitis
Gentamicin for end stage intractable meniere disease to destroy inner ear/trans tympanic injection
Mupirocin uses
MRSA
Nasal vestibular is, elimination of nasal MRSA colonization
Nucleoside analogues uses
Orally at first sign of viral activation, also topical
Herpes zoster oticus/ophthalmicus
Herpes simplex pharyngitis / keratitis
