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Clin Phase II Lecture > Week 1 Reading > Flashcards

Week 1 Reading Flashcards

1
Q

What are the two types of otitis media?

A

Acute otitis media - middle ear effusion with signs and symptoms of an acute infection

Otitis media with effusion - middle ear effusions without the signs of an acute infection. Can follow AOM.

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2
Q

What management method is used in most AOM and OME scenarios?

A

Watchful waiting. These conditions are often self-limited

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3
Q

What treatment is suggested for severe cases of AOM?

A

Antibiotics and or surgery

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4
Q

What are some concerns with cases of OME?

A

Can become a chronic condition that requires weeks or months of monitoring to avoid hearing loss or learning disabilities

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5
Q

What are some risk factors implicated in otitis media?

A

Eustachian tube dysfunction, chronic upper respiratory infections, food sensitivities, environmental/social risk factors

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6
Q

What group is most affected by otitis media?

A

Children under 6

May affect all ages

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7
Q

AOM is most common in _____ and preceded by ______

A

Children, upper respiratory infection

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8
Q

Presence of infection in AOM can only be diagnosed by what?

A

Aspirated fluid of the middle ear. However it is too invasive to be used for diagnostic purposes.

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9
Q

What happens in the first stage of Acute Otitis Media

A

The insulating pathogen causes local vasodilation that results in a greater than normal red reflex on inspection. Entire tympanic membrane may become red and inflamed.

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10
Q

What happens in the second stage of Acute Otitis Media

A

Bacterial toxins cause the vascular elements to increase in permeability.
Middle ear begins to fill with exudates and WBCs flow into the middle ear
Tympanic membrane may rupture

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11
Q

What are the likely sequelae of AOM?

____, ____, ____, ____, ____, ____, ____, ____

A

Mucosal edema of adenoid and lymphoid tissue
Blockage of eustachian tube
Bacterial infiltration into nasopharynx
Sneezing/coughing/sniffing forces bacteria up Eustachian tube
Spreading of bacteria or inflammation
Accumulation of exudate leading to Middle Ear Effusion

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12
Q

Rate of incidence of otitis media by the first birthday? by the third?
By age three __% have had three or more episodes

A

62%, 83%

46%

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13
Q

What are two causes of OME?

A

May occur along with upper respiratory infections or is the sequelae of AOM

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14
Q

__% of children will experience OME before their first birthday. By the time they reach school __% have had OME

A

50%, 90%

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15
Q

Recurrence of AOM

A

high rate of recurrence. when rates equal or exceed 3 in 6 months or 4 in a year the conditions is classified as recurrent.

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16
Q

Most common complications of AOM from most to least common

A

Eardrum perforation, cholesteatoma, mastoiditis, and atelectasis (collapse) of eardrum

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17
Q

Most serious complications of AOM

A

Meningitis, sigmoid sinus thrombosis, brain abscesses

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18
Q

Acute, subacute, and chronic timelines for OME

A

less than 3 weeks, 3 weeks to 3 months, longer than 3 months

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19
Q

80% of OME clear within _ months, 30-40% have recurrent problems and 5-10% last ___ __ ____

A

2, one year or more

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20
Q

Risk factors that increase OME

A 
Bottle fed or pacifier use
Secondary smoke
Attending day care
Low S/E status
Winter
Craniofacial distortions
Dairy
Allergies or family hx of allergies
Diet deficiencies
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21
Q

3 clues for a certain diagnosis of AOM

A

Rapid onset of signs and symptoms
Middle ear effusion
Signs and symptoms of middle ear inflammation

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22
Q

The only isolated symptoms useful in diagnosing AOM is what?

A 
ear pain (specific 82-92%, LR 3-7.3)
Ear tugging in an infant
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23
Q

Useful clues for OME

A

Patient appears normal
Little or no pain
Slower onset (<48 hours), more chronic in nature
No fever

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24
Q

What are the steps for evaluation of Otitis Media

A 
Appropriate history
Check for facial distortion
Check for signs of infection
Check for signs of hearing loss
Evaluate external ear
Evaluate middle ear
Evaluate neck biomechanics
If there is no evidence of otitis media or other ear pathology check for other sources of pain
If necessary ancillary studies (acoustic tympanometry, audiometric evaluation, CBC)
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25
Q

Co-factors placing children at greater risk for developmental difficulties

A 
Permanent hearing loss apart from OME
Speech and language disorder or delay
Autism-spectrum
syndromes or craniofacial disorders
Blindness or uncorrected visual impairment
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26
Q

In cases where there is an acute change in hearing is suspected how long should a patient be monitored?

A

3 months

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27
Q

Because evaluating bacterial presence in AOM is invasive what two tests are often employed?

A

The ear is first evaluated with otoscopy

Pneumatic endoscopy can be used to differentiate AOM from OME and diagnose OM

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28
Q

What joint should be evaluated in cases of ear pain and dysfunction?

A

TMJ

and look for MFTP in lateral and medial pterygoid, masseter and SCM

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29
Q

What is tympanometry used for?

A

indirect measure of mobility of tympanic membrane and may be used as a confirmatory test for OME
Negative predictive value for normal test is between 64 and 93%

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30
Q

What is acoustic reflectometry used for?

A

Diagnosis of MEE and does not require a full seal so it can be used with an uncooperative patient

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31
Q

What is tympanocentesis?

A

Surgical puncture of the tympanic membrane to drain the middle ear and is similar to myringotomy where tunes are inserted
both can be used for diagnosis

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32
Q

Mastoiditis from AOM

A

Follows several weeks of untreated AOM
Post-auricular pain with reddening and a spiking fever
X-ray reveals destroyed mastoid air cells

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33
Q

Petrous apicitis from AOM

A

Medial portion of the petrous bone becomes a site of infection when drainage of pneumatic cells is blocked
May cause foul discharge, deep ear and retro-orbital pain and 6th nerve palsey

34
Q

Facial palsey from AOM

A

associated with either acute or chronic otitis media

inflammation of the 7th cranial nerve

35
Q

Sigmoid sinus thrombosis from AOM

A

Trapped infection within mastoid air cells
Systemic sepsis and increased intracranial pressure
(HA, lethargy, nausea, vomiting, papilledema)

36
Q

CNS infection from OM

A

Otogenic meniongitis is the most common intracranial complication from ear infection
AOM - from hematogenous spread of bacteria
chronic otitis media - passage of bacteria along certain pathways or from extension through dural plates of petrous pyramid

37
Q

Epidural abscesses from OM

A

From direct extension of the disease from chronic infection

usually asymptomatic but may present with pain, HA and low grade fever

38
Q

Definition of rhinosinusitis

A

Symptomatic inflammation of paranasal sinuses and nasal cavity

39
Q

Rhinitis definition

A

Inflammation of the nasal mucous membrane

infection can then spread to the sinuses causing RS

40
Q

Types of rhinosinusitis

A

Acute RS and Chronic RS

both can be bacterial or nonbacterial

41
Q

Acute rhinosinusitis duration

A

longer than 7 days but less than 4 weeks

Less than 7 days is rhinitis

42
Q

Chronic rhinosinusitis duration

A

Longer than 12 weeks with or without acute exacerbations

43
Q

Chronic rhinosinusitis (polyps)

A

In addition to bacterial or viral there can be the addition definition of with/without polyps
With polyps responds poorly to treatment and has a higher rate of recurrence

44
Q

Possible origins of RS

A

bacterial, fungal, viral, allergic, environmental

Ethmoid and sphenoid are most often affected. Isolated sphenoid is serious.

45
Q

Diagnosis of acute RS

A

ARS is clinical in nature, based on a combination of symptoms and signs, and does not require ancillary
studies.

46
Q

Diagnosis of chronic RS

A

By symptoms and due to low specificity may require endoscopy or CT imaging for confirmation

47
Q

Cardinal diagnosis of RS

A

Nasal discharge OR nasal obstruction
AND
Facial pain-pressure-fullness OR reduction/loss of smell.

48
Q

Clinical pneumonic for RS

A

PODS

(Pain or facial pressure, nasal Obstruction, discolored Discharge, loss of Smell.

49
Q

Presence of discharge in RS

A

May or may not be purulent and if clear should be congested

50
Q

RS discharge locations

A

If nasal it implicates frontal or maxillary sinuses

if pharyngeal

51
Q

VIral pattern of RS

A

Viral RS symptoms generally peak days 2 to 3 after onset and then begin to improve.
Symptoms may persist 14 days or longer, but a key differentiating feature (from bacterial) is that they are mild
and continue to decrease in severity

52
Q

Bacterial pattern of RS

A

Duration is a key factor
Significant symptoms persisting beyond 10 days indicate a possible bacterial infection.
Suspect bacterial if symptoms initially improve and then get worse

53
Q

AAO-HNS criteria for bacterial RS

A

symptoms or signs of acute rhinosinusitis persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms.

54
Q

Three Cardinal Symptoms of Bacterial RS

A

Purulent (infected, colored, or oozing) nasal drainage.
Patient complaints of nasal obstruction
Facial or dental pain (unilateral over teeth or maxilla)

(double sickening), presence or absence of discharge is not enough to rule it out

55
Q

Fokken’s criteria for RS

A

In addition to typical signs there is also at least 2 of the following

Symptoms last longer than 7 to 10 days or worsens
again after initial improvement;
Symptoms, particularly pain over teeth and maxilla,
are severe (7 to 10 cm VAS);
Purulent secretions on rhinoscopy;
Increased ESR or elevated CRP;
Fever >38°C; 100.4°F

56
Q

Complication due to RS most frequently occur in _____ and ______

A

In children with acute RS

Adults with chronic RS

57
Q

Indicators for infectious spread of RS

A 
Orbital pain
High fever (102°)
Painful edema (possible preseptal cellulitis)
Limited and painful ocular movement
Visible swelling of the conjunctiva
Exophthalmos (post-septal inflammation)
Alerted mental status with high fever
Frontal or retro-orbital migraine
58
Q

Clues for allergic rhinitis

A

Thin watery discharge
History of allergic response
Consistently positive skin-prick test
Absence of fever, chills, myalgia, lymphadenopathy, productive cough, and sore throat.

59
Q

DDX for ARS

A

Viral and allergic rhinitis, dental disease, and various

headaches and facial pain syndromes

60
Q

Use of ancillary studies for acute RS

A

Neither nasal endoscopy, radiographs, blood work, nor any other ancillary study is required to make the initial diagnosis of uncomplicated acute RS.

CT scan and/or endoscopy are the most common tests of choice to increase the accuracy of the diagnosis in the case of chronic or recurrent RS.

61
Q

Treatment failure of RS for ___ should result in

a referral for CT or endoscopy without first performing plain film radiography

A

2-3 months

62
Q

Radiographs for RS

A

not indicated unless there is a complication

63
Q

INDICATIONS FOR CT for RS

A

CT without contrast, not plain radiography or MRI, is the modality of choice to confirm chronic RS

One approach is to order CT initially in cases of suspected chronic RS to confirm the diagnosis
Another approach is to limit the use of CT to
patients 1) who have not responded to maximum medical therapy, 2) to plan for sinus surgery, or 3) to clarify the diagnosis in patients with symptoms of chronic RS, but who lack any objective evidence from anterior rhinoscopy or endoscopy.

64
Q

INDICATION FOR MRI for RS

A

Usually is reserved for differential diagnoses of more
serious conditions already identified by CT, such as intracranial and intraorbital complications of sinusitis, neoplasms, and fungal disease

65
Q

Basic blood tests in diagnosis for RS

A

not required to make a diagnosis of acute RS. Useful for diffferentiation
CRP and /or ESR have some limited value in
supporting a diagnosis of acute RS.

An ESR >30 has a reported +LR of 4.1 and if
>40 a +LR of 7.40. A positive CRP had a +LR of
2.9.

66
Q

Assessment strategy for RS

A
  1. Differentiate RS vs rhinitis vs other causes of the symptoms
  2. If the patient has RS, differentiate acute,
    chronic, or recurrent. (If chronic, record as
    chronic with or without polyps).
  3. If the patient has RS, differentiate viral vs
    bacterial (or allergic/irritant).
  4. Screen for severe complications resulting
    from infectious spread beyond the sinuses
    and refer as needed.
  5. Establish a baseline to monitor
    improvement especially for chronic or recurrent RS.
  6. Assess patients who have chronic rhinosinusitis or recurrent acute rhinosinusitis for co-morbidities such as asthma, cystic fibrosis, ciliary dyskinesia* and any
    immunocompromised state.
67
Q

Pain location of RS by affected sinus

A

Maxillary sinusitis: pain in the maxillary area, toothache and frontal headache.
Frontal sinusitis: pain over the sinuses or frontal headache, severe pain to the temple or sometimes to the occiput.
Ethmoid sinusitis: pain behind and between the eyes, and a frontal headache that is often described as “splitting.”
Isolated sphenoid sinusitis (rare). Pain is less well localized and is referred to the frontal or occipital area.

68
Q

Predisposing factors for RS

A

Recent upper respiratory infection dental procedures, exposure to smoke, physical or chemical irritants, household molds, and forceful nose blowing.
Frequent participation in swimming and diving, immuno-suppressive therapy, chronic diseases such as diabetes or renal disease.
History of allergies

69
Q

Where to palpate and percuss for RS

A 
Medial angle of the eye (ethmoid sinus)
Roof of the orbit (beneath the frontal
ridge) (frontal sinus)
The bony prominence at the cheek
(maxillary)
Anterior frontal wall (frontal sinus)
The palate (intraoral) (maxillary sinus)
70
Q

Transillumination

A

opaque transillumination ruled in sinusitis and normal

transillumination ruled it out

71
Q

If polyps are seen on a rhinoscopic exam

A

patient is under the age of 16, arrange for a sweat test to rule out cystic fibrosis
patient is an adult, consider referral for an ENT evaluation.

72
Q

Nasal tumors are more common in ___ ____ years

A

men > 60

Malignant nasal tumors are rare (3% of all head and neck cancers) but can present as chronic RS

73
Q

If there are crusty patches on a rhinoscopic exam

A

fungal infection should be highly suspected

74
Q

If the patient has nasal discharge that is watery without pus on a rhinoscopic exam

A

Suspect allergic or vasomotor rhinitis

75
Q

If discharge is cloudy but colorless on a rhinoscopic exam

A

Suspect nonbacterial or viral sinusitis.

76
Q

If there is drainage of pus from ostia of the

nasal meatus

A

Suspect acute sinusitis.

77
Q

Sinusitis may lead to and perpetuate myofascial trigger points (MFTPs) in the ___

A

SCM

78
Q

Reduced _____ ___ _____

of the neck could be associated with extraspinal spread of an infection

A

Active range of motion

79
Q

In children an ____ ______ should be performed to assess possibility of OM in children

A

Otoscopic exam

80
Q

Red flags for poorer prognosis with RS

A

Fever of 102F and/or chills may indicate an extension of the bacterial infection
Yellow, brown or green discharge, positive culture, or positive ESR/CRP may indicate bacterial infection and may warrant referral for possible antibiotic therapy
Stiff neck and/or disorientation are signs of extension of infection to the central nervous system
Changes in visual acuity or deficits in cranial nerve III

81
Q

Immediate referral for antibiotic therapy

A

include orbital pain, periorbital swelling/

erythema, or facial swelling/erythema

Clin Phase II Lecture (6 decks)

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