Week 1 Reading Flashcards
What are the two types of otitis media?
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.
What management method is used in most AOM and OME scenarios?
Watchful waiting. These conditions are often self-limited
What treatment is suggested for severe cases of AOM?
Antibiotics and or surgery
What are some concerns with cases of OME?
Can become a chronic condition that requires weeks or months of monitoring to avoid hearing loss or learning disabilities
What are some risk factors implicated in otitis media?
Eustachian tube dysfunction, chronic upper respiratory infections, food sensitivities, environmental/social risk factors
What group is most affected by otitis media?
Children under 6
May affect all ages
AOM is most common in _____ and preceded by ______
Children, upper respiratory infection
Presence of infection in AOM can only be diagnosed by what?
Aspirated fluid of the middle ear. However it is too invasive to be used for diagnostic purposes.
What happens in the first stage of Acute Otitis Media
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.
What happens in the second stage of Acute Otitis Media
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
What are the likely sequelae of AOM?
____, ____, ____, ____, ____, ____, ____, ____
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
Rate of incidence of otitis media by the first birthday? by the third?
By age three __% have had three or more episodes
62%, 83%
46%
What are two causes of OME?
May occur along with upper respiratory infections or is the sequelae of AOM
__% of children will experience OME before their first birthday. By the time they reach school __% have had OME
50%, 90%
Recurrence of AOM
high rate of recurrence. when rates equal or exceed 3 in 6 months or 4 in a year the conditions is classified as recurrent.
Most common complications of AOM from most to least common
Eardrum perforation, cholesteatoma, mastoiditis, and atelectasis (collapse) of eardrum
Most serious complications of AOM
Meningitis, sigmoid sinus thrombosis, brain abscesses
Acute, subacute, and chronic timelines for OME
less than 3 weeks, 3 weeks to 3 months, longer than 3 months
80% of OME clear within _ months, 30-40% have recurrent problems and 5-10% last ___ __ ____
2, one year or more
Risk factors that increase OME
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
3 clues for a certain diagnosis of AOM
Rapid onset of signs and symptoms
Middle ear effusion
Signs and symptoms of middle ear inflammation
The only isolated symptoms useful in diagnosing AOM is what?
ear pain (specific 82-92%, LR 3-7.3) Ear tugging in an infant
Useful clues for OME
Patient appears normal
Little or no pain
Slower onset (<48 hours), more chronic in nature
No fever
What are the steps for evaluation of Otitis Media
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)
Co-factors placing children at greater risk for developmental difficulties
Permanent hearing loss apart from OME Speech and language disorder or delay Autism-spectrum syndromes or craniofacial disorders Blindness or uncorrected visual impairment
In cases where there is an acute change in hearing is suspected how long should a patient be monitored?
3 months
Because evaluating bacterial presence in AOM is invasive what two tests are often employed?
The ear is first evaluated with otoscopy
Pneumatic endoscopy can be used to differentiate AOM from OME and diagnose OM
What joint should be evaluated in cases of ear pain and dysfunction?
TMJ
and look for MFTP in lateral and medial pterygoid, masseter and SCM
What is tympanometry used for?
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%
What is acoustic reflectometry used for?
Diagnosis of MEE and does not require a full seal so it can be used with an uncooperative patient
What is tympanocentesis?
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
Mastoiditis from AOM
Follows several weeks of untreated AOM
Post-auricular pain with reddening and a spiking fever
X-ray reveals destroyed mastoid air cells
Petrous apicitis from AOM
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
Facial palsey from AOM
associated with either acute or chronic otitis media
inflammation of the 7th cranial nerve
Sigmoid sinus thrombosis from AOM
Trapped infection within mastoid air cells
Systemic sepsis and increased intracranial pressure
(HA, lethargy, nausea, vomiting, papilledema)
CNS infection from OM
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
Epidural abscesses from OM
From direct extension of the disease from chronic infection
usually asymptomatic but may present with pain, HA and low grade fever
Definition of rhinosinusitis
Symptomatic inflammation of paranasal sinuses and nasal cavity
Rhinitis definition
Inflammation of the nasal mucous membrane
infection can then spread to the sinuses causing RS
Types of rhinosinusitis
Acute RS and Chronic RS
both can be bacterial or nonbacterial
Acute rhinosinusitis duration
longer than 7 days but less than 4 weeks
Less than 7 days is rhinitis
Chronic rhinosinusitis duration
Longer than 12 weeks with or without acute exacerbations
Chronic rhinosinusitis (polyps)
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
Possible origins of RS
bacterial, fungal, viral, allergic, environmental
Ethmoid and sphenoid are most often affected. Isolated sphenoid is serious.
Diagnosis of acute RS
ARS is clinical in nature, based on a combination of symptoms and signs, and does not require ancillary
studies.
Diagnosis of chronic RS
By symptoms and due to low specificity may require endoscopy or CT imaging for confirmation
Cardinal diagnosis of RS
Nasal discharge OR nasal obstruction
AND
Facial pain-pressure-fullness OR reduction/loss of smell.
Clinical pneumonic for RS
PODS
(Pain or facial pressure, nasal Obstruction, discolored Discharge, loss of Smell.
Presence of discharge in RS
May or may not be purulent and if clear should be congested
RS discharge locations
If nasal it implicates frontal or maxillary sinuses
if pharyngeal
VIral pattern of RS
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
Bacterial pattern of RS
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
AAO-HNS criteria for bacterial RS
symptoms or signs of acute rhinosinusitis persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms.
Three Cardinal Symptoms of Bacterial RS
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
Fokken’s criteria for RS
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
Complication due to RS most frequently occur in _____ and ______
In children with acute RS
Adults with chronic RS
Indicators for infectious spread of RS
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
Clues for allergic rhinitis
Thin watery discharge
History of allergic response
Consistently positive skin-prick test
Absence of fever, chills, myalgia, lymphadenopathy, productive cough, and sore throat.
DDX for ARS
Viral and allergic rhinitis, dental disease, and various
headaches and facial pain syndromes
Use of ancillary studies for acute RS
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.
Treatment failure of RS for ___ should result in
a referral for CT or endoscopy without first performing plain film radiography
2-3 months
Radiographs for RS
not indicated unless there is a complication
INDICATIONS FOR CT for RS
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.
INDICATION FOR MRI for RS
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
Basic blood tests in diagnosis for RS
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.
Assessment strategy for RS
- Differentiate RS vs rhinitis vs other causes of the symptoms
- If the patient has RS, differentiate acute,
chronic, or recurrent. (If chronic, record as
chronic with or without polyps). - If the patient has RS, differentiate viral vs
bacterial (or allergic/irritant). - Screen for severe complications resulting
from infectious spread beyond the sinuses
and refer as needed. - Establish a baseline to monitor
improvement especially for chronic or recurrent RS. - Assess patients who have chronic rhinosinusitis or recurrent acute rhinosinusitis for co-morbidities such as asthma, cystic fibrosis, ciliary dyskinesia* and any
immunocompromised state.
Pain location of RS by affected sinus
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.
Predisposing factors for RS
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
Where to palpate and percuss for RS
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)
Transillumination
opaque transillumination ruled in sinusitis and normal
transillumination ruled it out
If polyps are seen on a rhinoscopic exam
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.
Nasal tumors are more common in ___ ____ years
men > 60
Malignant nasal tumors are rare (3% of all head and neck cancers) but can present as chronic RS
If there are crusty patches on a rhinoscopic exam
fungal infection should be highly suspected
If the patient has nasal discharge that is watery without pus on a rhinoscopic exam
Suspect allergic or vasomotor rhinitis
If discharge is cloudy but colorless on a rhinoscopic exam
Suspect nonbacterial or viral sinusitis.
If there is drainage of pus from ostia of the
nasal meatus
Suspect acute sinusitis.
Sinusitis may lead to and perpetuate myofascial trigger points (MFTPs) in the ___
SCM
Reduced _____ ___ _____
of the neck could be associated with extraspinal spread of an infection
Active range of motion
In children an ____ ______ should be performed to assess possibility of OM in children
Otoscopic exam
Red flags for poorer prognosis with RS
Fever of 102F 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
Immediate referral for antibiotic therapy
include orbital pain, periorbital swelling/
erythema, or facial swelling/erythema
