AOM
Risk Factors:
6-18 months, daycare, pacifier/bottle use, second hand smoke.
Organisms: Strep pneumo, H. Flu, Moraxella catarrhalis.
Patho: Preceded by viral URI → blocking of Eustachian tube.
Complications: TM rupture, mastoiditis, bacterial meningitis, brain abscess, or dural sinus thrombosis.
Clinical Manifestations:
Fever, Otalgia, ear tugging
Bulging/red TM w/ effusion
Pneumatic Otoscopy → decreased TM mobility.
Management:
TOC: Amoxicillin 80-90mg/kg/day x10-14days (High dose)
2nd line: Augmentin, Cephalosporins
PCN allergy → Azithromycin
Severe/recurrent → Myringotomy (surgical drainage) w/ tubes
External Ear trauama Management:
Cauliflower: Refer for I&D by ENT and kephlex x5days
Laceration: Debridement and prophylatic abx, <12hrs = can close wound
Pinna = skin margins sutured
Cartilage penetration: splint w/ benzoin impregnated cotton and dressing. oral abx given
Human bite
Avulsion → plastic surgeon job
Fracture → surgical correction.
Time line for AOM
Acute: <3 weeks
Chronic: >3 months, clear serous fluid in the middle ear w/o sxs of an ear infection.
Recurrent: 3x in 6 months OR 4x in 12 months.
Acute Viral Pharyngotonsillitis
Clinical Manifestations:
Sore throat, pain, or swallowing
Viral is often assoc. w/ cough, hoarseness, coryza, conjunctivitis, diarrhea, fever.
management:
Mainstay: Symptomatic treatment
Fluids, warm saline gargles, topical anesthetics, NSAIDs
General Management:
If from EBV, be conscious about risk for splenic rupture.
Acute Fungal Pharyngotonsillitis
Etiology: Common w/ inhaled steroids.
Clinical Manifestations;
SOre throat, dysphagia, cheesy white patches in the oropharynx
Seen in AIDs pts. and small children.
Management:
Clotrimazole troches (10mg dissolved slowly 5x daily)
Miconazole mucoadhesive buccal tablets
Nystatin swish and swallow
HIV+ → Fluconazole
Acute Bacterial Pharyngotonsillitis
Etiology: Group A strep.
Clinical Manifestations:
Dysphagia, fever → Not usu. assoc. w/ viral sxs (No cough)
On exam: Exudate (white/yellow), petechia, Anterior cervical adenopathy
Dx:
Rapid antigen detection test: Best initial test
If negative then obtain a throat culture. (gold standard)
Centor Criteria for strep
Management:
First-line: PCN (Pen G, VK, or Amoxicillin)
PCN allergy → Macrolides, Clindamycin, Cephalosporins.
General Measures:
Rare in children <3, Highest incidence of rheumatic fever if untreated
May lead to acute glomerulonephritis or peritonsillar abscess.
Scarlet Fever
-Diffuse skin eruption that occurs in the setting of Group A Strep. infection.
Patho: Type IV (delayed) hypersensitivity reaction
Clinical manifestations:
Fever, chills, pharyngitis
Rash → diffuse, Blanche-able, sandpaper texture
Strawberry tongue
Pastia’s lines: Linear petechial lesions seen at pressure points, axillary, antecubital, abdominal, or inguinal areas.
Dx: Testing for GABHS (rapid step, throat culture)
Management:
Pen G or VK = First line (Can also use amoxicillin)
PCN allergy → Macrolides
Can return to school 24hrs after abx
Allergic Rhinitis
-IgE-medaited mast cell histamine release due to airborne antigens.
Clinical Manifestation
Sneezing, nasal congestion, itching, clear, watery rhinorrhea
ENT involvement may be present; maybe bluish discoloration around the eyes.
Allergic shiners (edema and dark circles under the eyes)
Management:
Intranasal corticosteroids = first-line (Mometasone, Fluticasone)
Antihistamines, mast cell stabilizers, short-term decongestants.
Anticholinergics can be given for rhinorrhea.
General Measures:
Common in pts w/ atopic disease (eczema, asthma, dermatitis) and FH.
most common type of rhinitis
Nasal polyps common.
Epiglottitis
MEDICAL EMERGENCY; Supraglottic inflammation/obstruction of the airway.
Patho: Most common cause = H. Flu type B (kids in underserved areas or w/o vaccinations)
Immunized? → Strep species
Assoc. w/cocaine use in adults
Most common in children 3 months - 6 years
Clinical Manifestations:
3D’s → Drooling, dysphagia, distresses
Tripod/sniffing dog position (leaning forward, elbow on lap, neck hyperextended, chin protruding.)
Hot potato voice
Dx: Definitive Dx = Laryngoscopy → cherry red epigoltis.
Managment:
Most important → Maintian airway (intubate and Dexamethasone)
2nd/3rd gen Cephalosporin (Ceftriaxone/Cefotaxime)
PCN or vanco can be added.
Prevention: Rifampin to close contact; routine use of HiB vaccine.
Conjunctivitis
Bacterial
MCC in neonates = Chlamydia
Purulent discharge (eye “stuck shut” in the morning)
Chlamydia → acute follicular conjunctivitis.
Dx → bunch of stuff; Giemsa stain for chlamydia
Management
Erythromycin ointment
Trimethoprim-Polymixin B
FQs (severe or contact lenses)
Chlamydia → Macrolide or tetracycline 3x weeks.
Suspect Moraxella/Gonococcal if excessive discharge to nonresponsive.
Viral:
MC: Adenovirus, high contagious from direct contact; swimming pool = most common place
Griddy/FB feeling, Unilateral and then bilateral.
Managment → Supportive (cool compress, artificial tears, antihistamines for itching)(Olopatadine)
Allergic:
Pruritus = hallmark
Allergy sxs distinguish from viruses (Nasal congestion, sneezing)
Management:
Topical antihistamines. (H1 blockers)
Olopanatidine (mast cell stabilizer)
Topical NSAIDs (Ketorolac)
Red Flags of Conjunctivitis
-Reduction of Visual acuity → Concern about infx keratitis, iritis, or angle closure glaucoma
-Ciliary Flush: Pattern of injection in which redness more pronounced @ limbus
Concerns about infx keratitis, iritis, angle closure glaucoma.
-Photophobia → Infx keratitis, iritis
-Severe FB sensation or Corneal Opacity → Infx keratitis
-Fixed pupil or severe HA w/ nausea → Acute angle glaucoma.
Epistaxis
Anterior:
Kiesselbach’s venous plexus = MC site
MC assoc. w/ nasal trauma (Nose picking common), low humidity, hot environment. alcohol, cocaine use.
Management:
Direct Pressure = first-line therapy.
Adjunction Meds: Oxymetazoline, Lidocaine w/ epi. (caution in HTN)
Cauterization w/ silver nitrate
Nasal packing
Post-management
Avoid exercise for a few days, and avoid spicy foods.
Humidifiers helpful
Posterior:
Sphenopalatine artery and branches of Woodruff’s Plexus = Most common site.
May cause bleeding in both nares and pharynx.
Risk factors: HTN, Older, Nasal neoplasms
Management:
Balloon catheters = Most common initial management
Foley cath w/ cotton packing
CT if FB, tumor, or sinusitis is suspected.
-Always ask pts. w/ epistaxis about aspirin & Ibuprofen
Mastoiditis
-Inflammation of the mastoid air cells of the temporal bone
Patho:
Complication from preceding AOM or recurrent AOM.
Clinical Manifestations:
Deep ear pain (Worse @ night), fever, lethargy, malaise
Signs of Otitis media (bulging TM and redness)
Mastoid (postauricular) tenderness w/ edema & Erythema.
Diagnosis: First-line: CT w/ contrast of temporal bone.
Management:
IV abx (IV vanco. + Cephalosporin) + Middle ear or Mastoid drainage (myringotomy)
Tympanocentesis for cultures
Complicated/refractory → Mastoidectomy
General Measures
May develop cutaneous abscess (fluctuance) and narrowed auditory canal.
Oral Candidiasis
-Overgrowth of Candida Albicans due to local or systemic immunosuppressed states.
Clinical Manifestations
Asymptomatic
Loss of taste or cotton-like feel in mouth.
White curd-like plaques, easily scraped off.
Denture form → maybe only erythema present
Dx: Clinical or KOH prep can be done
Management:
Topical therapy: 1st line therapy
Nystatin liquid swish and swallow, Clotrimazole troches, or Miconazole mucoadhesive buccal tablets.
Oral Fluconazole reserved for refractory or pts w/ both oral and esophageal infection.
Orbital (Septal) Cellulitis
-Infection of the orbit (fat & ocular muscles) posterior to the orbital septum.
Patho:
Often polymicrobial (S. aureus, Strep, GABHS, H. flu)
MC secondary to untreated sinus infections in children.
Clinical Manifestations
Ocular pain esp. w/ eye movement, ophthalmoplegia (muscle weakness) w/ diplopia, proptosis (bulging), and visual changes
Eyelid edema/erythema
Dx: CT w/ contrast.
Management:
Ophthalmology evaluation
Admit + IV abx (vanco + Ceftriaxone or Cefotaxime)
General Measures:
Periorbital cellulitis is only an infx of the skin, & NOT the fat behind. Wont have worsening pain w/ eye movements.
Otitis Externa
-Inflammation of the external auditory canal.
Patho:
Often secondary to trauma (Q-tips and earwax, 7-12yrs old) or moist environment (swimmer’s ear)
Excess moisture raises PH → infection
If the canal is closed, Weber lateralizes to the abnormal ear (blocked canal)
Etiology: P. aeruginosa = Most common
Clinical Manifestations:
Ear pain, pruritis in the ear canal
Auricular discharge, hearing loss.
Pain on traction of the tragus
Dx: Clinical + otoscopy: edema of the external auditory canal w/ erythema, debris, or discharge.
Management:
Protect the ear against moisture (dry ear precautions), drying agents = isopropyl alcohol & acetic acid.
Removal of debris + topical abx w/ coverage against Pseudomonas & Staph
abx = Cipro-dexa, Ofloxacin
Aminoglycoside combo (neomycin/polymixcin B/Hydrocortisone)
NOT used if sus TM perforation.
Fungal → Topical therapy (2% acetic 3-4 drops QID, or clotrimazole or Itraconazole oral.
Peritonsillar Abscess
-Abscess between the palatine tonsil & the pharyngeal muscles.
Patho: Complication of tonsillitis or pharyngitis
Most common in adolescents/young adults (15-30yrs)
Etiology: Predominant is Group A strep. (S. pyogenes)
Clinical Manifestations:
Dysphagia, severe unilateral pharyngitis, high fever.
Muffled “hot potato” voice, drooling, lock jaw.
Uvula deviation to the contralateral side
Dx: Primarily Clinical, can do U/S
Needle aspiration: culture, and differentiate abscess from cellulitis.
CT scan is imaging of choice
Management:
Drainage (aspiration [preferred] or I&D + abx)
abx: PO (amoxicillin, Augment, clindamycin); Parenteral (ampicillin-sulbactam, clindamycin.)
Tonsillectomy: for pts who fail to resond to drainage, PTA w/ complications, hx of prior episodes, or recurrent severe pharyngitis.
Secure the airway early in a severe infection
Prevention: prompt treatment of strep infection
Strabismus
-Misalignment of one or both eyes.
General:
Stable ocular alignment is not usu. present until 2-3 months.
Referral is needed if it persists over 4-6 months of age (reduce incidence of amblyopia (lazy eye)
Clinical Manifestations
Diplopia, scotomas, or amblyopia
Asymmetric corneal reflex.
Dx:
Hirschber corneal light reflex testing:
Asymmetric deflection of the corneal light reflex in one eye is seen in strabismus.
Cover Test: Refixation of the uncovered eye is consistent w/ manifest strabismus (tropica)
Cover-uncover test: Looks for latent strabismus (phoria) → Misalignment will appear to deviate inward/outward, convrgence testing.
Management for Strabismus
Managment:
First-Line: Patch (occlusive) therapy → cover the normal eye to stimulate & strengthen the affected eye
Typically used for amblyopia and not strabismus, but may imporve vision/improve prognosis.
Eyeglasses = primary treatment for accommadative esotropia.
Corrective surgery: severe or unresponsive to conservative therapy.
Major types of Strabismus
Esotropia: Convergent strabismus
Deviated inward (nasally) “crossed-eyed”
Exotropia: Divergent strabismus
Deviated outward (temporally)
TM perforation
Patho:
Most commonly occurs due to penetrating or noise trauma. (@ the pars tensa)
May lead to cholesteotoma development.
Clinical Manifestations:
Acute ear pain, hearing loss, tinnitus, vertigo
Pts w/ otalgia prior to rupture may develop sudden pain relief w/ bloody otorrhea.
Dx:
Ear exam: DO NOT perform pneumatic otoscopy
may have conductive hearing loss
Management:
Most heal spontaneously, surgery may be needed if TMP 2m+
Topical abx if there is infection (Ofloxacin drops)
Avoid water & topical aminoglycosides
Acute sinusitis
-Includes both viral and bacterial infections (initial symptoms indistinguishable between the two)
Most will resolve, with decreasing symptoms by 7-10 days
Diagnostic:
Purulent nasal drainage AND
Nasal obstruction OR facial pain, pressure, or fullness.
If lasting 10 days or worsening → Acute Bacterial Rhinosinusitis (ABRS)
if less than 10 days or getting better → viral ARS
CT= imaging of choice (NOT for uncomplicated or classic presentation)
Tx:
Symptomatic management → analgesics, saline irrigation, steroid sprays = mainstay
Bacterial (only if present >10-14days)
Augmentation = DOC
Alternative: Doxycycline.
Dacyroadenitis
-Inflammation of the lacrimal gland
Acute: usu. infectious → staph a. = MCC
Chronic: >1month, noninfectious inflammatory disorders
Sjogren syndrome, Thyroid eye dz, Sarcoidosis
MC than acute. (esp. in older pt., often assoc. w/ tumor or inflam. eye dz)
Clinical Manifestations:
swelling/fullness, redness, tender in outer third upper eyelid.
Bacterial: Intense severe symptoms.
Tx:
Chronic → tx underly cause
Bacterial:
Mild → Oral cephalexin, Bactrim, augmentin
Severe → IV Nafcillin, Ampicillin-sulbactam, Vanco.
Barotrauma
-Tissue injury caused by pressure
sx: Ear pain, vertigo, hearing loss, sinus pain, epistaxis, abdominal pain, dyspnea, LOC
Tx:
Supportive (anti-inflammatory)
Pseudoephrdrine/aftin can be good for prophylaxis.
Vision loss (general)
Painful vision loss:
Trauma,
glaucoma,
uveitis, ulcer,
temporal arteritis,
Optic neuritis
Painless Vision loss:
Amaurosis fugax/TIA,
central retinal artery/vein occlusion,
vitreous hemorrhage,
retinal detachment,
lens dislocation,
HTN encephalopathy, pituitary tumors,
macular disorders, toxic ingestions.