ENT/Ophthalmology (copy)

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.