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226 Cards in this Set
- Front
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What is the early presentation of the common cold in children?
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Onset of symptoms about 1-3 days after viral infection
1st system is usually a sore, scratchy throat, followed by nasal obstruction and rhinorrhea Sore throat usually resolves quickly, nasal symptoms predominate by the 2nd or 3rd day |
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How commonly is "cough" associated with the common cold?
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About 30% of colds have a cough component
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How long does a usual infection from the common cold last?
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Usually persists for about 1 week
10% may last up to two weeks |
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Describe nasal findings for the common cold.
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Nasal cavity may reveal swollen, erythematous nasal turbinates
Nasal secretions may be clear or thicken to greenish - not indicative of sinusitis or bacterial infection |
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What are six other illnesses that should be considered for the DDx of the common cold?
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Allergic Rhinitis
Foreign Body Sinusitis Streptococcus Pertussis Congenital Syphiliis |
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How may you differentiate allergic rhinitis from the common cold?
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Allergic rhinitis has prominent itching and sneezing, nasal eosinophils
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How may you differentiate a child with a foreign body obstruction from the common cold?
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Unilateral foul smelling secretion (rancid food), Bloody nasal secretions
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How can sinusitis be differentiated from the common cold?
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Fever, HA, facial pain, periorbital edema, persistence of cough/rhinorrhea > 14 days
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How can you differentiate Streptococcus from the common cold?
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Nasal discharge that excoriates the nares
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How do you differentiate Pertussis from the common cold?
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Onset of persistent or severe cough, Posttussive emesis
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How do you differentiate congenital syphilis from the common cold?
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Congenital syphilis may present as persistent rhinorrhea with onset within the 1st 3 months of life
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What common medications should not be used for the common cold?
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Cough medications (like children's cough syrup) on children under the age of 6
Antibiotics (ineffective) |
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What is stridor?
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A high pitched sound audible without a stethoscope, usually means "creaking, whistling, or grating"
The result of turbulent airflow |
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How does stridor develop?
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There is partial obstruction of the respiratory passages, resulting in a harsh, vibratory sound of variable pitch - though usually benign, may be the first sign of a serious and even life-threatening disorder.
Requires immediate attention! |
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What are some useful drugs for pediatric common cold?
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First-generation antihistamines - reduces rhinorrhea by 25-30%, also sedating
Acetaminophen or ibuprofen for sore throat/fever Albuterol for patients with reactive airway disease |
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What is viral croup? What are the symptoms?
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A respiratory illness characterized by inspiratory stridor, cough, and hoarseness - from inflammation in the larynx and subglottic airway
"Barking cough" is hallmark among infants and young children. Hoarseness in older kids and adults. |
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What are the complications of croup?
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May develop into a significant upper airway obstruction, respiratory distress, rarely death may occur.
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What are some upper respiratory conditions that may manifest as Croup?
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Laryngitis - inflammation limited to the larynx
Laryngotracheitis - inflammation of larynx and trachea Laryngotracheobronchitis - inflammation into bronchi, resulting in lower airway signs (wheezing, rales, tachypnea) Bacterial tracheitis - bacterial infection of subglottic trachea, with thick purulent exudate, causes symptoms of upper airway obstruction Spasmodic croup - sudden onset of inspiratory stridor at night, short duration, sudden cessation |
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Explain the mnemonic PM AIR.
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PM AIR is for the causes of croup
Parainfluenza Virus Measles (Metapneumovirus) Adenovirus Influenza Virus RSV Virus (Rhinovirus) |
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What age range does Croup most often affect?
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Children 6 months - 36 months old - rarely beyond 6 years of age
Most often in Fall or early Winter |
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Describe the clinical onset of Croup.
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Gradual symptoms - nasal irritation, congestion, coryza
In 12-48 hours, fever, hoarseness, barking cough, stridor Respiratory distress increases as obstruction becomes more severe, symptoms last about 3-7 days Stridor at rest - sign of significant upper airway obstruction |
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What is assessed when a patient comes in with Croup?
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Rapid assessment of general appearance, including stridor at rest
Vital signs, pulse oximetry, airway stability, mental status Endotracheal intubation < 1% of the time |
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What are major signs of respiratory failure?
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Fatigue, listlessness
Marked retractions Decreased/absent breath sounds Depressed level of consciousness Tachycardia out of proportion to fever Cyanosis or pallor |
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When would one take an Xray with a patient with Croup?
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If the diagnosis is in question
If the course is atypical An inhaled or swallowed foreign body is suspected Croup is recurrent Failure to respond as expected to therapeutic interventions |
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What is a "steeple sign"?
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An AP CXR demonstrates subglottic narrowing, commonly called the "steeple sign".
Lateral view may demonstrate overdistension of the hypopharynx during inspiration and subglottic haziness. |
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What other conditions are included in the DDx for Croup (7)?
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Acute epiglottis
Peritonsillar and retropharyngeal abscesses Foreign body aspiration or ingestion Allergic reaction Upper airway injury Congenital anomalies of the upper airway Laryngeal diphtheria |
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What are the treatments for Croup?
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Corticosteroids - long-lasting and effective treatment of mild, moderate, and severe croup - two doses usually
Nebulized/racemic epinephrine - rapid improvement if upper airway obstruction, duration of effect is less than two hours Oxygen - only useful if patient is hypoxemic or in moderate-severe respiratory distress Humidified air - frequently used for croup, but does not reduce subglottic edema, may decrease drying of inflamed mucosal surfaces and reduce thickening of secretions, and mist source may be comforting/reassuring to the child and family Antitussives/decongestants - unproven benefits |
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What is epiglottitis?
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Inflammation of the epiglottis and adjacent supraglottic structures - without treatment it may progress to life-threatening airway obstruction
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How does epiglottitis present?
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Abrupt onset and rapid progression, with dysphagia, drooling, and distress (the 3 D's)
Usual duration of notable illness before hospitalization is 12-24 hours Sudden onset of high fever, severe sore throat, odynophagia Usually appear "toxic" Choking sensation, distressed, anxious, restless, irritable, speech muffled (hot potato voice) Tripod posture - sitting position with the trunk leaning forward, neck hyperextended, chin thrust forward in an effort to maximize the diameter of the obstructed airway. |
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What causes epiglottitis?
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Most commonly: Haemophilus influenzae type b (Hib) - most common cause, incidence has declined due to vaccines
Streptococcus pneumoniae, Staphylococcus aureus, beta-hemolytic streptococci If immunocompromised, may be caused by Pseudomonas aeruginosa and Candida species Traumatic causes include thermal injury, foreign body, caustic ingestion |
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What is tripod posture?
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Sitting position with the trunk leaning forward, neck hyperextended, chin thrust forward in an effort to maximize the diameter of the obstructed airway.
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What are the 3 D's of epiglottitis?
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Dysphagia, drooling, distress
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What are the typical symptoms of pediatric epiglottitis?
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Dyspnea (80%)
Stridor (80%) Muffled/hoarse voice (79%) Pharyngitis (73%) Fever (57%) Sore throat (50%) Tenderness of anterior neck (38%) Cough (30%) Dysphagia (26%) Change in voice (20%) |
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How do you go about examining a patient who you suspect has epiglottitis?
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Should examine in a setting where the airway can be secured immediately if necessary - patient may close up when physician tries to see epiglottis and suffer cardiorespiratory arrest
Avoid intraoral examination Keep child calm, accompany to the OR with experienced anesthetist and surgeon/ENT In OR, epiglottitis and supraglottic airway can be assessed via direct laryngoscopy and bronchoscopy and an artificial airway can be established under controlled circumstances |
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If a patient has mild symptoms how do you examine for epiglottitis?
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May use a tongue depressor or indirect laryngoscopy (with mirror, or flexible nasopharyngoscopy)
Alternatively, lateral neck radiographs may be obtained |
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How is epiglottitis managed/treated?
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Secure airway - if abrupt obstruction, attempt bag-valve mask ventilation first
Perform needle cricothyrotomy (<8 years) or surgical cricothyrotomy (>8 years) if unable to ventilate or intubate Laboratory studies - epiglottal cultures after establishment of artificial airway - blood cultures after airway secured Antimicrobial therapy - administer empiric antimicrobial therapy - Cefotaxime or Ceftriaxone, and Clindamycin or Vancomycin |
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What organisms should be covered by empiric antibiotic therapy for epiglottitis?
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Haemophilus influenzae type b, penicillin resistant Streptococcus pneumoniae, Beta-hemolytic streptococci, Staphylococcus aureus, including MRSA
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What are some clinical findings for a Retropharyngeal Abscess?
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Cervical adenopathy (83%)
Retropharyngeal bulge (43%) Fever (86%) Neck stiffness (59%) Drooling (22%) Agitation (43%) Neck mass (91%) Lethargy (42%) |
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What X-Ray findings are there for a Retropharyngeal Abscess?
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A lateral neck X-ray is taken - widening of the retropharyngeal soft tissues and loss of normal cervical spine curvature is seen
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What are the clinical findings for Bacterial Tracheitis?
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Inspiratory stridor
Bark-like or brassy cough Hoarseness Worsening or abruptly occurring stridor Varying degrees of respiratory distress: dyspnea, retractions, nasal flaring, cyanosis Sore throat, odynophagia Dysphonia No drooling No specific position of comfort |
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What X-Ray findings may there be in Bacterial Tracheitis?
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Subglottic narrowing on AP views - Steeple sign
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What are the clinical findings for a foreign body in the upper airway?
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Abrupt onset choking (not always present)
Stridor Gasping for air Drooling Cough Tracheal tugging Intercostal and subcostal indrawing on inspiration Asynchrony of chest and abdominal wall movement |
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What are the X-Ray findings for a patient with a foreign body in the upper airway?
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There may be visualization of a radio-opaque foreign body - may see deviation of the trachea and/or air trapping
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How do acute pharyngitis and tonsillitis present and what is the cause?
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Acute infections are most often from viruses
Group A beta-hemolytic streptococcus (GABHS) is the most common cause of bacterial infection Other organisms - S. aureus, G-negative organisms, Mycoplasma pneumoniae, rarely Neisseria gonorrhoeae, Corynebacterium diphtheriae Oral candidiasis may occur in immunocompromised patients, or children who are being chronically treated with antibiotics or inhaled steroids |
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How do chronic pharyngitis and tonsillitis present and what is the cause?
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The tonsillar crypts can accumulate desquamated epithelial cells, lymphocytes, bacteria, and other debris, causing cryptic tonsillitis - may calcify into tonsilar concretions or tonsillolith.
Tonsils and adenoid may be chronically infected by multiple microbes, may include high incidence of beta-lactamase producing organisms Aerobic microbes: H. influenzae Anaerobic microbes: Peptostreptococcus, Prevotella, Fusobacterium |
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What is Strep Pharyngitis?
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An infection by group A beta-hemolytic streptococcus - may develop to an asymptomatic carrier or acute infection
Uncommon before age 2-3, declines in late adolescence and adulthood |
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What is the onset of Strep Pharyngitis?
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Onset is often rapid, with sore throat, absence of cough, fever
Headache and GI symptoms are frequent |
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What are some signs of Strep Pharyngitis?
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Red pharynx, with enlarged tonsils - classically covered in a yellow, blood-tinged exudate
There may be petechiae on the soft palate, posterior pharynx, uvula may be red, stippled, and swollen Anterior cervical lymph nodes are enlarged, tender Incubation period - 2-5 days |
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In a patient with Strep Pharyngitis, what are additional symptoms for scarlet fever?
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Circumoral pallor, strawberry tongue, red finely papular rash that feels like sandpaper and resembles a sunburn w/ goosebumps
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What is the onset of Viral Pharyngitis?
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Rhinorrhea, cough, diarrhea
May have a more gradual onset Viral etiology suggested by presence of conjunctivitis, coryza, hoarseness, cough |
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What are some of the features of viral pharyngitis associated with the following viruses:
Adenovirus Coxsackievirus EBV Primary HSV |
Adenovirus pharyngitis may feature concurrent conjunctivitis and fever
Coxsackievirus pharyngitis - may produce small, grayish vesicles and punched out ulcers in the posterior pharynx. EBV pharyngitis - may have prominent tonsillar enlargement with exudate, cervical lymphadenitis, hepatosplenomegaly, rash, and generalized fatigue as part of the infectious mononucleosis syndrome Primary HSV infections - in young children, often presents as high fever and gingivostomatitis but pharyngitis may be present |
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What is the gold standard for differentiating streptococcal pharyngitis from viral pharyngitis? What may cause a false positive or false negative?
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Throat culture - false-positives may occur if other organisms are misidentified as GABHS, and in children who are streptococcal carriers.
False negatives may be from inadequate throat swab specimens, and surreptitious use of antibiotics |
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Are rapid strep tests specific or sensitive? How do they compare to cultures?
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Rapid strep tests are very specific - so do not need to do a throat culture if rapid strep tests are positive
Rapid strep tests are not very sensitive, so if the suspicion of GABHS is very high, double check a possible false-negative rapid strep test with a throat culture. |
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When and why should antibiotics be used for Streptococcal pharyngitis?
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Untreated episodes resolve in a few days, but antibiotics speed up recovery
Primary benefit - prevents acute rheumatic fever, almost completely successful if antibiotics given within 9 days of onset of symptoms Start therapy if patient has a positive rapid strep, clinical diagnosis of scarlet fever, a household contact with documented streptococcal pharyngitis, past history of acute rheumatic fever, recent history of acute rheumatic fever in a family member |
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What antibiotics should be used for streptococcal pharyngitis?
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Penicillin V - inexpensive
Amoxicillin - more recommended for children, better tolerated Azithromycin - 1/day, more expensive, more resistance Cephalosporins - may be better than Penicillins because they eradicate the microbe in carriers Erythromycin - recommended for patients allergic to beta-lactam antibiotics |
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What is the mnemonic: JONES crITERIA?
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A mnemonic for the criteria for acute rheumatic fever
Major Criteria - JONES: Joint (arthritis), Obvious (cardiac), Nodule (rheumatic), Erythema marginatum, Sydenham chorea Minor Criteria - ITERIA: Inflammatory cells (Leukocytosis), Temperature (Fever), ESR/CRP elevated, Raised PR interval, Itself (previous Hx of Rheumatic Fever), Arthralgia |
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When are tonsillectomies warranted?
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Usually performed for recurrent or chronic pharyngotonsillitis
Indications: 7 or more ABx-treated throat infections in previous year, 5 or more in each of the last two years, 3 or more in each of the last three years |
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What is sinusitis?
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Acute sinusitis is an illness that results from infection of one or more of the paranasal sinuses
Viral infection associated with common cold is most frequent cause - more properly caused viral rhinosinusitis About 6-13 percent of episodes are complicated by acute bacterial sinusitis (ABS) |
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What are the three potential clinical presentations of ABS?
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Persistent symptoms - 10+ days
Severe symptoms - high fever, purulent nasal discharge, ill appearing Worsening symptoms - the patient becomes acutely and substantially worse |
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What are the exam findings for sinusitis?
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Anterior nasal discharge
Purulent material in the posterior pharynx Fever Sinus tenderness (in adults) or periorbital swelling (in children, ethmoid sinusitis) Mild erythema and swelling of the nasal turbinates with mucopurulent discharge |
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What are some radiographical findings for sinusitis? Can it differentiate bacterial vs viral vs other kinds of sinusitis?
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Cannot differentiate different kinds of sinusitis
Complete opacification Mucosal thickening of at least 4mm Air-fluid level |
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What are the more common causes of sinusitis?
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S. pneumoniae
H. influenzae Moraxella catarrhalis |
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What are the goals of bacterial therapy in bacterial sinusitis?
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The goal is to hasten recovery and prevent suppurative complications - depends on administering the correct ABx, in adequate doses, over an adequate period of time - usually 14-21 days
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What antibiotics are usually chosen for bacterial sinusitis?
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Amoxicillin
Amox-Clavulonic Acid Ceftriaxone |
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What are lateral pharyngeal abscesses and associated clinical features?
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Lateral pharyngeal abscesses produce symptoms similar to retropharyngeal infections but occur less often. High fever is common. Other signs include trismus and swelling below the mandible.
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What is a peritonsillar abscess and what are its associated clinical features?
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A peritonsillar abscess may complicate a previously diagnosed infectious pharyngitis or may be the initial source of a child's discomfort. This disease is most common in older children and adolescents. The diagnosis is evident from visual inspection, augmented occasionally by careful palpation. The abscess produces a bulge in the posterior aspect of the soft palate, deviates the uvula to the contralateral side of the pharynx, and has a fluctuant quality on palpation.
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What is Diphtheria and what are its clinical features?
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Diphtheria is a life-threatening but seldom encountered cause of infectious pharyngitis, characterized by a thick pharyngeal membrane and marked cervical adenopathy.
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What is Lemierre's syndrome and what are its associated clinical features?
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This unusual mixed anaerobic infection is associated with jugular venous thrombophlebitis and the dissemination of infection by septic emboli. It should be considered in the ill-appearing patient with severe pharyngitis.
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What is infectious mononucleosis and what are its associated clinical features?
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The only other common infectious agent in pharyngitis is the Epstein-Barr virus (EBV), which causes infectious mononucleosis and affects adolescents most frequently. An additional consideration in adolescents with an infectious mononucleosis-like syndrome is human immunodeficiency virus (HIV).
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What is a pulmonary embolus?
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A material (plug) obstructing pulmonary arterial blood flow - it may be a blood clot, fat from a bone fracture, a foreign body.
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What is pulmonary embolism often a complication of?
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DVT
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What is the gold standard for diagnosing pulmonary embolus?
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It used to be Pulmonary Arteriography
Now the gold standard is a fast CT |
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About how many deaths from pulmonary embolus occur per yera? What percent originate from DVTs? How many die within the first hour?
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120,000 deaths / year in the US
90% originate from DVT in lower extremities 8-10% with acute PE die within the first hour |
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What are the risk factors for pulmonary embolism?
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Immobilization > 72 hours = 55%
Recent hip surgery = 40% Cardiac disease = 30% Malignancy = 20% Estrogen use (prostate cancer, contraception) = 6% Prior DVT = 20% *Percentage of patients who present with pulmonary embolism who had the risk factor* |
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What are some of the S/S of pulmonary embolism?
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Nonspecific presentation
Chest pain 90% Tachypnea 90% Dyspnea 85% Rales 60% Cough 55% Tachycardia 40% Fever 45% Phlebitis 35% Hemoptysis 30% Cardiac gallup 30% Diaphresis 25% Syncope 15% |
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What are some signs in the cardiac physical exam that may indicate PE?
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Murmur of tricuspid insufficiency, increased pulmonic component of S2, right ventricular heave, right sided S3
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What are some pulmonary physical exam signs that may indicate PE?
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Rales, localized wheezing, friction rub, hemoptysis
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If there is a low-moderate suspicion for PE, what lab test is performed?
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D-Dimer - Rapid ELISA - rules in/out DVT
If negative, no treatment If positive - further tests |
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What signs may be seen in a CXR of a patient with PE?
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If there is an incomplete infarct - hemorrhagic pulmonary edema, appears as pleural based focal infiltrate, resolution in several days.
Complete infarction - tissue necrosis, healing by scar formation Increased infiltrative density, filling of the alveolar sacs |
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What imaging modalities besides CXR may be useful in diagnosing PE?
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Lower extremity deep vein duplex ultrasound
*Helical CT scan of pulmonary arteries* Nuclear medicine V/Q scan Angiography |
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Where are DVTs most common, and how are they identified?
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DVTs are most common in the lower extremities
Ultrasounds are used to evaluate the lower extremities for DVT - 95% accuracy compared to venography |
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What values are evaluated in a Deep Venous Doppler Ultrasound?
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Phasicity (respiration)
Augmentation Compression |
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What is a normal change in a vessel with compression in an ultrasound?
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A normal, unobstructed vessel will close when compressed
An obstruction will remain dilated, the vessel is held open by the clot/embolus |
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How is a ventilation-perfusion scan performed?
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Ventilation portion - patient inhales radionuclide, multiple projection gamma camera images are taken
Perfusion portion - microaggregates of sulfur colloid particles are injected, they lodge in peripheral capillaries and arterioles, causing an obstruction. Multiple projection images are taken |
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How is a ventilation-perfusion scan analyzed/interpreted?
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The ventilation scan reveals where air is able to enter the lungs
The perfusion scan reveals where blood flow is in the lungs When the ventilation and perfusion scans are compared, areas of mismatch suggest failure of perfusion (in case of PE) |
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How is angiography performed?
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Radioactive chemical is injected, to visualize the areas in which flow is restricted or blocked
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What is a "tram/train track" sign in an angiography?
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It shows a clot filling the center of the lumen, with normal blood flow passing through the lumen along the edges of the clot
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What are the benefits of CT angiography?
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Minimally invasive, readily available, fast results, little patient cooperation required
Limited if patient has allergy to iodine or renal problems |
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What are the anticoagulant treatments for a pulmonary embolus?
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Anticoagulation therapy
Heparin - Bolus 5000, drip 1000u/hr, continue til INR therapeutic with Coumadin Coumadin - start dose, maintain INR between 2 and 3 Neither lyse the thrombus - prevent existing thrombi from getting worse, prevent new ones from forming |
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What is mechanical prophylaxis and when would it be used?
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An inferior vena cava filter (below the kidneys) may be placed in a patient with PE - usually if anti-coagulation treatment fails, or there is contraindication to anti-coagulation.
Other reasons - if there has been recent surgery, hemorrhagic CVA, GI/GU or pulmonary bleeding |
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How is a IVC filter placed into the IVC?
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Inserted by going through the right femoral vein unless precluded by thrombus in IVC or femoral vein
Other approaches: right internal jugular vein, left femoral vein |
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What are the two main treatment types for PE?
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Anticoagulation
IVC filter |
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What are some primary causes for increased risk of thrombosis?
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Factor V Mutations
Prothrombin mutations Antithrombin III deficiency Protein C or S deficiency |
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What are some secondary causes for VERY increased risk of thrombosis?
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Prolonged Immobilization
MI Tissue damage (surgery, fracture, burn) Cancer Prosthetic Valve DIC Lupus anticoagulant |
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What are some secondary causes for SLIGHT increased risk of thrombosis?
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Atrial fibrillation
Cardiomyopathy Nephrotic syndrome Hyper-estrogenic states Oral Contraceptives Sickle cell anemia Smoking |
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What are the stages in formation and resolution of a thrombus?
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1. Propagation
2. Embolization 3. Dissolution 4. Organization and recanalization |
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What are the three parts of Virchow's triangle?
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Endothelial Injury
Hypercoagulability Abnormal Blood Flow |
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What percentage of pulmonary thromboembolisms originate in deep veins in the leg above the knee?
How much (%) occlusion of pulmonary circulation is fatal? |
95% of pulmonary thromboembolisms originate in deep leg veins above the knee
It is fatal if >60% of pulmonary circulation obstructed |
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How may emboli cause pulmonary hypertension?
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If there are multiple emboli, showers of clots, then it may cause pulmonary hypertension and cor pulmonae due to loss of vascular bed
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If a patient has a pulmonary embolus, what is it that specifically kills the patient?
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Sudden death from...
Acute cor pulmonale Cardiovascular collapse |
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What are Lines are Zahn?
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Lines of Zahn for clots are comparable to tree rings - a clot starts, and it grows as new layers of blood cells, platelets, and fibrin are laid down.
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How can you determine a fresh pulmonary embolus from an old pulmonary embolus?
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If it is fresh, there are no lines of Zahn and no reaction in the intimal wall
In an old embolus, the clot would have caused irritation, inflammation, damage to the intimal wall and lines of Zahn would have begun forming on the surface. |
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What may be seen histologically in a pulmonary embolus with organization?
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The thromboembolus is stuck to the intimal wall
There is granulation tissue between the wall and the embolus There is proliferation of blood vessels within the granulation tissue |
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What structure is formed by a remote organizing pulmonary thromboembolus?
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Fibrous bands - bands which stretch across the blood vessel lumen
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What are characteristics of red infarcts?
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1. May result from either arterial or venous occlusion
2. Characterized by coagulative necrosis 3. Distinguished by bleeding into the necrotic area from adjacent arteries and veins 4. Occur principally in organs with a dual blood supply (lung) or those with extensive collateral circulation (small intestine, brain) 5. In the heart a red infarct occurs when the infected area is reperfused following spontaneously or therapeutically induced lysis of the occluding thrombus 6. Grossly, red infarcts are sharply circumscribed, firm and dark red to purple 7. Over a period of several days, acute inflammatory cells infiltrate the necrotic area from the viable border 8. The cellular debris is digested by PMNs and phagocytosed by macrophages 9. Granulation tissue forms and is replaced ultimately by a scar 10. In a large infarct the necrotic center remains inaccessible to the inflammatory exudate may persist for months |
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What are characteristics of pale infarcts?
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Results from arterial occlusion
Typical in the heart, kidneys, and spleen - dry gangrene of the leg due to arterial occlusion, like a complication of diabetes, is a large pale infarct Characterized by coagulative necrosis ... etc. |
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How would sclerosis of the pulmonary artery appear?
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Yellow-white atherosclerotic plaques are present in the intima of the peripheral pulmonary arteries, causes narrowing.
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Clinically, what are the results of an amniotic fluid embolism?
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Acute dyspnea with cyanosis, shock, sudden death -
If mother survives the acute phase, DIC and DAD in the second phase could still be fatal |
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What are some of the most commonly seen foreign bodies in the ear?
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In adults: noise-reducing ear plugs, Q-tips, pins, insects
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What tool should be used to remove a foreign body from the ear canal?
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Extraction loop
Caution that you don't push the object further in |
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When should irrigation be used in the ear?
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To remove cerumen (earwax) - not for objects!
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What fluid may be used to kill insects in the ear?
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10% lidocaine solution
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What is Debrox?
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A commercial OTC preparation that helps stimulate migration of the external auditory canal epithelium, which begins at the tympanic membrane and migrates forward. This facilitates natural removal of cerumen.
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What is an auricular hematoma?
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Occurs during trauma in which perichondrium is sheared from the underlying cartilage - cartilage derives blood suppy from the perichondrium, so over a few days the cartilage will lose blood supply and deform
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How is an auricular hematoma treated?
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Needle aspiration
Incision with drain if necessary Pressure dressing Antibiotics for skin flora Hold on antibiotics (check if patient is currently taking any) |
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What is cauliflower ear?
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A common sequellae of auricular hematoma
After the cartilage becomes devoid of blood supply, outer ear becomes fibrotic, permanently swollen, deformed. |
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What typically causes a rupture or perforation of the tympanic membrane? How is it treated?
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TM injury usually from perforation by a foreign object, or from an infection or pressure injury.
While healing, inner ear should be protected from water, soap, shampoo, etc. Sometimes scarring results - impairs hearing, worse if middle ear was involved in injury. |
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What is Meniere's disease?
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A disorder of the inner ear that can affect hearing and balance
Ranges in intensity - symptoms can present as mild annoyance or progress to a chronic lifelong disability Thought to be caused from endolymphatic hydrops or excess fluid in the inner ear. Fluid bursts from its normal channels and flows into the other areas, causing damage. |
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What are the presenting symptoms of Meniere's disease?
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Waxing/waning hearing loss
Ringing in the ears (tinnitus) Periodic episodes of dizziness, vertigo "Drop attacks" Aural fullness/pressure in the ears *Not all symptoms need to be present for Dx* |
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What tests should be run to confirm Meniere's disease?
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Vertigo workup must be negative
Fluctuating hearing loss revealed by audiogram Brain MRI scan should be done to exclude a tumor on the 8th (vestibulocochlear nerve) which could cause similar symptoms |
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How can Meniere's disease be managed/controlled?
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Low-salt diet
Stress reduction Hydrochlorothiazide twice daily Benozidiazepine or promethazine may help for dizziness Also, refer to an ENT specialist |
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What is perichondritis?
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Patient presents with red, tender and swollen left ear - one common cause: ear piercing. Also trauma, surgery, burns.
Infection of the thin fascial layer surrounding the auricular cartilage. There are signs of infection/inflammation - if untreated can result in permanent deformity |
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What is usually the causative organism of perichondritis?
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Psuedomonas aeruginosa
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What complications may occur with perichondritis?
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Cartilage, necrosis, deformity of pinna
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What is the standard treatment for perichondritis?
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Tubal drainage for 4 weeks if subperichondrial abscess
Anti-pseudomonas antibiotics (Cipro) |
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What is otitis externa? What may cause it?
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Diffuse infection of the external ear canal
Most often occurs through infiltration of water into the ear canal while swimming, also known as "swimmer's ear" Sometimes due to Q-tip or other foreign body trauma Found in people who swim frequently, especially in lakes |
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What are some symptoms of otitis externa?
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Otalgia exacerbated by jaw movement
Feeling of fullness in the ear Itching of the ear canal Discharge from the ear canal (otorrhea) Decreased auditory acuity Fever is rare |
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What are some findings upon examination for otitis externa?
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Pain from manipulation of the pinna, tragus
Ear canal may appear red, swollen, or macerated Thick white keratinous malodorous debris in canal TM may appear red, should not be fluid behind it |
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What organism commonly causes otitis externa?
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Pseudomonas aeruginosa (95-99%)
Fungal (<5%) |
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How is otitis externa treated?
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Ear canal must first be cleaned
Vinegar:rubbing alcohol 50/50 solution lowers the pH, may be enough to resolve problem Topical antibiotic ear drops - usually with quinolone/gentamycin +/- steroid drops with wick - mainstay of treatment Local heat application and warm compression for pain |
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When would systemic treatment be used for otitis externa?
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Only in an immunocompromised patient and if the infection is very severe
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What may cause acute otitis media?
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If the patency of the Eustachian tube is impaired (from URI, allergies, rhinitis, etc) then secretions fail to drain and infection may result.
Most common in children, since Eustachian tube is shorter and at less of an angle |
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What are the presenting symptoms of acute otitis media?
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Fever
Otalgia Decreased auditory acuity Pressure feeling in the ear Discharge from the ear, otorrhea if there is perforation |
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How does the ear look through the otoscope in acute otitis media?
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Erythematous, bulging tympanic membrane
Effusion between membrane Conductive hearing loss |
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What pathogens cause acute otitis media?
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Streptococcus pneumoniae (25-50%)
Haemophilus influenzae (15-30%) Moraxella catarrhalis (3-20%) Strep pyogenes (group A) 2% Staph aureus 1% Viruses 45-70% No microorganism - 16-25% |
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What is the treatment for acute otitis media?
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Observe for 48-72 hours to determine causative agent before prescribing antibiotics
First line therapy - Penicillin-derived antibiotics Second line - Penicillin-based antibiotic + Clavulanic acid Penicillin-allergic patients - sulfa based antibiotic, quinolone, macrolide |
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What step can be taken if there is recurrent, or intractable acute otitis media?
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May be controlled by low-dose prophylactic antibiotics
Myringotomy with T-tube placement to improve middle ear ventilation |
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What is chronic otitis media?
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Non-intact tympanic membrane and discharge for at least the two preceding weeks
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What is the presentation of chronic otitis media?
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Chronic drainage
Fluid is foul-smelling Decreased hearing |
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What physical exam findings are there for chronic otitis media?
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Foul smelling drainage during periods of exacerbation
TM perforation, often at margin White keratinous debris |
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What is the treatment for chronic otitis media?
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Quinolone ear drops +/- steroids
PO antibiotics - penicillins Surgery - when infection calms down, tympanomstoidectomy is performed |
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What are some complications of otitis media?
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Acute/chronic mastoiditis
Meningitis Brain abscess Labrynthitis Sigmoid sinus thrombosis Facial nerve VII paralysis Scarring and destruction of the middle ear ossicles/tympanic membrane --> hearing impairment |
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What is serous otitis media?
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A collection of fluid in the middle ear space that occurs due to the negative pressure produced by altered Eustachian tube function
This may occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media. |
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What are some presenting symptoms of serous otitis media?
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Fluid in the middle ear space with or without symptoms of an ear infection
Decreased hearing Feeling of fullness in the ears |
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What are the physical exam findings for a patient with serous otitis media?
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Retracted tympanic membrane
No movement or reverse movement with insufflator Conductive hearing loss |
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What are some causes or risk factors for serous otitis media?
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Eustachian tube dysfunction
Allergic upper respiratory disease Bacterial sinusitis (acute, chronic) Residual otitis media Nasopharyngeal obstruction due to adenoids, nasopharyngeal tumor, polyps Cleft palate |
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What is the treatment for serous otitis media?
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Observe for two weeks
Nasal steroids for 4-6 weeks to help decompress the Eustachian tube Antibiotics +/- systemic steroids if nasal steroid unsuccessful If all of the above do not work, myringotomy with T-tube placement may be indicated |
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What is otomycosis?
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Colonization of the cerumen by fungi - normally they do not cause pathologic problems but if the surface of the auditory meatus has been compromised, the organisms can easily cause infection
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What organisms cause otomycosis?
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Candida albicans, Aspergillus, Mucor
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What are the presenting symptoms of otomycosis?
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Severe itching
Rare otalgia Feeling of fullness in the ear |
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What are the physical exam findings of otomycosis?
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Inflamed, often excoriated and erythematous skin of the auditory meatus
White, yellow, or black membrane lining the ear canal May appear identical to other forms of otitis externa, so microscopic evaluation may be necessary to differentiate |
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What is the treatment for otomycosis?
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Difficult, since often refractory to treatment
Thoroughly irrigate ear canal, dry Apply salicylate-containing solution to aid uncovering the skin to be treated Antifungal drops, locally Systemic antifungal therapy only if patient is immunocompromised |
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What is mastoiditis and how does it develop?
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Infection of the mastoid bone of the skull - the mucous membrane/bony inflammation in air cells of the mastoid process.
Inadequate treatment of OM can lead to mastoiditis - the most common complication of otitis media. |
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What are the presenting symptoms of mastoiditis?
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Fever
Pain Drainage from the ear Ear pain or discomfort in mastoid region Fever, may be high or suddenly increase Headache Redness of the ear or behind the ear Swelling behind ear, may cause ear to stick out |
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What is the classic triad for mastoiditis?
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1) prominent auricle with retroauricular swelling
2) tenderness in mastoid region 3) otorrhea |
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What is the presentation of TMJ syndrome?
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Pain to the region anterior to the ear, in the distribution of cranial nerve V
Pain when opening the mouth, chewing Difficulty opening the mouth Clicking/crepitus of temporomandibular joint |
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What are the physical exam findings of TMJ syndrome?
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Tenderness with palpation over TMJ when opening and closing mouth
Misaligned dental occlusion Spasm of muscles of mastication Dental evidence of bruxism or teeth clenching |
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What are some treatments for TMJ syndrome?
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Hot or cold packs to TMJ region
Soft diet Avoid chewing gum NSAIDs Physical therapy Teach stress reduction techniques Orthodontic splint to gradually adjust bite angle to lessen stress on the TMJ |
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What are the three types of rhinitis?
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Allergic
Vasomotor Chemical |
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How does allergic rhinitis develop?
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The lining of the nose becomes sensitive to certain allergens, resulting in production of antibodies which induce release of histamines, leukotrienes, and other inflammatory factors from mast cells in the nasal mucosa
The result is inflammation and congestion of nasal mucosa |
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What are the most common allergens that cause allergic rhinitis?
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pollens (trees, grasses, weeds)
molds animal dander dust mite / dust cockroach feces |
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What are the nasal symptoms of allergic rhinitis?
|
Clear rhinorrhea
Nasal pruritis Sneezing Nasal congestion |
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What are the non-nasal symptoms of allergic rhinitis?
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Conjunctival swelling and erythema
Eyelid swelling/pruritis, Middle ear effusion/ Eustachian tube dysfunction Post-nasal drip Cough Loss of taste/smell |
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What is vasomotor rhinitis and how does it develop?
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A non-allergic trigger causes dilation of the blood vessels in the lining of the nose, resulting in swelling and drainage
Sometimes known as 'chemical rhinitis' Triggers include: cigarette smoke, perfumes/smells/fragrance, changes in temperature |
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What is the alternative name for B4?
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lipoic acid
Arsenic inhibits B4 (Vomiting, Rice water stool, Garlic Breath) |
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What are some treatments for rhinitis?
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Avoid exposure to causative agent
Nasal irrigation Inflammatory cascade inhibitors (intranasal corticosteroids) Substances that prevent activation of cells or degranulation processes - antihistamine intranasal sprays/tablets, leukotriene antagonists, cromolyn sodium Anticholinergics - ipratoprium Adrenomimetics - results in blood vessel constriction - oxymetazoline (afrin) |
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What is rhinitis medicamentosa?
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"addiction" to rhinitis medications - the drugs that induce vasoconstriction of the vessels results in reactive vasodilation, which causes rhinitis to recur. Viscious cycle can repeat, causing chronic rhinitis.
Adrenomimetic medications, like oxymetazoline, should not be used more than 3 days, and patients should be warned of this phenomenon |
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What is epistaxis?
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Nose bleeds - about 60% of the population at some point in life, but only about 10% require medical attention
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Why might postmenopausal women have higher incidence of epistaxis than men of equivalent age and health?
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Estrogen plays a protective role in maintaining healthy mucous membranes and in vascular integrity
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Where does epistaxis occur most of the time?
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Anteriorly - 90% occur in Keisselbach's plexus, the region of the vascular watershed area of the nasal septum
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Which is more severe, posterior or anterior epistaxis?
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Posterior - it has the early branches of the sphenopalatine artery, and due to the blood supply it may require ENT or ER management
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What are the usual causes of epistaxis?
|
Nose picking most common cause
Dry mucosal membranes, irritation due to lack of ambient moisture Mucosal hyperemia Facial trauma Foreign body - especially if associated with purulent discharge |
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What are some risk factors for epistaxis?
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Conditions - tumors, coagulation disorders
Medicatiosn - warfarin, steroids Recent/prior trauma or surgery Autoimmune conditions - like Wegeners granulomatosis |
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What treatments are there for epistaxis?
|
Attempt to tamponade bleed with gauze nasal pack - if continues to bleed, go to ENT
ENT will inject bleeding site with Lidocaine-epinephrine Silver nitrate stick held against lesion Electrocautery Balloon or gauze nasal pack to tamponade lesion If recalcitrant, internally maxillary/ethmoid artery ligation may be performed |
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What are nasal polyps?
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Fleshy outgrowths of the nasal mucosa - form at the site of dependent edema in the lamina propria of the mucous membrane, usually around the ostia of the maxillary sinuses
Usually occur bilaterally. Unilateral nasal polyps may indicate neoplasm |
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What are some predisposing factors for nasal polyps?
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allergic rhinitis
longstanding recurrent or chronic sinus infections cystic fibrosis chronic aspirin use asthma |
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How are nasal polyps treated?
|
Nasal corticosteroids, given as 1 or 2 sprays in each nasal cavity bid until polyps disappear or up to 3 months, whichever occurs first
One week tapered course of oral corticosteroids. Surgical removal is still required in many cases. |
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What are some complications of nasal polyps?
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Frequent or chronic sinus infections
Obstructive sleep apnea Altered facial structure leading to double vision or unusually wide-set eyes (more likely associated with cystic fibrosis) |
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What causes sinusitis?
|
Infection – bacterial, viral, or fungal
Allergic phenomenon Autoimmune disorders |
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What are some predisposing factors for sinusitis?
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Preexisting URI
Allergies Nasal / upper airway obstruction (deviated septum, polyps) Smoking history, or exposure to second hand smoke Cystic fibrosis Prior bouts of sinusitis |
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What are some of the presenting symptoms of sinusitis?
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Facial pain
Pressure sensation in forehead, behind eyes, cheeks Often pt will state this worsens on bending over Fever Nasal discharge, often purulent and thick (yellow/green) Post-nasal drip |
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What physical exam findings are associated with sinusitis?
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Pain with palpation or tapping over sinuses
Fever Oropharyngeal erythema Generalized inflammation of the airways so may also be associated with various signs of nasal, oropharyngeal, or bronchial pathology |
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What are the causative organisms in sinusitis?
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Most often it is viral - most last about 7 days
Bacterial pathogens - only consider if it has lasted 7 or more days - Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis Fungal organisms may also be involved in immunocompromised patients, diabetes patients, people on anti-rejection medications |
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When is sinusitis classified as chronic?
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When sinusitis has lasted 3 months or more
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In chronic sinusitis, what investigative method is best for visualizing the source of the problem?
|
CT scan of the sinuses may be useful - helps localize mucosal thickening, obstructive elements, opacification of symptoms
Also, nasal endoscopy by ENT |
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What treatments are available for sinusitis?
|
Conservative management for first 7-14 days - nasal saline rinses, OTC pain meds, natural nasal sprays, nasal decongestants
Antibiotics should be reserved for when symptoms get really bad or go beyond 14 days - use penicillin (amoxicillin +/- clavulanic acid), macrolide or fluoroquinolones for PCN allergy Surgery in chronic/recurrent cases may be useful, especially if the predisposing cause is an obstruction |
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What is a ranula?
|
Pseudocyst associated with the sublingual glands and submandibular ducts.
appear as blue, fluctuant, swellings lateral to the midline in the lower mouth |
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How is a ranula treated?
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Referral to ENT
Complete excision, often in continuity with the associated sublingual gland, is the preferred treatment Marsupialization + suturing of the pseudocyst wall to the oral mucosa may be effective if complete excision cannot be performed |
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What are some causes for cough?
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Inhaled irritants (smoke, dust, silica, asbestos)
Aspiration (saliva, gastric contents, foreign bodies) Inflammation (viral, bacterial, asthma, COPD, infiltrating bronchogenic carcinoma, CHF, ACE inhibitors) |
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How are coughs characterized as acute, subacute, or chronic?
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Acute < 3 weeks duration
Subacute 3-8 weeks duration Chronic > 8 weeks duration |
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How does one adequately evaluate a cough?
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Take a good history
Consider patients PMHx ROS Do a good physical exam Labs Radiology Other special tests |
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What is the DDx for acute cough?
|
URIs
Viral syndrome i.e.: flu-like symptoms Viral or bacterial sinusitis Pneumonia Allergies Acute exacerbation of COPD Pulmonary embolism Foreign body aspiration ACE inhibitors |
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What is acute tonsillitis?
|
Infection of the palatine tonsils
Treatment is a challenge - difficult to distinguish bacterial from viral. |
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What are the presenting symptoms of acute tonsillitis?
|
Pain on swallowing, may be severe
Fever Pain radiating to ipsilateral ear Oropharyngeal swelling, causing hoarseness/voice changes |
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What are the diagnostic criteria (3) for acute bacterial tonsillitis?
|
Fever
Cervical lymphadenopathy Whitish plaques on the tonsillar pillars 2/3 = high confidence of acute bacterial tonsillitis |
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What are the physical exam findings for acute tonsillitis?
|
Examination should include the oral cavity, the lateral pharyngeal walls (including tonsils) and the posterior pharyngeal wall.
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What should be included in the DDx for Acute Tonsillitis?
|
Viral URI
Peritonsillar abscess Infectious mononucleosis Gonorrheal tonsillitis Sinusitis with post-nasal drip Oral candidiasis |
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What are the more common causative organisms for Acute Tonsillitis?
|
GABHS
Staphylococcus Hemophilus influenzae |
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What studies/assays are performed to further diagnose Acute Tonsillitis?
|
Rapid strep test - makes use of anti-strep antibodies on reagent strips
Throat culture - takes longer, may be helpful for treatment failure or recurrence |
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What are the treatments for Acute Tonsillitis?
|
Penicillins remain the drug of choice for GABHS
10-14 day course recommended Second generation macrolide if PCN-allergic Augmentin (amox-clavulanic acid) is second-line tx Analgesics for pain relief |
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What are some complications of Acute Tonsillitis?
|
Inadequately or untreated GABHS may lead to rheumatic heart disease, post-streptococcal glomerulonephritis, rheumatoid arthritis
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|
What is Vincent's angina?
|
Caused by fusiform rods and spirochetes
Unilateral dysphagia Fetid breath odor Unilateral, exudate coated ulcer appears on palatine tonsil Treated by cautery + antibiotics (penicillin) |
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What is trismus?
|
Difficulty opening the mouth, due to pain
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|
What are some presenting symptoms of retropharyngeal abscesses?
|
Fever/chills
Sore throat, often severe, with progressive difficulty swallowing Drooling Trismus, or difficulty opening the mouth, due to pain Muffled speech, aka “Hot potato” voice Tender cervical lymphadenopathy Facial swelling |
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|
What are the physical exam findings for retropharyngeal abscesses?
|
Unilateral oropharyngeal/hypopharyngeal swelling, often profound.
Involves peritonsillar tissue as well as tonsils +/- lymphadenopathy |
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|
What are some complications of retropharyngeal abscesses?
|
Dysphagia
Difficulty securing the airway due to inflammation Dyspnea Odynophagia |
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|
What are some treatments for retropharyngeal abscesses?
|
Pain control
Aspiration of pus Antibiotics aimed at the causative organisms - typically Clindamycin X, Augmentin, Penicillin + Flagyl If recurs, tonsillectomy advised |
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|
What is infectious mononucleosis?
|
Also known as Pfeiffer's glandular fever or the “kissing disease”
Predominantly seen in teens and young adults Caused by the Epstein-Barr virus (EBV) Has an incubation period of 7-9 days |
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|
What are the presenting symptoms of infectious mononucleosis?
|
Tonsillitis, often with severe pain on swallowing
Fatigue Anorexia Fever, often moderate (102-104 degrees) Headache Limb pain / myalgia |
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|
What are the physical exam findings for infectious mononucleosis?
|
Generalized lymphadenopathy – mono affects lymphatic tissue (mostly cervical, occipital/nuchal, axillary and inguinal nodes)
Splenomegaly may be noted! Hepatomegaly Erythematous, edematous, hypertrophied tonsils with a greyish coating (some say resembles yogurt) |
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|
What are some laboratory tests for infectious mononucleosis?
|
CBC reveals leukopenia initially, which later turns to leukocytosis (WBC > 20K)
Atypical lymphocytes noted (lymphomonocytoid cells) EBV capsid antigens by ELISA LFTs may be significantly elevated US abdomen to r/o splenomegaly |
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|
What is the treatment for infectious mononucleosis?
|
Pain and fever control
Antibiotics not recommended – unless evidence of a bacterial superinfection (e.g. rapid strep +) If severe tonsillar hypertrophy/pain, oral corticosteroids may be helpful to reduce inflammation If respiratory distress, or stridor, emergent tonsillectomy may be indicated |
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|
What are some complications of infectious mononucleosis?
|
Myocarditis
Nephritis Hepatitis Meningitis/encephalitis Splenic hemorrhage – remember to warn patients regarding sports precautions (particularly contact sports) Peripheral facial paralysis |
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|
When should mastoiditis be suspected?
|
Often times if acute otitis media fails to resolve or worsen after 2-3 week period of treatment
Via otoscopy, it will have features of acute OM and erythema of the posterior wall of the external auditory canal |
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|
What radiographical study is useful for mastoiditis?
|
A head CT will reveal:
Clouding of the mastoid air cells/middle ear spaces Erosion of the structure of the mastoid bones |
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|
What are some complications of mastoiditis?
|
Inflammatory sigmoid sinus thrombosis, which may lead to...
Disseminated sepsis Intracranial venous outflow obstruction, leading to increased intracranial pressure |
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|
What is the treatment for mastoiditis? How urgent is it?
|
Considered an emergency! Requires inpatient management, so often if noted in clinic, send directly to ER/direct admit to hospital
Mastoidectomy indicated Cultures are taken during procedure Targeted IV antibiotic therapy based on culture results. If sigmoid thrombus noted on CT scan, surgical removal of thrombus during mastoidectomy |
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|
What are some complications of mastoiditis?
|
Dizziness or vertigo
Destruction of the mastoid bone Facial paralysis Meningitis Partial or complete hearing loss Spread of infection to the brain or throughout the body |
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|
What is cholesteotoma?
|
Keratinous squamous epithelium found in abnormal location (ie in bony spaces)
Destruction of bone via an inflammatory, osteoclastic process |
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|
How does a cholesteotoma develop?
|
Most often occurs due to inadequate middle ear ventilation (esp Eustachian tube dysfunction)
Retraction pocket forms in the tympanic membrane, which is lined with squamous epithelium These cells migrate along the tympanic membrane, into the external canal, causing inflammation and bone resorption Secondary infection of the debris that forms worsens the above effects |
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|
What are the presenting symptoms of cholesteotoma?
|
Clinically appears as chronic otitis media
Feeling of fullness/pressure of ear Hearing loss (ranges from mild to profound) If “wet cholesteotoma” unremitting otorrhea, often fetid May be further complicated by Labrynthitis – rotational, vertigo/dysequilibrium, Facial nerve palsy, Intracranial infection |
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|
What is the treatment for cholesteotoma?
|
Surgical intervention necessary to halt the bony destruction
Tympanoplasty may help to improve hearing |
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|
What is Herpes Zoster Osticus?
|
Also known as Ramsey-Hunt disease
Caused by reactivation of prior infection with Varicella Zoster virus (VZV) in ganglion cells Commonly affects CN VII and VIII |
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|
What are some symptoms of Herpes Zoster Osticus?
|
Ear pain/characteristic burning/buzzing sensation often in the absence of physical findings
Begins with acute inflammatory changes (pain, redness, swelling) Vesicles form on auricle and within external ear canal Associated with inner ear disturbance, dizziness/vertigo, loss of equilibrium, sensorineural hearing loss |
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|
How is the diagnosis for Herpes Zoster Osticus made?
|
Aspirate of vesicles reveals electron microscopic evidence of VZV (rarely done)
At least a 4-fold increase in VZV antibody on serologic tests |
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|
What is the treatment for Herpes Zoster Oticus?
|
Systemic anti-virals – acyclovir, valaciclovir, or famciclovir
Treat bacterial super-infection, most often due to staphylococci or Pseudomonas Systemic corticosteroids indicated if facial nerve palsy is present |
