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355 Cards in this Set
- Front
- Back
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This is an infection or irritation of the middle ear.
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Otitis media
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What are the bacterial causes for Acute Otitis Media? (3 of them)
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Strep. pneumoniae,
Haemophilus influenzae, Moroxella catarrahalis |
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What is the age range that AOM peaks?
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6 months to three years.
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What is the primary anatomical contribution to AOM?
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Usually due to eustachian tube dysfunction.
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Risk Factors:
Day care Formula Feeding 2nd Hand Smoke Male Gender Bottle Feed Infants in Supine Position Low-Socioeconomic Status These are all risk factors for what? |
Acute Otitis Media
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What are the three things that can lead to a diagnosis of AOM?
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History of Acute onset
Signs and symptoms of middle ear inflammation Presence of middle ear effusion |
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What are two signs of middle ear inflammation seen in AOM?
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Erythema of the TM
Otalgia (or ear pulling in children) |
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What are five presentations of middle ear effusion seen in AOM?
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1. Bulging of the TM
2. Limited or absent mobility of the TM 3. Opacity of TM 4. Air Fluid level behind the TM 5. Otorrhea |
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What are the four nonspecific signs and symptoms associated with AOM?
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Fever
Irritability Loss of Balance Other URI symptoms |
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True or False, It is possible for an infant to show no symptoms in the first few months of life.
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True
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This is almost always diagnosed clinically?
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AOM
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What is a test that can be used, but isn't really necessary, to detect AOM?
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Tympanogram
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This measures the impedance at the TM, and determines the presence of fluid. A manometer (pump) varies air pressure against TM, a speaker introduces 220Hz probe tone, microphone measures loudness in ear canal.
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Tympanogram
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This treatment is reserved for persistent AOM infections.
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Tympanocentesis
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This treatment involves making a small incision in the TM to drain fluid.
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Tympanocentesis
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When does a tympanic membrane perforation become problematic?
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When they are occurring repeatedly.
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What is the treatment plan for AOM in infants that are less than six months old?
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Use ABX when there is a positive diagnosis including signs of rapid onset, middle ear effusion, and middle ear inflammation.
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What is the treatment plan for AOM in children >6 months to 2 years old?
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With positive diagnosis use ABX
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What is the treatment plan for AOM in children >6 months to 2 years old if there is an uncertain diagnosis and the illness is severe? Also, what defines the illness as severe?
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ABX, severe illness is registered when a temp of >39C occurs with moderate to severe pain.
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What is the conservative Tx for AOM in a child age >6 months to 2 years old when the illness is nonsevere? Also, what defines the AOM as nonsevere?
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Conservative Treatment involves 48-82 hours of observation.
Adult must monitor child Must be able to communicate with the provider Available for urgent follow up if needed Analgesics - Acetaminophen, Ibuprofen The illness is classified as nonsevere because the fever is <39C and there is mild otalgia. |
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When using analgesics in conservative treatment of AOM, what is something that should be done?
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When the analgesics wear off check the signs/symptoms to see how things are progressing.
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What is the Tx plan for children aged 2 years and older who have a severe illness AOM?
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Positive Diagnosis:
Severe Illness = Antibiotic |
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What is the Tx plan for children ages 2 years and older who have a non severe illness AOM?
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Conservative Tx = Observation and analgesics.
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If there is an uncertain diagnosis and AOM is thought to be involved in children ages 2 years and older what is the Tx plan?
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Conservative Tx = Observation and analgesics.
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Pharmacologic Therapy for AOM:
What is the first line Tx for Nonsevere AOM? |
Amoxicillin and analgesics
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Pharmacologic Therapy for AOM:
What is the first line Tx for severe AOM? |
Amoxicillin/Clavulanate = Augmentin
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Why do you add a clavulanate to amoxicillin, ie. Augmentin, to Tx severe cases of AOM?
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To make sure you have a drug that can fight Beta-lactamase.
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Pharmacologic Therapy for AOM:
What are the Tx options for a patient who has an Amoxicllin Allergy-Non Type I Hypersensitivity? (4 drugs) |
1. Cefdinir (Omnicef)
2. Cefpodoxime (Vantin) 3. Cefuroxime axetil (Zinacef, Ceftin) 4. IV or IM Ceftriaxone (Rocephin) |
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Pharmacologic Therapy for AOM:
What are the Tx options for a patient who has an Amoxicillin Allergy Type I Hypersensitivity? (4 drugs) |
1. Azithromycin (Zithromax)
2. Clarithromycin (Biaxin) 3. Erythromycin 4. Sulfamethoxazole-Trimethoprim (Bactrim) |
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What is the length of Tx for AOM in a patient less than five years of age, or a severe presentation?
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10 days
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What is the length of Tx for AOM in a child older than 6 years of age with mild to moderate presentation?
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5 - 7 Days
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What is something that should be done if a child presents to the clinic with AOM after having just been treated for AOM?
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Make sure that the mother gave the full prescription of ABX, if so, then it could be a resistant strain of bacteria causing the AOM.
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If there is a failure to respond to conservative Tx for AOM what is the Tx plan?
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1. Reassess to confirm AOM
2. Begin ABX Tx A) Non Severe - Amoxicillin B) Severe - Augmentin 3. If a non type 1 hypersensitivity, or a type 1 hypersensitivity to Amoxicillin exists then implement Tx from the alternative ABX. |
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What do you give a patient who has AOM if they fail to respond to Amoxicillin?
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1. High Dose Amoxicillin-Clavulanate
2. If patient is non-type I hypersensitivity to Amoxicillin give Ceftriazone for three days. 3. If patient is type I hypersensitivity to Amoxicillin give Azithromycin or Clarithromycin |
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What do you give a patient who has AOM if they fail to respond to Amoxicillin-Clavulanate (Augmentin)?
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Ceftriaxone for three days, IV for very young patients, otherwise IM.
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If AOM persists after giving Ceftriaxone IV for three days, as a result of the patient origionally not responding to Augmentin, what is the Tx plan?
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Clindamycin due to the possibility of a penicillin resistant pneumococcal infection.
Tympanocentesis so that you can preform a gram stain and culture. |
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When is there the greatest percentage of middle ear effusion after Tx of AOM?
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Two weeks after the AOM infection, 60-70%.
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If middle ear effusion occurs after the Tx of AOM, what is something that you should ask your patient?
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If they have had any hearing loss. If so, you send them for an audiogram.
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This is when there is fluid behind the TM, no inflammation and a dull TM is visualized, Associated with conductive hearing loss - patient will complain of "cotton in ears" feeling, no antibiotic Tx is required.
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Otitis media with effusion.
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If you see a fluid line on the TM what does this indicate?
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Effusion
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This is Otitis Media with effusion lasting over three months, similar presentation to AOM or changes in balance, decrease in speech development, may result in permanent hearing loss.
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Chronic Otitis Media
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What constitutes a diagnosis of recurrent otitis media?
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Three episodes of AOM within six months or four episodes within one year.
Also, when there is a noticeable lack of speech development and hearing loss. |
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What is the prophylaxis used before Tympanostomy tubes?
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Sulfisoxazole
Amoxicillin Three month trial |
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What constitutes placing tympanostomy tubes when a patient has OME?
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If the OME is >4-6 months bilaterally or >6 months unilaterally.
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What constitutes placing tympanostomy tubes when a patient has Recurrent Otitis Media (ROM)?
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>2-3 AOM experiences while on prophylaxis.
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This is the inflammation of the external auditory canal?
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Otitis externa
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What differentiates acute otitis externa from chronic otitis externa?
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Chronic otitis externa lasts over six weeks.
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This otitis externa extends into deeper tissues, may include osteomyolitis and cellulitis.
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Necrotizing or "malignant" otitis externa.
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What are the etiological causes for acute otitis externa? (five things)
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Streptococcus
Pseudomonas Staphylococcus Proteus Varous Yeast/Fungals (Rare) |
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How do you differentiate between a bacterial and fungal AOE?
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Bacterial - Scant to thick white mucus
Fungal/Yeast - Fluffy, white to off white to grayish black. |
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This is responsible for causing chronic and necrotizing Otitis externa?
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Pseudomonas
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What are the risk factors (four of them) for otitis externa?
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Trauma - Q Tips, ear plugs, hearing aids
Swimming Perspiration, High Humidity Diabetes - especially in cases of necrotizing otitis externa |
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What are the signs and symptoms of Otitis externa? (Four things)
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Itching
Otalgia - Pull Pinna and there is pain Ear drainage Decrease sense of hearing, fullness. |
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What is seen on the physical examination with otitis externa?
(3 main things) |
Pre-auricular lymphadenopathy and swelling
Tragal Tenderness External canal edema, exudate, erythema |
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What is the ototopical Tx for an acute bacterial otitis externa?
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Neomycin-hydrocortisone-polymyxin B (Cortisporin Otic)
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What are two things you have to remember when you are considering Neomycin-Hydrocortisone-Polymyxin B (Cortisporin Otic) as ototopical Tx for otitis externa?
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There may be a neomycin sensitivity
Possible ototoxicity |
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What is the ototopical Tx for otitis externa if it is caused by both an acute and chronic bacterial infection?
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Fluoroquinolones - No Ototoxic Effects
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What can you use in ototopical Tx of otitis externa to cover pseudomonas?
(3 things) |
Ofloxacin (Floxin Otic) - FDA approved for use in TM perforations.
Ciprofloxacin + Hydrocortisone (Cipro HC Otic) Ciprofloxacin +Dexamethasone (Ciprodex) |
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When do you use oral ABX Tx for Otitis Externa? (two things)
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1. When it is Chronic
2. When local or systemic spread has occurred. |
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What are the signs that a otitis externa has spread systemically? (4 things)
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1. Temperature greater than 101
2. Regional lymphadenopathy 3. Early signs of necrotizing otitis externa 4. A positive history of diabetes |
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What Tx do you use when you have acute otitis media with tympanostomy tubes?
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1. Ciprofloxacin-dexamethasone (Ciprodex Otic)
2. Ofloxacin (Floxin Otic) |
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What are the Tx for fungal otitis externa? (two of them)
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Clotrimazole 1% Solution (Lotrimin)
Oral Itraconazole (Sporanox) |
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What Tx do you use if you have a fungal otitis externa infection with a TM rupture?
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Tolnaftate 1% soln. (Tinactin)
There is no ototoxicity! |
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What are the two main causes of fungal infections in otitis externa?
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1. 80-90% Aspergillus
2. 10-20% Candida |
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What are the three things you do when formulating a Tx plan for necrotizing or malignant otitis externa?
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Four to six weeks of Tx
Surgical Debridement may be needed in addition to ABX Rule out underlying osteomyelitis CT or MRI |
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What are the ABX Treatments for Necrotizing or malignant otitis externa?
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Quinolones - Ciprofloxacin IV or IM
Carbapenems - Imipenem/Cilostatin IV |
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What are three things that can be used prophylacticly to prevent otitis externa?
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Drying Agents - Instill after showering, swimming
Mix of 1/3 white vinegar and 2/3 rubbing alcohol Isopropyl alcohol + anhydrous glycerins (swim-ear) |
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What six dermatologic conditions can result in otitis externa?
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Herpes zoster of the facial nerve
Atopic dermatitis Psoriasis Seborrheic dermatitis Acne Lupus |
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What are the bacterial causes of pharyngitis? 7 of them.
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Group A Beta Hemolytic Streptococci (GABHS)
Haemophilus influenzae Moraxella catarrhalis Mycoplasma pneumonia Corynebacterium diphtheriae Gonorrhea Chlamydia |
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What bacterial cause of pharyngitis is more common in adolescence?
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Mycoplasma pneumoniae
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What is the least common cause of bacterial pharyngitis?
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Corynebacterium diphtheriae
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What is the most common bacterial pharyngitis overall?
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Group A Beta Hemolytic Streptococci (GABHS)
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This pharyngitis is most common in children ages 5-8. It occurs most often in the late fall, winter and early spring. Microaerosolized droplet transmission from nasal and respiratory secretions pass it and the incubation period is 2-5 days.
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Group A Beta-Hemolytic Streptococci
(Strep Throat) |
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What are the signs and symptoms of Strep throat?
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Chief Complaint: Sore Throat - "swallowing razorblades"
Constitutional Symptoms: Fever Malaise Anorexia Vomiting |
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What are the criteria for diagnosing Strep throat?
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Tonsillar exudate
Tender anterior cervical lymphadenopathy History of fever or temp over 100.4 Absence of cough The presence of 3 out of four means patient is likely to have strep, if less than three it probably isn't strep. |
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What is the gold standard for identifying strep throat?
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Throat culture
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What is the first line Tx for Strep throat?
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Penicillin oral 10 days
Benzathine penicillin G single IM injection Amoxicillin 10 days |
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What do you give for strep throat if there is a PCN allergy?
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Macrolides:
Erythromycin ethylsuccinate Azithromycin (Zithromax) Cephalosporins: Cefpodoxime (Vantin) Cefuroxime (Ceftin, Zinacef) |
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If there is a Tx failure with PCN or amoxicillin when Tx strep throat, what is used?
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This means it is beta-lactamase resistant
Use Amoxicillin-Clavulanate (Augmentin) Cephalosporins Macrolides |
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When is a patient with strep throat presumed non infectious?
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After 24 hours.
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What are complications from strep throat?
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Peritonsillar abscess
Otitis media Sinusitis GABHS Toxin Mediated: Scarlet Fever Acute Rheumatic Fever Post-streptococcal glomerulonephritis - Cause renal function damage and HTN |
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What can acute rheumatic fever, a complication from strep throat, cause?
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damage to the heart and valves - usually the mitral valve
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This is a group A streptococcal infection of the skin and subcutaneous tissue?
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Erysipelas
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What is the prophylaxis for rheumatic fever?
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Penicillin for 10 days
Carriers of GABHS: Typically do not actively transmit infection Provide Tx if symptomatic, family history of rheumatic fever, community outbreak, Recurrent infections in family members. |
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You have to consider these pharyngitis etiologies in sexually active patients, or possible child abuse.
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Neisseria Gonorrhea
Chlamydia Trachomatis |
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What is the Tx for Gonorrhea?
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Ceftriaxone (Rocephin
or Ciprofloxacin (Cipro) |
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What is the Tx for Chlamydia?
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Azithromycin
or Doxycycline |
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This is usually seen outside of the country, it presents as a gray pseudomembrane adhering to the pharynx. Its underlying mucosa bleeds when membrane removed.
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Corynebacterium diphtheriae
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How do you treat corynebacterium diphtheriae?
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Diphtheria antitoxin and erythromycin
Equine antitoxin needs to be obtained from CDC |
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What are 8 viruses that cause pharyngitis?
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Adenovirus
Rhinovirus Enterovirus Influenza Epstein Barr HSV RSV CMV |
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How do you differentiate viral and bacterial pharyngitis?
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With viral pharyngitis you rarely see exudative tonsillar tissue.
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What are the various signs with a viral pharyngitis?
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Absent or low grade fever
Pharyngeal edema/erythema Lack of exudate Ulcers Hepatosplenomegaly Posterior cervical adenopathy Conjunctivitis, cough, coryza |
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What do you use to Tx viral pharyngitis?
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Analgesics/Antipyretics
Throat lozenges Influenza vaccine Acyclovir for herpes |
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This virus is spread by person to person contact, via saliva. In rare instances the virus has been transmitted by blood transfusion or transplacentally.
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Infectious Mononucleosis
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How long does mono last?
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It usually runs its course in two to four weeks, although cases may be as brief as a week or last six to eight weeks.
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This is a human herpes DNA virus. It is estimated that 95 percent of the world population is exposed to this virus. In infectious mononucleosis this virus affects B-lymphocytes.
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Epstein-Barr Virus
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This virus is characterized by fever, fatigue, chills, headache, myalgia, skin rash, splenomegaly, and cervical adenopathy.
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Epstein-Barr Viral Infection
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What is the most important and most characteristic symptom of infectious mononucleosis?
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Sore throat. It usually develops a few days after the onset of the illness, increases in severity during the first week, and then rapidly subsides during the next five to seven days.
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If a patient presents with pharyngitis and upper respiratory infection, what must you make sure to include in the diff. diagnosis?
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Mononucleosis and a spleen exam
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What is a sign and symptom associated with infectious mononucleosis?
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Lymphadenopathy - Enlargement of lymph nodes usually begins two or three days after the onset of the first symptoms and by the end of the week palpable lymphadenopathy is present in 70-80% of patients.
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What are the clinical manifestions of infectious mononucleosis?
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Increase in white blood cells due to appearance of many atypical lymphocytes in blood
Blood serum in IM often contains an antibody known as heterophil antibody that agglutinates, or clumps, the red blood cells of sheep Heterophil antibody titers rise Levels of antibody gradually decline and usually disappear in eight to twelve weeks. |
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What is the Tx for infectious mononucleosis?
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Rest
Analgesics Avoid excessive physical activity (risk of spleen rupture) Prednisone for severe airway obstruction, hemolytic anemia, or thrombocytopenia NO ROLE FOR ACYCLOVIR!!! |
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This is the most common cause of rhinitis.
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Allergic rhinitis
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This is an IgE mediated reaction to extrinsic allergens, many mast cells are released.
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Allergic rhinitis
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This is an inflammation of the lining of the nose, characterized by one or more of the following:
Nasal congestion Nasal pruritis Rhinorrhea Sneezing |
Allergic rhinitis
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Nasal symptoms lasting longer than one hour on most days is an indication for?
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Allergic rhinitis
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What is the peak age for allergic rhinitis?
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30
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How does allergic rhinitis present in the elderly and why?
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Elderly:
Decrease in IgE production Old man's drip |
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What are the predisposing factors for allergic rhinitis?
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Genetic - positive FHx - polygenic inheritance
Atopic dermatitis Previous exposure/environmental factors, ie. child growing up in a smoker's home |
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What are three comorbidities associated with allergic rhinitis?
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Asthma
Sinusitis Otitis media with effusion |
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What are the direct symptoms of allergic rhinitis?
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Nasal congestion
Rhinorrhea Pruritis Sneezing Eye tearing and pruritis Ear and Palate pruritis Post nasal drip Anosmia - inability to smell |
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What are the non-nasal symptoms of allergic rhinitis?
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Headache
Sore Throat Chronic Cough Mouth Breathing |
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What are the psychosocial/cognitive symptoms of allergic rhinitis?
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Fatigue
Depression Irritability Anxiety Sleep disturbance Poor concentration Reduced productivity Impaired learning, decision making and psychomotor speed |
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What are the three mediator effects of allergic rhinitis?
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Vasodilation and increased vascular permeability
Increased glandular secretion Stimulation of afferent nerves |
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What are the two types of allergic rhinitis?
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Season (intermittent sx)
Perennial (chronic and persistent sx) |
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What are the primary causes of Season rhinitis? (3 of them)
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Pollen:
Trees, Grass, Weeds Mold House Dust Mites |
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What are the four major causes of perennial rhinitis?
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Fungi/Mold
Pet Dander House Dust Mites Cockroaches |
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Allergic rhinitis nasal discharge is?
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Clear and watery
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Bacterial rhinitis/sinusitis nasal discharge is?
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Pus (thick/discolored)
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Chronic sinusitis nasal discharge is?
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Purulent nasal drainage, along with headache, hallitosis.
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What physical features can be seen in the nose and eyes of someone who has allergic rhinitis?
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Allergic salute, Dennie-Morgan lines, Allergic shiners
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What are three tests that can be used for allergy testing?
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Skin pricking test
In vitro serum test (RAST) Nasal smears |
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Benadryl works best in what type of rhinitis?
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Seasonal rhinitis
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What are the first generation antihistamines?
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Benadryl and Chlor-Trimeton
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What is the mechanism of action for the first generation antihistamines?
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Inhibition of histamine H1 receptors
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What is the effect of first generation anthistamines?
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Reduce sneezing, nasal pruritis, and rhinorrhea, but not congestion.
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What are side effects associated with first generation antihistamines?
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Anticholinergic activity - adverse CNS effects.
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What are the second generation antihistamines?
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Claritin, Allegra, Zyrtec
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What is the mechanism of action for the second generation antihistamines?
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Inhibit histamine H1 receptors
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Which second generation anthistamine is non sedating?
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Zyrtec
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Which second generation antihistamine is Rx only?
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Allegra
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These drugs can make you jittery, cause insomnia, and heart palpitations. It is best to avoid using them in children and elderly.
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Degongestants (oral/topical)
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What are two typical decongestants?
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Sudafed (oral)
Afrin (topical) |
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What is the MOA for decongestants?
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Alpha-Adrenergic Agonist
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What is the effect of decongestants?
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Vasoconstriction restricts blood flow to nasal mucosa decreasing nsal obstruction (no influence on pruritis, sneezing or nasal secretion)
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What are the side effects of decongestants?
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Oral - Headache, nervousness, irritability, tachycardia, palpitations, insomnia
Topical - Prolonged use over 5-7 days leads to RHINITIS MEDICAMENTOSA |
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What are two corticosteroids used in rhinitis?
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Vancenase, Flonase
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What is the MOA for the corticosteroids?
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Reduce inflammation
Suppress Neutrophil chemotaxis Mildly vasoconstrictive Reduce intracellular edema |
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What is the effect of corticosteroids?
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reduce nasal blockage, pruritis, sneezing and rhinorrhea
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What is the most potent single medication Tx for allergic rhinitis?
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Corticosteroids
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These act intanasal - act locally
Control Sx with lowest possible dose >90% achieve symptomatic relief Most effective when started several days before exposure and used regularly Therapeutic efficacy within 1-3 days, but max efficacy may take 3 weeks Compliance is critical |
Corticosteroids
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What are the side effects for corticosteroids?
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Nasal irritation
Bleeding (Nasal septal perforation) |
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What are the three intranasal Tx for rhinitis?
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Cromolyn Sodium, Ipratropium, Saline
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What is the MOA for Cromolyn sodium ie. Nasalcrom?
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Mast cell stabilizing agent, reduces release of histamine and other mediators.
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What is the effect of Cromolyn sodium (nasalcrom)?
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Reduces nasal pruritis, sneezing, rhinorrhea, and congestion
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Prophylactic use with this should start before pollinosis Sx or unavoidable/predicable exposures. Disadvantages to this drug are that it requires frequent dosing every four hours.
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Cromolyn Sodium
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What are the side effects of Cromolyn sodium?
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Locally, <10% of patients have sneezing, nasal stinging, burning, irritation.
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What is the MOA for Ipratropium, ie. atrovent?
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Inhibits muscarinic cholinergic receptors.
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What is the effect of Ipratropium (Atrovent)?
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Reduces watery rhinorrhea (no effect on nasal itching, sneezing or nasal congestion).
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This drug is limited to control of watery secretions, it is effective at reducing both "cold air" and "gustatory" rhinitis.
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Ipratropium (Atrovent)
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What are the side effects for Ipratropium (Atrovent)?
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Irritation, crusting, epistaxis
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What are the effects of Saline (NaSal, SeaMist, Ocean, Ayr)?
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Relief from crusting and can be soothing.
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What is a first line treatment for sneezing, pruritis, and rhinorrhea?
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Antihistamine
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When do you add a decongestant to antihistamine for Tx of allergic rhinitis?
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When it is an intermittent AR episode
Also, if nasal congestion is a major Sx, you add an oral decongestant. |
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When do you incorporate a nasal steroid into the Tx of allergic rhinitis?
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When there are prolonged Sx
Add to antihistamine/decongestant regimen Will reverse preexisting inflammation Will prevent nasal priming |
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What is a Tx option for allergic rhinitis that doesn't involve any medication?
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Avoidance/Modifying Factors/Patient Education:
Bed encasements Wash bed sheets >130F Dusting/Vacuuming Air Conditioning/Filters Indoor Humidity <40% Pets Choosing Environment Explain to patient how medications work |
|
|
What are three things that let you know when it is time to refer to an allergist?
|
1. The need to assess allergen specific IgE mediated mechanisms of Sx causation
2. When Pt does not respond to indicated tx (may need rhinoscopy, imaging studies or eval of immunocompetence). 3. Any Pt with a treatable complication of allergic dz may benefit from a specialized referral. |
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Allergic or nonallergic rhinitis nearly always precedes this?
|
Sinusitis
|
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|
Sinusitis ____ rhinitis is rare.
With or Without? |
Without
|
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|
This is classified as infectious or noninfectious inflammation of 1 or more sinuses.
Nasal discharge and congestion are prominent symptoms of this. |
Sinusitis
|
|
|
Two of the four sinuses are hard to treat because of their location. What two sinuses are these?
|
Ethmoid and Sphenoid sinuses
|
|
|
Viral rhinosinusitis usually lasts how long?
|
Less than 10 days.
|
|
|
How do you Tx viral rhinosinusitis?
|
Decongestants
Nasa Lavage Rest Fluids |
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|
This is a sinus infection lasting 4 weeks, symptoms resolve completely, children within 30 days.
|
Acute bacterial sinusitis
|
|
|
This is a sinus infection lasting between 4 to 12 weeks, yet resolves completely, children 30 to 90 days.
|
Subacute bacterial sinusitis
|
|
|
This is a sinus infection that has symptoms lasting more than 12 weeks, children over 90 days.
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Chronic sinusitis
|
|
|
This is classified as sinus infection episodes lasting fewer than four weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic. This is when there are 3 episodes in 6 months or 4 episodes in a year.
|
Recurrent Acute Bacterial Sinusitis
|
|
|
Sinusitis vs. Rhinitis:
What are the 7 symptoms of Sinusitis? |
Nasal Congestion
Purulent rhinorrhea Postnasal drip Headache Facial pain Anosmia Cough, Fever |
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|
Sinusitis vs. Rhinitis:
What are the 6 symptoms of Rhinitis? |
Nasal Congestion
Rhinorrhea clear Runny nose Itching, red eyes Nasal crease Seasonal symptoms (coming and going symptoms) |
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|
Which problem, sinusitis or rhinitis, have seasonal symptoms?
|
Rhinitis
|
|
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What are the four things that contribute to the pathogenesis of nasal obstruction?
|
Viral upper respiratory infections (daycare centers)
Allergic and nonallergic stimuli Immunodeficiency disorders (IgA, IgG immunoglobulin deficiency) Anatomic changes (deviated septum, concha bullosa, polyps) |
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|
These are all a cause of what?
Pollens House dust mite Animal dander Molds Allergic foods and beverages |
Rhinosinusitis
|
|
|
What are four things that cause ciliary dysfunction?
|
Immotile cilia syndrome
Prolonged exposure to cigarette smoke Common cold viruses causing URI Increased viscosity of mucus |
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What medications can cause ciliary dysfunction? (5 of them Four A's and a B")
|
First generation antihistamines
Anticholinergics Aspirin Anesthetic agents Benzodiazepenes |
|
|
What are four diseases that slow ciliary function?
|
Allergic and nonallergic rhinitis
Rhinosinusitis Aging rhinitis Cystic fibrosis |
|
|
These are causes for what?
Deviated nasal septum Concha bullosa Foreign body Nasal polyps Congential atresia Lymphoid hyperplasia Nasal structural changes found in Downs syndrome |
These are all causes for mechanical obstruction in the nose.
|
|
|
People who have the diseases listed below are more prone to what?
Churg-Strauss vasculitis Systemic lupus erythematosis Sjogren's syndrome Sarcoidosis Wegener granulomatosis |
Sinusitis
|
|
|
This usually begins with viral upper respiratory illness. Symptoms initially improve, but then symptoms become persistent or severe, persistent 10-14 days but fewer than four weeks. Severe is temperature at 102, purulent nasal discharge for 3-4 days, child appears ill. Disease clears with appropriate medical Tx.
|
Acute Bacterial Sinusitis
|
|
|
What are the physical exam findings with acute bacterial sinusitis?
|
Mucopurulent nasal discharge (HIGHEST positive predictive value)
Swelling of nasal mucosa Mild erythema Facial pain (unusual in children) Periorbital swelling |
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|
What are the 6 options for Tx of acute sinusitis?
|
Antihistamines (Recommended if allergy present)
Decongestants ABX if bacterial Nasal Irrigation Guaifenesin Hydration |
|
|
What decongestants can be used to treat acute sinusitis?
|
Topical nasal sprays (limit to 3-7days):
Phenylephrine Naphthazoline Tetrahydrozoline Zylometazoline Topical nasal spray (unlimited use) Ipatropium Oral: Pseudophedrine Phenylephrine |
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|
What is the only topical nasal decongestant that can have unlimited use?
|
Ipatropium
|
|
|
What must you tell a patient who is taking decongestants?
|
Make sure to tell patients to drink lots of fluid to avoid setting themselves up for further infection.
|
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|
What bacteria are responsible for causing acute bacterial sinusitis?
(four of them) |
Streptococcus pneumoniae
Haemophilus influenza Moraxella catarrhalis Sterile |
|
|
What ABX Tx do you use for Tx of Acute Bacterial Sinusitis?
|
Amoxicillin for 10-14 days
|
|
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What is the ABX Tx for acute bacterial sinusitis when beta lactamase resistance is an issue? (four)
|
Amoxicillin/Clavulanate - Augmentin
Cefuroxime Cefpodoxime Cefprozil |
|
|
What are the three tenants for the rational behind starting a Tx of acute bacterial sinusitis with amoxicillin?
|
In the absence of risk factors, ie. attendance in daycare center, recent ABX, age younger than 2 etc.
80% of patients will respond Give Rx for 5 days with a refill - if responding treat for 10-14 days, if not, switch to something else. |
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|
If there is a penicillin allergy, what do you use to Tx acute bacterial sinusitis?
|
Azithromycin
Clarithromycin |
|
|
What ABX does not provide adequate Tx for acute bacterial sinusitis?
|
Erythromycin
|
|
|
What ABX have significant pneumococcal resistance?
|
Trimethoprim/Sulfamethoxazole (bactrim)
Erythro/Sulfisoxazole (pediazole) |
|
|
What are the four reasons to use alternative ABX in the Tx of acute bacterial sinusitis?
|
No response to amoxicillin within 3-5 days
Recent Tx with amoxicillin for other causes Symptoms present for more than 30 days Recurrent in sinus infections |
|
|
What are the secondary ABX for acute sinusitis if not using Amoxicillin? (5)
|
Cefdinir (Omnicef)
Cefuroxime (Ceftin) Cephpodoxime (Vantin) Azithromycin Clarithromycin |
|
|
What is the optimal duration of ABX?
|
Give ABX until Pt free of symptoms and then add 7 days.
|
|
|
What are the types of nasal irrigation? (4 of them)
|
Commercial buffered sprays
Bulb syringe Waterpik with lavage tip Disposable enema bucket |
|
|
What does nasal irrigation accomplish? (5 things)
|
Washes away irritants
Moistens the dry nose |
|
|
What steps do you take if therapy for acute bacterial sinusitis fails? (4 things)
|
Assess for chronic causes:
Identify allergic and nonallergic triggers - allergy testing, nasal smears for eosinophila Consider other medical conditions associated with sinusitis Rhinolaryngoscopy Imaging studies - X-Ray, CT Scanning (limited, coronal views) |
|
|
With this symptoms present longer than 8 weeks or 4 times in a year in adults or 12 weeks or 6 episodes a year in children.
|
Chronic Sinusitis
|
|
|
What are three things associated with chronic sinusitis?
|
Eosinophilic inflammation or chronic infection
Associated with positive CT scans Poor (if any) response to antibiotics |
|
|
What is something that is a characteristic sign of chronic sinusitis?
|
Cough that is worse when lying down
|
|
|
What are the symptoms that present with chronic sinusitis? 7 of them
|
Nasal discharge
Nasal congestion Headache Facial pain or pressure Olfactory disturbance Fever and halitosis Cough (worse when lying down) |
|
|
The conditions listed below cause what?
Allergic and non allergic rhinitis Uncorrected anatomic conditions ciliary dyskinesia cystic fibrosis tumors immunodeficiency disorders (IgA, IgM) Granulomatous diseases |
Chronic sinusitis
|
|
|
What are the 6 Tx options for chronic sinusitis?
|
Nasal steroid spray
Guafenesin Decongestants Steam inhalation Nasal irrigation ABX with exacerbations |
|
|
What bacteria are involved with chronic sinusitis? 6 of them
|
Streptococcus pneumoniae
Haemophilus influenza Moraxella catarrhalis Staph aureus Coagulase negative staphylococcus Anerobic bacteria |
|
|
What orbital complications can occur from sinusitis?
|
Diplopia (double vision), proptosis (eye bulging)
Periorbital erythema and swelling |
|
|
What bone complications can occur from sinusitis?
|
Periosteal abscesses
|
|
|
What brain complications can occur from sinusitis?
|
Intracranial abscesses causing neurologic symptoms.
|
|
|
What are the three indications for hospitalization for sinusitis?
|
Acutely ill child or adult with high fever, severe head pain.
Suspected sphenoid sinusitis Anytime complications of eye, bone or intracranial structures are present. |
|
|
These are blue-gray protuberances in the area of the ethmoid bone, middle meatus, nose and middle turbinate.
|
Nasal Polyposis
|
|
|
These are characterized by eosinophil inflammation, accompanied by acetylsalicylic intolerance in up to 25% of cases, 40% of cases are associated with intrinsic asthma, Samter's triad includes these, aspirin allergy, and asthma) Associations have also been described between Churg-Strauss syndrome and eosinophilic forms of these.
|
Nasal Polyposis
|
|
|
What comprisies approximately 60% of nasal polyps?
|
Eosinophils
|
|
|
Where are polyps seen in more severe diseases?
|
Polyps originating from the middle and superior turbinates.
|
|
|
What is the typical history of a pt with nasal polyps?
|
A "cold" that persisted over months or years
Nasal obstruction and discharge are prominent symptoms. |
|
|
This is a typical symptom for nasal polyps?
|
Anosmia
|
|
|
What is generally indicated for the evaluation, removal and/or treatment of nasal polyposis?
|
Referral to ENT
|
|
|
This is the most common cause of non-traumatic ulcerations of the oral cavity. Etiology is unclear, and occurs in 10-20% of the general population.
|
Apthous ulcers
|
|
|
When you are performing the diagnosis of exclusion for aphthous ulcers what are you doing?
|
You are screening out viral causes
|
|
|
These are <1cm in diameter, located on freely mobile oral mucosa, appear as a well delineated white lesion with an erythematous halo, there is a prodrome of burning or tingling in area prior to ulcer's appearance. Resolves in 7-10 days, never scars.
|
Minor Aphthous Ulcer
|
|
|
These are >1cm in diameter, involves freely mobile mucosa, tongue and palate, last 6 weeks or more, typically scar upon healing.
|
Major Aphthous Ulcer
|
|
|
These are small 1-3 mm in diameter ulcerations appearing in crops of 20-200 ulcers, they are typically located on mobile oral mucosa, tongue and palate. They last 1-2 weeks.
|
Herpetiform Ulcers
|
|
|
These have their name because the ulcerations resemble those of HSV, but there is NO VESICULAR PHASE.
|
Herpetiform ulcers
|
|
|
What is the Tx plan for aphthous ulcers?
|
Topical tetracycline for 5-7 days
Topical steroids shown to shorten disease duration Sucralfate suspension shown to improve pain as well as shorten disease duration |
|
|
Major aphthous ulcers or more severe forms of disease require two weeks of what?
|
two week course of systemic steroids
|
|
|
This is inflammation of the parotid gland, may be infectious or non-infections?
|
Parotitis
|
|
|
What are the 5 common causes of parotitis?
|
Mumps
Sjogren's syndrome Bacterial infection of parotid gland Blocked salivary duct Stone in salivary duct |
|
|
What bacteria causes bacterial parotitis?
|
Staph Aureus
|
|
|
What are the two major symptoms of parotitis?
|
Pain/Tenderness of the parotid glands
Enlargement of the parotid glands |
|
|
With this the patient reports progressive painful swelling of the gland, chewing aggravates the pain.
|
Acute bacterial parotitis
|
|
|
Pain and swelling of the gland last 5-9 days, moderate malaise, anorexia, and fever occur, bilateral involvement is present in most instances.
|
Acute viral parotitis (mumps)
|
|
|
Nonpainful swelling of the gland occurs, otherwise patient is asymptomatic.
|
HIV parotitis
|
|
|
What are the more serious and infrequent causes of parotitis? 4 of them.
|
Parotitis in tuberculosis
Sjogren's Syndrome Recurrent parotitis of childhood Sarcoidosis |
|
|
What is the Tx plan for acute parotitis?
|
ABX
Rehydration stimulating salivary flow Possible IND (incision and drain) |
|
|
What is the Tx plan for chronic parotitis?
|
Eliminate causative agent
Warm compress Sialogogues (drug increases saliva flow) Possible surgical resection Ligation of the duct in hopes of atrophy |
|
|
Viral parotitis is?
|
The mumps
|
|
|
Acute Sialadenitis, listed under the MUMPS category, is caused by what RNA virus?
|
Paramyxovirus
|
|
|
What other viruses, besides paramyxovirus, cause salivary gland infection?
|
Cytomegalovirus
Coxsackieviruses Echovirus |
|
|
This is transmitted via airborne droplets, mainly effects the parotid gland, mainly effects children between the ages of 5-18 years old, has a 2-3 week incubation period.
|
Mumps
|
|
|
What do you see clinically with the mumps?
|
Will see rapid swelling of parotids bilaterally
Acute pain when salivating |
|
|
What is the Tx for mumps?
|
No antiviral therapy
Analgesics and antipyretics Liquid diet with vitamins Bed rest |
|
|
This is an inflammation of the salivary glands.
|
Sialadentitis
|
|
|
What are four factors that can cause sialadentitis?
|
Mumps
Coxacki virus Parainfluenza Systemic disease |
|
|
What viruses cause croup?
|
parainfluenza 1, rsv, adenovirus
|
|
|
-What is the age range in croup patients?
|
3 months - 3 years
|
|
|
Croup patients lack what symptom?
|
no drooling
|
|
|
What symptoms of cough and breathing are present in croup?
|
barky cough, inspiratory stridor, abdominal breathing
|
|
|
What is an essential component of intubation in croup patients?
|
performed by an expert in a controlled environment
|
|
|
What is seen on xrays of croup patients?
|
steeple sign
|
|
|
What treatments are given to a croup patient with a stridor cough?
|
oxygen, nebulized racemic epinephrine, or IM dexamethasone
|
|
|
How long do croup symptoms typically last?
|
1-3 days
|
|
|
Pertussis has highest mortality in what age group?
|
<6 months old
|
|
|
Pertussis is caused by what?
|
Bordetella pertussis and Bordatella parapertussis
|
|
|
What lung symptoms are caused by pertussis?
|
peribronchial lymphoid hyperplasia, atelectasis
|
|
|
What are the 3 stages of pertussis?
|
catarrhal stage, paroxysmal stage, convalescent stage
|
|
|
How long does each stage of pertussis last?
|
2 weeks
|
|
|
What are the symptoms of pertussis in the catarrhal stage?
|
regular cough, nasal congestion, rhinorrhea, low fever, red eyes
|
|
|
The paroxysmal stage of pertussive is characterized by what symptoms?
|
whooping cough, posttussive vomiting, often cyanotic, subconjunctival hemorrhages
|
|
|
How do infants present in the paroxysmal stage?
|
episodes of apnea instead of whooping cough
|
|
|
What symptom of pertussis is seen in the convalescent stage?
|
chronic cough
|
|
|
For a diagnosis of pertussis, a patient must have a cough of at least 2 wks and what other symptoms?
|
paroxysmal cough, posttussive vomiting, inspiratory whoop
|
|
|
What confirms a diagnosis of pertussis?
|
nasopharyngeal or posterior nasopharyngeal culture
|
|
|
What pertussis patients should be hospitalized?
|
pts with severe illnesses or comorbidities, infants < 3 m.o., premature infants, infants with pulmonary or cardiac disease
|
|
|
Giving ABX during what stage of pertussis can prevent its progression?
|
catarrhal stage
|
|
|
What first line meds are given for pertussis?
|
erythromycin, azithromycin, clarithromycin
|
|
|
What alternative to macrolides can be given to pertussis pts?
|
bactrim
|
|
|
What treatment is recommended to all household members of a patient with pertussis?
|
erythromycin
|
|
|
When is a pertussis booster vaccine given?
|
11 years old
|
|
|
What organisms cause epiglottitis?
|
H. influenzae, Strep. pneumoniae, Candida (in immunocompromised)
|
|
|
What is the age range in epiglottitis patients?
|
1-7 y.o.
|
|
|
What clinical symptoms are seen in epiglottitis over the course of 12 hrs?
|
rapid onset fever, throat pain and dysphagia, drooling
|
|
|
Epiglottitis patients often present in what positions?
|
tripoding, sniffing dog
|
|
|
What symptom is not seen in epiglottitis, which differentiates it from croup?
|
no cough
|
|
|
What medication is given when the airway has been established in epiglottitis?
|
IV ceftriaxone
|
|
|
What is seen on xray of an epiglottitis patient?
|
thumbprint sign
|
|
|
How long should ABX be continued after extubation in eppiglottitis?
|
2-3 days IV, then 10 days p.o.
|
|
|
How long does RSV illness last?
|
1-2 weeks, virus shed for up to 20 days later
|
|
|
What is the most common RSV infection?
|
bronchiolitis
|
|
|
What does bronchiolitis cause in the lungs?
|
necrosis of bronchial epithelium, hypersecretion of mucus, bronchiole edema
|
|
|
What symptoms on exam are seen in RSV pts?
|
tachypnea, wheezing, rales/rhonchi, apneic spells, retractions, cyanosis, palpable liver/spleen
|
|
|
RSV antigen may be detected by ELISA staining from what type of test?
|
nasopharyngeal swab
|
|
|
What may be seen on xray of RSV patients?
|
hyperinflation, atelectasis, segmental consolidation or interstitial pneumonia
|
|
|
What treatment is given to RSV pts?
|
fluids, O2, bronchodilators, steroids
|
|
|
What meds are given to children at risk who acquire RSV?
|
IV immune globulin, RSV antibody
|
|
|
What viruses cause the common cold?
|
rhinovirus, adenovirus, parainfluenza, coronovirus, enterovirus
|
|
|
What will be seen on a CBC of a pt with the common cold?
|
leukocytosis
|
|
|
What will be seen on a CBC of a pt with pertussis or RSV?
|
lymphocytosis
|
|
|
What treatment is given for the common cold?
|
antipyretics, fluids, antitussives
|
|
|
What is the most frequent cause of intestinal obstruction in kids <2 yrs?
|
intussusception
|
|
|
What is the most common cause of intussusception?
|
ileum telescoping into the colon
|
|
|
What is a characteristic symptom of intussusception?
|
currant jelly stool
|
|
|
A kid with intussesception presents with what history of symptoms?
|
colicky abdominal pain with vomiting, bloody stool within 12-24 hrs
|
|
|
What is felt in the mid epigastric area (with intussesception) on physical exam?
|
sausage shaped mass
|
|
|
What treatment for intussusception is diagnostic and therapeutic?
|
air enema or barium enema with fluoro
|
|
|
What is a meckel diverticulum?
|
heterotrophic gastric tissue in the distal ileum
|
|
|
What symptoms present in meckel diverticulum?
|
painless maroon rectal bleeding, abd pain if obstruction
|
|
|
What complications can result from meckel diverticulum?
|
anemia, intussusception, diverticulitis
|
|
|
Complications from meckel diverticulum occur most often in what patients?
|
males, < 2 yo
|
|
|
What is the treatment for meckel diverticulum?
|
excision of MD and ileum proximal and distal to it
|
|
|
When is the main presentation of Hirschsprungs?
|
newborn
|
|
|
What causes Hirschsprungs disease?
|
failure of ganglion cells to migrate to distal bowel, muscle cant relax
|
|
|
What is caused by the inflammation of the bowel in Hirschprungs disease?
|
thinned mucosa, diarrhea, bleeding, protein loss
|
|
|
Where does Hirschsprungs disease occur most often?
|
rectosigmoid colon
|
|
|
What symptoms of Hirschsprungs are seen in newborns?
|
failure to pass meconium, then vomiting, abdominal distention, decreased feeding
|
|
|
What do you find on an abdominal exam in Hirschsprungs?
|
distention, masses, peristalsis, venous distention
|
|
|
What is seen with a barium enema on xray in Hirschsprungs?
|
narrow distal segment with sharp transition zone to dilated proximal bowel
|
|
|
How is surgical repair done in cases of Hirschsprungs?
|
initial diverting colostomy, resection of bowel when baby is bigger
|
|
|
What causes pyloric stenosis?
|
acquired hypertrophy of circular pyloric muscle leads to obstruction
|
|
|
When does vomiting start in pyloric stenosis?
|
2-4 wks old
|
|
|
What is a classic finding on abdominal exam in pyloric stenosis?
|
olive in RUQ
|
|
|
What findings are seen in CHEM 7 panel in pyloric stenosis?
|
hypochloremic, hypokalemic metabolic alkalosis, elevate HCT and BUN
|
|
|
What classic sign is seen on barium upper GI xray in pyloric stenosis?
|
string sign
|
|
|
Plain film abdominal xray will show what in pyloric stenosis?
|
large stomach with little GI gas
|
|
|
What treatment is done for pyloric stenosis?
|
IVF and pyloromyotomy
|
|
|
What is the normal stool frequency/pattern for infants?
|
6-8 per day
|
|
|
What is the normal stool frequency/pattern for toddlers and older children?
|
1-2 per day
|
|
|
What is the usual stool weight for a child?
|
15-20 g/kg/day
|
|
|
How often do infants poop?
|
6-8 times per day
|
|
|
What bacteria cause diarrhea?
|
E. collie, salmonella, shigella, campylobacter, vibrio, yersinia, c. diff
|
|
|
What viruses cause diarrhea?
|
norwalk, rotavirus
|
|
|
What parasites cause diarrhea?
|
giardia, ent-amoeba
|
|
|
What kind of stool is characteristic of parasitic diarrhea?
|
greasy, black, foul smelling, intermittent frequency
|
|
|
What are the 4 types of diarrhea?
|
osmotic, secretory, exudation, abnormal motility
|
|
|
What is osmotic diarrhea?
|
increased amounts of poorly digested, osmotically active solutes in gut
|
|
|
What can cause osmotic diarrhea?
|
antacids, sorbitol, lactase deficiency, celiac sprue, viruses
|
|
|
What is secretory diarrhea?
|
excess secretion of electrolytes and water into gut, coupled with inhibition of absorption
|
|
|
What causes secretory diarrhea?
|
bacterial or viral enterotoxins, hormonal secretagogues, laxatives
|
|
|
What is exudative diarrhea?
|
inflamed and ulcerated gut causes impaired absorption and increased secretion
|
|
|
What organisms cause exudative diarrhea?
|
shigella, campylobacter, yersinia, E. histolytica, EHEC, cdiff
|
|
|
What are pathologic causes of exudative diarrhea?
|
crohns disease, ulcerative colitis, ischemia
|
|
|
What pathologic conditions cause abnormal motility diarrhea?
|
irritable bowel syndrome, hyperthyroidism, post-op dumping, scleroderma, incontinence
|
|
|
What viruses cause acute diarrhea?
|
rotavirus, adenovirus, calicivirus, astrovirus, Norwalk virus
|
|
|
What is the first symptom in rotavirus infection?
|
vomiting
|
|
|
What symptoms occur in 24 hours in rotavirus infection?
|
low grade fever, voluminous watery stool
|
|
|
What bacteria cause acute diarrhea?
|
shigella, salmonella, campylobacter, e.coli
|
|
|
How long does acute diarrhea last?
|
< 2-3 weeks
|
|
|
What kind of chronic diarrhea is caused by low-residue, low-fat, high carb diets?
|
toddlers diarrhea
|
|
|
What medications commonly cause chronic diarrhea in children?
|
abx therapy
|
|
|
What is used to treat C.diff infection?
|
Metronidazole (flagyl), or vancomycin
|
|
|
What are 3 nonspecific bowel causes of chronic diarrhea?
|
abnormal bile acid absorption, incomplete carb absorption, abnormal bowel motility
|
|
|
What psychological condition of the mother may lead to diarrhea in her child?
|
munchausens by proxy
|
|
|
What are allergies cause chronic diarrhea?
|
protein allergy, lactose intolerance
|
|
|
What are causes of intractable secretory diarrhea?
|
nutrient malabsorption, unconjugated bile acids, hydroxyl fatty acids, toxins, -prostaglandin secreting tumors
|
|
|
What vital signs are seen on physical exam in pts with diarrhea?
|
tachycardia, tachypnea, hypotension, fever
|
|
|
What are abdominal findings on physical exam in pts with diarrhea?
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flat/distended, hyperactive bowel sounds, tympany to percussion, soft/tender to palpation
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What is constipation?
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passage of bulky or hard stool at infrequent intervals, for > 2wks
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What are non-organic causes of constipation?
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voluntary or involuntary retention, painful defecation, psych issues
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What are organic causes of constipation?
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dietary, medications, gut abnormalities, hirschprungs disease
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What are abdominal findings on physical exam in pts with constipation?
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distention, absent bowel signs, dullness to percussion, firmness/tenderness to palpation
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What is seen on a KUB in constipation?
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free air, dilated loops, bowel obstruction, air fluid levels
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What is done for acute management of constipation?
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disimpaction, lubricants, stool softeners (colace), stimulants (miralax), evacuants (enemas)
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What is the repeated passage of feces into non appropriate places?
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encopresis
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80% of patients with encopresis have a history of what?
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constipation or painful BMs
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What are the two types of encopresis?
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retentive, nonretentive
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What pathologic conditions cause nonretentive encoporesis?
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spina bifida, hirschsprung disease, imperforate anus, dysfunction of anal sphincter from spinal injury
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What are abdominal and rectal findings on exam in pts with encoporesis?
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stoop in colon and rectum, stool smeared around anus, lax sphincter tone, anal wink
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What procedure tests decreased sensation to distention or dilation of the colon?
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anorectal manometry
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How do you treat encoporesis?
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evacuate stool, stool softeners/stimulants, behavioral psychology
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