Pediatrics EOR - ENT

acute otitis media
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Terms in this set (111)
acute otitis media
infection of middle ear
AOM risk factors
- peak age is 6-24 months
- daycare
- pacifier/bottle use
- secondhand smoke
- not being breastfed
Why are 6-24 mo old infants at higher risk for AOM
eustachian tubes are shorter, narrower, and more horizontal
AOM etiology
s. pneumonia, h. influenzae, and m. catarrhalis
AOM pathophysiology
most commonly preceded by a viral URI, which leads to blockage of eustachian tubes
AOM clinical presentation
otalgia, tugging at ear (infants), congestion, fussiness, and fever/irritability
AOM PEx
- bulging and erythema of TM
- decreased TM mobility with pneumatic otoscopy
AOM complications
Mastoiditis and bullous myringitis
AOM abx
high dose amoxicillin
2nd line: augmentin or cephalosporin (cefuroxime, cefdinir, cefpodoxime, IM ceftriaxone)
AOM abx if allergy to PCN
- macrolide such as azithromycin, clarithromycin, or erythromycin
- bactrim
severe/recurrent AOM txmyringotomy with tympanovstomy tube insertionWhat age group should always be treated for AOMinfants <6 moSevere features warranting tx in infant with AOM that is >6 mo oldhigh fever, bilateral dz, severe or persistent pain >48 hrs, otorrhea, immunocompromisedif child is <2 yrs old, what is duration of abx tx for AOM10 daysif child is >2 yrs old, what is duration of abx tx for AOM5-7 daysMC cause of acute pharyngitis/tonsillitisviral - adenovirusMC bacterial cause of acute pharyngitis/tonsillitsgroup A strep aka s. pyogenesSx associated with viral pharyngitis"common cold" (cough, hoarseness, rhinorrhea, coryza, etc.)1What type of acute pharyngitis/tonsillitis should be on your differential in a patient who uses inhaled corticosteroids?fungalStrep pharyngitis clinical presentationabrupt onset sore throat +/- fever, HA, abd pain, N/V, or decreased appetiteWhat age group is strep pharyngitis most common in?kids 3 yrs old and greaterUntreated strep pharyngitis has a higher incidence of ________ ___________ in kids aged ___-___ yrs oldrheumatic fever; 5-15 yrs oldenlarged tender anterior/posterior cervical lymphadenopathy can be seen in pts with strep pharyngitisanteriordescribe the rash associated with strep pharyngitiserythematous, finely papular rash that characteristically starts in groin and axilla, then spreads to trunk and extremities, followed by desquamationBest initial test for strep pharyngitisrapid antigen detection testrapid antigen strep test has a high sensitivity/specificity and therefore has a high rate of false positives/negativesspecificity; false negativesstrep pharyngitis gold standardthroat cultureFirst line tx for strep pharyngitisPCN - PCN VK, amoxicillin, PCN GTreat this patient 6 yr old male comes in with abrupt onset sore throat and fever. Denies rhinorrhea, cough, or congestion. PEx showed petechiae on soft palate and tender anterior cervical lymphadenopathy. Mother states he gets a rash from PCN.cephalosporin, macrolide, or clindamycinRheumatic fever is preventable/non-preventable when strep throat is treated with abxpreventable *** acute glomerulonephritis is not preventable!strep pharyngitis complications- rheumatic fever - acute glomerulonephritis - peritonsillar abscess - PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcus)centor criteriaUsed to ID streptococcal pharyngitis 1. fever, 2. tonsillar exudate, 3. tender anterior cervical LAD 4. lack of coughmononucleosis etiologyEpstein-Barr virusanterior/posterior cervical lymphadenopathy is more consistent with infectious mononucleosisposterior (anterior more c/w strep pharyngitis)atypical lymphocytes and positive heterophile agglutination testmononucleosisName that diagnosis - clear rhinorrhea - pale blueish, boggy mucosa - blue discoloration underneath eyesallergic rhinitisallergic rhinitis pathophysiologyIgE mediated mast cell histamine release due to allergensWhat can happen if a pt uses intranasal decongestants for >3-5 daysrhinitis medicamentosaviral or bacterial conjunctivitis - acute onset of unilateral or bilateral erythema of conjunctiva - foreign body or gritty sensation - itching - mild to moderate tearingviralMC cause of viral conjunctivitisadenovirusMC cause of bacterial conjunctivitisStaph aureusMC way viral conjunctivitis is spreadswimming pools (also spread via direct contact)most likely diagnosis 8 yr old female presents with c/o right eye irritation. She has associated watery tearing and right sided enlarged, tender pre auricular lymphadenopathy. Pt's mother states a friend in swim class has similar symptomsviral conjunctivitispunctate staining on slit lamp examviral conjunctivitistreatment for bacterial conjunctivitiserythromycin ointment ** if contact wearer, need to cover pseudomonas → topical cipro or ofloxacinMost likely diagnosis On PEx, pt has painless mucopurulent discharge and lid crustingbacterial conjunctivitismost likely diagnosis (hint: involves etiology) copious purulent discharge from eye in pt not responding to conventional therapybacterial conjunctivitis d/t M. catarrhalis or N. gonorrheaallergic conjunctivitis clinical presentationred eyes marked pruritis (help to differentiate from viral) usually bilateral cobblestone mucosa of upper/inner eyelid other allergy symptomsneisseria conjunctivitis txprompt referral and topical + systemic abxchlamydial conjunctivitis txsystemic tetracycline or erythromycin x 3 wks + TP ointments ** Assess for STD and/or child abuseepiglottitisinflammation of epiglottis that causes obstruction of airway due to H. influenzae type B (HIB)In pt who has been vaccinated against HIB, what other etiologies should you consider in epiglottitisstreptococcus species and other H. influenzaeHib vaccine schedule2, 4, 6, and 12-15 months3 D's of epiglottitisDysphagia Drooling DistressHow might older children, adolescents, and adults present with epiglottitis?severe sore throat with a relatively benign oropharyngeal examT/F you should use a tongue depressor to visualize the airway in young children with suspected epiglottitisFALSE - this may result in loss of the airwaywhat imaging may be ordered when evaluating suspected epiglottitis?soft tissue lateral neck radiographsbuzz word thumb or thumbprint signepiglottitisdefinitive diagnosis for epiglottitislaryngoscopyepiglottitis first line treatmentsecure the airway!!!epiglottitis abxceftriaxone (or other 3rd generation cephalosporinepiglottitis preventionrifampin to close contacts Hib vaccinecauses of anterior epistaxisnasal trauma, dryness, cocaine, EtOHanterior epistaxis etiologykiesselback venous plexus (watershed area of the anterior nasal septum)posterior epistaxis etiologysphenopalatine artery branches and woodruffs plexus (more common in older pts)first line tx 5 yr old male comes into ER with uncontrollable epistaxis.direct pressure for at least 10 minutes with pt in seated position, leaning forward - may also add oxymetazoline nasal sprayIf direct pressure and topical vasoconstrictors fail, what is the next line of treatment for anterior epistaxiselectrocautery or chemical (silver nitrate) as long as bleeding site can be visualizedwhen should anterior epistaxis be treated with nasal packingwhen all other treatment methods fail (direct pressure, vasoconstrictors, electrocautery) - consider adjunct abx such as cephalexin, augmentin, or TP mupirocin to prevent TSSposterior epistaxis txballoon cathetersmastoiditissuppurative infection of mastoid air cell → usually a complication of AOMdiagnostic of choice for mastoiditisCT scan of temporal bone with contrastmastoiditis txIV abx (ceftriaxone)+ myringotomy with or without tympanostomyRefractory or complicated mastoiditis treatment?mastoidectomyclinical presentation of mastoiditisFever, otalgia, pain, erythema posterior to ear and forward displacement of the external earWhat pathogens can cause mastoiditiss. pneum h. influenzae m. catarrhalis s. aureus s. pyogeneswhat pathogens typically cause otitis externaPseudomonas aeruginosa - swimming Staph aureus or epidermis - digital trauma GABHS, proteus, anaerobes aspergillus, fungiotitis externa clinical presentationear pain - esp. with movement of tragus or pinna pain with eating purulent, cheesy white dischargeotitis externa tuning forkbone conduction > air conduction (d/t conductive hearing loss)Pathophysiology of otitis externa due to water emersionexcess moisture raises the pH from the normal acidic pH of the ear, which facilitates bacterial overgrowthotitis externa risk factors (5)water exposure local mechanical trauma age 7-12 yrs narrowed ear canals psoriasisotitis externa treatmentTP abx + TP glucocorticoid → ciprofloxacin-dexamethasone or OfloxacinComplication of otitis externamalignant otitis externamalignant otitis externainvasive infection of the external auditory canal and skull basemalignant otitis externa causePseudomonasmalignant otitis externa risk factorsimmunocompromised DM (elderly with DM MC)what additional neurologic finding makes malignant otitis externa more likelycranial nerve palsies (i.e. CN VII)what is seen on otoscopy in a pt with malignant otitis externagranulation tissue at the bony cartilaginous junction of the ear canal floorHow is diagnosis of malignant otitis externa made?CT or MRI to confirm bx is most accurateserous otitis mediamiddle ear fluid + no signs or sx of acute inflammation or infectionMC sx of serous otitis mediadecreases in sound conduction and hearing - children with OME may exhibit impaired language development or communication difficultiesmost likely diagnosis PEx shows gray, amber, or colorless effusion (air fluid levels or bubbles behind the membrane)serous otitis mediaClassic PEx finding c/w serous otitis mediaretracted or flat TM that is hypomobile with insufflationSerous otitis media treatmentwatchful waiting - typically resolves spontaneously in 4-6 wkspersistent/complicated serous otitis media treatmenttympanostomy tube for drainagePeritonsillar abscessabscess between palatine tonsil and pharyngeal muscles resulting from complication of tonsillitis or pharyngitispathogens that typically cause peritonsillar abscessusually polymicrobial → predominant species include s. pyogenes, S. aureus, and respiratory/oral anaerobesperitonsillar abscess treatmentI&D + abx → oral augmentin or clindamycinstrabismusany form of ocular misalignmentexotropiaoutward turning of the eyeesotropiainward turning of the eyeoral candidiasis etiologyCandida albicansoral candidiasis treatmentnystatin rinse, clotrimazole troches oral fluconazole if refractoryclassic oral candidiasis PExwhite plaques that can be scraped (pseudomembranous form)oral candidiasis risk factorsimmunocompromised states inhaled corticosteroids without spacer abx use xerostomia denture useKOH for oral candidiasisbudding yeast and pseudohyphaeorbital cellulitisinfection of orbital muscles and fat posterior to the orbital septumMC cause of orbital cellulitissecondary to sinusitis, especially ethmoid sinusesMC pathogens in orbital cellulitiss. aureus streptococci GABHS h. influenzaehow is diagnosis of orbital cellulitis madeclinical if still unclear → CT scan of orbitsorbital cellulitis treatmentadmission + vancomycin PLUS one of the following - ceftriaxone, cefotaxime, ampicillin-sulbactam, pip tazo, or clindamycinPt on abx for orbital cellulitis however optic nerve function continues to deteriorate. What are the next stepsprompt surgical drainage