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NELSON’S CLUB. Kimberly S. Tsai, MD, MBA. TOPICS. Acute sinusitis Eye pain & discharge Conjunctivitis Orbital cellulitis Otitis media & externa Foreign body. Acute sinusitis. Acute Sinusitis. ETIOLOGY. SIGNS & SYMPTOMS. nasal congestion purulent nasal discharge Fever Cough
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NELSON’S CLUB Kimberly S. Tsai, MD, MBA
TOPICS • Acute sinusitis • Eye pain & discharge • Conjunctivitis • Orbital cellulitis • Otitis media & externa • Foreign body
Acute Sinusitis ETIOLOGY SIGNS & SYMPTOMS nasal congestion purulent nasal discharge Fever Cough Halitosis Hyposmia Periorbital edema Headache facial pain maxillary tooth discomfort pain or pressure exacerbated by bending forward • VIRAL • BACTERIAL • Streptococcus pneumoniae (30%) • nontypableHaemophilusinfluenzae (20%) • Moraxellacatarrhalis (20%)
Acute Sinusitis DIAGNOSIS TREATMENT Amoxicillin (45mg/kg/day) Co-amoxiclav (80-90 mg/kg/day for non responders) TMP-SMX , cefuroxime, clarithromycin & azithromycin for penicillin allergic patients • Based on history • Persistent URTI for 10-14 days without improvement • Sinus aspirate culture • Rigid nasal endoscopy – adults • Transillumination – unreliable • radiography
Acute Sinusitis TREATMENT COMPLICATIONS Periorbital & orbital cellulitis Epidural abcess meningitis Cavernous sinus thrombosis Brain abcess Osteomyelitis of the frontal bone (Pott puffy tumor) mucocele • Decongestant, antihistamine, mucolytics & intranasal steriods is not recommended in uncomplicated bacterial sinusitis.
EYE PAIN & DISCHARGE EYE INJURIES ORBITAL INFECTIONS Laceration Abrasion Foreign body Hyphema Open globe Orbital Fracture Penetrating wound Firework related injury Sports Related Injury • Dacryoadenitis • Dacryocystitis • Preseptalcellulitis • Orbital cellulitis
Eye Pain & Discharge HYPHEMA • Presence of blood in the anterior chamber & may occur with blunt injury • Presentation: acute loss of vision & eye pain • TX: bed elevated to 30 degrees, eye shield, cycloplegic, topical steroid (to dec. IOP). NSAIDS must be avoided.
Eye Pain & Discharge DACRYOCYSTITIS DACRYOADENITIS Inflammation of the lacrimal gland Can occur with mumps (acute), TB, syphilis, sarcoidosis (chronic) Staphyaureous can produce suppurativedacryoadenitis If both lacrimal & salivary glands enlarge as a result of a systemic disease, it’s Mikulicz syndrome • Infection of lacrimal sac • Treatend with warm compress & antibiotics
Eye Pain & Discharge PRESEPTAL CELLULITIS • Inflammation of lids without signs of true orbital involvement (NO proptosis or limitation of eye movement) • MCC: H. influenzae type B
Orbital Cellulitis SIGNS & SYMPTOMS ETIOLOGY Mean age: 7 yo 10 mos to 18 year olds may be affected Direct extension or venous spread from paranasal sinuses, lacrimal gland, conjunctiva, lids More prevalent in children due to thinner bony septa, porosity of bones & larger vascular foramina • inflammation of orbital tissues & eyelids • Proptosis • Limited eye movement • Conjunctival edema/chemosis • Decreased visual acuity • Fever • leukocytosis
Orbital Cellulitis PATHOGENS COMPLICATIONS Vision loss Retinal artery occlusion Optic neuritis Cavernous sinus thrombosis Meningitis Epidural/subdural empyema Brain abcess • Staphylococcus species • methicillin-resistant S. aureus (MRSA) • Streptococcus species • Haemophilus species
Orbital Cellulitis DIAGNOSTICS TREATMENT 3rd Generation Cephalosporin (cefotaxime, ceftriaxone) + vancomycin Amoxicillin+Clavulanic acid Urgent abcess drainage depending on clinical presentation • CT of the orbit with IV contrast
Conjunctivitis • reaction to a wide range of bacterial and viral agents, allergens, irritants, toxins, and systemic diseases • May be infectious or non-infectious
ConjunctivitisOphthalmiaNeonatorum EPIDEMIOLOGY MANIFESTATION Redness & chemosis of conjunctiva Edema of eyelids Discharge (serosanguinous becomes purulent within 24 hrs) • Usually gonococcal or chlamydial thru vaginal delivery • Occurs in infants <4 weeks of age • Incubation period: 2-5 days • May present beyond 5 days due to ocular prophylaxis
ConjunctivitisOphthalmiaNeonatorum COMPLICATIONS DIAGNOSIS Gram stain & culture of purulent discharge • corneal ulceration and perforation • Iridocyclitis • anterior synechiae • panophthalmitis
ConjunctivitisOphthalmiaNeonatorum TREATMENT Pseudomonas: local saline irrigation + aminoglycoside + gentamycin ophthalmic ointment Staphylococcus: IV methicillin + local saline irrigation • Initial: eye irrigation every 10-30 mins, to 2 hour intervals to clear purulent discharge • Goncococcal: ceftriaxone, 50 mg/kg/24 hr for 1 dose, not to exceed 125 mg • Chlamydial: oral erythromycin (50 mg/kg/24 hr in 4 divided doses) for 2 weeks
ConjunctivitisOphthalmiaNeonatorum PREVENTION NOTES Infant born to mom with untreated gonorrhea single dose of ceftriaxone, 50 mg/kg (maximum 125 mg) IV or IM Topical prophylaxis does not prevent chlamydial pneumonia so systemic TX should be given. • Instill 0.5% erythromycin or 1% silver nitrate directly to open eye at birth • Povidone-iodine (2% solution) may also be used • Pregnant women tx with Erythromycin to prevent neonatal disease
Otitis Media Categories: Definition: Hx of acute S/SX Presence of middle ear effusion Bulging TM Limited mobility of TM Air fluid behind the TM Otorrhea S/SX of middle ear inflammation Distinct Erythema of TM Distinct Otalgia (interferes activity or sleep) • Acute/Suppurative OM • Initial acute infection • Secretory OM or OME • Followed by inflammation with effusion
Otitis Media Risk Factors Etiology VIRAL RSV & Rhinovirus BACTERIIAL Streptococcus pneumoniae, nontypeableHaemophilusinfluenzae Moraxellacatarrhalis Other Bacteria: group A streptococcus, Staphylococcus aureus, gram-negative organisms (neonates) • Age: 6-20 mos • Gender: M>F • Race: Native American, Australian (whites) • SES: poverty • Breast Milk is protective • Exposed to tobacco • Exposed to other children • Cold season where URTI is common • Children with unrepaired cleft palate • No flu vaccination
Otitis Media Presentation NOTE NORMAL TM: Slightly concave Pearly gray translucent • Varies • Irritability • Change in sleeping habits • Fullness of the ear • Fever • Otorrhea • Hearing loss • Balance difficulty
Otitis Media with Effusion Treatment
Otitis Media Treatment Tx Duration: >=10 days esp <2yo & severe symptoms
Otitis Media Infratemporal Complications: Intracranial complications: Meningitis, epidural abscess, subdural abscess, focal encephalitis, brain abscess, Sigmoid/lateral sinus thrombosis, otitic hydrocephalus (caused by obstruction of venous drainage by a thrombus) • mastoiditis, • hearing loss, • dermatitis, • CSOM, • cholesteatoma (superior part of TM or pars flaccida) • labyrinthitis
Otitis Media Additional Notes: • Prevention • Avoid risk factors • Antimicrobial prophylaxis • Not recommended • Tympanostomy tube is found effective in • Recurrent AOM • Persistent OME
OTITIS EXTERNA(Swimmer’s Ear) Etiology Presentation Acute ear pain esp if pinna is manipulated Pain disproportionate to degree of inflammation Conductive hearing loss Edema of ear canal Erythema If necrotizing/Malignant Otitis Externa, (+) facial paralysis &/ SNHL • commonly by • P. aeruginosa, • S. aureus, E • nterobacteraerogenes, • Proteus mirabilis, • Klebsiellapneumoniae, • streptococci, • coagulase-negative staphylococci, • diphtheroids, • fungi (Candida and Aspergillus) • Chronic irritation or excess moisture of the canal
OTITIS EXTERNA Diagnosis Treatment (Otic Drops) Neomycin (GPB espProteus) with polymyxin (GNB espPseudomonas) Ofloxacin/ciprofloxacin With Sterioids: if with marked edema How? Insert wick into canal & instill drops TID for 2-3days then remove wick Add: Oral analgesics for pain IV antibx: if febrile with lymphadenopathy • Pain on manipulation of auricle • Concentric swelling of canal • Vs. 1 quadrant swelling in furunculosis
OTITIS EXTERNA Prevention • Instill 2% acetic acid or dilute alcohol after swimming or bathing • Avoid swimming if with AOE • Use hair dryer to clean moisture from ear
Foreign Body ETIOLOGY MANIFESTATIONS Initial: Violent paroxysms of coughing, choking, gagging & airway obstruction Asymptomatic interval: coughing reflex fatigue Complications: Obstruction, erosion, infection. Fever, cough, hemoptysis, pneumonia, and atelectasis • Children <3 yo use their mouths to explore surroundings • Peanuts, carrot, apple, dried beans, popcorn, sunflower or watermelon seeds, small toys or toy parts • MOST SERIOUS COMPLICATION: complete airway obstruction sudden respi distress w/ inability to speak or cough
Foreign Body DIAGNOSIS TREATMENT Prompt removal of foreign body (endoscopy) • History highly suggested by coughing/choking with wheezing • 58% lodge on right bronchus • 10% larynx or trachea • Opaque foreign bodies occur in only 10-25% of cases
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