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Unit 1 568

EENT, Fever, Antimicrobials

QuestionAnswer
2 causes of tearing in the eyes of newborns Nasolacrimal obstruction but may be associated with congenital glaucoma
Watery eye discharge is associated with viral infection, iritis, superficial foreign body, nasolacrimal obstruction
Mucoid discharge due to allergy typically contain Eosinophils
Leukocoria White pupil - Causes: retinoblastoma, retinopathy of prematurity, papillary membrane, cataract, vitreous opacities, retinal detachment, Toxocara infection, retinal dysplasia
Myopia Nearsightedness - objects that are close are clear, Distant objects are blurred
Hyperopia Farsighted - Distant objects - close; Close objects - blurred
Astigmatism Cornea curved unevenly; distant and close objects are blurred
Referral to opthalmology : 3-5 years - 6 years - 3-5 years = visual acuity less than 20/40 6 years - visual acuity less than 20/30
Herpes simplex lesions of the corneal epithelium dendrite or branchlike pattern
Contact lens wear produce central staining pattern
Viral keratitis or medication toxicity in stained eye exam fine, scatter punctuate pattern
Children have ______ pupils than adults or infants larger
Infants and adults have ______ pupils Miotic (constricted)
What medications can cause pupillary dilation Atropine and antihistamine
What is aniscoria? What causes it? Size difference btwn two pupils; horner syndrome, third nerve palsy, Adie tonic pupil, iritis, trauma
Findings with corneal abrasions: eyelid edema, tearing, injection of the conjunctiva, and poor cooperation with ocular exam due to the pain.
Treatment for corneal abrasion: erythromycin ointment or 1% cyclopenlate if brow ache is present.
Signs of ruptured globe shallow anterior chamber with hyphema, traumatic cataract, irregular pupil
Which penetrates deeper the eye? Acids or alkali Alkali
Immediate first aid for burns to the eyes Copious irrigation and removal of precipitates; topical antibiotics, and patching the injured eye closed; Cyclopentolate 1% can be given if corneal involvement is present to reduce pain.
Treatment for hyphema (layer of blood in the anterior chamber) eye shield, head elevated, and referral
Treatment of blepharitis Lid scrubs with a non burning baby shampoo several times a week, warm compresses to the eyelids, and application of topical antibiotic ointment - erythromycin
Amblyopia Lazy eye
Otorrhea Ear discharge
First line antibiotic for OM Amoxicillin (90mg/kg)
Amoxicillin, max dose up to 4g/d
A situation where low dose antibiotic prophylaxis may be recommended - Part 1 of 2 child being considered for tympanostomy tube placement for recurrent infections who presents in late spring. A 1-2 month course of amoxicilin might prevent infection until the low risk summer season when AOM is uncommon .
Another situation would be the child with patent tympanostomy tubes who experiences recurrent AOM and has been found to have an immune deficiency on more than one occasion.
Antibiotic prophylaxis is not recommended for children with OME.
The seven valent pneumococcal conjugate vaccine (PCV7) was designed to prevent meningitis and sepsis, not AOM. However it did produce a 55% reduction in AOM resulting from the seven serotypes found in the vaccine.
Intranasal influenza vaccine reduced the # of influenza associated AOM by 92%
What is mastoiditis? occurs when infection spreads from the middle ear space to the mastoid portion of the temporal bone, which lies behind the ear.
What should be concerned with when a patient has mastoiditis? Meningitis and brain abscess
Common pathogens of mastoiditis S pneumoniae and S progenies with S aureus and H influenze occasionally seen
What may be the cause of the rising numbers of mastoiditis? S pneumoniae
Hallmark of Mastoiditis postauricular tenderness and ear protrusion
Mastoiditis can progress to sigmoid sinus thrombosis, epidural abscess, or intraparenchymal brain abscess
Treatment for mastoiditis 1. myringotomy with or without tube for mastoiditis without a subperiosteal abscess, followed by IV abc plus ofloxacin or ciprofloxacin ear gtts
Treatment for mastoiditis 2. surgical drainage of mastoid if no clinical improvement in 24-48 hrs
Treatment for mastoiditis 3. Cortical mastoidectomy is usual primary mgt for coalescent mastoid its (with abscess formation and breakdown of the mastoid air cells)
Treatment for mastoiditis 4. after clinical improvement is achieved with parental therapy, oral abx are begun and should be continued for 3 weeks.
Emergency condition for FB in ear: disk-type battery; An electric current is generated in the moist canal, and a severe burn with resultant scarring can occur in less than 4 hrs.
Children exhibiting pre auricular tags, ectopic cartilage, fistulas, sinuses, and cysts should have what checked? Hearing and renal US because external ear anomalies may be associated with renal anomalies as both form during the same period of embryogenesis.
What should children with rXn to amocillin get when treating acute otitis media? Cephalosporin: Cefuroxime, Cefpdoxime, Cefdinir
What is not recommended as a second line agent in AOM? Macrolides such as Azithromycin and Clarithromycin because S pneumonia is resistant and all strains of H influenza have an intrinsic macrolide efflux pump pumping this ABX out of the cell.
When should tubes be placed for persistent effusions? after effusion has persisted for 4 months and accompanied by bilateral hearing impairment of 20 dB or greater
What is the earliest finding in mastoiditis? severe tenderness on mastoid palpation
Most common pathogens in mastoiditis? S pneumoniae and S pyogens,
Hallmark of mastoiditis postauricular tenderness and ear protrusion
OE is commonly caused by Staph Aureus, Pseudomonas aeurginos
Most common causes of OM RSV and influenza; 3rd most common M. Catarrhalis, 4th Streptococcus pyogenes
What is a cause of OM seen more commonly in school aged than infants Strep pyogenes
Most likely cause of mastoiditis S. pneumoniae
Common causes of bacterial conjunctivitis Haemophilus species, S. pneumonia, M. Catarrhalis, S.Aurues
Treatment for bacterial conjunctivitis topical antibiotics such as erythromycin, polymysin-bacitracin, sulfacetamide, tobrmycin, and fluroquinolones.
Systemic therapy for treatment of bacterial conjunctivitis if patient has chlamydia trachomatis, N gonorrhoae, and neisseria meningtides
Observation option in AOM: older than 2 with non severe disease for first 48-72 hours after onset of symptoms. ALWAYS ABX IN YOUNGER THAN 6 MONTHS. YOUNGER THAN 2 YEARS AND OLDER CHILDREN WITH SEVERE PAIN OR FEVER GET ABX.
Characteristics of OE External canal edema, thick drainage, severe pain worsened by manipulation of pinna, often unable to visualize the TM; hearing is normal
What is not advised for corneal abrasion caused by contact lens or other potentially contaminated surfaces? patching the affected eye
Follow up after corneal abrasion daily follow up is required until treatment is complete
If pain from corneal abrasion is referred to the ipsilateral brow it may be treated with? topical cycloplegic agent such as cyclopentolate.
pulling down on the lower eye lid provides visualization of inferior cul-de-sac (palpebral conjunctiva)
Visualizing the upper cul-de-sac and superior bulbar conjunctiva is possible by having the patient look inferiorly while the upper lid is pulled away from the globe and the examiner peers into the upper recess.
Upper lid should be everted to evaluate the superior tarsal conjunctiva
How do you inspect the anterior segment of the globe and its adnexa? adequate illumination and often magnification
After applying flouroscein you must have? woods lamp or blue filter cap
Where do you instill fluorescein soln? the lower cul-de-sac
Blue light stains defects _________? yellow green
Herpes simplex stains? lesions of the corneal epithelium produce a dendrite or branchlike pattern.
FB stains> beneath the upper lid shows one or more vertical lines of stain on the cornea due to the constant movement of the FB over the cornea
Contact lens overwear produces a central staining pattern
A fine, scattered punctuate pattern may be a sign of Viral keratitis or medication toxicity
What is the swinging flashlight test used for? pupillary defect
Ways to test corneal light reflex? observation (educated guess), Hirschberg test, cover test
Antibiotics and steroids are no longer recommended for Otitis media with effusion
Evaluation with OME Evaluate monthly by pneumatic otoscopy or tympanometry
With acute trauma to the middle ear; how long until hearing returns to normal? 6-8 weeks
When would you refer acute trauma to the middle ear to otolaryngologist? Traumatic perforation of the TM; hearing loss
Treatment of middle ear hematomas consists mainly of? Watchful waiting
Are antibiotics given to traumas to the middle ear? Not unless signs of infection appear
Why should hematomas of the pinna be treated by otolargynologist and how? It can result in a cauliflower ear due to pressure necrosis; OTO will drain the hematoma and apply a carefully molded pressure dressing
A low set ear is associated with? Renal malformations (Potter syndrome).
Conductive hearing loss occurs when? blockage of sound transmission from external canal to cochlear receptor cells
Most common cause of conductive hearing loss? fluid in middle ear
Can conductive hearing loss be treated with surgery> Yes
Hearing and language skills should be assessed in children who have recurrent acute otitis media or MEE longer than 3 months
Sensorineural hearing loss occurs defect in neural transmission of sound, arising from a defect in the cochlear hair cells or the auditory nerve (CN 8-Vestibulocochlear)
The most common congenital sensory impairment? Sensorineural hearing loss
Nonhereditary causes of congenital sensorineural hearing loss? prenatal infections, tertogenic drugs, and perinatal injuries.
Acquired heredity hearing loss can be delayed: T or F True
Causes of Acquired hearing loss that is non genetic and has delayed onset ? exposure to ototoxic meds, meningitis, autoimmune or neoplastic conditions, noise exposure, trauma, syphilis or Lyme disease, CMV, pulmonary htn, extracorporeal membrane oxygenation therapy.
What is the threshold, or 0 dB r/t hearing measurement? the level at which a sound is perceived in normal subjects 50% of the time.
Hearing is considered normal if an individual's thresholds are within? 0-15 dB
profound hearing loss is how many dB? over 91dB
Goal of hearing loss identification 3 months
Appropriate intervention with hearing loss is by age 6 months
T or F : A parents report of infant behavior is reliable for hearing loss identification. False
Birth - 4 months: suspect a hearing loss if: infant does not show the startle reflex or blink eyes in response to a sudden loud sound (>70 dB)
Normal response if hearing is intact in a 4 month old when a noisemaker is sounded out of the vision at the child's waist level? widening of eyes, interruption of other activity, and perhaps a slight turning of the head in the direction of the sound.
Normal response if hearing is intact in a 6 month old when a noisemaker is sounded out of the vision at the child's waist level head turns toward sound
Normal response if hearing is intact in a 9 month old and older child when a noisemaker is sounded out of the vision at the child's waist level the child is usually able to locate a sound originating from below as well as turn to the appropriate side.
Normal response if hearing is intact in a child above 1 year when a noisemaker is sounded out of the vision at the child's waist level child can locate sound and whether its below or above
What can the clinician do to rule out deafness in a child? loud horn or clacker and watch for eye blink or startle reflex
mama, dada, baba should be present in speech by age 11 months
Conditions that warrant hearing test: hearing loss, developmental delay, bacterial meningitis, ototoxic med exposure, neurodegenerative disorders, hx of mumps, measles, or infections
Emergent referral to otolaryngoloist is warranted for a diagnosis of? bacterial meningitis; cochlear ossification can occur, necessitating urgent cochlear implantation
High risk children should receive audiologic monitoring even if no deficits are found until the age of ? 3 and appropriate intervals.
What drugs are ototoxic? Aminoglycosides and diuretics, particularly in combination.
What can possible reverse sudden onset of SNHL? steroid therapy by OTO
True or False? conductive hearing loss is reversible? True
True or False? SNHL is reversible? False
Most common pediatric infectious disease? Acute Viral Rhinitis
Under 5 yrs: how many colds per year? 6-12
What causes approximately 30-40% of Acute Viral Rhinitis (common cold)? Rhinoviruses
S/S of acute viral rhinitis (common cold): sore throat, rhinorrhea (clear or mucoid), sneezing, nasal congestion, possibly fever
At what point should the clinician consider bacterial rhino sinusitis? s/s of acute viral rhinitis beyond 10-14 days.
How many does does it take acute viral rhinitis (common cold) to resolve? 7-10 days
What is the treatment for Acute Viral Rhinitis (common cold)? symptomatic tx (ibuprofen, tylenol, humidification, nasal saline gtts), topical decongestant (afrin, neo spray) x 3 days, Oral decongestants for adults
OTC could and cough meds: Not effective in children, don't use in children under 4 yrs
If the patient has been s/s nasal congestion and rhino-sinusitis (sinusitis) less than 10 days what is the treatment? pain meds, humidified air, saline nose gtts, cough suppressants?
If the patient has been s/s nasal congestion and rhino-sinusitis (sinusitis) less than 10 days what is the likely diagnosis? Upper respiratory infection (URI) (viral sinusitis)
If the patient has been s/s nasal congestion and rhino-sinusitis (sinusitis) greater than 10 days without improvement what is the likely diagnosis? Bacterial sinusitis
If the patient with nasal congestion and rhino-sinusitis (sinusitis) any duration and has focal signs such as periorbital edema, sinus tenderness, or severe headache what is the likely diagnosis? bacterial sinusitis
If you determine the patient has bacterial sinusitis with mild symptoms what is the treatment? High dose amoxicillin = 90mg/kg/d in 2 divided doses .
If in daycare, have severe symptoms, or have been on antibiotics in the past 1-3 months for ABRS what is the treatment? High dose amox/clav = 90 mg/k/d amox; 6.4 mg/kg/d clav in two divided doses.
If the patient has a non-type 1 hypersensitivity to PCN what should he get instead of Amox or Augmentin? Cefuroxime, Cefpodixime, Cefdinir, or other cephalosporin
What meds are reserved for patients with anaphylactic reaction to PCN? Macrolide - Clarithromycin or Azithromycin
Clindamycin is not effective against? Gram negative organisms such as H influenzae
If there is poor response with first line ABX when treating ABRS, what should the clinician do? Prescribe second line antibiotic ( Amox-Clav or Cephalosporin). If patient is already on a second line...give IV ABX
If bacterial sinusitis symptoms are severe or immunosuppressed what is the treatment? naficillin or clindamycin IV with a third generation cephalosporin such as cefotaxime.
Bacterial infection of the paranasal sinuses that last less than 30 days and symptoms resolve completely Acute Bacterial Rhinosinusitis
What almost always precedes bacterial rhino sinusitis? viral URI (cold); allergies and trauma can also predispose
S/S of ARBS: cold that doesn't improve by 10-14 days or worsens after 5-7 days in a child; nasal congestion, nasal drainage, postnasal drainage,
What sinuses are most commonly involved in ARBS Maxillary and ethmoid
What sinuses are present at birth? Maxillary and ethmoid
Sphenoid sinuses form by age 5
Frontal sinuses form by age 7-8
True or false? Gram stain or culture of nasal discharge correlates with sinus aspirates? False
What complications occur withARBS when infection spreads to adjacent structures (overlying tissues, eyes, or brain), streptococcus anginosus (milleri) , orbital, pot's puffy tumor
What bacterial pathogens cause acute rhinosinusitis S pneumoniae, H influenzae (non typeable), M. Catarrhalis, B hemolytic strep
Treatment for ARBS for children? no improvement by 10 days or severe symptoms with fever at least 102.2 and purulent nasal drainage for 3-4 consecutive days, ABX recommended to decrease duration and severity
When do you NOT prescribe penicllins? with diagnosis of MONO
First line of therapy in ABRS Amoxicillin 90mg/kg/d in 2 divided doses
Severe symptoms in ABRS Amox/Clav 90mg/kg/d amox with 6.4 mg/kg/d of clav in two divided doses
If in daycare or prescribed ABX in the past 1-3 months and treating ABRS prescribe: Amox/Clav 90mg/kg/d amox with 6.4 mg/kg/d of clav in two divided doses
Side effect of Amox/Clav ? Diarrhea - Clav causes diarrhea
2nd line therapy is indicated in ABRS when? 48-72 hrs with no improvement ; if already on amox/clav or cephalosporin - IV ABX should be considered
Chronic rhinosinusitis is diagnosed when? A child has not cleared the infection in the expected time but no acute complications have developed.
What would prompt a workup for cystic fibrosis? allergic polyps
treatment for chronic rhinosinusitis ABX therapy same as for ABRS, but for 3-4 wks total
What are you treating if you prescribe intranasal corticosteroids, oral and intranasal antihistamines, leukotriene antagonists, and decongestants, Ipratropium nasal spray, nasal saline rinses recurrent rhinitis
Difference in allergic and nonallergic rhinitis both have rhinorrhea and nasal congestion but no immunologic rxn with nonallergic .
Epistaxis arises from anterior portion of the nasal spectrum (kiesselbach area)
What could manifest as recurrent epistaxis? Nasopharyngeal angiofibroma
Tx for epistaxis one time application of oxymetazoline, gel foam, surgicel
Nasal infection treatment dicloxacillin or cephalexin x 5 days; I&D; bacitracin topical; follow patient closely until healing is complete because the lesion is draining into the cavernous sinus.
Following a nasal trauma of nasal furnace, if a nasal septum infection occurs: hospitalize and I&D by OTO because of possible spread to CNS
See OTO with nasal bone fractures within? 48-72 hours
What meds are effective against allergic rhinitis? intranasal corticosteroids, oral and intranasal antihistamines, leukotrienes antagonists, and decongestants. Ipratroprium nasal spray may also be used as an adjunctive therapy. Nasal saline rinses are helpful to wash away allergens.
Triggers of nonallergic rhinitis sudden changes in environmental temperature, air pollution, and other irritants such as tobacco smoke
What antibiotics for epistaxis with packing? cephalexin 250-500 mg QID and amoxicillin/clavulanate 250-500 mg TID. Second choices include clindamycin 150-300 mg QID or trimethoprim/sulfamethoxazole DS BID.10 also beneficial to coat packing with antibiotic prior to placing in nose
Treatment of aphthous ulcers (canker sores) coating lesion with corticosteroid ointment such as triamcinolone dental paste BID, bland diet, ibuprofen and actaminophen
Treatment of thrush nystatin, if not cured then systemic antifungal
Herpes Simplex Gingivostomatitis treatment symptomatic; acyclovir
Over 90% of sore throats and fever are due to viral infection
What is contraindicated in patients with mono and why? Amoxicillin because it causes a rash
S/S Mono exudative tonsillitis, generalized cervical adenitis, and fever (usually over 5); palpable spleen or axillary adenopathy increases the likelihood of the diagnosis
Herpangina ulcers: classically 3 mm in size, surrounded by a halo, and are found on the anterior tonsillar pillars, soft palate, and uvula.
What causes Herpangina? coxsackie A group of viruses
Hand foot mouth disease: where are lesions found palms, soles, interdigital area, and buttocks; younger children may be seen on the distal extremities and even face
Pharyngoconjunctival fever is caused by adenovirus
main findings in pharyngoconjunctival fever exudative tonsillitis, conjunctivitis, lymphadenopathy, and fever
Most common cause of acute bacterial phayrngitis group A streptococcus
Untreated streptococcal pharyngitis can result in: acute rheumatic fever, glomerulonephritis, and suppurative complications (cervical adenitis, peritonsillar abscess, oM, cellulitis, septicemia).
What symptoms suggest acute bacterial pharyngitis sudden onset of sore throat, odynophagia, fever, headache, anterior cervical nodes, palatal petechiae, beefy red uvula, tonsillar exudate
When trying to decipher viral/bacterial pharyngitis; what would raise suspicion for viral cause? cough, hoarseness, URI symptoms, anterior stomatitis, discrete ulcerative lesions, viral rash, and diarrhea
What is scarlet fever?? Develops occasionally with a child with group A streptococcal infection after the onset of symptoms. Diffuse, finely papular, erythematous eruption producing a blanch able bright red discoloration of skin
Suspected or proven group A streptococcal infection should be treated with Oral Penicillin VK, a cephalosporin, or IM penicillin G benzathine LA
How many times daily should Pen VK given to adolescents 3 doses
What is contraindicated in treating Herpes Simplex Gingivostomatitis? Corticosteroids
Presentation with Acute Bacterial Pharyngitis? sudden onset of sore throat, odynophagia (painful swallowing), fever, HA, anterior cervical nodes, petechiae on palate, beefy red uvula, tonsillar exudate.
What is the % of strep in children with fever and sore throat? 10%
Positive rapid antigen test for bacterial pharyngitis indicates S pyogenes infection
Children who fail to respond to to PenVK, cephalosporin, or IM treatment are treated with Amoxicillin/Clav or azithromycin
What is not recommended in treating bacterial pharyngitis? Trimethoprim-sulfamethoxale (Bactrim, Sulfa)
To eradicate the carrier state of frequent strep infections give? Clindamycin x 10 days or Rifampin for 5 days or tonsillectomy
Most common pathogen of peritonsillar cellulits or abscess B-hemolytic strep
Severe sore throat, unilateral tonsillar swelling, deviation of the uvula, limited mouth open: Peritonsillar cellulitis or abscess (quinsy)
S/S retropharyngeal abscess fever, respiratory symptoms, neck hyperextension. dysphagia, drooling, dyspnea, and gurgling respirations are also found and are due to impingement by the abscess
Most common pathogen of retropharyngeal abscess B hemolytic strep and S aureus
Treatment for retropharygeal abscess immediate hospitalization and IV abx. {Semisynthetic penicillin or clindamycin}. Drainage when definite abscess is seen or airway is compromised
What is a rapidly progressive cellulits of the submandibular space that can cause airway obstruction and death? Ludwig Angina
Treatment of Ludwig Angina Clindamycin or Ampicillin plus Nafcillin
70% of these cases are due to B-hemolytic streptococcal infection ACUTE CERVICAL ADENITIS
Typical case of Acute Cervical Adenitis Unilateral, solitary, anterior cervical node
Tests for acute cervical adenitis Rapid group A strep, cbc(looking for atypical lymphocytes), and a PPD test (looking for nontuberculous mycobacteria; rapid mono test if multiple enlarged nodes are present in addition to the sentinel node.
Where is the typical node involved in acute cervical adenitis anterior cervical node
What gives a positive PPD skin test with reactions less than 10 mm Cervical lymphadenitis
Common malignancies in the neck Hodgkin disease, non-Hodgkin lymphoma, rhabdomyosarcoma, thyroid carcinoma
Gold standard for diagnosis of OSA Polysomnogram
Fever is defined as 38 degrees C and higher - Rectally
Petechial skin rash with fever meningeal toxemia
First line treatment for pediatric fever after cultures- Rocephin 50mg/kg/day
Created by: 697499765