MIDTERM STUDY GUIDE: PART-1

1. CHALAZIONS – Benign, chronic lipogranulomatous inflammation of the eyelid  Causes – blockage of the meibomian cyst  Risk – hordeolum or any condition which may impede flow through the meibomian gland. Also, mite species that reside in lash follicles  Assessment – PAINLESS, NOT INVOLVING LASHES Lid edema, or palpable mass Red or grey mass on the inner aspect of lid margin  Prevention – good eye hygiene  Treatment – warm, moist compresses 3x per day Antibiotics not indicated because chalazion is granulomatous condition, if secondarily infected consider SULFACETAMIDE, ERYTHROMYCIN  Follow up – 2-4 weeks, if still present after 6 weeks follow up with ophthalmologist 2. BLEPHARITIS – Inflamation/infection of the lid margins (chronic problem)  2 types – seborrheic (non ulcerative) : irritants (smoke, make up, chemicals) o s&s – chronic inflammation of the eyelid, erythema, greasy scaling of anterior eyelid, loss of eyelashes, seborrhea dermatitis of eyebrows and scalp  Ulcerative- infection with staphylococcus or streptococcus o s&s – itching, tearing, recurrent styes, chalazia, photophobia, small ulceration at eyelid margin, broken or absent eyelashes  the most frequent complaint is ongoing eye irritation and conjunctiva redness  Treatment – clean with baby shampoo 2-4 times a day, warm compresses, lid massage (right after warm compress) For infected eyelids – antistaphyloccocal antibiotics BACITRACIN, ERYTHROMYCIN 0.05% for 1 week AND QUIONOLONE OINTMENTS For infection resistant to topical – TETRACYCLINE 250 MG PO X4 DOXYCYCLINE 100 MG PO X2 3. OTITIS MEDIA- AOM is an acute infection of the middle ear The AAP Clinical Practice Guideline requires the presence of the following three components to diagnose AOM • Recent, abrupt onset of signs and symptoms of middle ear inflammation and effusion (ear pain, irritability, otorrhea, and/or fever) • MEE as confirmed by bulging TM, limited or absent mobility by pneumatic otoscopy, air-fluid level behind TM, and/or otorrhea • Signs and symptoms of middle ear inflammation as confirmed by distinct erythema of the TM or onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal manner) TYPE CHARACTERISTICS AOM Suppurative effusion of the middle ear Bullous myringitis AOM which bullae form between inner and middle layers of the TM and bulge outward Persistent AOM AOM that has not resolved when antibiotic therapy has been completed or AOM recurs with days of treatment Recurrent AOM 3 separate bouts of AOM with in 6 mth period or 4 with in a 12-month period; often a positive family history of otitis media and other ENT disease S. pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, and S. pyogenes (group A streptococci) are the most common infecting organisms in AOM. S. pneumoniae continues to be the most common bacteria responsible for AOM. The strains of S. pneumoniae in the heptavalent pneumococcal conjugate vaccine (PCV7) have virtually disappeared from the middle ear fluid of children with AOM. With the introduction of the 13-valent S. pneumoniae vaccine, the bacteriology of the middle ear is likely to continue to evolve. Bullous myringitis is almost always caused by S. pneumonia. Nontypeable H. influenza remains a common cause of AOM. It is the most common cause of bilateral otitis media, severe inflammation of the TM, and otitis-conjunctivitis syndrome. M. catarrhalis obtained from the nasopharynx has become increasingly more beta-lactamase positive, but the high rate of clinical resolution in children with AOM 2 Mid term study guide from M. catarrhalis makes amoxicillin a good choice for initial therapy. M. catarrhalis rarely causes invasive disease. S. pyogenes is responsible for AOM in older children, is responsible for more TM ruptures, and is more likely to cause mastoiditis. Although a virus is usually the initial causative factor in AOM, strict diagnostic criteria, careful specimen handling, and sensitive microbiologic techniques have shown that the majority of AOM is caused by bacteria or bacteria and virus together Clinical Findings History Rapid onset of signs and symptoms: • Ear pain with possible ear pulling in the infant; may interfere with activity and/or sleep • Irritability in an infant or toddler • Otorrhea • Fever Other key factors or symptoms: • Prematurity • Craniofacial anomalies or congenital syndromes associated with craniofacial anomalies • Exposure to risk factors • Disrupted sleep or inability to sleep • Lethargy, dizziness, tinnitus, and unsteady gait • Diarrhea and vomiting • Sudden hearing loss • Stuffy nose, rhinorrhea, and sneezing • Rare facial palsy and ataxia Physical Examination • Presence of MEE, confirmed by pneumatic otoscopy, tympanometry, or acoustic reflectometry, as evidenced by: • Bulging TM • Decreased translucency of TM • Absent or decreased mobility of the TM • Air-fluid level behind the TM • Otorrhea • Signs and symptoms of middle ear inflammation indicated by either: • Erythema of the TM (Amber is usually seen in otitis media with effusion [OME]; white or yellow may be seen in either AOM or OME or • Distinct otalgia that interferes with normal activity or sleep • In addition, the following TM findings may be present: • Increased vascularity with obscured or absent landmarks • Red, yellow, or purple TM (Redness alone should not be used to diagnose AOM, especially in a crying child.) • Thin-walled, sagging bullae filled with straw-colored fluid seen with bullous myringitis Diagnostic Studies Pneumatic otoscopy is the simplest and most efficient way to diagnose AOM. Tympanometry reflects effusion (type B pattern). Tympanocentesis to identify the infecting organism is helpful in the treatment of infants younger than 2 months old. In older infants and children, tympanocentesis is rarely done and is useful only if the patient is toxic or immunocompromised or in the presence of resistant infection or acute pain from bullous myringitis. If a tympanocentesis is warranted, refer the patient to an otolaryngologist for this procedure. Management Many changes have been made in the treatment of AOM because of the increasing rate of antibiotic-resistant bacteria related to the injudicious use of antibiotics. Ample evidence has been presented that symptom management may be all that is required in children with MEE without other symptoms of AOM Treatment guidelines are decided based on the child's age, illness severity, and the certainty of diagnosis. shows the recommendation for the diagnosis and subsequent treatment of AOM. 1. Pain management is the first principle of treatment. 3 Mid term study guide • Weight-appropriate doses of ibuprofen or acetaminophen should be encouraged to decrease discomfort and fever. • Topical analgesics, such as benzocaine or antipyrine/benzocaine otic preparations, can be added to systemic pain management if the TM is known to be intact. Topical analgesics should not be used alone. • Distraction, oil application, or external use of heat or cold may be of some use. 2. Antibiotics are also effective. • Amoxicillin remains the first-line antibiotic for AOM if there has not been a previous treated AOM in the previous 30 days, there is no conjunctivitis, and no penicillin allergy Beta-lactam coverage (amoxicillin/clavulanate, third-generation cephalosporin) is recommended when the child has been treated with amoxicillin in the previous 30 days, there is an allergy to penicillin, and the child has concurrent conjunctivitis or has recurrent otitis that has not responded to amoxicillin. If there is a documented hypersensitivity reaction to amoxicillin, the following antibiotics are acceptable, follow the non-type 1 hypersensitivity and type 1 hypersensitivity recommendations in • Ceftriaxone may be effective for the vomiting child, the child unable to tolerate oral medications, or the child who has failed amoxicillin/clavulanate. • Clindamycin may be considered for ceftriaxone failure but should only be used if susceptibilities are known. • Prophylactic antibiotics for chronic or recurrent AOM are not recommended. 3. Observation or “watchful waiting” for 48 to 72 hours allows the patient to improve without antibiotic treatment. Pain relief should be provided, and a means of follow-up must be in place. Options for follow-up include: • Parent-initiated visit or phone call for worsening or no improvement • Scheduled follow-up appointment • Routine follow-up phone call • Given a prescription to be started if the child's symptoms do not improve or if they worsen in 48 to 72 • Communication with the parent, reevaluation, and the ability to obtain medication must be in place. 4. Recommendations for follow-up include: • After 48 to 72 hours if a child has not showed improvement in ear symptomatology, the child should be seen to confirm or exclude the presence of AOM. If the initial management option was an antibacterial agent, the agent should be changed. Diagnosis Treat Any child with moderate/severe bulging TM with otorrhea not associated with AOM Yes Any child with mild bulging of the TM with recent (<48 hours) onset pain (holding, tugging, and so on) or intensely erythematous TM Yes Babies ≥6 months of age with severe signs of AOM (fever >102.2° F [39° C], otalgia for ≥48 hours)     Yes Any child 6 to 23 months old with acute bilateral otitis media without severe symptoms, without fever, and sick less than 48 hours Yes Young children with unilateral AOM without severe symptoms and fever <102.2° F [39° C]     Provide prescription and/or wait Close follow-up Children ≥24 months old without severe symptoms Provide prescription and/or wait Close follow-up Children not treated and no improvement in 48 to 72 hours See the patient again Clinician discretion whether or not to treat 4 Mid term study guide 4. CONJUCTIVITIS – inflammation or irritation of conjunctiva Bacterial (PINK EYE) – in peds bacteria is the most common cause, contact lens, rubbing eyes, trauma, S&S – purulent exudate, initially unilateral, then bilateral Sensation of having foreign body in the eye is common Key findings – redness, yellow green, purulent discharge, crust and matted eyelids in am Self-limiting 5-7 days. Eye drops – polytrim, erythromycin, tobramycin or cipro Improvement 2-4 days Most common organism H. influenza <7 Viral – adenovirus, coxsackie virus, herpes, molluscum  S&S – profuse tearing, mucous discharge, burning, concurrent URI, enlarged or tender preauricular nose  Antihistamines/decongestant  Improvement, self-limiting, 7-14 days Chlamydial – chlamydia trachomatis  S&S – profuse exudate, associated with genitourinary symptoms, 1-2 weeks after birth  Gonococcal – 2-4 days after birth, most concern can cause blidness  PO azithromycin, doxycycline (tetracyclines increase photosensitivity, don’t use in pregnancy)  Improvement 2-3 weeks Allergic – IgE mast cell reaction, environmental, cosmetics  S&S – marked conjuctival edema, severe itching, tearing, sneezing  Topical antihistamine or topical steroids  Improvement 2-3 days Chemical –thimerosal, erythromycin, silver nitrate  S&S conjuctival erythema, 30 minutes afer prophylactic antibiotics drops  Avoid contact  Can consider steroids Conjunctivitis never accompany vision changes Diagnostic studies: swap and scraping must be done, gram and Giemsa staining, ELISA, PCR testing, newborn < 2 weeks needs to be tested for gonorrhea Non –pharm – clean towels, change pillows, warm compress, no contacts, no eye make up – mascara Gonococcal conjunctivitis: newborn – give Ceftriaaxone IM once (don’t give if hyperbilirubinemia, Non-gonococcal – erythromycin 0.5% ointment Consider fluorescein staining if abrasion suspected CDC recommends prophylactic administration of antibiotic eye ointment (ERYTHROMYCIN) 1 hour after delivery Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis or ulcerations present May return to work/school 24 hours after topical 5. OTITIS EXTERNA- Otitis externa (OE), commonly called swimmer's ear, is a diffuse inflammation of the EAC and can involve the pinna or TM. Inflammation is evidenced as (1) simple infection with edema, discharge, and erythema; (2) furuncles or small abscesses that form in hair follicles; or (3) impetigo or infection of the superficial layers of the epidermis. OE can also be classified as mycotic otitis externa, caused by fungus, or as chronic external otitis, a diffuse low-grade infection of the EAC. Severe infection or systemic infection can be seen in children who have diabetes mellitus, are immunocompromised, or have received head and neck irradiation. OE results when the protective barriers in the EAC are damaged by mechanical or chemical mechanisms. OE is most frequently caused by retained moisture in the EAC, which changes the usually acidic environment to a neutral or basic environment, thereby promoting bacterial or fungal growth. Chlorine in swimming pools adds to the 743problem because it kills the normal ear flora, allowing the growth of pathogens. Regular cleaning of the EAC removes cerumen, which is an important barrier to water and infection. Soapy deposits, alkaline drops, debris from skin conditions, local trauma, sweating, allergy, stress, and hearing aids can also be responsible for causing OE OE is most often caused by Pseudomonas aeruginosa and Staphylococcus aureus, but it is not uncommon for the infection to be polymicrobial. Furunculosis of the external canal is generally caused by S. aureus and Streptococcus pyogenes. Otomycosis is caused by Aspergillus or Candida and can be the result 5 Mid term study guide of systemic or topical antibiotics or steroids. Otomycosis is also more common in children with diabetes mellitus or immune dysfunction and in these cases is most commonly caused by Aspergillus niger, Escherichia coli,or Klebsiella pneumonia. Group B streptococci are a more common cause in neonates. Long-standing ear drainage may suggest a foreign body, chronic middle ear pathology (such as, a cholesteatoma), or granulomatous tissue. Bloody drainage may indicate trauma, severe otitis media, or granulation tissue. Chronic or recurrent OE may result from eczema, seborrhea, or psoriasis. Eczematous dermatitis, moist vesicles, and pustules are seen in acute infection, whereas crusting is more consistent with chronic infection. Clinical Findings History The following can be found: • Itching and irritation • Pain that seems disproportionate to what is seen on examination • Pressure and fullness in ear and occasionally hearing loss that can be conductive or sensorineural • Rare hearing loss and otorrhea or systemic complaints and symptoms • Sagging of the superior canal, periauricular edema, and preauricular and postauricular lymphadenopathy with more severe disease Extension to the surrounding soft tissue results in the obstruction of the canal with or without cellulitis. Physical Examination Findings on physical examination can include the following: • Pain, often quite severe, with movement of the tragus (when pushed) or pinna (when pulled) or on attempts to examine the ear with an otoscope • Swollen EAC with debris, making visualization of the TM difficult or impossible • Rare otorrhea • Occasional regional lymphadenopathy • Tragal tenderness with a red, raised area of induration that can be deep and diffuse or superficial and pointing, which is characteristic of furunculosis • Red, crusty, or pustular spreading lesions • Pruritus associated with thick otorrhea that can be black, gray, blue-green, yellow, or white, and black spots over the TM are indicative of mycotic infection • Dry-appearing canal with some atrophy or thinning of the canal and virtually no cerumen visible with chronic OE • Presence of pressure-equalizing tube or perforation of TM Diagnostic Studies Culturing the discharge from the ear is not customary but may be indicated if clinical improvement is not seen during or after treatment, severe pain persists, the child is a neonate, the child is immunocompromised, or chronic or recurrent OE is suspected. Culturing requires a swab premoistened with sterile nonbacteriostatic saline or water. The following steps outline the management of OE: • Eardrops are the mainstay of therapy for OE . Eardrops containing acetic acid or antibiotic with and without corticosteroid drops are the treatment of choice for OE. Symptoms should be markedly improved within 7 days, but resolution of the infection may take up to 2 weeks. Drops should be used until all symptoms have resolved. Ototoxic drugs should not be used if there is a risk of TM perforation. • Antibiotic agents should be chosen based on efficacy, resistance patterns, low incidence of adverse effects, cost, and likelihood of compliance. Neomycin, polymyxin, or hydrocortisone drops should not be used if the TM is not intact, because these drugs are known to cause damage to the cochlea. • The quinolone products are effective against Pseudomonas, S. aureus, and Streptococcus pneumoniae, which may be a factor if the OE is a complication of AOM. • Systemic antibiotics should not be used unless there is extension of infection beyond the ear or host factors that require more systemic treatment (severe OE, systemic illness, fever, lymphadenitis, or failed topical treatment). • Treatment for OE must include thorough parent education regarding the instillation of otic drops so that they are effective in eradicating infection. The drops should be administered with the child lying down with the affected ear upward. Drops should run into the EAC until it is filled. Move