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  1. NELSON’S CLUB Kimberly S. Tsai, MD, MBA

  2. TOPICS • Acute sinusitis • Eye pain & discharge • Conjunctivitis • Orbital cellulitis • Otitis media & externa • Foreign body

  3. Acute sinusitis

  4. 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%)

  5. 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

  6. 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.

  7. Eye pain & discharge

  8. 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

  9. 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.

  10. 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

  11. 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

  12. Orbital cellulitis

  13. 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

  14. 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

  15. Chandler Classification

  16. 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

  17. conjunctivitis

  18. Conjunctivitis • reaction to a wide range of bacterial and viral agents, allergens, irritants, toxins, and systemic diseases • May be infectious or non-infectious

  19. Conjunctivitis

  20. Conjunctivitis

  21. Conjunctivitis

  22. Conjunctivitis

  23. 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

  24. ConjunctivitisOphthalmiaNeonatorum COMPLICATIONS DIAGNOSIS Gram stain & culture of purulent discharge • corneal ulceration and perforation • Iridocyclitis • anterior synechiae • panophthalmitis

  25. 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

  26. 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

  27. Ear pain

  28. Otitis media & externa

  29. 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

  30. 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

  31. 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

  32. Otitis Media

  33. Otitis Media with Effusion Treatment

  34. Otitis Media Treatment Tx Duration: >=10 days esp <2yo & severe symptoms

  35. 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

  36. Otitis Media Additional Notes: • Prevention • Avoid risk factors • Antimicrobial prophylaxis • Not recommended • Tympanostomy tube is found effective in • Recurrent AOM • Persistent OME

  37. 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

  38. 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

  39. 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

  40. Foreign body

  41. 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

  42. 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

  43. END Thank you for listening!