EENT: Conjunctivitis (Pink Eye)

EENT Disorders

• EENT stands for Eye, Ear, Nose, and Throat

Ophthalmic Disorders

Conjunctivitis

• Transparent mucosa that lines the eye and eyelids inner surface
• Broad term describing swelling, inflammation, or infection of the conjunctiva
• Can be hyperacute, acute, or chronic
• Can be bacterial, viral, or allergic
• Commonly known as "pink eye"

Viral Conjunctivitis

• Accounts for 70% of all infectious cases, adenovirus is the cause of 65-90% of viral cases
• Other viral agents that cause conjunctivitis: herpes simplex virus (HSV), rubella, measles, varicella-zoster (chickenpox/shingles), Epstein-Barr (mono), and Molluscum contagiosum (pox virus)
• Lasts 5-14 days
• Is contagious as long as tearing is present or for at least 1 week
• Presents after recent upper respiratory infection via coughing or sick contact
• Symptoms: red eye, excessive watery discharge, burning/itching, photophobia, watering, and foreign body sensation
• Classically starts in one eye and involves the other within days
• Patients can usually recall when symptoms began
• About 50% of patients develop bilateral involvement
• Resolves spontaneously after 1-2 weeks

Viral Treatment

• It is self-limiting, resolves in 5-14 days, and is supportively treated
• Avoid prophylactic antibiotic treatments
• Can use antihistamine/decongestant drops
• Supportive, non-pharmacological treatment includes ocular decongestants, artificial tears, and cool compresses
• Patients with symptoms that do not resolve after 7-10 days or who develop corneal involvement should be referred to an ophthalmologist

Bacterial Conjunctivitis

• Acute bacterial conjunctivitis is the most common bacterial infection
• Most common in adults is Staphylococcus aureus
• Haemophilus influenzae and Streptococcus pneumoniae are common in children
• It is most commonly spread through direct contact with contaminated fingers
• Classified as hyperacute, acute, or chronic based on signs and symptoms
• Hyperacute is associated with gonorrhea in sexually active adults. It shows copious, purulent yellow or green discharge, pain, and diminished vision loss, with eyes "sticky or glued shut" and worse in the morning. It's characterized by sudden onset and rapid progression
• Acute is the most common form of bacterial conjunctivitis caused by Staphylococcus aureus, persists for less than 3-4 weeks
• Chronic persists for at least four weeks with frequent relapses
• Refer patients with chronic bacterial conjunctivitis to an ophthalmologist

Treatment of Bacterial Conjunctivitis

• Use primary treatments for mild to moderate cases
  • Azithromycin ophthalmic drops 1%: 1 drop BID x 2 days, then 1 drop daily x 5 days
  • Erythromycin ophthalmic ointment 0.5%: apply a 1cm ribbon to affected eye up to 6x a day for 7-10 days
  • Polymyxin B/trimethoprim ophthalmic drops: 1 gtt q 3 hours for 7-10 days
• Try secondary treatments if primary treatments fail
  • Bacitracin ophthalmic ointment 500units/g: apply to the affected eye every 3-4 hours
  • Sulfacetamide ophthalmic drops 10%: 1-2 drops into affected eye(s) every 2-3 hours
• If moderate to severe or includes contact lens wearers, use primary treatments for seven days
  • Ofloxacin ophthalmic 0.3%: 1-2 drops in affected eye every 2-4 hours x 2 days, then 1-2 drops QID x 5 days
  • Moxifloxacin ophthalmic 0.5%: 1 drop into the affected eye 3x day
  • Levofloxacin ophthalmic 0.5%: 1-2 drops into the affected eye every 2 hours up to 8x a day for 2 days and then every 4 hours 4x daily

Acute Allergic Conjunctivitis

• Common agent is hay fever
• It is caused by allergic substances such as pollen, dust mites, animal dander, molds, and contact lens solutions and cosmetics
• Seasonal allergic conjunctivitis is secondary to environmental allergens such as ragweed (75% of cases)
• 75% of patients with acute allergic conjunctivitis have allergic rhinitis present
• Symptoms include headache and fatigue, and a history of hay fever or atopy.
• Symptoms present simultaneously in both eyes: burning/itching/erythema
• With clear/stringy/white discharge present, the conjunctiva will be boggy

Acute Allergic Treatment

• Treat by identifying and eliminating allergen
• Remove allergen
• Symptoms resolve once allergen is removed
• Use oral histamines such as Benadryl, Allegra, or Claritin to control ocular signs and symptoms
• Use supportive care and artificial tears, cool compresses to start
• If symptoms persist, add an antihistamine-vasoconstrictor with caution (do not use for more than 2 weeks due to rebound vasodilation and conjunctivitis)
• Antihistamines with mast cell stabilizers are used as prophylactic treatment for recurrent or persistent conditions (Xatador, Patanol, Pataday)

Red Eye Differential Diagnosis algorithm

• Pain?
  • Yes
    • Fluorescein Uptake?
      • Yes -> Keratitis, Corneal Abrasion
      • No -> Elevated IOP?
        • Yes -> Acute Angle Closure Glaucoma
        • No -> Consensual Photophobia?
          • Yes -> Anterior Uveitis
          • No -> Scleritis
  • No -> Subconjunctival Hemorrhage, Conjunctivitis, Episcleritis

Types of Conjunctivitis

• Direct photophobia refers to pain with light shone in the affected eye; consensual photophobia refers to pain with light shone in the unaffected eye

Conjunctivitis Considerations

• Anyone with a confirmed infection should not work/attend school until symptoms resolve for 3-7 days

When to Refer a Patient With Conjunctivitis

• Ophthalmologist referral required for:
  • Decrease in vision/visual problems
  • Eye pain
  • Photophobia
  • Fixed or sluggish pupils
  • Severe purulent drainage
  • Corneal involvement
  • Recent trauma
  • Recent ocular surgery
  • Contact lens use
  • No response to treatment or worsening symptoms
  • Recurring symptoms
  • Suspected herpetic infection (hx. HSV infection or rash involving dermatone)

Conjunctivitis Education and Prevention

• Identify underlying cause
• Practice hand hygiene often with antimicrobial soap
• Throw away old contacts, solutions & holders
• Clean glasses
• Wash your bedding
• Do not wear contacts during acute infection
• Ointments can cause blurry vision
• Avoid touching their eyes
• Avoid shaking hands
• Avoid sharing towels/bedclothes
• Avoid swimming

Glaucoma

• Optic nerve damage caused by pressure in the eye

Acute Closed Angle Glaucoma

• Closed angle, narrow-angle
• Sudden, marked increase in intraocular pressure
• More prevalent in Asian and Eskimos
• Sudden onset of vision loss: rapid peripheral vision loss then central
• Poorly reacting pupils, fixed and mid-dilated, and oval
• Sudden onset of headache, blurry vision, tearing, halos, nausea, and vomiting
• Emergency situation that requires referral to ED
• Occurs congenitally

Primary Open-Angle Glaucoma

• Elevated IOP is the main characteristic
• 85% of cases of glaucoma are primary open-angle
• Gradual increase in intraocular pressure >22 mmHg
• Ischemic retinal damage results from blockage of the aqueous humor
• Risk factors: age >65, family history, DM, HTN, African American, steroid use
• Generally asymptomatic, producing gradual changes in peripheral vision and then central vision
• Cupping upon funduscopic exam indicates IOP is too high requiring immediate referral to ophthalmologist
• Leading cause of blindness in African Americans and is common in the elderly

Pharmacologic Management for Glaucoma

• Primary medications include prostaglandin analogs: latanoprost, travoprost, bimatoprost: 1 drop into the affected eye at bedtime
• Alternate/Add-on medications include Beta-Blockers: timolol, carteolol, bexaxolol: 1-2 drops into affected eye BID
• Secondary medications include Alpha-2 adrenergic agonists: apraclonidine, brimonidine: 1 ggt to affected eye 3x/day
• Tertiary medications include Cholinergic agonists: pilocarpine: 1 drop into affected eye 4x a day

Glaucoma Management

• Reduce intraocular pressure with laser treatment for optic nerve changes/treatment failure
• Patients may need ongoing topical ophthalmic therapy
• Surgery to facilitate aqueous humor outflow is done for treatment failure or rapidly progressing disease

Medications That Can Cause Glaucoma

• Steroid use can cause elevated eye pressure and open-angle glaucoma
• Many medications can cause narrow-angle glaucoma
• OTC decongestants/antihistamines can dilate the pupil leading to elevated eye pressure
• Prescription medications for bladder incontinence, motion sickness, psychiatric disorders, diet pills and some sulfa derivatives can cause closed-angle glaucoma
• Use topical beta-adrenergic blockers with caution in those on oral beta-adrenergic blockers, or with COPD, asthma, and cardiac conditions
• Do not recommend antihistamines in patients with narrow angle glaucoma
• Always check with your ophthalmologist before starting new medications if you have glaucoma

Macular Degeneration

• Loss of central vision

Age-Related Macular Degeneration

• Most common cause of permanent vision loss in older adults
• More common in smokers
• Atrophic or dry form of macular degeneration is more common and “less severe"
• Wet form responsible for 80% of vision loss
• Symptom: loss of central vision over years
• The first sign is scotoma (blind spot)
• Peripheral and color vision are normal
• Requires referral to ophthalmologist
• Treat by stopping smoking and taking "AREDS" ocular vitamins (high zinc and antioxidants)

Ear Disorders

Otitis Externa

• Inflammation or infection of the external auditory canal (EAC) or the auricle
• Can be called "Swimmer's ear"
• The most common cause is S. aureus and Pseudomonas aeruginosa
• Hallmark sign: Pain upon palpation of the tragus or traction of the pinna
• Other signs and symptoms: otalgia (mild to severe, progressing over 1-2 days), hearing loss, ear fullness/pressure, erythema, edema, narrowing of the canal, tinnitus, fever, itching (especially in fungal infections), severe deep pain (Immunocompromised patients), discharge (starts clear, turns purulent and foul-smelling), and a history of water exposure or ear trauma

Otitis Externa Treatment

• Primary treatment ciprofloxacin/dexamethasone otic: for children > 6 months of age, 4 drops into the affected ear(s) twice daily for 7-10 days
• Ofloxacin otic: 10 drops into the affected ear(s) once daily for 7 days
• Ciprofloxacin otic: 0.25ml into affected ear BID for 7 days
• Secondary treatment for ciprofloxacin/hydrocortisone otic, do not use with a perforated tympanic membrane or tympanostomy: 3 drops BID x 7 days
• Neomycin/polymyxin B/hydrocortisone: 3-4 drops into affected ear 3-4x day for 7-10 days

Acute Otitis Media With Effusion

• Fluid accumulation in the middle ear without evidence of infection
• Usually asymptomatic; patients describe feeling of fullness, diminished hearing, and TM decreased mobility or retraction
• Management includes administering antimicrobial agents, steroids, antihistamines and decongestants, and mucolytics, but it's not recommended due to a lack of evidence supporting effectiveness
• Surgical interventions are used to treat chronic effusion like myringotomy with or without tubes

Otitis Media

• An ear infection (acute otitis media) is most often a bacterial or viral infection that affects the middle ear
• Children are more likely than adults to get ear infections
• Ear infections are often painful due to the inflammation and fluid buildup in the middle ear
• Treatment starts with managing pain and monitoring the problem

Acute Otitis Media

• Requires a diagnosis of acute otitis media
  • History of acute onset of signs and symptoms
  • Presence of middle ear effusion
  • Signs and symptoms of middle ear inflammation
• Often viral
• If bacterial, the cause is typically S. pneumoniae, H. influenzae, or M. catarrhalis
• Key features include a bulging tympanic membrane, reduced mobility of the tympanic membrane when pneumatic pressure is applied

Suspected Acute Otitis Media Treatment

• If symptoms have been present for less than 3 days, the cause most likely is viral
• Primary treatment is acetaminophen and ibuprofen
• Non-pharm treatment: heat
• Consider myringotomy with or without tubes if symptoms are persistent or chronic

Acute Otitis Media Antibiotic Management

• If symptoms worsen/do not improve in 3 days, treat for 5-7 days normally and 10 days for severe cases
• Amoxicillin: 500 mg TID or 875mg BID up to 4000 mg/day
• Amoxicillin/clavulanate: 500 mg/125 PO TID or 875 mg/125 mg BID
• PCN Allergy: -Cefdinir: 300 mg orally twice daily or 600 mg once daily
• Cefuroxime: 250- 500 mg orally twice daily
• Azithromycin: PO 500mg OD x 5 days
• Improvement should be seen within 48-72 hours, otherwise consider switching to 2nd line
• Start with 2nd line if symptoms are severe or recent antibiotic use (3 months)

Upper Respiratory infection

Allergic Rhinitis

• Presumptive diagnosis requires nasal congestion, sneezing, and itchy nose/palate/eyes with a pattern of allergic triggers
• Definitive diagnosis requires specific IgE reactivity

Allergic Rhinitis Physical Findings

• Allergic shiners
• Conjunctival injection
• Pale boggy turbinates, clear nasal secretion
• Allergic salute
• Mouth breathing, dry lips
• Lymph nodes
• Cobblestone appearance in pharynx and tonsils – chronic allergies

Allergic Rhinitis Pharmacological Management

• Saline nasal spray
• Nasal steroids: fluticasone, beclomethasone, strong recommendation
• Antihistamines: strong recommendation and has 1st generation and 2nd generation options
  • 1st generation(drowsy): diphenhydramine 25-50 mg q 4-6 h (max 300 mg)
  • 2nd generation (less drowsy):
    • cetirizine 5-10 mg OD
    • levocetrizine 5 mg OD
    • loratadine 10 mg OD
    • fexofenadine 180 mg OD
• Nasal anti-histamine is an option for patients with seasonal, perennial, or episodic allergic rhinitis, use olopatadine 2 sprays BID

Allergic Rhinitis Management

• Sinonasal is not routinely performed in patients presenting with symptoms of allergic rhinitis
• Use avoidance of allergens
• Surgical removal of polyps or surgical reduction of turbinates to relieve obstruction
• Refer to allergist

Allergic Rhinitis Pharmacology

• Oral Leukotriene Receptor Antagonists (LTRAs): not recommended as primary therapy for patients with allergic rhinitis
• Montelukast can be used, 10 mg orally once daily
• Use decongestants and systemic steroids with caution

Allergic Rhinitis Referral

• Perform or refer patients with clinical allergic rhinitis for specific IgE (skin/blood) allergy testing
• Do this in patients who do not respond to empiric treatment, the diagnosis is uncertain, or knowledge of the specific causative allergen is needed

Pharyngitis/Tonsillitis

• Acute inflammation of the pharynx/tonsils
• Etiology: bacterial or viral
• Assessment findings: sore throat and pharyngeal edema or tonsillar exudate and/or enlarged tonsils
• Malaise
• Clinical findings are not specific for diagnosis of bacterial or viral illness

Features of Bacterial vs Viral Pharyngitis/Tonsillitis

• Bacterial: cervical adenopathy, fever >102, absence of other upper respiratory findings (cough or nasal congestion), petechiae on soft palate
• Viral: conjunctivitis, nasal congestion, hoarseness, cough, diarrhea, viral rash

Centor Criteria for Adults

• Assessment tool to evaluate the probability of acute GAS infection
• Absence of Cough: 1 point
• Swollen and Tender Anterior Cervical Nodes: 1 point
• Temp of > 100.4° F (38°C): 1 point
• Tonsillar Exudates or Swelling: 1 point
• Age is scored as follows
  • 3-14 years: 1 point
  • 15-44 years: 0 point
  • 45+: -1 point
• Results:
• 3-4 points: treat empirically for strep
• 2 points: RADT, and treat If positive
• 1 point: Strep infection is unlikely
• 0 to +1 point: No test or treatment needed

Pharyngitis/Tonsillitis Treatment Options

• Come to the Health Center: is Bacterial
• Monitor at home, gargle with salt water: Non-bacterial/Viral

Pharyngitis/Tonsillitis Treatment

• Non-pharmacologic approaches include gargling with warm salt water, increase fluids, and patient education.
• Pharmacologic treatment is with antipyretics/analgesics for fever and throat pain
  • Primary treatment:
    • penicillin G 1.2-million-unit IM injection
    • penicillin V potassium: 500 mg BID-TID x 10 days
    • amoxicillin: 500 mg TID or 875 mg BID x 10 days
• Secondary (PCN allergy or resistance):
  • azithromycin
  • clarithromycin 250 mg q12h x 10 days
  • Cephalexin 500mg BID c 10 days
  • clindamycin 300 mg q8h x 10 days

Acute Rhinosinusitis

• Defined as symptomatic inflammation of the nasal cavity and paranasal sinuses
• Uncomplicated rhinosinusitis is rhinosinusitis without clinically evident extension of inflammation outside the paranasal sinuses and nasal cavity when diagnosed
  • <4 weeks is identified as Acute
• 4-12 weeks is identified as Subacute

• 12 weeks is identified as Chronic

Rhinosinusitis Pathophysiology

• Results from acute viral infection which is most common for an upper respiratory tract infection (URI)
• Causes typically stem from maxillary sinus infections and anterior ethmoidal sinus infections
• Result from the maxillary sinus, which is the largest of the paranasal sinuses

Rhinosinusitis Risk Factors

• Allergies
• Asthma
• Dental problems
• Smoking
• Exposure to contaminated water
• Existing medical issues and or conditions that might lead to swollen nasal passages such as cold or allergies
• Anatomical problems with the nasal passage

Rhinosinusitis Symptoms

• URI symptoms, Postnasal drip, fatigue, congestion, fever, ear fullness/pressure sore throat hyposmia/anosmia
• Three cardinal symptoms: purulent nasal discharge, nasal obstruction, facial pain/pressure/fullness
• Frontal headache indicates frontal sinusitis
• Cheek and tooth pain indicates maxillary sinusitis indications, ethmoid sinusitis gives pain/pressure behind or between the eyes

Rhinosinusitis Pathogens

• Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis for bacterial
• Rhinovirus, coronavirus, influenza A and B, parainfluenza virus, and respiratory syncytial virus for viral

Sinusitis Clinical Practice Guidelines

• Symptoms caused by Viral Infections lasts less 10 days and do not worsen
• In Bacterial Infection symptoms fail to improve with in 10 or more days of worsening

Rhinosinusitis Diagnosis

• Examination of the nose and throat
  • Fever may also be present and assessed
  • The need to patency of bilateral nares and structural abnormalties are assessed
  • Examine throat and signs of postnasal drip is assessed through reddening and or signs of postnasal drip
• Assess eyes
  • Maxillary sinuses are checked through percussion and palpation
• Possible if needed is tapping and examination of teet

Diagnostics Rhinosinusitis

• This illness should not be diagnosed through symptoms of the affected
• Symptom and medical will allow to diagnose to diagnose in appropriate way

Rhinosinusitis Symptomatic Relief

• Management often makes use of nasal sprays, which should only be advised if you are showing signs of Mucus
• Analgesics used such as Intranasal or coricosteriods, it can also be useful if is saline
• NSAIDS are a common drug used when managing fever,face and headaches
• It commonly involves antibiotics and anti-fluids

Non- Pharmalogical Treatment for Rhinosinusitis

• Watch and wait if signs point t viral sinusitis
• Tell the patient to avoid irratants
• Manage allergic rhinitis to protect sinusutis
• Use of humidifies may improcve clearing mucus
• Increased amount of fluids may protect

Pharmacological Management for Rhinosinusitis

• Management and prescription depend of type of virus being treated
  • It often does not need antibiotic unless to case is severe to to long to treat
• The virus or condition is often treated with the following
  • Amoxicillin 500-1000mg (TID) PO daily to treat of for several week The second treatment will be
  • Levofloxacin (Levaquin) 500mg

Rhinosinusitis Referral

• If high fevers persistent the the patients has periorbital edema, inflammation, or erythema refer paticent to hospital

Chronic Sinusitis

• Often chronic sinuses often gets missed or confused with other illnesses Patients with the following will be more acceptable to treatment
  • Two or extra symptoms such as
  • Nasal Obstruction -Facial congestion
  • Discolored Nasal Drainage
    • Inbility with smell or taste

Rhinosinusitis Risk Factors

• The following contribute to the condition and can lead to several risk factors. These often include factors, allergies, pollens, tobacco smoke, nasal problems

Management for Rhinosinusistis

• The main point of focus is treating the causes that are lead to symptoms that cause this effect with antibiotics that may include
  • Follow-UPS, or ER visits
  • Medical Therpy to assess