Sinusitis: Viral vs. Bacterial

Viral Sinusitis

• Most sinusitis cases are viral.
• Symptoms include malaise, headache, cough, nasal congestion, facial pressure, rhinorrhea, and hyposmia (decreased sense of smell).
• Examination shows erythematous, engorged nasal mucosa without intranasal purulence.
• Symptoms typically last less than 10 days.
• Diagnostic imaging is not needed; check for failure of transillumination.
• Treatment includes supportive care, rest, hydration, OTC analgesics & decongestants, and saline nasal sprays.

Bacterial Sinusitis

• More likely if symptoms last over 10 days, or worsen after initial improvement.
• Viral URIs usually precede bacterial sinus infections.
• Signs and symptoms: purulent yellow-green nasal discharge or expectoration, fever, unilateral face or tooth pain, and nasal obstruction.
• No imaging is needed, check for failure of transillumination during diagnosis.
• Pathogens include strep pneumoniae and h. influenzae.
• Treatment consists of amoxicillin-clavulanate (Augmentin) - educate about GI side effects, doxycycline for penicillin allergy, and intranasal steroids
• It may be aggravated by physiologic nasal congestion during pregnancy; avoid tetracyclines and quinolones during pregnancy & lactation.

Hearing Loss

• Conductive hearing loss: inability for the eardrum to vibrate in response to sound.
• It can be caused by anything that occludes or mechanically blocks sounds from traveling through the external auditory canal or middle ear.
• Sensorineural hearing loss involves the inner ear or CN VIII with diminished & distorted sounds.
• Due to anything preventing sound from traveling through the inner ear or preventing CN VIII from functioning.
• Presbycusis is age-related high-frequency sensorineural hearing loss.
• Congenital hearing loss is present at birth.
• Traumatic hearing loss is caused by anything that injures CN VIII or the eardrum.
• Diagnosis includes otoscopic exam, tuning fork and whisper test.
• Health promotion: All infants should be screened by age 1 month; those who fail the initial screening should have an audiologic evaluation by age 3 months and intervention by age 6 months.
• Sudden hearing loss is a medical emergency requiring immediate referral to ENT.

Allergic Rhinitis

• Symptoms include nasal congestion with clear mucus or postnasal drip.
• Cough due to postnasal drip worsens when supine.
• Other symptoms: nasal, throat, or eye itch, watery eyes, pale boggy or violaceous turbinates (due to venous engorgement) in contrast to viral rhinitis having erythema, dark circles (raccoon eyes), transverse nasal crease (allergic salute), cobblestoning to posterior pharynx, and long-term nasal polyps.
• First-line treatment: nasal steroid sprays; topical antihistamine sprays or combinations.
• Use Decongestants in the PM, oral antihistamines in the AM, and eliminate allergens.

Impacted Cerumen

• Impacted cerumen can cause reversible hearing loss.
• Patients are usually asymptomatic, but may have a feeling of fullness, conductive hearing loss, or tinnitus.
• Treatment includes gentle irrigation with warm tap water, cerumen curette, or cerumenolytic agents: Debrox drops
• Do not use Debrox drops with ruptured eardrums or otitis media.
• Nasal saline can cause acute otitis media and acute sinusitis.

Epistaxis

• Bleeding from a unilateral anterior nasal cavity along the septum is most common (Kiesselbach plexus).
• Posterior, bilateral, or large-volume epistaxis should be triaged immediately to a specialist in a critical care setting.
• Usually related to atherosclerotic disease & HTN
• Risk factors include ASA, NSAIDs, cocaine abuse, severe HTN, anticoagulant use, and trauma (nose picking).
• Treatment involves applying direct pressure to the bleeding site for 15 minutes and avoid tilting head backwards (may lead to aspiration).
• Nasal decongestants act as vasoconstrictors.
• Other treatments include cautery with silver nitrate or thermal or electrocautery, surgical intervention or gelfoam, and nasal tamponade.

Foreign Body in the Ear

• More frequent in children.
• Treatment involves removing firm objects with a loop or hook.
• Do not use aqueous irrigation for organic foreign bodies (e.g., beans, insects) because water can cause them to swell.
• Living insects are best immobilized with lidocaine or mineral oil.
• Never use lidocaine if there is a possible TM perforation.

Periorbital Cellulitis

• Requires emergent referral for urgent CT and ophthalmology consultation.
• Check WBC, and culture.
• Concerning symptoms include diplopia, vision changes, and pre-septal cellulitis (acute eyelid erythema and edema).
• Concern is that an abscess has formed and proximity to the brain
• IV antibiotics include Ampicillin or Clindamycin; Vanco for MRSA.
• Pain with eye movement... lateral gains something.
• Check CN 3, 4, 6.
• Consider untreated sinus infection or HIB vaccine.

Eustachian Tube Dysfunction

• Symptoms include aural fullness, discomfort with barometric pressure changes, retracted eardrum, mild-moderate hearing impairment.
• Symptoms present when they swallow.
• Caused by seasonal allergies and inflammation of the intratubal linings.
• Can be treated with nasal steroids.
• Refer to ENT.
• Poor bone conduction with Rhine and Webber test.

Nasopharyngitis

• Viral condition.
• Gradual onset, self-limiting for 2 weeks.
• Symptoms include congestion, sore throat, sneezing, fever, and fatigue.
• Treatment is supportive, sipping warm and cold drinks, NSAIDs, increasing fluids, avoiding smoking, and using a humidifier.

Sensoryneuro hearing hoss

• Nerve damage
• Sounds diminished and distorted
• High frequency goes away first
• Sudden hearing loss is an emergency
• CN8
• Older adults more common

Otitis Media with Effusion

• Inflammation of the middle ear with fluid, with or without acute ear infection symptoms.
• Often asymptomatic or patients may have ear fullness & “popping”.
• Usually resolves spontaneously.
• VIRAL
• Use oral decongestants: Sudafed or Mucinex D as well as Flonase, Zyrtec, or Singular (Montelukast).

Foreign object in ear

• Use mineral oil for bugs
• Water for other objects
• Use an ear wick with light

Pharyngitis/Tonsillitis

• Usually due to a virus,
• Viral causes include: Rhinovirus, Adenovirus, Parainfluenza, Epstein-Barr virus, RSV, HIV, HSV
• Bacterial causes include Group A beta-hemolytic streptococcus, 10% of pts w/ mono have concomitant strep infection
• Sore throat & pharyngeal edema
• Tonsillar exudate and/or enlarged tonsils
• Malaise

Suggestive of Strep

• Cervical adenopathy
• Fever >102F
• Petechiae on soft palate
• “beefy” red tonsils
• “sandpaper” rash (nose bridge, neck, and/or torso)
• Abdominal pain, HA
• Distinct odor
• Lack of cough

Suggestive of viral

• Concurrent conjunctivitis
• Nasal congestion
• Hoarseness
• Cough
• Diarrhea
• Or viral rash

Dx; Pharyngitis/Tonsillitis

• Rapid antigen strep test (95-99% specific)- throat culture. Antistreptolysin (ASO) titer should not be ordered to dx acute infection; ASO detects past infection.

Tx; Pharyngitis/Tonsillitis

• Strep: 10-day regimen of amoxicillin or PCN V is 1st line with PCN allergy: cephalexin/cefadroxil/clindamycin or macrolides, mupirocin to nares if carrier
• Strep pharyngitis : Penicillin V 500 mg BID to TID x 10 days, Amoxicillin 500 mg BID x 10 days; PCN allergy Azithromycin (Zpak) x 5 days.
• Red Flag: treat to prevent RF, scarlet fever, glomerular nephritis- renal issues.

Otitis Externa

• "Swimmer's ear"
• Hallmark sign: traction of pinna elicits pain
• Edema and erythema to external ear canal
• Discharge/or flaky debris in canal
• Itching in external ear canal
• Normal TM
• Tx: otic antibiotic w/steroid combo

Epiglottitis

• Critical narrowing of airway
• Medical emergency for airway & antimicrobial treatment
• Most common cause: Haemophilus influenza

S/S of Epiglottitis

• 1st sign=fever; abrupt & high
• Sore throat
• Drooling (80% of cases)
• "Sniffing posture” (patient leans forward & hyperextends neck to maintain patent airway)
• Health promotion: Hib vaccine:
• Require hospitalization for IV antibiotics such as:
  • Cefuroxime (Ceftin)
  • Ceftriaxone (Rocephin)
  • Ampicillin/sulbactam (Unasyn)
• Dexamethasone (Decadron) should also be administered IV and tapered as signs and symptoms resolve.

Acute Otitis Media

• S/S: are acute ear pain interferes with sleep or activity, tympanic membrane erythema, middle ear effusion, rapid onset fever, rapid onset ear pain, hearing loss, buldging or full TM, displaced light reflex, cloudy dull TM, pneumototscopy or tympanoscopy
• Amoxacillin-> Cefdnir-> Azithromycin

Infectious Mononucleosis

• Self-limiting
• Caused by EBV, transmitted via saliva
• S/S: Sore throat (exudative), Extreme Fatigue, High Fever, Myalgias, Lymphadenopathy, Splenomegaly
• Tx: Symptomatic and supportive, bed rest, analgesics, avoidance of contact sports x min of 3 weeks, & longer if spleen remains enlarged
• Dx: Clinically, Monospot: low sensitivity, rapid strep may be coinfected
• Red flags: Rash in patients treated with amoxicillin or ampicillin

Mastoiditis

• Bacterial infection of the mastoid air cells surrounding the inner and middle ear
• it can be asymptomatic & life-threatening
• Typically, results from untreated or undertreated AOM
• Most common streptococcus pneumoniae
• S/S:- Drainage from ear, creamy profuse otorrhea, persistent throbbing otalgia, auricular protrusion: pinna displaced, abnormal TM: bulging, perforation, erythema and/or dull, fever: high or sudden increase, facial nerve (CN VII) paralysis or palsy
• Suspect when symptoms of AOM persist beyond 2 weeks, even in TM normal refer to ENT, palpation of the mastoid bone, pinna can be displaced (ears stick out), culture the drainage for the antibiotics.

Peritonsillar Abscess- Send to ER

• S/S are severe unilateral throat pain, muffled voice “hot potato voice”, trimus: lock jaw, displaced uvula, drooling, rancid breath, lymphadenopathy, neck swelling, Dx: Gold standard: needle aspiration U/S guided

Dental Abscess

• amoxicillin
• S/S: are referred ear pain, leukocytosis with left shift, severe- tongue displacement.
• Dx: CBC w/ diff; panoramic radiograph

Conjunctivitis

Viral Conjunctivitis

• symptoms are injected conjunctiva- initially unilateral, then bilateral, photosensitivity, adenovirus- tear testing- POC testing, results from a URI. Treatment includes artificial tears for symptomatic relief and antihistamines for itching.

Bacterial conjunctivitis

• symptoms are Self-limiting, eye stuck in morning, matting, purulent exudates, pseudomonas for contact lenses wearers, strep pyogenes for everyone else, contact transmission.
• Treatment include gentamycin drops? & fluoroquinolones eye drops are 1st line for contact lens wearers- the floxacin

Allergic conjunctivitis

• symptoms are cobble-stoning on conjunctiva, IgE and MAST cell sensitivity
• Treatment include topical antihistamine

STI Conjunctivitis

• chlamydia and gonorrheal.

other Conjunctivitis

• chlamydia after birth, gonorrheal nasty adults
• Treatment is IV or IM ceftriaxone and oral azithromycin or erythromycin

TMJ

• S/S are clicking/ popping & pain in joints,
• Tx: include behavior modifications, avoid clenching or grinding, avoid extreme mandibular movements, NSAIDs, muscle relaxers, soft foods, jaw rest, wear mouth guard at night & analgesic NSAIDs.

Blepharitis

• Description: inflammation or infection of the eyelids

Etiology

• Anterior: Staphylococcal, Seborrheic dermatitis, rosacea
• Posterior: Meibomian gland dysfunction

Risk Factors

• Frequent hordeola or chalazia
• Facial or scalp seborrhea
• Immunocompromised state
• Rosacea, acne
• Dry eye

Clinical Presentation

• Burning, itching, tearing, lid crusting in the morning, flaking or scaling of eyelid skin, red eyes
• First-Line: Topical antibiotics and lid hygiene
• Topicals: erythromycin ointment, azithromycin otic drops
• Treat with eyelid margin scrubs (diluted baby Johnson's shampoo), BID, and warm compresses. Unilateral inflammation- sebaceous carcinoma testing.

Hand-Foot-Mouth Diseases

• macule popular lesions, highly contagious, viral illness: coxsackie A16 & enterovirus, presents on hands, feet, buccal mucosa, palate, & buttocks;
• Tx:- symptomatic, NSAIDs, acetaminophen; Red flags:- virus sheds for several weeks in feces

Hordeolum (Stye)- hurts

• Acute inflammation or infection of the eyelid margin involving the sebaceous gland of an eyelash (external hordeolum) or a meibomian gland (internal hordeolum), Commonly caused by staphylococcus aureus, Sudden onset of localized tenderness, redness, swelling of the eyelid;
• Hordeolum should NOT be expressed
• Treatment includes baby shampoo, warm compress for 15 mins, erythromycin Opthalmic ointment.

Thrush (Oral candidiasis)

• White oral base on the erythematous base, Dx: KOH wet prep,
• tx: nystatin suspension (Fluconazole PO; Clotrimazole dissolvable)
• Red flag: may be 1sy sign in HIV

Chalazion- chill

• May appear the same as a stye but painless lesion that does not involve the lashes
• Chronic recurrent chalazion in same place may be an eyelid tumor (sebaceous gland carcinoma)
• Develop slowly.
• No abx necessary- warm compress.

Stomatitis

• Inflammation of the mucus membranes in the mouth, causing sores, ulcers, and pain
• Avoid spicy foods, acidic foods, toothpaste

Ocular Foreign Body-

• Description: Presence of substance, material, objects adhering to the eye or imbedded in the eye in the cul-de-sacs, under the upper lid, or on the cornea.

Risk factors

• Improper use of protective eyewear
• Lack of protective eyewear

Clinical Presentation

• Red eye with foreign body sensation
• Blurry vision; photophobia; pain; tearing Appearance of dark speck against the iris

Differential Diagnosis

• Corneal abrasion; intraocular penetration of foreign body
• Consultation/Referral A penetrating injury is a medical emergency and must be referred immediately
• Refer to ophthalmologist for all but simple nonpenetrating injuries
• Refer to ophthalmologist if changes in visual acuity occur with any eye injury Assessment - Feeling of “something is in my eye", red eye, tearing, pain, photophobia, frequent eye rubbing

Herpangina

• Viral infection caused by enteroviruses
• S/S: fever, may be high, severe sore throat, post pharyngeal ulcers, petechiae or papules on soft palate Treatment is symptomatic

Iritis/Uveitis/Keratitis

Iritis

• Inflammation of the iris.
• Refer to ophthalmologist
• Slit lamp with dilating eye drops.
• Corticosteroids eye drops.
• Treat underlying cause.
• Photophobia, small pupils, floaters.

Uveitis

• Inflammation of the uvia
• Posterior ciliary body in pars plana
• Refer to ophthalmologist
• Acute- sudden
• Recurrent- many episodes that come and go

Keratitis

• Inflammation of the cornea
• prolonged contact wearing
• dry eye disease
• EMERGENCY- major cause of blindness
• slit lamp test with transillumination of the iris corneal scraping, eye pain, redness, blurry vision, and photophobia
• increase intraocular pressure hx herpes or varicella, treatment includes tobramycin or gentamycin given for tx and codeine oxycodone given from pain

Aphthous Ulcer

• Small painful round ulcer with yellow gray fibrinoid centers surrounded by red halo
• Topical corticosteroids
• Tapering oral prednisone

Acute Angle Closure Glaucoma

• Refer to ED due to the sudden increase of IOP
• Sudden vision loss
• Pain, usually unilateral, severe, throbbing headache
• N/V
• Blurry or hazy vision, halos around sight
• Rapid loss of peripheral vision, then central vision
• Poorly reacted pupils

Corneal Abrasion

• DX: Confirm with corneal exam using fluorescein & woods lamp or cobalt blue filter and green looking under woods lamp.

TX for Corneal Abrasion

• Topical antibiotic drops/ointment
• Oint is 1st line due to lubricating
• Topical fluoroquinolones.
• nS flushes
• NSAIDs topically; ketorolac drops
• Do not use contacts and corticosteroids
• Usually heals in 24-72 hours

Subconjunctival Hemorrhage

• Benign versus hyphema (blood in anterior chamber; between iris and cornea **emergency)
• Broken blood vessel in the eye
• Self-limiting,Hyphema blood in anterior chamber; between iris and cornea **emergency, No asa or Cycloplegic eye drops

Nasolacrimal Duct Obstruction

• S/S are watery eyes due to lack of tears & mucous drainage
• Tx probing if over 1 year; 1st line intervention. It is most common in neonates and massage

Dacryostenosis

• (Blocked lacrimal sac (tear duct), most common cause of ocular discharge in newborns, inferior turbinate fails to complete canalization, persistent overflow of tears (epiphora), acute distention and inflammation of the lacrimal sac, mucus reflux with pressure; it is common, resolves in 6-9 months, refer if lasting longer than 9-12 months and Treat: massage duct 2-3 times per day

Dacryocystitis

• (Infection of the lacrimal sac due to obstruction)
• Pain, redness, and swelling over the inner aspect of the lower eyelid and watery eyes (epiphora)
• Commonly caused by Staph aureus or Strep pneumoniae
• Treat: warm compresses, oral antibiotics

Herpangia

• Basically “cold sores” with abrupt high fever
• From inner lining of the lips to inside the throat and mouth
• Avoid spicy foods, acidic foods, and toothpaste
• Treatment includes orabase- lidocaine, Benadryl suspension and sucralfate

H. pylori breath test most reliable.