Transcript Otitis & Pharyngitis in Peds

Otitis & Pharyngitis in Peds
Chp 121 Tintinalli
4/13/06
Dr. Batizy
Slides by Bogdan Irimies
Otitis Media: definitions
• Otitis media: inflammation of middle ear
• Acute otitis media (AOM): s/sx’s of
infection, otalgia, otorrhea, fever, irritability,
anorexia or vomiting.
• Otitis media w/effusion(OME):
asymptomatic collection of fluid in middle
ear
Ear Anatomy:
Ear Anatomy:
Otitis Media:
• OME: duration can be divided into:
– Acute <3 wks
– Subacute 3wks-3 mos
– Chronic >3 mos.
Most important distinction between OME and
AOM is the s/sx’s of acute infection (otalgia,
otorrhea,fever) are lacking in OME.
Acute Otitis Media:
• Peak incidence b/w 6-18 mos.
• Bacteria most common organism, isolated
60-75% of cultures
• Bacteria colonize the nasopharynx and
enter middle ear thru Eustachian Tube.
Acute Otitis Media: Organisms
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Strep. Pneumoniae 40-50%
H. Flu 30-40%
M. catarrhalis 10-15%
GABHS/Strep. Pyogenes & Staph. Aureus
2%
• Chlamydia pneumonia in those <6 mos old
Acute Otitis Media:
Pathophysiology
• Abnormal function of eustachian tube
appears to be dominant factor: obstruction
and abnormal patency
• Upper respiratory tract infections or
allergies can cause obstruction and
decrease ET function
• Abnormal Patency may allow reflux of
nasopharyngeal secretions
Acute Otitis Media: Clinical
Features
• Otalgia, otorrhea, fever, ear pulling &
irritability (especially in infants)
• Most important diagnostic tool is
pneumatic otoscopy
• Light reflex is no diagnostic value
• TM of AOM:
– Opaque, pale yellow, red, bulging and bony
landmarks are lost, loss of or decrease in
mobility of TM
Acute Otitis Media:
Acute Otitis Media: Treatment
• Selection of ATBX is based on the following
factors:
– 1. Knowledge of likely etiologic agent or recovery of
specific pathogen from middle ear
– 2. Efficacy of specific ATBX’s for responsible
organisms
– 3. ATBX penetration into middle ear fluid
– 4. Drug allergy hx
– 5. Compliance
– 6. Drug side effects
– 7. Treatment failure or success of previous drug
regimens for that child
Acute Otitis Media: Treatment
• High dose Amoxicillin is 1st line
– Due to prevalence of Drug resistant strep.
Pneumoniae(DRSP)
– Dose is 80-90 mg/kg/day
– High risk patients for DRSP:
• ATBX w/in past 3 mos
• Day Care
• Age < 2 y/o
Acute Otitis Media: Other Options
• Amox-Clav
• TMP/SMX
• Cefaclor/cefuroxime/
Cefprozil/Cephalexin
• Cefdinir/ceftriaxone
• Azithromax/Clarithro
mycin
• 10 day course for all
ATBX (except Zithro)
• If after 3 days of
treatment and still
AOM:
• High dose amox-clav
• Cefuroxime
• IM Ceftriaxone (50
mg/kg /day) for 3
consecutive days
• Cefdinir(Omnicef)
Acute Otitis Media: Special
Treatment
• PCN Allergy: Clinda, Erythromycin, TMP/SMX,
clarithromycin, azithromycin
• Infant < 2wks old:
– GBS, S. aureus, Gram neg. Bacilli
– Full septic W/U: CBC, Blood cx’s, UA/C&S, LP/CSF
C&S, CXR
– Admit for IV ATBX: amp + Gent or ceftriaxone
– If 2-6 wks old: possible septic W/U depending on
appearance of infant, available close follow up
Acute Otitis Media: Additional
Therapy
• Antipyretics
• Analgesics: Auralgan instilled into EAC
(don’t use if TM perforated)
• Peds should F/U 10-14 days after
completion of ATBX therapy
Recurrent Otitis Media:
• Definition: 3 or > of AOM in 6 mos or 4
episodes of AOM w/in 12 mos with at least
1 episode w/in past 6 mos.
• Risk factors: onset of AOM < 1 y/o, day
care, genetic susceptibility/family hx
• Tx: prophylactic ATBX
– Amox 20mg/kg/d for 3-6 mos
– If fail ATBX, myringotomy w/tympanostomy
tube insertion
Persistent Otitis Media:
• Defined as presence of AOM w/in 3 days
of Tx or recurrence of s/sx’s w/in
completion of 10 day ATBX course
• Caused by either relapse or reinfection
• Tx: High dose amox-clav/cefdinir/
cefuroxime/IM ceftriaxone x 3 days
Chronic Suppurative Otitis Media:
CSOM
• Defined as persistence > 6 wks of a
chronic inflammation of middle ear and
mastoid in the presence of perforated or
non-intact TM.
• Usually the sequela of partly treated or
untreated AOM or recurrent AOM
• Ofloxacin otic for peds >12 y/o and for
AOM in peds > 1 y/o w/T-tubes or nonintact TM’s.
Chronic Suppurative OM:
Complications & Sequelae of OM:
• Hearing loss
• TM perforation or
retraction
• Tympanosclerosis
• Adhesive OM
• Ossicular
discontinuity
• CSOM
• Cholesteatoma
•
•
•
•
Mastoiditis
Petrositis
Labyrinthitis
Facial paralysis
Complications & Sequelae of OM:
• Intracranial complications:
– meningitis
– extradural abscess
– subdural empyema
– focal encephalitis
– Brain abscess
– Sigmoid sinus thrombosis
– Otic hydrocephalus
Otitis Media w/Effusion: OME
• Collection of fluid in middle ear w/out
acute s/sx’s of infection. Usually follows an
episode of AOM.
• Hearling loss is most prevalent and
dangerous complication of OME
– Cognitive linguistic and speech development
is affected
OME:
Otitis Media w/Effusion: OME
• Management options:
– Peds 1-3 y/o w/OME for at least 3 mos: obs
w/no treatment or treatment w/ATBX for 10-14
days
– Peds w/ OME for at least 3 mos and hearing
loss: refer to ENT for T-tubes
– T-Tubes remain in for few wks to several
years
Otitis Externa:
• Def: inflammatory condition of auricle,
external ear canal or outer surface of TM.
• Caused by infection, inflammatory
dermatoses, trauma or any combination
of the 3.
• Pathogenic organisms: P. aeruginosa, S.
aureus, fungi
Otitis Externa:
• Clinical s/sx’s: itching, sense of fullness in
ear, pain, redness, edema, tenderness of
canal, cheesy/purulent drainage from
canal.
• Otomycosis: OE caused by fungus,
Aspergillus niger, intense itching, more
common w/underlying immune disorders
and Diabetes mellitus
Otitis Externa:
Otitis Externa:
Otitis Externa: Treatment
• Atraumatic cleaning of the ear is most
important step, can use gentle suctioning
• Mild OE: cleaning & acetic acid eardrops
(Otic Domeboro) 3-4 x a day for 1 week.
• Moderate OE: cleaning plus ATBX drops
such as neomycin & polymyxin B, Floxin
Otic, Cipro HC
• Otomycosis: 2% acetic acid
Pharyngitis: Non-Streptococcal
• Most are caused by viruses: adenovirus,
EBV, influenza virus, parainfluenza,
rhinovirus, herpes simplex, enterovirus.
• Clinically difficult to distinguish from Group
A Beta hemolytic Strep.(GABHS).
• Other non-GABHS causes are
Corynebacterium diphtheriae, N.
gonorrhea, HIV 1.
Pharyngitis: Non-Streptococcal
• C. diptheria: cause of pharyngitis in developed
countries
– Infectious invasion can produce tissue necrosis and
pseudomembrane that can cause airway obstruction.
– Produces an exotoxin that can cause wide spread
organ damage: myocarditis, cardiac dysrhythmia,
neuritis w/bulbar and peripheral paralysis, nephritis,
and hepatitis
– TX: PCN or erythromycin and horse serum anti-toxin
Pharyngitis: Non-Streptococcal
• N. gonorrhea: cause of pharyngitis in
sexually active adolescents
– Maybe asymptomatic or cause mild
symptoms w/exudative tonsillitis and/or
cervical lymphadenopathy
– Obtain rectal/vaginal/urethral cx’s and test for
Hep. B and syphilis when suspected
– Tx: ceftriaxone 125 mg IM x 1
Gonococcal Pharyngitis:
Pharyngitis: Non-Streptococcal
• EBV:
– Herpes virus that causes Infectious
mononucleosis(IM)
– Classic IM: malaise, fatigue, fever, sore throat,
adenopathy, organomegally
– Can be co-infected w/EBV & GABHS
– Supportive treatment (fluids,rest,
acetaminophen)
Pharyngitis: Non-Streptococcal
• HIV: can produce an IM like syndrome
w/fever, sore throat, adenopathy
• Can have GI and mucocutaneous
symptoms which occur more likely w/HIV
v/s IM infection
Streptococcal Pharyngitis:
• Peak months are Jan.-May
• Peak ages 4-11, GABHS uncommon < 3
y/o
• Characteristic s/sx’s
– Fever, sore throat, erythema of tonsils &
pharynx, exudate of tonsils & pharynx,
erythema & edema of uvula, petechiae of soft
palate, enlarged tender ant. Cervical lymph
nodes, scarlatiniform rash
Streptococcal Pharyngitis:
• Headache, vomiting, abd. Pain,
meningismus and torticollis can also occur
• Coughing, rhinorrhea or ulceration suggest
alternative diagnosis
Strep. Pharyngitis:
Streptococcal Pharyngitis:
• Dx:
– Multitude of rapid antigen procedure including
ELISA, latex agglutination, coagglutination
– Sensitivity 85-90%, specificity 98-100% under
ideal conditions but more like sensitivity of
50%
– False positive rate is low, false neg. rate is
high
– If test is +, treat GABHS, if neg, send throat
culture
Streptococcal Pharyngitis: Tx
• Objectives to treat GABHS are:
– Prevent rheumatic fever
– Prevent suppurative complications
(peritonsillar/retropharyngeal abscess,
cellulitis, suppurative cervical lymphadentis
– Hasten clinical recovery
Streptococcal Pharyngitis: Tx
• PCN G IM 600,000 units if <27 kg or 1.2
million units IM if > 27 kg (good choice if
compliance an issue)
• Oral PCN 250-500 mg bid x 10 days
• Amoxicillin soln for peds unable to swallow
pills
• PCN allergy: erythromycin or
cephalosporin
Streptococcal Pharyngitis: Tx
• Recommended peds w/GABHS infection
receive ATBX for 24 hrs before returning to
school/day care
• Summary: if rapid test is +, treat.
– If classic clinical finding or a scarletiniform
rash is present, treat regardless of rapid test.
Streptococcal Pharyngitis:
Complications
• Overall incidence of rheumatic fever
<1:100,000 in U.S.
• Post-strep. Glomerulonephritis is not
prevented w/ATBX, related to
nephritogenic strain of streptococci
• Invasive GABHS infections include:
– Septicemia, toxic shock like syndrome,
pneumonia, cellulitis, lymphangitis,
necrotizing fasciitis
Skin and Soft Tissue
Infections
Chp 122 Tintanalli
Dr. Batizy
Slides by Bogdan
Conjunctivitis:
• Inflammation of the conjunctivae
• Result of infection, allergy, mechanical or
chemical irritation
• In newborns: Chlamydia trachomatis & N.
gonorrhea
• Children: adenovirus, Hemophilus species,
strep. pneumoniae
Conjunctivitis: Clinical
• Photophobia
• Ocular pain or
pruritus
• Foreign body
sensation
• Conjunctival
erythema
• Crusting of the
eyelids
Conjunctivitis: Clinical
• Examination for: visual acuity, visual fields, EOM
function, periorbital area, eyelid eversion,
conjunctiva fluorescein staining of cornea,
pupillary reflex, anterior chamber, and fundus.
• In conjunctivitis: erythema, increased secretions,
cornea stain is neg. except if herpetic keratitis
and adenovirus, visual acuity is normal
• Gram stain only is neonates or confusing cases
Conjunctivitis: bacterial
D/Dx: Red Eye
• Infectious
Conjunctivitis
• Orbital/periorbital
cellulitis
• Foreign body
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Corneal abrasion
Uveitis
Glaucoma
Allergic conjunctivitis
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–
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Chronic
Seasonal
Pruritus
Symptoms of allergic
rhinitis
Allergic Conjunctivitis:
Conjunctivitis: Tx
• If fluorescin stain + for dendritic
ulcerations, treat herpetic disease
w/acyclovir, Opth. C/S
• Neonate(<1mos): gram stain for N.
gonorrhea and ceftiaxone IV
• Other infectious species(H/Flu, strep.
pneumo etc) : topical ointments or eye
drops( erythromycin or sulfa)
Sinusitis:
• Inflammation of the paranasal sinuses:
maxillary, ethmoid, frontal or sphenoid
• Can be infectious or allergy related
• Can be acute, subacute or chronic
• Major pathogens: Strep. Pneumo, M.
Catarrhalis, H. Flu
Sinusitis:
• Ethmoid and maxillary sinuses present at
birth, frontal and sphenoid sinuses at 6-7
y/o
• Obstruction of ostia are from mucosal
swelling or mechanical obstruction:
– Viral URI’s, allergic inflammation, CF, trauma,
choanal atresia, deviated septum, polyps,
foreign body, tumor
Sinusitis:
• Sx: headache, bilateral mucopurulent
nasal discharge, fever, localized swelling
or erythema, facial tenderness
• CT of face/sinuses should be obtained in
patients w/uncertain clinical diagnosis or
cases of severe sinusitis
– Mucosal thickening > 4mm indicative of
infection
Sinusitis: Complications
• Periorbital/orbital cellulitis
• Osteomyelitis: Potty puffy tumor, osteo of frontal
bone
• Epidural/subdural or brain abscess
• Meningitis
• Cavernous sinus thrombosis
• Suspicion of intracranial lesion requires
neuroimaging such as CT head w/contrast for
brain abscess and subdural empyema
• MRI for cavernous sinus thrombosis or epidural
empyema
Sinusitis: Tx
• Amox high dose 80-90 mg/kg/d for 10-14
days
• 2nd/3rd gen cephalosporin's
• Amox-clav
Impetigo:
• Superficial skin infection confined to the
epidermis
• 2 types: impetigo contagiosa and bullous
impetigo
• Epidemic spread assoc w/ warm weather,
overcrowding, poor hygiene
• GABHS and staph. Aureus most common
organisms
Impetigo:
• Infection develops after break in skin from
abrasion or insect bite
• Lesions are erythematous papules that
progress to crusted lesions.
– Honey colored and fine
– Appear most commonly upper lip and nose
areas
Impetigo:
Impetigo:
• Bullous impetigo: superficial bullae filled
w/purulent material
• Tx is oral or topical ATBX
– Cephalexin
– Mupirocin topical
– Routine cleanliness
Bullous Impetigo:
Cellulitis:
• Infection of the skin and SC tissues
• Extends below the dermis differentiating it
from impetigo but does not involve
muscle(pyogenic myositis) or bone
(osteomyelitis)
• Most common organisms: S. aureus, S.
pyogenes, H. Flu
Cellulitis:
• Local inflammatory response after breach
in skin
• Erythema, edema, warmth, and
tenderness
• Trunk & extremity: most likely S. aureus
• Face/cheek: H. flu
Cellulitis:
• Lab test like CBC, blood cx’s, aspirate cultures
are indicated only for: immunocompromise,
fever, severe local infection, facial involvement,
failure to respond to therapy
• Admit:
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–
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–
Signs of sepsis
Immunocompromise
<6 mos old
Clinically ill appearing
Periorbital/Orbital Cellulitis:
• Periorbital:cellulitis anterior to the orbital
septum
• Orbital: cellulitis within the orbit
• S. aureus, S. pneumonia, H. Flu most
common microrganisms
• Organisms reach area either
hematogenously or by direct extension
from ethmoid sinuses
Cellulitis:
• Tx:
– Cephalexin
– Dicloxacillin
– Amp/sulbactam
– Ceftriaxone
– Immunocompromised: use Oxacillin IV or
cefazolin IV plus aminoglycoside
Periorbital Cellulitis:
Orbital Cellulitis:
Orbital Cellulitis:
Periorbital/Orbital Cellulitis:
• Orbital/periorbital cellulitis causes the periorbital
area to be red and swollen.
• Proptosis or limitation of EOM function indicates
orbital involvement.
• Perform CT if orbital involvement.
• Complications:
– Periorbital cellulitis can serve as focus for mets
bacterial disease, i.e meningitis
– Orbital cellulitis can cause subperiosteal abscess
Periorbital/Orbital Cellulitis:
• Treatment:
– Admit
– IV ATBX: amp/sulbactam or ceftriaxone
– Blood cx’s
Questions:
• 1. Which of the following organisms are
most common cause of AOM:
• A. Strep. Pneum/H.Flu/M.CAT
• B. Pseudomonas
• C. S. Aureus
• D. None of the above
Question:
• 2. What is most common organsim for
Otitis Externa:
• A. Pseudomonas
• B. S. aureus
• C. Strep. Pneumo
• D. Strep. pyogenes
Question:
• 3. Which of the following is a risk factor for
DRSP:
• A. Daycare
• B. < 2/yo
• C. Previous ATBX w/in past 3 mos.
• D. all of above
Question:
• 4. Which of the following can cause non.
Strep pharynguitis:
• A. HIV
• B. EBV
• C. C. Dipth
• D. N. gonorrhea
• E. all of above
Question:
• 5. What distinguishes Periorbital from
Orbital cellulitis?
• A. Proptosis/EOM limitation
• B. Degree of erythema
• C. Fever, WBC
• D. Duration of infection
Answers
•
•
•
•
•
1. A
2. A
3. all of above
4. all of above
5. A