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EENT Infections

EENT Infections. Dr. Patamasucon September 2011. EYE. Conjunctivitis. Neonatal Chemical (silver nitrate)  1-2 days Gonococcal  2-3 days Chlamydia  >5 days

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EENT Infections

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  1. EENT Infections Dr. Patamasucon September 2011

  2. EYE

  3. Conjunctivitis Neonatal • Chemical (silver nitrate)  1-2 days • Gonococcal  2-3 days • Chlamydia  >5 days • HSV  Varies

  4. Neonatal Conjunctivitis Gonococcal Chlamydia trachomatis

  5. Conjunctivitis • Neonatal prevention: • G.C.  Silver nitrate or Penicillin • Chlamydia  No effective drug • (Tetracycline, Erythromycin*, and Silver nitrate not effective) * One report of effectiveness in US but later disproved by the same author and other studies in Nairobi and Taiwan

  6. Conjunctivitis Children • Bacterial • NT H.influ Most common • S.pneumo  Common • G.C.  Adolescents • Viral • Adenovirus  Most common • Enterovirus 70  Epidemic hemorrhagic conjunctivitis

  7. Conjunctivitis • Treatment • Gonoccocal: • Single dose of ceftriaxone or cefotaxime • Copious amount of normal saline or sterile water • Chlamydia: • Erythromycin (PO): 40-50 mg/kg/day x 2 weeks • No topical Rx is needed • Adenovirus/Enterovirus: • Supportive care • HSV: • IV Acyclovir + topical Vidarabine

  8. Periorbital and Orbital Cellulitis • Divided by the orbital septum • Predisposing factors: • Periorbital (preseptal): • Trauma, conjunctivitis, eyelid infection, dacryocystitis, acute sinusitis (esp. ethmoiditis), hematogenous seeding • Orbital (postseptal): • Acute ethmoiditis sinusitis orbital abscess • Hematogenous seeding, trauma

  9. Preseptal (Periorbital) Cellulitis • Etilogy: • If 2° to acute sinusitis: • NT H. influenzae, S.pneumonaie, M.catarrhalis • If 2° to hematogenous spread: • S.pneumo, H.influ type a-f • If 2° to trauma: • S.aureus, GAS • If 2° to conjunctivitis: • NT H.influenzae, S.pneumoniae, N.gonorrhoeae • If 2° to dacryocystitis: • S.aureus, S.pneumoniae, H. influenzae, Group B Strep

  10. Preseptal (Periorbital) Cellulitis • Diagnosis based on: • History • Physical Exam • CT or MRI • Always inquire about HIB and Pneumococcal vaccine immunization

  11. Preseptal (Periorbital) Cellulitis • Treatment: • If secondary to trauma: • Oral Cephalexin or Clindamycin (MRSA) • If secondary to sinusitis: • Augmentin, cefdinir, cefuroxime, cefpodoxime • Severe cases: Ceftriaxone + Vancomycin • If secondary to hematogenous spread: • Ceftriaxone + Vancomycin

  12. Postseptal (Orbital) Cellulitis • May be secondary to: • Acute sinusitis: • S. pneumoniae, Non-typeableHaemophilus, • M. catarrhalis, anerobes (occasionally) • Penetrating Trauma: • S. aureus, GAS, anerobes (Prevotella, Fusobacterium, Veillonella, Bacteroides sp.), occasionally GN organisms • Hematogenous spread: • S. aureus, S. pneumoniae, H. influenzae (type a-f), GAS

  13. Postseptal (Orbital) Cellulitis • Symptoms: • Proptosis, nerve palsy, abscess seen on CT or MRI • Treatment: • I&D with ENT, ophthalmologic evaluation • If 2° to sinusitis: • IV ceftriaxone + vancomycin + metronidazole • If 2° penetrating trauma: • Same as sinusitis + GN coverage • If 2° to hematogenous spread: • Same as sinusitis

  14. Postseptal (Orbital) Cellulitis

  15. Sinuses

  16. Sinusitis Age of sinus development • Birth  Maxillary & Ethmoid • 8 years +  Frontal Duration of Illness • Acute  10-30 days • Subacute  31-120 days • Chronic  >120 days

  17. Sinusitis • Microbiology (acute & subacute) • Viruses: rhinovirus, adenovirus, influenza, parainfluenza • Predisposes to bacterial infection • Bacteria: • S.pneumoniae (30-40%), NT H.influenzae (20%), M.catarrhalis (20%) • Less common: Strep Group A or C, Strep Viridan, E.corrodens • Uncommon: anerobes, S.aureus, GNB, mycoplasma, and fungi (aspergillus, mucor)

  18. Sinusitis • Microbiology (chronic) • Similar to acute & subacute organisms + anaerobes, S.aureus(3%), GNB (2%), and S.pneumoniae resistant

  19. Sinusitis • Diagnosis: • Clinical history and physical exam • Transillumination (up to 80% in older than 1 yo) • X-Ray (plain film, CT, MRI): unnecessary and can be positive for 2 weeks post viral URI

  20. Sinusitis • Clinical Presentation: • Acute bacterial sinusitis: • Nasal discharge and day time cough >10-14 days • Facial pain ≥ 3 days • Headache • Morning facial periorbital edema • Fever > 39°C, purulent nasal discharge

  21. Sinusitis • Chronic Sinusitis Clinical Presentation: (> 4 months) • Congestion/ postnasal drip • Cough • Mouth breathing • Bad breath • Sore throat • Impaired sleep • Diagnosis: history, PE, with CT or MRI • Treatment: • Sinus aspiration for culture and sensitivity • Amoxicillin/Clavulanate • IV Oxacillin or Clindamycin + Ceftriaxone • Ampicillin/sulbactam (Unasyn)

  22. Sinusitis • Sinusitis in a seriously ill patient with complications • Aspirate and Culture • Add coverage against S.aureus • Ceftriaxone and Vancomycin • Surgical drainage of sinuses may be necessary

  23. Sinusitis • Treatment: • Acute bacterial sinusitis: • 40% is self limiting • Persistant/uncomplicated sinusitis: • High dose Amoxicillin 80-90mg/kg/day ÷ BID for 7 asymptomatic days • Severe sinusitis (not responsive to meds > 3 days): • High dose Amoxicillin/Clavulanate (PO) for 7 asymptomatic days • Alternative drugs: Cefdinir, cefuroxime, cefpodoxime • Ceftriaxone 50mg/kg/day

  24. Sinusitis • Predisposing factors for recurrent or chronic sinusitis • Recurrent URI • Daycare or school aged sibling • Allergies • Immunodeficiency (IgG; IgG subclasses, IgA, AIDS • Cystic Fibrosis • CiliaryDyskinesia • Anatomical • Deviated nasal septum, nasal polyps, osteomeatal complex disease

  25. Sinusitis • Major complications of sinusitis • Orbital Region • Preseptalcellulitis • Subperiosteal abscess • Orbital cellulitis/abscess • Optic neuritis • Osteomyelitis • Frontal (Pott’s puffy tumor) • Maxillary • Intracranial • Epidural abscess • Subdural empyema • Cavernous sinus thrombosis • Meningitis • Brain abscess

  26. Ears

  27. Otitis Media Definition of AOM A diagnosis of AOM requires 1) a history of acute onset of signs and symptoms 2) the presence of MEE*, and 3) signs and symptoms of middle-ear inflammation. MEE*: Buldging of tympanic membrane Limited or absent TM mobility Air fluid level behind TM Otorrhea

  28. Otitis Media • Etiologic Agents: • S. pneumoniae (40-50%) • Nontypeable H. influenzae (20-30%) • M. catarrhalis (10-15%) • Treatment: • First Line: • High dose Amoxicillin (80-90mg/kg/day) • Second Line: • High dose Amoxicillin/Clavulanate(clavulanate <10mg/kg/day) • Cefdinir • Third Line: • Clindamycin • IM Ceftriaxone (daily x 3 days)

  29. Otitis Media • Duration of Treatment of AOM: • 5-7 days for uncomplicated course in child > 2yo* • ≥ 10 days for child <2 yo or complicated course • *Uncomplicated course no perforation of TM

  30. Mastoid

  31. Mastoiditis • Etiology: • Acute/Subacute: • Common: S.pneumoniae, Group A Strep, S.aureus • Uncommon: NT Haemophilis, M.catarrhalis, Strep viridans • Chronic: • S.aureus, anaerobic or GNB

  32. Mastoiditis • Clinical Presentation: • Fever with tenderness at the region of the mastoid process ± swelling behind the ear • Pinna position is down and out • Tympanic membrane is usually inflamed • Occasionally have palpable subperiosteal abscess over the mastiod

  33. Mastoiditis • Diagnosis: • History, Physical exam + CT or MRI • Fluid and/or bony destruction of the mastoid air cells • Tympanocentesis can provide causative agent(s) • Treatment: • Myringotomy (drain C/S) • Mild cases: Amoxicillin/Clavulanate • Moderate/ Severe cases: IV Ceftriaxone + Vancomycin • Mastoid abscess I&D

  34. Throat

  35. Peritonsillar Abscess (Quinsy) • Pus in tonsillar fossa • Usually in young adolescents • 5-15 years old • Symptoms: • Fever, sore throat, dysphagia, drooling • Refusal to eat • Trismus, muffled voice (hot potato voice) • Unilateral neck or ear pain

  36. Peritonsillar Abscess • Signs: • Unilateral peritonsillar bulging • Uvular deviation • Fluctuance of palatal swelling • Red, swollen pharynx and exudative tonsils • Cervical adenopathy • Torticollis • Causative Agents: • Most common: • Strep Group A, α-hemolytic streptococci, oral anerobes, S.aureus

  37. Peritonsillar Abscess • Treatment: • Penicillin • Clindamycin • Oxacillin • Cefazolin • Ampicillin/sulbactam

  38. Retropharyngeal Abscess • Etilogy: • Most common: • GAS, α-hemolytic streptococci, oral anaerobes, S.aureus • History: • Fever, sore throat, dysphagia, drooling, refusal to eat, neck pain or stiffness, • Physical Exam: • Neck pain: especially with extension • Torticollis, head in neutral position

  39. Retropharyngeal Abscess • Diagnosis: • Lateral neck x-ray • CT scan • Treatment: • Antibiotics + ENT drainage • Cefotaxime + metronidazole • Clindamycin • Ampicillin/sulbactam

  40. Retropharyngeal Abscess • Complications: • Extension to carotid sheath • Extension posteriorly causing atlantoaxial dislocation • Spontaneous rupture aspiration asphyxiation • Mediastinitis

  41. Neck

  42. Names to Recognize • Ludwig Angina: • Cellulitis bilateral sublingual, submandibular space • “Bull Neck” • Abscesses are infrequent • Respiratory obstruction is a major risk • Most severe in immunocompromised hosts • Treatment: • Secure airway, drain any abscesses, antimicrobials • Amoxicillin/clavulanate, ampicillin/sulbactam, clindamycin

  43. Names to Recognize • Lemierre Syndrome: • Caused by Fusobacteriumnecrophorum • Intense toxicity, spiking fevers, tonsillar exudates, increased ICP, HA, meningismus • Anterior sternocleidomastoid muscle pain and swelling • Complications: • Erosion of carotid artery • Intracranial extension • Lateral pharyngeal space infection internal jugular septic emboli (lung, liver, systemic) cavernous sinus thrombosis

  44. Names to Recognize • Lemierre Syndrome: • Treatment: • Antibiotics • Clindamycin OR ampicillin/sulbactam • Zosyn • Vein ligation

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