Otitis

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Otitis Pharyngitis in PedsChp 121 Tintinalli

• 4/13/06
• Dr. Batizy
• Slides by Bogdan Irimies

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Otitis Media definitions

• Otitis media inflammation of middle ear
• Acute otitis media (AOM) s/sxs of infection,
  otalgia, otorrhea, fever, irritability, anorexia
  or vomiting.
• Otitis media w/effusion(OME) asymptomatic
  collection of fluid in middle ear

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Ear Anatomy
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Ear Anatomy
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Otitis Media

• OME duration can be divided into
• Acute lt3 wks
• Subacute 3wks-3 mos
• Chronic gt3 mos.
• Most important distinction between OME and AOM is
  the s/sxs of acute infection (otalgia,
  otorrhea,fever) are lacking in OME.

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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.

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Acute Otitis Media Organisms

• Strep. Pneumoniae 40-50
• H. Flu 30-40
• M. catarrhalis 10-15
• GABHS/Strep. Pyogenes Staph. Aureus 2
• Chlamydia pneumonia in those lt6 mos old

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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

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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

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Acute Otitis Media
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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 ATBXs 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

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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 lt 2 y/o

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Acute Otitis Media Other Options

• Amox-Clav
• TMP/SMX
• Cefaclor/cefuroxime/Cefprozil/Cephalexin
• Cefdinir/ceftriaxone
• Azithromax/Clarithromycin
• 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)

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Acute Otitis Media Special Treatment

• PCN Allergy Clinda, Erythromycin, TMP/SMX,
  clarithromycin, azithromycin
• Infant lt 2wks old
• GBS, S. aureus, Gram neg. Bacilli
• Full septic W/U CBC, Blood cxs, UA/CS, LP/CSF
  CS, 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

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Acute Otitis Media Additional Therapy

• Antipyretics
• Analgesics Auralgan instilled into EAC (dont
  use if TM perforated)
• Peds should F/U 10-14 days after completion of
  ATBX therapy

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Recurrent Otitis Media

• Definition 3 or gt 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 lt 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

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Persistent Otitis Media

• Defined as presence of AOM w/in 3 days of Tx or
  recurrence of s/sxs 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

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Chronic Suppurative Otitis Media CSOM

• Defined as persistence gt 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 gt12 y/o and for AOM in
  peds gt 1 y/o w/T-tubes or non-intact TMs.

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Chronic Suppurative OM
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Complications Sequelae of OM

• Hearing loss
• TM perforation or retraction
• Tympanosclerosis
• Adhesive OM
• Ossicular discontinuity
• CSOM
• Cholesteatoma

• Mastoiditis
• Petrositis
• Labyrinthitis
• Facial paralysis

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Complications Sequelae of OM

• Intracranial complications
• meningitis
• extradural abscess
• subdural empyema
• focal encephalitis
• Brain abscess
• Sigmoid sinus thrombosis
• Otic hydrocephalus

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Otitis Media w/Effusion OME

• Collection of fluid in middle ear w/out acute
  s/sxs 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

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OME
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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

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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

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Otitis Externa

• Clinical s/sxs 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

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Otitis Externa
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Otitis Externa
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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

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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.

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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

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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 cxs and test for
  Hep. B and syphilis when suspected
• Tx ceftriaxone 125 mg IM x 1

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Gonococcal Pharyngitis
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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)

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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

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Streptococcal Pharyngitis

• Peak months are Jan.-May
• Peak ages 4-11, GABHS uncommon lt 3 y/o
• Characteristic s/sxs
• 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

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Streptococcal Pharyngitis

• Headache, vomiting, abd. Pain, meningismus and
  torticollis can also occur
• Coughing, rhinorrhea or ulceration suggest
  alternative diagnosis

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Strep. Pharyngitis
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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

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Streptococcal Pharyngitis Tx

• Objectives to treat GABHS are
• Prevent rheumatic fever
• Prevent suppurative complications
  (peritonsillar/retropharyngeal abscess,
  cellulitis, suppurative cervical lymphadentis
• Hasten clinical recovery

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Streptococcal Pharyngitis Tx

• PCN G IM 600,000 units if lt27 kg or 1.2 million
  units IM if gt 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

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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.

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Streptococcal Pharyngitis Complications

• Overall incidence of rheumatic fever lt1100,000
  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

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Skin and Soft Tissue Infections

• Chp 122 Tintanalli
• Dr. Batizy
• Slides by Bogdan

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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

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Conjunctivitis Clinical

• Photophobia
• Ocular pain or pruritus
• Foreign body sensation

• Conjunctival erythema
• Crusting of the eyelids

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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

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Conjunctivitis bacterial
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D/Dx Red Eye

• Infectious Conjunctivitis
• Orbital/periorbital cellulitis
• Foreign body

• Corneal abrasion
• Uveitis
• Glaucoma
• Allergic conjunctivitis
• Chronic
• Seasonal
• Pruritus
• Symptoms of allergic rhinitis

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Allergic Conjunctivitis
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Conjunctivitis Tx

• If fluorescin stain for dendritic ulcerations,
  treat herpetic disease w/acyclovir, Opth. C/S
• Neonate(lt1mos) gram stain for N. gonorrhea and
  ceftiaxone IV
• Other infectious species(H/Flu, strep. pneumo
  etc) topical ointments or eye drops(
  erythromycin or sulfa)

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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

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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 URIs, allergic inflammation, CF, trauma,
  choanal atresia, deviated septum, polyps, foreign
  body, tumor

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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 gt 4mm indicative of infection

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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

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Sinusitis Tx

• Amox high dose 80-90 mg/kg/d for 10-14 days
• 2nd/3rd gen cephalosporin's
• Amox-clav

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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

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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

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Impetigo
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Impetigo

• Bullous impetigo superficial bullae filled
  w/purulent material
• Tx is oral or topical ATBX
• Cephalexin
• Mupirocin topical
• Routine cleanliness

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Bullous Impetigo
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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

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Cellulitis

• Local inflammatory response after breach in skin
• Erythema, edema, warmth, and tenderness
• Trunk extremity most likely S. aureus
• Face/cheek H. flu

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Cellulitis

• Lab test like CBC, blood cxs, aspirate cultures
  are indicated only for immunocompromise, fever,
  severe local infection, facial involvement,
  failure to respond to therapy
• Admit
• Signs of sepsis
• Immunocompromise
• lt6 mos old
• Clinically ill appearing

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Periorbital/Orbital Cellulitis

• Periorbitalcellulitis 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

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Cellulitis

• Tx
• Cephalexin
• Dicloxacillin
• Amp/sulbactam
• Ceftriaxone
• Immunocompromised use Oxacillin IV or cefazolin
  IV plus aminoglycoside

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Periorbital Cellulitis
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Orbital Cellulitis
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Orbital Cellulitis
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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

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Periorbital/Orbital Cellulitis

• Treatment
• Admit
• IV ATBX amp/sulbactam or ceftriaxone
• Blood cxs

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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

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Question

• 2. What is most common organsim for Otitis
  Externa
• A. Pseudomonas
• B. S. aureus
• C. Strep. Pneumo
• D. Strep. pyogenes

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Question

• 3. Which of the following is a risk factor for
  DRSP
• A. Daycare
• B. lt 2/yo
• C. Previous ATBX w/in past 3 mos.
• D. all of above

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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

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Question

• 5. What distinguishes Periorbital from Orbital
  cellulitis?
• A. Proptosis/EOM limitation
• B. Degree of erythema
• C. Fever, WBC
• D. Duration of infection

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Answers

• 1. A
• 2. A
• 3. all of above
• 4. all of above
• 5. A