Download OME (otitis media with effusion)

OME (otitis media with effusion)
AOM(acute otitis media)
-sterile (non-infectious) secretory otitis media, secondary to a viral
URTI
-aural fullness with mild hearing loss due to E tube occlusion and
absorption of air
-prominent appearance of manubrium and short process with
retraction of ear drum
-fluid and air bubble are visible
-reduced TM-mobility
-accumulation or serous effusion in the middle ear
-acute bacterial infection of the middle ear secondary to a viral
URTI, often after OME
-bulging TM / opaque
-ruptured eardrum
-pus accumulation in middle ear
-thickened eardrum with erythema (hyperemia)
-distorted (dullness) / absent light reflex
-reduced TM-mobility
-may lead to TM perforation or rare complications
-swelling and destruction of the mucosa in the URT, including E
tube
-E tube dysfunction (ETD)
ETD => absorption of air from middle ear =>
retraction of TM and accumulation of sterile effusion
-hear loss, ear popping, gurgling sound (common in child)
-don’t treat with antibiotics yet
-may develop into AOM
-chronic OME = may have to be treated with ear tube to avoid
serious complication
-bacterial infection of the middle ear
-initial viral URTI
-swelling and destruction of the mucosa of the URT, including E
tube
-E tube dysfunction (ETD)
-secondary bacterial infection in the middle ear (NPH flora):
Streptococcus pneumoniae / Hemophilus influenzae
Moraxella catarrhalis
-pus accumulation and increase pressure in the middle ear
-painful and fever
-AOM is common in young children (peak age 2)
-spontaneous rupture of TM = common complication
-AOM leads to OME in the healing stage
-very slow healing (6 to 8 weeks)
(Chronic OME and Complication):
-permanent hearting loss and learning difficulties
-tympanosclerosis
-perforation of the ear drum
-retraction pockets
-cholesteatoma:
skin cyst grows into the middle ear and mastoid
cyst is not cancerous but can erode tissue and cause destruction of
the ear / benign epidermoid tumor
(presentation of cholesteatoma):
hearing loss / facial paralysis / dizziness / imbalance / vertigo
slow erosion into the brain cavity / intracranial complication risk
-OME is the most common cause of conductive hearing loss in
children (hearing loss dominates as the main symptom)
-OME cause milder earache
-OME is a harmness and self-limiting condition in most cases
-conservative treatment is suggested
-treatment of B/L chronic OME = myringotomy / grommets
(early signs): OME sign
(1) immobile and retracted TM
(2) moderate erythema of the TM / clear fluid and air bubble in ME
(consecutive signs): AOM sign
(1) formation of yellow, purulent effusion
(2) increased middle ear pressure
(3) bulging eardrum
(4) intense pain
(AOM complication):
-extracranial (intratemporal) complication:
(1) acute mastoiditis = infection of mastoid air cells
(2) facial palsy (paresis)
(3) labyrinthitis = light-headedness / loss of balance / nausea
-intracranial complication:
(1) meningitis = nuchal rigidity / photophobia / headache
(2) brain abscess = ICU brain surgery
(3) neurological deficit symptoms (increased DTR) = spinal cord
(4) venous thrombosis of lat / sigmoid venous sinus = vessels
-occur in patients with cholesteatoma
(early symptoms):
high fever => meningism => change consciousness => death
-two most common complications to AOM
perforation of the eardrum / chronic AOM or chronic OME
-Bullous myringitis :
results from viral infection / may accompany AOM
large vesicles and bullae visible on the drum / TM is red
-AOM causes intense otalgia
-sensory nerves in ear:
posterior roots of spinal nerves C2 / 3 and CN 5, 7, 9, 10
tensor tympani (CN 5:3) / stapedius mm (CN7) / CN 7 travels through temporal bone = referred pain cause earache
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URTI
(common URTI symptoms and signs):
-rhinitis = swelling of nasal mucosa and nasal obstruction
-conjunctivitis / coryza / rhinorrhea / pharyngitis / tonsillitis
-earache / dysphagia / cough / hoarseness / fever / fatigue
-sore throat = odynophagia
-malaise / abdominal pain / vomiting / diarrhea / mouth breathing
(bacterial infection):
-bacterial infections tend to spread and cause severe complications
-effective antibiotic treatment is still effective for bacterial
infections
-one dominant symptom
-intense pharyngeal erythema
-purulent discharge (yellow / green / brownish)
-exudates on tonsil
-fever spike and new symptoms = secondary bacterial infection
-(CBC finding) = neurophilia (neutrophilic granulocytosis = PMN)
increased CRP (acute bacterial infection)
increased ESR (chronic bac or viral infection)
TB or osteomyelitis
* CRP reacts quickly to infection activity
ESR reacts slowly to infection activity
(viral infection):
-many symptoms = generally viral spread in the whole URT
-if cough = viral infection
-(CBC finding) = lymphocytosis (or lymphopenia)
(lab tests to differentiate viral and bacterial infection):
(1) rapid streptococcal antigen test = group A beta-hemolytic
(GABHS)
(2) bacterial / viral cultures
(3) serologic test = increase titers of pathogen-specific Ab (M & G)
(lab tests for infectious mononucleosis):
(1) monospot test = rapid slide agglutination test / heterophile Ab
sensitivity decrease by increasing time
usually -ve in children less than 6 to 8 years old
(2) serologic test = increase titers of EBV-specific Abs (M &G)
(3) lymphocytosis
-SNOUT = only in test with increased sensitivity
if test is -ve => rule out disease
-SPIN = only in test with increased specificity
if test is +ve => rule in disease
--------------------------------------------------------------------------------(follicular bacterial skin infections):
follicititis / furuncle / carbuncle
(bacterial skin infection):
impetigo / ecthyma / erysipelas / lymphangitis / cellulitis
SORE THROAT
(bacterial pharyngitis):
is diagnosed clinically by typical symptoms such as dysphagia and
sore throat and physical examination findings of the pharynx
-elevated hemoglobin and granulocytosis = bacterial infection
(tonsillitis):
likely when the tonsils are swollen and red
the exudate indicates bacterial origin and so does intense
pharyngeal erythema
(cause of most URTI) = viruses
-viral pharyngitis / tonsillitis tend to be accompanied by additional
symptoms, such as cough, coryza, conjunctivitis (same virus,
usually adenovirus), and general myalgia
-bacterial pharyngitis / tonsillitis = likely caused by GABHS
--------------------------------------------------------------------------------Streptococcus pneumoniae
-G+ve coccus
-habitat = URT (endogen)
-causes:
AOM ,sinusitis , pneumonia
meningitis, conjunctivitis
-treatment:
penicillin, fights G+ve cocci
*most common cause of acute
meningitis in children
Moraxella catarrhalis
-G-ve diplocuccus
-cause = AOM,
sinusitis,conjunctivitis
-treatment:
same as H influenzae
Hemophilus influenzae
-G-ve coccus
-habitat = URT (endogen)
-causes:
AOM 2nd most common
sinusitis 2nd most common
tonsillitis
pneumonia / CB
conjunctivitis
*capsulated form = type B
*non-capsulated type causes
AOM, sinusitis, conjunctivitis
Group A beta - hemolytic
streptocci (GABHS)
-G+ve coccus
-habitat = URT
-causes:
“strep throat”
most common bacterial
pharyngitis / tonsiliitis / scalet
fever
-age = 5 to 11
-skin infection = impedigo
cellulitis / necrotizing fascitis
streptococcal toxic shock synd
(strep throat / scarlet fever (GABHS)):
-purulent complication = direct bacterial spread:
peritonsillitis (quinsy) / lymphadenitis / AOM / sinusitis / epiglottis
-non-purulent complication = delayed hypersensitivity rxn:
rheumatic fever (including endocarditis and arthritis)
post-streptococcal glomerulonephritis
PANDAS (pediatric autoimmune neuropsychiatric disorders)
tics / ADHD / OCD
Sydenham’s chorea (irregular contractions that is not repetitive)
-scalet fever = incubation period 2 to 4 days
complications (otitis media / cervical adenitis ..)
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(epiglottitis):
age = 2 to 12 years
pathogens = H influenzae type B / Strep pneumoniae / GABHS
Candida
-bacterial / caustic burns and trauma / drooling and retraction
-inspiratory stridor / unable to talk or swallow
-cherry-red epiglottis
-acute airway obstruction
(croup = larynotracheobronchitis):
-viral (parainfluenza virus) / common in fall / after cold viral URTI
-sudden inspiratroy stridor / barking cough
-acute airway obstruction (esp. infants)
-TX: fluids, moist air // bronchodilators, glucocorticoids
-reactive lymphadenopathy = secondary lymphadenopathy
-lymphadenitis = infection of a lymph node
-lymphangitis = infection of a lymph vessel
(primary lymphadenopathy):
-diffuse lymph node enlargement in the neck B/L
they are hard and non-tender
-usually malignant
-Hodgkin lymphoma / non-Hodgkin lymphoma / hair cell leukemia
(secondary lymphadenopathy):
-metastasis, Virchow’s node (aka signal or sentinel lymph node)
(acute bronchiolitis):
-respiratory syncytial virus (RSV)
-common in winter
-infection of respiratory and ciliated epithelial cells of bronchioles
-mucus secretion and submucosal edema
-critical narrowing and obstruction of small airways
-hypoxia = risk for respiratory failure
-age = 2 to 24 months
-TX: supportive treatment of O2. humidified air, chest clapping
rest, clear fluids, bronchodilators, glucocorticoids
-most deaths occurs in infants <6
Adult sore throat
Children sore throat
-viral most common
bacterial fungal (candida)
-peritonsillar abscess
-ulcerative conditions
-viral most common
URTI with pharyngitis
tonsillitis / infectious MN
herpangina, croup
-harsh “barking” cough,
stridor and fever
(chronic sore throat):
(1) alcohol
(2) smoking
(3) chronic reflux
(4) neoplasia
(symptoms and signs in oral cavity):
-pain / mass / ulceration / hemorrhage / halitosis / discoloration/
hypogeusia / dysgeusia / ageusia
-enlarged neck glands = infection / neoplsia
*bacterial:
pharynitis
tonsillitis
(vincent’s / strep. throat)
epiglottitis
diphtheria
(summary for pharyngitis / tonsillitis):
-viral etiology :
most common cause = adenovirus / myxovirus / picornavirus / EBV / Coxsackie virus A or B
dominance of cold symptoms
tonsils usually less involved
-bacterial (eg. strep throat)
less symptoms from other sites
treatment = conservative / antibiotic should only be considered in case of GABHS infection or serious bacterial pharyngitis/tonsillitis
bacterial tonsillitis = GABHS / strep throat is aggressive form
prominent erythema and exudate on pharyngeal tonsils / odynophagia / fever / malaise / fatigue / headache
purulent nasal discharge / ear pain / anterior cervical lymphadenopathy / few upper respiratory symptoms
scalet fever = macular exanthema on cheeks / strawberry red tongue
peritonsillar abscess / AOM / lymphadenitis
non-purulent complications
lab = +ve ASO titer / increased ESR
unilateral tonsillitis = exclude malignancy / vincent’s angina
Vincent’s Angina = ulcerating infection of the pharyngeal mucosa involving one or both tonsils (stomatitis / gingivitis possible)
agents = Fusobacterium nucleatum / Treponema vincentii (Borelia spirochete)
presentation = mild symptoms / halitosis / odynophagia
maliganant if unilateral presentation
Herpangina = blistering ulcers in the pharynx and roof of the mouth, and lips
agent = Coxsackie virus A (or B)
presentation = fever / headache / myalgia / sore throat
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