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Download OME (otitis media with effusion)
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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 1 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 ..) 2 (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 3