otitis & pharyngitis in peds chp 121 tintinalli 4/13/06 dr. batizy slides by bogdan irimies

Otitis & Pharyngitis in PedsChp 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:

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

• 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/

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)

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 non-intact 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

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: 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.


• 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


• 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:


• 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)


• 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

• Headache, vomiting, abd. Pain, meningismus and torticollis can also occur

• Coughing, rhinorrhea or ulceration suggest alternative diagnosis


Strep. 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


• 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


• 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

• Corneal abrasion• Uveitis• Glaucoma• Allergic conjunctivitis

– 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: – 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/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


• 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

otitis & pharyngitis in peds chp 121 tintinalli 4/13/06 dr. batizy slides by bogdan irimies

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