Pathogens that cause otitis media
- Strep pneumoniae 30-40%
- Haemophilus influenzae 21%
- Moraxella Catarrhalis 12%
- Staph aureus 6%
- Group A Strep, Pseudomonas aeruginosa
- Mycoplasma pneumoniae
cholesteatoma
- keratinized, desquamated epithelial collection in the middle ear or mastoid
- may occur secondary to tympanic membrane perforation, but also may occur as a primary lesion
- Some patients may be totally asymptomatic, others may present with some combination of hearing loss, dizziness, and/or otorrhea
- Cholesteatomas associated with tympanic membrane perforation are typically detected earlier than primary acquired cholesteatomas as the inferior portion of the ear drum is easier to inspect, and hearing loss occurs early
vertigo, etiologies,
- Cardinal symptom of vestibular disease
- Peripheral or central etiologies
- Peripheral: sudden onset, often associated with hearing loss and tinnitus
- Central: gradual onset, no associated auditory sx
- Sensation of motion when there is no motion, or exaggerated sense of motion in response to body movements
- Duration of vertigo is key to diagnosis
- Ask about associated symptoms (tinnitus, hearing loss, n/v), severity, onset, triggers (salt, stress, bright lights)
- PE includes eyes (nystagmus), ears, CN and Romberg, possibly other CNS/cerebellar tests
- Dix-Hallpike maneuver
- Most common etiologies include labyrinthitis, BPPV, Meniere’s syndrome, migraine
- Referral to ENT or Neurology if vertigo persists or CNS lesion suspected
Dix-Hallpike maneuver, used to determine which disease
- quickly lowering pt to supine position with head extending over edge of bed 30 degrees lower than body, turned either to left or right
- D-H will elicit delayed onset of fatigable nystagmus in BPPV; nonfatigable nystagmus indicates CNS etiology
Hearing loss
- Most commonly due to cerumen impaction or related to URI or aging
- 3 types: conductive, sensory, neural
- Refer for audiology examination unless cause is easily treated/reversible
Weber test
tests for lateralization of sound; if sound lateralizes to BAD ear, then conductive hearing loss is present (bone conduction is intact); if sound lateralizes to GOOD ear, then sensorineural hearing loss is present (nerve does not conduct sound in affected ear)
Rinne
AC>BC in normal ears; BC>AC in conductive hearing loss (sound is blocked in air conduction by something, such as cerumen impaction); AC>BC but overall decreased hearing in sensorineural hearing loss
etiology of hearing loss
Conductive: dysfunction of external or middle ear
- Acute: cerumen impaction, middle ear effusion (URI), otosclerosis
- Chronic: chronic ear infection, trauma, otosclerosis
Sensory: deterioration of the cochlea, loss of hair cells
- Progressive, high frequency loss related to aging is very common
- Noise exposure, head trauma, DM or other systemic diseases
Neural: CN 8 or auditory tract/cortex lesions; least common
-Acoustic neuroma, MS, cerebrovascular disease
Incidence/Transmission of common cold
- Decreases with age
- Adults have 2-4 episodes per year
- Children have 6-8 episodes per year
- Transmission: (Direct contact, Aerosolized particles, Fomites, Incubation 24-72 hours)
Influenza
- Antigenic variations occur almost annually in influenza serotype A which is responsible for the most morbidity and mortality; requires yearly update in vaccine
- Transmitted through aerosolized particles; incubation 18-72 hours
- Viral shedding 5-10 days; highest titer in secretions first 48 hours
- Infectious until 24 hours after fever breaks
acute sinusitis
- Sinuses: air filled bony cavities that produce and drain up to 2 pints of mucus every day
- Movement of the mucus is propelled by cilia, through the ostia located behind the turbinates
- Acute sinusitis is a viral or bacterial infection of one or more of the paranasal sinuses which occurs when normal drainage is blocked
etiology of acute sinusitis
- Viral URI’s commonly cause obstruction of the ostia; 0.5% will develop acute bacterial sinusitis as a result
- 10% of sinusitis cases are due to extension of dental abscess
- Complication of noninfectious rhinosinusitis, polyps, foreign bodies, swimming/diving, anatomic nasal obstruction, nasogastric tubes
clinical characteristics of acute sinusitis
- Sinus pain caused by periosteal reaction due to purulent inflammation behind an obstructed ostium
- Initially pain described as dull; then progresses to throbbing and more severe
- Coughing and percussion over the involved sinus or teeth exacerbate the pain
- Ddx: dental abscess, cluster HA, trigeminal neuralgia, migraine
Trigeminal neuralgia
-sudden, usually unilateral, severe, brief, stabbing or lancinating, recurrent episodes of pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve
Cluster headaches
-unilateral HA associated with rhinorrhea, tearing, may include Horner’s syndrome; usually in men, occurs in clusters of time
migraine
-Unilateral HA associated with n/v, may include other neuro sx, often typical triggers
pharyngitis
- Most important task is to identify and treat group A Strep; approximately 10% of those presenting
- Caused by a variety of bacterial and viral pathogens (β-hemolytic Strep groups A and G, Mycoplasma pneumoniae, Chlamydia pneumoniae, Corynebacterium diphtheriae, Neisseria gonorrhea, RSV, influenza A&B, parainfluenza, herpes simplex virus, adenovirus, Epstein-Barr virus, coronavirus, rhinovirus, adenovirus, enterovirus, HIV)
clinical variations of pharyngitis
- Corynebacterium haemolyticum: exudative, scarlitinaform rash, fever, and adenopathy
- Mononucleosis: sore throat, fever, lymphadenopathy, hepatosplenomegaly, maculopapular skin rash
- Adenovirus: associated with conjunctivitis and influenza-like symptoms
- Coxsackie A, herpes simplex: mucosal vesicles or ulcers
streptococcal pharyngitis
- Incubation 2-4 days
- Abrupt onset of sore throat, malaise, fever, headache
- Only 10% have classic syndrome
- Cough, hoarseness, rhinorrhea are distinctly absent
- Distinctive scarlitinaform rash: diffuse red blushing on the trunk, blanches with pressure and desquamates in one week
clinical predictive criteria of streptococcal pharyngitis
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy
- Fever
- Absence of cough
- If 3-4 of these criteria met, positive predictive value is 40%-60%
Culture or not? Tonsillar exudate and lymphadenopathy, T>100°
-43% positive cx
-culture and treat
culture or not? Tonsillar exudate or lymphadenopathy, T>100° 14% positive cx
culture then defer antibiotic until culture results
none of these clinical findings 3% positive cx
Neither culture nor treat
Treatment of streptococcal pharyngitis
- Treat all patients with h/o rheumatic fever
- Principle goals of treatment are relief of symptoms, prevention of local suppurative complications, prevention of spread
- Most clinicians do not wait for culture results in very symptomatic patients
- Preferred tx: 1.2 million units benzathine PCN given IM; or Pen VK 500mg PO QID x 10 days (Can use Amoxicillin, or in PCN allergic patients macrolides are recommended)
