NELSON’S CLUB Kimberly S. Tsai, MD, MBA. TOPICS Acute sinusitis Eye pain & discharge Conjunctivitis Orbital cellulitis Otitis media & externa Foreign

NELSON’S CLUB

Kimberly S. Tsai, MD, MBA

TOPICS

• Acute sinusitis• Eye pain & discharge• Conjunctivitis• Orbital cellulitis• Otitis media & externa• Foreign body

ACUTE SINUSITIS

Acute Sinusitis

ETIOLOGY• VIRAL• BACTERIAL

– Streptococcus pneumoniae (30%)

– nontypable Haemophilus influenzae (20%)

– Moraxella catarrhalis (20%)

SIGNS & SYMPTOMS• nasal congestion• purulent nasal discharge • Fever• Cough• Halitosis• Hyposmia• Periorbital edema• Headache• facial pain• maxillary tooth discomfort• pain or pressure exacerbated by

bending forward

Acute Sinusitis

DIAGNOSIS• Based on history

– Persistent URTI for 10-14 days without improvement

• Sinus aspirate culture• Rigid nasal endoscopy –

adults• Transillumination –

unreliable• radiography

TREATMENT• Amoxicillin (45mg/kg/day)• Co-amoxiclav (80-90

mg/kg/day for non responders)

• TMP-SMX , cefuroxime, clarithromycin & azithromycin for penicillin allergic patients

Acute Sinusitis

TREATMENT• Decongestant,

antihistamine, mucolytics & intranasal steriods is not recommended in uncomplicated bacterial sinusitis.

COMPLICATIONS• Periorbital & orbital

cellulitis• Epidural abcess• meningitis• Cavernous sinus thrombosis• Brain abcess• Osteomyelitis of the frontal

bone (Pott puffy tumor)• mucocele

EYE PAIN & DISCHARGE

EYE PAIN & DISCHARGE

EYE INJURIES

• Dacryoadenitis• Dacryocystitis• Preseptal cellulitis• Orbital cellulitis

ORBITAL INFECTIONS

• Laceration• Abrasion• Foreign body• Hyphema• Open globe• Orbital Fracture• Penetrating wound• Firework related injury• Sports Related Injury

Eye Pain & Discharge

HYPHEMA• Presence of blood in the

anterior chamber & may occur with blunt injury

• Presentation: acute loss of vision & eye pain

• TX: bed elevated to 30 degrees, eye shield, cycloplegic, topical steroid (to dec. IOP). NSAIDS must be avoided.


DACRYOCYSTITIS• Infection of lacrimal sac• Treatend with warm

compress & antibiotics

DACRYOADENITIS• Inflammation of the lacrimal

gland • Can occur with mumps

(acute), TB, syphilis, sarcoidosis (chronic)

• Staphy aureous can produce suppurative dacryoadenitis

• If both lacrimal & salivary glands enlarge as a result of a systemic disease, it’s Mikulicz syndrome


PRESEPTAL CELLULITIS• Inflammation of lids without

signs of true orbital involvement (NO proptosis or limitation of eye movement)

• MCC: H. influenzae type B

ORBITAL CELLULITIS

Orbital Cellulitis

SIGNS & SYMPTOMS• inflammation of orbital

tissues & eyelids• Proptosis• Limited eye movement• Conjunctival

edema/chemosis• Decreased visual acuity• Fever• leukocytosis

ETIOLOGY• Mean age: 7 yo• 10 mos to 18 year olds may

be affected• Direct extension or venous

spread from paranasal sinuses, lacrimal gland, conjunctiva, lids

• More prevalent in children due to thinner bony septa, porosity of bones & larger vascular foramina

Orbital Cellulitis

PATHOGENS• Staphylococcus species• methicillin-resistant S.

aureus (MRSA)• Streptococcus species• Haemophilus species

COMPLICATIONS• Vision loss • Retinal artery occlusion• Optic neuritis• Cavernous sinus thrombosis• Meningitis• Epidural/subdural empyema• Brain abcess

Chandler ClassificationCHANDLER

CLASS STAGE CLINICAL DESCRIPTION AND DEFINITION

I Inflammatory edema

Eyelid edema and erythemaNormal extraocular movementNormal visual acuity

II Orbital cellulitis Diffuse edema of orbital contents without discrete abscess formation

III Subperiosteal abscess

Collection of purulent exudate* beneath periosteum of lamina papyraceaDisplacement of globe downward/laterally

IV Orbital abscess

Purulent collection within orbit*ProptosisChemosisOphthalmoplegiaDecreased vision

V Cavernous sinus thrombosis

Bilateral eye findingsProstration or weaknessMeningismus ( triad of nuchal rigidity, photophobia and headache)

Orbital Cellulitis

DIAGNOSTICS• CT of the orbit with IV

contrast

TREATMENT• 3rd Generation

Cephalosporin (cefotaxime, ceftriaxone) + vancomycin

• Amoxicillin+Clavulanic acid• Urgent abcess drainage

depending on clinical presentation

CONJUNCTIVITIS

Conjunctivitis

• reaction to a wide range of bacterial and viral agents, allergens, irritants, toxins, and systemic diseases

• May be infectious or non-infectious

ConjunctivitisCONDITION ETIOLOGY SIGNS AND SYMPTOMS TREATMENT

Bacterial conjunctivitis

Haemophilus influenzae, Haemophilus aegyptius, Streptococcus pneumoniae

Mucopurulent unilateral or bilateral discharge, normal vision, photophobia

Topical antibiotics, parenteral ceftriaxone for gonococcus, H. influenzae

Neisseria gonorrhoeaeConjunctival injection and edema (chemosis); gritty sensation

Viral conjunctivitis

Adenovirus, ECHO virus, coxsackievirus

As above; may be hemorrhagic, unilateral Self-limited

Neonatal conjunctivitis

Chlamydia trachomatis, gonococcus, chemical (silver nitrate), Staphylococcus aureus

Palpebral conjunctival follicle or papillae; as above

Ceftriaxone for gonococcus and erythromycin for C. trachomatis

Allergic or Vernal conjunctivitis

Seasonal pollens or allergen exposure

Itching, incidence of bilateral chemosis (edema) greater than that of erythema, tarsal papillae

Antihistamines, topical mast cell stabilizers or prostaglandin inhibitors, steroids


Keratitis

Herpes simplex virus, adenovirus, S. pneumoniae, S. aureus, Pseudomonas, Acanthamoeba, chemicals

Severe pain, corneal swelling, clouding, limbus erythema, hypopyon, cataracts; contact lens history with amebic infection

Specific antibiotics for bacterial/fungal infections; keratoplasty, acyclovir for herpes

Endophthal-mitis

S. aureus, S. pneumoniae, Candida albicans, associated surgery or trauma

Acute onset, pain, loss of vision, swelling, chemosis, redness; hypopyon and vitreous haze

Antibiotics

Anterior uveitis (iridocyclitis)

JRA, postinfectious with arthritis and rash, sarcoidosis, Behcet disease, Kawasaki disease, inflammatory bowel disease

Unilateral/bilateral; erythema, ciliary flush, irregular pupil, iris adhesions; pain, photophobia, small pupil, poor vision

Topical steroids, plus therapy for primary disease

Posterior uveitis (choroiditis)

Toxoplasmosis, histoplasmosis, Toxocara canis

No signs of erythema, decreased vision

Specific therapy for pathogen


Episcleritis/scleritis

Idiopathic autoimmune disease (e.g., SLE, Henoch-Schonlein purpura)

Localized pain, intense erythema, unilateral; blood vessels bigger than in conjunctivitis; scleritis may cause globe perforation

Episcleritis is self-limiting; topical steroids for fast relief

Foreign body Occupational exposure Unilateral, gritty feeling;

visible or microscopic sizeIrrigation, removal; check for ulceration

Blepharitis

S. aureus, Staphylococcus epidermidis, seborrheic, blocked lacrimal duct; rarely molluscum contagiosum, Phthirus pubis, Pediculus capitis

Bilateral, irritation, itching, hyperemia, crusting, affecting lid margins

Topical antibiotics, warm compresses, lid hygiene

Dacryocys-titis

Obstructed lacrimal sac: S. aureus, H. influenzae, pneumococcus

Pain, tenderness, erythema and exudates in area of lacrimal sac (inferomedial to inner canthus); tearing (epiphora); possible orbital cellulites

Systemic, topical antibiotics; surgical drainage


Dacryoaden-itis

S. aureus, Streptococcus, CMV, measles, EBV, enteroviruses; trauma, sarcoidosis, leukemia

Pain, tenderness, edema, erythema over gland area (upper temporal lid); fever, leukocytosis

Systemic antibiotics; drainage of orbital abscesses

Orbital cellulitis (postseptal cellulitis)

Paranasal sinusitis: H. influenzae, S. aureus, S. pneumoniae, streptococciTrauma: S. aureusFungi: Aspergillus, Mucor spp. if immunodeficient

Rhinorrhea, chemosis, vision loss, painful extraocular motion, proptosis, ophthalmoplegia, fever, lid edema, leukocytosis

Systemic antibiotics, drainage of orbital abscesses

Periorbital cellulitis (preseptal cellulitis)

Trauma: S. aureus, streptococciBacteremia: pneumococcus, streptococci, H. influenzae

Cutaneous erythema, warmth, normal vision, minimal involvement of orbit; fever, leukocytosis, toxic appearance

Systemic antibiotics

ConjunctivitisOphthalmia Neonatorum

EPIDEMIOLOGY• Usually gonococcal or

chlamydial thru vaginal delivery

• Occurs in infants <4 weeks of age

• Incubation period: 2-5 days • May present beyond 5 days

due to ocular prophylaxis

MANIFESTATION• Redness & chemosis of

conjunctiva• Edema of eyelids• Discharge (serosanguinous

becomes purulent within 24 hrs)


COMPLICATIONS• corneal ulceration and

perforation• Iridocyclitis• anterior synechiae• panophthalmitis

DIAGNOSIS• Gram stain & culture of

purulent discharge


TREATMENT• Initial: eye irrigation every

10-30 mins, to 2 hour intervals to clear purulent discharge

• Goncococcal: ceftriaxone, 50 mg/kg/24 hr for 1 dose, not to exceed 125 mg

• Chlamydial: oral erythromycin (50 mg/kg/24 hr in 4 divided doses) for 2 weeks

• Pseudomonas: local saline irrigation + aminoglycoside + gentamycin ophthalmic ointment

• Staphylococcus: IV methicillin + local saline irrigation


PREVENTION• Instill 0.5% erythromycin or

1% silver nitrate directly to open eye at birth

• Povidone-iodine (2% solution) may also be used

• Pregnant women tx with Erythromycin to prevent neonatal disease

NOTES• Infant born to mom with

untreated gonorrhea single dose of ceftriaxone, 50 mg/kg (maximum 125 mg) IV or IM

• Topical prophylaxis does not prevent chlamydial pneumonia so systemic TX should be given.

EAR PAIN

OTITIS MEDIA & EXTERNA

Otitis Media

Categories:• Acute/Suppurative OM

– Initial acute infection

• Secretory OM or OME– Followed by inflammation

with effusion

Definition:1. Hx of acute S/SX2. Presence of middle ear

effusion• Bulging TM• Limited mobility of TM• Air fluid behind the TM• Otorrhea

3. S/SX of middle ear inflammation• Distinct Erythema of TM• Distinct Otalgia (interferes

activity or sleep)

Otitis Media

Risk Factors• Age: 6-20 mos• Gender: M>F• Race: Native American,

Australian (whites)• SES: poverty• Breast Milk is protective• Exposed to tobacco• Exposed to other children• Cold season where URTI is

common• Children with unrepaired cleft

palate• No flu vaccination

EtiologyVIRAL• RSV & RhinovirusBACTERIIAL• Streptococcus pneumoniae, • nontypeable Haemophilus

influenzae• Moraxella catarrhalisOther Bacteria:• group A streptococcus, • Staphylococcus aureus,• gram-negative organisms

(neonates)

Otitis Media

Presentation• Varies• Irritability• Change in sleeping habits• Fullness of the ear• Fever• Otorrhea• Hearing loss• Balance difficulty

NOTE• NORMAL TM:

– Slightly concave– Pearly gray– translucent

Otitis Media

Otitis Media with Effusion

TreatmentDuration of OME Intervention<3 mos Watchful waiting as

it spontaneously clears during summer months

>3-6 mos Myringotomy or tympanostomy

Otitis Media

TreatmentAGE Diagnosis

Certain (3/3) Uncertain

<6 mo Antibacterial therapy

Antibacterial therapy

6 mo-2 yr

Antibacterial therapy

Antibacterial therapy if severe; observe if nonsevere

≥2 yrAntibacterial therapy if severe; observe if nonsevere

Observation with ff/up after 2-3 days

Tx Duration: >=10 days esp <2yo & severe symptoms

Temp > 39 plus/minus

At time of DX or after 2-3day observation

Severe otalgia Recommended Penicillin

AllergicNo(nonsevere)

Amoxicillin, 80-90 mg/kg per day

Cefu, cefdinirazith or clarith

Yes(severe)

Amoxicillin-clavulanate, 90 mg/kg per day of amox, with 6.4 mg/kg per day of clavulanate

IM Cefti, 1 or 3 days

Otitis Media

Infratemporal Complications:• mastoiditis, • hearing loss, • dermatitis, • CSOM, • cholesteatoma (superior

part of TM or pars flaccida)• labyrinthitis

Intracranial complications:• Meningitis,• epidural abscess, • subdural abscess, • focal encephalitis, • brain abscess, • Sigmoid/lateral sinus

thrombosis, • otitic hydrocephalus (caused

by obstruction of venous drainage by a thrombus)

Otitis Media

Additional Notes:• Prevention

– Avoid risk factors

• Antimicrobial prophylaxis– Not recommended

• Tympanostomy tube is found effective in– Recurrent AOM– Persistent OME

OTITIS EXTERNA(Swimmer’s Ear)

Etiology• commonly by

– P. aeruginosa, – S. aureus, E– nterobacter aerogenes, – Proteus mirabilis, – Klebsiella pneumoniae, – streptococci, – coagulase-negative staphylococci, – diphtheroids, – fungi (Candida and Aspergillus)

• Chronic irritation or excess moisture of the canal

Presentation• Acute ear pain esp if pinna

is manipulated• Pain disproportionate to

degree of inflammation• Conductive hearing loss• Edema of ear canal• Erythema• If necrotizing/Malignant

Otitis Externa, (+) facial paralysis &/ SNHL

OTITIS EXTERNA

Diagnosis• Pain on manipulation of

auricle• Concentric swelling of canal

– Vs. 1 quadrant swelling in furunculosis

Treatment (Otic Drops)• Neomycin (GPB esp Proteus)

with polymyxin (GNB esp Pseudomonas)

• Ofloxacin/ciprofloxacin• With Sterioids: if with marked

edema • How? Insert wick into canal &

instill drops TID for 2-3days then remove wick

• Add: Oral analgesics for pain• IV antibx: if febrile with

lymphadenopathy

OTITIS EXTERNA

Prevention• Instill 2% acetic acid or

dilute alcohol after swimming or bathing

• Avoid swimming if with AOE• Use hair dryer to clean

moisture from ear

FOREIGN BODY

Foreign Body

ETIOLOGY• Children <3 yo use their

mouths to explore surroundings

• Peanuts, carrot, apple, dried beans, popcorn, sunflower or watermelon seeds, small toys or toy parts

• MOST SERIOUS COMPLICATION: complete airway obstruction sudden respi distress w/ inability to speak or cough

MANIFESTATIONS• Initial: Violent paroxysms of

coughing, choking, gagging & airway obstruction

• Asymptomatic interval: coughing reflex fatigue

• Complications: Obstruction, erosion, infection. Fever, cough, hemoptysis, pneumonia, and atelectasis

Foreign Body

DIAGNOSIS• History highly suggested by

coughing/choking with wheezing

• 58% lodge on right bronchus

• 10% larynx or trachea• Opaque foreign bodies

occur in only 10-25% of cases

TREATMENT• Prompt removal of foreign

body (endoscopy)

END

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NELSON’S CLUB Kimberly S. Tsai, MD, MBA. TOPICS Acute sinusitis Eye pain & discharge Conjunctivitis Orbital cellulitis Otitis media & externa Foreign