EENT Infections

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EENT Infections

• Dr. Patamasucon
• September 2011

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• EYE

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Conjunctivitis

• Neonatal
• Chemical (silver nitrate) ? 1-2
  days
• Gonococcal ?
  2-3 days
• Chlamydia ?
  gt5 days
• HSV ?
  Varies

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Neonatal Conjunctivitis

• Gonococcal
• Chlamydia trachomatis

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Conjunctivitis

• Neonatal prevention
• G.C. ? Silver nitrate or Penicillin
• Chlamydia ? No effective drug
• (Tetracycline, Erythromycin, and Silver nitrate
  not effective)
• One report of effectiveness in US but later
  disproved by the same author and other studies in
  Nairobi and Taiwan

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Conjunctivitis

• Children
• Bacterial
• NT H.influ ? Most common
• S.pneumo ? Common
• G.C. ? Adolescents
• Viral
• Adenovirus ? Most common
• Enterovirus 70 ? Epidemic hemorrhagic
  conjunctivitis

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Conjunctivitis

• Treatment
• Gonoccocal
• Single dose of ceftriaxone or cefotaxime
• Copious amount of normal saline or sterile water
• Chlamydia
• Erythromycin (PO) 40-50 mg/kg/day x 2 weeks
• No topical Rx is needed
• Adenovirus/Enterovirus
• Supportive care
• HSV
• IV Acyclovir topical Vidarabine

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Periorbital and Orbital Cellulitis

• Divided by the orbital septum
• Predisposing factors
• Periorbital (preseptal)
• Trauma, conjunctivitis, eyelid infection,
  dacryocystitis, acute sinusitis (esp.
  ethmoiditis), hematogenous seeding
• Orbital (postseptal)
• Acute ethmoiditis? sinusitis? orbital abscess
• Hematogenous seeding, trauma

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Preseptal (Periorbital) Cellulitis

• Etilogy
• If 2 to acute sinusitis
• NT H. influenzae, S.pneumonaie, M.catarrhalis
• If 2 to hematogenous spread
• S.pneumo, H.influ type a-f
• If 2 to trauma
• S.aureus, GAS
• If 2 to conjunctivitis
• NT H.influenzae, S.pneumoniae, N.gonorrhoeae
• If 2 to dacryocystitis
• S.aureus, S.pneumoniae, H. influenzae, Group B
  Strep

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Preseptal (Periorbital) Cellulitis

• Diagnosis based on
• History
• Physical Exam
• CT or MRI
• Always inquire about HIB and Pneumococcal vaccine
  immunization

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Preseptal (Periorbital) Cellulitis

• Treatment
• If secondary to trauma
• Oral Cephalexin or Clindamycin (MRSA)
• If secondary to sinusitis
• Augmentin, cefdinir, cefuroxime, cefpodoxime
• Severe cases Ceftriaxone Vancomycin
• If secondary to hematogenous spread
• Ceftriaxone Vancomycin

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Postseptal (Orbital) Cellulitis

• May be secondary to
• Acute sinusitis
• S. pneumoniae, Non-typeable Haemophilus,
• M. catarrhalis, anerobes (occasionally)
• Penetrating Trauma
• S. aureus, GAS, anerobes (Prevotella,
  Fusobacterium, Veillonella, Bacteroides sp.),
  occasionally GN organisms
• Hematogenous spread
• S. aureus, S. pneumoniae, H. influenzae (type
  a-f), GAS

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Postseptal (Orbital) Cellulitis

• Symptoms
• Proptosis, nerve palsy, abscess seen on CT or MRI
• Treatment
• ID with ENT, ophthalmologic evaluation
• If 2 to sinusitis
• IV ceftriaxone vancomycin metronidazole
• If 2 penetrating trauma
• Same as sinusitis GN coverage
• If 2 to hematogenous spread
• Same as sinusitis

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Postseptal (Orbital) Cellulitis
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• Sinuses

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Sinusitis

• Age of sinus development
• Birth ? Maxillary Ethmoid
• 8 years ? Frontal
• Duration of Illness
• Acute ? 10-30 days
• Subacute ? 31-120 days
• Chronic ? gt120 days

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Sinusitis

• Microbiology (acute subacute)
• Viruses rhinovirus, adenovirus, influenza,
  parainfluenza
• Predisposes to bacterial infection
• Bacteria
• S.pneumoniae (30-40), NT H.influenzae (20),
  M.catarrhalis (20)
• Less common Strep Group A or C, Strep Viridan,
  E.corrodens
• Uncommon anerobes, S.aureus, GNB, mycoplasma,
  and fungi (aspergillus, mucor)

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Sinusitis

• Microbiology (chronic)
• Similar to acute subacute organisms
  anaerobes, S.aureus (3), GNB (2), and
  S.pneumoniae resistant

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Sinusitis

• Diagnosis
• Clinical history and physical exam
• Transillumination (up to 80 in older than 1 yo)
• X-Ray (plain film, CT, MRI) unnecessary and can
  be positive for 2 weeks post viral URI

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Sinusitis

• Clinical Presentation
• Acute bacterial sinusitis
• Nasal discharge and day time cough gt10-14 days
• Facial pain 3 days
• Headache
• Morning facial periorbital edema
• Fever gt 39C, purulent nasal discharge

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Sinusitis

• Chronic Sinusitis Clinical Presentation (gt 4
  months)
• Congestion/ postnasal drip
• Cough
• Mouth breathing
• Bad breath
• Sore throat
• Impaired sleep
• Diagnosis history, PE, with CT or MRI
• Treatment
• Sinus aspiration for culture and sensitivity
• Amoxicillin/Clavulanate
• IV Oxacillin or Clindamycin Ceftriaxone
• Ampicillin/sulbactam (Unasyn)

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Sinusitis

• Sinusitis in a seriously ill patient with
  complications
• Aspirate and Culture
• Add coverage against S.aureus
• Ceftriaxone and Vancomycin
• Surgical drainage of sinuses may be necessary

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Sinusitis

• Treatment
• Acute bacterial sinusitis
• 40 is self limiting
• Persistant/uncomplicated sinusitis
• High dose Amoxicillin 80-90mg/kg/day BID for 7
  asymptomatic days
• Severe sinusitis (not responsive to meds gt 3
  days)
• High dose Amoxicillin/Clavulanate (PO) for 7
  asymptomatic days
• Alternative drugs Cefdinir, cefuroxime,
  cefpodoxime
• Ceftriaxone 50mg/kg/day

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Sinusitis

• Predisposing factors for recurrent or chronic
  sinusitis
• Recurrent URI
• Daycare or school aged sibling
• Allergies
• Immunodeficiency (IgG IgG subclasses, IgA, AIDS
• Cystic Fibrosis
• Ciliary Dyskinesia
• Anatomical
• Deviated nasal septum, nasal polyps, osteomeatal
  complex disease

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Sinusitis

• Major complications of sinusitis
• Orbital Region
• Preseptal cellulitis
• Subperiosteal abscess
• Orbital cellulitis/abscess
• Optic neuritis
• Osteomyelitis
• Frontal (Potts puffy tumor)
• Maxillary
• Intracranial
• Epidural abscess
• Subdural empyema
• Cavernous sinus thrombosis
• Meningitis
• Brain abscess

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• Ears

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Otitis Media

• Definition of AOM
• A diagnosis of AOM requires
• 1) a history of acute onset of signs
• and symptoms
• 2) the presence of MEE, and
• 3) signs and symptoms of middle-ear inflammation.
• MEE
• Buldging of tympanic membrane
• Limited or absent TM mobility
• Air fluid level behind TM
• Otorrhea

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Otitis Media

• Etiologic Agents
• S. pneumoniae (40-50)
• Nontypeable H. influenzae (20-30)
• M. catarrhalis (10-15)
• Treatment
• First Line
• High dose Amoxicillin (80-90mg/kg/day)
• Second Line
• High dose Amoxicillin/Clavulanate (clavulanate
  lt10mg/kg/day)
• Cefdinir
• Third Line
• Clindamycin
• IM Ceftriaxone (daily x 3 days)

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Otitis Media

• Duration of Treatment of AOM
• 5-7 days for uncomplicated course in child gt 2yo
• 10 days for child lt2 yo or complicated course
• Uncomplicated course? no perforation of TM

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• Mastoid

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Mastoiditis

• Etiology
• Acute/Subacute
• Common S.pneumoniae, Group A Strep, S.aureus
• Uncommon NT Haemophilis, M.catarrhalis, Strep
  viridans
• Chronic
• S.aureus, anaerobic or GNB

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Mastoiditis

• Clinical Presentation
• Fever with tenderness at the region of the
  mastoid process swelling behind the ear
• Pinna position is down and out
• Tympanic membrane is usually inflamed
• Occasionally have palpable subperiosteal abscess
  over the mastiod

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Mastoiditis

• Diagnosis
• History, Physical exam CT or MRI
• Fluid and/or bony destruction of the mastoid air
  cells
• Tympanocentesis can provide causative agent(s)
• Treatment
• Myringotomy (drain? C/S)
• Mild cases Amoxicillin/Clavulanate
• Moderate/ Severe cases IV Ceftriaxone
  Vancomycin
• Mastoid abscess? ID

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• Throat

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Peritonsillar Abscess (Quinsy)

• Pus in tonsillar fossa
• Usually in young adolescents
• 5-15 years old
• Symptoms
• Fever, sore throat, dysphagia, drooling
• Refusal to eat
• Trismus, muffled voice (hot potato voice)
• Unilateral neck or ear pain

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Peritonsillar Abscess

• Signs
• Unilateral peritonsillar bulging
• Uvular deviation
• Fluctuance of palatal swelling
• Red, swollen pharynx and exudative tonsils
• Cervical adenopathy
• Torticollis
• Causative Agents
• Most common
• Strep Group A, a-hemolytic streptococci, oral
  anerobes, S.aureus

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Peritonsillar Abscess

• Treatment
• Penicillin
• Clindamycin
• Oxacillin
• Cefazolin
• Ampicillin/sulbactam

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Retropharyngeal Abscess

• Etilogy
• Most common
• GAS, a-hemolytic streptococci, oral anaerobes,
  S.aureus
• History
• Fever, sore throat, dysphagia, drooling, refusal
  to eat, neck pain or stiffness,
• Physical Exam
• Neck pain especially with extension
• Torticollis, head in neutral position

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Retropharyngeal Abscess

• Diagnosis
• Lateral neck x-ray
• CT scan
• Treatment
• Antibiotics ENT drainage
• Cefotaxime metronidazole
• Clindamycin
• Ampicillin/sulbactam

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Retropharyngeal Abscess

• Complications
• Extension to carotid sheath
• Extension posteriorly causing atlantoaxial
  dislocation
• Spontaneous rupture? aspiration? asphyxiation
• Mediastinitis

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• Neck

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Names to Recognize

• Ludwig Angina
• Cellulitis bilateral sublingual, submandibular
  space
• Bull Neck
• Abscesses are infrequent
• Respiratory obstruction is a major risk
• Most severe in immunocompromised hosts
• Treatment
• Secure airway, drain any abscesses,
  antimicrobials
• Amoxicillin/clavulanate, ampicillin/sulbactam,
  clindamycin

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Names to Recognize

• Lemierre Syndrome
• Caused by Fusobacterium necrophorum
• Intense toxicity, spiking fevers, tonsillar
  exudates, increased ICP, HA, meningismus
• Anterior sternocleidomastoid muscle pain and
  swelling
• Complications
• Erosion of carotid artery
• Intracranial extension
• Lateral pharyngeal space infection? internal
  jugular? septic emboli (lung, liver, systemic)?
  cavernous sinus thrombosis

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Names to Recognize

• Lemierre Syndrome
• Treatment
• Antibiotics
• Clindamycin OR ampicillin/sulbactam
• Zosyn
• Vein ligation

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Suggested Reading

• American Academy of Pediatrics. Committee on
  Quality Improvement, Subcommittee on sinusitis
  management Practice guideline Management of
  sinusitis. Pediatrics 2001 108798-808
• American Academy of Pediatrics, Subcommittee on
  Management of Acute Otitis Media Diagnosis and
  management of acute otitis media. Pediatrics
  2004 113 1451-65

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Future Topics

• Croup (acute laryngotracheoa bronchitis)
• Epiglotittis
• Bacterial tracheitis
• Cervical adenitis/ deep neck infections

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• Special thanks to Dr. Rema Merhi for her help in
  compiling the slides for this presentation.