Transcript File - Jamie McGuire, MS, AGACNP-BC

Diagnosis, Prevention and Management of: acute pharyngitis,
otitis media, sinusitis, conjunctivitis, corneal abrasion
NUR7202 – Fall 2013
Wright State University – Miami Valley School of Nursing and Health
Group Members
•
•
•
•
Sarah Bunch BSN, RN, CEN
Jessica Gutsjo BSN, RN, CCRN
Michelle Lozano BSN, RN
Jamie McGuire BSN, RN
Objectives
• Describe the pathologic process and etiology of acute pharyngitis, otitis
media, sinusitis, conjunctivitis, and corneal abrasion.
• Describe the signs and symptoms acute pharyngitis, otitis media,
sinusitis, conjunctivitis, and corneal abrasion including differential
diagnoses of each disease
• Identify appropriate diagnostic testing for each disease
• Identify evidence-based management of each disease including
relevant contraindications, complications, and/or adverse reactions.
• Provide rationale for health promotion activities and follow up
Acute Care of Pharyngitis
PHARYNGITIS
Definition
An infection or irritation
of the pharynx and/or
tonsils
Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.
Pathophysiology
• A bacteria or virus
invades the pharyngeal
mucosa and causes a
localized inflammatory
response
• Other viruses can
cause irritation of the
pharyngeal mucosa
secondary to nasal
secretions
Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.
Pathophysiology cont.
Tintinalli, J., & Stapczynski, J. (2011). Tintinalli's emergency medicine : a comprehensive study guide /
editor-in-chief, Judith E. Tintinalli ; co-editors, J. Stephan Stapczynski ... [et al.]. New York : McGraw-Hill,
c2011.
Prevalence
• Frequency
– Approximately 30 million cases of pharyngitis are diagnosed annually
– Pharyngitis accounts for over 10% of all office visits to primary care and 50% of
outpatient antibiotic use
– Viruses are the most common cause of acute pharyngitis
• Age
– Streptococcal infection occurs predominantly in patients between the ages of 5
and 18 years.
– Pharyngitis in patients under 3 years old is uncommon but possible; it is nearly
always due to viral etiologies.
• Genetics
– Individuals with a positive family history of rheumatic fever have a higher
incidence of rheumatic complications if streptococcal infections are untreated.
•Streptococcus pyogenes is the most significant bacterial agent causing
pharyngitis in both adults and children
Group A Streptococcal infection (Streptococcus pyogenes) (100x Magnification)
Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.
Symptoms
Features suggestive of GAS as causative agent - bacterial
•
#1 Sore throat – most common symptom
– Sudden onset and varying duration
•
Odynophagia and dysphagia
– May need to be admitted for IV fluids and IV antibiotics
•
•
•
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•
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Fever
Headache
Abdominal pain
Nausea/vomiting
The individual may report contact with individuals diagnosed with GAS or
rheumatic fever.
A history of rheumatic fever may be reported and is important in selecting
appropriate treatment
Patient 5-15 years of age
Present in winter or early spring
Symptoms
Features suggestive of viral
origin
•
•
•
•
Diarrhea
Cough
Hoarseness
Coryza
Features suggestive of
either viral or bacterial origin
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Neck pain
Rhinorrhea
Nasal congestion
Arthralgia and/or joint
stiffness
Lymphadenopathy
Dyspnea
Chills
Malaise
Differential Diagnosis: GAS
Disease/Condition
Differentiating
Signs/Symptoms
Differentiating Tests
Epiglottitis
•Severe and acute onset
of sore throat
•Notable change in the
quality of voice (muffled
voice)
•Fever and drooling of
saliva
•Direct visualization of
the epiglottis (immediate
capability of intubation),
or lateral neck x-rays
Retropharyngeal,
peritonsillar, and lateral
abscess
•Sore throat, fever, neck
pain, muffled voice
•Usually in children 4
years of age or younger
•CT & MRI of neck with
contrast
Infectious
mononucleosis
•Pharyngitis of longer
than several days'
duration
•Adenopathy,
splenomegaly
•Serum monospot
positive for Epstein-Barr
virus infection
•Atypical lymphocytes in
peripheral blood
Differential Diagnosis
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•
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Mycoplasma
Chlamydia trachomatis
Herpetic stomatitis
Gonococcal
pharyngitis
Primary HIV infection
Diphtheria
Lemierre syndrome
Behcet syndrome
• Kawasaki disease
• Hand-foot-and-mouth
disease
• Oropharyngeal cancer
or candidiasis
• Influenza
• Toxic shock syndrome
• Apthous ulcers
Physical Assessment
Features suggestive of GAS as
causative agent - bacterial
Features suggestive of viral
origin
• Tender, enlarged anterior
cervical nodes
• Tonsillopharyngeal
erythema and/or
exudates
• Soft palate petechiae
• Uvulitis
• Scarlatiniform rash
• Fever
• Conjunctivitis
• Characteristic exanthems
& enanthems
Diagnostic Tests
• Lab testing is not indicated in all patients with pharyngitis
• All adults should be screened for (the four classic
symptoms of GAS):
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–
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A history of fever
Lack of cough
Pharyngotonsillar exudates
Tender anterior cervical adenopathy
The “Centor Criteria”
• None or one of these findings should not be tested or
treated for GAS
Pelucchi, C., Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., , & Verheij, T. (2012).
Guideline for the management of acute sore throat. Clinical microbiology and infection : the official
publication of the European Society of Clinical Microbiology and Infectious Diseases, 18 Suppl 1, 1-28.
doi:10.1111/j.1469-0691.2012.03766.x
Diagnostic Tests cont.
First Test to Order
Results for positive test
Rapid antigen test for group A
Streptococcus (GAS)
Positive in GAS infection
Other Tests to Consider
Culture of throat swab for group A
Streptococcus
Growth of GAS
Culture of throat swab for gonococcus
Positive chocolate agar culture
Serum monospot for Epstein-Barr
virus infection
Positive heterophile antibodies
Diagnosis Algorithm
Esherick, J. S., Clark, D. S., & Slater, E. D. (2012). Current practice guidelines in primary care 2012.
New York: McGraw-Hill Medical.
Treatment
• Analgesics
– Acetaminophen:
• children: 10-15 mg/kg orally every 4-6 hours when required, maximum 90 mg/kg/day
• adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
– Ibuprofen:
• children: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day
• adults: 400-800 mg orally every 6-8 hours when required, maximum 3200 mg/day
• Local anesthetics
– Lidocaine oronasopharyngeal solution – topical (oral) spray:
• children and adults: 5% - apply 1 spray to affected area, then wait >1 minute and spit;
may repeat up to 4 times daily
• Benzocaine
• Gargling with salt water
• Antibiotic treatment should be reserved for patients with confirmed
pharyngitis and not based on clinical diagnosis alone
• Use of corticosteroids
• Antibiotic therapy of GAS accelerates resolution by 1-2 days if initiated
within 2-3 days of symptom onset
Group A Streptococcus (GAS) pharyngitis
FOCUS IS TO TREAT GROUP A BETA-HEMOLYTIC
STREPTOCOCCUS INFECTION TO PREVENT
RHEUMATIC SEQUELAE
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#1Penicillin or Amoxicillin
• penicillin V potassium:
– children ≤27 kg: 250 mg orally two to three
times daily for 10 days
– children >27 kg and adults: 500 mg orally two
to three times daily for 10 days
• penicillin G benzathine:
– children ≤27 kg: 600,000 units intramuscularly
as a single dose
– children >27 kg and adults: 1.2 million units
intramuscularly as a single dose
» *Use if worried about PO compliance
• amoxicillin:
– children: 50 mg/kg/day orally given in 2 divided
doses for 10 days, maximum 1000 mg/day
– adults: 875 mg orally twice daily for 10 days
– Amoxicillin should be avoided when
concomitant infectious mononucleosis is
suspected
Penicillin allergy: Macrolide, cephalosporin, or Clindamycin
•
•
GAS resistance to macrolides has been reported
azithromycin:
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clarithromycin:
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children: 25-50 mg/kg/day orally given in divided doses every 12
hours for 10 days, maximum 1000 mg/day
adults: 500 mg orally twice daily for 10 days
cefadroxil:
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children: 25-50 mg/kg/day orally given in 4 divided doses for 10
days, maximum 2000 mg/day
adults: 250-500 mg orally four times daily for 10 days
cephalexin:
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•
children: 15 mg/kg/day orally given in divided doses every 12
hours for 10 days, maximum 500 mg/day
adults: 250 mg orally twice daily for 10 days
#1 erythromycin:
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•
children: 12 mg/kg orally once daily for 3 days, maximum 500
mg/day
adults: 500 mg orally once daily for 3 days
children: 30 mg/kg/day orally given in 1-2 divided doses for 10
days, maximum 1000 mg/day
adults: 1000 mg/day orally given in 1-2 divided doses for 10 days
clindamycin:
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children: 20 mg/kg/day orally given in divided doses every 8
hours for 10 days, maximum 1800 mg/day
adults: 300-600 mg orally every 8 hours for 10 days
•Doxycycline and trimethoprim/sulfamethoxazole are ineffective
•Antibiotic prophylaxis in individuals with a history of rheumatic fever is recommended to decrease the risk of recurrence of rheumatic fever
•Goal: prevent acute rheumatic fever, reduce the severity and duration of symptoms, and prevent transmission
Treatment: Rheumatic Fever
Duration of Secondary Rheumatic
Fever Prophylaxis
Secondary Prevention of Rheumatic
Fever (Prevention of Recurrent
Attacks)
Rheumatic fever
with carditis and
residual heart
disease
(persistent
valvular disease)
10 years or until 40
years of age
(whichever is
longer), sometimes
lifelong prophylaxis
Benzathine
penicillin G
(IM)
600,000 for children <
27kg;
1,200,000 U for > 27kg
every 4 weeks
Penicillin V
(PO)
250mg BID
Rheumatic fever
with carditis but
no residual heart
disease (no
valvular disease)
10 years or until 21
years of age
(whichever is
longer)
Sulfadiazin
e (PO)
0.5g once daily for <
27kg;
1.0g once daily for > 27kg
Rheumatic fever
without carditis
5 years or until 21
years of age
(whichever is
longer)
Individuals allergic to penicillin and
sulfadiazine
Macrolide
or azalide
(PO)
Treatment:
Mononucleosis/E
BV
•
About 1/3 of patients with infectious mononucleosis have secondary
streptococcal tonsillitis, requiring treatment
–
Avoid Ampicillin
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Supportive care
May require IV fluids and IV pain medication
A dose of PO of IV steroid may be administered
Splenomegaly: risk factors and symptoms of splenic rupture should be given
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Rest is a frequent recommendation
Avoidance of strenuous physical activity in the initial 3 to 4 weeks of illness is
desirable in light of the potential for splenic rupture
IVIG may be used in patients with immune thrombocytopenia.
•
Primary Options
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prednisone:
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children: 1-2 mg/kg/day orally
adults: 30-60 mg/day orally
immune globulin (human):
•
children and adults: consult specialist for guidance on dose
AGACNP Formulary
• The AGACNP can prescribe all drugs discussed for the
treatment of Acute Pharyngitis!! (except immune globulin)
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Analgesics: Acetaminophen & Ibuprofen
Local anesthetics
Penicillin or Amoxicillin
Macrolides, Cephalosporins, or Clindamycin
Prednisone
• Immune globulin
– Physician Initiated OR Physician Consult
• Must be noted on the standard care arrangement with the
collaborating physician
Ohio Board of Nursing (2012). The formulary developed by the Committee on Prescriptive
Governance.
Complications
• Rheumatic fever
– Low likelihood
• Glomerulonephritis
– Low likelihood
• Peritonsillar abscess
– Low likelihood
• Otitis media
– Low likelihood
• Mastoiditis
– Low likelihood
• Sinusitis
– Low likelihood
• Bacteremia
– Low likelihood
• Pneumonia
– Low likelihood
Health Promotion
• Antibiotic use increases the risk of an antibiotic resistant
infection
– Symptoms should improve within 3 or 4 days
– No need for bed rest or isolation
• However close contacts who have symptoms of GAS pharyngitis or
who have had rheumatic fever or post-streptococcal
glomerulonephritis previously should be tested
• Aspirin should be avoided in children because of its
association with Reye syndrome
• Children may return to school or daycare after taking
antibiotics for at least 24 hours.
• Hand-washing!
• Cover mouth with coughing!
Prevention
• Hand-washing!
• Antibiotic prophylaxis is for GAS is in individuals with a
history of rheumatic fever
• No vaccine to prevent GAS pharyngitis!
Outcomes
• Antibiotic therapy of GAS pharyngitis results in a
decrease of symptom intensity and duration, and
prevents the long-term complication of rheumatic fever
• Symptom resolution is within a few days
• Infected individuals are not immune to reinfection
• Complications of viral pharyngitis are extremely
uncommon
• Symptoms usually go away within 7 to 10 days
Follow-up
• There is no need to confirm successful antibiotic treatment
after antibiotic therapy
– EXCEPT for patients with:
1.
2.
A history of rheumatic fever
Infection due to an outbreak of GAS strains causing rheumatic fever
or poststreptococcal glomerulonephritis.
• If pharyngitis symptoms have not improved after 3 to 4
days alternate diagnoses should be considered.
Acute Care of Otitis Media
OTITIS MEDIA
Pathophysiology
• Bacterial or viral infection
– Pathogens from the nasopharynx pass into the middle ear
– Most frequent pathogens identified:
•
•
•
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Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Viruses
– Respiratory syncytial virus (RSV), rhinoviruses, influenza, adenoviruses
• Congestion/dysfunction of the eustachian tube
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Purulent material formation
Middle ear cleft
Pneumatized mastoid air cells
Petrous apex
Anatomy of the Ear
AOM vs OME
• Acute Otitis Media
– Middle ear effusion
– Acute inflammation
– Symptoms
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•
otalgia
drainage from the ear
irritability
fever
hearing difficulty
problems with balance
• Otitis Media with Effusion
– Middle ear effusion with no other symptoms
Prevalence
• Predominantly a pediatric diagnosis
– Due to changes in ear anatomy with aging
– 50-84% by age 3 have had AOM
• 3-15% of adults
AOM and CSOM incidence rate, HI prevalence and mortality
estimates for the year 2005, by WHO areas.
Monasta L, Ronfani L, Marchetti F, Montico M, et al. (2012) Burden of Disease Caused by Otitis Media: Systematic Review and Global
Estimates. PLoS ONE 7(4): e36226. doi:10.1371/journal.pone.0036226
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036226
Global AOM and CSOM incidence rate, HI prevalence and
mortality estimates for the year 2005, by WHO age groups.
Monasta L, Ronfani L, Marchetti F, Montico M, et al. (2012) Burden of Disease Caused by Otitis Media: Systematic Review and Global
Estimates. PLoS ONE 7(4): e36226. doi:10.1371/journal.pone.0036226
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036226
Signs & Symptoms
• Major Presenting Complaint:
– Otalgia
• May be Associated With:
– Fever
– Otorrhea
– Hearing Loss
• Rarely Associated With:
– Tinnitus
– Vertigo
– Nystagmus
Signs & Symptoms
• Tympanic membrane:
– May be Bulging or Retracted
– May appear Red
• Inflammation
– May appear White/Yellow
• Fluid in the middle ear
– Pneumatic Otoscopy
• Generally demonstrates impaired mobility
Pneumatic Otoscopy
• http://www.youtube.com/watch?v=FqSCfqoCNiI
• http://www.youtube.com/watch?v=eD5gLRHkmIs
Differential Diagnosis
• Eustachian Tube Dysfunction
– Patulous Eustachian
Tubes
– Eustachian Tube
Obstruction
– Eustachian Tube
Salpingitis
• Otitis Media with Effusion
• Chronic Otitis Media
• Tympanosclerosis
• Foreign Body
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Cholesteatoma
Bullous Myingitis
Nasopharyngeal Cancer
Mastoiditis
TMJ Dysfunction
Referred Pain
– Pharyngitis
– Sinusitis
– Tooth Pain
Physical Assessment
• Subjective report form the patient
• Otoscopy
– Bulging tympanic membrane
• Pneumatic otoscopy
– Tympanic membrane movement
• Tympanometry
Diagnostic Tests
• No “Gold Standard” test
• Middle ear aspirate for culture
– Bacterial and viral
Treatment of AOM
• Amoxicillin 875 mg BID x 10 days or Amoxicilin 500 mg, 2
tabs BID x 10 days
• If allergic to amoxicillin: Azithromycin 30 mg/kg x 1 dose
• If no improvement after 3 days of starting treatment
consider changing to: Augmentin ES 875/125 mg BID x 10
days
• If significant symptoms remain after treatment consider:
Rocephin IM/IV 1-2 gm daily x 1-3 days
Treatment
• If perforation of tympanic membrane:
– Cortisporin otic 4 drops in affected ear, 3 times a day for 7 days
• For pain:
– OTC analgesics such as tylenol or motrin can be recommended
• Decongestants and antihistamines have not been shown to
improve outcomes
AGACNP Formulary
Complications
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•
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Perforation
Mastoiditis
Facial nerve paresis
Labyrinthitis
• Meningitis
• Hydrocephalus
• Abscess
Health Promotion and
Prevention
• Hib vaccine
• Pneumococcal vaccine
• Smoking cessation
• Hand washing
Outcomes
• Most will recover fully
– Within 4 weeks
• Most hearing loss will improve as symptoms resolve
Follow-up
• If patient has symptomatic relief no follow up is required
• If no relief of symptoms
– Re-evaluate in 6 weeks
– consider more extensive work-up to rule out other potential causes
• Computed Tomography (CT) scan
– Refer to otolaryngology
Acute Care of Sinusitis
SINUSITIS
Anatomy
https://www.google.com/search?q=sinuses&source=lnms&tbm=isch&sa=X&ei=i1F5Uq_0IqTKsQTatoKoBA&ved=0CAcQ_AUoAQ&biw=1600&bih=730#q=sinus+ostia&tbm=isch&facrc=_&imgdii=_
&imgrc=AYUq0L9VmIoNiM%3A%3BEemPlZh7ShlNHM%3Bhttp%253A%252F%252Fwww.sinuses.com%252Fimages%252Fcoronal4.jpg%3Bhttp%253A%252F%252Fwww.sinuses.com%252Fctscan
.htm%3B640%3B480
Sinusitis Definition
• An inflammatory condition involving the lining of the four
paired structures surrounding the nasal cavities
• Classified by duration of illness, etiology, and pathogen
• Frequently called rhinosinusitis because it almost always
involves the nose
• Many infections involve more than one sinus area
– Maxillary most frequently infected area
• Uncomplicated rhinosinusitis is defined as rhinosinusitis
without clinically evident extension of inflammation out side
the paranasal sinuses and nasal cavity
Pathophysiology
• Each sinus is lined with
cilia that move mucus
produced by the epithelium
out through the sinus ostia
to the nasal cavity
• When the flow of the cillia
is impaired, or the ostia is
obstructed, mucus builds
up
• Secretions may become
infected by variety of
pathogens
http://sinuvil.com/
Causative Factors
Noninfectious Causes
•
•
•
•
•
•
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Allergic rhinitis
Barotrauma
Chemical Irritants
Tumors
Granulomatous diseases
Cystic fibrosis
Nasotracheal intubation,
orotracheal intubation
• Nasogastric tubes
• Deviated Septum
• Large adenoids
http://www.sinus-pro.com/images/Sinus-causes.jpg
http://ei.realself.com/ful
l/e05b30cbc6ea63ed5c8
8388956b1273e/images
/up-42902.jpg
http://www.ci.irving.tx.us/begreen/images/chemicals.jpg
Causative Factors
Infectious Causes
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Rhinovirus
Parainfluenza virus
Influenza virus
Streptococcus pneumoniae
Haemophilus influenzae
http://www.erkbiz.com/commoncold/images/rhinovirusscope.jpg
Staphylococcus aureus
Pseudomonas aeruginosa
Serratia marcescens
Candida albicans
Klebsiella pneumoniae
Mucorales or Aspergillus fungi
http://textbookofbacteriology.net/themicrobialworld/S.pneumoniaeFA1.jpeg
Incidence & Prevalence
• Upper respiratory tract
infections (URI) have a large
impact on public health
• Time away from work and/or
school
• Sinusitis is 5th leading cause
for antibiotics
• Effects 1 in 7 adults annually
• Sinusitis is one of the most
common diseases in the
United States, affecting
about 30 million Americans
each year
– Includes both incidence and
prevalance as chronic and
acute overlap
http://50.87.46.241/~hartingt/media/feedgator/image
s/daily/2013/01/23/7_sinusitis.jpg
Special Populations at Increased
Risk
• Elderly
–
–
–
–
Dry nasal passages
Weakened cartilage in nasal passages causes airflow changes
Diminished cough and gag reflexes
Decreased immune system response
• Persons with Allergies
– Frequent inflammation
– Polyps
• Hospitalized patients
– Head injuries
– Conditions requiring insertion of tubes through the nose
• 20% get sinusitis
– Breathing aided by mechanical ventilators
– Weakened immune system
Signs & Symptoms
• After or concurrnt with
other URI
• Nasal drainage
• Nasal congestion
• Facial pain and pressure
• Headache
• Cough
• Sneezing
• Fever
• Sore throat
• Tooth pain
• Halitosis
http://inkjot.files.wordpress.com/2012/01/sinus-infection-takes-a-turn.jpg
http://victorchacon.blogspot.com/2006/11/por-qu-si-tengo-malaliento-nadie-me.htmlnPro.com
Signs & Symptoms
http://www.pediatricsconsultantlive.com/display/article/1803329/1404497
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Orbital swelling
Cellulitis
Ptosis
Decreased EOM
Retroorbital pain
Nasopharygeal ulcerations
Episaxis
Involvment of CN V and VII
Boney errosion
Pott’s puffy tumor
Meningitis
Epidural abcess
Cerebral abcess
Differential Diagnosis
•
Allergic rhinitis - the conditions often occur
together due to nasal obstruction and
congestion
–
–
–
–
•
Migraine and Other Headaches - Many
primary headaches may closely resemble
sinus headache, and may coexist
–
–
•
Thin, clear, and runny nasal discharge
Itchy nose, eyes, or throat
Recurrent sneezing
Exposure to allergen
Sinus headaches are usually more
generalized than migraines
Correlate with other symptoms of sinusitis if
present
Trigeminal Neuralgia – Headache and
pressure sensitive pain on the face
–
Correlate with other symptoms of sinusitis,
evaluate duration
http://3.bp.blogspot.com/zrRMsbP2rWg/TnfwkwD5gDI/AAAAAAAABFk/QOqlekpo4KQ/s1600/7018_medical_cartoon+small.gif
Differential Diagnosis
•
•
•
Dental problems – Pain can radiate
to the head or face
A foreign object in the nasal
passage – Causes blockage and
similar s/s
Persistent upper respiratory tract
infections - difficult to distinguish
from sinusitis
– Correlate symptoms, duration,
progress of illness
•
•
http://libweb.lib.buffalo.edu/hslblog/dentistry/wp-content/uploads/2013/04/ZebraHorse.jpg
Temporomandibular disorders radiating pain may mimic sinus
headache
Vasomotor rhinitis - a condition in
which the nasal passages become
congested in response to irritants or
stress
– Frequently occurs in pregnant women
– Correlate symptoms, recent stress,
progress of illness
Differential Diagnosis
• Acute vs. chronic sinusitis vs. reoccurant
• Fungal rare except in immunocompromised
• Bacterial vs. viral acute illness
– Clinical Features
• Tooth pain, hallitosis
• Thick, purulent drainage
• High fever >102⁰F
– Duration of illness longer for bacterial diagnosis
• Greater than 10 days for adults, 10-14 days for children
– Symptoms do not change in bacterial illness
• Exception: symptoms get better and then dramatically worse again
after 7-10D
(Rosenfeld R M et al. , 2013)
(Rosenfeld R M et al. , 2013)
History & ROS
•
http://www.bunnydojo.com/2011/HealthHistoryAppBoxUIIcons.jpg
•
Evaluate symptoms
– Nasal drainage including amount,
color, duration
– Pain including specific location,
duration, radiation
– Congestion including fluctuations with
position, duration
– speech indicating “fullness of the
sinuses”
History
– Medical including weakened immune
system, DM
– Allergies
– Headaches
– Recent URI including duration
– Sinisitis episodes that did not respond to
treatment
– Known structrual abnormalties in the head
or face, or any recent injury to these areas
– Medical conditions that could cause pain
or pressure in head or face
– Medications being taken (decongestants)
– Exposure to irritants including ciggerette
smoke
– Recent air travel or scuba diving
– Recent dental procedures
– Family history of allergies, immune
disorders, cystic fibrosis, or Kartagener's
(immotile cilia) syndrome
– Exposure to small children
Physical Assessment
• Press over frontal and maxillary areas
– swelling, erythema, or edema localized over the involved cheekbone or
periorbital area
– palpable cheek tenderness
• Otoscope with nasal speculum
– Mucosal irritation
– Structural abnormalties
• Assess nasal discharge, or purulent drainage in the posterior pharynx
–
–
–
–
Color
Odor
Consistency
Amount
• Percussion tenderness of the upper teeth
• Evaluate for signs of extrasinus involvement (orbital or facial cellulitis,
orbital protrusion, abnormalities of eye movement, neck stiffness)
Diagnostic Test
• Occipitomental x-ray
“Waters view”
– Presence of air-fluid
level suggest the
diagnosis
• Sinus CT if portable
films poor quality
• Sinus aspirate needed
for confirmed diagnosis
and culture
• Endoscopy for
evaluation of polyps,
mucus, specimen
collection
http://www.sinusitis-solutions.com/radiologic.html
Occipitomental X-ray
“Waters View”
Supportive Treatment for Chronic
and Acute Sinusitis
• Antihistamines not
recommended
• Decongestants not
recommended
• Facilitate sinus drainage
– Saline lavage
– Nasal glucocorticoids:
Fluticasone (Flonase)
50mcg/spray – give 2 sprays
per nostril once daily OR can
divide dose to twice daily
– Hydrate with H2O
– Expectorants: Guifenesin
400mg PO Q6H
– Steam therapy
– Eating spicy foods
http://www.medicinenet.com/sinusitis_pictures_slideshow/article
Treatment of Acute Sinusitis
•
•
•
•
•
2-10% caused by bacteria
Antibiotics frequently prescribed = resistance to Streptococcus pneumoniae
Treat severe symptoms with ATB regardless of duration
Consider “watch and wait” approach: wait an additional 7 days to determine if the infection
will clear on its own
Emprical treatment with narrow spectrum ATB against most likely suspects
–
–
–
•
•
•
•
Amoxicillin/clavulanate ER 500mg PO TID or 875mg PO BID for 5-7 days
Allergy to PCN or severe symptoms
•
Levofloxacin 500-750mg PO daily for 5-7 days, or Doxycycline 200mg PO daily for 5-7 days (can divide dose to
100mg BID if prefered)
Exposure to ATB within 30D, immunocompramised, or prevalence of PCN-resistant S.Pneumoniae
•
Amoxicillin/clavulanate ER 2000mg PO BID for 5-7 days, OR Antipneumocccal floroquinolone i.e. levofloxacin
500-750mg PO daily for 5-7 days
Nosocomial – broad spectrum
–
–
–
–
Trimethoprim/sulfamethoxazole 160mg/800mg 1-2 tab PO BID
Deescalate
Remove tubes if possible
Do we care?
10% do not respond to ATB- get sinus aspirate, consult otolaryngologist
–
If no reponse to tx within 5-7 days then reevaluate ATB, diagnosis
Fungal infections can be life-threatening and may need surgery and Amphotericin B
IV ATB and surgical interventions are reserved for severe disease and/or intracranial
complications
–
IV ATB inpatient
Treatment of Chronic and
Reoccurring Sinusitis
• Patients have had multiple ATB and surgeries = higher risk for resistant
colonization
• Diagnostics
– CT and biopsy for culture
•
•
•
•
•
Culture-guided ATB
Intranasal glucocorticoids
Otolaryngologist consult
Surgery to debride or remove mucus
Tx underlying issues if present
– Allergies, cystic fibrosis, anatomical issues
• Testing for underlying issues if not previously performed.
– Allergies, HIV, DM
– Decreases in serum IgA, IgG and its subclasses, and abnormalities in markers
of T-lymphocyte function
Treatment of Chronic &
Reoccurring Sinusitis
• Chronic
– Due to chronic mucociliary clearance issues
– Possibly old acute infection that was not treated
– Most commonly associated with bacteria or fungi and difficult to
cure
– Symptoms are more vague and usually less intense than acute
cases
– Chronic fungal usually fixed with endoscopic surgery without need
for antifungals
Follow-Up
• Symptoms persistant
beyond 7 days of
treatment
• Return of symptoms after
initial period of relief
• Any type of facial swelling
• Mental status changes
• Vision changes
• Neck stiffness
• Rash
http://newsimg.bbc.co.uk/media/images/41204000/jpg/_41204046_men
ingitis_rash203.jpg
Health Promotion &
Prevention
•
•
•
•
•
•
Avoid allergens
Smoking Cessation
Oral hygiene
URI prevention and early treatment
WASH YOUR HANDS NASTY!!
Saline nasal irrigation
– improved mucociliary function, decreased nasal mucosal edema, and
mechanical rinsing of infectious debris and allergens
• Vaccines
– Flu – 6mos and older
– Children and adults older than 65
– Immunocompromised, smokers
Acute Care of Conjunctivitis
CONJUNCTIVITIS
The most common eye disease
Anatomy Review
(Jones, 2013)
Prevalence
• Not a reportable illness, and many do not seek treatment
• Outbreaks are reportable
• Estimated 40% of individuals will have at least once in their
lifetime
• Increased incidence in persons with allergies
Prevention – Health
Promotion of Conjunctivitis
Differential Diagnosis
•
•
•
•
•
•
•
Viral Conjunctivitis
Bacterial Conjunctivitis
Gonococcal Conjunctivitis
Chlamydial Conjunctivitis
Keratoconjunctivitis Sicca
Allergic Eye Disease
Acute vs Chronic
Viral Conjunctivitis
•
•
•
•
•
•
•
•
•
Adenovirus most common pathogen
Usually bilateral
Copious watery discharge
Often sensation of foreign body
Follicular involvement
2 week course
Can be associated with pharyngitis, fever malaise,
preauricular adenopathy
Treatment with cold compresses for pain
management and topical sulfonamides or
antibiotics to prevent secondary bacterial infection
If unilateral could be due to herpes simplex virus
with vesicles present. Treat with topical or
systemic antivirals
(Papadakis & McPhee, 2013)
Bacterial Conjunctivitis
•
•
•
•
•
•
•
Most common organisms: staphylococci,
streptococci (S. pneumoniae), Haemophilus,
Pseudomonas, and Moraxella
Copious purulent drainage
No blurring of vision
Mild discomfort
If hyperpurulent consider culture for gonococcal
infection
Usually self-limited with 10-14 day course
Treat with topical Sulfonamide or 10% ophthalmic
solution three times daily, should clear infection in
two to three days
(Papadakis & McPhee, 2013)
Gonococcal Conjunctivitis
•
•
•
•
•
•
•
Acquired through contact with infected genital
secretions
Copious purulent discharge
Ophthalmologic emergency – corneal involvement
can lead to perforation
Diagnosis confirmed by stained smear and culture
of discharge
Treat with single dose of Ceftriaxone 1g IM
Topical antibiotics such as erythromycin and
bacitracin may be added
Consider presence of other STD’s such as
chlamydia, syphilis, and HIV
(Papadakis & McPhee, 2013)
Chlamydial
Keratoconjunctivitis
•
Trachoma
–
–
–
–
–
–
•
Most common infectious cause of blindness
Recurrent throughout lifespan, early presentation of follicular
conjunctivitis
Development of corneal scarring
Test for immunology and polymerase chain reaction on
conjunctival samples
Treatment initiated on clinical findings, administer single dose
oral azithromycin 20mg/kg
Surgical intervention for eyelid correction and corneal
transplantation may be required
Inclusion Conjunctivitis
–
–
–
–
–
–
–
Exposure to infected genital secretions
Acute redness, discharge, and irritation
Follicular conjunctivitis and mild keratitis
Non-tender preauricular lymph node may be palpated
Diagnosis confirmed by immunology and polymerase chain
reaction on conjunctival samples
Treatment with single dose 1g azithromycin oral
Assess for genital involvement and other STD’s to determine
appropriate therapy
(Papadakis & McPhee, 2013)
Allergic Eye Disease
•
•
•
Number of forms such as atopic, vernal, and
allergic
Symptoms include itching, tearing, redness,
stringy discharge, occasionally photophobia and
vision loss
Treatment includes topical H1-receptor
antagonists and systemic antihistamines
(Papadakis & McPhee, 2013)
Keratoconjunctivitis
Sicca aka Dry Eyes
•
•
•
•
•
•
•
Common disorder, especially older women
Hypofunction of lacriminal glands, loss of aqueous
component of tears
Can be due to aging, hereditary disorders,
systemic diseases (eg, Sjogren syndrome), or
systemic drugs, environmentalfactors, vitamin A
Deficiency
Findings of dryness, redness, or foreign body
sensation
May have increased mucus production
Can lead to abrasion or ulceration
Initial treatment with artificial tears, identify cause
(Papadakis & McPhee, 2013)
Physical Assessment
Findings
Treatment
Options
Treatment
Options
AGACNP Formulary
Follow-Up
•
Frequency of follow-up visits varies with the severity of the
condition, the diversity of etiologies considered, and the
potential for ocular morbidity.
•
Follow-up should be designed for careful monitoring of
disease progression and verification that the selected
treatment regimen is effective.
•
Alteration of therapy, when needed, as well as recognition of
adverse side effects and re-evaluation of the condition and its
response to treatment at regular intervals, are integral to
successful patient management.
Acute Care of Corneal Abrasions
CORNEAL ABRASION
Anatomy Review
Signs & Symptoms and
Diagnosis
•
History of recent trauma with subsequent acute
pain (as minimal as aggressive eye rubbing)
•
Presence of photophobia, pain with extraocular
muscle movement, excessive tearing,
blepharospasm, foreign body sensation, gritty
feeling, blurred vision, and or headache
•
Diagnosis confirmed by visualizing the cornea
under cobalt-blue filtered light after application of
fluorescein stain with findings of the abrasion
highlighted in green
•
Can use topical anesthetic such as proparacaine if
pain limits exam.
Picture of eye after application of
fluorescein
Picture of eye after application of
fluorescein, under cobalt-blue light
(Wilson & Last, 2004)
Causes
• Cuts
• Scratches
• Abrasions
•
•
•
•
•
•
Rubbing eyes
Dust
Foreign objects
Contact lenses
Trauma
Dry Eyes
(Wilson & Last, 2004)
Treatment Options
(Wilson & Last, 2004)
Primary Prevention and
Health Promotion
•
•
•
•
•
Most corneal abrasions are
preventable.
Persons in high-risk occupations
should wear eye protection.
Careful fitting and placement of contact
lenses.
Keep fingernails short.
•
•
•
Corneal abrasion, the most common perioperative ocular injury, results from
lagophthalmos during general anesthesia. It
can be prevented by taping the patient’s
eyelids closed or instilling soft contact lenses
or aqueous gels; paraffin-based ointments
(e.g., Lacrilube, Duratears)
Screening is important in sedated or paralyzed
patients on a ventilator and persons who wear
contact lenses.
Adults who are deeply sedated or receiving
neuromuscular blocking agents while on a
ventilator are high risk due to the protective
corneal reflex is suppressed. Recommend use
of ofprophylactic lubricating ointment
administered every four hours
Screening for corneal abrasions also may be
needed after airbag deployment in automobile
crashes.
(Wilson & Last, 2004)
Follow-up, Referral and
Prognosis
Follow-up and Referral
Guidelines
• Re-evaluated in 24
hours; if the abrasion
has not fully healed, they
should be evaluated
again three to four days
later.
• Referral to an
ophthalmologist is
indicated for patients
with deep eye injuries,
foreign bodies that
cannot be removed
Prognosis
• Healing time depends on the size of the
corneal abrasion. Most abrasions heal in two
to three days, while larger abrasions that
involve more than one half of the surface
area of the cornea may take four to five days.
Quick Reference
Acute Conjunctivitis
Corneal Trauma
Discharge
Purulent
Watery, can be purulent
Vision
No effect
Usually blurred
Pain
Mild
Moderate to Severe
(Papadakis & McPhee, 2013)
Do you remember???
REVIEW QUESTIONS
Question #1
A 30-year-old woman presents to the ED with a 9-day history
of fever, sore throat, and neck swelling. She denies cough,
rhinorrhea, and hoarseness. Upon physical examination you
find tonsillar exudates and right-side submandibular
adenopathy. You obtain a rapid strep test and a strep culture;
results are pending. What is the best treatment option for this
patient?
a)
b)
c)
d)
Penicillin G benzathine 1.2million units IM once
Amoxicillin 500mg PO BID for 7 days
Linezolid 600mg PO BID for 7 days
Doxycycline 100mg PO BID for 7 days
Question #1
A 30-year-old woman presents to the ED with a 9-day history
of fever, sore throat, and neck swelling. She denies cough,
rhinorrhea, and hoarseness. Upon physical examination you
find tonsillar exudates and right-side submandibular
adenopathy. You obtain a rapid strep test and a strep culture;
results are pending. What is the best treatment option for this
patient?
a)
b)
c)
d)
Penicillin G benzathine 1.2million units IM once
Amoxicillin 500mg PO BID for 7 days
Linezolid 600mg PO BID for 7 days
Doxycycline 100mg PO BID for 7 days
Question #2
28 year old Caucasian male presents to the emergency room
with complaints of eye irritation and drainage. Upon exam
you find copious purulent discharge and scleral irritation. The
drainage was confirmed by stained smear and culture
identifying gonococcal conjunctivitis. Treatment includes:
a) Single dose of Ceftriaxone 1g IM
b) Single dose 1g azithromycin oral
c) Assess for genital involvement and other STD’s to determine
appropriate therapy
d) All of the above
Question #2
28 year old Caucasian male presents to the emergency room
with complaints of eye irritation and drainage. Upon exam
you find copious purulent discharge and scleral irritation. The
drainage was confirmed by stained smear and culture
identifying gonococcal conjunctivitis. Treatment includes:
a) Single dose of Ceftriaxone 1g IM
b) Single dose 1g azithromycin oral
c) Assess for genital involvement and other STD’s to determine
appropriate therapy
d) All of the above
Question #3
Diagnosis of corneal abrasion is made by?
a) Based upon patient’s symptomatology and history.
b) Visualizing the cornea under cobalt-blue filtered light after
application of fluorescein stain with findings of the abrasion
highlighted in green.
c) Visualizing the cornea under cobalt-blue filtered light after
application of fluorescein stain with findings of the abrasion
highlighted in blue.
d) CT scan with ocular view.
Question #3
Diagnosis of corneal abrasion is made by?
a) Based upon patient’s symptomatology and history.
b) Visualizing the cornea under cobalt-blue filtered light after
application of fluorescein stain with findings of the abrasion
highlighted in green.
c) Visualizing the cornea under cobalt-blue filtered light after
application of fluorescein stain with findings of the abrasion
highlighted in blue.
d) CT scan with ocular view.
Question #4
You are rounding with the trauma team and go into to see a
55 y/o male who was admitted yesterday after he fell from a
ladder while hanging his Christmas lights. He tells that he
has also had some symptoms lately, that you determine are
consistent with a sinus infection for 5 days now. What do you
do?
a) Prescribe him Augmentin 500mg PO TID
b) Wait 5 more days and if symptoms persist then prescribe him
Trimethoprim/sulfamethoxazole 160mg/800mg 2 tab PO BID
c) Wait 5 more days and if symptoms persist prescribe him Amoxicillin
500mg PO TID
d) None of the above
Question #4
You are rounding with the trauma team and go into to see a
55 y/o male who was admitted yesterday after he fell from a
ladder while hanging his Christmas lights. He tells that he
has also had some symptoms lately, that you determine are
consistent with a sinus infection for 5 days now. What do you
do?
a) Prescribe him Augmentin 500mg PO TID
b) Wait 5 more days and if symptoms persist then prescribe him
Trimethoprim/sulfamethoxazole 160mg/800mg 2 tab PO BID
c) Wait 5 more days and if symptoms persist prescribe him Amoxicillin
500mg PO TID
d) None of the above
Question #5
A 33 year-old man presents with continued otalgia, otorrhea
and fever of 100.8 degrees farenheit after four days of
treatment with amoxicillin. What should be done next in the
treatment of this patient?
a) Tylenol 1 gram every six hours for pain and fever and have patient
return in one week
b) Refer to otolaryngology for further work-up
c) Augmentin 875/125 mg 2 times a day for 10 days and Tylenol 1 gram
every six hours for pain and fever and have patient return if symptoms
do not resolve
d) Continue current therapy with no changes
Question #5
A 33 year-old man presents with continued otalgia, otorrhea
and fever of 100.8 degrees farenheit after four days of
treatment with amoxicillin. What should be done next in the
treatment of this patient?
a) Tylenol 1 gram every six hours for pain and fever and have patient
return in one week
b) Refer to otolaryngology for further work-up
c) Augmentin 875/125 mg 2 times a day for 10 days and Tylenol 1 gram
every six hours for pain and fever and have patient return if symptoms
do not resolve
d) Continue current therapy with no changes
McPhee, S. J., Papadakis, M. A., & Rabow, M. W. (2014). Current medical diagnosis & treatment 2014. New York: McGraw-Hill Medical.
Questions?
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