Diagnosis, Prevention and Management of: acute pharyngitis, otitis media, sinusitis, conjunctivitis,...

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

PHARYNGITISAcute Care of 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


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)


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• 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

• Neck pain• Rhinorrhea• Nasal congestion• Arthralgia and/or joint

stiffness• Lymphadenopathy• Dyspnea• Chills • Malaise

Symptoms

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: GAS

Differential Diagnosis

• 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

Features suggestive of GAS as causative agent - bacterial

• Tender, enlarged anterior cervical nodes

• Tonsillopharyngeal erythema and/or exudates

• Soft palate petechiae• Uvulitis• Scarlatiniform rash• Fever

Features suggestive of viral origin

• Conjunctivitis• Characteristic exanthems

& enanthems

Physical Assessment

Diagnostic Tests

• Lab testing is not indicated in all patients with pharyngitis• All adults should be screened for (the four classic

symptoms of GAS):– A history of fever– Lack of cough– Pharyngotonsillar exudates– Tender anterior cervical adenopathy

• None or one of these findings should not be tested or treated for GAS

The “Centor Criteria”

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

– #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:

– children: 12 mg/kg orally once daily for 3 days, maximum 500 mg/day

– adults: 500 mg orally once daily for 3 days• clarithromycin:

– 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:

– 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:

– 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:

– 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:

– 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

Group A Streptococcus (GAS) pharyngitis

FOCUS IS TO TREAT GROUP A BETA-HEMOLYTIC STREPTOCOCCUS INFECTION TO PREVENT RHEUMATIC SEQUELAE

Treatment: Rheumatic FeverSecondary Prevention of Rheumatic Fever (Prevention of Recurrent Attacks)

Benzathine penicillin G (IM)

600,000 for children < 27kg; 1,200,000 U for > 27kg every 4 weeks

Penicillin V (PO)

250mg BID

Sulfadiazine (PO)

0.5g once daily for < 27kg;1.0g once daily for > 27kg

Individuals allergic to penicillin and sulfadiazine

Macrolide or azalide (PO)

Duration of Secondary Rheumatic Fever Prophylaxis

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

Rheumatic fever with carditis but no residual heart disease (no valvular disease)

10 years or until 21 years of age (whichever is longer)

Rheumatic fever without carditis

5 years or until 21 years of age (whichever is longer)

Treatment: Mononucleosis/EBV• About 1/3 of patients with infectious mononucleosis have secondary streptococcal

tonsillitis, requiring treatment– Avoid Ampicillin

• 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

• 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– prednisone:

• 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)– 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. Retrieved from http://www.nursing.ohio.gov/PDFS/AdvPractice/10-21-13_Formulary.pdf

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. A history of rheumatic fever

2. 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.

OTITIS MEDIAAcute Care of Otitis Media

Pathophysiology

• Bacterial or viral infection – Pathogens from the nasopharynx pass into the middle ear– Most frequent pathogens identified:

• Streptococcus pneumoniae• Haemophilus influenzae• Moraxella catarrhalis• Viruses

– Respiratory syncytial virus (RSV), rhinoviruses, influenza, adenoviruses

• Congestion/dysfunction of the eustachian tube– 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

• 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.0036226http://www.plosone.org/article/info: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.0036226http://www.plosone.org/article/info: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

http://www.youtube.com/watch?v=FqSCfqoCNiI

http://www.youtube.com/watch?v=eD5gLRHkmIs


• Eustachian Tube Dysfunction– Patulous Eustachian

Tubes– Eustachian Tube

Obstruction– Eustachian Tube

Salpingitis• Otitis Media with Effusion• Chronic Otitis Media• Tympanosclerosis• Foreign Body

• 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

• 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

SINUSITISAcute Care of 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• 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/full/e05b30cbc6ea63ed5c88388956b1273e/images/up-42902.jpg

http://www.ci.irving.tx.us/begreen/images/chemicals.jpg

Causative Factors

Infectious Causes• Rhinovirus• Parainfluenza virus• Influenza virus• Streptococcus pneumoniae• Haemophilus influenzae• Staphylococcus aureus• Pseudomonas aeruginosa• Serratia marcescens• Candida albicans• Klebsiella pneumoniae• Mucorales or Aspergillus fungi

http://www.erkbiz.com/commoncold/images/rhinovirusscope.jpg

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/images/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://victorchacon.blogspot.com/2006/11/por-qu-si-tengo-mal-aliento-nadie-me.htmlnPro.com

http://inkjot.files.wordpress.com/2012/01/sinus-infection-takes-a-turn.jpg

Signs & Symptoms

• 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

http://www.pediatricsconsultantlive.com/display/article/1803329/1404497


• Allergic rhinitis - the conditions often occur together due to nasal obstruction and congestion– Thin, clear, and runny nasal discharge– Itchy nose, eyes, or throat – Recurrent sneezing– Exposure to allergen

• Migraine and Other Headaches - Many primary headaches may closely resemble sinus headache, and may coexist – 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


• 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• 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

http://libweb.lib.buffalo.edu/hslblog/dentistry/wp-content/uploads/2013/04/ZebraHorse.jpg


• 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 >102 F⁰

– 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)

History & ROS

• 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

http://www.bunnydojo.com/2011/HealthHistoryAppBoxUIIcons.jpg

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_meningitis_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

CONJUNCTIVITISAcute Care of 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


• 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


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


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


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


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


Physical Assessment Findings

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.

CORNEAL ABRASIONAcute Care of Corneal Abrasions

Anatomy Review

• 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)

Signs & Symptoms and Diagnosis

Causes

• Cuts• Scratches• Abrasions

• Rubbing eyes• Dust• Foreign objects• Contact lenses• Trauma• Dry Eyes



Treatment Options

• Corneal abrasion, the most common peri-operative 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.

• Most corneal abrasions are preventable.

• Persons in high-risk occupations should wear eye protection.

• Careful fitting and placement of contact lenses.

• Keep fingernails short.


Primary Prevention and Health Promotion

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.

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

Follow-up, Referral and Prognosis

Quick Reference

Acute Conjunctivitis Corneal Trauma

Discharge Purulent Watery, can be purulent

Vision No effect Usually blurred

Pain Mild Moderate to Severe


REVIEW QUESTIONSDo you remember???

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) Penicillin G benzathine 1.2million units IM once

b) Amoxicillin 500mg PO BID for 7 days

c) Linezolid 600mg PO BID for 7 days

d) 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) Penicillin G benzathine 1.2million units IM once

b) Amoxicillin 500mg PO BID for 7 days

c) Linezolid 600mg PO BID for 7 days

d) 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 #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 #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?

References

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Diagnosis, Prevention and Management of: acute pharyngitis, otitis media, sinusitis, conjunctivitis,...

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