Infectious Disease [EARS NOSE THROAT]

1) Otitis Media Severe Symptoms of Acute Otitis Media

Otitis media is an infection of the middle ear caused by the respiratory - Persistent pain for 48 hours
bugs. The disease is characterized by a unilateral ear pain that they - Temperature > 39°C
tug on (relief of pain with pulling pinna). The diagnosis is confirmed - Toxic appearance
by pneumatic insufflation (a little puff of air reveals a tense immobile
membrane) and visualization of a moderately bulging tympanic If not severe and child is 2yr +, observation is ok
membrane. While a middle ear effusion is required for diagnosis, the
presence of this by itself does not diagnose acute otitis media. First line
treatment is amoxicillin. If it recurs, use amoxicillin-clavulanate. If it URI Bugs
re-recurs (3x/6 months of 4x in 12 months) ear tubes (tympanoplasty) Most S. pneumoniae Amoxicillin (1st line)
are indicated. If penicillin allergic, try a cephalosporin such as cefdinir Common H. influenzae + clavulanate
if no anaphylactic history to penicillins, azithromycin if there is. M. catarrhalis

Mastoiditis Otitis Pseudomonas Treat with topical

This is a potential complication of acute otitis media where the mastoid Externa antibiotics and topical
air cells become acutely infected. Risk is increased with Staph aureus steroids
tympanoplasty (for pseudomonas). If there’s acute otitis media and
swelling behind the ear or anteriorly rotated ear, prompt surgical Think malignant OE
evaluation is needed.

2) Otitis Externa Ear Pain Otitis Media Visual inspection

Otitis externa presents as unilateral ear pain (like media), but there’s Otitis Externa Pinna manipulation
pain on palpation of pinna (unlike media). Caused by frequent contact Foreign Body Lidocaine / Retrieval
with water (“swimmer’s ear”), it’s commonly caused by Pseudomonas.
It can also be caused by repeated trauma or an infection by Staph
aureus. On physical exam an angry erythematous canal can be seen. Rhinorrhea Viral Sinusitis < 10 days
It usually improves spontaneously. It becomes important to educate Bacterial Sinusitis Treat with abx
patients not to put anything in their ear and to dry their ears after Foreign Body Inspection
swimming and showering. Treat with topical antibiotics and topical
steroids. Oral antibiotic therapy is only needed if severe disease or
evidence of malignant OE. Sore Bacterial Rapid Strep à Culture
Throat Viral Symptomatic tx
3) Sinusitis Mono Monospot
An infection of the nose and sinuses that occurs in both kids and adults.
Purulent nasal discharge is a giveaway something’s wrong nearby.
Adults and older kids may complain of a congested, stuffed feeling with Bloody Digital Trauma Cold compress, lean
sinus tenderness. Radiographs are not necessary but will show air- Nose forward, ablation if
fluid levels and opacification (XR + CT). They’re expensive and are recurrent
usually reserved for refractory or recurrent sinusitis to make sure there’s
no anatomical defect. But before doing anything make sure this isn’t
just a cold - a regular viral illness. If it’s been > 10 days simply
presume bacterial infection. In patients with severe symptoms (high
fever > 39°C, purulent nasal discharge/facial pain for 3-4 days) or
acutely worsening symptoms (especially after initial improvement) then
antibiotic therapy should be considered. This is an URI so treat the URI
bugs with amoxicillin-clavulonate. Don’t use azithromycin! In Is it viral (wait) or is it bacterial (amox-clav)?
younger children with symptoms of sinusitis, don’t forget to evaluate
for a foreign body. Short Duration Longer Duration
Low-Grade Fever High Fever
4) Cold – Viral Nasal Mild Symptoms Worsening sxs
Typically caused by rhinovirus and transmitted between people by
large droplets. It’s also gives “boogers”, rhinorrhea, congestion, and 10 days
low-grade fever so it looks like sinusitis. Don’t perform any studies
– this includes nasopharyngeal washes, cultures, PCR, imaging, etc. If
it’s <10 days it’s likely viral - the patient should wait it out.

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 Infectious Disease [EARS NOSE THROAT]

5) Pharyngitis Modified Centor (aka “McIsaac”) Criteria
Much like sinusitis, viral pathogens are the most common cause C Absent Cough +1
occurring in kids and adults. The primary complaint will be sore throat E Exudates (tonsillar) +1
with pain on swallowing. Some exam findings (pharyngitis plus N Nodes = Anterior Chain +1
conjunctivitis = adenovirus; pharyngitis plus rash on palms/soles = Lymphadenopathy
coxsackie) can help point towards a specific pathogen. Because a T Temp > 38°C +1
bacterial infection with Group A Strep (GAS) can cause rheumatic OR < 14 yrs old or +1
fever if untreated, diagnosing and treating this is important. Post-strep > 44 yrs -1
glomerulonephritis (PSGN) can still happen even if you get treated for
Strep A Pharyngitis. The symptoms are the same whether it’s viral or Score Interpretation
bacterial; the job becoming deciding whether to treat empirically, or if <1 No further testing needed
testing is needed first. 2-3 Perform rapid testing
>4 Empiric antibiotics*
There are scoring systems (Centor, Modified Centor) which can *IDSA doesn’t recommend empiric treatment – test first!
indicate the next step for the patient – supportive care, test for GAS, or
treat for GAS*. Patients under 3 years old have the lowest incidence Group A Strep Pharyngitis Summary
and should not be tested; ages 5-15 years have the highest incidence - Don’t test patients with viral symptoms
so jumping straight to testing in a patient without viral symptoms - Avoid the Centor Criteria in patients under 15
(cough, rhinorrhea) is reasonable. The Modified Centor (aka - Test all patients before treating!
“McIsaac”) criteria attempt to take the higher incidence of the younger - Rapid test has high specificity so confirm negatives
age into consideration.

The Rapid-Strep test (the screening test) is specific (which is the

opposite of how a screening test should be). This is because of the rapid
turnaround time (minutes). If positive, treat. The confirmatory test - the
culture - takes days to return, and so is only used in the setting when the
rapid strep is negative, but suspicion high. Treat with amoxicillin or
amox-clav.

If pharyngitis + enlarged spleen is seen, it’s mono. Get an EBV panel.

6) Foreign Bodies 8) Choanal Atresia

Kids like to stick things in places. Things can go into the nose Finally, something isolated to pediatrics. This is an atretic
(producing foul-smelling unilateral rhinorrhea), ear (pain), and or anatomically stenosed connection between the nose and
sometimes down their throat (aspiration, covered in the pulmonary mouth. It can be unilateral or bilateral (which is an
lectures). Essentially, the object has to be retrieved after seeing it and emergency). In severe cases the baby will be blue at rest
any infection treated. One particular foreign body are insects; as they are obligate nose breathers (think breathing and
homeless are aware of this and sometimes sleep with coins in their ears. breastfeeding simultaneously). They will pink up with
Bugs present with a unilateral scratching or buzzing and should be crying (as he/she uses his/her mouth). If there’s a partial
treated with lidocaine and retrieval but never light (they just burrow obstruction there might be a childhood snore. Kids
deeper). shouldn’t snore. If there’s complete atresia a catheter will
fail to pass. If it’s incomplete a fiber-optic scope will
7) Epistaxis identify the lesion. Surgery is required to open the atretic
Whether out of habit or because the nose itches, epistaxis is most passage.
commonly caused by digital trauma (nose-picking). Normal
nosebleeds are unilateral and last < 30 minutes. Applying a cold
compress (vasoconstriction) and leaning forward (backwards is just
drinking the blood causing a cough breaking the clot) can cause an
active bleed to stop. Look inside the nose to make sure there isn’t
anything anatomical or foreign within. Recurrent bleeds with visible
target vessel with evidence of bleeding can be cauterized with silver
nitrate if anterior. Posterior bleeds need ENT intervention and can
involve packing and empiric antibiotics.

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