Eye, Ear, Nose, and Throat

Infections

Nenad Pandak
 Why ?

• Ophthalmologist
• ENT specialist
• ID specialist & GP
– Familiar with these infections
– Preliminary empiric therapy
 Task
• Eye infections
– Conjuctivitis
– Keratitis
– Endophtalmitis
• Throat infections
– Pharyngitis
– Epiglottitis
 Task
• Ear infections
– Otitis externa
– Otitis media
– Mastoiditis
• Sinus infections
– Sinusitis
Eye anatomy
 Conjuctivitis

• Inflammation of conjuctiva
• Doesn’t threaten the vision
• Rapid respond to therapy
 Conjuctivitis
• Direct contact with the environment
• Tears
– Antibacterial agents
– Lysozyme, IgA, IgG
• Decresed tear production
– Recurrent infections
 Clinical presentation
• Vessel dilatation
• “red eye”
• Pus formation
• Eyelid swelling
• Itching, pain
• Glued eyelid shut
(dried purulent
exudate)
 Causes
• Bacteria • Viruses
• Staph. aureus • Adenoviruses
• Str. pneumoniae • Enteroviruses
• H. influenzae • HSV
• M. catarrhalis • VZV
• N. gonorrhoeae • Measles
• N. meningitidis
• P. aeruginosa
• C. trachomatis
 Causes
• Fungi • Parasites
• Candida • Trichinella spiralis
• Blastomyces • Taenia solium
• Sporothrix schenckii • Schistosoma
haematobium
• Lola loa
• Onchocerca volvulus
 Causes
• Viral
• The most common
• Highly contagious
• Spread to the 2nd eye in 24-48 hrs
• Bacterial
• Highly contagious
• Profuse pus formation
 Causes
• Allergic and toxic
• Pollens
• Symmetrical
• Itching
• Systemic diseases
• Reiter syndrome
• Vasculitis
• SLE
 Diagnosis

• History & examination

• Severe cases
– Swab or scraping: Gram stain & culture
– Viral: mononuclear cell exudate
– Allergic: eosinophils
– Bacterial: PMNs
 Treatment
• Topical antibiotics?
• To do or not to do?
– Are your eyelids glued in the morning?(+5)
– Does your eye itch? (-1)
– Do you have recurrent conjuctivitis?(-2)
• Score:
• 5 – bacterial 77%
• 2 – bacterial 2%
 Treatment
• Prefered therapy
– Moxifloxacin 0.5% sol TID 7 days
• Alternate therapy
– Gentamycin
– Tobramycin
– Polymyxin B / bacitracin
– Neomycin / polymixin
Eye anatomy
 Keratitis

• Inflammation of cornea
• Prompt treatment
• Corneal perforation – blindness
 Predisposing conditions
• Minimal injury of cornea
– Trauma
– Contact lens abrasion
– Eye surgery
• Impaired tear production
• Diabetes mellitus
• Immunosupression
• Comatose patient
 Causes
• Bacteria – 65-90%
– Some produce toxins
and enzymes
– Penetration without
epithelial disruption
– Hypopyon is the rule
– Perforation
 Causes

• Staph. aureus
• P. aeruginosa (contact lenses)
• N. gonorrhoeae
• N. meningitidis
• H. influenzae
 Causes
• Viruses
– HSV recurrent
keratitis
– Unilateral
– Dendritic lesion
– Erythema, pain,
foreign body
sensation
 Causes
• Fungi
– After organic material injury (tree branch)
– Prolonged corticoid eye drop therapy
– Aspergillus
• Protoza
– Unsterilized tap water for contact lens
cleaning
– Acanthamoeba
 Clinical presentation

• Eye pain
• Foreign body sensation
• Corneal edema – impaired vision
• Photophobia
• Reflex tearing
 Diagnosis
• Medical history & exam
• Swab or scraping
– Gram stain, Giemsa stain, methenamine
silver stain, culture
• Therapy
– Emergently
– Experienced ophthalmologist
 Endophthalmitis

• Serious infection
• Ocular chamber & adjacent structures
• Involving all tissue layers: panophthalmitis
• Often leads to blindness
 Predisposing conditions
• Posttraumatic
– Staph. aureus and epidermidis
– Str. spp
– Bacillus cereus
– Fungi
• Organic matter penetrating injuries
 Predisposing conditions
• Hematogenous
– Any source of bacteremia
– 2/3 – right eye
• Candida albicans
• G + and G – bacteria
• Bacillus cereus – IDU
 Predisposing conditions

• Contiguous spread
– Uncontrolled keratitis
– Delays in antibiotic therapy
 Predisposing conditions
• Ocular surgical procedures
– Staph. aureus and epidermidis
– Str. spp
• Early
– 1 – 5 days after the surgery
• Delayed
– Weeks to months after the surgery
• Opportunistic pathogens
 Clinical presentation
• Eye pain
• Eye redness
• Photophobia
• Reduced vision
• Fever, algic syndrome
 Diagnosis and therapy
• Cultures and smears
• Systemic broad spectrum antibiotics
• Intravitreal antibiotic injection
• 1/10 patients – enucleation
• Experienced ophthalmologist
ENT infectios
 Pharyngitis

• Common infectious disease

• Usually self-limiting
• Antibiotics malpractice
 Causes
• Viruses
– Rhino, corona, adeno, HSV, EBV, CMV,
influenza, parainfluenza, coxsackie A, HIV
• Bacteria
– Group A streptococci (GAS)
• Children 50% of all cases
• Adults 10%
GAS pharygitis
 Diagnosis
• Centor clinical criteria
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Fever
• Abscence of cough
 Diagnosis
• 3-4 criteria
– Positive predictive value 40-60%
• 3-4 criteria absent
• Negative predictive value 80%
• Adding age
– 3 – 14 y/o: +1
– >45 y/o: -1
 Therapy
• Penicillin the drug of choice
– Oral Penicillin VK 10 days
– Benzathine penicillin 1.2-2.4 MU im once
• Penicillin-allergic patients
– Clarithromycin, clindamycin, cephalosporins
10 days, azithromycin 3 days
 Peritonsillar abscess
• Symptoms worsening
despite antibiotics
• Medial displacement
of uvula
• Soft palate bulging
• Surgical intervention
• Recurrent abscess –
tonsillectomy
 Epiglottitis
• High fever
• Difficulty swallowing
• Drooling
• Difficulty breathing
• Indirect laryngoscopy
• Swollen, cherry-red epiglottis
 Epiglottitis
• High risk of airway obstruction
• Children
– Mortality 80%
• Adult
– Closely monitored
• Endotracheal intubation
 Epiglottitis
• Causes
– H. influenzae
– Str. pneumoniae
– Staph. aureus
• Therapy
– 3rd generation cephalosporins iv 7-10 days
Ear infections
 Otitis externa

• Immunocompetent
– Mild disease
• Immunocompromised
– Possible life – threatening
 Otitis extrena

• Local itching and pain

• Redness and swelling of the external
canal skin
• Tenderness of the auricula
 Causes

• Gram-negative bacteria
• P. aeruginosa the most prevalent
• Staph. epidermidis or aureus
• Candida or Aspergillus
 Therapy

• Polymyxin neomicin sol. + Hydrocortison

sol.
• Clotrimazol or miconazol
 Malignant otitis externa
• Immunocompromised
• Severe pain
• Spreading of necrotizing infection
– Skull, meninges, brain
• CT scan, MRI
• Gallium scan
• P. aeruginosa almost always!
• Systemic therapy 6 weeks + surgical
debridement
 Otitis media

• Most commonly in childhood

• Up to 3 y/o 2/3 of children at least 1
episode
• Consequence of the Eustachian tube
obstruction
 Otitis media

• Viral upper respiratory infection

• Serous fluid accumulation
• Eustachian tube obstruction
• 5-10 days later – fluid infected with mouth
flora
 Clinical presentation
• Ear pain
• Ear drainage
• Occasionally hearing loss
• Fever
• Vertigo, tinnitus, nystagmus
• Loose stools (children)
 Diagnostic criteria
• Abrupt onset of middle-ear inflamation
• Presence of middle-ear effusion (any)
– Bulging of the tympanic membrane
– Limited mobility of the tympanic membrane
– Air-fluid level behind the tympanic membrane
– Otorrhea
• Signs of middle-ear inflamation (any)
– Erythema of the tympanic membrane
– Otalgia that interferes with normal activity or sleep
 Causes
• Str. pneumoniae
• H. influenzae
• M. catarrhalis
• GAS
• Staph. aureus
 Therapy
• Amoxycillin
• after 72 hrs – revision
– Improvement – continuation
– Failure
• Amoxycillin – clavulante
• Cefuroxime
• 10 days
 Mastoiditis
• Rare otitis media complication
• Manifestation
– Swelling, redness, tenderness in the area of
the mastoid bone
• Possible spreading – temporal bone –
temporal lobe – brain abscess
• CT, MRI
• Prolonged antibiotic therapy
Sinuses - anatomy
 Sinusitis

• Nasal and sinus mucosa inflammation

• Rhinosinusitis
• Viral upper respiratory infection preceding
• 0.5 – 1% progress to bacterial sinusitis
 Sinus physiology
• Respiratory
epithelium
• Goblet cells – mucin
• Cilia lining – move
mucin out
• Sinus drainage into
nasal cavity
• Osteomeatal complex
 Pathogenesis

• OMC obstruction
• Sinus drainage impaired
• Accumulation of serous fluid
• Fluid infection with oral flora
 Predisposing conditions
• Septal deformities
• Nasal polyps
• Intranasal neoplasms
• Indwelling nasal tubes
• Nasogastric tubes
• Nasal allergies
• Dental abscess
• Cystic fibrosis (abnormally voscous mucous)
• Kartagener syndrome (impaired ciliary function)
 Clinical presentation
• Headache
• Facial pressure
• Nasal obstruction
• Nasal discharge
• Loss of smell
• Foul-smelling breath
• Fever
 Bacterial causes
• Str. pneumoniae
• H. influenzae
• M. catarrhalis
• S. aureus
• S. epidermidis
• GAS
• G-neg bacteria
• Anaerobs
 Diagnosis
• WBC often normal, CRP may be elevated
• Culture of nasal swabs poorly corelate
with intrasinus cultures
• Direct sampling complicated and painful
• X-rays, CT, MRI not helpful for the etiology
diagnosis
• Medical history & exam
 Bacterial sinusitis
• Peristent acute sinusitis symptoms >10
days
• Abrupt onset with high fever (39°C) and
purulent nasal discharge, facial pressure
lasting 3-4 consecutive days
• Sudden worsening of typical viral upper
respiratory infection
 Therapy
• Amoxycillin – clavulanic acid 2x1.0 g
• Fluoroquinolones
– Levofloxacin 1x250 mg
– Moxifloxacin 1x400 mg
• Doxycyclin 2x100 mg
• Cefuroxim – axetil 2x250-500 mg
• Cefixim 1x400 mg
 Therapy

• Intravenous therapy
• Frontal, ethmoid, sphenoid sinusitis
• Prevent the infection spreading
• Vital organs beyond the thin sinus walls
 Therapy
• Nasal decongestants in viral infections
• Saline irrigation
• Intranasal corticosteroids in patients with
nasal allergy
• Symptomatic treatment
• Bed resting, fluid replacement, analgesics,
antipyretics