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 Throat infections Conjuctivitis Keratitis Endophtalmitis Throat infections Pharyngitis Epiglottitis

Task Ear infections Sinus 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 Str. pneumoniae H. influenzae M. catarrhalis N. gonorrhoeae N. meningitidis P. aeruginosa C. trachomatis Viruses Adenoviruses Enteroviruses HSV VZV Measles

Causes Fungi Parasites Candida Blastomyces Sporothrix schenckii Trichinella spiralis Taenia solium Schistosoma haematobium Lola loa Onchocerca volvulus

Causes Viral Bacterial The most common Highly contagious Spread to the 2nd eye in 24-48 hrs Bacterial Profuse pus formation

Causes Allergic and toxic Systemic diseases 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? Score: 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 Alternate 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 Protoza 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 Therapy 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 Bacteria 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

Centor clinical criteria Diagnosis Centor clinical criteria Tonsillar exudates Tender anterior cervical adenopathy Fever Abscence of cough

Diagnosis 3-4 criteria 3-4 criteria absent 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 Penicillin-allergic patients 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 Adult Mortality 80% Adult Closely monitored Endotracheal intubation

Epiglottitis Causes Therapy H. influenzae Str. pneumoniae Staph. aureus Therapy 3rd generation cephalosporins iv 7-10 days

Ear infections

Otitis externa Immunocompetent Immunocompromised Mild disease 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 10 days 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