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Eye, Ear, Nose, and Throat Infections
Nenad Pandak
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Why ? Ophthalmologist ENT specialist ID specialist & GP
Familiar with these infections Preliminary empiric therapy
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Task Eye infections Throat infections Conjuctivitis Keratitis
Endophtalmitis Throat infections Pharyngitis Epiglottitis
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Task Ear infections Sinus infections Otitis externa Otitis media
Mastoiditis Sinus infections Sinusitis
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Eye anatomy
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Conjuctivitis Inflammation of conjuctiva Doesn’t threaten the vision
Rapid respond to therapy
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Conjuctivitis Direct contact with the environment Tears
Antibacterial agents Lysozyme, IgA, IgG Decresed tear production Recurrent infections
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Clinical presentation
Vessel dilatation “red eye” Pus formation Eyelid swelling Itching, pain Glued eyelid shut (dried purulent exudate)
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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
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Causes Fungi Parasites Candida Blastomyces Sporothrix schenckii
Trichinella spiralis Taenia solium Schistosoma haematobium Lola loa Onchocerca volvulus
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Causes Viral Bacterial The most common Highly contagious
Spread to the 2nd eye in hrs Bacterial Profuse pus formation
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Causes Allergic and toxic Systemic diseases Pollens Symmetrical
Itching Systemic diseases Reiter syndrome Vasculitis SLE
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Diagnosis History & examination Severe cases
Swab or scraping: Gram stain & culture Viral: mononuclear cell exudate Allergic: eosinophils Bacterial: PMNs
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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%
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Treatment Prefered therapy Alternate therapy
Moxifloxacin 0.5% sol TID 7 days Alternate therapy Gentamycin Tobramycin Polymyxin B / bacitracin Neomycin / polymixin
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Eye anatomy
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Keratitis Inflammation of cornea Prompt treatment
Corneal perforation – blindness
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Predisposing conditions
Minimal injury of cornea Trauma Contact lens abrasion Eye surgery Impaired tear production Diabetes mellitus Immunosupression Comatose patient
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Causes Bacteria – 65-90% Some produce toxins and enzymes
Penetration without epithelial disruption Hypopyon is the rule Perforation
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Causes Staph. aureus P. aeruginosa (contact lenses) N. gonorrhoeae
N. meningitidis H. influenzae
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Causes Viruses HSV recurrent keratitis Unilateral Dendritic lesion
Erythema, pain, foreign body sensation
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Causes Fungi Protoza After organic material injury (tree branch)
Prolonged corticoid eye drop therapy Aspergillus Protoza Unsterilized tap water for contact lens cleaning Acanthamoeba
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Clinical presentation
Eye pain Foreign body sensation Corneal edema – impaired vision Photophobia Reflex tearing
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Diagnosis Medical history & exam Swab or scraping Therapy
Gram stain, Giemsa stain, methenamine silver stain, culture Therapy Emergently Experienced ophthalmologist
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Endophthalmitis Serious infection Ocular chamber & adjacent structures
Involving all tissue layers: panophthalmitis Often leads to blindness
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Predisposing conditions
Posttraumatic Staph. aureus and epidermidis Str. spp Bacillus cereus Fungi Organic matter penetrating injuries
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Predisposing conditions
Hematogenous Any source of bacteremia 2/3 – right eye Candida albicans G + and G – bacteria Bacillus cereus – IDU
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Predisposing conditions
Contiguous spread Uncontrolled keratitis Delays in antibiotic therapy
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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
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Clinical presentation
Eye pain Eye redness Photophobia Reduced vision Fever, algic syndrome
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Diagnosis and therapy Cultures and smears
Systemic broad spectrum antibiotics Intravitreal antibiotic injection 1/10 patients – enucleation Experienced ophthalmologist
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ENT infectios
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Pharyngitis Common infectious disease Usually self-limiting
Antibiotics malpractice
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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%
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GAS pharygitis
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Centor clinical criteria
Diagnosis Centor clinical criteria Tonsillar exudates Tender anterior cervical adenopathy Fever Abscence of cough
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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
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Therapy Penicillin the drug of choice Penicillin-allergic patients
Oral Penicillin VK 10 days Benzathine penicillin MU im once Penicillin-allergic patients Clarithromycin, clindamycin, cephalosporins 10 days, azithromycin 3 days
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Peritonsillar abscess
Symptoms worsening despite antibiotics Medial displacement of uvula Soft palate bulging Surgical intervention Recurrent abscess – tonsillectomy
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Epiglottitis High fever Difficulty swallowing Drooling
Difficulty breathing Indirect laryngoscopy Swollen, cherry-red epiglottis
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Epiglottitis High risk of airway obstruction Children Adult
Mortality 80% Adult Closely monitored Endotracheal intubation
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Epiglottitis Causes Therapy H. influenzae Str. pneumoniae
Staph. aureus Therapy 3rd generation cephalosporins iv 7-10 days
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Ear infections
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Otitis externa Immunocompetent Immunocompromised Mild disease
Possible life – threatening
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Otitis extrena Local itching and pain
Redness and swelling of the external canal skin Tenderness of the auricula
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Causes Gram-negative bacteria P. aeruginosa the most prevalent
Staph. epidermidis or aureus Candida or Aspergillus
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Therapy Polymyxin neomicin sol. + Hydrocortison sol.
Clotrimazol or miconazol
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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
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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
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Otitis media Viral upper respiratory infection
Serous fluid accumulation Eustachian tube obstruction 5-10 days later – fluid infected with mouth flora
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Clinical presentation
Ear pain Ear drainage Occasionally hearing loss Fever Vertigo, tinnitus, nystagmus Loose stools (children)
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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
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Causes Str. pneumoniae H. influenzae M. catarrhalis GAS Staph. aureus
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Therapy Amoxycillin after 72 hrs – revision 10 days
Improvement – continuation Failure Amoxycillin – clavulante Cefuroxime 10 days
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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
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Sinuses - anatomy
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Sinusitis Nasal and sinus mucosa inflammation Rhinosinusitis
Viral upper respiratory infection preceding 0.5 – 1% progress to bacterial sinusitis
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Sinus physiology Respiratory epithelium Goblet cells – mucin
Cilia lining – move mucin out Sinus drainage into nasal cavity Osteomeatal complex
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Pathogenesis OMC obstruction Sinus drainage impaired
Accumulation of serous fluid Fluid infection with oral flora
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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)
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Clinical presentation
Headache Facial pressure Nasal obstruction Nasal discharge Loss of smell Foul-smelling breath Fever
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Bacterial causes Str. pneumoniae H. influenzae M. catarrhalis
S. aureus S. epidermidis GAS G-neg bacteria Anaerobs
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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
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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
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Therapy Amoxycillin – clavulanic acid 2x1.0 g Fluoroquinolones
Levofloxacin 1x250 mg Moxifloxacin 1x400 mg Doxycyclin 2x100 mg Cefuroxim – axetil 2x mg Cefixim 1x400 mg
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Therapy Intravenous therapy Frontal, ethmoid, sphenoid sinusitis
Prevent the infection spreading Vital organs beyond the thin sinus walls
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Therapy Nasal decongestants in viral infections Saline irrigation
Intranasal corticosteroids in patients with nasal allergy Symptomatic treatment Bed resting, fluid replacement, analgesics, antipyretics
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