Wright State University – Miami Valley School of Nursing and Health

Wright State University – Miami Valley School of Nursing and Health
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

Acute Care of Pharyngitis

An infection or irritation of the pharynx and/or tonsils
Definition An infection or irritation of the pharynx and/or tonsils Acute Pharyngitis is defined as “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 Acute Pharyngitis occurs when 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 Examples include rhinovirus and coronavirus but they are most common in pediatrics Oropharyngeal infections range from mild, self-limited viral illnesses to serious, life-threatening bacterial infections. Most cases of acute pharyngitis are of viral origin and are benign and self-limiting Bacterial infections causing pharyngitis are also typically self-limiting On the right side of the slide, there is a list of infectious etiologies of acute pharyngitis divided by viruses or bacteria with its’ associated clinical syndrome Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.

Pathophysiology cont. This slide was added for completion. It is a list of the common causes of viral pharyngitis in CHILDREN 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 Age Genetics
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. Approximately 30 million cases of pharyngitis are diagnosed annually The incidence of acute pharyngitis is reported to be higher internationally, primarily due to higher rates of resistance of bacterial pharyngitis to antibiotics. Pharyngitis accounts for over 10% of all office visits to primary care and 50% of outpatient antibiotic use with viruses as the most common cause of acute pharyngitis 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. 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) The infection with the highest concern for acute pharyngitis is group A -hemolytic Streptococcus (S. pyogenes), a spherical gram-positive bacteria. Streptococcus pyogenes is the most significant bacterial agent causing pharyngitis in both adults and children It is associated with acute glomerulonephritis and acute rheumatic fever. The risk of rheumatic fever can be reduced by timely treatment Seasonal colonization with group A Streptococcus (GAS) reaches its peak during the winter months. GAS pharyngitis represents less than 1/3 of all cases of acute pharyngitis. GAS infection is diagnosed in about 15% percent of all individuals seeking emergency room care for a sore throat. Only 5-15% of adult cases of acute pharyngitis are caused by GAS GAS pharyngitis is estimated to occur in 616 million individuals worldwide each year, with acute cases resulting in rheumatic heart disease in 6 million individuals. Uncommon in children less than 3 years old. Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.

Symptoms 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 The most common presenting symptom of acute pharyngitis is sore throat Sore throat is a symptom in many noninfectious illnesses; however, the majority of patients with a new sore throat have acute pharyngitis Other symptoms the patient may present with are seen here

Symptoms Neck pain Rhinorrhea Diarrhea Nasal congestion Cough
Features suggestive of either viral or bacterial origin Features suggestive of viral origin Neck pain Rhinorrhea Nasal congestion Arthralgia and/or joint stiffness Lymphadenopathy Dyspnea Chills Malaise Diarrhea Cough Hoarseness Coryza

Differential Diagnosis: GAS
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 Acute pharyngitis is not always GAS but since it is the most commonly occurring infection causing pharyngitis, the differential diagnosis will be based upon GAS The main concern with acute pharyngitis is determining who is likely to have a GAS infection and who does not Because those with GAS infection require antibiotic treatment to prevent subsequent complications such as rheumatic fever and acute glomerulonephritis On this slide are the top three differential diagnosis’ for acute pharyngitis. You can also see the disease or condition with its’ associated signs & symptoms and differential testing

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 The previous slide was the top three differential diagnosis’, this slide is the other differential diagnosis’

Physical Assessment Tender, enlarged anterior cervical nodes
Features suggestive of GAS as causative agent - bacterial Features suggestive of viral origin Tender, enlarged anterior cervical nodes Tonsillopharyngeal erythema and/or exudates Soft palate petechiae Uvulitis Scarlatiniform rash Fever Conjunctivitis Characteristic exanthems & enanthems So now you are assessing the patient, what are you looking for and what are you expecting to find? Above you will see the different findings associated with bacterial or viral origin causing acute pharyngitis Just to point out, pharyngitis is the best known acute clinical manifestation of epstein-barr virus (EBV). It often begins with malaise, headache, and fevers before development of the more specific signs of exudative pharyngitis and posterior cervical lymph node enlargement. Splenomegaly and hepatomegaly can also occur. Patients mistakenly are treated for a bacterial pharyngitis with amoxicillin or ampicillin and often develop a pruritic maculopapular rash that aids in the diagnosis of EBV.

This slide depicts some of the possible physical assessment findings.

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” There are a number a diagnostic tests that can be performed to diagnosis GAS or EBV but some of the physical findings found together can lead to a diagnosis without definitive testing Therefore, 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 Tonsillar exudates Tender anterior cervical adenopathy Also known as The Centor Criteria. Which is a set of criteria that may be used to identify the likelihood of a bacterial infection in patients complaining of a sore throat. If the patient presents with none or one of these findings, he or she should not be tested or treated for GAS When 3 of the 4 are present, laboratory sensitivity of rapid antigen testing for GAS pharyngitis exceeds 90% However, there is a 44% chance that individuals who present with the four classic symptoms of GAS will NOT have GAS

Here is another pictorial of the Centor Criteria for Bacterial related sore throat
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: /j 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 Rapid antigen test for group A Streptococcus (GAS): is the first test to order if GAS is suspected – it is 90-99% sensitive Results are available in about 15 minutes Testing is recommended for patients with two or more of the four Centor criteria symptoms of GAS, with antibiotic therapy restricted to those with positive test results However, antibody tests (ASOT) are of no immediate value in the diagnosis or treatment of acute GAS Culture of throat swab for GAS: must be done to reliably diagnose GAS – it is 90-95% sensitive Cultures are not recommended for routine evaluation of adult pharyngitis or for confirmation of negative results on rapid antigen tests Throat cultures maybe useful for outbreak investigation, monitoring rates of antibiotic resistance, or when other pathogens (e.g., gonococcus) are being considered. Repeat (post treatment) throat cultures are not routinely recommended. Throat cultures do NOT need to be done when viral infection is suspected by the presence of: rhinorrhea, hoarseness, cough, and conjunctavitis The monospot test typically does not turn positive in cases of EBV until symptoms have been present for 1 week or more. A negative test, does not exclude the diagnosis of EBV. You can do a EBV IgM and IgG because both are sensitive and specific but results are not readily available. With about 90% sensitivity, lymphocyte to WBC ratios of >35% suggest EBV infection and not tonsillitis. Hepatosplenomegaly and a positive heterophil aggluntination test or elevated anti-EBV titer are corroborative

Diagnosis Algorithm Diagnosis algorithm for acute pharyngitis
Esherick, J. S., Clark, D. S., & Slater, E. D. (2012). Current practice guidelines in primary care 2012. New York: McGraw-Hill Medical.

Treatment Analgesics Local anesthetics Gargling with salt water
Acetaminophen: children: mg/kg orally every 4-6 hours when required, maximum 90 mg/kg/day adults: 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: 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 Symptomatic treatment with OTC pain relievers such as oral acetaminophen or ibuprofen may be helpful in relieving discomfort from pharyngitis Local anesthetics such as a lidocaine oronasopharyngeal solution may be used to anesthetize the sore throat Products such as antiseptic/antibacterial lozenges, sprays and antibacterial mouthwashes/gargles are not recommended as they may lead to resistance Gargling with salt water is found to be soothing by some patients Antibiotic treatment should be reserved for patients with confirmed pharyngitis and not based on clinical diagnosis alone Viral pharyngitis: Antibiotics are NOT indicated Systemic corticosteroids should be reserved for patients with severe airway obstruction, severe thrombocytopenia, and hemolytic anemia Antibiotic therapy of GAS accelerates resolution by 1-2 days if initiated within 2-3 days of symptom onset

Group A Streptococcus (GAS) pharyngitis
FOCUS IS TO TREAT GROUP A BETA-HEMOLYTIC STREPTOCOCCUS INFECTION TO PREVENT RHEUMATIC SEQUELAE 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: mg/kg/day orally given in 4 divided doses for 10 days, maximum 2000 mg/day adults: mg orally four times daily for 10 days cephalexin: children: 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: mg orally every 8 hours for 10 days #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 The number one treatment for Group A Streptococcus pharyngitis is penicillin (either a single dose of IM benzathine penicillin or a full 10-day course of oral penicillin). What if my patient is allergic to penicillin?!  Erythromycin And as a side note, Penicillin-resistant GAS have not been reported in the United States. Amoxicillin can be used in place of penicillin but should be avoided when concomitant infectious mononucleosis is suspected, because of the increased possibility of developing a severe rash Extended spectrum macrolides and fluoroquinolones are not appropriate for uncomplicated GABHS pharyngitis. Antibiotic treatment of pharyngitis due to S. pyogenes provides numerous benefits, including: a decrease in the risk of rheumatic fever (the importance of this benefit is fairly small, since rheumatic fever is now a rare disease, even among untreated patients); however, when therapy is started within 48 h of illness onset, symptom duration is decreased AND the potential to reduce the transmission of streptococcal pharyngitis, particularly in areas of close contact. Testing for cure is unnecessary and may reveal only chronic colonization. There is no evidence to support antibiotic treatment of group C or G streptococcal pharyngitis or pharyngitis in which mycoplasmas or chlamydiae have been recovered. Penicillin prophylaxis (benzathine penicillin G, 1.2 million units IM every 3–4 weeks) is indicated for patients at risk of recurrent rheumatic fever. Treatment of viral pharyngitis is entirely symptom-based except in infection with influenza virus or HSV. For influenza, the list of therapeutic agents includes Symmetrel or Flumadine and Oseltamivir and Zanamivir. Oropharyngeal HSV infection sometimes responds to treatment with antiviral agents such asacyclovir, although these drugs are often reserved for immunosuppressed patients. 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

Treatment: Rheumatic Fever
Secondary 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: mg/day orally immune globulin (human): children and adults: consult specialist for guidance on dose Ampicillin should routinely be avoided if mononucleosis is suspected because it induces a rash that might be misinterpreted by the patient as a penicillin allergy A dose of PO of IV systemic corticosteroids should be reserved for patients with severe airway obstruction to reduce tonsillar enlargement, severe thrombocytopenia, and hemolytic anemia. Treatment course is usually 5 to 7 days. When splenomegaly is noted, proper counseling regarding risk factors and symptoms of splenic rupture should be given. Rest remains a frequent recommendation, but its true usefulness is unknown. 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, which modulates the immune system response, may be used in patients with immune thrombocytopenia.

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

Complications Rheumatic fever Glomerulonephritis Peritonsillar abscess
Low likelihood Glomerulonephritis Peritonsillar abscess Otitis media Mastoiditis Low likelihood Sinusitis Bacteremia Pneumonia Although rheumatic fever is the best-known complication of acute streptococcal pharyngitis, the risk of its following acute infection remains quite low. Another complication of GAS is acute glomerulonephritis but the risk is quite low as well Although antibiotic treatment of acute streptococcal pharyngitis can prevent the development of rheumatic fever, there is no evidence that it can prevent acute glomerulonephritis. Other complications include: peritonsillar abscess, otitis media, mastoiditis, sinusitis, bacteremia, and pneumonia—all of which occur at low rates. Abscesses usually are accompanied by severe pharyngeal pain, dysphagia, fever, and dehydration; in addition, medial displacement of the tonsil and lateral displacement of the uvula are often evident on examination. Although early use of IV antibiotics (e.g., clindamycin, penicillin G with metronidazole) may prevent the need for surgical drainage in some cases, treatment typically involves needle aspiration or incision and drainage.

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! We are responsible to tell patients that antibiotic use increases the risk of antibioticresistant infection Just because the patient feels lousy does not mean that they NEED an antibiotic Tell the patient that they should expect their symptoms to improve within 3 or 4 days. We need to also tell the patient that there is no need for bed rest or isolation However close contacts to the patient who have symptoms of GAS pharyngitis or who have had rheumatic fever or poststreptococcal glomerulonephritis previously should be tested Remind parents of children that ASA should be avoided due to its’ associated 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: A history of rheumatic fever 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.

Acute 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 Usually bacterial – can have a viral etiology Middle ear is unable to properly drain Petrous apex – located in the temporal bone — one of the bones of the skull that houses the structures of the ear.

Anatomy of the Ear Review of the anatomy of the ear
Outer ear vs middle ear

AOM vs OME Acute Otitis Media Otitis Media with Effusion
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 AOM – effusion is usually pus. painful may improve with antibiotics OME – also termed chronic OM and serous OM fluid in the ear, no pus more common will usually self resolve – no antibiotics often associated with URI, allergies, irritants - eustachion tube blockage, excess fluid in sinuses

Prevalence Predominantly a pediatric diagnosis 3-15% of adults
Due to changes in ear anatomy with aging 50-84% by age 3 have had AOM 3-15% of adults 2nd most common pediatric diagnosis (1st is URI) Pediatric eustachian tube is shorter an less angled

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): e doi: /journal.pone

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): e doi: /journal.pone

Signs & Symptoms Major Presenting Complaint: May be Associated With:
Otalgia May be Associated With: Fever Otorrhea Hearing Loss Rarely Associated With: Tinnitus Vertigo Nystagmus Sudden relief of ear pain – possible tympanic rupture

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 Obscured view of bony landmarks May see air bubbles

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

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 Otoscopy - visual examination of the auditory canal and the eardrum with an otoscope Tympanometry - examination used to test the condition of the middle ear and mobility of the eardrum (tympanic membrane) and the conduction bones by creating variations of air pressure in the ear canal.

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: For pain:
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

Acute Care of Sinusitis

Anatomy

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 ---eg, no neurologic, ophthalmologic, or soft tissue involvement

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 -Sinuses are normally sterile and there is no mucus accumulation -Build up of fluid is sometimes what is causing the symptoms without even an infection -Viruses, bacteria, and fungi oh my!

Causative Factors Noninfectious Causes Allergic rhinitis Barotrauma
Chemical Irritants Tumors Granulomatous diseases Cystic fibrosis Nasotracheal intubation, orotracheal intubation Nasogastric tubes Deviated Septum Large adenoids -rhinitis causes mucosal edema or polyp obstruction -barotrauma including deep sea diving or flying can disrupt sinuses -chemicals effect mucosal barrier and cillia -tumors can obstruct outflow of mucus Granulomatous diseases rhinoscleroma can obstruct sinuses – less common in US -cystic fibrosis causes it through impaired mucus clearance -intubation and NG tubes damage mucosa and block ostia that drain sinuses --20% of pts. With nasal tubes

Causative Factors Infectious Causes Rhinovirus Parainfluenza virus
Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Pseudomonas aeruginosa Serratia marcescens Candida albicans Klebsiella pneumoniae Mucorales or Aspergillus fungi -Viruses are MUCH more common than bacterial infections -Community aquired are strep and haemophilus -staphy. In hostpitals along with rest of list---in hosptitals usually polyorganismal infections that are resistant  -

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

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 ---Inflammation leads to blockage of outflow ostia = mucus buildup and infection ------Hospitalized pts. Aslo have weakened cough and gag, dry nasal passages

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 -difficult to distinguish features of URI vs. sinusitis as common cold may cause inflammation that feels like sinusitis -thick purulent drainage is often considered bacterial but may be present in early viral infection --Localized pain that is worse over area of sinus and worse when the patient bends forward, or is supine ----Consider sinusitis when fever of unknown origin in ICU especially if nasotracheal intubated!

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 ---Life threatening complications include meningitis, spidural abcess, cerebral abcess ---Pott’s = localized swelling and pitting edema over frontal sinus due to communicating subperiosteal abcess—serious buisness ---Fungal infections from orbital swelling – boney errosion ----Most fungal found in immunocompramized pts. And is for real! ---meningitis, epidural abcess, and cerebral abcess are all complications—serious bidnes ---Often pt. will not appear seriously ill but is!!

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 ---purulent in bacterial

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

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 >102⁰F Duration of illness longer for bacterial diagnosis Greater than 10 days for adults, days for children Symptoms do not change in bacterial illness Exception: symptoms get better and then dramatically worse again after 7-10D -Acute is less than 4weeks duration-most common ---Chronic is >12 weeks ---Reoccurant is greater than 4 acute bacterial infections in one year -bacterial vs. viral difficult to differentiate but antibiotics given in 85% of cases—thick purulent drainage not always bac. = can occur after 4D in viral but is not consistant ---Fever initially in viral but then goes away -Still only bacterial in 40-50% of cases even with these differentiations

(Rosenfeld R M et al. , 2013)

---Two or more s/s lasting at least 12 weeks ---
(Rosenfeld R M et al. , 2013)

History & ROS 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 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 of episodes that didn’t respond to tx consider consult to otolaryngologist

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 ---Not recommended unless complicated infection is suspected OR to r/o other illness OR in chronic or recoccurant sinusitis --X-ray doesn’t show ethmoid sinus well, and need more than one angle to show spenoid and frontal --Only CT if serious infection, or immunocomprimised state that could lead to serious infection or complications ---MRI inferior to CT and more expensive ---Want to treat specific infection in nosocomial and evaluate for resistance ---can have sinusitis without infection = aspirate for confirmation ---Aspirate only done in suspiscion of unusual infection or high risk for serious complications

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 ---Do not use antihistamines because can dry out mucous membranes and thicken secretons making issue worse as cannot drain ---oral or nasal decongestants no longer recommended by the IDSA due to potential to worsen inflammation and lack of known benefit ----Neti pots for saline lavage….should use distilled or boiled and cooled water = bacteria in water into brain --zombie --History of chronic sinusitis or allergies need nasal steroids, and consider leukotriene antagonist = Montelukast 10mg PO QD ---Steam – boil water and then sit over pot (not while boiling) with towel over head for 10 min. Also sip on hot beverages and soup

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 mg 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 mg 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 ------S.pneumoniae, and H. influenza --- S.aureus nosocomial ---Severe symptoms include unilateral/focal facial swelling or tooth pain ---Nosocomial = treat for pseudomonas, s. arueus, candida albicans = IV ATB to prevent blood stream infections ---Unclear rather nosocomial infection should be evalutated as source of FOUO, as clinical significance is unclear.

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
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 ----longer than 12 weeks duration ---Multiple infections cause cilliary clearance to be permanantly effected but is poorly understood ---chronic fungal ususally aspergillus and is found when tx doesn’t work for bacterial

Follow-Up Symptoms persistant beyond 7 days of treatment
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

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 ---Frequent dental visits ---Irrigation especially for chronic, reoccuring, post-surgical and pts. With conditions that make vunerable i.e. allergies.

Conjunctivitis The most common eye disease
Acute Care of Conjunctivitis 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 VIRAL CONJUNCTIVITIS IS HIGHLY CONTAGIOUS. MOST VIRUSES THAT CAUSE CONJUNCTIVITIS ARE SPREAD THROUGH DIRECT HAND-TO-EYE CONTACT BY HANDS THAT ARE CONTAMINATED WITH THE INFECTIOUS VIRUS. HANDS CAN BECOME CONTAMINATED BY COMING IN CONTACT WITH INFECTIOUS TEARS, EYE DISCHARGE, FECAL MATTER, OR RESPIRATORY DISCHARGES. (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 day course Treat with topical Sulfonamide or 10% ophthalmic solution three times daily, should clear infection in two to three days BACTERIAL CONJUNCTIVITIS IS HIGHLY CONTAGIOUS. MOST BACTERIA THAT CAUSE CONJUNCTIVITIS ARE SPREAD THROUGH DIRECT HAND-TO-EYE CONTACT FROM CONTAMINATED HANDS. PEOPLE CAN GET CONJUNCTIVITIS JUST BY TOUCHING OR USING SOMETHING THAT HAS BEEN INFECTED BY A PERSON WHO HAS THE EYE INFECTION. THIS IS WHY PEOPLE WHO ARE DIAGNOSED WITH CONJUNCTIVITIS, PARTICULARLY CHILDREN, SHOULD STAY HOME UNTIL AFTER TREATMENT IS STARTED TO AVOID INFECTING OTHERS. INFECTIOUS CONJUNCTIVITIS (VIRAL OR BACTERIAL) CAN ALSO BE SPREAD BY LARGE RESPIRATORY TRACT DROPLETS. BACTERIAL CONJUNCTIVITIS IS LESS COMMON IN CHILDREN OLDER THAN 5 YEARS OF AGE (Papadakis & McPhee, 2013)

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 Gonococcal Conjunctivitis In the only published study of the treatment of gonococcal conjunctivitis among U.S. adults, all 12 study participants responded to a single 1-g IM injection of ceftriaxone (317). Recommended Regimen Ceftriaxone 1 g IM in a single dose Consider lavage of the infected eye with saline solution once. Persons treated for gonococcal conjunctivitis should be treated presumptively for concurrent C. trachomatis infection. (Papadakis & McPhee, 2013)

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 Globally, the bacterium Chlamydia trachomatis (trachoma) is the leading cause of preventable blindness of infectious origin. Trachoma is a chronic follicular conjunctivitis, which is transmitted from person-to-person, through shared items or by flies Follicular conjunctivitis is an inflammation of the conjunctiva of the eye(s) associated with increased formation of lymphoid follicles Keratitis may be mild, moderate, or severe and may be associated with inflammation of other parts of the eye. Keratoconjunctivitis is inflammation of the cornea (Papadakis & McPhee, 2013)

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 ALLERGIC CONJUNCTIVITIS IS COMMON IN PEOPLE WHO HAVE OTHER SIGNS OF ALLERGIC DISEASE, SUCH AS HAY FEVER, ASTHMA, AND ECZEMA. IT IS CAUSED BY THE BODY’S REACTION TO CERTAIN SUBSTANCES TO WHICH IT IS ALLERGIC, SUCH AS POLLEN FROM TREES, PLANTS, GRASSES, AND WEEDS DUST MITES ANIMAL DANDER MOLDS CONTACT LENSES AND LENS SOLUTION COSMETICS (Papadakis & McPhee, 2013)

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 RESTASIS® (Cyclosporine Ophthalmic Emulsion) 0.05% helps increase your eyes’ natural ability to produce tears, which may be reduced by inflammation due to Chronic Dry Eye. RESTASIS® did not increase tear production in patients using anti-inflammatory eye drops or tear duct plugs. (Papadakis & McPhee, 2013)

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.

Acute Care of Corneal Abrasions

Anatomy Review

Signs & Symptoms and Diagnosis
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 Blepharospasm is any abnormal contraction or twitch of the eyelid Picture of eye after application of fluorescein, under cobalt-blue light (Wilson & Last, 2004)

Causes Cuts Scratches Abrasions Rubbing eyes Dust Foreign objects
Contact lenses Trauma Dry Eyes (Wilson & Last, 2004)

Treatment Options (Wilson & Last, 2004) EYE PATCHING
Eye patching is no longer recommended for corneal abrasions.2,3,5 A meta-analysis of five randomized controlled trials (RCTs) failed to reveal an increase in healing rate or improvement on a pain scale.5 Two subsequent RCTs (one in children, one in adults) reported similar results.2,3 In the past, patching was thought to reduce pain by reducing blinking and decreasing eyelid-induced trauma to the damaged cornea. However, the patch itself was the main cause of pain in 48 percent of patients.6 Children with patches had greater difficulty walking than those without patches.3 Furthermore, patching can result in decreased oxygen delivery, increased moisture, and a higher chance of infection. Thus, patching may actually retard the healing process.7,8 TOPICAL ANALGESICS Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren) and ketorolac (Acular) are modestly useful in reducing pain from corneal abrasions.9 In a systematic review of five RCTs, topical NSAID use decreased pain by an average of 1.3 cm on a standard 10-cm pain scale.9 Qualitatively, patients using topical NSAIDs indicated greater relief from pain and other symptoms.9 Patients using topical NSAIDs may take fewer oral analgesics (two of three studies), return to work earlier (one study), and require fewer narcotics.9 Topical anesthetics should be avoided after the initial examination. They can retard healing and cause corneal damage. MYDRIATICS Mydriatics are no longer recommended for the treatment of pain in patients with corneal abrasions.10 Mydriatics formerly were prescribed to relieve ciliary muscle spasm that was thought to occur in patients with corneal abrasions. However, in one RCT with limited follow-up, pain was similar in patients using an eye lubricant or mydriatic (2 percent homatropine [Homapin]), alone or combined with a topical NSAID.10 TOPICAL ANTIBIOTICS Because a concomitant infection can cause slower healing of corneal abrasions, some clinicians use prophylactic antibiotic treatment, although there is no strong evidence for this use. A two-year, non–placebo-controlled, prospective cohort study11 of topical antibiotic prophylaxis for corneal abrasion showed that the use of 1 percent chloramphenicol ointment was associated with lower risk of subsequent ulcer, especially if prophylaxis began within 18 hours after the injury. A single-blind, non–placebo-controlled randomized trial12 showed that corneal abrasions in patients treated with fusidic acid eye drops did not heal significantly faster than patients treated with chloramphenicol ointment. If antibiotics are used, ointment (e.g., baci-tracin [AK-Tracin], erythromycin, gentamycin [Garamycin]) is more lubricating than drops and is considered first-line treatment. In patients who wear contact lenses, an anti-pseudomonal antibiotic (e.g., ciprofloxacin [Ciloxan], gentamycin, ofloxacin [Ocuflox]) should be used, and contact lens use should be discontinued. Clinical trial data are lacking, but it is recommended that contact lenses be avoided until the abrasion is healed and the antibiotic course completed.13 (Wilson & Last, 2004)

Primary Prevention and Health Promotion
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 Screening Most corneal abrasions are preventable. Persons in high-risk occupations (e.g., miners, woodworkers, metal workers, landscapers) and those who participate in certain sports (e.g., hockey, lacrosse, racquetball) should wear eye protection. Levels of protection include plastic safety glasses, polycarbonate lenses of varying thickness, industrial safety goggles with polycarbonate, and helmets with facemasks. All provide barrier protection from airborne debris (e.g., sand, sawdust, metal) and other objects that could cause ocular trauma (e.g., fingernails, tree branches, sports balls). Eye guards without lenses are not sufficient. Other preventive measures include careful fitting and placement of contact lenses, keeping the fingernails of infants and young children clipped short, and removing low-hanging tree branches or objects from the home environment. 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) appear to be less effective.14 Screening is important in three populations: neonates on mask ventilation, sedated or paralyzed patients on a ventilator, and persons who wear contact lenses. Corneal abrasion, with subsequent Pseudomonas panophthalmitis, can occur in patients in neonatal intensive care units who are receiving continuous positive airway pressure ventilation. It is attributed to the pressure of the masks on the orbit.15 Eye discharge in mask-ventilated neonates should prompt evaluation for corneal abrasion and infection. A similar problem can occur in adults who are deeply sedated or receiving neuromuscular blocking agents while on a ventilator, because their protective corneal reflex is suppressed. The incidence of corneal abrasion in this population decreased from 18 to 4 percent when prophylactic lubricating ointment was administered every four hours.16 Persons who wear contact lenses are at higher risk of developing abrasions that become infected and ulcerate (Figure 6). Soft, extended-wear lenses have been associated with a 10-fold to 15-fold increase in ulcerative keratitis.17 Case reports and a nonsystematic review suggest that screening for corneal abrasions also may be needed after airbag deployment in automobile crashes.18 Lagophthalmos - Proper eyelid closure and a normal blink reflex are essential to maintaining a stable tear film and a healthy corneal surface. Patients affected with lagophthalmos are unable to fully close their eyelids, and they may describe symptoms of dry and irritated eyes. Common morbidities of lagophthalmos are corneal exposure and subsequent keratopathy, which may progress to corneal ulceration and infectious keratitis. It is important to recognize lagophthalmos early in the patient’s course and begin treatment as soon as possible. The choice of therapy requires an understanding of both the etiology and expected duration of the lagophthalmos. (Wilson & Last, 2004)

Follow-up, Referral and Prognosis
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 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 Most patients should be re-evaluated in 24 hours; if the abrasion has not fully healed, they should be evaluated again three to four days later. Patients who wear contact lenses should be re-evaluated in 24 hours and again three to four days later even if they feel well. Any worsening of symptoms should prompt a thorough re-evaluation for foreign bodies or full-thickness injuries. Immunocompromised or monocular patients also warrant closer attention and may require earlier ophthalmologic referral. Referral to an ophthalmologist is indicated for patients with deep eye injuries, foreign bodies that cannot be removed, and suspected RCE. Patients with persistent symptoms after three days, worsening symptoms, and symptoms that do not improve daily also should be referred. Patients who wear contact lenses should be referred if there is no improvement in symptoms within a few hours of lens removal.

Quick Reference Acute Conjunctivitis Corneal Trauma Discharge Purulent
Watery, can be purulent Vision No effect Usually blurred Pain Mild Moderate to Severe (Papadakis & McPhee, 2013)

Do you remember??? Review Questions

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? Penicillin G benzathine 1.2million units IM once Amoxicillin 500mg PO BID for 7 days Linezolid 600mg PO BID for 7 days Doxycycline 100mg PO BID for 7 days Penicillin G benzathine 1.2million units IM once Amoxicillin 500mg PO BID for 7 days – dose is too small and duration is too short Linezolid 600mg PO BID for 7 days – reserve for VRE Doxycycline 100mg PO BID for 7 days - INEFFECTIVE

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? Penicillin G benzathine 1.2million units IM once Amoxicillin 500mg PO BID for 7 days Linezolid 600mg PO BID for 7 days 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: Single dose of Ceftriaxone 1g IM Single dose 1g azithromycin oral Assess for genital involvement and other STD’s to determine appropriate therapy All of the above Consider lavage of the infected eye with saline solution once. Persons treated for gonococcal conjunctivitis should be treated presumptively for concurrent C. trachomatis infection.

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: Single dose of Ceftriaxone 1g IM Single dose 1g azithromycin oral Assess for genital involvement and other STD’s to determine appropriate therapy All of the above

Question #3 Diagnosis of corneal abrasion is made by?
Based upon patient’s symptomatology and history. Visualizing the cornea under cobalt-blue filtered light after application of fluorescein stain with findings of the abrasion highlighted in green. Visualizing the cornea under cobalt-blue filtered light after application of fluorescein stain with findings of the abrasion highlighted in blue. CT scan with ocular view. B. Diagnosis confirmed by visualizing the cornea under cobalt-blue filtered light after application of fluorescein stain with findings of the abrasion highlighted in green

Question #3 Diagnosis of corneal abrasion is made by?
Based upon patient’s symptomatology and history. Visualizing the cornea under cobalt-blue filtered light after application of fluorescein stain with findings of the abrasion highlighted in green. Visualizing the cornea under cobalt-blue filtered light after application of fluorescein stain with findings of the abrasion highlighted in blue. 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? Prescribe him Augmentin 500mg PO TID Wait 5 more days and if symptoms persist then prescribe him Trimethoprim/sulfamethoxazole 160mg/800mg 2 tab PO BID Wait 5 more days and if symptoms persist prescribe him Amoxicillin 500mg PO TID None of the above

Question #5 A 33 year-old man presents with continued otalgia, otorrhea and fever of degrees farenheit after four days of treatment with amoxicillin. What should be done next in the treatment of this patient? Tylenol 1 gram every six hours for pain and fever and have patient return in one week Refer to otolaryngology for further work-up 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 Continue current therapy with no changes

Question #5 A 33 year-old man presents with continued otalgia, otorrhea and fever of degrees farenheit after four days of treatment with amoxicillin. What should be done next in the treatment of this patient? Tylenol 1 gram every six hours for pain and fever and have patient return in one week Refer to otolaryngology for further work-up 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 Continue current therapy with no changes McPhee, S. J., Papadakis, M. A., & Rabow, M. W. (2014). Current medical diagnosis & treatment New York: McGraw-Hill Medical.

Questions?

References CDC, Centers for Disease Control and Prevention. Conjunctivitis. Retrieved from Cooper, R. et al. (2001). Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine 2001;134(6): Crocker, A., Alweis, R., Scheirer, J., Schamel, S., Wasser, T., & Levingood, K. (2013, July 5). Factors affecting adherence to evidence-based guidelines in the treatment of URI, sinusitis, and pharyngitis. Journal of Community Hospital Internal Medicine Perspective, 3(2). doi: /jchimp.v3i Djalilian, H. (2011). Pneumatic Otoscopy. Retrieved from Esherick, J. S., Clark, D. S., & Slater, E. D. (2012). Current practice guidelines in primary care New York: McGraw-Hill Medical. Gerber, M., Baltimore, R., Eaton, C., Gewitz, M., Rowley, A., Shulman, S., , & Taubert, K. (2009). Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation, 119(11), doi: /CIRCULATIONAHA Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical. Henderson, M. C., Tierney, L. M., & Smetana, G. W. (2012). The patient history: An evidence-based approach to differential diagnosis. New York: McGraw-Hill Medical. Jones, W., Gross anatomy of the eye. Webvision. Retrieved from webvision.med.utah.edu Lexi-comp (Version (160)) [Computer database application for mobile device]. (2013). United States: Lexi-Comp, Inc. Lin, Y., Lin, L., Lee, F., & Lee, K. (2009). The prevalence of chronic otitis media and its complication rates in teenagers and adult patients. Otolaryngology - Head and Neck Surgery, 140(2), doi: /j.otohns Lustig, L & Schindler, J. (2013). Chapter 8. Ear, Nose & Throat Disorders. In M. Papadakis & S. McPhee (Eds), Current Medical Diagnosis and Treatment, 52e. Retrieved October 1, 2013 from McPhee, S. J., Papadakis, M. A., & Rabow, M. W. (2014). Current medical diagnosis & treatment New York: McGraw-Hill Medical. 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): e doi: /journal.pone Ohio Board of Nursing (2013). The formulary developed by the Committee on Prescriptive Governance. Retrieved from 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, doi: /j x Rosenfeld, R., Andes, D., Bhattacharyya, N., Cheung, D., Eisenberg, S., Ganiats, T.,...Haydon, R. (2007, September). Clinical practice guideline: adult sinusitis. Otolaryngology Head and Neck Surgery, 137(3 Suppl), S1-S31. Retrieved from Rubin, M., Ford, F., & Gonzales, R. (2012). Chapter 31. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections. In D. Longo, A. Fauci, D. Kasper, S. Hauser, J. Jameson & J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e. Retrieved October 1, 2013 from

References Rujanavej, V., Soudry, E., Banaei, N., Baron, E., Hwang, P., & Nayak, J. (2013, March-April). Trends in incidence and suceptibility amoung methicillin-resistant staphylococcus aureus isolated from intranasal cultures associated with rhinosinusitis. American Journal of Rhinology and Allergy, 134(7), doi: /ajra Shaikh, N., Hoberman, A., Kaleida, P., Rockette, H., Kurs-Lasky, M., Hoover, H., Schwartz, R. (2011). Otoscopic signs of otitis media. The Pediatric Infectious Disease Journal, 30(10), doi: /INF.0b013e31822e6637 Shulman, S., Bisno, A., Clegg, H., Gerber, M., Kaplan, E., Lee, G., ,…Van Beneden, C. (2012). Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 55(10), doi: /cid/cis847 Silverberg, M. & Lucchesi, M. (2011). Chapter 237. Comman Disorders of the External, Middle, and Inner Ear. In J. Tintinalli, J. Stapczynski, D. Cline, O. Ma, R. Cydulka & G. Meckler (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Retrieved October 1, 2013 from 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. University of Maryland Medical Center. (2013). Sinusitis. . Retrieved from Welch Allyn (2011). Principles of Otoscopy. Retrieved from Wilson, S., & Last, A., (2004). Management of corneal abrasions, American Family Physicians, 70(1), p Retrieved from Zeiger, R. (2013) McGraw-Hill's Diagnosaurus 2.0. Retrieved from

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Wright State University – Miami Valley School of Nursing and Health

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