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OME otitis media with effusion

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					                 OME (otitis media with effusion)                                             AOM(acute otitis media)

-sterile (non-infectious) secretory otitis media, secondary to a viral   -acute bacterial infection of the middle ear secondary to a viral
URTI                                                                     URTI, often after OME
-aural fullness with mild hearing loss due to E tube occlusion and       -bulging TM / opaque
absorption of air                                                        -ruptured eardrum
-prominent appearance of manubrium and short process with                -pus accumulation in middle ear
retraction of ear drum                                                   -thickened eardrum with erythema (hyperemia)
-fluid and air bubble are visible                                        -distorted (dullness) / absent light reflex
-reduced TM-mobility                                                     -reduced TM-mobility
-accumulation or serous effusion in the middle ear                       -may lead to TM perforation or rare complications


-swelling and destruction of the mucosa in the URT, including E          -bacterial infection of the middle ear
tube                                                                     -initial viral URTI
-E tube dysfunction (ETD)                                                -swelling and destruction of the mucosa of the URT, including E
ETD => absorption of air from middle ear =>                              tube
retraction of TM and accumulation of sterile effusion                    -E tube dysfunction (ETD)
-hear loss, ear popping, gurgling sound (common in child)                -secondary bacterial infection in the middle ear (NPH flora):
-don’t treat with antibiotics yet                                            Streptococcus pneumoniae / Hemophilus influenzae
-may develop into AOM                                                                        Moraxella catarrhalis
-chronic OME = may have to be treated with ear tube to avoid             -pus accumulation and increase pressure in the middle ear
serious complication                                                     -painful and fever
                                                                         -AOM is common in young children (peak age 2)
(Chronic OME and Complication):                                          -spontaneous rupture of TM = common complication
-permanent hearting loss and learning difficulties                       -AOM leads to OME in the healing stage
-tympanosclerosis                                                        -very slow healing (6 to 8 weeks)
-perforation of the ear drum
-retraction pockets                                                      (early signs): OME sign
-cholesteatoma:                                                          (1) immobile and retracted TM
skin cyst grows into the middle ear and mastoid                          (2) moderate erythema of the TM / clear fluid and air bubble in ME
cyst is not cancerous but can erode tissue and cause destruction of
the ear / benign epidermoid tumor                                        (consecutive signs): AOM sign
(presentation of cholesteatoma):                                         (1) formation of yellow, purulent effusion
hearing loss / facial paralysis / dizziness / imbalance / vertigo        (2) increased middle ear pressure
slow erosion into the brain cavity / intracranial complication risk      (3) bulging eardrum
                                                                         (4) intense pain
-OME is the most common cause of conductive hearing loss in
children (hearing loss dominates as the main symptom)                    (AOM complication):
-OME cause milder earache                                                -extracranial (intratemporal) complication:
-OME is a harmness and self-limiting condition in most cases             (1) acute mastoiditis = infection of mastoid air cells
-conservative treatment is suggested                                     (2) facial palsy (paresis)
-treatment of B/L chronic OME = myringotomy / grommets                   (3) labyrinthitis = light-headedness / loss of balance / nausea

                                                                         -intracranial complication:
                                                                         (1) meningitis = nuchal rigidity / photophobia / headache
                                                                         (2) brain abscess = ICU brain surgery
                                                                         (3) neurological deficit symptoms (increased DTR) = spinal cord
                                                                         (4) venous thrombosis of lat / sigmoid venous sinus = vessels
                                                                         -occur in patients with cholesteatoma
                                                                         (early symptoms):
                                                                         high fever => meningism => change consciousness => death

                                                                         -two most common complications to AOM
                                                                         perforation of the eardrum / chronic AOM or chronic OME

                                                                         -Bullous myringitis :
                                                                         results from viral infection / may accompany AOM
                                                                         large vesicles and bullae visible on the drum / TM is red

                                                                         -AOM causes intense otalgia

-sensory nerves in ear:
posterior roots of spinal nerves C2 / 3 and CN 5, 7, 9, 10
tensor tympani (CN 5:3) / stapedius mm (CN7) / CN 7 travels through temporal bone = referred pain cause earache

                                                                                                                                             1
                                    URTI                                                                         SORE THROAT

(common URTI symptoms and signs):                                                   (bacterial pharyngitis):
-rhinitis = swelling of nasal mucosa and nasal obstruction                          is diagnosed clinically by typical symptoms such as dysphagia and
-conjunctivitis / coryza / rhinorrhea / pharyngitis / tonsillitis                   sore throat and physical examination findings of the pharynx
-earache / dysphagia / cough / hoarseness / fever / fatigue                         -elevated hemoglobin and granulocytosis = bacterial infection
-sore throat = odynophagia
-malaise / abdominal pain / vomiting / diarrhea / mouth breathing                   (tonsillitis):
                                                                                    likely when the tonsils are swollen and red
(bacterial infection):                                                              the exudate indicates bacterial origin and so does intense
-bacterial infections tend to spread and cause severe complications                 pharyngeal erythema
-effective antibiotic treatment is still effective for bacterial
infections                                                                          (cause of most URTI) = viruses
-one dominant symptom                                                               -viral pharyngitis / tonsillitis tend to be accompanied by additional
-intense pharyngeal erythema                                                        symptoms, such as cough, coryza, conjunctivitis (same virus,
-purulent discharge (yellow / green / brownish)                                     usually adenovirus), and general myalgia
-exudates on tonsil
-fever spike and new symptoms = secondary bacterial infection                       -bacterial pharyngitis / tonsillitis = likely caused by GABHS
-(CBC finding) = neurophilia (neutrophilic granulocytosis = PMN)
                   increased CRP (acute bacterial infection)                        ---------------------------------------------------------------------------------
                   increased ESR (chronic bac or viral infection)
                                        TB or osteomyelitis                            Streptococcus pneumoniae                   Hemophilus influenzae
* CRP reacts quickly to infection activity
  ESR reacts slowly to infection activity                                            -G+ve coccus                             -G-ve coccus
                                                                                     -habitat = URT (endogen)                 -habitat = URT (endogen)
(viral infection):                                                                   -causes:                                 -causes:
-many symptoms = generally viral spread in the whole URT                             AOM ,sinusitis , pneumonia               AOM 2nd most common
-if cough = viral infection                                                          meningitis, conjunctivitis               sinusitis 2nd most common
-(CBC finding) = lymphocytosis (or lymphopenia)                                      -treatment:                              tonsillitis
                                                                                     penicillin, fights G+ve cocci            pneumonia / CB
(lab tests to differentiate viral and bacterial infection):                                                                   conjunctivitis
(1) rapid streptococcal antigen test = group A beta-hemolytic                        *most common cause of acute
                                           (GABHS)                                   meningitis in children                   *capsulated form = type B
(2) bacterial / viral cultures                                                                                                *non-capsulated type causes
(3) serologic test = increase titers of pathogen-specific Ab (M & G)                                                          AOM, sinusitis, conjunctivitis
(lab tests for infectious mononucleosis):
                                                                                     Moraxella catarrhalis                    Group A beta - hemolytic
(1) monospot test = rapid slide agglutination test / heterophile Ab
                                                                                                                              streptocci (GABHS)
                     sensitivity decrease by increasing time
                                                                                     -G-ve diplocuccus                        -G+ve coccus
                     usually -ve in children less than 6 to 8 years old
                                                                                     -cause = AOM,                            -habitat = URT
(2) serologic test = increase titers of EBV-specific Abs (M &G)
                                                                                     sinusitis,conjunctivitis                 -causes:
(3) lymphocytosis
                                                                                     -treatment:                              “strep throat”
                                                                                     same as H influenzae                     most common bacterial
-SNOUT = only in test with increased sensitivity
                                                                                                                              pharyngitis / tonsiliitis / scalet
           if test is -ve => rule out disease
                                                                                                                              fever
-SPIN = only in test with increased specificity
                                                                                                                              -age = 5 to 11
       if test is +ve => rule in disease
                                                                                                                              -skin infection = impedigo
                                                                                                                              cellulitis / necrotizing fascitis
---------------------------------------------------------------------------------
                                                                                                                              streptococcal toxic shock synd
(follicular bacterial skin infections):
follicititis / furuncle / carbuncle
                                                                                    (strep throat / scarlet fever (GABHS)):
                                                                                    -purulent complication = direct bacterial spread:
(bacterial skin infection):
impetigo / ecthyma / erysipelas / lymphangitis / cellulitis                         peritonsillitis (quinsy) / lymphadenitis / AOM / sinusitis / epiglottis
                                                                                    -non-purulent complication = delayed hypersensitivity rxn:
                                                                                    rheumatic fever (including endocarditis and arthritis)
                                                                                    post-streptococcal glomerulonephritis
                                                                                    PANDAS (pediatric autoimmune neuropsychiatric disorders)
                                                                                    tics / ADHD / OCD
                                                                                    Sydenham’s chorea (irregular contractions that is not repetitive)

                                                                                    -scalet fever = incubation period 2 to 4 days
                                                                                                    complications (otitis media / cervical adenitis ..)



                                                                                                                                                                   2
(epiglottitis):                                                         (acute bronchiolitis):
age = 2 to 12 years                                                     -respiratory syncytial virus (RSV)
pathogens = H influenzae type B / Strep pneumoniae / GABHS              -common in winter
              Candida                                                   -infection of respiratory and ciliated epithelial cells of bronchioles
-bacterial / caustic burns and trauma / drooling and retraction         -mucus secretion and submucosal edema
-inspiratory stridor / unable to talk or swallow                        -critical narrowing and obstruction of small airways
-cherry-red epiglottis                                                  -hypoxia = risk for respiratory failure
-acute airway obstruction                                               -age = 2 to 24 months
                                                                        -TX: supportive treatment of O2. humidified air, chest clapping
(croup = larynotracheobronchitis):                                            rest, clear fluids, bronchodilators, glucocorticoids
-viral (parainfluenza virus) / common in fall / after cold viral URTI   -most deaths occurs in infants <6
-sudden inspiratroy stridor / barking cough
-acute airway obstruction (esp. infants)
-TX: fluids, moist air // bronchodilators, glucocorticoids




-reactive lymphadenopathy = secondary lymphadenopathy
-lymphadenitis = infection of a lymph node                               Adult sore throat                   Children sore throat
-lymphangitis = infection of a lymph vessel
                                                                         -viral most common                  -viral most common
(primary lymphadenopathy):                                                bacterial fungal (candida)          URTI with pharyngitis
-diffuse lymph node enlargement in the neck B/L                          -peritonsillar abscess               tonsillitis / infectious MN
 they are hard and non-tender                                            -ulcerative conditions               herpangina, croup
-usually malignant                                                                                           -harsh “barking” cough,
-Hodgkin lymphoma / non-Hodgkin lymphoma / hair cell leukemia            (chronic sore throat):              stridor and fever
                                                                         (1) alcohol
(secondary lymphadenopathy):                                             (2) smoking                         *bacterial:
-metastasis, Virchow’s node (aka signal or sentinel lymph node)          (3) chronic reflux                  pharynitis
                                                                         (4) neoplasia                       tonsillitis
(symptoms and signs in oral cavity):                                                                         (vincent’s / strep. throat)
-pain / mass / ulceration / hemorrhage / halitosis / discoloration/                                          epiglottitis
hypogeusia / dysgeusia / ageusia                                                                             diphtheria
-enlarged neck glands = infection / neoplsia




(summary for pharyngitis / tonsillitis):
-viral etiology :
 most common cause = adenovirus / myxovirus / picornavirus / EBV / Coxsackie virus A or B
 dominance of cold symptoms
 tonsils usually less involved

-bacterial (eg. strep throat)
 less symptoms from other sites
 treatment = conservative / antibiotic should only be considered in case of GABHS infection or serious bacterial pharyngitis/tonsillitis
 bacterial tonsillitis = GABHS / strep throat is aggressive form
                         prominent erythema and exudate on pharyngeal tonsils / odynophagia / fever / malaise / fatigue / headache
                         purulent nasal discharge / ear pain / anterior cervical lymphadenopathy / few upper respiratory symptoms
scalet fever = macular exanthema on cheeks / strawberry red tongue
                peritonsillar abscess / AOM / lymphadenitis
                non-purulent complications
                lab = +ve ASO titer / increased ESR
                unilateral tonsillitis = exclude malignancy / vincent’s angina
Vincent’s Angina = ulcerating infection of the pharyngeal mucosa involving one or both tonsils (stomatitis / gingivitis possible)
                        agents = Fusobacterium nucleatum / Treponema vincentii (Borelia spirochete)
                        presentation = mild symptoms / halitosis / odynophagia
                        maliganant if unilateral presentation
Herpangina = blistering ulcers in the pharynx and roof of the mouth, and lips
                agent = Coxsackie virus A (or B)
                presentation = fever / headache / myalgia / sore throat




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