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NR602 Midterm Study Guide
MIDTERM STUDY GUIDE: PART-1
1. CHALAZIONS – Benign, chronic lipogranulomatous inflammation of the eyelid
Causes – blockage of the meibomian cyst
Risk – hordeolum or any condition which may impede flow through the meibomian gland. Also, mite
species that reside in lash follicles
Assessment – PAINLESS, NOT INVOLVING LASHES
Lid edema, or palpable mass
Red or grey mass on the inner aspect of lid margin
Prevention – good eye hygiene
Treatment – warm, moist compresses 3x per day
Antibiotics not indicated because chalazion is granulomatous condition, if secondarily infected
consider SULFACETAMIDE, ERYTHROMYCIN
Follow up – 2-4 weeks, if still present after 6 weeks follow up with ophthalmologist
2. BLEPHARITIS – Inflamation/infection of the lid margins (chronic problem)
2 types – seborrheic (non ulcerative) : irritants (smoke, make up, chemicals)
o s&s – chronic inflammation of the eyelid, erythema, greasy scaling of anterior eyelid,
loss of eyelashes, seborrhea dermatitis of eyebrows and scalp
Ulcerative- infection with staphylococcus or streptococcus
o s&s – itching, tearing, recurrent styes, chalazia, photophobia, small ulceration at eyelid
margin, broken or absent eyelashes
the most frequent complaint is ongoing eye irritation and conjunctiva redness
Treatment – clean with baby shampoo 2-4 times a day, warm compresses, lid massage (right after warm
compress)
For infected eyelids – antistaphyloccocal antibiotics BACITRACIN, ERYTHROMYCIN 0.05% for 1 week
AND QUIONOLONE OINTMENTS
For infection resistant to topical – TETRACYCLINE 250 MG PO X4
DOXYCYCLINE 100 MG PO X2
3. OTITIS MEDIA- AOM is an acute infection of the middle ear The AAP Clinical Practice Guideline
requires the presence of the following three components to diagnose AOM
• Recent, abrupt onset of signs and symptoms of middle ear inflammation and effusion (ear pain,
irritability, otorrhea, and/or fever)
• MEE as confirmed by bulging TM, limited or absent mobility by pneumatic otoscopy, air-fluid
level behind TM, and/or otorrhea
• Signs and symptoms of middle ear inflammation as confirmed by distinct erythema of the TM or
onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal manner)
TYPE CHARACTERISTICS
AOM Suppurative effusion of the middle ear
Bullous myringitis AOM which bullae form between inner and middle layers of
the TM and bulge outward
Persistent AOM AOM that has not resolved when antibiotic therapy has been
completed or AOM recurs with days of treatment
Recurrent AOM 3 separate bouts of AOM with in 6 mth period or 4 with in a
12-month period; often a positive family history of otitis
media and other ENT disease
S. pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, and S. pyogenes (group A
streptococci) are the most common infecting organisms in AOM. S. pneumoniae continues to be the most common
bacteria responsible for AOM. The strains of S. pneumoniae in the heptavalent pneumococcal conjugate vaccine
(PCV7) have virtually disappeared from the middle ear fluid of children with AOM. With the introduction of the 13-
valent S. pneumoniae vaccine, the bacteriology of the middle ear is likely to continue to evolve. Bullous myringitis
is almost always caused by S. pneumonia.
,2
Nontypeable H. influenza remains a common cause of AOM. It is the most common cause of bilateral otitis media,
severe inflammation of the TM, and otitis-conjunctivitis syndrome. M. catarrhalis obtained from the nasopharynx
has become increasingly more beta-lactamase positive, but the high rate of clinical resolution in children with AOM
from M. catarrhalis makes amoxicillin a good choice for initial therapy. M. catarrhalis rarely causes invasive
disease.
S. pyogenes is responsible for AOM in older children, is responsible for more TM ruptures, and is more likely to
cause mastoiditis.
Although a virus is usually the initial causative factor in AOM, strict diagnostic criteria, careful specimen handling,
and sensitive microbiologic techniques have shown that the majority of AOM is caused by bacteria or bacteria and
virus together
Clinical Findings
History
Rapid onset of signs and symptoms:
• Ear pain with possible ear pulling in the infant; may interfere with activity and/or sleep
• Irritability in an infant or toddler
• Otorrhea
• Fever
Other key factors or symptoms:
• Prematurity
• Craniofacial anomalies or congenital syndromes associated with craniofacial anomalies
• Exposure to risk factors
• Disrupted sleep or inability to sleep
• Lethargy, dizziness, tinnitus, and unsteady gait
• Diarrhea and vomiting
• Sudden hearing loss
• Stuffy nose, rhinorrhea, and sneezing
• Rare facial palsy and ataxia
Physical Examination
• Presence of MEE, confirmed by pneumatic otoscopy, tympanometry, or acoustic reflectometry, as
evidenced by:
• Bulging TM
• Decreased translucency of TM
• Absent or decreased mobility of the TM
• Air-fluid level behind the TM
• Otorrhea
• Signs and symptoms of middle ear inflammation indicated by either:
• Erythema of the TM (Amber is usually seen in otitis media with effusion [OME]; white or yellow may be seen in
either AOM or OME
or
• Distinct otalgia that interferes with normal activity or sleep
• In addition, the following TM findings may be present:
• Increased vascularity with obscured or absent landmarks
• Red, yellow, or purple TM (Redness alone should not be used to diagnose AOM, especially in a crying
child.)
• Thin-walled, sagging bullae filled with straw-colored fluid seen with bullous myringitis
Diagnostic Studies
Pneumatic otoscopy is the simplest and most efficient way to diagnose AOM. Tympanometry reflects effusion (type
B pattern). Tympanocentesis to identify the infecting organism is helpful in the treatment of infants younger than 2
months old. In older infants and children, tympanocentesis is rarely done and is useful only if the patient is toxic or
immunocompromised or in the presence of resistant infection or acute pain from bullous myringitis. If a
tympanocentesis is warranted, refer the patient to an otolaryngologist for this procedure.
Management
Many changes have been made in the treatment of AOM because of the increasing rate of antibiotic-resistant
bacteria related to the injudicious use of antibiotics. Ample evidence has been presented that symptom management
may be all that is required in children with MEE without other symptoms of AOM Treatment guidelines are decided
,3
based on the child's age, illness severity, and the certainty of diagnosis. shows the recommendation for the
diagnosis and subsequent treatment of AOM.
1. Pain management is the first principle of treatment.
• Weight-appropriate doses of ibuprofen or acetaminophen should be encouraged to decrease discomfort
and fever.
• Topical analgesics, such as benzocaine or antipyrine/benzocaine otic preparations, can be added to
systemic pain management if the TM is known to be intact. Topical analgesics should not be used alone.
• Distraction, oil application, or external use of heat or cold may be of some use.
2. Antibiotics are also effective.
• Amoxicillin remains the first-line antibiotic for AOM if there has not been a previous treated AOM in the
previous 30 days, there is no conjunctivitis, and no penicillin allergy
Beta-lactam coverage (amoxicillin/clavulanate, third-generation cephalosporin) is recommended when the child has
been treated with amoxicillin in the previous 30 days, there is an allergy to penicillin, and the child has concurrent
conjunctivitis or has recurrent otitis that has not responded to amoxicillin. If there is a documented hypersensitivity
reaction to amoxicillin, the following antibiotics are acceptable, follow the non-type 1 hypersensitivity and type 1
hypersensitivity recommendations in
• Ceftriaxone may be effective for the vomiting child, the child unable to tolerate oral medications, or the
child who has failed amoxicillin/clavulanate.
• Clindamycin may be considered for ceftriaxone failure but should only be used if susceptibilities are
known.
• Prophylactic antibiotics for chronic or recurrent AOM are not recommended.
3. Observation or “watchful waiting” for 48 to 72 hours allows the patient to improve without antibiotic treatment.
Pain relief should be provided, and a means of follow-up must be in place. Options for follow-up include:
• Parent-initiated visit or phone call for worsening or no improvement
• Scheduled follow-up appointment
• Routine follow-up phone call
• Given a prescription to be started if the child's symptoms do not improve or if they worsen in 48 to 72
• Communication with the parent, reevaluation, and the ability to obtain medication must be in place.
4. Recommendations for follow-up include:
• After 48 to 72 hours if a child has not showed improvement in ear symptomatology, the child should be
seen to confirm or exclude the presence of AOM. If the initial management option was an antibacterial
agent, the agent should be changed.
Diagnosis Treat
Any child with moderate/severe bulging TM with Yes
otorrhea not associated with AOM
Any child with mild bulging of the TM with recent Yes
(<48 hours) onset pain (holding, tugging, and so on)
or intensely erythematous TM
Babies ≥6 months of age with severe signs of AOM Yes
(fever >102.2° F [39° C], otalgia for ≥48 hours)
Any child 6 to 23 months old with acute bilateral Yes
otitis media without severe symptoms, without
fever, and sick less than 48 hours
Young children with unilateral AOM without severe Provide prescription
symptoms and fever <102.2° F [39° C] and/or wait
Close follow-up
Children ≥24 months old without severe symptoms Provide prescription
and/or wait
Close follow-up
Children not treated and no improvement in 48 to See the patient again
, 4
Diagnosis Treat
72 hours Clinician discretion
whether or not to
treat
4. CONJUCTIVITIS – inflammation or irritation of conjunctiva
Bacterial (PINK EYE) – in peds bacteria is the most common cause, contact lens, rubbing eyes, trauma,
S&S – purulent exudate, initially unilateral, then bilateral
Sensation of having foreign body in the eye is common
Key findings – redness, yellow green, purulent discharge, crust and matted eyelids in am
Self-limiting 5-7 days. Eye drops – polytrim, erythromycin, tobramycin or cipro
Improvement 2-4 days
Most common organism H. influenza <7
Viral – adenovirus, coxsackie virus, herpes, molluscum
S&S – profuse tearing, mucous discharge, burning, concurrent URI, enlarged or tender preauricular nose
Antihistamines/decongestant
Improvement, self-limiting, 7-14 days
Chlamydial – chlamydia trachomatis
S&S – profuse exudate, associated with genitourinary symptoms, 1-2 weeks after birth
Gonococcal – 2-4 days after birth, most concern can cause blidness
PO azithromycin, doxycycline (tetracyclines increase photosensitivity, don’t use in pregnancy)
Improvement 2-3 weeks
Allergic –IgE mast cell reaction, environmental, cosmetics
S&S – marked conjuctival edema, severe itching, tearing, sneezing
Topical antihistamine or topical steroids
Improvement 2-3 days
Chemical –thimerosal, erythromycin, silver nitrate
S&Sconjuctival erythema, 30 minutes afer prophylactic antibiotics drops
Avoid contact
Can consider steroids
Conjunctivitis never accompany vision changes
Diagnostic studies: swap and scraping must be done, gram and Giemsa staining, ELISA, PCR testing, newborn < 2
weeks needs to be tested for gonorrhea
Non –pharm – clean towels, change pillows, warm compress, no contacts, no eye make up – mascara
Gonococcal conjunctivitis: newborn – give Ceftriaaxone IM once (don’t give if hyperbilirubinemia,
Non-gonococcal – erythromycin 0.5% ointment
Consider fluorescein staining if abrasion suspected
CDC recommends prophylactic administration of antibiotic eye ointment (ERYTHROMYCIN) 1 hour after delivery
Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis or ulcerations present
May return to work/school 24 hours after topical
5. OTITIS EXTERNA- Otitis externa (OE), commonly called swimmer's ear, is a diffuse inflammation of
the EAC and can involve the pinna or TM. Inflammation is evidenced as
(1) simple infection with edema, discharge, and erythema;
(2) furuncles or small abscesses that form in hair follicles; or
(3) impetigo or infection of the superficial layers of the epidermis. OE can also be classified as mycotic
otitis externa, caused by fungus, or as chronic external otitis, a diffuse low-grade infection of the EAC.
Severe infection or systemic infection can be seen in children who have diabetes mellitus, are
immunocompromised, or have received head and neck irradiation.
OE results when the protective barriers in the EAC are damaged by mechanical or chemical mechanisms.
OE is most frequently caused by retained moisture in the EAC, which changes the usually acidic
environment to a neutral or basic environment, thereby promoting bacterial or fungal growth. Chlorine in
swimming pools adds to the 743problem because it kills the normal ear flora, allowing the growth of
pathogens. Regular cleaning of the EAC removes cerumen, which is an important barrier to water and
