SINUSITIS

Sinusitis is the inflammation/infection of the mucosa of 1 or more paranasal sinuses.

Definitions: Acute Bacterial Sinusitis: Bacterial infection of the paranasal sinuses lasting less than 30 days in which symptoms resolve completely.

Subacute Bacterial Sinusitis: Bacterial infection of the paranasal sinuses lasting between 30 and 90 days in which symptoms resolve completely.

Chronic Sinusitis: Episodes of inflammation of the paranasal sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms: cough (tos), rhinorrhea, nasal

obstruction.

ANATOMY / DEVELOPMENT
4 Sinuses: Maxillary, Ethmoidal, Frontal, Sphenoidal

MAXILLARY SINUSES DEVELOPS DURING 3rd & 4th GESTATIONAL MONTH WITH PNEUMATIZATION BETWEEN BIRTH AND 12 MONTHS OF AGE

ETHMOID SINUSES DEVELOPS DURING 3rd & 4th GESTATIONAL MONTH. IS PRESENT AT BIRTH, DEVELOPING UNTIL 12-14 YEARS OF AGE

SPHENOID SINUS DEVELOPED BY AGE 8-10 YEARS

FRONTAL SINUS DEVELOPS DURING 5th AND 6th YEAR.

In the sides of the nasal septum, there is 3 shelf-like structures where discharge is drain and is called Turbinates

MAXILLARY ANT. ETHMOID FRONTAL

MIDDLE MEATUS

POST. ETHMOID SPHENOID

SUPERIOR MEATUS

LACRIMAL DUCTS

INFERIOR MEATUS (Largest and most visible)

ETIOLOGY:
Bacteria: S. pneumoniae (40%) H. influenza (30-40%) Moraxella catarrhalis
Virus: Rhinovirus, adenovirus, influenza, parainfluenza Allergy (chemical and particulate irritants, allergens)

EPIDEMIOLOGY: Occurs during viral respiratory season Attendance at Day Care Center School-age siblings in the household

PHYSIOLOGY:
Usually after URI Mucosal edema mucus transport obstruction of osteomeatal complex stagnation of secretions of pH/decrease O2 tension within the sinus promotes Bac/Viral growth.

THREE KEY ELEMENTS: PATENCY OF THE OSTIA FUNCTION OF THE CILIARY APPARATUS QUALITY OF SECRETIONS

-Patency of the Ostia: Mucosa Edema: allergy, viral Mechanical Obstruction: Obstruction of meatus Deviated nasal septum

-The function of the ciliary apparatus: Help nose filter bacteria/pollutant Help regulate temp/humidification -Quality of secretions: Hypersecretion obstruction less O2 growth of bacteria, impairs defenses, and alters the function of immune cells.

INFLAMED SINUSES

Factors Predisposing To Obstruction Of Sinus Drainage

A. MUCOSAL SWELLING Systemic disorder Allergic inflammation Immune disorder Local insult Swimming Rhinitis medicamentosa

Viral URI Cystic fibrosis Immotile cilia Facial trauma Diving

B. MECHANICAL OBSTRUCTION Choanal atresia Nasal polyp Tumor

Deviated septum Foreign body Ethmoid bullae

C. MUCUS ABNORMALITIES Viral URI Allergic Rhinitis Cystic fibrosis

Sg/Sx: URI symptoms for > than 10 days (acute) or > than 12 weeks (chronic) *Low grade fever (50%) *Mucopurulent rhinorrhea in middle meatus or postnasal discharge(descargar). (95%) *Nasal mucosa congested/edematous *Cough present during daytime but is worse at night (90%) * Painless periorbital edema occurring in the morning and with bad breath. *Facial pain/pressure above or below the eyes, and Headache. It may change with position, increasing when leaning forward or during percussion. (70%) *Frontal, Maxillary, and Ethmoid area are tender to palpation/percussion *Periorbital swelling (hinchazon) is suggestive of ethmoid sinusitis

SIGN/SYMPTOM Facial Pressure/ Pain

SINUSITIS Yes

ALLERGY Sometimes

COLD Sometimes

Duration of Illness

>Over 10-14 days

Varies

<Under 10 days

Nasal Discharge

Thick, yellow-green

Clear, thin, watery

Thick, whitish or thin

Fever Headache Pain in Upper Teeth

Sometimes Sometimes Sometimes

No Sometimes No

Sometimes Sometimes No

Bad Breath (resp) Coughing

Sometimes Sometimes

No Sometimes

No Yes

Nasal Congestion

Yes

Sometimes

Yes

Sneezing (estornudo)

No

Sometimes

Yes

Complications of Acute Bacterial Sinusitis

Preseptal cellulitis Orbital cellulitis Osteomyelitis Subperiosteal orbital abscess Subdural or Epidural Empyema Meningitis Brain abscess Cavernous sinus thrombophlebitis

Differential Diagnosis-Purulent Nasal Discharge

Uncomplicated viral URI Group A Strep infection Adenoiditis Nasal foreign body

Lab: Transillumination of the maxillary and frontal sinuses Sinus X ray: air-fluid level, complete opacity, mucosal thickening Waters-3 views

Coronal CT: demonstrate air fluids levels mucosal thickening, anatomical variations suspected intracranial or orbital complication. G.S.

TX: Amoxicillin Amoxicillin/potassium clavulanate Azythromycin Claritromycin Ceftriaxone

40-90 mg/kg/day x 10 d 80-90 mg/kg/day x 10 d 10/5 mg/kg/day x 5 d 15 mg/kg/day x 10 d 50 mg/kg/day x 5 d

Humidifier with Normal saline, Mucolytics ( guaifenesin) Topical nasal steroids, Antihistamines (not recommended). Treat for up to 21 days or until free symptoms for 7 days

EAR

The ear is divided in 3 regions:

External ear: (Sound Receptor Complex) Pinna (auricle), external auditory canal, up to TM

Middle ear: (Transmission Complex) Middle ear space, inner space of eardrum, ossicles, mastoid

Internal ear: (Perception Complex) Cochlea-Anterior Labyrinth (hearing), Semicircular canals-Posterior labyrinth (balance), Main nerve trunks of the 7th /8th cranial nerves.

Normal TM
The tympanic membrane (TM) is intact, thin, pearly/gray, pink, translucent, and freely mobile on insufflation (respond to pos/neg pressure, pars flacida vibrates) Neutral position (not retracted or bulging) The malleus as well as a cone- shaped light reflex are seen.

OTITIS EXTERNA (Swimmers ear)

Acute otitis externa is defined as diffuse inflammation of the external ear canal, and the ear canal structures, involving the pinna or tympanic membrane. Characterized by pain caused by infection of macerated skin tissue

Anatomy: The auditory canal is a curved structure Its medial 2/3 comprises a bone lined with a thin layer of skin. The outer 1/3 comprises cartilage with extensive subcutaneous tissue. It contains hair follicles, sebaceous and modified apocrine glands that produce cerumen that keeps the ear canal acidic (pH 6.1), and protects the middle ear from debris and trauma

Etiology:

Bacteria: Pseudomonas aeroginosa (G-)

Staphyloccocus aureus

Viral: Herpes zoster/Simplex

Fungal:

Aspergillus (90%-black spores) Candida

OTITIS MEDIA

Inflammation and infection reaction to foreign antigens in the middle ear, that cannot drain via the Eustachian tube. It is the most common infection of early childhood.

Anatomy of the Eustachian tube and immature immune systems of the children, contribute to the frequency of this infection.

Classification: 1-Acute otitis media AOM 2-Otitis media with effusion OME 3-Chronic Otitis media COM

Subcategories: Acute otitis media- Less than 3 weeks Recurrent otitis media- 3 weeks to 3 months Chronic otitis media- Greater than 3 months

Etiology
60 - 80% Bacterial Causes: Streptococcus pneumoniae (~40% ). Haemophilus influenzae (~30%). Moraxella catarrhalis (~20%). Group A beta-hemolytic streptococci (S. pyogenes ~3%).

20 - 40% Viral Infection: RSV, influenza A, adenovirus, parainfluenza type 3, rhinovirus

Pathophysiology:

Nasopharinx is colonized with bacterias inflammation of Eustachian tube fluids goes into middle ear fluids get infected by bacteria's from nasopharinx TM swelling, pain, pressure inability of TM to vibrate temporary decrease of hearing loss

ETIOLOGY OF ACUTE OTITIS MEDIA

Whos at Risk?
Young age 6-36 months Attendance at the Day care centers Male sex History of enlarged adenoid, tonsillitis, or asthma Other factors: Recent or recurrent URIs, nasal congestion or obstruction. Multiple previous episodes Has brothers and sisters close in age with Hx of ear infection Bottle feeding while laying in bed Anatomic position of Eustachian tube

Function of the Eustachian Tube:

Ventilation of the middle ear to equalize and regulate pressure (ventilatory function),
Drainage of middle ear secretions Protection of the middle ear from nasopharyngeal secretions, and pressures changes.

Eustachian tube dysfunction results in: Stagnation of middle ear contents, and bacterial multiplication Inflammatory response: fluid accumulation and infection Eustachian tube in children is shorter 18mm, acute angle 10 degree, flattened, wider than adult Eustachian tube. The shorter tube during infancy, facilitates reflux of bacteria-laden secretions from the nasopharinx. The acute angle reduces the protective function of the Eustachian tube. At 4/5 years of age, it became more vertical

What are the signs of an Ear infection?

AOM

Acute middle ear suppuration (suppurative or purulent OM) Has an acute onset, fever, otalgia, irritability, restless sleep. Red to yellow opaque and bulging TM with an absence of light reflex and poorly visualized landmarks. Decreased mobility on pneumatic otoscopy, light reflex

Hyperemic TM
Usually with hearing deficit

Otitis Media With Effusion (OME)

Is fluid within the middle ear space with visual fullness or high air/fluid level (fluid/bubbles) behind the TM without signs or Sx of infection Dull, opaque with minimal erythema in TM with gray/pink colored effusion behind membrane Retracted TM (negative middle ear pressure) Decrease mobility of TM on pneumatic otoscopy Hearing loss (clogged ear), speech / language difficulty, fullness in the ears

Erythematous, opaque, bulging TM Light reflex is reduced, landmarks gone

Air and fluids bubbles

TM bulging with a yellow purulent effusion

LAB: Culture and sensitivity TX: Antibiotics: First Line: Amoxicillin (Amoxil)

If not working: Amoxicillin with Potassium clavulanate (Augmentin) Cephalosporines 3rd generation: Omnicef, Ceftin Ceftriaxone: Rocephin IM 3 doses Tympanocentesis

If allergic to Penicillin: Azythromycin (Zithromax)

Clarithromycin (Biaxin)

Warm compresses on ears to relieve pain Acetaminophen or Ibuprofen for pain S. pneumonia produce a more acute course and slower resolution than H. influenza or Moraxella

Complications: Mastoiditis, meningitis. OME Hearing decrease Hearing test

Timpanostomy Tubes:
Insertion of ventilation tubes in the TM for ventilation/drainage. (Silicone) most recent development
Incision on Anterior Inferior region. Not responding to ATB treatment

Recurrent AOM infections in a period of time

*Uni or bilateral chronic OME for more than 3 months. *Conductive hearing loss in excess of 30 dB in patients with Otitis media with Effusion *Recurrent AOM infections: Children with > 3 separate episodes within 3 months Children with 4 episodes in a 6 months period or with 6 episodes in a 12 months period

AOM WITH OTORRHEA THROUGH TYMPANOSTOMY

Insertion of ventilation tubes in the TM for ventilation/drainage. Otorrhea is a major complication after their insertion

Bacterial isolated: S.pneumonia, H. influenza, M. catarrhalis, S.aureus, P. aeruginosa.

S/S: Fever, draining from ear, earache.

Tx: Due to the inflammatory response from these bacterias, it is better to combine an Atb with dexamethasone 0.1% topical. (Ciprodex Otic for patients above 6 months, Floxin) If it is necessary, can give oral Atb.

Cholesteatoma.

It is an accumulation of desquamated epithelium or keratin that often appears as a white mass behind or involving the tympanic membrane; it may be congenital or acquired. The acquired type is commonly caused by recurrent acute or chronic otitis media, but can also be iatrogenic (after tympanostomy tube placement or other procedures). Cholesteatoma can enlarge and erode the bone, including the ossicles, causing hearing loss. They can also become infected, leading to a foul-smelling discharge from the ear. A cholesteatoma needs to be removed surgically.

PHARYNGITIS-TONSILITIS
Inflammation/infection of the membrane and underlying structures of pharynx and tonsils.

Epidemiology: Streptococcal pharyngitis-more common between 5-15 years.

Viral pharyngitis: Most of cases are due to a virus, at young age, winter
Day care/kindergarten is a risk factor

Etiology: Bacterial: G-A beta hemolytic streptococcus (S. pyogenes #1) Corynebacterium diphteria Viral: Adenovirus (mcc), EBV virus, Coxsackie (herpangina) Fungi: Candida (trush)- immunosuppressed infants. Chlorinated pool: adenovirus pharyngoconjunctival fever

S/S: Symptoms: Strep: fever, sudden onset, headache, N/V, often abd. Pain. Viral: Rhinorrhea, cough, hoarseness, conjunctivitis, ulcerative lesions

Signs: Pharyngeal erythema, tonsils yellowish exsudate, cervical tender lymph Petechia in soft palate and uvula, White pustules on the palatine tonsils Dysphagia, bad breath GAS Scarletiniform rash suggest GAS Splenomegaly and generalized adenopathy, rash after ampi/amox EBV !!!!!!!

Diagnosis: Clinically Rapid Streptococcal test- Specificity 95-98% Sensitivity can be low (70-85%) Culture (gold standard) Monospot (Heterophyle Agglutination Antibody test) Viral Capsid Antigen Immunoglobin-M (vca-IgM) r/o acute EBV (serology)

Risk factors: Acute Rheumatic fever, Glomerulonephritis

Treatment: Viral: Symptomatic, nasal saline, lozenges, analgesics (Tylenol) Bacterial: 10 days course of Penicillin, Amoxil, Augmentin Alternative: one IM injection of benzathine Penicillin G 600.000/1.200.000U Pen Allergy: Erythromycin, Azythromycin, Cephalosporin

Complications: Peritonsillar Abscess, Retropharyngeal abscess

Risk factors: Acute Rheumatic fever, Glomerulonephritis

Peritonsillar Abscess
Complication of tonsillitis/pharyngitis result in abscess in tonsillar fossa

Cause: Group A B-hemolytic Strept., Staph aureus, Anaerobic bacteria

Complication: Upper Respiratory Obstruction

S/S: Fever, sore throat, dysphagia, trismus (pain when opening the mouth), Muffled voice (hot potato), Drooling, Cervical adenopathy, Unilateral peritonsillar bulging, superior soft palate with deviation of the uvula. Unilateral neck pain. Pharinx: erythematous/edematous with enlarged and exsudative tonsils.

Lab: CBC- leukocytosis with left shift, Rapid Strep test, gram stain. Cx of aspirate specimen. CT or U/S

TX: High dose IV penicillin. Surgical drainage if needed. Tonsillectomy. Clindamycin, nafcillin, oxacillin if Staph is cultured

PERITONSILLAR ABSCESS

Differential Diagnosis of a Sore Throat

VIRAL:
Infectious mononucleosis: EBV Exsudative tonsillitis, cervical adenitis, fever. Pharyngeal inflammation, axillar lymphadenopathy, splenomegaly maculopapular rashes, petecchial enanthema in palate. Common in teenagers Diagnosis: >20% atypical lymphocytes on blood smear, positive Monospot (heterophyle agglutination antibody test) viral capsid antigen IgG / IgM, EBNA

Pharyngoconjunctivitis: Adenovirus (APC) Fever, exsudative pharyngotonsillitis, conjunctivitis Herpangina: Coxsakie A virus Ulcers in anterior pillars and soft palate Common in summer Fever, vesicles in palate

Hand, foot and mouth disease: Coxsakie (vesicles on palms, soles, mouth, buttocks)

Bacterial:
Retropharyngeal (tonsillar) abscess: GABHS (S pyogenes) or St. aureus. < 2 years. Fever, stridor, drooling, neck hyperextension w/ resistance to movement, sore throat, hoarseness, trismus, asymmetric tonsillar enlargement, Ant. Cervical nodes enlarged Severe Sx: dyspnea, SOB Dx: lateral neck films increase in retropharyngeal space Tx: Emergency, hospitalization, surgical drainage, IV PCN or Clindamycin

Epiglottitis : Hemophilus type B Children: high fever, toxic, drooling, absence of cough

Fungal:
Candida (oral trush)- on low imunosuppressed patients

RETROPHARANGEAL ABSCESS