Otitis Externa (Swimmer’s Ear)

Definition

•  Infection (Pseudomonas, S. aureus) of the outer ear due to breakdown of natural barriers

History

•  Summer, water exposure, cotton swab trauma, hearing aids, pain/itching/drainage

Physical Findings

•  Pain w/ movement of tragus/helix, redness/exudate in canal, white/gray debris, ±green d/c/yellow crusting, ±abscess

Treatment

•  Remove debris, dry canal w/ suction, drain abscess if present

•  Mild infections: Cleanse w/ 2% acetic acid OR sterile saline; no good evidence for these

•  Severe infections: Topical antibiotic (eg, ofloxacin) + steroid × 7 d

•  Use wick (cotton, gauze, or cellulose) 10–12 mm into canal × 2–3 d to allow med delivery

•  No swimming × 48 h, keep ear dry in shower × 1 wk (ear plugs or Vaseline gauze seal)

Disposition

•  Home. Diabetics w/ simple OE should get close f/u.

Malignant (Necrotizing) Otitis Externa

Definition: Aggressive infection (95% Pseudomonas) of the outer ear canal to skull base/bony structures, usually in diabetics/immunocompromised

History: Ear pain extending to TMJ (pain w/ chewing), swelling, otorrhea

Physical Findings: Granulation tissue, severe inflammation, may have CN palsy

Evaluation: CT scan to eval extent & intracranial cx

Treatment

•  IV ciprofloxacin. 2nd line: Ceftazidime, imipenem, OR piperacillin/tazobactam.

•  Consider amphotericin B for aspergillus in HIV/immunocompromised

Disposition: Admission for IV abx ± operative débridement

Pearls

•  10% mortality

•  Cx: Cerebral/epidural abscess, dural sinus thrombophlebitis, meningitis

Otitis Media

Definition

•  Inflammation of the middle ear

•  Acute OM: Infection (50% S. pneumoniae, 20% H. influenzae, 10% M. catarrhalis, viral 50–70%) + effusion <3 wk

•  Chronic OM: Effusion w/o infection

History: Unilateral ear pain, fever (25%), winter/spring, 2–10 y/o, URI

Physical Findings: Bulging TM, loss of light reflex/TM mobility (most sens), effusion, erythema (not sufficient alone to diagnose OM), purulent drainage

Treatment

•  Majority improve w/ no abx w/o cx

•  Pain control: Acetaminophen/ibuprofen, auralgan (topical)

•  Nonsevere acute OM: Amoxicillin to start in 2–3 d if sxs do not improve

•  Severe (<6 mo, bilateral, bulging TM, otorrhea, fever > 39, systemically ill) = immediate abx

•  Pediatric: Amoxicillin 80–90 mg/kg/d (1st line) 7–10 d, amoxicillin/clavulanate if recent abx or concurrent conjunctivitis (Pediatrics 2010;125(2):384)

•  Adult: Cefpodoxime OR cefuroxime

Disposition: Home, PCP f/u 2–3 d

Pearls

•  Cx (rare): Meningitis, mastoiditis, persistent effusion → hearing loss

•  TM perforation does not require any change in management

Mastoiditis

Definition: Extension of infection from the middle ear into the mastoid air cells

History: Unilateral ear pain, fever, HA

Physical Findings: Tenderness, erythema, fluctuance over mastoid, outward bulging pinna

Evaluation: CT scan to eval extent/destruction of the septa of the air cells, ENT consult

Treatment

•  Abx: Nafcillin/cefuroxime/ceftriaxone

•  ±Myringotomy/tympanostomy; mastoidectomy (if 50% of air cells involved)

Disposition: Admission, possible operative débridement

Pearl: Cx include meningitis, dural sinus thrombosis, brain abscess, hearing loss

HEARING LOSS

Approach

•  Nature, acuity of onset, unilateral/bilateral, associated pain/systemic sxs

Cerumen Impaction/Foreign Body

Definition: Buildup of earwax or FB in the external canal

History: Unilateral hearing loss, placement of FB in ear, drainage, pain

Physical Findings: Visualization or cerumen/FB in ear

Treatment

•  Irrigate the external canal w/ room temperature NS (cold/hot NS can cause nystagmus/vertigo/nausea), past FB if possible

•  For cerumen: Instill colace, cerumenex, or H₂O₂ for 15 min to dissolve, then irrigate

•  For FB: Alligator forceps OR cyanoacrylate (glue) to cotton-tipped applicator, hold against object for 60 sec; OR try suction for smooth objects

Disposition: D/c

Ruptured Tympanic Membrane

Definition: Rupture of the TM. Etiologies include trauma (open hand slap over ear), FB (cotton swab, pipe cleaner), barotrauma (high altitude, diving), infection (OM).

History: Pain, hearing loss

Physical Findings: Perforation of TM, ±blood in the canal

Treatment

•  Keep ear dry (earplugs during shower, no swimming)

•  Abx needed if pre-existing infection; treat as usual OM; benefit o/w unproven

•  Operative repair if > ¼ of TM damaged

Disposition

•  D/c, ENT f/u 2–4 d for audiogram; perforations usually heal in 2–3 mo

•  Admit in acute trauma w/ associated facial nerve injury, incapacitating vertigo

SORE THROAT

Approach

•  Nature, acuity of onset, duration, associated sxs (cough, fever, drooling, voice change, dysphagia, difficulty breathing)

Group A Streptococcus Pharyngitis (“Strep Throat”)

Definition: Infection of the oropharynx caused by GABHS

History: Sore throat, odynophagia, myalgias, fever; no cough

Physical Findings: Erythematous oropharynx, tonsillar exudate, cervical LAD

Evaluation

•  Centor criteria: Fever >38°C, tonsillar exudate, tender LAD, absence of cough

•  Rapid strep: Sens 60–90%, spec 90% (send culture if negative given low sens)

•  GABHS culture: 90% sens

•  Consider culture for gonorrhea (if oral sex exposure), or Monospot for EBV

Treatment

•  There are multiple conflicting guidelines (NEJM 2011;364:648). One reasonable approach:

•  If 0–1 Centor criteria met: No testing, no tx

•  If 2–3 Centor criteria met: Rapid strep, treat if positive, confirm w/ culture

•  If all Centor criteria met: No testing, yes tx

•  Abx

•  Benzathine penicillin 25000 U/kg max 1.2 million U IM ×1 OR penicillin VK, OR amoxicillin OR azithromycin. If refractory: Clindamycin, augmentin.

•  Dexamethasone 8 mg ×1 may ↓ time to pain relief (J Emerg Med 2008;35(4):363)

Disposition: D/c

Pearl: Treat w/ entire course of abx to prevent rheumatic fever/cx

Croup (Laryngotracheobronchitis)

Definition

•  Upper respiratory tract infection in children (6 mo–6 yr) usually by parainfluenza virus causing inflammation/exudate/edema of subglottic mucosa

History: Barky cough, worse at night, mild fever, following 2–3 d of URI sxs

Physical Findings: High-pitched inspiratory stridor, hoarse voice, tachycardia, tachypnea

Evaluation: Neck film if unsure of Dx → narrowing of subglottic trachea (“steeple sign”)

Treatment

•  Calm child, monitor pulse oximetry

•  Cool mist (no clear benefit)

•  Dexamethasone 0.3–0.6 mg/kg (↓ time to improvement) (Cochrane Syst Rev 2004;(1):CD001955)

•  Moderate–severe or stridor at rest: Nebulized racemic epinephrine 0.5 mL of 2.25%

Disposition

•  Admit if no improvement in ED, hypoxic, persistent stridor at rest, <6 mo old

•  Croup severity score ≤4 can usually be discharged, score >6 may require ICU

Pearl: If epinephrine given, should observe for >3 h for rebound edema

Epiglottitis

Definition

•  Inflammation of the epiglottis caused by H. influenzae >> Staph/Strep

•  Can lead to rapidly progressing, life-threatening airway obstruction

History

•  Sore throat, muffled “hot potato” voice, odynophagia, respiratory distress, fever

•  ↓ Pediatric incidence since vaccination, now more common in adult diabetics

Physical Findings: Dysphonia, stridor, drooling, sitting in tripod position

Evaluation

•  Lateral neck XR (90% sens): Epiglottis >7 mm (“thumbprint”), loss of vallecular air space

•  Adult: If nl x-ray → indirect or fiberoptic laryngoscopy (have surgical airway ready)

•  Pediatric: Avoid agitation (↑ risk of acute airway obstruction), do NOT attempt to visualize in the ED. To OR for DL w/ anesthesia & ENT/surgery.

Treatment: Abx (ceftriaxone, ampicillin–sulbactam); no proven benefit w/ steroids. Disposition: ICU admission.

Pertussis (Whooping Cough)

Definition: Lower respiratory tract infection by B. pertussis (gram-negative rod)

Presentation

•  Commonly a prolonged course (AKA “hundred-day cough”)

•  Stages: (1) Catarrhal (most infectious): 2 wk mild URI sxs; (2) Paroxysmal: 1–2 wk intense paroxysmal cough ± posttussive emesis, inspiratory “whoop”; (3) Convalescent: Several weeks of chronic cough

•  ↑ Risk if unvaccinated, but immunity wanes after ∼12 yr; ↑ morbidity if <6 mo old

Evaluation

•  Rapid PCR may be useful esp during epidemics

•  May develop PNA; consider CXR if refractory to abx

Treatment

•  Droplet precautions × 7 d, abx (only effective in catarrhal stage)

•  Azithromycin or clarithromycin, albuterol prn, treat household contacts

•  Low threshold for empiric tx in infants, pregnant, healthcare workers

Disposition: Admit <1 y/o or ill appearing

Lemierre’s Syndrome

Definition

•  Suppurative thrombosis of internal jugular vein w/ F. necrophorum

•  Septic emboli to lung are common (can be confused w/ R-sided endocarditis)

History

•  Usually previously healthy young adults’ high fever, sore throat ± cough

•  Typical course is pharyngitis that improves & then followed by severe sepsis

Physical Findings: Unilateral neck swelling, tenderness, induration

Evaluation: Contrast CT of neck

Treatment: Abx: Ampicillin–sulbactam or a carbapenem. Anticoagulation is controversial.

Disposition: Admit

SINUSITIS

Acute Sinusitis

Definition

•  Inflammation of the paranasal sinuses

•  Usually viral or allergic

•  Common bacterial etiologies: S. pneumoniae, nontypable H. influenzae, M. catarrhalis

•  Pseudomonas is seen in HIV, cystic fibrosis, or after instrumentation

•  Mucormycosis is invasive fungal sinusitis (Rhizopus) in diabetics or immunocompromised

Presentation

•  Mucopurulent d/c, postnasal drip, cough, sinus pressure, HA, ±fever

•  Typically progresses over 7–10 d & resolves spontaneously

•  Sxs >7 d, worsening course, or worsening after improving, all suggest bacterial dz

•  Consider sinusitis w/ positional HA that is worse when bending forward

•  Sphenoid sinusitis is a difficult Dx, often presents late; classically worse w/ head tilt

Evaluation

•  Clinical, no routine imaging. CT sens but not spec, can r/o cx.

•  Cx to look out for orbital cellulitis, osteomyelitis, cavernous sinus thrombosis, cerebral abscess, meningitis, frontal bone abscess (Pott’s puffy tumor)

Treatment

•  Supportive (analgesics, antipyretics, decongestants, antihistamines if allergic)

•  Decongestants: Neo-Synephrine nasal spray TID × 3 d, Afrin nasal spray BID × 3 d

•  Abx not routinely indicated. Reserve for pts w/ sxs >7 d, worsening sxs, fever, purulent d/c, or high risk for severe infection or cx.

•  Amoxicillin 500 mg PO TID × 10 d, or TMP–SMX or azithromycin

•  If no improvement: Amoxicillin–clavulanate, fluoroquinolone, clindamycin

Disposition

•  Vast majority are managed outpt

•  Admit if toxic, severe HA, high fever, immunocompromised, poor f/u

Pearl

•  Sphenoid/ethmoid sinusitis is less common than maxillary sinusitis but has significant potential cx (eg, orbital cellulites, cavernous sinus thrombosis)

EPISTAXIS

Definition: Bleeding from the nose. 90% of cases are anterior & involve Kiesselbach’s plexus on the septum. 10% of cases are posterior & arise from a branch of sphenopalatine artery.

History

•  Etiologies include URI (most common), trauma, nose picking, environmental irritants (dry air), intranasal drug use, neoplasm, FB, polyps, anticoagulation/TCP

•  RFs: Alcoholism, diabetes, anticoagulation, HTN, hematologic disorder

Physical Findings

•  Evaluate w/ nasal speculum after having pt blow nose to express clots

Evaluation

•  Can usually identify anterior source on exam; posterior bleeds are heavy, brisk, can cause airway compromise. If still bleeding after anterior packing, consider posterior source.

•  Check hematocrit if extensive/prolonged bleeding, INR if on warfarin

Treatment

•  If significantly hypertensive, consider antihypertensive to help w/ hemostasis

•  Anterior: Start w/ oxymetazoline (Afrin) 3 sprays & hold pressure for 15 min

•  May also insert cotton pledgets soaked in cocaine/lidocaine/epinephrine/phenylephrine

•  Once vasoconstricted, try to identify a focal bleeding site, then use silver nitrate cautery in ring around bleeding (will not work on active bleeding; caution on septum)

•  If bleeding has stopped, observe for 60 min; if recurs, insert a lubricated nasal tampon

•  If nasal tampon is not successful, pack the contralateral side. If still unsuccessful, pack bilaterally w/ ¼-in Vaseline gauze accordion-style.

•  Posterior: Bleeding can cause airway compromise & be life threatening

•  Commercial double balloon device OR pass Foley catheter through nose into posterior pharynx, fill balloon, hold gentle traction

Disposition

•  Anterior: D/c w/ 48 h f/u, typically w/ prophylactic abx for TSS (unproven) (eg, clindamycin, augmentin, or dicloxacillin)

•  Posterior: Admit w/ ENT consult

EYE PAIN/REDNESS

Approach

•  Ask about FB exposure, chemicals, trauma, contact lens use, freshwater exposure

•  Always check visual acuity. Use topical anesthetics (tetracaine, proparacaine) for exam.

•  Complete eye exam: Visual acuity (corrected), visual fields, external inspection, periorbital soft tissue & bones, extraocular movement, pupils (including swinging light test for afferent pupillary defect), pressure (tonometry), slit lamp (lids, conjunctiva, sclera, cornea w/ fluorescein, anterior chamber, iris, lens), funduscopy

Acute Angle-closure Glaucoma

Definition: Increased IOP due to ↓ aqueous outflow. Generally due to reduction in the angle of the anterior chamber in setting of the dilated pupil pushing against trabecular meshwork.

History

•  Sudden onset of severe unilateral pain, HA, nausea, vomiting, blurry vision, halos

•  May be triggered by dim light, mydriatic drops, stress, sympathomimetics

Physical Findings

•  Unilateral perilimbal eye injection, ↓ VA, “steamy” (cloudy) cornea, nonreactive midsize pupil (5–7 mm), shallow anterior chamber, ↑ IOP >21 mmHg, firm globe

Treatment

•  Immediate optho consult

•  Reduce aqueous production: Timolol 0.5% 1–2 drops q30min (avoid if CI to systemic βB) or acetazolamide 500 mg IV, then 250 q6h

•  Facilitate aqueous outflow (miotics): Pilocarpine 2% 1 drop q15min until pupil constricts

•  Decrease vitreous volume (osmotics): Mannitol 1–2 mg/kg IV over 30–60 min

Disposition

•  Per optho recommendations. Admit for intractable vomiting or need for systemic agents.

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VI: RENAL & GENITOURINARY VIII: DERMATOLOGY XVII: AIRWAY MANAGEMENT X: ENVIRONMENTAL XVI: TOXICOLOGY XVIII: TRAUMA