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.