Pharyngitis

What are the common causative agents for pharyngitis?

Answer

Common

• Acute pharyngitis, whether febrile or not, is generally caused by viruses.
  • In enteroviral infection (herpangina)
  • Adenovirus infection (pharyngoconjunctival fever) 
  • Epstein-Barr virus infection (infectious mononucleosis)
• Group A B-hemolytic Streptococcus is the only common bacterial causative agent and except during epidemics it accounts for probably fewer than 15% of cases.

What are the rare causative agents for pharyngitis?

Answer

Rare

• Mycoplasma and Arcanobacterium hemolyticum 
• Corynebacterium diphtheria
• M mixture of anaerobic bacteria and spirochetes
• Neisseria gonorrhoeae infection

Answer

• Group A streptococcus (Scarlet fever) 
• Arcanobacterium hemolyticum
• Corynebacterium diphtheria
• Anaerobic pharyngitis (Vincent's angina)
• Adenovirus
  • Epstein-Barr Virus

List  agents that cause exudative pharyngitis associated with rash?

Answer

• Group A streptococcus (Scarlet fever) 
• Arcanobacterium hemolyticum
• Epstein-Barr Virus

Under what circumstances will you suspect rare etiology for pharyngitis?

Answer

• Mycoplasma 
  • Associated with pneumonia
• Corynebacterium diphtheria
  • unimmunized
  • low socioeconomic groups
  • Membrane in throat
• Anaerobic bacteria and spirochetes
  • Foul odor
• Neisseria gonorrhoeae infection
  • Sexually active age group
  • Homosexuals

How is infection transmitted in pharyngitis?

Answer

Transmission 

• The common etiologic agents are spread by respiratory droplets and via contaminated hands.
• Food-borne outbreaks of streptococcal disease can occur.
• Kissing and transfer of infected saliva in infectious mononucleosis
• Oral sex with Neisseria gonorrhoeae infection

Answer

• With respiratory virus infections, such as adenovinis and coxsackie virus, there is evidence that direct invasion of pharyngeal mucosa occurs.
• The usual pathologic changes occurring in viral pharyngitis are edema and hyperemia of the tonsils and the pharyngeal mucous membrane.
•  An inflammatory exudate may be present with adenovirus and EBV virus infections; with the latter, nasopharyngeal lymphoid hyperplasia also occurs.

Answer

• The events leading to invasive streptococcal infection of the pharynx and tonsil are also not well understood. 
• Pharyngeal carriage of S. pyogenes is commonly observed in asymptomatic people. 
• Factors that influence the balance between colonization and invasive infection may include natural and acquired host immunity and interference among the bacteria present in the oropharynx. 
• Streptococcus pyogenes elaborates a number of extracellular factors, including erythrogenic toxin, hemolysins, streptokinase, deoxyribonuclease, proteinase, and hyaluronidase, which are of known or possible pathogenic importance. 
• Certain M serotypes (1,2,4, and 12) of streptococci have been most frequently isolated from patients with uncomplicated pharyngitis, and others (1,3, and 12) from patients with serious invasive infection. 
• Scarlet fever results from infection with a streptococcal strain that elaborates streptococcal pyrogenic exotoxin (erythrogenic toxin). Toxin production is dependent on lysogeny of the infecting streptococcus by a temperate bacteriophage.

Answer

The primary objectives in the diagnosis of acute pharyngitis, are to distinguish cases of common viral etiology from those due to S. pyogenes and to detect and identify the occasional case due to an unusual or rare cause. 

• Streptococcal pharyngitis.
  • Throat culture  (48 hours) is the preferred method for diagnosing streptococcal pharyngitis.
  • Rapid streptococcal  antigen screen  (45 minutes) is  highly specific but the sensitivity is approximately 85%.
  • Serum antibody titers do not rise until convalescence and are thus of no help in short-term management.
• Infectious mononucleosis.
  • Heterophile antibody test (monospot test) is used to diagnose suspected infectious mononucleosis.
• Diphtheria
• Neisseria gonorrhoeae

Answer

•  Rheumatic fever
  • occurs in about 3% of times following Streptococcal pharyngitis.
  • is a non-suppurative sequela of Streptococcus pyogenes infections. 
  • It occurs approximately 3 weeks after streptococcal pharyngitis
  • M protein has been found to be antiphagocytic and it also has epitopes which are antigenically similar to one found in the cardiac myosin and sarcolemmal membrane proteins.
  • Acute RF is thought to be an auto-immune disease.
  • Antibodies directed against M protein cross-react with cardiac tissue. 
  • These antibodies bind to the cross-reactive antigens in muscle and damage the muscle tissue. Other group A strep antigens may also cross-react with other cardiac antigens causing damage to the heart valves. 
• Acute glomerulonephritis 

are late complications of streptococcal infection and are related to immunologic response to group A streptococcal, infection.

What is your strategy for pharyngitis therapy?

Answer

Since even exudative tonsillitis is usually of viral origin, for which there is no specific therapy, the use of antibiotics should be guided by the results of antigen detection tests or cultures, unless there are strong clinical and epidemiologic grounds to suspect a streptococcal infection.

Therapy of Streptococcal pharyngitis 

• Oral penicillins, cephalosporins, erythromycin and clindamycin are effective against Group A streptococcus.
• Sulfonamides are ineffective against group A streptococcal pharyngitis.
• Streptococcal pharyngitis is best treated orally with penicillin (125-250 mg of penicillin V three times daily for 10 days). 
• This usually produces prompt clinical response with defervescence within 24 hr. and shortens the course of illness by an average of 1.3 days.
• Administration of a single intramuscular injection of 600,000 - 1.2 million units of benzathine penicillin G is a satisfactory alternative.
• A streptococcal carrier is not at risk for rheumatic fever, is unlikely to transmit infection, and does not require treatment unless there is a history of rheumatic fever in the patient or a sibling. 
• A few children require antibiotic prophylaxis against streptococcal. disease, such as those with past history of rheumatic fever.
• In penicillin allergic patients, erythromycin is the therapy of choice.
• Symptomatic therapy (Tylenol, Fluids and electrolytes)
• Complications ( Acute glomerulonephritis, Carditis etc)

Answer

• Decrease duration of symptoms
• The primary rationale for detection and treatment of streptococcal pharyngitis  is to prevent the subsequent development of rheumatic fever. 
• Treatment of group A streptococcal pharyngitis as long as 9 days after onset is still effective in the prevention of rheumatic fever.
• There is no convincing evidence that treatment affects the incidence or severity of acute glomerulonephritis.

Otitis media

What is otitis media?

Answer

• Otitis media is  inflammation of the middle ear
• is defined by the presence of fluid in the middle ear 
• accompanied by signs or symptoms of acute illness. 

What age group is predisposed to otitis media and why?

Answer

• The peak incidence occurs in the first 3 years of life. 
  • The eustachian tube wall lacks stiffness in infants and young children. 
• The disease is less common in the school-aged child, adolescents, and adults 
  • Older individuals have eustachian tubes with stiffer walls which are less likely to collapse.

Is bacteriology different between adults and children?

Answer

• No
• The bacteriology and therapy of otitis media are similar to those in children.  

What are the long term sequelae of otitis media in childhood?

Answer

• hearing loss
• cholesteatoma
• adhesive otitis media
• chronic perforation of the tympanic membrane

What are the predisposing factors for Otitis media?

Answer

Predisposing factors

• The vast majority of children have no obvious defect responsible for severe and recurrent otitis media
• The eustachian tube wall lacks stiffness in infants and young children. 
•  In addition, as the eustachian tube grows with an individual, a small amount of swelling due to an upper respiratory infection is less likely to occlude the tube or cause significant tube dysfunction.
• A small number have 
  • Eustachian tube dysfunction include anatomic abnormalities (Down's syndrome, cleft palate, cleft uvula, submucous cleft)
  • alteration of normal physiologic defenses (patulous eustachian tube)
  • congenital or acquired immunologic deficiencies. 
•  Breast-feeding for 3 or more months is associated with a decreased risk of  acute otitis media in the first year of life. 
•  Race and ethnicity provide additional data suggesting a genetic basis for recurrent middle ear infections; Native Americans, Alaskan and Canadian Eskimos, and Australian aborigines have an extraordinary incidence and severity of otitis media.
• The introduction of infants into large day care groups increases the incidence of respiratory infections, including otitis media. 
• Passive smoking documented by a biochemical marker, the serum nicotine level, increased the incidence of new episodes of otitis media with effusion and the duration of effusion. 

How do you classify otitis media?

Answer

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

What are the common etiologic agents for otitis media?

Answer

Etiologic agents 

The most common causes of otitis media are

• Streptococcus pneumoniae (40 %)
• Hemophilus influenzae (30%)
• Moraxella catarrhalis (15%)

Group A streptococcus and Staphylococcus aureus are rare causes of otitis media

Viruses

• Virologic and epidemiologic data suggest that viral infection is frequently associated with acute otitis media. 
• Respiratory syncytial virus, influenza virus, enteroviruses, and rhinoviruses were the most common viruses found in middle ear fluids.
• Many patients with virus in middle ear fluid have a mixed viral-bacterial infection.

Mycoplasma, Chlamydia, and Unusual Organisms rarely.

What is the pathogenesis of otitis media?

Answer

Pathogenesis

• The middle ear is part of a continuous system that includes the nares, nasopharynx, and eustachian tube medially and anteriorly, and the mastoid air cells posteriorly. 
• These structures are lined with a respiratory epithelium that contains ciliated cells, mucus-secreting goblet cells, and cells capable of secreting local immunoglobulins.
• The eustachian tube is the structure which plays a major role in the development of acute otitis media. 
  • The eustachian tube has at least three physiologic functions with respect to the middle ear: 
    • protection of the ear from nasopharyngeal secretions
    • drainage into the nasopharynx of secretions produced within the middle ear
    • ventilation of the middle ear to equilibrate air pressure with that in the external ear canal
  • When one or more of these functions is compromised, the results may be the development of fluid and infection in the middle ear. 
• Viral or allergy
  • Viral upper respiratory infection or allergy causes inflammation and edema in the eustachian tube, impairing its normal functions. 
  • When ventilation of the middle ear is lost, oxygen is absorbed from the air in the middle ear and negative pressure results.
  • This negative pressure draws bacteria into the middle ear. 

What are the symptoms of otitis media?

Answer

• ear pain
• ear drainage
• hearing loss
• nonspecific, such as fever, lethargy, or irritability
• Vertigo, nystagmus, and tinnitus may occur

Describe the physical findings of otitis media.

Answer

• Redness of the tympanic membrane is an early sign of otitis media, but erythema alone is not diagnostic of middle ear infection since it may be caused by inflammation of the mucosa throughout the upper respiratory tract. 
• The presence of fluid in the middle ear is determined by the use of pneumatic otoscopy, a technique that permits an assessment of the mobility of the tympanic membrane. 
  • Fluid persists in the middle ear for prolonged periods after the onset of acute otitis media even though symptoms usually resolve within a few days after the initiation of antimicrobial therapy. 
• The motion of the tympanic membrane is proportional to the pressure applied by gently squeezing and then releasing the rubber bulb attached to the head of the otoscope. 
  • Normal mobility is apparent when positive pressure is applied and the tympanic membrane moves rapidly inward; with release of the bulb and the resulting negative pressure, the membrane moves outward.
  • Fluid or high negative pressure in the middle ear dampens the mobility of the tympanic membrane.
  • Tympanometry uses an electroacoustic impedance bridge to record compliance of the tympanic membrane and
    middle ear pressure. 
  • This technique presents objective evidence of the status of the middle ear and the presence or absence of fluid.
•   hearing loss of variable severity. 
•  lower in tests of speech, language, and cognitive abilities than do their disease-free peers. 

What are the complications and long-term consequences  of otitis media?

Answer .

• Mastoiditis was a very common infection in the pre-antibiotic era, and results from spread of infection from the middle ear to the mastoid air cells of the temporal bone
• A bulging tympanic membrane will occasionally spontaneously perforate, with purulent discharge seen from the ear canal. 
  • These perforations spontaneously heal and cause no long-term damage. 
• Persistent middle ear effusion may follow an acute otitis media, and result in hearing loss and language delay in young children. Intracranial infections such as meningitis can occasionally occur. 
• Chronic otitis media may result in formation of a cholesteatoma, an overgrowth of squamous epithelium in the middle ear which must be removed by resection to restore proper hearing.

What is tympanocentesis and what are the indications?

Answer

 The only way to determine the specific pathogen in the middle ear is to perform  tympanocentesis . It is not commonly performed, and antibiotic therapy is generally used empirically. Tympanocentesis should be considered in selected patients:  

• the patient who is critically ill at the onset
• for patients who fail to respond to therapy, in 48 to 72 hours and is toxic
• for neonates in whom the bacteria causing, otitis media may be different (group B streptococcus and gram-negatives)
• for immunocompromised patients 

Answer

Therapy 

• Amoxicillin remains the drug of choice for the treatment of acute otitis media. 
  • It will cover non-penicillin resistant Streptococcus pneumoniae, and beta-lactamase negative strains of Hemophilus influenzae and Moraxella catarrhalis.
  • With appropriate antimicrobial therapy, most children with acute otitis media are significantly improved within 48 to 72 hours. If there is no improvement, the patient should be reexamined. 
• Penicillin resistant Streptococcus pneumoniae. 
  • If a patient fails to respond, he may require treatment with a second-line agent for presumed beta-lactamase positive organisms.
  • In these patients, tympanocentesis to establish a bacteriologic diagnosis is helpful. 
  • Optimal treatment of penicillin-resistant S. pneumoniae otitis media is currently unclear, but may include drugs such as IM ceftriaxone or oral clindamycin.
• Antimicrobial agents are indicated for treatment of AOM
• Acute otitis media can be treated with a 5- to 7-day course of antimicrobial agents in certain children 2 years of age or older.
• Younger children and children with underlying medical conditions, craniofacial abnormalities, chronic or recurrent otitis media, or perforation of the tympanic membrane, should be treated with a standard 10-day course.
• Persistent middle ear effusion (OME) for 2 to 3 months after therapy for AOMis expected and does not require retreatment.

How do you treat OME?

Answer

• Antimicrobial agents are not indicated for initial treatment of OME.
• Treatment may be indicated if effusions persist for 3 months or more. 

What is the role of decongestants, antihistamines, and corticosteroids in therapy of otitis media?

Answer.

Decongestants, Antihistamines, and Corticosteroids.: no significant evidence of efficacy of any of these preparations.

Define and describe the characteristics of chronic otitis media.

Answer

Chronic Otitis Media

• The term chronic otitis media includes recurrent episodes of acute infection and a prolonged duration of middle ear effusion usually resulting from a previous episode of acute infection. 

What is the role of chemo prophylaxis for otitis media?

Answer

• A reduction of episodes of acute febrile illnesses due to otitis media occurred. 
•  Children should be considered for prophylaxis if they have had two episodes of acute otitis media in the first 6 months of life or, in older children, three episodes in 6 months or four episodes in 1 year. 
• Amoxicillin, 20 mg/kg, or sulfisoxazole, 50 mg/kg, may be administered once a day.
• The physician who chooses to use chemo prophylaxis to prevent acute recurrent disease must examine the patient at approximately 1-month intervals for middle ear effusion. 

What is the role of immunoprophylaxis for otitis media?

Answer

• immunoprophylaxis (the use of vaccines or immunoglobulin)
  • Pneumococcal vaccines have been evaluated for the prevention of recurrences of acute otitis media in children. 
  •  As in previous studies, children younger than 2 years had unsatisfactory responses to single-dose regimens. 
  • The vaccine reduced the number of episodes of acute otitis media due to types of S. pneumoniae present in the vaccine, but the reduction was not sufficient to alter the experience of the children with middle ear infections. 
  • The basis for failure of the vaccine was due to the poor immunologic response to the polysaccharide antigens in the young infants enrolled in the trials.
  •  The data suggested that the vaccine was likely to be more effective in children older than 2 years.
  •  Vaccines composed of pneumococcal capsular polysaccharides conjugated to proteins increased immunogenicity in young infants and are currently undergoing clinical evaluation.
  • Because of the importance of respiratory viruses in the pathogenesis of acute otitis media, viral vaccines could be of preventive value.
  •  Influenza virus vaccine has been documented to decrease the incidence of acute otitis media in children in day care in Finland and North Carolina. 

What is the surgical management of otitis media?

Answer

• Myringotomy
  • Myringotomy, or incision of the tympanic membrane, is a method of draining middle ear fluid. 
  • Myringotomy offers quick pain relief when a patient is in severe pain from otitis media. 
  • Today, the use of myringotomy is limited to the relief of intractable ear pain, hastening resolution of mastoid infection, and drainage of persistent middle ear effusion that is unresponsive to medical therapy.
• Adenoidectomy
  • Enlarged adenoids may obstruct the orifice of the eustachian tube in the posterior portion of the nasopharynx and interfere with adequate ventilation and drainage of the middle ear. 
• Tympanostomy tubes resemble small collar buttons.
  • They are placed through an incision in the tympanic membrane to provide drainage of fluid and ventilation of the middle ear. 
  • The criteria for the placement of tubes include persistent middle ear effusions unresponsive to adequate medical treatment over a period of 3 months and persistent negative pressure. 
  • Hearing improves dramatically after placement of the ventilating tubes.
  • The tubes have also been of value in patients who have difficulty maintaining ambient pressure in the middle ear such as would occur due to barotrauma in airline personnel.
  • The liabilities of the placement of tubes include those of anesthesia associated with the procedure, persistent perforation, scarring of the tympanic membrane, the development of cholesteatoma, and otitis media caused by swimming with ventilating tubes in place, but these occur infrequently.

What are the preventive strategies for otitis?

Answer

Prevention 

•  Recurrences may be prevented in patients with recurrent otitis media by either placement of tympanostomy tubes (which provide continuous ventilation of the middle ear by means of a plastic ventilation tube which has one end in the middle ear and the other end in the external ear canal) or prophylactic antibiotic therapy. 
• Both pneumococcal vaccine and influenza vaccine have been shown to be effective in reducing the number of episodes of otitis media in otitis-prone patients. 
  • Unfortunately, currently available pneumococcal vaccine is not effective in children less than 2 years of age, the group at greatest risk of developing recurrent otitis media. 
• Otitis media due to H. influenzae is associated with nontypable strains in the vast majority of patients. 
• Antimicrobial prophylaxis should be reserved for control of recurrent AOM, defined as 3 or more distinct and well-documented episodes per 6 months or 4 or more episodes per 12 months.

Sinusitis 

How do you classify sinusitis?

Answer

• Infectious
  • community or hospital setting
  • the immune status of the patient
  • viral, bacterial, or fungal cause
• Non infectious

What are the predisposing factors for sinusitis?

Answer

• Allergy
• Swimming
• Nasal obstruction due to polyps, foreign bodies, and tumors
• Other less common risk factors are immune deficiencies such as 
  • agammaglobulinemia  
  • acquired immunodeficiency syndrome
  • abnormalities of white cell function as found in chronic granulomatous disease
  • structural defects, especially cleft palate
  • disorders of mucociliary clearance including 
    • cilial dysfunction 
    • cystic fibrosis.

What are the etiologic agents for acute community-acquired sinusitis?

Answer

•  The most common causes of sinusitis are the same as for otitis media: 
  • Streptococcus pneumoniae (40%)
  • Hemophilus influenzae (30%)
  • Moraxella catarrhalis (15%)
•  Other streptococcal species including Streptococcus intermedius, Streptococcus pyogenes, and other alpha-hemolytic streptococci; M. catarrhalis; Staphylococcus aureus; and anaerobic bacteria  each account for an additional proportion of cases.
•  Most sinusitis due to anaerobic bacteria arises from infection of the roots of the premolar teeth, thus representing a pure bacterial infection.
• Staphylococcus aureus and anaerobes are seen in chronic sinusitis and are often the pathogens seen in intracranial extension of infection. 
• Chlamydia pneumoniae has been identified in patients with respiratory illness that includes features of sinusitis.
•  Only approximately 60% of sinus aspirates in suspected cases of sinusitis yield bacteria.
  • The cause of the culture-negative cases is not clear, but undoubtedly, many have a viral cause. 

What are most common agents causing nosocomial sinusitis?

Answer

•  Nosocomial sinusitis has been most often associated with Staph. aureus, Pseudomonas Proteus mirabilis and is often polymicrobic.
• Pseudomonas aeruginosa is the most frequent isolate in sinus aspirates from patients with cystic fibrosis.  
• Legionella pneumophila was identified in sinus tissue from a patient with acquired immunodeficiency syndrome

What do you know about fungal sinusitis?

Answer

• Fungi are a well-established cause of occasional cases of acute community-acquired sinusitis. 
• Also, fungal infections occur in hospitalized patients and those with other diseases such as diabetes mellitus. 

What are the non-infectious causes for sinusitis?

Answer

Noninfectious

• chemical irritation
• nasal and sinus tumors
• foreign bodies 
• Wegener's granulomatosis
• midline granuloma.

What is the normal function of sinuses?

Answer

Physiology/Normal function

• reduce the bony mass and weight of the skull
• participate in warming and humidification of inspired air
• add resonance to the voice.

The paranasal sinuses, although directly connected to the nasal passages, which are colonized with bacteria,  are themselves sterile under normal conditions. 

Describe the anatomy of sinuses.

Answer

Anatomy of the sinuses 

• Ethmoid and maxillary sinuses are formed in utero and are present at birth.
• Frontal sinuses are not present until age 5-6 years.
• The ostia or outflow tract of the maxillary sinus is high on its medial wall; this positioning creates a situation where drainage is against gravity-this explains part of the reason why maxillary sinuses are so commonly infected.
• The ethmoid sinus is separated from the orbit by the paper-thin, fenestrated lamina paprycea bone. 
  • It is very easy for pus to get from the ethmoid sinus into the orbit. 
  • Therefore, sinusitis in the ethmoid is most likely to lead to orbital cellulitis and abscess.
  • The anterior ethmoid and frontal sinuses also empty into the middle meatus. 
• The sinus is lined with ciliated pseudostratified epithelium and is covered with a mucous blanket.
• The epithelium is well supplied with goblet cells 

What is the pathogenesis of sinusitis?

Answer

Pathogenesis 

• The nasal passages and nasopharynx are colonized with the same bacterial species that cause sinusitis, and, undoubtedly, the bacteria in these areas serve as the reservoir for this infection.
• Three factors are important in the normal functioning of the sinuses, to keep these cavities sterile: 
  • the ostia (through which the sinus drains into the nose) must be patent
  • the cilia must be functioning properly
  • the secretions of the mucosa must be thin and not very copious
•  An upper respiratory infection or a allergy may alter all of these factors: ostia may become occluded by mucosal inflammation and swelling, cilia may not function properly in the presence of inflamed mucosal tissue, and the secretions may become thick and copious, overpowering the ability of the cilia to direct the secretions toward the ostia and into the nose.
  • It has been estimated that 5- 10 % of upper respiratory infections in early childhood are complicated by acute sinusitis. 
  • Since children average 6-8 colds per year, sinusitis is a very common problem in pediatrics.
• Sneezing, coughing, and nose blowing may create pressure differentials that deposit these bacteria into the sinuses. 
• Once bacteria are deposited into the cavity of an obstructed sinus, growth conditions are favorable.
• However, granulocyte phagocytosis may be impaired by the reduced oxygen tension present in an obstructed sinus.

What are the clinical features of bacterial sinusitis?

Answer

Clinical features of bacterial sinusitis 

• nasal discharge
• daytime cough without improvement for 10 to 14 days
• temperature of 39°C (102°F) or higher
• facial swelling, facial pain 
• Voice change
• Hyposmia may also be present. 

Describe the clinical course of predisposing viral or dental extraction leading to sinusitis?

Answer

• Following  Viral bacterial/Acute sinusitis
  
  • Most cold patients are improved by the end of a week, so that worsening or continuing symptoms raise the suspicion of a complication.
  • the clinical features of the illness reflect the dual nature of the infection.
  •  In most cases, it is not possible to separate the clinical features of viral from those of bacterial sinusitis.. 
  • Patients with bacterial infection of the sphenoid sinus have presented with severe frontal, temporal, or retroorbital headache that radiates to the occipital region and hypesthesia or hyperesthesia of the ophthalmic or maxillary dermatomes of the fifth cranial nerve. 
• Following Dental infection
  • When the sinusitis follows dental infection, molar pain and a foul odor to the breath are characteristic features.

How do complications of sinusitis present?

Answer

• Lethargy and the clinical findings of cavernous sinus or cortical vein thrombosis may also be present as well as signs of orbital cellulitis and abscess. 
• With severe frontal sinusitis, pus may collect under the periosteum of the frontal bone causing swelling and edema of the forehead, which is known as Pott puffy tumor. 

What are the clinical features of nosocomial sinusitis?

Answer

• Nosocomial sinusitis of bacterial origin has features that are similar to those of Sinusitis, but because many patients with this condition are severely ill or unconscious, typical clinical features may not be obvious. 
• Nosocomial sinusitis should be suspected when fever of undetermined origin occurs in patients with risk factors such as nasal intubation. 

What are the clinical features of chronic sinusitis?

Answer

• Signs of chronic infection
• Refractory productive cough
• Post nasal drip
• Worsening cough in supine position
• Acute exacerbations

Describe the characteristics of fungal sinusitis?

Answer

• Patients with community-acquired fungal sinusitis usually present with masses, proptosis, and bony erosion due to pressure effects. 
• The invasive form of fungal sinusitis typically presents as a rapidly progressive infection.
• Acute fungal sinusitis can resemble bacterial sinusitis but occurs in patients with serious underlying diseases and has a marked propensity for invading through contiguous bone into the orbit, brain, and hard palate 
• Chronic fungal sinusitis has three forms: 
  • invasive sinusitis
    • Invasive infection resembles squamous carcinoma, Wegener's granulomatosis, midline granuloma, and rhinoscleroma.
  • fungus ball of the sinus 
    • Fungus ball of the sinus is a benign mass of hyphae, usually Aspergillus. 
  • allergic fungal sinusitis
    • Allergic fungal sinusitis presents as chronic sinus pain and an expansile mass of inspissated mucus, eosinophils, and hyphae that can deform outward the bony wall between the ethmoid sinus and the orbit or between the maxillary sinus and the nasal cavity. 
    • Patients usually have a history of allergic rhinitis and nasal polyps.

What are the complications and  long term consequences of  sinusitis?

Answer

Complications and long-term consequences 

• Intracranial
  • meningitis
  • brain abscess 
  • subdural empyema
  • cavernous sinus
  • cortical vein thrombosis
• Orbital complications are most common in young children and include 
  • orbital cellulitis
  • subperiosteal abscess
  • orbital abscess
• Respiratory
  • Sinusitis is also associated with the onset or exacerbation of asthma and bronchitis. 
  • Sino pulmonary disease is a well-recognized combination, especially when the condition has become chronic

What is the diagnostic strategy for sinusitis?

Answer

• Para nasal sinuses are not accessible to direct examination and to noninvasive sampling for microbial culture. 
• Physicians have to rely on clinical findings that are either insensitive or nonspecific. 
• Diagnostic evaluation should include a history and an examination of the pharynx, nose, ears, sinuses, teeth, and chest.
• Information should be obtained about coryzal and influenzal illnesses, respiratory allergies, toothache, and other dental complaints. 
• Because of its superior sensitivity, CT scanning of the sinuses has largely supplanted conventional radiography as the imaging method of choice. 
• Imaging studies are not recommended for the routine diagnosis of community-acquired sinusitis because of their lack of specificity. 
• Nasal cultures are of no use in determining the bacterial agent because of the large number of bacteria which colonize the nose
• Sinus aspiration is occasionally performed, but generally therapy is aimed at covering the most likely pathogens, similar to otitis media.
  • Sinus puncture is a relatively painless and safe procedure when performed by an experienced operator, although it is not appropriate for routine clinical use.
  • Immunocompromised patients may require a diagnostic procedure, as they may develop sinusitis with a variety of unusual organisms including fungi.
• It is not possible to enter the sinus cavities with an endoscope by way of the natural ostia and avoid nasal flora contamination..

Answer

Therapy 

• Since the pathogens of acute otitis media and sinusitis are similar, the antimicrobial agent used are also similar.
• Antimicrobial therapy is usually selected on an empirical basis because sinus aspirate culture results are not available in the usual clinical setting. 
• Amoxicillin remains the drug of choice for uncomplicated sinusitis.
• With a 10-day course of an antimicrobial with an appropriate spectrum used at the correct dose, the symptoms of acute community-acquired sinusitis usually improve after 2 or 3 days of treatment and are generally resolved by 7 to 14 days with bacteriologic cure rates of 90% or higher 
• The beta-lactam antimicrobials that continue to show the best activity against intermediately resistant strains of pneumococci and are also effective against beta-lactamase-producing H. influenzae and M. catarrhalis are amoxicillin-clavulanate, cefpodoxime, cefdinir, and cefuroxime.
•  Also, the new quinolones provide excellent activity against pneumococci and other sinusitis pathogens. Of these drugs, amoxicillin-clavulanate, cefdinir, cefuroxime, and levofloxacin have been shown to be effective in pre- and post-therapy sinus puncture clinical trials in patients with Sinusitis. 
• There are no pre- and post sinus aspirate culture data on the effectiveness of longer or shorter courses of treatment for Sinusitis.
• However, it is important to be aware that patients with acute sinusitis may have substantial symptomatic improvement despite the persistence in the sinus of purulent material containing high titers of bacteria. 
•  Severe infection or in whom intracranial or orbital extension of infection
  •  intravenous therapy should be started with vancomycin and ceftriaxone or cefotaxime until the results of culture and sensitivity testing are available for directing treatment. 

What is the treatment for nosocomial sinusitis?

Answer

• Antimicrobial treatment of patients  should be directed by culture and sensitivity information when available, or when empirical, should cover the usual pathogens responsible for these infections.

How would you treat fungal sinusitis?

Answer

• Community-acquired fungal sinusitis in persons with normal immunity surgical debridement 
• Complicated cases and patients with immunodeficiencies suspected of having invasive infection : appropriate surgical and antifungal therapy.

Describe the symptomatic therapy of sinusitis?

Answer

Decongestants, Topical steroids and mucoevacuants are of no proven value.

What are the preventive strategies for sinusitis?

Answer

Prevention

• Preventing colds 
• The promotion of decongestion and drainage is of limited value
• Prophylactic antimicrobial administration to prevent recurrent Sinusitis is not recommended 
• Avoiding nasal intubation has been shown to be effective in reducing the incidence of nosocomial sinusitis. 

Cervical adenitis in children

Answer

Cervical adenitis is a condition characterized by inflammation of one or more lymph nodes of the neck. The most common cause of cervical adenitis is infection. The most common infectious agents are viral. 

Though cervical lymphadenitis can be a manifestation of focal viral infections of the oropharynx or respiratory tract, often it is part of a more generalized reticuloendothelial. response to systemic infection. 

• Viruses commonly associated with prominent cervical adenitis include 
  • Epstein Barr virus (EBV) 
  • Cytomegalovirus (CMV) 
  • HIV
• Acute unilateral cervical adenitis is associated in the majority of cases with 
  • Staphylococcus aureus
    • more frequent fluctuance and longer duration of symptoms. 
  • Streptococcus pyogenes
• Neonatal cervical adenitis is generally due to S. aureus; however, a cellulitis-adenitis syndrome caused by group B streptococci has been described. Bacteremia occurs in many of these neonatal patients.
• Anaerobic bacteria may cause lymphadenitis usually in association with dental caries and periodontal disease.
• Recurrent cervical adenitis associated with unusual pathogens (Enterobacteriaceae, fungi, Staphylococcus epidermidis) is often associated with a defect in granulocyte function.
• Subacute or chronic cervical adenitis, which develops slowly over two or more weeks is most often caused by cat-scratch disease or mycobacterial infection, and less frequently due toxoplasmosis.
  • Bartonella henslae is the presumptive etiologic agent of cat-scratch disease.

Answer

• The lymphatic system of cervical area serves as a line of defense against infections of the upper respiratory tract, teeth or the soft tissue infections of the face and scalp.
•  Microorganisms that invade these glands are trapped and destroyed by phagocytic cells. 
• The initial histologic response is one of swelling and hyperplasia of sinusoidal lining cells and infiltration of lymphocytes.
• The major portals of entry of the microorganisms that spread to the cervical lymph nodes are upper respiratory tract, mouth, teeth and skin.

Answer

• Staph aureus, anaerobes and atypical mycobacteria are normal inhabitants of upper respiratory tract.
• Group A Streptococcus, M. tuberculosis and C. diphtheria infection of cervical lymph nodes result from contact with infected humans by way of airborne droplets. 
• Atypical mycobacteria usually enter through the oral mucosa. Organisms ingested in infected meat or through unpasteurized milk may enter the peripharyngeal lymphatics through a break in mucous membranes or secondary to blood stream.
• EBV and CMV are acquired through contact with infected saliva and other body fluids.
• Acute infection following trauma or impetigo or other cutaneous lesions often is due to S. aureus or Group A Streptococci.
• Chronic infection of regional lymph nodes associated with an inoculative skin lesion (lymphocutaneous syndrome) suggest infection due to cat-scratch disease, tuberculosis, nocardia, tularemia, sporotrichosis or cutaneous mycobacterial infection.

What are the clinical characteristics of lymph nodes that you should evaluate when they are palpable?

Answer

• Localized or diffuse
• Systemic (Lymph nodes, Liver, spleen, marrow) or lymph nodes only
• Tenderness, Warmth
• Soft, firm, hard
• Matting, adherence to skin, adherence to deeper tissues
• Fluctuation
• Drainage sites
• Mode of onset
• Associated findings
• Duration

What are the common causes for chronic adenitis?

Answer

Chronic adenitis

• If the adenopathy is of longer duration (subacute or chronic) and the involved nodes are well localized, non-tender, a granulomatous infection or malignancy is most likely. 
• A history of exposure to TB, insects and animals may help clarify the most likely etiology. 
• If the adenopathy is generalized and particularly if mediastinal nodes are involved, tuberculosis and histoplasmosis are more likely.
• If the adenopathy is unilateral, an atypical mycobacterial infection or cat-scratch disease is more likely.

Describe the characteristics of adenopathy secondary to cat scratch disease?

Answer

• Cat-scratch disease is sometimes associated with an indolent granulomatous papule, vesicle or ulcer, however, the primary lesion may disappear by the time adenitis is seen..
• The inflammation generally involves a single node or a single group of nodes. 
• Suppuration occurs in over half of the patients.
• Granulomatous inflammation by palisading epithelioid cells is seen in cat-scratch disease.

Describe the characteristics of adenopathy secondary to atypical tuberculosis?

Answer

• Cervical lymphadenitis attributed to atypical mycobacteria is much more common in the young child than that caused by M. tuberculosis.
• is generally localized to a single tonsillar or submandibular node. 
• In mycobacterial infection the nodes are often non-tender, the skin overlaying the node may develop a purple color, the overlying skin may become thinner if untreated. 
• Suppuration develops in about half the cases, followed by skin adhering to the node and spontaneous drainage resulting in fistula formation.
• Biopsied lymph nodes reveal granulomatous inflammation with caseating necrosis in mycobacterial and fungal infections. 

What is your diagnostic strategy for cervical adenitis?

Answer

Diagnosis

• Establishment of specific cause whenever the infection does not respond to empiric treatment is important. 
• Aspiration of the affected, inflamed node is a valuable diagnostic test. 
• The aspirate should be sent for
  • Gram and acid-fast stains
  • Aerobic, anaerobic, mycobacterial and fungal cultures.
• Chronic adenitis: The following tests are recommended 
  • Intradermal skin testing for tuberculosis (5 IU tuberculin).
  • Serologic testing for EBV, CMV, toxoplasmosis, B. henslae, HIV and fungi.
  • Chest X-ray.
• Positive PPD skin test may signify tuberculous infection or cross-reactivity from atypical mycobacterial infection. 
• Abnormal chest x-ray is rare in atypical mycobacterial infection.
• If the diagnosis still remains in doubt and the adenitis is progressing: Biopsy of the node should be performed.
• Biopsy material should be submitted for the studies outlined above for lymph node aspirate cultures as well as for routine histology, Giemsa, periodic acid-Schiff (PAS), and methenamine silver stains. 
• Other special stains, for example the Warthin-Starry silver stain for the CSD bacillus, may be requested when appropriate.
• If the histology reveals noncaseating granulomas, and the child has a history of cat exposure, the most likely diagnostic possibility is CSD (cat-scratch disease).

Answer

•  Because of the frequent occurrence of infection due to these two agents, empiric antimicrobial therapy should be directed against them. 
• The incidence of penicillinase-producing strains of S. aureus is high in most communities, therefore, penicillinase-resistant penicillins should be used.
•  If the patient requires parenteral therapy, oxacillin or nafcillin may be used, or when oral therapy is deemed to be adequate, cloxacillin or dicloxacillin is recommended. 
• In nodes that progress to rapid suppuration and abscess formation, S. aureus is the most frequent agent isolated and drainage is mandatory. 

How would you treat tuberculous adenitis?

Answer

• A 2-month regimen of daily INH, rifampin, and pyrazinamide followed by a daily regimen of INH and rifampin for 4 months is currently recommended for treatment of uncomplicated intrathoracic pulmonary tuberculosis and isolated cervical lymphadenitis in children.

How would you treat adenitis due to atypical tuberculosis?

Answer

• These microorganisms frequently demonstrate in vitro resistance to commonly employed anti-tuberculous drugs.
• Surgical excision is the treatment of choice for non-tuberculous mycobacterial lymphadenitis.

How would you treat Cat scratch disease?

Answer

• Antimicrobials have no effect on the course of this illness. (Few patients have been reported to respond to rifampin therapy.)
•  If the lymph node progresses to fluctuance, needle aspiration may hasten resolution and also relieve the discomfort caused by the enlarged node.