It’s all in their Head
Management of
EENT Infections
Presented by: Allen Prettyman, PhD, FNP
Objectives

Discuss common infections in the adult
and pharmacologic treat for:
 Ears
 Eyes
 Nose
 Throat
Infections of the
External Ear
Anatomy and Physiology

Consists of the auricle and EAM

Skin-lined apparatus

Approximately 2.5 cm in length

Ends at tympanic membrane
Anatomy and Physiology


Auricle is mostly skinlined cartilage
External auditory
meatus

Cartilage: ~40%

Bony: ~60%

S-shaped

Narrowest portion at
bony-cartilage
junction
Anatomy and Physiology

EAC is related to
various contiguous
structures
 Tympanic
membrane
 Mastoid
 Glenoid
 Cranial
fossa
fossa
 Infratemporal
fossa
Anatomy and Physiology

Innervation: cranial nerves V, VII,
IX, X, and greater auricular nerve

Arterial supply: superficial
temporal, posterior and deep
auricular branches

Venous drainage: superficial
temporal and posterior auricular
veins

Lymphatics
Anatomy and Physiology

Squamous pithelium

Bony skin – 0.2mm

Cartilage skin 0.5 to 1.0 mm
Otitis Externa
 Bacterial
infection of external
auditory canal
 Categorized
 Acute
 Subacute
 Chronic
by time course
Acute Otitis Externa (AOE)

Severe“Swimmer’s Ear”
 Preinflammatory
 Acute
stage
inflammatory stage
 Mild
 Moderate
Review of System - AOE






In general, a history of 1-2 days of
progressive ear pain
Frequently, a history of exposure to or
activities in water, such as swimming,
surfing, and kayaking
Pruritus within the ear canal
Purulent discharge
Conductive hearing loss
Feeling of fullness or pressure
Physical Exam

The sine qua non of otitis externa is pain on
gentle traction of the external ear structures.

Periauricular adenitis may occur but is not
necessary for the diagnosis.

Examination of the canal reveals erythema,
edema, and narrowing of the external
auditory canal.

Typically, accumulation of moist debris is
observed in the external canal.
Physical Exam

The tympanic membrane may be difficult to
visualize and may be mildly inflamed, but it
should be normally mobile on insufflation.

Spores and hyphae may be seen in the
external canal if the etiology is fungal.

Eczema of the pinna may be present.

By definition, cranial nerve (CN) involvement
(ie, of CNs VII and IX-XII) is not associated
with simple otitis externa.
Differential Diagnosis

Otitis media with tympanic membrane
rupture

Herpes zoster oticus

Polychondritis

Cellulitis

Eczema or other skin conditions

Foreign body

Bullous or granular external otitis
Complications

Common: conductive hearing loss, narrowing
of external auditory canal.

Rare: extension beyond canal invading soft
tissues/bone = malignant otitis externa (MOE
+/- cranial nerve involvement, usually P.
aeruginosa or fungal).

This condition requires urgent attention. Obtain
cultures to guide therapy.

Usually seen in diabetics, immunocompromised
states, also facial nerve paralysis w/ progression
to involve CN IX, X, XI and XII.

May evolve into skull base osteomyelitis. CT of
temporal bone/skull base mandatory if
concerned. Bone scan may be more sensitive.
AOE: Preinflammatory Stage

Edema of stratum corneum and
plugging of apopilosebaceous unit

Symptoms: pruritus and sense of
fullness

Signs: mild edema

Starts the itch/scratch cycle
AOE: Mild to Moderate Stage



Progressive infection
Symptoms

Pain

Increased pruritus
Signs

Erythema

Increasing edema

Canal debris,
discharge
AOE: Severe Stage

Severe pain, worse
with ear movement

Signs
 Lumen
obliteration
 Purulent
otorrhea
 Involvement
of
periauricular soft
tissue
AOE: Pathogens

Most common pathogens:
Pseudomonas aeruginosa and
Staphylococcus aureus

Other bacteria, often polymicrobial.

Fungi seen in patients not responding
to topical antibacterials, often in
warmer climates.
Treatment
 Four
principles
 Frequent
 Topical
 Pain
canal cleaning
antibiotics
control
 Instructions
for prevention
Treatment

Treatment should include analgesia

First line: NSAIDs, acetaminophen.

Second line: narcotics, but consider also
engaging otolaryngology consult to
exclude severe pathology.

Symptoms of patient treated with routine
antibiotic/steroid drops should resolve in
6 days
Administration of Ear Drops

Tilt ear upwards and
hold position for 3-5
min.

Ear should not be
occluded but left
open to dry.

Self-administration
difficult, enlist other
to help.
Ear Wick

The wick may be commercially prepared from a hard
sponge material that expands when wet (eg, the Merocel
ear wick or the Pope Oto-Wick), cut from a bigger
sponge by the healthcare provider, or made from narrow
gauze (0.25-in. packing works well).
Preferred: Otic antibiotics
Antibacterial and anti-inflammatory
solution for otic use.
 Cure rates between 87% and 97%
 Neomycin + polymyxin + hydrocortisone
(Cortisporin Otic):
 4 drops three times a day x 7-10d
 Prescribe suspension, solution causes
burning sensations

Preferred: Otic antibiotics

Drug Name Ciprofloxacin (Ciloxan,
Cipro HC Otic)

Ciprofloxacin + steroid (Cipro HC
with hydrocortisone or Ciprodex
with dexamethasone):

3-4 drops twice daily x 7-10 d.
Alternative: Otic Antibiotics

Ofloxacin (Floxin):

10 drops once-daily or twice-daily x
7-10 d

Often used by PCPs in the setting of
TM perforation or tympanostomy
tube, but most otolaryngologists use
Cortisporin suspension or Cipro HC
Alternative: Acidifying Agents
Drug Name Acetic acid solution Rx (VoSol)
 Description Inexpensive agent; works well
in treating superficial bacterial infections
of otitis externa.
 Adult Dose 1-2 gtt q4-6h in canal or on
ear wick
 VōSoL (Acetic acid otic solution, USP),
containing acetic acid (2%), is available in
15 mL, measured-drop, safety-tip plastic
bottles

Prevention

No measures particularly well
studied

Use of earplugs for swimming

Drying ears with hair dryer (low
setting)

Tilting head to drain water

Acetic acid (2% drops, Vosol) 2-5
drops to ears after swimming
Follow-up




Most cases of uncomplicated OE should
improve within 48-72h. Progression or
lack of benefit with initial approach
should prompt referral.
Referral to otolaryngologist or otologist
essential in severe otitis externa.
Outpatient debridement using binocular
otomicroscopy essential.
Hypersensitivity to some topical
preparations, especially neomycin, may
occur in up to 15-30% of patients,
especially if eczema exists.
Eternal Eye Infections
Viral Conjunctivitis
Viral Conjunctivitis
Viral conjunctivitis is the most common cause
of an acute red eye.
 A self-limited infection, it usually resolves
within a week and leaves no permanent
damage.
 It probably spreads by contact; contagiousness
varies with the viral species.
 Caused most often by adenovirus, it cannot be
treated effectively with antimicrobial agents.
 Instead, management is directed at
scrupulous hygiene to prevent spread, which
is most likely when discharge is present.

Viral Conjunctivitis
How does it present?

The patient reports a swollen, tight, warm,
uncomfortable feeling in the affected eye
and a watery discharge.

Vision is usually normal unless mild mucus
gets on the cornea, which can be blinked
away.

One or both eyes may be involved.

There may be an ongoing or preceding upper
respiratory infection or a history of recent
exposure to someone with a red eye.
Viral Conjunctivitis
How does it present?
 The conjunctiva is diffusely hyperemic.
 The eyelids are slightly swollen.
 The eye is dripping with a watery and
mucoid—but not purulent—discharge.
 A tender pre-auricular node is often
present.
Viral Conjunctivitis
What to do?

Don't prescribe anti-infectives! They don't
work, and applying them only leads to
infection of an unaffected eye or other
people's eyes. Instead, urge two principles:

Hygiene: wash hands frequently, avoid
touching the eyes and sharing towels.

Quarantine: stay away from communal
activities—work, school, daycare—as long as
discharge is present.

Anti-inflammatory therapy
Viral Conjunctivitis

Refer only if:
 The diagnosis is in question.
 Symptoms appear to worsen.
 Keratitis is suspected.
Viral Conjunctivitis

Clinically there are two viral syndromes
distinguished from most – EKC and HSV

EKC (Epidemic keratoconjuctivitis)

This is an extremely contagious, adenovirus,
which almost always is associated with
preauricular node enlargement and
keratitis.

If allowed to go untreated for several days,
subepithelial corneal infiltrates will develop
and affect vision.
Viral Conjunctivitis
Viral Conjunctivitis (EKC)
EKC Treatment

When diagnosis is made early, treatment
includes lavage with 5% betadine
(anethesthetic before and after) then rinse
with saline. Have patient use tears and an
anti-inflammatory.

Steroids are treatment of choice if patient
has corneal infiltrates; however often a very
slow weaning process.
HSV – Herpes Simplex Virus

One of many important reasons you just
don’t call in a medication for a red eye
patient without seeing them!

Patient will present with conjunctival
hyperemia, eyelid edema, tearing and FBS

Look for clear skin vesicles with red base on
the lid or face; which progress to crusting.
These will hurt if scratched, similar to any
varicella infection.
HSV – Herpes Simplex Virus
HSV – Herpes Simplex Virus

It will cause a “dendrite”, or
tree –branch shaped keratitis,
which if not treated can lead to
permanent vision loss.

Treatment includes Viroptic 5-8
x’s/day and a cycloplegic if an
A/C reaction exist

May also add Acyclovir 500mg
bid x 7 days for moderate to
severe cases.

Use generics when possible
Bacterial Conjunctivitis
Normal Presentation
Extreme Presentation
Bacterial Conjunctivitis
What is it?

In normal hosts, bacterial conjunctivitis is
usually a benign, self-limited and very rare
infection caused by organisms susceptible to
a wide variety of antibiotics.

But in abnormal hosts—neonates, ocular
trauma or surgery, contact lens wear,
immunocompromised states—it can be a
virulent process that threatens vision and
even life.
Bacterial Conjunctivitis
How does it present?

The patient complains of:

Soreness, grittiness, burning, redness

Discharge

Heat in and around the affected eye

The conjunctiva is fiery red, boggy, and
covered with a thick, yellow pus.

The eyelids are swollen.
Bacterial Conjunctivitis
What to do?

Consult an eye care professional promptly
if the host is abnormal (including
neonates) or if vision is depressed.

Otherwise, treat empirically with topical
trimethoprim, aminoglycosides,
fluoroquinolones, or sulfacetamide 10%.

Be sure to demonstrate to the patient or
a caregiver the proper and improper ways
to instill eyedrops.
Bacterial Conjunctivitis

If there is no improvement within three
days of starting treatment, or if there is
worsening within several days, refer to an
eye care professional.

The incidence of MRSA is on the rise! We
must keep this in our differential, and be
prepared to treat with fortified
Vancomycin25mg/ml q1h alternating with
Zymar q1/2 h
Differential Diagnosis

Subconjunctival hemorrhage

Blepharitis

Eyelid disorders

Scleritis

Episcleritis

Keratitis

Pterygium

Acute anterior uveitis

Acute angle closure glaucoma
Testing




Specific testing: bacterial swabs for Gram
stain & aerobic culture will capture most
standard, non-fastidious bacteria.
Gonococcal disease is most commonly
diagnosed by Gram stain which shows
characteristic Gram negative intracellular
diplococci.
Chlamydia is most commonly diagnosed
by DFA (Direct Fluorescent Antibody)
staining of conjunctival smears.
Adenovirus conjunctivitis diagnosed by
rapid, 10-min office test (AdenpPlus)
General Comments

All doses indicated only while awake.

Ointments may blur vision x 20 min post
administration.

Must use systemic abx for
gonorrheal/chlamydial disease.
Lower Cost - Treatment

Trimethoprim/polymyxin B (Polytrim) sol
1gtt q3h x 7-10d.

Bacitracin/polymyxin B (Polysporin)
ophthalmic 1gtt q3-4h x 7-10d.

Sulfacetamide (Bleph-10) 10% sol 1-2gtt
q2-3h x 7-10d, taper to twice-daily with
improvement. Some staphylococcal
strains may be resistant.

Erythromycin ophthalmic oint 1/2-in four
times a day inside lower lid x 5-7d. Some
staph strains may be resistant.
More Expensive Treatment

Azithromycin (AzaSite) 1% sol 1 gtt q12h x
2 d followed by 1 gtt daily x 5d.

Offers fairly broad spectrum w/ high
tissue penetration, and long half life.

Not effective against Pseudomonas
aeruginosa.
More Expensive Treatment

Bacitracin/neomycin/polymyxin B
(Neosporin Ophthalmic) sol 1-2gtt q4h x
7-10d. Up to 10% pts allergic to bacitracin
or neomycin.

Tobramycin (Tobrex) 0.3% sol 1-2gtt q4h x
7d

Gentamicin (Garamycin, Genoptic) 0.3%
sol 1-2gtt q4h x 7d.
Fluoroquinolones

Use for more serious cases, especially if
suspected pseudomonal infection (contact
lens wearers) or corneal ulcers exist.

Levofloxacin (Quixin) 0.5% sol 1-2gtt q2h x
2d then 1-2gtt four times a day x 5d.

Ofloxacin (Ocuflox) 0.3% sol 1-2 gtt q2-4h x
2d then 1-2gtt four times a day x 5d.

Ciprofloxacin (Ciloxan) 0.3% sol 1-2gtt q2h x
2d then 1-2gtt q4h x 5d.
Systemic Antibiotics

Use required for patients with gonococcal
disease, treat sexual partners &
consider/treat chlamydial co-infection.

Vice versa for patients w/ chlamydial
conjunctivitis.
General Tips

Steroids: there is no role for the use of steroid
eye drops or antibiotic/steroid drop
combinations to treat conjunctivitis in the
primary care setting. Refer to ophthalmology if
contemplating use. Steroids may worsen some
underlying infections, e.g., HSV.

Contact lens: all patients with red eye should
discontinue contact lenses and resume only when
eye is white and without discharge after
treatment completed. Discard lens case and
disinfect or replace lens.

Comfort measures: include cold compresses and
artificial tears as needed.
Acute Sinusitis
Definitions

Acute sinusitis - symptoms for 3-4 weeks
consisting of any or all of the following:

Persistent URI symptoms, purulent
rhinorrhea, post nasal drainage, nasal
congestion, facial pain, headache, fever,
cough, and purulent mucus drainage.
Definitions

Chronic sinusitis – same symptoms as
acute sinusitis, of varying severity, for
3-8 weeks or longer. In chronic
sinusitis there should be abnormal
findings on CT or MRI.

Recurrent sinusitis – three or more
episodes of acute sinusitis in a year.
Different infectious pathogens may be
found at different times
Anatomic Considerations


The ethmoid bulla cells can occasionally
enlarge into the middle turbinate, causing
pneumatization (concha bullosa), which can
obstruct ventilation of the middle meatus.
Frontal recess cells can impinge upon the
nasofrontal duct. Blockage of the middle
meatus or the nasofrontal duct can lead to
sinusitis.
Nasal and sinus polyps can create obstruction
in multiple locations that can lead to
sinusitis.
Nasal Polyps
Nasal polyposis, right
nasal passage.
Nasal polyposis, right
nasal passage.
Anatomic Considerations

Septal deviation can
predispose to sinusitis
if the deviation
narrows the middle
meatus.

Infection and tumors
in the sphenoid
sinuses can progress
into the optic nerve,
cavernous sinus,
carotid artery, and
sella turcica.
Anatomic Considerations
Sinus Physiology

The sinuses are airfilled cavities with
pseudostratified
ciliated columnar
epithelium
interspersed with
goblet cells.

The cilia sweep
mucus toward the
ostial opening.
Sinus Physiology

Obstruction of the sinus ostia may lead to
mucus impaction and decreased
oxygenation in the sinus cavities.

During this obstruction, pressure in the
sinus cavity may decrease, which may
lead to pain, particularly in the frontal
region.
Microbiology

Acute sinusitis:
 Viral
URIs frequently precede bacterial
superinfection with Streptococcus
pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis.
 All
of these organisms may have significant
antibiotic resistance.
Clinical History

Acute sinusitis is typically first seen
as an upper respiratory infection
that has persisted beyond 5-7 days.

Factors that may predispose to
sinusitis include allergic or
occupational rhinitis, vasomotor
rhinitis, nasal polyps, rhinitis
medicamentosa, and
immunodeficiency.
Clinical Examination

Symptoms: nasal congestion, purulent
rhinorrhea, postnasal drainage, facial
or dental pain, headache, hyposmia,
and cough.

Signs: tenderness overlying the
sinuses, mucosal erythema, nasal
purulent secretions, increased
posterior pharyngeal secretions, and
periorbital edema.
Differential Diagnosis

Cystic fibrosis

Granulomatous diseases

HIV infection

Kartagener’s syndrome

Immotile cilia syndrome

Tumors
Associated Diseases

Asthma: the association between sinusitis
and asthma is generally stated to range
from 40% to 75% and the management of
sinusitis often results in improvement in
asthma.
Associated Diseases

Chronic rhinitis:


Allergic rhinitis and other forms of rhinitis (e.g.
vasomotor rhinitis) commonly precede the
development of recurrent or chronic sinusitis
because of the retention of mucopurulent
secretions within the sinus cavities.
Cystic fibrosis:

Chronic sinusitis is an important source of
morbidity in nearly all patients with cystic fibrosis,
creating nasal obstruction, post nasal drainage,
headache, and potential exacerbation of
pulmonary obstruction.
Treatment - Antibiotics

The most common bacteria observed are
polysaccharide encapsulated organisms of
which 30% to 40% produce b -lactamase.

Appropriate duration of therapy is not
well defined for acute sinusitis, but a 14day course is probably adequate for most
patients.

Choice of antibiotic should be based on
predicted effectiveness, cost, and side
effects.
DIAGNOSIS

Only 0.2-10% all clinical sinusitis cases are
bacterial -- on average, likely 2% of all cases.

Recommended tests with routine
presentation: nothing--no culture, no CT scan
or other x-rays or imaging.

Viral infections may now be confirmed with
rapid molecular methods -- need and
expense are unclear.
Initial therapy:

First line: amoxicillin/clavulanate 500
mg/125 mg PO three times daily or 875
mg/125 mg PO twice daily

Second line: 2000 mg/125 mg PO twice
daily

Doxycycline 100mg PO twice daily or
200mg once daily

Duration: complete 5-7d if improved.
Beta-lactam allergy:

Doxycycline 100mg PO twice daily or
200mg once daily

Levofloxacin 500mg once daily

Moxifloxacin 400mg once daily

Duration: complete 5-7d if improved.
Risk for antibiotic resistance or
failed initial therapy

(Amoxicillin/clavulanate 2000 mg/125 mg
PO twice daily

Levofloxacin 500 mg PO once daily

Moxifloxacin 400 mg PO once daily

Duration: 7-10d if improved
Adjunctive Therapies

Intranasal corticosteroids: recommended
as adjuncts to antibiotics especially with
a history of allergic sinusitis.

Decongestants: not recommended.

Antihistamines: not recommended.
When to Refer
Allergists/immunologists have unique
expertise in the evaluation and medical
management of sinonasal disorders.
 Accordingly, patients with chronic or
recurrent sinusitis, whose disease is
poorly controlled or in whom the nature
and cause of the disease remains in
question, should be referred
 Patients with associated diseases, such
as asthma, should be also referred to an
allergist/immunologist.

Pharyngitis
Streptococci

Gram-positive spherical cocci
arranged in chains

Significant portion of indigenous
microflora

Found in oral cavity and
nasopharynx

Classified based on their hemolysis
 Alpha,
beta, or nonhemolytic
Streptococcus

Beta hemolytic bacteria further
subdivided based on cell membrane
carbohydrates (Lancefield Groups A,
B, C, D, F, and G)
Group A Streptococcus
(beta-hemolytic)
Pharyngitis
Group
A streptococcus – most
common
Streptococcus
Group
No
pneumoniae
C streptococcus
proven benefit of treating
non-group A streptococcal
pharyngitis
Reasons for treating Group A
streptococcus
 Relief
of symptoms related to infection
 Prevent
rheumatic fever
 Prevent
suppurative sequelae
 Prevent
further spread of group A
streptococcus in the community
Symptoms

Sudden onset

Pain with swallowing

Fever +/-

Headache

Nausea and vomiting +/-

Abdominal pain
Clinical Exam
 Erythema
of the involved tissues with
or without purulent exudate
 Petechiae
of the soft and hard palate
Group A Streptococcus
Group A Streptococcus
Diagnosis / Testing

Rapid antigen detection tests (RADT) 8090% sensitive, available in minutes

Blood agar throat culture using a
bacitracin disk - overnight culture: 95%
sensitive, but culture lag time means
delays in treatment 24-48 hrs.
Group A Streptococcus
(beta-hemolytic)
Positive Culture: Note the beta
hemolysis on the blood agar plate
and inhibition of growth around
the bacitracin disk.
Negative Culture: Note how there is
no beta hemolysis on the blood agar
culture plate and how the growth on
the agar goes right up to and around
the bacitracin disk. Remember that
the Group A strep bacteria that
causes strep throat is inhibited by
the bacitracin disk.
Centor Criteria

Tends to over-diagnose GAS
compared to microbial diagnostic
methods.

Need 3 of 4 findings to favor GAS
diagnosis over viral:
 Fever
 Tonsillar
 No
exudates
cough
 Tender
cervical lymphadenopathy
Differential Diagnosis

Epiglottitis

Peritonsillar abscess

Retropharyngeal abscess

Thyroiditis

Oropharyngeal or laryngeal tumor
Treatment - GAS

Recommendations for antibiotic treatment
of group A streptococcal pharyngitis: since
~90% cases (in adults) are viral; therefore
give penicillin or erythromycin only if:

(+) rapid Strep antigen

(+) throat culture

Many authorities consider Centor clinical
criteria as poorly predicative, don’t use
First Line Treatment

Penicillin Vk 250 mg PO four times a day
or 500 mg PO twice daily x 10d

Amoxicillin 500 mg twice daily x 10d

Benzathine PCN 1.2 million units IM x 1
Alternative Treatment

Cephalexin 500 mg PO twice daily x 10d

Cefadroxil 1 gm PO once daily x 10d

Clindamycin 300 mg PO three times daily x 10d

Azithromycin 500 mg on day 1, then 250 mg
day 2-5.

Clarithromycin 250mg PO twice daily x 10d
Additional Treatment / Tips

Asymptomatic household contacts: neither
throat cultures or antibiotic treatment
indicated.

Adjunctive treatment: NSAIDS or
acetaminophen for moderate-severe
symptoms.
Questions?