media et al中耳炎详细信息等课件

COMMONE N T PROBLEMS B WAYNEBLOUNT MD MPHPROFESSOREMORYFAMILYMEDICINE LearningObjectives INSYLLABUS AcuteOtitisMedia B WAYNEBLOUNT MD MPHPROFESSOR EMORY OtitisMedia Classification AcuteOM rapidonsetofsigns sx 3wkcourseSubacuteOM 3wksto3mosChronicOM 3mosorlonger OtitisMediaetal Acuteotitismedia AOM Otitismediawitheffusion OME OtitisexternaOtherearfindings commonanduncommon Recommendation 1 Todiagnoseacuteotitismediatheclinicianshouldconfirm 1 ahistoryofacuteonset 2 identifysignsofmiddle eareffusion MEE and3 evaluateforthepresenceofsignsandsymptomsofmiddle earinflammation AOMGuidelineathttp www aafp org x26481 xml Recommendation 2 ThemanagementofAOMshouldincludeassessmentofpain Ifpainispresent theclinicianshouldrecommendtreatmenttoreducepain AOMGuidelineathttp www aafp org x26481 xml Recommendation 3A ObservationwithoutuseofantibacterialagentsinachildwithuncomplicatedAOMisanoptionforselectedchildrenbasedondiagnosticcertainty age illnessseverity andassuranceoffollow up AOMGuidelineathttp www aafp org x26481 xml Recommendation3B Ifadecisionismadetotreatwithanantibacterialagent theclinicianshouldprescribeamoxicillinformostchildren Whenamoxicillinisusedthedoseshouldbe80to90mg kg day AOMGuidelineathttp www aafp org x26481 xml Recommendation 4 Ifthepatientfailstorespondtotheinitialmanagementoptionwithin48to72hours theclinicianmustreassessthepatienttoconfirmAOMandexcludeothercausesofillness IfAOMisconfirmedinthepatientinitiallymanagedwithobservation theclinicianshouldbeginantibacterialtherapy Ifthepatientwasinitiallymanagedwithanantibacterialagent s theclinicianshouldchangetheantibacterialagent s AOMGuidelineathttp www aafp org x26481 xml AcuteOtitisMedia RiskFactors MalegenderSiblinghxorrecurrentotitismediaEarlyageofonsetofAOM before4mo Bottlefeeding orbreastfeedingfor 4moGroupdaycareExposuretotobaccosmokeSwanson Jill OtitisMediainYoungChildren MayoClinicProceedings 71 2 Feb1996 pp179 183 Eustachiantube UsuallyclosedOpensduringswallowing yawning andsneezing AcuteOtitisMedia PositivePredictiveValueofTMFindings FindingPPVBulgingTM89CloudyTM80Distinctlyimpairedmobility78DistinctlyredTM65Slightlyimpairedmobility33SlightlyredTM16Karmaetal Otoscopicdiagnosisofmiddleeareffusioninacuteandnon acuteotitismedia IntJPediatrOtolaryngol 1989 17 pp37 49 NormalEarDrum Microbiology S pneumoniae 30 35 H influenzae 20 25 M catarrhalis 10 15 GroupAstrep 2 4 Infantswithhigherincidenceofgramnegativebacilli Virology RSV 74 ofmiddleearisolatesRhinovirusParainfluenzavirusInfluenzavirus Microbiology PCN resistantStrep1979 1 8 1992 41 AlteredPCN bindingproteinsLysisdefectiveAge day cares andprevioustx H fluandM catarrhalisbeta lactamaseproductionAllM catarrhalis 45 50 H flu AcuteOtitisMedia PneumaticOtoscopy Pneumaticotoscopy insufflationwilldemonstratedecreasedmobilityofthetympanicmembraneincasesofmiddleeareffusionwithincreasedmiddleearpressure MobilityoftheTMisnotconsistentwithadiagnosisofAOM AcuteOtitisMedia Tympanometry Thisinstrumentisusedtodetectfluidwithinthemiddleear SeveraltypesoftympanogramsHighlysensitivewhendiseasepresent Lowerspecificitywhendiseaseabsent willbeabnormalinchildrenwithnormalTMs Onusko E Tympanometry AFP Nov 1 2004 pp1713 1720 AcuteOtitisMedia AcousticReflectometry AninstrumentsimilartothetympanogramisusedtobouncesoundwavesofftheTM Morewavesarereflectedwhenthemiddleearisfulloffluid Sensitivity 90 andspecificity 86 formiddleeareffusionorabnormalpressure Recommendation 2 ThemanagementofAOMshouldincludeassessmentofpain Ifpainispresent theclinicianshouldrecommendtreatmenttoreducepain AOMGuidelineathttp www aafp org x26481 xml AcuteOtitisMedia Treatment Ensurethatthepatienthasadequateanalgesia Tylenol10 15mg kguptoq4hrMotrin5 10mg kguptoq6 8hr maxdoseof20mg kg 24hrDon tforgettopicalanalgesiawithAuralgan topicalbenzocaine AcuteOtitisMedia Treatment IntheUSA onestudyhasdemonstratedthatAOMduetoS Pneumoniaspontaneouslyresolvedin20 while50 casesofH influenzaresolvedspontaneously McCracken Considerationsinselectinganantibioticfortreatmentofacuteotitismedia PediatrInfectDisJ 1994 13 Suppl pp1054 1057Thedifficultyisinchoosingwhichpatientnottogiveantibiotics Recommendation 3A ObservationwithoutuseofantibacterialagentsinachildwithuncomplicatedAOMisanoptionforselectedchildrenbasedondiagnosticcertainty age illnessseverity andassuranceoffollow up AOMGuidelineathttp www aafp org x26481 xml Recommendation3B Ifadecisionismadetotreatwithanantibacterialagent theclinicianshouldprescribeamoxicillinformostchildren Whenamoxicillinisusedthedoseshouldbe80to90mg kg day AOMGuidelineathttp www aafp org x26481 xml AcuteOtitisMedia Treatment Amoxicillinisstillthefirstlinetherapy 1 00perbottleMayalsoconsiderSeptra Bactrim 0 82perbottlePleaserememberthisbeforewritingforZithromax whichcostsWAYmore 15 00perbottle AcuteOtitisMedia Treatment Ceftriaxonehasbeenshowninmultiplestudiestobeequallyefficaciouswhengivenasaone timeIMinjectionof50mg kg max ComparisonofCeftriaxoneandTrimethoprim SulfamethoxazoleforAcuteOtitisMedia Pediatrics 99 1 January1997 pp23 28 Treatment RecurrentAOM ChemoprophylaxisSulfisoxazole amoxicillin ampicillin pcnlessefficacyforintermittentpropylaxisMyringotomyandtubeinsertiondecreased andseverityofAOMotorrheaandothercomplicationsmayrequireprophylaxisifsevereAdenoidectomy28 and35 fewerepisodesofAOMatfirstandsecondyears AcuteOtitisMedia Treatment AntihistaminesanddecongestantsarenotestablishedtherapiesforAOM However rememberthat70 90 ofchildrenwithAOMhave hadanantecedentURI cold sothismaynotreallybebadmedicine AcuteOtitisMedia TreatmentDuration Thestandardtreatmentis10days AstudyinPediatricsdemonstratedthattreatingforafull20daycoursewasnomoreefficaciousthantreatingfor10daysEfficacyof20 Versus10 DayAntimicrobialTreatmentofAcuteOtitisMedia Pediatrics 96 1 July1995 pp5 13 AcuteOtitisMedia Follow Up PatientswithAOMshouldhaveadecrease ifnotresolution intheirsymptomatologyoverthe48 72hoursafteradiagnosisismadeandtreatmentinstituted Ifnoresolutioninsymptoms considerabeta lactamaseproducingbacteriaorotherprocess nottoexcludepoorpatientcompliance Recommendation 4 Ifthepatientfailstorespondtotheinitialmanagementoptionwithin48to72hours theclinicianmustreassessthepatienttoconfirmAOMandexcludeothercausesofillness IfAOMisconfirmedinthepatientinitiallymanagedwithobservation theclinicianshouldbeginantibacterialtherapy Ifthepatientwasinitiallymanagedwithanantibacterialagent s theclinicianshouldchangetheantibacterialagent s AOMGuidelineathttp www aafp org x26481 xml AcuteOtitisMedia Follow Up Thepartyline 2weekearcheck Hathawayetalfoundthefollowingcriteriatobe97 accurateindeterminingifachildhadAOMatfollow up ParentalimpressionofresolvedAOMAbsenceofsymptomsAge 15monthsNofamilyhistoryofrecurrentAOMinasib Hathawayetal AcuteOtitisMedia WhoNeedsPosttreatmentFollow Up Pediatrics 94 2 August1994 pp143 147 AcuteOtitisMedia Recurrence Prophylaxis Ingeneral3episodesin6monthsor4episodesin1yeardeserveconsiderationforantibioticprophylaxis Knowledgeatlarge alsoinConn s1998DrugsAmoxilat20mg kgqdGantrisin50 75mg kgdividedbid AcuteOtitisMedia Recurrence Prophylaxis Follow upisusuallyoncepermonth atleastinitially Ifachildhadbreakthroughinfectionsonprophylaxis consideranENTreferral Howlongtocontinueprophylaxis Needhametal unpublisheddata 6 12monthsminimum Useyourbestjudgement AcuteOtitisMedia Recurrence Prophylaxis Thegoalofprophylaxisistoallowthechildtoageenoughsothathis hereustachiantubeapparatuswillbecomelesslikelybecomeinfected usuallyage3 ish again moreunpublisheddata i e opinion Usetheantibioticprophylaxistoavoidsurgery althoughthesurgerytakesallof2minutes OtitisMediawithEffusion OME OtitisMediawithEffusion SomeStickyBusiness SimplydefinedasfluidinthemiddleearwithoutsymptomsorsignsofAOM ClinicalPracticeGuideline expertpanelcomprisedofmembersfromAAP AAFP andAmericanAcademyofOtolaryngology HeadandNeckSurgery withreviewandapprovaloftheAgencyforHealthCarePolicyandResearch OM persistentmiddleeareffusion MEE HighincidenceofMEE avgof40daysChildrenlessthat2yearsmuchmorelikelytohavepersistentMEEWhitechildrenwithhigherincidenceofMEE ChronicMEE Previouslythoughtsterile30 50 growincultureover75 PCR Usualorganisms OtitisMediawithEffusion SomeREALLYStickyBusiness Glueear theREALglueear OtoscopicfindingsThickyellowfluidbehindtheTMAdifferentfishfromplainol OME thisisthehogbassfromthebogswamp Heain tmovin fonuttin Treatment OME MEE 3mosorassochearingloss vertigo frequency MEpathology discomfortAntibioticsshowntobeofbenefit 75 PCR bacterialDNAAntibiotics steroid21 improvementcomparedtoabxaloneprednisone1mg kgdayx7daysvaricella Myringotomy tympanostomy adenoidectomy Tympanostomytubeinsertion UnresponsiveOME 3mosbil or 6mosuni soonerifassochearingproblemsRecurrentMEEwithexcessivecumulativeduration Glueear OtitisExterna OtitisExterna CommonlyreferredtoasSwimmer sEarUsualinfectionsareskinbacteria Ifyouseegreen fouldischarge thinkofPseudomonas Indiabetics peopleonsteroids andimmunocompromised don tforgetfungalinfections Doyouthinkitwouldhurttopullonthistragus OtitisExterna Treatment Cortisporinsuspension safeinallearsNeomycin PolymyxinB HydrocortisoneCortisporinsolution moreburnforyourmoney Don tuseiftheTMisruptured ZotoHC Chloroxylenol pramoxine HCPOantibiotics 65 AcuteandChronicSinusitis APracticalGuideforDiagnosisandTreatment 66 DevelopmentofSinuses MaxillaryandethmoidsinusespresentatbirthFrontalsinusdevelopedbyage5or6Sphenoidsinuslasttodevelop 8 10 67 NormalWater sandTowne sViewsoftheSinuses 68 LateralViewShowingNormalSphenoidSinus 69 ClassificationofBacterialSinusitis Acutebacterialsinusitis infectionlasting4weeks symptomsresolvecompletely children30days Subacutebacterialsinusitis infectionlastingbetween4to12weeks yetresolvescompletely children30 90days Chronicsinusitis symptomslastingmorethan12weeks children 90days Someguidelinesaddtreatmentfailure apositiveimagingstudy 70 RecurrentAcuteBacterialSinusitis Episodeslastingfewerthan4weeksandseparatedbyintervalsofatleast10daysduringwhichthepatientistotallyasymptomatic3episodesin6monthsor4 year 71 DifferentiatingSinusitisfromRhinitis SinusitisNasalcongestionPurulentrhinorrheaPostnasaldripHeadacheFacialpainAnosmiaCough fever RhinitisNasalcongestionRhinorrheaclearRunnynoseItching redeyesNasalcreaseSeasonalsymptoms 72 X RayImageofSinuseswithMaxillarySinusitis 73 AcuteBacterialSinusitis UsuallybeginswithviralupperrespiratoryillnessSymptomsinitiallyimprove butthen SymptomsbecomepersistentorseverePersistent 10 14daysbutfewerthan4weeksSevere temperatureof102 purulentnasaldischargefor3 4days childappearsillDiseaseclearswithappropriatemedicaltreatment 74 PhysicalFindings MucopurulentnasaldischargeHighestpositivepredictivevalueSwellingofnasalmucosaMilderythemaFacialpain unusualinchildren Periorbitalswelling 76 TreatmentofAcuteSinusitis AntihistaminesrecommendedifallergypresentOralortopicalDecongestantsOralortopicalAntibioticwhenindicated bacteria NasalirrigationGuaifenesin200 400mgq4 6hrsHydration 77 Decongestants Topicalnasalsprays limituseto3 7days PhenylephrineOxymetazolineNaphthazolineTetrahydrozolineZylometazolineTopicalnasalspray unlimiteddailyuse IpatropiumOralPseudoephedrine30 60mgPhenylephrine2 4times day 78 TreatmentofAcute UncomplicatedSinusitis AntibioticmaynotbeindicatedManyareviralBenefitofantibioticsareonlymoderateWeighfactorsofcost sideeffects antibioticresistance andantibioticreactions 79 BacteriaInvolvedinAcuteBacterialSinusitis Streptococcuspneumoniae30 Haemophilusinfluenza20 Moraxellacatarrhalis20 Sterile30 80 AntibioticsforAcuteBacterialSinusitis Amoxicillin500mgtidfor10 14daysFirstlinechoiceinmostareasLocaldifferencesinantibioticresistanceoccurWherebeta lactanaseresistanceisanissueAmoxicillin clavulanateCefuroximeCefpodoximeCefprozil 81 AdditionalAntibioticsforAcuteBacterialSinusitis Amoxicillinshouldbeconsideredbecauseofitsefficacy lowcost side effectprofile andnarrowspectrum 45 90mg kg dinchildren 500mgtidorqidinadultsfor10to14days Ifpenicillin allergicclarithromycinorazithromycinErythromycindoesnotprovideadequatecoverageTrimethoprim suflamethoxazoleanderythro sulfisoxazolehavesignificantpneumococcalresistance 82 SecondaryAntibioticsforAcuteSinusitis Cefdinir Omnicef Cefuroxime Ceftin Cephpodoxime Vantin AzithromycinClarithromycin 83 OptimalDurationofAntibiotics Giveantibioticuntilpatientfreeofsymptomsthenadd7days 84 NasalIrrigation CommercialbufferedspraysBulbsyringe1 4tspofsaltto7ounceswaterWaterpikwithlavagetip1tspsalttoreservoirDisposableenemabucket2tspsalt 1tspsodaperquartofwater 85 WhenMedicalTherapyforAcuteBacterialSinusitisFails AssessforchroniccausesIdentifyallergicandnonallergictriggersAllergytesting nasalsmearsforeosinophiliaConsiderothermedicalconditionsassociatedwithsinusitisRhinolaryngoscopyImagingstudiesSinusx raysCTscanning limited coronalviews 86 Rhinoscope 87 RecommendationsforCTScans PatientspresentingwithcomplicationsofsinusitisNeurologicsymptoms diplopia periorbitalorfacialswellingwithorwithouterythemaPatientswithsinussymptomsaccompaniedbysevere boring mid headpainRuleoutsphenoidsinusitis 88 CTScanMaxillaryandEthmoidSinuses 89 Recommendation1 ThediagnosisofacutebacterialsinusitisisbasedonclinicalcriteriawithpatientspresentingwithURIsymptomsthatareeitherpersistentorsevere 90 Recommendation2a Imagingstudiesarenotnecessarytoconfirmadiagnosisofclinicalsinusitisinchildrenyoungerthan6years olderthanage6yearsiscontroversial Childrenwithpersistentsymptoms 10days 30days predictedabnormalradiographs80 ofthetimeChildren 6symptomspredicted88 ofthetimeNormalx raysuggestsABSisnotpresent 91 Recommendation2b CTscansoftheparanasalsinusesshouldbereservedfor PatientsinwhomsurgeryisbeingconsideredasamanagementstrategyPatientswhodonotrespondtomedicalregimeswhichincludeadequateantibioticuseAssistingindiagnosisofanatomicalchangesinterferingwithairflowordrainage 92 Recommendation3 AntibioticsarerecommendedforthemanagementofacutebacterialsinusitistoachieveamorerapidclinicalcurePatientsmustmeetrequirementsofpersistentorseverediseaseResponseimprovedwithdoses MinimalInhibitionConcentration 93 NoEBRecommendationsFoundforUseofAdjunctiveTherapyinABS MaybeHelpful NasalsalineirrigationOraldecongestantsOralornasalantihistaminesTopicaldecongestantsMucolyticagentsTopicalsteroids 94 Evidence BasedRecommendations PracticeRecommendation Reduceunnecessaryuseofantibiotics ProvidersshouldbeconsistentwiththerecommendedcriteriaforprescribingantibioticsinacutesinusitisendorsedbytheCDC AmericanAcademyofFamilyPhysicians theAmericanCollegeofPhysicians AmericanSocietyofInternalMedicine andtheInfectiousDiseasesSocietyofAmerica Allrecommendationsavailableat http www icsi org knowledge detail asp catID 29 itemID 148 AccessesAugust2003 Evidence BasedRecommendations PracticeRecommendation Usefirstlineantibiotics whichareamoxicillinortrimethoprim sulphamethoxazole TMP SMX PracticeRecommendation Useanantibioticthatcoversresistantbacteria amoxicillin clavulanate Augmentin oranothersecondlineagent totreatpatientsiffailedon10 14daysofamoxicillin http www icsi org knowledge detail asp catID 29 itemID 148 PHARYNGITIS 1SORETHROATPERDAY Idiopathic30 65 Viral30 60 Bacterial5 10 UsuallycannottellthedifferencebyexamConcernedaboutthebacterialcauses MOSTVALIDATEDSCORINGSYSTEM B Rec SymptomPointsFever1Absenceofcough1TenderAnt Cvcladenopathy1Tonsillarswellingorexudate1AGE45 1 SCORINGSYSTEM POINTSMEANING 0NoGABHS 2 1 3Rapidstreptest4 5ProbableGABHS 52 TESTS B Rec RapidStreptests SensitivityandSpecificity 94 3minsThroatCultures GoldStandard Sens 97 Spec 99 24hrs ENSUREADEQUATESWAB GABHSTREATMENT GOALS PREVENTACUTERHEUMATICFEVERPREVENTSUPPARATIVECOMPLICATIONSIMPROVECLINICALSXREDUCETRANSMISSIONMINIMIZEANTIBIOTICADVERSEEFFECTS GABHSTREATMENT Penicillins A RecPcn allergicpts Macrolides A Rec1stgencephalosporin A RecSteroids short acting relieveSx B Rec GABHSTREATMENT Mutiplerecurrences ClindamycinAugmentinPCNGAll B Rec ISITMONO Posteriorlymphadenopathy Monospot 67 sensin1stweek80 in2ndwkCBC 10 atypicallymphs 92 spec ISITG C HAVETOTHINKABOUTIT1STASKABOUTORAL GENITALSEXGETC S ApproachtotheDizzyPatient Overview PracticalapproachtovertigoBriefintroductiontodizzinessandvertigo centralvsperipheral Dizziness isitvertigo Lightheadedness 90 non neurologicalcause vasovagalresponseorthostasiscardiogeniccauseshyperventilationhypoglycemiamedicationeffects Dizziness isitvertigo Vertigo usuallyneurological sensationofmotionspinningfeelingmotionsickfeelingoftiltingtoonesideresultsfromasymmetricimpairmentofsensoryinputorofintegrationintoCNS Vertigo central 20 ofallvertigoUsuallyaccompaniedbyotherbrainstem cerebellar orlong tractsx s signs e g incoordination visualchangesordiplopia perioralnumbness dysarthria dropattacks weakness numbness etc However upto25 ofvertebrobasilarinsufficiencycanpresentwithisolatedvertigo Acutecerebellarinfarctscanmimicvestibularneuritis mayonlyhavevertigo gaitataxia andnystagmuslookatnystagmus gazeevokedorvertical increasesinamplitudeipsitolesion Focaldysmetriawouldsuggestipsilateralcerebellar Vertigo peripheral History focusononset duration NotethatallvertigocanworsenwithpositionchangesExam shouldnothavefocalneurologicfindings besideshearingloss tinnitus Nystagmus unilateral amplitudedecrindirectionawayfromfastphase Alexander slaw fatigues decrwithfixation Gait althoughuncomfortable ptswithperipheralvertigotypicallycanwalk unlikethosewithcentralNote vertigo hearinglosscanbevascular infarctionofinnerearbyocclusionofinternalauditoryartery branchofAICA causesvertigochearingloss Cluestowardsacentralprocess 1 Riskfactors age HTN DM lipids smoking2 Focalneurologicalfindings suggestiveofcentralprocess3 Nystagmus central vertical notunilateral doesnotfatigue doesnotdecrwithfixation peripheral unilateral decrindirectionawayfromfastcomp fatigues decrwithfixation4 Severityofataxia central moresevere unabletowalk peripheral uncomfortable butabletowalk 114 VestibularNeuritis SuddenonsetofperipheralvertigoUsuallywithouthearinglossPeriodofseveralhours severeLastsafewdays resolvesoverweeksInflammationofvestibularnerve presumablyofviraloriginSpontaneous completesymptomaticrecoverywithsupportivetreatmentTreatmentaimedatstoppingin