Case Study - Ear Infections & Sinusitis PDF

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Ear Infections & Sinusitis...

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Case Study 1: Ear Infections Anatomy of the Ear: The ear is the organ of hearing and balance. The parts of the ear include:

- Pinna or auricle. This is the outside part of the ear. - External auditory canal/tube. This is the tube that connects the outer ear to the inside or middle ear.

The tympanic membrane divides the external ear from the middle ear.

- Ossicles. Three small bones that are connected and transmit the sound waves to the inner ear. The bones are called… Malleus, Incus, Stapes.

A canal that links the middle ear with the back of the nose. The eustachian tube helps to equalize the pressure in the middle ear. Equalized pressure is needed for the proper transfer of sound waves. The eustachian tube is lined with mucous, just like the inside of the nose and throat. It also helps in draining and pirating the ear. If this becomes blocked can cause ear infection.

- Cochlea. (contains the nerves for hearing). - Vestibule. (contains receptors for balance). - Vestibule. (contain receptors for balance).

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Pathology of the Ear: Ear Wax (it is good to have some ear wax as it serves as a protective from foreign substances, thus prevents bacterial ear infections).

- it is produced by the sebaceous glands inside the ear. - cleans, lubricates and protects the ear lining. - too much ear wax – pain and hearing loss. ***otitis = inflammation or infection of the ear***

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- Inflammation of the external ear canal (not ear drum). - Between outer ear and the ear drum (inflammation that has not gone deep enough to effect the ear drum). ⟶ Common ‘Bacterial’ Causes:

- Pseudomonas aeruginosa. (most common species to cause this, normally associated with children going swimming).

- Staphylococcus aureus. (a part of our normal skin flora can also cause otitis externa).

⟶ Common

‘Fungal’ Causes:

- Candida albicans. - Aspergillus species.

NOTE!!

***Differential diagnosis between bacterial and fungal otitis externa = fungal infection tend to be a lot more itchy with a runnier discharge***

⟶ Can also be caused by an ‘allergic reaction’.

The following images show ‘Otitis Externa’ through a otoscope…

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- It is the infection and inflammation of the middle ear.

- Directly behind the ear drum (i.e. the tympanic membrane).

- Bacteria or virus can enter the middle ear from the throat via the ‘eustachian tube’. Often the eustachian tube can get blocked, resulting in a build up of ‘gooey’ or ‘gunk’.

- Most common in young children (75% of cases in children under the age of 10).

⟶ Common ‘Bacterial’ Causes:

- Streptococcus pneumoniae. - Haemophilus influenzae. - Moraxella catarrhalis. ***the following bacterial species above can all cause throat, sinus, all ENT infections. If you have a ENT infection, can result in otitis media as they can get there via the eustachian tube.***

⟶ Common ‘Viral’ Causes:

- Respiratory syncytial virus (RSV). - Rhinovirus. (causes common cold, can cause ear ache). - Influenza virus. The

following images show ‘Otitis Media’ through a otoscope… You can see the external or the auditory canal is fine, but there is a ‘bulge’ in the eardrum. This is due to a build-up of fluid behind the eardrum and this fluid has nowhere to go. The middle image shows a ruptured

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tympanic membrane (this will result in the ear ache disappearing but with a exertion of the build-up) due to the increase build up of pressure due to fluid build-up due to otitis media.

- Glue ear is a common childhood condition where the middle ear becomes filled with fluid.

- It is also known otitis media with effusion (OME). - You can see the presence of bubbles. This is the build up of fluid along with the ‘gooey gunk’ that is present in otitis media.

- Caused by problems with the Eustachian tube. The Eustachian tube can get blocked. - 8/10 children will suffer this before the age of 10. - Signs that your child may be having problems hearing include: + struggling to keep up with conversations. + becoming aggravated because they're trying harder to hear. + regularly turning up the volume on the television.

- Inner ear infection – due to inflamed labyrinth. - Affects most inner part of the ear (containing cochlea and vestibular system). - Causes hearing loss, dizziness, loss of balance, vertigo (person feels as if they or the objects around them are moving when they are not).

***Some children receive surgically fitted grommets (also known as tympanostomy tube, is a small tube inserted into the eardrum) as they get a lot of fluid build-up in there ear. So overtime fluid builds up, it can run out through the ‘grommet’ and so the child does not end up with ‘nasty’ ear infections or glue ear.

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Patient Presentation: ⟶ A 6-year-old boy accompanied by his mum, presented to the GP. ⟶ His mum states that he has been complaining of pain in his left ear for 3 days and yesterday complained that the pain was worse with movement of his ear or when he is eating. ⟶ He appears to be in some distress, holding his ear and crying intermittently. ⟶ He does not appear to have a sore throat or temperature. ⟶ Upon examination of the patient’s right ear, it had a normal appearance. ⟶ However the following is observed in the left ear : + The ear canal appears red and swollen. + No fluid or discharge is seen. Antimicrobial Chemotherapy Theory and Practice

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+ The eardrum appears intact, no bulging is observed. + No pus or debris is present in the ear canal.

⟶ Upon further questioning the following facts are provided: + Patient has been spending the summer at an urban day camp, swimming in the pool. + The patients appetite is good and he is normally “very energetic”. + Both parents are smokers. + There is a history of frequent ear infections as well as asthma. + Also a history of mild seasonal allergies.

The following images show both the right and left ear of the presenting patient through an otoscope…

Right Ear

Left Ear

⟶ What is your differential diagnosis?

⟶ Which of the following Is The Most Likely Causative Organism?

causing otitis externa in this patient is most likely… Pseudomonas sp. This is partially true as Pseudomonas aeruginosa are the most common species to cause otitis externa particular when going swimming.

⟶ Should This Patient Receive Treatment?

⟶ What Type of Treatment Would You Consider? Antimicrobial Chemotherapy Theory and Practice

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and Anti-inflammatories. But selection of use depends on the patient details, patient history etc… ***see pages in BNF 74… Topical Antibiotics and Anti-inflammatories - pg.1093. and Systemic treatment - pg.485.

⟶ Antimicrobial treatment options? The antimicrobial options that are available are… Dependent upon: + The severity of the condition to how inflamed it is. + Also depends if there is any involvement of surrounding tissues. (i.e. with otitis externa the canal will be swollen and be inflamed as well as the pinna being inflamed. This would indicate maybe a development of a systemic infection where the treatment protocol would differ to localised infection).

+ Acetic acid 2% spray (available OTC). + Aminoglycoside antibiotic (i.e. Neomycin) + steroid (for anti-inflammatory).

+ Oral antibiotic (i.e. Flucloxacillin, Ciprofloxacin or Clarithromycin if allergic to penicillin). ___________________________________________________________

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⟶ Which Types of Supportive Therapy Would be Beneficial to This Patient? from; analgesia, fluids/electrolytes or oxygen… Analgesia would be of most benefit. Such as… paracetamol or NSAID’s.

Other considerations: ⟶ How long would this patient need to instil the ear drops or use the ear spray for?

- 7 days. ⟶ Would this patient benefit from any other advise?

- No swimming for at least 5 days. - Dry ears carefully after swimming. - Do not to put anything in the ear — including fingers and cotton buds.

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Otitis externa summary: ⟶ Precipitating factors…

- Water, trauma, hearing aid / plugs, diabetes (as well as presence of glucose in urine, glucose is also secreted in ears thus at more risk of candida fungal infections),

immunosuppression.

⟶ Severity of symptoms…

- Pain or tenderness, itch, hearing loss, discharge. ⟶ Severity of inflammation…

- Ear canal red and oedematous, hearing loss, discharge, lymphadenopathy, cellulitis, fever. ⟶ Treatment…

- Analgesia, topical acetic acid (2%), topical antibiotic and steroid, or maybe oral antibiotic.

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Case Study 2: Sinusitis Anatomy of the Sinuses: The paranasal sinuses (“the sinuses”) are air-filled cavities located within the bones of the face and around the nasal cavity and eyes. Each sinus is named for the bone in which it is located: Frontal sinus, Ethmoid sinus, Sphenoid sinus and the Maxillary sinus.

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Pathology of the Sinuses:

- It is the inflammation of the lining of the sinuses. - Symptoms include: + blocked nose. + headache. + facial pain. + reduced sense of smell. ⟶ Common ‘Bacterial’ Causes:

- Streptococcus pneumoniae. - Staphylococcus aureus. - Streptococci.

⟶ Common

‘allergy ’ Causes:

- Allergic rhinitis (Hay fever). - Asthma.

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⟶ Irritants

that can cause sinusitis:

- Pesticides. - Air pollution. - Smoke and chemicals. Patient Presentation: ⟶ A 21 year old males arrives at the local pharmacy complaining of severe nasal congestion, headaches and blurred vision. ⟶ He has recently changed his job to become a painter and decorator. ⟶ He has recently been suffering from cold symptoms and has taken paracetamol which relieved the symptoms slightly. ⟶ He has noticed that the pain has moved to above the bridge of his nose and below his eyes.

⟶ Upon further questioning the patient reveals that: + He had childhood asthma. + He is allergic to penicillin. + A friend has told him to take some antihistamine and decongestant tablets/nasal spray to help relieve the symptoms he is experiencing.

⟶ Upon even further questioning the patient reveals that: + He has had a greenish yellow discharge for the last 3 days. + He has noticed a loss in his sense of smell and taste since the cold symptoms started. + He has not experienced any temperatures. (temperature may indicate a systemic involvement)

Considerations: From the patient presenting information we can see the patient is experiencing…

- Headaches. - Blurred vision. - Extreme nasal congestion. - He is a painter and decorator. - He has taken paracetamol which relieved the symptoms a little. - He is allergic to penicillin. ___________________________________________________________

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⟶ Should This Patient Receive Antibiotic Treatment? ***see pages in BNF 74… pg.487, under… Nose infections, bacterial for ‘Antibacterial therapy for sinusitis’. NO, the patient should not receive antibiotics since under the BNF guideline it states that… “antibacterial therapy should usually be used for persistent symptoms and purulent discharge lasting at least 7 days or if severe symptoms.

⟶ Which Types of Supportive Therapy Would be Beneficial to This Patient? Due to the causes and symptoms the patient presents, Analgesia, Fluids/electrolytes (drinking more will help water out excess mucous production helping symptoms) and Steam inhalation is advisable.

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One week later… ⟶ The same patient returns to the pharmacy explaining that his symptoms had improved until the previous day. He is now experiencing: + Fever. + Dizziness. + Slight hearing loss and ear pain. + Pain in bridge of nose and below both eye. + Purulent nasal discharge. **What would you recommend???

⟶ Should This Patient NOW Receive Antibiotic Treatment? YES, the patient now meets the BNF criteria and should be prescribed the appropriate antibiotic regiment.

⟶ Which of the following treatments could be considered? Amoxicillin, Penicillin, Clarithromycin, Co-amoxiclav or Doxycycline.

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The BNF guidelines state that either Amoxicillin or Doxycycline or Clarithromycin should be the

preferred use of antibiotics for sinusitis. BUT since patient is allergic to penicillin, Doxycycline or Clarithromycin may be used.

Southampton, Hampshire, Isle of Wight & Portsmouth along with Surrey Heath & Berkshire East Guidelines for Antibiotic Prescribing in the Community 2014:

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Further considerations: ⟶ Suggest the length of treatment this patient should be prescribed? BNF guidelines suggest… 7 days.

⟶ Suggest any possible side effects that this patient may experience. …Nausea, taste disturbance…

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⟶ When considering treatment with doxycycline should the patient be informed of any foods or remedies to avoid? Take doxycycline Caps. or Tabs. with plenty of fluid and should be taken with meals. Also the combination of doxycycline with dairy, antacids, calcium supplements, iron products, and laxatives containing magnesium is not inherently dangerous, but any of these foods and supplements may decrease doxycycline's effectiveness. Thus in view of these results, it is advisable to instruct the patients to take doxycycline on an empty stomach.

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