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2. Tobradex ophthalmic drops: 1 to 2 drops every 2 hours for first 24 to 48 hours, then every 4 to 6 hours. Reduce dose as the condition improves. Treat for 5 to 7 days as needed. Not recommended in children younger than 2 years. 3. Intrachalazion corticosteroid injection is performed by an ophthalmologist. Follow-Up A. For large infected chalazia, follow up with patient in 1 week and then evaluate the patient every 2 to 4 weeks. Consultation/Referral A. If the chalazion does not resolve spontaneously, incision and curettage by an ophthalmologist may be necessary. Conjunctivitis Jill C. Cash and Nancy Pesta Walsh Definition A. Conjunctivitis is inflammation of the conjunctiva. Incidence A. Viral conjunctivitis is the most common type; conjunctivitis occurs in 1% to 12% of newborns. Pathogenesis Primarily three types of conjunctivitis are seen: A. Bacterial (Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus aureus, Neisseria gonorrhoeae, and Chlamydia) B. Viral (adenovirus, coxsackievirus, and enteric cytopathic human orphan [ECHO] viruses) C. Allergic (seasonal pollens or allergic exposure) Predisposing Factors 266 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Contact with another person with the diagnosis of conjunctivitis B. Exposure to sexually transmitted infection (STI) C. Other atopic conditions (allergies) Common Complaints A. Red eyes B. Eye drainage C. Itching (with allergic conjunctivitis) Other Signs and Symptoms A. Bacterial 1. Fast onset, 12 to 24 hours of copious purulent or mucopurulent discharge 2. Burning, stinging, or gritty sensation in eyes 3. Crusted eyelids upon awakening, with swelling of eyelid 4. Usually starts out unilaterally; may progress to bacterial infection 5. Bacterial conjunctivitis may present as beefy red conjunctiva B. Viral 1. Symptoms may begin in one eye and progress to both eyes 2. Tearing of eyes 3. Sensation of foreign body 4. Systemic symptoms of upper respiratory infection (runny nose, sore throat, sneezing, fever) 5. Preauricular or submandibular lymphadenopathy 6. Photophobia, impaired vision 7. Primary herpetic infection: Vesicular skin lesion, corneal epithelial defect in form of dendrite, uveitis C. Allergic 1. Itchy, watery eyes, bilateral 2. Seasonal symptoms 3. Edema of eyelids without visual change 4. With allergic conjunctivitis, hyperemia of eyes is always bilateral and giant papillae on tarsa may be seen. 5. May also see eczema, urticaria, and asthma flare Subjective Data 267 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Elicit the onset, duration, and course of symptoms. B. Question patient regarding the presence of discharge upon awakening. C. Elicit changes in vision since symptoms began. D. Determine whether there has been any injury or trauma to the eye. E. Assess whether these symptoms have appeared before. F. Rule out exposure to anyone with conjunctivitis. G. Ask patient about any new events, such as use of contact lenses or change in contact lenses or solutions. H. Review patient and family history of allergies. Physical Examination A. Check temperature. B. Inspect 1. Observe eyes for color and foreign objects. Perform complete eye examination. 2. Note lid edema. 3. Assess pupillary reflexes. 4. Examine skin. 5. Inspect ears, nose, and throat. C. Auscultate 1. Auscultate heart and lungs. D. Palpate 1. Palpate preauricular lymph nodes and anterior and posterior cervical chain lymph nodes. Diagnostic Tests A. Gram stain testing for discharge/exudate extracted from eyes if gonococcal infection is suspected and/or all neonates. B. Culture for chlamydia, if suspected. C. Perform fluorescein stain of eye if foreign body is suspected or corneal abrasion/ulceration is suspected. D. Test visual acuity with the Snellen chart. Assess peripheral vision and EOMs. Differential Diagnoses A. Conjunctivitis 268 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Corneal abrasion C. Blepharitis D. Drug-related conjunctivitis E. Herpetic keratoconjunctivitis F. Iritis G. Gonococcal or chlamydial conjunctivitis Plan A. General interventions 1. Distinguish among bacterial, allergic, or viral infection. 2. Consider other diagnoses if eye pain is noted. B. Patient education: See Section III: Patient Teaching Guide for this chapter, “ Eye Medication Administration. ” 1. Cool compresses to the affected eye should be applied several times a day. 2. Clean eyes with warm, moist cloth from inner to outer canthus to prevent spreading infection. 3. Encourage good handwashing technique with antibacterial soap. 4. Instruct on the proper method of instilling medication into eye. Give patient the teaching guide on “How to Administer Eye Medications. ” 5. Instruct the female patient to discard all eye makeup, including mascara, eyeliner, and eye shadow, worn at the time of the infection. 6. Teach the patient/parent the difference among bacterial, allergic, and viral infections. Educate according to appropriate diagnosis. 7. If using aminoglycoside or neomycin ointments or drops, use caution and monitor closely for reactive keratoconjunctivitis. 8. Bacterial conjunctivitis is contagious until 24 hours after beginning medication. 9. Viral conjunctivitis is contagious for 48 to 72 hours, but it may last up to 2 weeks. This is typically self-limiting, and does not require antibiotic treatment. C. Pharmaceutical therapy 1. Bacterial a. Aminoglycosides: Gentamicin 0. 3%: Severe infections: 2 gtts every hour on day 1, then 1 to 2 gtts every 4 hours for 5 to 7 days. Mild/moderate infections: 1 to 2 gtts every 4 hours for 5 to 7 days 269 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
b. Tobramycin 0. 3%; severe infections: 2 gtts every hour on day 1, then 1 to 2 gtts four times a day for 5 to 7 days. Mild-to-moderate infections: 1 to 2 gtts four times a day for 5 to 7 days c. Polymyxin B: Trimethoprim/polymyxin B sulfate (Polytrim) ophthalmic ointment in each eye four times daily for 7 days. Polymyxin B/bacitracin (Polysporin) drops may also be used, 1 gtt every 3 hours for 7 to 10 days d. Macrolides: Erythromycin (Ilotycin) ophthalmic ointment 0. 5% in each eye four times daily for 7 days e. Fluoroquinolones: Ciprofloxacin 0. 3%: 1 to 2 gtts every 2 hours for 2 days, then every 4 hours for 5 days. Moxifloxacin (Vigamox) 0. 5% 1 gtt three times a day for 7 days 2. Viral a. Antiviral medications i. Trifluridine 1% drops: 1 drop every 2 hours while awake; no more than 9 drops per day. May then alter to 1 drop every 4 hours for 7 days. Not recommended for children younger than 6 years. ii. Oral antiviral medications (trifluridine, valacyclovir) may be used for herpes simplex keratitis. Herpes zoster ophthalmicus is often treated with acyclovir, famciclovir, or valacyclovir and lessens symptoms if started within 72 hours of onset of symptoms. 3. Allergic a. Topical antihistamines/mast cell stabilizer i. Azelastine HCl (Optivar): Not recommended for those younger than 3 years. For those older than 3 years, 1 drop to the affected eye twice a day. ii. Olopatadine HCl (Pataday) 0. 2%: Not recommended for those younger than 3 years. For those older than 3 years, 1 drop to the affected eye daily. iii. Olopatadine HCl (Patanol) 0. 1%: Not recommended for those younger than 3 years. For those older than 3 years, 1 drop twice a day to the affected eye. b. Mast cell stabilizer i. Cromolyn sodium (Crolom) ophthalmic solution for children older than 4 years, 1 to 2 drops four to six times daily. c. Topical nonsteroidal anti-inflammatory drug (NSAID) 270 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
i. Ketorolac tromethamine (Acular) 0. 5%: Not for use in children younger than 3 years: 1 drop four times a day. This is used for severe symptoms of atopic keratoconjunctivitis. d. Artificial tears four to five times daily e. Oral antihistamines may be used in severe cases (loratadine or diphenhydramine HCl). 4. Concurrent conjunctivitis and otitis media should be treated with a systemic antibiotic; no topical eye antibiotic is needed. Follow-Up A. If resolution occurs within 5 to 7 days after proper treatment, follow-up is not needed. B. If patient continues to have symptoms or if different symptoms appear, then follow-up with the primary provider is recommended. Consultation/Referral A. Consult or refer patient to a physician if patient is not responding to treatment. B. Refer if patient is suspected of having periorbital cellulitis. C. Refer to eye specialist if patient has vision change or eye pain, or is not responding to treatment. Individual Considerations A. Pediatrics: In neonates, consider gonococcal and chlamydial conjunctivitis. Perform culture if suspected. B. Partners: Check partners for gonorrhea and chlamydia when adolescent or adult presents with gonococcal or chlamydial conjunctivitis. Corneal Abrasion Jill C. Cash and Nancy Pesta Walsh Definition A. A corneal abrasion is the loss of epithelial tissue, either superficial or deep, from trauma to the eye. 271 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Incidence A. In the United States, approximately 2. 4 million eye injuries occur annually. B. Corneal abrasions account for approximately 10% of new admissions to eye emergency units. Pathogenesis A. Trauma occurs to the epithelial tissue of the cornea. Predisposing Factors A. Trauma to the eye caused by a human fingernail, tree branches, wood particles, children's toys, and sports injuries B. A history of surgical trauma, causing globe weakening. Common Complaints A. Sudden onset of eye pain B. Foreign-body sensation in the eye C. Watery eye D. Mild photophobia E. Blurred vision F. Headache Other Signs and Symptoms A. Change in vision B. Redness, swelling, inability to open the eye Subjective Data A. Elicit the onset, duration, and course of symptoms; note any past history of similar symptoms. B. Question the patient regarding visual changes (blurred, double, or lost vision, or loss of a portion of the visual field). C. Question the patient regarding the mechanism of injury and how much time has elapsed since the injury (minutes, hours, or days). Ask: What is his or her occupation, and what sports are involved? Were goggles being worn and are they routinely worn during the sport or activity? 272 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Review the patient's history of exposure to herpetic outbreaks. E. Determine the degree of pain, if any; headache; photophobia; redness; itching; or tearing. F. Ascertain whether the patient wears contact lenses or glasses and for what length of time. G. Ask if the patient has tried any treatments before presentation to the office. If so, what? H. Rule out the presence of any other infections, such as sinus infection. Conjunctival discharge signifies an infectious etiology. Physical Examination A. Vital signs: Temperature B. Inspect 1. Observe both eyes. 2. Test visual acuity and pupil reactivity and symmetry. 3. Observe the corneal surface with direct illumination, noting any shadow on the surface of the iris. 4. Perform funduscopic examination. 5. Evert eyelids for cornea inspection. 6. Inspect for foreign body and remove if indicated. 7. Fluorescein stain to visualize changes in epithelial lining. Cobalt blue light or Wood's lamp should be used for visualization. Diagnostic Test A. Perform fluorescein stain test: An epithelial defect that stains with fluorescein is the hallmark symptom. Differential Diagnoses A. Corneal abrasion B. Corneal foreign body C. Acute-angle glaucoma D. Herpetic infection (herpes simplex virus [HSV]):HSV is associated with decreased corneal sensation. E. Recurrent corneal ulceration F. Ulcerative keratitis G. Corneal erosion 273 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Plan A. General interventions 1. Superficial corneal abrasions do not need patching. 2. For deeper abrasions, apply a patch that prevents lid motion for 24 to 48 hours. 3. Pressure patch is no longer recommended. B. Patient teaching 1. Discuss the use of protective eyewear and prevention of future ocular trauma for the patient with a history of use of power tools or hammering. 2. See Section III: Patient Teaching Guide for this chapter, “ Eye Medication Administration. ” 3. Advise that the patient should not use/wear contact lenses until the eye is completely healed. C. Pharmaceutical therapy 1. Antibiotic drops or ointment. Ointments are suggested over drops as they provide lubrication for the eye. Never instill antibiotic ointment if there is a possibility of a perforation. Patch the eye and refer the patient to a physician or ophthalmologist. a. Adults and children: Sulfacetamide sodium ophthalmic solution 10% (Sulamyd), 1 to 2 drops instilled into the lower conjunctival sac every 2 to 3 hours during the day; may instill every 6 hours during the night × 5 to 7 days. b. Sulfacetamide's sodium (Sulamyd) ophthalmic solution or ointment interacts with gentamicin. Avoid using them together. c. Para-aminobenzoic acid (PABA) derivatives decrease sulfacetamide's action. Wait 0. 5 to 1 hour before instilling sulfacetamide. d. Sulfacetamide precipitates when used with silver preparations. Avoid using them together. 2. Adults and children: Polymyxin B sulfate (Polytrim) 10,000 U/g, bacitracin zinc 500 U/g ophthalmic ointment (Polysporin), a small ribbon of ointment applied into the conjunctival sac one or more times daily or as needed. 3. Adults and children: Erythromycin ophthalmic ointment 0. 5% (Ilotycin), 1-cm ribbon of ointment applied into the conjunctival sac up to 274 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
four to six times daily, depending on the severity of infection. 4. Bacitracin 500 U/g ointment, 1/2-inch ribbon twice a day to four times a day for 7 days. 5. Contact lens wearers are often colonized with Pseudomonas, and should be treated with either a fluoroquinolone or an aminoglycoside. Ciprofloxacin 0. 3% solution, 1 to 2 drops four times a day, for 3 to 5 days; gentamycin 0. 3% solution 1 to 2 drops, four times a day, for 3 to 5 days; or tobramycin (Tobrex) ointment or drops, four times a day for 3 to 5 days. 6. Analgesics: Topical analgesics should be used sparingly. Diclofenac (Voltaren) 0. 1% solution to eye four times a day as needed, or ketorolac (Acular) 0. 5% solution in eye four times a day as needed. 7. Avoid use of home prescriptions that will interfere with the healing process. 8. Avoid the use of medications containing steroids. These products may increase the risk of superinfection and may slow down the healing process. Follow-Up A. Reevaluate the patient within 24 hours. The cornea usually heals within 24 to 48 hours. B. Ophthalmic ointment or drops should be continued for 4 days after reepithelialization occurs to help in the healing process. C. If the patient is still symptomatic in 48 hours, consider referral to an ophthalmologist. Consultation/Referral Immediate referral to an ophthalmologist is required for large or central lesions, or deep or penetrating wounds. Individual Considerations A. Pregnancy: Retinal detachment should be considered as a source of eye pain and visual loss, especially in a woman with severe pregnancy-induced 275 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
hypertension. B. Pediatrics: The use of ointments is suggested over the use of eye drops due to the lubricating effect. Blurry vision may be experienced; therefore, apply the ointment at nap time and bedtime. Eye drops commonly burn/sting. 1. Pressure patches are not recommended for children. Children commonly pull patches off and this counteracts the purpose of the use of a pressure patch. 2. Preventive precautions include encouraging the use of protective eyewear for contact sports, including hockey, soccer, baseball, and basketball. Dacryocystitis Jill C. Cash and Nancy Pesta Walsh Definition A. Infection or inflammation of the lacrimal sac, or dacryocystitis, can be acute or chronic. B. Dacryocystitis is usually secondary to obstruction. Incidence A. The incidence is unknown. Pathogenesis A. Bacterial infection of the lacrimal sac usually is caused by Staphylococcus or Streptococcus. Predisposing Factors A. Nasal trauma B. Deviated septum C. Nasal polyps D. Congenital dacryostenosis E. Inferior turbinate hypertrophy Common Complaints 276 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Pain in the eye B. Redness C. Swelling D. Fever E. Tearing Other Signs and Symptoms A. Purulent exudate may be expressed from the lacrimal duct. Subjective Data A. Elicit the onset, course, and duration of symptoms. Are symptoms bilateral or unilateral? B. Review the patient's activity when the symptoms began to determine if etiology is chemical, traumatic, or infectious. C. Review other presenting symptoms such as fever and discharge. D. Review the patient's history for previous episodes. Note treatments used in past. E. Review history for a recent HSV or fever blister. F. Review ophthalmologic history. G. Review medications. Physical Examination A. Check temperature, pulse, and blood pressure. B. Inspect 1. Assess both eyes. 2. Check peripheral fields of vision, and sclera. 3. Evaluate conjunctiva for distribution of redness, ciliary flush, and foreign bodies. 4. Inspect lid margins: Evaluate for crusting, ulceration, and masses. C. Palpate: Palpate lacrimal duct. Discharge can be expressed from the tear duct with the application of pressure. Diagnostic Tests A. Check visual acuity. B. Culture discharge for Neisseria if suspected. 277 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Differential Diagnoses A. Dacryocystitis B. Chalazion C. Blepharitis D. Xanthoma E. Bacterial conjunctivitis F. Hordeolum G. Foreign body H. Cellulitis Plan A. General interventions 1. Apply warm, moist compresses at least four times per day. 2. Instruct female patients to discard old makeup, including mascara, eyeliner, and eye shadow, used before infection. B. Patient teaching: Application of compresses, handwashing, and proper cleaning. See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration. ” See Figure 5. 1: How to instill eye drops into the eye. C. Pharmaceutical therapy 1. Dicloxacillin 250 mg by mouth four times daily for 7 days 2. Erythromycin 250 mg by mouth four times daily for 7 days Follow-Up A. Follow up in 2 weeks if symptoms are not resolved. Consultation/Referral A. Refer the patient to an ophthalmologist for irrigation and probing if needed. B. Lab studies are generally performed by an ophthalmologist. 278 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
FIGURE 5. 1 How to instill eye drops into the eye. Dry Eyes Jill C. Cash and Nancy Pesta Walsh Definition A. Insufficient lubrication of the eye, or dry eyes, is caused by a deficiency of any one of the major components of the tear film. B. Defects in tear production are uncommon but may occur in conjunction with systemic disease. Presence of systemic disease should be evaluated. Incidence A. Increased incidence of dry eyes in the elderly is due to decreased rate of lacrimal gland secretions. Pathogenesis A. Decreased production of one or more components of the tear film results in dry eyes. The tear film comprises three layers: 1. An outermost lipid layer, excreted by the lid meibomian glands 2. A middle aqueous layer, secreted by the main and accessory lacrimal glands 3. An innermost mucinous layer, secreted by conjunctival goblet cells B. A defect in production of the aqueous phase by lacrimal glands causes dry eyes or keratoconjunctivitis sicca. The condition most often occurs as a physiological consequence of aging, and it is commonly exacerbated by dry 279 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
environmental factors. It may also develop in patients with connective tissue disease. C. In Sjögren's syndrome, the lacrimal glands become involved in immune-mediated inflammation. D. Mucin production may decline with vitamin A deficiency. E. Loss of goblet cells can occur secondary to chemical burns. Predisposing Factors A. History of severe conjunctivitis B. Eyelid defects such as fifth or seventh cranial nerve palsy, incomplete blinking, exophthalmos, and lid movement hindered by scar formation C. Drug-induced conditions, including the use of anticholinergic agents 1. Phenothiazine 2. Tricyclic antidepressants 3. Antihistamines 4. Diuretics 5. Isotretinoin (Accutane) D. Systemic disease such as rheumatoid disease, Sjögren's syndrome, and neurologic disease E. Environmental factors such as heat (wood, coal, and gas), air conditioners, winter air, and tobacco smoke F. Use of contacts G. Increasing age H. Lipid abnormalities Common Complaints A. Ocular fatigue B. Foreign-body sensation in the eye C. Itching, burning, irritation, or dry sensation in the eye D. Redness E. Eye discharge Other Signs and Symptoms A. Photophobia B. Cloudy, blurred vision C. Rainbow of color around lights. Acute angle-closure glaucoma can 280 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
present with a red, painful eye; cloudy, blurred vision and a rainbow of color around lights; dilatation of the pupil; nausea and vomiting D. Bell's palsy, signs of stroke, or other conditions that affect the blinking mechanism Subjective Data A. Elicit the onset, duration, and frequency of symptoms. B. Note factors that worsen or alleviate symptoms. C. Note medical history for systemic conditions and strokes. D. List current medications, noting anticholinergic drugs and isotretinoin (Accutane) use. E. Note whether the patient wears contact lenses or glasses, and ask for what length of time. F. Review occupational and home exposure to irritants and allergens. G. Assess whether the patient produces tears. Note eye drainage amount, color, and frequency. H. Review history of any previous ocular disease, surgeries, and so forth. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Observe and evaluate both eyes. 2. Conduct a detailed eye examination: Check the eye, lid, and conjunctiva for masses and redness. 3. Check pupil reactivity and corneal clarity. The corneal reflex should be checked if there is concern about a neuroparalytic keratitis or facial nerve palsy. 4. Complete a funduscopic examination. Check for completeness of lid closure as well as position of eyelashes. 5. Examine mouth for dryness. 6. Inspect skin for butterfly rash. C. Palpate 1. Palpate lacrimal ducts for drainage. 2. Invert upper lid and check for foreign body or chalazion. 3. Check sinuses for tenderness. 4. Palpate thyroid. 281 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
5. Palpate joints for warmth and redness or inflammation. Diagnostic Test A. Perform Schirmer's test. Use Whatman no. 41 filter paper, 5 mm by 35 mm. A folded end of filter paper is hooked over the lower lid nasally, and the patient is instructed to keep his or her eyes lightly closed during the test. Wetting is measured after 5 minutes; less than 5 mm is usually abnormal. More than 10 mm is normal. Differential Diagnoses A. Dry eyes B. Stevens-Johnson syndrome C. Sjögren's syndrome: Chronic dry mouth, dry eyes, and arthritis triad suggest Sjögren's syndrome. Facial telangiectasias, parotid enlargement, Raynaud's phenomenon, and dental caries are associated features. Patients complain first of burning and a sandy, gritty, foreign-body sensation, particularly later in the day. D. Systemic lupus erythematosus E. Scleroderma F. Ocular pterygium G. Superficial pemphigoid H. Vitamin A deficiency Plan A. General interventions 1. If no ocular disease is present, reduce environmental dryness by use of a room humidifier for a 2-week trial. 2. Apply artificial tear substitutes and nonprescription drops. 3. Consider stopping medications being used that may be contributing to the source of dry eye symptoms. 4. Caution should be used when using over-the-counter (OTC) allergy medications, if allergy is a contributing cause. Topical antihistamines may exacerbate the condition over time. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration. ” C. Pharmaceutical therapy 282 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Topical artificial tears 1 or 2 drops four times daily, preferably one without preservatives (i. e., Thera-tears, Dry Eye Therapy, Tears Naturale). 2. Drops may be instilled as often as desired. Follow-Up A. Determined by the severity of the issue. Reevaluate the patient in 2 weeks. Consultation/Referral A. Refer the patient to an ophthalmologist if symptoms are unrelieved at the 2-week follow-up. B. Make an immediate referral for red eye, visual disturbance, or eye pain. Individual Consideration A. Geriatrics: The rate of lacrimal gland secretions diminishes with age; therefore, the elderly are at an increased risk for developing dry eye. B. ACE inhibitors may reduce the risk of dry eye syndrome in some patients. Consider treatment with ACE inhibitors for hypertension as appropriate in clients. Excessive Tears Jill C. Cash and Nancy Pesta Walsh Definition A. Excessive tears disorder is an overproduction of tears. Complaints vary from watery eyes to overflowing tears that run down the cheeks, a condition known as epiphora. Incidence A. The incidence is unknown. Pathogenesis A. The most common cause is reflex overproduction of tears (as occurs in 283 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
the elderly) due to a deficiency of the tear film. B. Lacrimal pump failure and obstruction of the nasolacrimal outflow system are other causes of excessive tears. C. Canalicular infections may be caused by Actinomyces israelii (Streptothrix) and Candida. Predisposing Factors A. Blepharitis (inflammation of the eyelid) B. Allergic conjunctivitis (infectious or foreign body) C. Exposure to cold, air conditioning, or dry environment D. Lid problems: Impaired pumping action of the lid motion due to seventh nerve palsy or conditions that stiffen the lids such as scars or scleroderma E. Lid laxity from aging or ectropion (sagging of the lower lid) F. Sinusitis G. Atopy H. Age: Increased incidence in the elderly due to an overproduction of tears by the lacrimal gland I. Congenital obstruction Common Complaints A. Watery eyes or tears running down cheeks are common complaints. Other Signs and Symptoms A. Unilateral tearing: Obstructive etiology B. Bilateral tearing: Environmental irritants Subjective Data A. Inquire about onset, course, and duration of symptoms. Note frequency of excessive tearing. B. Ascertain whether this is a new symptom or whether the patient has a past history of similar complaints. Ask how it was treated, and what was the response to treatment(s). C. Determine severity. Do the tears run down the cheek? D. Ascertain whether tearing is unilateral or bilateral. E. Review common environmental predisposing factors. F. Question the patient regarding vision changes. 284 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Review medical history. H. Review recent history for sinus infections or drainage, facial fractures, and surgery. Physical Examination A. Inspect 1. Evaluate both eyes. 2. Observe the lid structure and motion. 3. Conduct a dermal examination to rule out butterfly rash. B. Palpate 1. Apply gentle pressure over the lacrimal sac to check drainage. 2. Invert upper lid to check for foreign body. 3. Palpate face for sinus tenderness. Diagnostic Test A. Culture any drainage expressed from the lacrimal sacs. Differential Diagnoses A. Excessive tears B. Dendritic ulcer: Early symptoms are tears running down cheeks associated with a foreign-body sensation. C. Congenital glaucoma D. Dacryocystitis (purulent discharge) E. Reflex tearing caused by dry eye F. Blepharitis Plan A. General interventions 1. Eliminate identifiable irritants. 2. Treatment is mainly aimed at the underlying condition (i. e., ocular infection). 3. Dacryocystitis is treated with hot compresses at least four times a day and systemic antibiotics. B. Patient teaching: Instruct the patient on the application of compresses. C. Pharmaceutical therapy 1. None is required for diagnosis of excessive tears without infectious 285 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
pathology. 2. Dacryocystitis a. Erythromycin 250 mg four times daily for 7 days b. Dicloxacillin 250 mg four times daily for 7 days Follow-Up A. See patient in 48 to 72 hours to evaluate symptoms, especially if antibiotic therapy was needed. Consultation/Referral A. Patients unresponsive to treatment should be promptly referred to an ophthalmologist. B. Consider referral for lid malposition or nasolacrimal duct obstructions. Individual Consideration A. Pediatrics: Nasolacrimal duct obstruction. Approximately 6% of newborns are diagnosed with a congenital obstruction within the first weeks of life. With moist heat and massage, many resolve spontaneously. Eye Pain Jill C. Cash and Nancy Pesta Walsh Definition A. Sensation of pain may affect the eyelid, conjunctiva, or cornea. Incidence A. Unknown. Pain in the eye is most often produced by conditions that do not threaten vision. Pathogenesis A. The external ocular surfaces and the uveal tract are richly innervated with pain receptors. As a result, lesions or disease processes affecting these surfaces can be acutely painful. B. Pathology confined to the vitreous, retina, or optic nerve is rarely a source 286 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
of pain. Predisposing Factors A. Eyelids: Inflammation such as hordeolum (stye), trichiasis (in-turned lash), and tarsal foreign bodies B. Conjunctiva: Viral and bacterial conjunctivitis or allergic conjunctivitis; toxic, chemical, and mechanical injuries C. Cornea: Keratitis (inflammation of the cornea) accompanying trauma, infection, exposure, vascular disease, or decreased lacrimation; microbial keratitis from contact use. If blood vessels invade the normally avascular corneal stroma, vision may become cloudy. Severe pain is a prominent symptom; movement of the lid typically exacerbates symptoms. Common Complaints A. Eye pain (sharp, dull, deep): The quality of the pain needs to be considered. Deep pain is suggestive of an intraocular problem. Inflammation and rapidly expanding mass lesions may cause deep pain. Displacement of the globe and diplopia may ensue. B. Eye movement may cause sharp pain due to meningeal inflammation (the extraocular rectus muscles insert along the dura of the nerve sheath at the orbital apex). Most cases are idiopathic, but 10% to 15% are associated with multiple sclerosis. C. Headache Other Signs and Symptoms These symptoms may be unilateral or bilateral. A. Eyelids 1. Tenderness 2. Sensation of foreign body 3. Redness 4. Edema B. Conjunctiva 1. Mild burning 2. Sensation of foreign body 3. Itching (allergic) C. Cornea 287 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Burning 2. Foreign-body sensation 3. Considerable discomfort 4. Reflex photophobic tearing 5. Blinking exacerbates pain 6. Pain relieved with pressure (i. e., holding the lid shut). With a foreign body or a corneal lesion, pain is exacerbated by lid movement and relieved by cessation of lid motion. D. Sclera: Redness E. Uveal tract (uveitis or iritis) 1. Dull, deep-seated ache and photophobia 2. Profound ocular and orbital pain radiating to the frontal and temporal regions accompanying sudden elevation of pressure (acute angle-closure glaucoma) 3. Vagal stimulation with high pressure may result in nausea and vomiting. 4. Usual history of mild intermittent episodes of blurred vision preceding onset of throbbing pain, nausea, vomiting, and decreased visual acuity 5. Halos around light F. Orbit 1. Deep pain with inflammation and rapidly expanding mass lesions 2. Eye movement causing sharp pain due to meningeal inflammation G. Sinusitis: Secondary orbital inflammation and tenderness on extremes of eye movement Subjective Data A. Review the onset, duration, and course of symptoms. Inquire regarding the quality of pain. B. Review any predisposing factors such as trauma or a foreign object. Ask: Was the onset sudden or gradual? C. Note reported changes in visual acuity or color vision. D. Note aggravating or alleviating factors. E. Determine whether the eye pain is bilateral or unilateral. F. Review history for herpes, infections, and toxic or chemical irritants. G. Review history for glaucoma and previous eye surgeries or treatments. H. Assess the patient for any other symptoms such as migraine headache, 288 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
sinusitis, or tooth abscess. I. Inquire whether the patient has lost a large amount of sleep. J. Inquire whether he or she has been exposed to a large amount of ultraviolet (UV) light or sunlight (vacation, tanning beds). K. Review history for any other medical problems such as lupus, sarcoidosis, or inflammatory bowel disease. Physical Examination A. Inspect 1. Evaluate both eyes. 2. Test visual acuity and color vision. 3. Observe for EOMs. 4. Check the eye, lid, and conjunctiva for masses and redness. 5. Check pupil reactivity and corneal clarity. 6. Conduct a funduscopic examination for disc abnormalities. 7. Perform ear, nose, and throat examination. B. Palpate 1. Palpate lacrimal ducts for drainage. 2. Palpate sinus for tenderness. 3. Invert upper lid and check for foreign body or chalazion. Diagnostic Tests A. Fluorescein stain B. Measurement of intraocular pressure (IOP) Differential Diagnoses A. Eye pain B. Hordeolum C. Chalazion D. Acute dacryocystitis E. Irritant exposure F. Conjunctival infection G. Corneal abrasion H. Foreign body I. Ulcers J. Ingrown lashes 289 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
K. Contact lens abuse L. Scleritis M. Acute angle-closure glaucoma; may present with fixed, midposition pupil, redness, and a hazy cornea N. Uveitis O. Referred pain from extraocular sources such as sinusitis, tooth abscess, tension headache, temporal arteritis, and prodrome of herpes zoster Plan A. General interventions 1. The initial task is to be sure that there is no threat to vision. 2. Treatment modality depends on the underlying cause of eye pain. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration. ” See Figure 5. 1: How to instill eye drops into the eye. C. Pharmaceutical therapy: Medication depends on the underlying cause. Follow-Up A. Follow-up depends on the underlying cause. Consultation/Referral A. Any change in visual acuity or color vision requires an urgent ophthalmologic consultation. Glaucoma, Acute Angle-Closure Jill C. Cash and Nancy Pesta Walsh Definition A. This ocular emergency is caused by elevations in intraocular pressure (IOP) that damage the optic nerve, leading to loss of peripheral fields of vision; it can lead to loss of central vision and result in blindness. Incidence A. Acute angle closure glaucoma is the second leading cause of blindness in 290 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
the United States. Approximately 5% to 15% of the patient population develops glaucoma. Pathogenesis A. The essential pathophysiologic feature of glaucoma is an IOP that is too high for the optic nerve. Increased IOP increases vascular resistance, causing decreased vascular perfusion of the optic nerve and ischemia. Light dilates the pupil, causing the iris to relax and bow forward. As the iris bows forward, it comes into contact with the trabecular meshwork and occludes the outflow of aqueous humor, resulting in increased IOP. Predisposing Factors A. Narrow anterior ocular chamber B. Prolonged periods of darkness C. Drugs that dilate the pupils (i. e., anticholinergics) D. Advancing age: Greater than 60 years E. African American heritage F. Family history G. Trauma H. Neoplasm I. Corticosteroid therapy J. Neovascularization K. Female sex Common Complaints A. Ocular pain B. Blurred vision, decreased visual acuity, “cloudiness” of vision C. “Halos” around lights at night D. Neurologic complaints (headache, nausea, or vomiting) Other Signs and Symptoms A. Red eye with ciliary flush B. “Silent blinder” causes extensive damage before the patient is aware of visual field loss C. Dilated pupil D. Hard orbital globe 291 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. No pupillary response to light F. Increase IOP (normal IOP is 10-20 mm Hg). Subjective Data A. Review the onset, course, and duration of symptoms; note visual changes in one or both eyes. B. Review medical history and medications. C. Review family history of glaucoma. D. Determine whether there has been any difficulty with peripheral vision, any headache photophobia, or any visual blurring. E. In children, ask about rubbing of eyes, refusal to open eyes, and tearing. F. Rule out presence of any chemical, trauma, or foreign bodies in the eye. G. Review any recent history of herpes outbreak. H. Ask the patient whether this has ever occurred before, and if so, how it was treated. Physical Examination A. Blood pressure B. Inspect 1. Examine both eyes. 2. Rule out foreign body. 3. Inspect for redness, inflammation, and discharge. 4. Check pupillary response to light. 5. Redness noted around iris, pupil is dilated, and cornea appears cloudy. 6. Inspect anterior chamber of eye by holding penlight laterally and direct toward nasal area. Shallow chamber will cast a shadow on the nasal side of the iris. C. Palpate: Palpate the globe of the eye, which will feel firm on palpation. D. Funduscopic examination: This may reveal notching of the cup and a difference in cup-to-disc ratio between the two eyes. Diagnostic Tests A. Check visual acuity and peripheral fields of vision. B. Measure IOP with a tonometer. Normal level is 10 to 21 mm Hg; acute angle closure glaucoma IOP is greater than 50 mm Hg. Tonometer examination is not recommended if external infection is present. 292 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Slit-lamp examination: Edematous and/or cloudy cornea Differential Diagnoses A. Acute angle-closure glaucoma B. Acute iritis C. Acute bacterial conjunctivitis D. Iridocyclitis E. Corneal injury F. Foreign body G. Herpetic keratitis Plan A. General interventions 1. Severe attacks can cause blindness in 2 to 3 days. Seek medical attention immediately to prevent permanent vision loss. 2. Frequency of attacks is unpredictable. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration. ” C. Pharmaceutical therapy: Must be instituted by an ophthalmologist. 1. Acetazolamide (Diamox) 250 mg orally 2. Pilocarpine (Pilocar) 4% every 15 minutes during acute attack D. Surgical intervention 1. Surgery is indicated if IOP is not maintained within normal limits with medications or if there is progressive visual field loss with optic nerve damage. 2. Surgical treatment of choice is peripheral iridectomy—excision of a small portion of the iris whereby the aqueous humor can bypass the pupil. Follow-Up A. Annual eye examinations by an ophthalmologist are necessary to monitor IOP and treatment efficacy. Consultation/Referral A. All patients should be referred to an ophthalmologist immediately for measurement of IOP, acute management, and possible surgical intervention (laser peripheral iridectomy). 293 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Individual Considerations A. Pediatrics: Infants with tearing, rubbing of eyes, and refusal to open eyes should be referred to a pediatric ophthalmologist for immediate care. B. Adults 1. Women normally have slightly higher IOPs than men. 2. Asians may have higher IOPs than African Americans and Caucasians. 3. Individuals older than age 40 years should have their IOP measured periodically. Every 3 to 5 years is sufficient after a stable baseline is established for the patient. C. Geriatrics: Incidence increases with age, usually in those older than 60 years. Hordeolum (Stye) Jill C. Cash and Nancy Pesta Walsh Definition A. Hordeolum is an infection of the glands of the eyelids (follicle of an eyelash or the associated gland of Zeis [sebaceous] or Moll's gland [apocrine sweat gland]), usually caused by Staphylococcus aureus. B. If swelling is under the conjunctival side of the eyelid, it is an internal hordeolum. C. If swelling is under the skin of the eyelid, it is an external hordeolum. Incidence A. The incidence is unknown; it is more common in children and adolescents than in adults. Pathogenesis A. Acute bacterial infection of the meibomian gland (internal hordeolum) or of the eyelash follicle (external hordeolum) is usually caused by S. aureus. Predisposing Factor A. Age: More common in the pediatric population 294 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Common Complaints A. Eye tenderness B. Sudden onset of a purulent discharge Other Signs and Symptoms A. Redness and swelling of the eye Subjective Data A. Review the onset, course, and duration of symptoms. B. Determine whether there is any visual disturbance. C. Note whether this is the first occurrence. If not, ask how it was treated before. D. Evaluate how much pain or discomfort the patient is experiencing. E. Review the patient's history for chemical, foreign body, and/or trauma etiology. F. Review the patient's medical history and medications. Physical Examination A. Inspect 1. Examine both eyes; note redness, site of swelling, and amount and color of discharge. 2. Evert the lid and check for pointing. 3. Assess sclera and conjunctivae for abnormalities. 4. Inspect ears, nose, and throat. B. Palpate 1. Palpate eye for hardness and expression of discharge. 2. Evaluate for preauricular adenopathy. Diagnostic Tests A. Test visual acuity. B. Discharge can be cultured but is usually treated presumptively. Differential Diagnoses A. Hordeolum B. Chalazion: The main differential diagnosis is chalazia, which point on the 295 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
conjunctival side of the eyelid and do not usually affect the margin of the eyelid. C. Blepharitis D. Xanthoma E. Bacterial conjunctivitis F. Foreign body Plan A. General interventions: Contain the infecting pathogen. Crops occur when the infectious agent spreads from one hair follicle to another. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Eye Medication Administration. ” See Figure 5. 1: How to instill eye drops into the eye. 2. Reinforce good handwashing. 3. Instruct on proper eyelid hygiene. 4. Patients should discard all eye makeup, including mascara, eyeliner, and eye shadow. C. Pharmaceutical therapy 1. Sulfacetamide sodium (Sulamyd) ophthalmic ointment 10%; 0. 5 to 1. 0 cm placed in the conjunctival sac four times daily for 7 days 2. Sulfacetamide sodium (Sulamyd) 10% ophthalmic drops; 2 drops instilled every 3 to 4 hours for 7 days 3. Polymyxin B sulfate and bacitracin zinc (Polysporin) ophthalmic ointment; 0. 5 to 1. 0 cm placed in the conjunctival sac four times daily for 7 days 4. If crops of styes occur, some clinicians recommend a course of tetracycline to stop recurrences (consult with a physician). Follow-Up A. Have patient telephone or visit the office in 48 hours to check response. B. If crops occur, diabetes mellitus must be excluded. Perform blood glucose evaluation. Consultation/Referral A. Hordeolum may produce a diffuse superficial lid infection known as 296 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
preseptal cellulitis that requires referral to an ophthalmologist. B. If hordeolum does not respond to topical antimicrobial treatment, refer the patient to an ophthalmologist. Individual Consideration A. None Strabismus Jill C. Cash and Nancy Pesta Walsh Definition Strabismus is an eye disorder in which the optic axes cannot be directed toward the same object due to a deficit in muscular coordination. It can be nonparalytic or paralytic. A. Esotropia is a nonparalytic strabismus in which the eyes cross inward. B. Exotropia is a nonparalytic strabismus in which the eyes drift outward. Exotropia may be intermittent or constant. C. Pseudostrabismus gives a false appearance of deviation in the visual axes. Incidence A. Strabismus occurs in approximately 3% of the population. B. Esotropia (nonparalytic strabismus) is the most common ocular misalignment, representing more than half of all ocular deviations in the pediatric population. Accommodative esotropia typically occurs between 1 and 3 years of age, with an average age of 2. 5 years, and it may be intermittent or constant. C. Intermittent exotropia is the most common type of exotropic strabismus and is characterized by an outward drift of one eye, most often occurring when a child is fixating at distance. Pathogenesis A. Paralytic strabismus is related to paralysis or paresis of a specific extraocular muscle. Nonparalytic strabismus is related to a congenital imbalance of normal eye muscle tone, causing focusing difficulties, unilateral 297 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
refractive error, nonfusion, or anatomical difference in the eyes. Predisposing Factors A. Familial tendencies B. Congenital defects Common Complaints A. Crossing of the eyes B. Turning in of the eyes C. Photophobia D. Diplopia Other Signs and Symptoms A. The patient's head or chin tilts or the patient closes one eye to focus on objects. Subjective Data A. Describe the onset, duration, and progression of symptoms. B. Review any history of eye problems. Ask: How were they corrected? C. Determine whether the patient, if a child, has reached the age-appropriate milestones in development. D. Does the patient make faces or move his or her head to see better (tilting the head or chin to improve acuity or to correct diplopia)? E. Rule out any eye damage, surgery, and so forth. Physical Examination A. Inspect: Observe alignment of lids, sclera, conjunctiva, and cornea. B. Check pupillary response to light, size, shape, and equality. C. Check the red reflex. Diagnostic Tests A. Test visual acuity. B. Perform the cover-uncover test: In this test, the “lazy eye” drifts out of position and snaps back quickly when uncovered. C. Corneal light reflex (Hirschberg's) test: Perform the Hirschberg's test for symmetry of the pupillary light reflexes to help detect strabismus. Normally, 298 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
the light reflexes are in the same position on each pupil, but not with strabismus (positive Hirschberg's test). D. Test EOMs: If a nerve supplying an extraocular muscle has been interrupted or the muscle itself has become weakened, the eye fails to move in the direction of the damaged muscle. If the right sixth nerve is damaged, the right eye does not move temporally. This is paralytic strabismus. Differential Diagnoses A. Strabismus B. Pseudostrabismus C. Ocular trauma D. Congenital defect Plan A. General interventions 1. When poor fixation is present, patch the stronger, dominant eye to promote vision and muscle strengthening in the weaker eye. B. Patient teaching: Reinforce the need to consistently wear an eye patch, especially with children. C. Pharmaceutical therapy: None. Follow-Up A. Monitor progress with eye patch. B. Surgical intervention depends on the degree of deviation. Consultation/Referral A. Additional testing should be done by an ophthalmologist. B. Pseudostrabismus (a false appearance of strabismus when visual axes are really in alignment) is one of the most common reasons a pediatric ophthalmologist is asked to evaluate an infant. Individual Considerations A. Pediatrics 1. Use the tumbling or illiterate E to test children; for preschoolers, use the Allen picture cards. 2. In very young children, test visual acuity by assessing developmental 299 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
milestones: Looking at mother's face, responsive smile, reaching for objects. By 3 to 5 years of age, most children can cooperate for performance of accurate visual acuity screening tests. 3. The eyes of the newborn are rarely aligned during the first few weeks of life. By the age of 3 months, normal oculomotor behavior is usually established, and an experienced examiner may be able to document the existence of abnormal alignment by that time. Subconjunctival Hemorrhage Jill C. Cash and Nancy Pesta Walsh Definition A. Subconjunctival hemorrhage presents as blood patches in the bulbar conjunctiva. Incidence A. Frequently seen in newborns, subconjunctival hemorrhage may also be seen in adults after forceful exertion (coughing, sneezing, childbirth, strenuous lifting). Pathogenesis A. This disorder is believed to be secondary to increased intrathoracic pressure that may occur during labor and delivery or with physical exertion. Predisposing Factors A. Local trauma B. Systemic hypertension C. Acute conjunctivitis D. Vaginal delivery (pushing during delivery) E. Severe coughing F. Severe vomiting Common Complaint A. Red-eyed appearance without pain 300 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Other Signs and Symptoms A. Bright red blood in plane between the conjunctiva and sclera B. Usually unilateral C. Normal vision Subjective Data A. Identify onset and duration of symptoms. B. Elicit information about trauma to the eye; is it due to severe coughing or vomiting? C. Identify history of conjunctivitis or hypertension. Physical Examination A. Check temperature, pulse, respirations, and blood pressure (rule out hypertension). B. Inspect 1. Observe eyes. 2. Inspect ears, nose, and mouth. 3. Inspect skin for bruises or other trauma. 4. Assess for signs of trauma or abuse. Blood in the anterior chamber (hyphema) can result from injury or abuse. C. Other physical examination components are dependent on etiology. Diagnostic Tests A. Perform visual screening. B. Test EOMs and peripheral vision. Differential Diagnoses A. Subconjunctival hemorrhage B. Systemic hypertension C. Blood dyscrasia D. Trauma to eye E. Conjunctivitis F. Hyphema G. Abuse Plan 301 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. General interventions: Reassure the patient. The hemorrhage is not damaging to the eye or vision, and the blood reabsorbs on its own over several weeks. B. Teach safety to prevent trauma to the eye. C. Pharmaceutical therapy: None. Follow-Up A. If subconjunctival hemorrhage recurs, evaluate the patient further for systemic hypertension or blood dyscrasia. Consultation/Referral A. Consult or refer the patient to a physician if hyphema is noted, if glaucoma is suspected, or if the patient has additional eye injuries. Individual Considerations A. Pediatrics: Hemorrhage is common in newborns after vaginal delivery. B. Adults: Always measure blood pressure to rule out systemic hypertension. C. Geriatrics 1. Always measure blood pressure to rule out systemic hypertension. 2. Consider evaluation for blood dyscrasia. 3. Check clotting times if patient is taking warfarin (Coumadin). Uveitis Jill C. Cash and Nancy Pesta Walsh Definition A. Uveitis, also known as iritis, is inflammation of the uveal tract (iris, ciliary body, and choroid) and is usually accompanied by a dull ache and photophobia resulting from the irritative spasm of the pupillary sphincter. Incidence A. The true incidence is unknown. Approximately 15% of patients with sarcoidosis present with uveitis. Pathogenesis 302 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. The cause is unknown. Underlying causes include infections, viruses, and arthritis. Predisposing Factors A. Collagen disorders B. Autoimmune disorders C. Ankylosing spondylitis D. Sarcoidosis E. Juvenile rheumatoid arthritis F. Lupus G. Reiter's syndrome H. Behcet's syndrome I. Syphilis J. Tuberculosis K. AIDS L. Crohn's disease Common Complaints A. Eye pain: Painless to deep-seated ache B. Photophobia C. Blurred vision with decreased visual acuity D. Black spots E. Eye redness Other Signs and Symptoms A. Unilateral or bilateral symptoms 1. Unilateral: The pupil is smaller than that of the other eye because of spasm. B. Ciliary flush C. Pupillary contraction D. Nausea and vomiting with vagal stimulation E. Halos around lights F. Hypopyon (pus in anterior chamber) G. Limbal flush with small pupil Subjective Data 303 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Elicit the onset, course, duration, and frequency of symptoms. Are symptoms bilateral or unilateral? B. Identify the possible causal activity or agent (chemical, traumatic, or infectious etiologies). C. Review the patient's history of previous uveitis and other ophthalmologic disorders. D. Review any associated fever, rash, weight loss, joint pain, back pain, oral ulcers, or genital ulcers. E. Review full medical history for comorbid conditions. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Assess both eyes for visual acuity and peripheral fields of vision. 2. Check sclera and conjunctiva. C. Other physical components need to be completed related to comorbid conditions. Diagnostic Tests A. Slit-lamp test: Slit-lamp examination reveals cells in the anterior chamber and “flare,” representing increased aqueous humor protein. Inflammatory cells, called keratic precipitates, can collect in clusters on the posterior cornea. B. Penlight examination: Flashlight examination shows a slightly cloudy anterior chamber in the uveitic eye. Differential Diagnoses A. Uveitis: Uveitis is usually idiopathic, but it may be associated with many systemic and ocular diseases. B. Acute angle closure glaucoma C. Retinal detachment D. Central retinal artery occlusion E. Endophthalmitis Plan A. General interventions 304 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Treat underlying cause as indicated. 2. Provide immediate referral to an ophthalmologist due to possible complications of cataracts and blindness. B. Patient teaching: Inform the patient that recurrent attacks are common and also require immediate attention. C. Pharmaceutical therapy 1. Medications are given per ophthalmologist. 2. Uveitis and colitis often flare simultaneously; oral steroids are effective for both. Follow-Up A. The patient with uveitis needs a follow-up with an ophthalmologist. Consultation/Referral A. The patient should be referred immediately to an ophthalmologist for evaluation and intervention. Individual Considerations A. Recurrent uveitis may be a sign of another systemic condition. Other conditions to consider: Infections (bacterial, spirochetal, viral, fungal, and parasitic infections); inflammatory diseases, including spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis); inflammatory bowel disease; multiple sclerosis; and the use of new medications. Further workup should be performed for recurrent uveitis. Resources American Academy of Ophthalmology P. O. Box 7424 San Francisco, CA 94120-7424 415-561-8500 Fax: +1 415-561-8533 E-mail: member_services@aao. org American Council of the Blind 1703 N. Beauregard St. Suite 420 Arlington, VA 22201 Phone: 202-467-508, 1 800-424-8666 Fax: 703-465-5085 305 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E-mail: info@acb. org American Foundation of the Blind 2 Penn Plaza, Suite 1102 New York, NY 10121 Phone: 212-502-7600 Fax: 888-545-8331 E-mail: afbinfo@afb. net American Printing House for the Blind 1839 Frankfort Avenue P. O. Box 6085 Louisville, KY 40206-6085 Phone: 800-223-1839; 502-895-2405 Fax: 502-899-2284 E-mail: info@aph. org Books on Tape Phone: 800-733-3000 Glaucoma Research Foundation 251 Post Street, Suite 600 San Francisco, CA 94198 Phone: 415-986-3162 800-826-6693 E-mail: questions@glaucoma. org Guide Dog Foundation for the Blind 371 E Jerico Turnpike Smithtown, NY 11787 Phone: 631-930-9000; 800-548-4337 Fax: 631-930-9009 9 a. m. to 5 p. m. (Eastern Standard Time), Monday through Friday, E-mail: info@guidedog. org National Service for the Blind and Physically Handicapped National Library of Congress 1291 Taylor Street NW Washington, DC 20542 Phone: 800-424-8567; 202-707-5100; TDD 202-707-0744; Fax: 202-707-07128 a. m. to 4:30 p. m. (Eastern Standard Time), Monday through Friday E-mail: nls@loc. gov National Society to Prevent Blindness Prevent Blindness America 211 West Wacker Drive 306 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Suite 1700 Chicago, IL 60606 www. preventblindness. org/contact-us 800-331-2020 Bibliography American Academy of Ophthalmology. (2013a, October). Blepharitis PPP 2013. Retrieved from https://www. aao. org/preferred-practice-pattern/blepharitis-ppp--2013 American Academy of Ophthalmology. (2013b, October). Conjunctivitis PPP 2013. Retrieved from https://www. aao. org/preferred-practice-pattern/conjunctivitis-ppp--2013 American Academy of Ophthalmology. (2013c, October). Dry eye syndrome PPP 2013. Retrieved from https://www. aao. org/preferred-practice-pattern/dry-eye-syndrome-ppp--2013 American Academy of Ophthalmology. (2015, November). Conjunctivitis summary benchmark 2015. Retrieved from https://www. aao. org/summarybenchmarkdetail/conjunctivitissummarybenchmark--october-2012 Carlisle, R. T., & Digiovanni, J. (2015). Differential diagnosis of the swollen red eyelid. American Family Physician, 15(92), 106-112. Centers for Disease Control and Prevention. (2015, September). Vision quest initiative. Retrieved from https://www. cdc. gov/visionhealth/faq. htm Dohm, K. D. (2015, January). Practice pearls for managing anterior uveitis. Review of Optometry, 2015(1), 58-63. Gunton, W. B., Wasserman, B. N., & De Benedictis, C. (2015). Strabismus. Primary Care: Clinics in Office Practice, 2(3), 393-407. Swaminathan, A., Otterness, K., Milne, K., & Rezaie, S. (2015). The safety of topical anesthetics in the treatment of corneal abrasions: A review. Journal of Emergency Medicine, 49(5), 810-815. Wipperman, J. L., & Dorsch, J. N. (2015). Evaluation and management of corneal abrasions. American Family Physician, 87(2), 114-120. 307 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
6Ear Guidelines Acute Otitis Media Jill C. Cash and Moya Cook Definition A. Acute otitis media (AOM) is inflammation of the middle ear associated with an acute bacterial infection of the middle ear. Incidence A. AOM may occur at any age. It is most commonly seen in children. B. Over two thirds of children have had at least one episode of otitis media by 3 years of age. C. One third of children have had three or more episodes by 3 years of age. D. One third of all pediatric visits are for otitis media. Pathogenesis A. Obstruction of the Eustachian tube can lead to a middle-ear effusion and infection. Contamination of this middle-ear fluid often results from a backup of nasopharyngeal secretions. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Predisposing Factors A. Age less than 12 months B. Recurrent otitis media (three or more episodes in the last 6 months) C. Previous episode of otitis media within the last month 308 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Medical condition that predisposes to otitis media (i. e., Down syndrome, AIDS, cystic fibrosis, cleft palate, and craniofacial abnormalities) E. Native American heritage F. Exposure to tobacco smoke and air pollution G. Day-care attendance H. Bottle propping I. Family history of allergies J. Pacifier use Common Complaints A. Ear pain B. Pulling ears C. Fever may or may not be present Other Signs and Symptoms A. Sleeplessness within past 48 hours B. Decreased appetite C. Increased fussiness D. Acute hearing loss E. Upper respiratory infection (URI) symptoms F. Mastoiditis presenting with a swollen and red mastoid G. Perforated tympanic membrane (sudden severe pain followed by immediate relief of pain with fluid drainage from the ear) H. Cholesteatoma (saclike structure in the middle ear accompanied by white, shiny, greasy debris) Subjective Data A. Elicit onset and duration of symptoms. B. Inquire whether the patient recently had (or has concurrently) a URI. C. Determine whether the patient has any change in hearing. D. Assess the patient for any drainage from the ear(s). E. Question the patient or his or her caregiver regarding risk factors. F. Identify the patient's history of otitis media. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. 309 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Inspect 1. Observe the canal and auricle for redness, deformity, drainage, or foreign body. 2. Inspect the tympanic membrane position to determine if it is neutral and whether landmarks are visible, retracted, full, or bulging. 3. Observe ears for decreased or absent tympanic membrane mobility. 4. Inspect nose, mouth, and throat. C. Auscultate heart and lungs. Diagnostic Tests A. Tympanogram shows flat or type B curve. B. Hearing test should be done in patients with persistent otitis media (greater or equal to 3 months' duration). C. Consider complete blood count if the patient appears toxic with a high fever. Differential Diagnoses A. AOM B. Otitis media with effusion (OME) C. Red tympanic membrane secondary to crying (differentiated from AOM by mobility with pneumatic otoscopy) D. URI E. Mastoiditis F. Foreign body in the ear G. Otitis externa Plan A. General intervention: Pain relief with acetaminophen or ibuprofen. Auralgan may be used for a topical pain relief in children older than 3 years. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “Acute Otitis Media. ” 2. Educate parents and care providers that children should avoid smoke exposure. Smoke-filled rooms increase the risk of frequent ear infections in children. 3. For young children who use a bottle for feeding, stress the importance 310 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
of NOT propping bottles at any time for feeding. Propping bottles increases the risk of ear infections. C. Pharmaceutical therapy 1. Drug of choice: Amoxicillin 90 mg/kg/d divided into two daily doses for 10 days, up to a maximum of 3 g/d. 2. For concerns of amoxicillin resistance, treatment failure, recent use of antibiotic in the previous 30 days, and/or concurrent other infections, use an antibiotic with beta-lactamase activity such as amoxicillin-clavulanate (Augmentin). Other alternatives include cefdinir, cefpodoxime, cefuroxime, and ceftriaxone. 3. For penicillin allergy: Cefdinir 14 mg/kg/d in one to two doses, maximum dose 600 mg/d. Cefpodoxime 10 mg/kg/d, once daily, maximum dose 800 mg/d. Cefuroxime susp, 30 mg/kg/d in two divided doses, maximum dose 1 g/d. Capsules: 250 mg every 12 hours. 4. Alternative: One dose of ceftriaxone 50 mg/kg intramuscularly (IM). If clinically improved in 48 hours, no further treatment is recommended. If signs/symptoms continue, administer the second dose of ceftriaxone in 48 hours. 5. Other alternatives: Macrolides a. Erythromycin plus sulfisoxazole (Pediazole): 50 to 150 mg/kg/d of erythromycin divided into four doses/d for 10 days; maximum dose 2 g erythromycin or 6 g sulfisoxazole/d. Do not use in children younger than 2 months. b. Azithromycin 10 mg/kg/d, maximum dose 500 mg/d as single dose on day 1, then 5 mg/kg/d, maximum dose of 250 mg/d on days 2 to 5 for 10 days c. Clarithromycin 15 mg/kg/d divided into two doses, maximum dose 1 g/d. d. Trimethoprim with sulfamethoxazole 8 mg/kg/d of trimethoprim (40 mg/kg/d of sulfamethoxazole) divided into two daily doses for 10 days 6. Children younger than 2 years should be treated with antibiotic therapy for 10 days. Children older than 2 years, without a previous history of otitis media, may be treated for 5 to 7 days. Erythromycin with sulfisoxazole 40 mg/kg/d (150 mg/kg/d of sulfisoxazole [Pediazole]) divided into four daily doses for 10 days. Do not use in children 311 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
younger than 2 months. 7. If the patient is asymptomatic and AOM is found on examination, consider observation without antibiotics only if child is older than 2 years. Recommend follow-up examination in 48 hours. 8. Other antibiotics (if first-line antibiotic fails): Amoxicillin and clavulanic acid (Augmentin), cefixime (Suprax), azithromycin (Zithromax), and cefprozil (Cefzil). 9. For persistent otitis media (3 months or longer), consider using an antibiotic for 21 days. Residual otitis media may need treatment with additional amoxicillin or beta-lactamase-resistant antibiotic. Follow-Up A. Check the patient in 2 to 4 weeks or if fever and complaints persist for more than 48 hours after the antibiotic is begun. Documentation of the resolution of the ear infection is valuable information if recurrent infections occur. Consultation/Referral A. Consult or refer the patient to a physician if he or she is less than 6 weeks of age, appears septic, or has mastoiditis. B. A patient with persistent otitis media with a hearing loss of 20 d B or more should be referred to an otolaryngologist. Individual Considerations A. Pregnancy: Do not use sulfa medications (sulfonamides) in pregnant patients, clients at gestation. B. Pediatrics 1. Children 6 weeks old or younger: Consider a blood culture and lumbar puncture if septicemia is suspected. The patient may need intravenous (IV) antibiotics depending on culture results. Do not use sulfa medications (sulfonamides) in children younger than 2 months. 2. The American Academy of Pediatrics does not recommend the use of over-the-counter (OTC) cough and cold medications for children younger than 6 years. In older children, consider decongestants for nasal congestion. Antihistamines are not recommended. C. Geriatrics: Elderly patients may present with OME and/or otitis media 312 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
secondary to a blocked Eustachian tube and/or URI. Cerumen Impaction (Earwax) Jill C. Cash and Moya Cook Definition A. Cerumen impaction, or earwax buildup, can cause conductive hearing loss or discomfort. Incidence A. Cerumen impaction occurs in patients of all ages. It is commonly seen in the elderly. The incidence in nursing home patients is 40%. Pathogenesis A. Wax builds up in the external canal. With age, the normal self-cleaning mechanisms of the ear fail. Cilia, which have become stiff, cannot remove cerumen and dirt from the ear canal. The pushing of cotton swabs, paper clips, bobby pins, and so forth, into the ear canal may also impact cerumen. Predisposing Factors A. Aging (decreased function of ear cilia) B. Use of hearing aids C. Use of cotton swabs to clean ear canals Common Complaints A. Dryness and itching of ear canal B. Dizziness C. Ear pain D. Hearing loss Subjective Data A. Elicit onset and duration of symptoms. B. Elicit history of cerumen impaction. C. Question the patient regarding the method of cleaning ears. 313 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Observe ears for thick, light-to dark-brown wax occluding the auditory canal. 2. Observe the tympanic membrane if possible. A perforated tympanic membrane is associated with otitis media. 3. Inspect the nose and throat. C. Auscultation: Auscultate heart and lungs. Diagnostic Tests A. Conductive hearing loss of 35 to 40 d B B. Perform Rinne and Weber tests. 1. The Rinne tuning-fork test reveals bone conduction greater than air conduction in the affected ear (abnormal). The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops. 2. The Weber test reveals conductive hearing loss when sound travels toward the poor ear. Sensorineural hearing loss is present when sound travels toward the good ear. This is performed by striking a tuning fork and then placing it on the middle of the head. The patient should be asked where sound is being heard: from the left ear, the right ear, or equal in both ears. Normal results are reflected by sound being heard equally in both ears. Differential Diagnoses A. Cerumen impaction B. Foreign body in the ear canal C. Otitis externa: White, mucus-like ear discharge associated with otitis externa Plan 314 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. General interventions 1. Remove impaction by means of lavage or curettage. Be sure to inspect the canal and tympanic membrane after removal of the cerumen. 2. Document the patient's hearing before and after removal of cerumen. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Cerumen Impaction (Earwax). ” 2. Instruct the patient not to clean ears with cotton swabs, bobby pins, and so forth. Using these devices pushes the wax further into the ear canal and can worsen symptoms. C. Pharmaceutical therapy 1. Drug of choice: Debrox, mineral oil, or olive oil two to three drops in the ear every day for 1 week to loosen the cerumen before lavage or curettage. Do not use Debrox if perforation of tympanic membrane is suspected. 2. For prevention, have the patient use the aforementioned softeners for 2 to 3 days. Then have him or her use one capful of hydrogen peroxide in the ear twice daily, allow it to bubble for 5 to 10 minutes, then turn head to allow it to run out. Follow-Up A. No follow-up is needed unless indicated. Recurrence is common. Consultation/Referral A. Consult or refer the patient to a physician when cerumen cannot be cleared. Individual Considerations A. Geriatrics 1. Cerumen impaction is very common in the elderly due to atrophic cilia and dry epithelium in the ear canal. 2. The use of hearing aids also can contribute to wax buildup and cause wax to be pushed further into the canal. Persons with hearing aids should be evaluated for wax buildup as indicated. 315 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Hearing Loss Jill C. Cash and Moya Cook Definition Impaired hearing (complete or partial hearing loss) results from interference with the conduction of sound, its conversion to electrical impulses, or its transmission through the nervous system. There are three types of hearing loss: A. Conductive hearing loss B. Sensorineural hearing loss C. Combined conductive and sensorineural loss Incidence A. Hearing loss is present in 10% to 15% of patients; approximately 30 million Americans have some degree of hearing impairment. Pathogenesis A. Conductive hearing loss presents with a diminution of volume, particularly low tones and vowels. It may be caused by one of the following: 1. Otosclerosis disorder of the architecture of the bony labyrinth fixes the footplate of the stapes in the oval window. 2. Exostoses are bony excrescences of the external auditory canal. 3. Glomus tumors are benign, highly vascular tumors derived from normally occurring glomera of the middle ear and jugular bulb. B. Sensorineural hearing loss characteristically produces impairment of the high-tone perception. Affected patients can hear people speaking, but they have difficulty deciphering words because discrimination is poor. It may be caused by one of the following: 1. Presbycusis is hearing loss associated with aging and is the most common cause of diminished hearing in the elderly; onset is bilateral, symmetric, and gradual. 2. Noise-induced hearing loss is due to chronic exposure to sound levels in excess of 85 to 90 d B. 3. Drug-induced hearing loss can be caused by aminoglycoside antibiotics, furosemide, ethacrynic acid, quinidine, and aspirin. 316 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4. Ménière's disease produces a fluctuating, unilateral, low-frequency impairment usually associated with tinnitus, a sensation of fullness in the ear, and intermittent episodes of vertigo. 5. Acoustic neuroma is a benign tumor of the eighth cranial nerve (rare). 6. Sensorineural hearing loss is generally bilateral and symmetric, and it may be genetically determined. 7. Sudden deafness can derive from head trauma, skull fracture, meningitis, otitis media, scarlet fever, mumps, congenital syphilis, multiple sclerosis, and perilymph leaks or fistulas. Predisposing Factors A. Acoustic or physical trauma B. Ototoxic medications (such as gentamicin and aspirin) C. Changes in barometric pressures D. Recent upper respiratory infection (URI) E. Pregnancy F. Otosclerosis G. Nasopharyngeal cancer H. Serous otitis media I. Cerumen impaction J. Foreign body in the ear Common Complaints A. Partial hearing loss B. Total hearing loss C. Difficulty understanding the television, phone conversations, and people talking Other Signs and Symptoms A. Unilateral or bilateral hearing loss B. Hearing noises as “ringing,” “buzzing,” and so forth C. Fullness in ear(s) Subjective Data A. Elicit the onset, duration, progression, and severity of symptoms. Note whether symptoms are bilateral or unilateral. 317 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Obtain the patient's history of past or recent trauma. C. Review the patient's occupational and recreational exposure to risk factors. D. Review the patient's medical history and medications, including OTC drugs and prescriptions. E. Review the patient's history for recent URI or ear infections, especially for chronic ear infections. F. Elicit data about any previous hearing loss, how it was treated, and how it affected daily activities. There is often a history of previous ear disease with conductive hearing loss. G. Review the patient's other symptoms such as dizziness, fullness or pressure in the ears, and noises. H. Review what causes difficulty with hearing, high tones versus low frequencies. Can the patient hear people talking, the television at normal volume, doorbells ringing, telephone ringing, and watch ticking? Physical Examination A. Temperature B. Inspect 1. Examine both ears for comparison. 2. Externally inspect ears for discharge; note color and odor. Obstruction of the auditory canal by impacted cerumen, a foreign body, exostoses, external otitis, OME, or scarring or perforation of the eardrum due to chronic otitis may be present. 3. Conduct otoscopic examination to observe the auditory canal for cerumen impaction or foreign body. 4. Examine tympanic membrane for color, landmarks, contour, perforation, and acute otitis media (AOM). A reddish mass visible through the intact tympanic membrane may indicate a high-riding jugular bulb, an aberrant internal carotid artery, or a glomus tumor. C. Palpate 1. Palpate auricle and mastoid area for tenderness, swelling, or nodules. 2. Check lymph nodes if infection is suspected. D. Neurologic testing 1. Weber test a. Perform a Weber screen. The Weber test reveals conductive 318 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
hearing loss when sound travels toward the poor ear. Sensorineural hearing loss is present when sound travels toward the good ear. This is performed by striking a tuning fork and then placing it on the middle of the head. The patient should be asked where sound is being heard from, the left ear, the right ear, or equal in both ears. Normal results are reflected by sound being heard equally in both ears. 2. Rinne screen a. The Rinne tuning-fork test reveals bone conduction greater than air conduction in the affected ear (abnormal). The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops. Diagnostic Tests A. Audiogram in primary setting B. Air insufflation for tympanic membrane mobility C. Tympanometry brainstem-evoked response audiogram D. CT or MRI after consultation with an otolaryngologist Differential Diagnoses A. Congenital hearing loss B. Traumatic hearing loss C. Ototoxicity D. Presbycusis E. Ménière's syndrome F. Acoustic neuroma G. Cholesteatoma H. Infection I. Cerumen impaction J. Otitis externa K. Foreign body in the ear L. Tumors M. Otosclerosis 319 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
N. Perforation of tympanic membrane O. Serous otitis media P. Hypothyroidism Q. Paget's disease Plan A. General interventions 1. Treat any primary cause (i. e., remove impacted cerumen). 2. Inform the patient regarding results of screening and indications for further testing. B. Patient teaching 1. Discuss avoiding loud noises, using earplugs, and so forth. 2. Instruct the patient not to insert small objects into the ear. C. Pharmaceutical therapy: Treat primary condition if applicable. Follow-Up A. If the primary cause of hearing loss is not identified, refer the patient to a physician. Consultation/Referral A. The patient should be referred to an otolaryngologist for an extensive workup when the primary cause cannot be identified. B. Referral should be made to a hearing aid specialist for hearing evaluation and treatment as indicated (i. e., hearing aids). Individual Considerations A. Pediatrics 1. Most children are able to respond to a test of gross hearing using a small bell. To determine the patient's hearing ability, note if the child stops moving when the bell is rung and if the child turns his or her head toward the sound. 2. When examining children, pull the pinna back and slightly upward to straighten the canal. B. Adults 1. The external auditory canal in the adult can best be exposed by pulling the earlobe upward and backward. 320 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Geriatrics 1. Impaired hearing among the elderly is common and can lower the quality of life. 2. People with seriously impaired hearing often become withdrawn or appear confused. 3. Subtle hearing loss may go unrecognized. 4. Impacted cerumen is very common in the elderly. Otitis Externa Jill C. Cash and Moya Cook Definition A. Otitis externa is a common, acute, self-limiting inflammation or infection of the external auditory canal and auricle. Incidence A. Otitis externa is seen in patients of all ages. Incidence is higher during summer months. All varieties (with exception of necrotizing otitis externa) are common. Pathogenesis A. Acute diffuse otitis externa (swimmer's ear): Pseudomonas is the most common bacterial infection (67%), followed by Staphylococcus and Streptococcus. Infection can also be fungal (Aspergillus, 90%). Bacterial or fungal invasion is usually preceded by trauma to the ear canal, aggressive cleaning of the naturally bactericidal cerumen, or frequent submersion in water (swimming). B. Chronic otitis externa: Condition generally results from a persistent, low-grade infection and inflammation with Pseudomonas. C. Eczematous otitis externa: Otitis externa associated with primary coexistent skin disorder such as atopic dermatitis, seborrheic dermatitis, and psoriasis. D. Necrotizing or malignant otitis externa: Invasive Pseudomonas infection results in skull base osteomyelitis. It is most commonly seen in the 321 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
immunocompromised or diabetic geriatric patient. Predisposing Factors A. Ear trauma from scratching with a foreign object or fingernail, overly vigorous cleaning of cerumen from canal B. Humid climate C. Frequent swimming D. Use of a hearing aid E. Eczema (eczematous otitis externa) F. Debilitating disease (necrotizing otitis externa) Common Complaints A. Otalgia B. Itching C. Erythematous and swollen external canal D. Purulent discharge E. Hearing loss from edema and obstruction of canal with drainage Other Signs and Symptoms A. Plugged ear sensation (aural fullness) B. Tenderness to palpation (tragus) Subjective Data A. Elicit the onset, duration, and intensity of ear discomfort. B. Inquire into the patient's history of previous ear infections. C. Determine whether the patient notes any degree of hearing loss. D. Question the patient about recent exposure to immersion in water (swimming). E. Question the patient as to ear canal cleaning practices and any recent trauma to the canal. Physical Examination A. Temperature B. Inspect 1. Carefully examine the ear with an otoscope for extreme tenderness. 2. Observe the ear for erythematous and edematous external canal; look 322 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
for otorrhea and debris. 3. Observe the tympanic membrane, which may appear normal. 4. Inspect nose and throat. C. Auscultate heart and lungs. D. Palpate 1. Apply gentle pressure to tragus and manipulate pinna to assess for tenderness. 2. Palpate cervical lymph nodes. Diagnostic Tests A. Examine ear canal scrapings and drainage under a microscope for hyphae (if fungal infection is suspected from previous history or ineffective topical therapy). B. Culture vesicular lesions for viruses. Differential Diagnoses A. Otitis externa B. Otitis media C. Foreign body D. Mastoiditis E. Hearing loss F. Wisdom tooth eruption G. Herpetic otitis externa (vesicular eruptions in the ear canal are associated with herpetic otitis externa). H. Necrotizing or malignant otitis externa (life-threatening condition that occurs in diabetic or immunocompromised patients). Cranial nerve palsies (of the seventh, ninth, and twelfth cranial nerves) and periostitis of the skull base have been associated with necrotizing otitis externa. Plan A. General interventions 1. When the patient's ear canal is sufficiently blocked by edema or drainage, preventing passage of ear drops, cautiously irrigate the canal and insert a cotton wick (approximately 1 in. long for adults) to allow passage of drops. 2. Insert the wick by gently rotating it while inserting it into the ear. The 323 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
patient then places ear drops on the wick. The drops are absorbed through the wick, which allows medicine to reach the external canal. The provider may need to change the wick daily or several times per week. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “Otitis Externa. ” 2. The patient should be advised to keep water out of the ear for 4 to 6 weeks. The patient should not swim until symptoms are completely resolved and the wick is removed. 3. Bathing or showering is permitted with a cotton ball coated with petroleum jelly inserted into the ear to block water passage into the ear canal. C. Pharmaceutical therapy 1. For early, mild cases associated with swimming in which the primary symptom is pruritus, homemade preparations of 50% isopropyl alcohol and 50% vinegar can be used as a drying agent and to create an unsatisfactory environment for Pseudomonas growth. 2. Mild infection: Topical therapy—Use of acidifying agent such as Vosol or Vosol HC, which includes a glucocorticoid therapy: Instill five drops in the ear canal three to four times daily. (Vosol and Vosol HC are contraindicated with perforated eardrum; Vosol HC is contraindicated with viral otic infections. ) 3. Moderate infection: Use of an acidifying agent, antibiotic and glucocorticoid therapy (Cipro HC), and Cortisporin is suggested. Other alternatives include Ciprofloxacin (Cipro HC), Ofloxacin (Floxin), Polymyxin B, Neomycin (Cortisporin Otic) suspension or solution. Adults should apply four drops to the canal four times daily for 7 days; children should apply three drops to the canal four times daily for 7 days. The suspension is recommended rather than the solution if the integrity of the tympanic membrane is in question. a. If fungal infection is suspected, Nystatin 100,000 units/m L or clotrimazole topical solutions may be used for candidal or yeast infections. 4. Severe or resistant infections may require additional management with oral antibiotics and antifungals: a. Ciprofloxacin for pseudomonal infections; dicloxacillin or 324 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
cephalexin for staphylococcal infections. b. Itraconazole (Sporanox) for treatment of otomycosis (fungal otitis externa). 5. For analgesia, use acetaminophen or ibuprofen. Short-term use of opiates may be necessary when acetaminophen and ibuprofen fail to control pain. Follow-Up A. Usual follow-up is within 48 hours to assess improvement. Recheck in 1 to 2 weeks. B. In severe cases requiring antibiotic drops instilled by means of a wick, follow-up may be required daily or several times per week to remove and replace the wick. Consultation/Referral A. Parenteral antibiotics are required for necrotizing otitis externa. These patients should be immediately referred to a physician. B. Consult or refer the patient to a physician if osteomyelitis is suspected. Individual Considerations A. Geriatrics 1. Persistent otitis externa in the geriatric patient (especially those who are immunocompromised or diabetic) may evolve into osteomyelitis of the skull base. 2. The external ear is painful and edematous, and a foul, green discharge is usually present. 3. Treatment may require parenteral gentamicin with a beta-lactam agent. Surgery may be necessary. 4. Oral fluoroquinolones may be useful if infection has not progressed to osteomyelitis. Otitis Media With Effusion Jill C. Cash and Moya Cook Definition 325 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Otitis media with effusion (OME) is asymptomatic middle-ear fluid without signs of bacterial infection. Incidence A. OME is seen in patients of all ages. B. After the onset of acute otitis media (AOM), approximately 70% of children have fluid present at 2 weeks. 1. 40% have fluid present at 1 month. 2. 20% have fluid present at 2 months. 3. 10% have an effusion at 3 months. Pathogenesis A. The effusion may be sterile fluid secondary to upper respiratory infection (URI) and Eustachian tube dysfunction. It may be residual fluid after an episode of AOM. Predisposing Factors A. Recent otitis media B. Concurrent URI Common Complaints A. Ear pain B. Increased pressure sensation in the ears C. Recent hearing loss Other Signs and Symptoms A. The patient has a sense of fullness in the ears. Subjective Data A. Elicit the onset and duration of symptoms. B. Question the patient about recent history of otitis media or URI. C. Question the patient about hearing loss. D. Determine if the patient has a past history of frequent otitis media. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. 326 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Inspect 1. Ears, noting fluid level, serous middle fluid, and a translucent, amber, gray membrane with decreased mobility. 2. Nose, mouth, and throat. C. Auscultate heart and lungs. D. Palpate head, neck, and lymph nodes. E. Neurologic examination 1. Perform the Rinne test. This test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops. 2. Perform the Weber test. Diagnostic Tests A. Pneumatic otoscopy reveals decreased mobility. Assessment with pneumatic otoscopy is strongly recommended. B. Negative pressure on tympanogram. Differential Diagnoses A. OME B. Cerumen impaction C. AOM D. Foreign body in the ear Plan A. General interventions 1. Patient should be monitored closely for resolution of effusion without treatment within several weeks. 2. Patients who have persistent effusion are at risk for hearing loss, speech, language, and learning disorders. 3. Children with persistent OME should be referred to an otolaryngologist for a hearing evaluation and possible tympanostomy tubes as indicated. 4. Speech and language evaluation or documentation of hearing loss is 327 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
recommended for children with OME older than 3 months. B. Patient teaching 1. See Section III: Patient Teaching Guide for this chapter, “ Otitis Media With Effusion. ” 2. Educate parents that OME is not treated with antibiotics since no infection is present. 3. If symptoms change, infection should be suspected and the primary care provider should be notified of new symptoms and that reevaluation is needed. 4. Teach the parents/care provider that routine use of antihistamines and decongestants is not recommended. C. Pharmaceutical therapy 1. The American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology-Head Neck Surgery do not recommend routine use of antibiotic therapy for OME. However, in certain situations, a course of antibiotics (Amoxil) for 10 to 14 days is recommended. 2. Intranasal glucocorticoids are not recommended for routine use for OME in children. 3. Antihistamines and decongestants are not recommended for routine use for OME in children. Follow-Up A. Recheck the patient's ears after 4 to 6 weeks to evaluate effectiveness of treatment. Consultation/Referral A. Consult or refer the patient to a physician if treatment is not effective or if the patient has a persistent effusion (at least 3 months) along with a hearing loss of 20 d B or more. B. Consider referring the patient to an otolaryngologist. Individual Considerations A. Geriatrics 1. OME may be present in the elderly, usually unilaterally, and usually associated with a URI or allergies due to a blocked Eustachian tube. 328 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. If there is no accompanying URI, a nasopharyngeal mass must be ruled out. Tinnitus Jill C. Cash and Moya Cook Definition A. The word tinnitus comes from the Latin tinnire, which means “to ring. ” It refers to any sound heard in the ears or head. Incidence A. It is estimated that 6. 4% of the adult population has experienced tinnitus at some point. More than 7 million people in the United States are thought to experience tinnitus. Pathogenesis A. Tinnitus is poorly understood. It is best described as a nonspecific manifestation of pathology of the inner ear, eighth cranial nerve, or the central auditory mechanism. Predisposing Factors A. Cerumen impaction B. Tympanic membrane perforation C. Fluid in the middle ear D. Acute otitis media (AOM) E. Acoustic trauma F. Ototoxic drugs 1. Sulfas 2. Aminoglycosides 3. Salicylate 4. Indomethacin 5. Propranolol 6. Levodopa 7. Carbamazepine 329 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Vascular aneurysm H. Jugular bulb anomaly. Compression of the ipsilateral jugular vein abolishes the objective tinnitus of a jugular megabulb anomaly I. Anemia J. Temporomandibular joint syndrome K. Hypertension Common Complaints A. Ringing B. Roaring C. Buzzing D. Clicking E. Hissing F. Hearing loss Other Signs and Symptoms A. “Muffled” hearing B. Change in own voice, lower pitch Subjective Data A. Review the onset, duration, course, and type of symptoms; note whether they are bilateral or unilateral. B. Determine the frequency and quality of sound; is the ringing constant, intermittent, or pulsating? C. Review all medications, including over-the-counter (OTC) drugs and prescriptions. D. Determine whether the patient has experienced trauma (domestic violence, motor vehicle accident, and so forth). E. Rule out a recent sinus, oral, or ear infection. F. Review any previous occurrences. Ask: How was it treated? G. Review work, hobbies, and music habits for noise levels (potential damage). H. Assess the date of last hearing examination and determine whether there was any known hearing loss. I. Review whether the patient uses cotton-tipped swabs or other small objects for ear cleaning. 330 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Physical Examination A. Take temperature if infectious cause is suspected. B. Inspect 1. Observe the external ear for discharge; note color and odor. 2. Conduct otoscopic examination of the auditory canal for cerumen impaction or foreign body. 3. Inspect tympanic membrane for color, landmarks, contour, perforation, and AOM. a. The landmarks (umbo, handle of malleus, and the light reflex) should be visible on a normal examination. b. The tympanic membrane should be pearly gray in color and translucent. c. A bulging tympanic membrane is more conical, usually with a loss of bony landmarks and a distorted light reflex. d. A retracted tympanic membrane is more concave, usually with accentuated bony landmarks and a distorted light reflex (pathologic conditions in the middle ear may be reflected by characteristics of the tympanic membrane). C. Auscultation 1. The skull should be auscultated for a bruit if the origin of the problem remains obscure. D. Palpate 1. Palpate auricle and mastoid area for tenderness, swelling, or nodules. 2. Check lymph nodes if infection is suspected. E. Visual examination 1. Check for nystagmus if vertigo is reported. F. Neurologic examination 1. The eighth cranial nerve is tested by evaluating hearing. 2. First evaluate how the patient responds to your questions. 3. Patients who speak in a monotone or with erratic volume may have hearing loss. 4. Check the patient's response to a soft whisper (should respond at least 50% of the time). 5. Perform the Rinne test: The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the 331 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops. 6. Perform the Weber test. Diagnostic Tests A. Audiogram is performed in the primary care setting; other testing is performed by an otolaryngologist. Any association of the sound with respiration, drug use, vertigo, noise trauma, or ear infection should be checked. When the problem is present only at night, it suggests increased awareness of normal head sounds. B. CT scan or MRI after referral to an otolaryngologist C. Posterior fossa myelography Differential Diagnoses A. Tinnitus B. Cerumen impaction C. Foreign body in the ear D. AOM E. Otitis externa F. Acoustic traumas G. Vascular aneurysm H. Temporomandibular joint syndrome I. Otosclerosis J. Ototoxicity K. Ménière's syndrome L. Presbycusis M. Central nervous system lesion Plan A. General interventions 1. Stress the importance of not placing small objects in the ear and using cotton-tipped applicators to clean external ear only. 2. Suggest to the patient that keeping a radio on for background noise often facilitates sleep or work. 332 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Address underlying conditions if present (depression, insomnia, hearing loss, drug toxicity). 4. Consider behavioral therapy, such as biofeedback or cognitive behavioral therapy, to teach patient coping strategies. B. Patient teaching 1. Educate the patient regarding techniques/therapies to improve symptoms of tinnitus. 2. Encourage the patient to attend therapy sessions as indicated. C. Pharmaceutical therapy 1. No medication “cures” tinnitus. 2. Vasodilators, tranquilizers, antidepressants, and seizure medications have been shown to reduce symptoms. 3. Placebos are also of therapeutic value. Follow-Up A. No specific follow-up is required for tinnitus unless a treatable problem is identified. Consultation/Referral A. Consult with an otolaryngologist as indicated. B. Referral of an anxious patient to the otolaryngologist may be necessary to satisfy the patient that everything has been explored and that there is no serious or correctable underlying condition. C. Any patient with a history of head trauma should be referred to a physician because tinnitus may be associated with an arteriovenous fistula or an aneurysm of the intrapetrous portion of the internal carotid artery. Bibliography Bhattacharyya, N., & Meyers, A. D. (2015). Auditory brainstem response auditometry. Medscape. Retrieved from http://emedicine. medscape. com/article/836277-overview#a6 Bird, S. (2008). Ear syringing: Minimizing the risks. Australian Family Physician, 37(4), 359-360. Retrieved from www. racgp. org. au/afp/backissues/2008 Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. (2013). Noise and hearing loss prevention. DHHS (NIOSH) Pub. No. 2001-103. Retrieved from www. cdc. gov Dinces, E. (2015). Cerumen. In D. Deschler (Ed. ), Up To Date. Retrieved from 333 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
https://www. uptodate. com/contents/cerumen? source=machine Learning&search=ear+lavage&selected Title=1%7E150§ion Rank=1&anchor=H9#H9 Klein, J. O, & Pelton, S. (2015). Acute otitis media in children: Treatment. In M. Edwards & G. Isaacson (Eds. ), Upto Date. Retrieved from http://www. uptodate. com/contents/acute-otitis-media-in-children-treatment Klein, J. O., & Pelton, S. (2016). Management of otitis media with effusion (serous otitis media) in children. In S. Kaplan & G. Isaacson (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/management-of-otitis-media-with-effusion-serous-otitis-media-in-children?source=search_result&search=otitis+meda+with+effusion&selected Title=1~48 Lustig, L. R., Limb, C. J., Baden, R., & La Salvia, M. T. (2015). Chronic otitis media, cholesteatoma, and mastoiditis in adults. In D. Deschler (Ed. ), Up To Date. Retrieved from http://www. uptodate. com/contents/chronic-otitis-media-cholesteatoma-and-mastoiditis-in-adults? source=search_result&search=otitis+media+adult&selected Title=2%7E150 Mener, D. J., Betz, J., Genther, D. J., Chen, D., & Lin, F. R. (2013). Hearing loss and depression in older adults. Journal of the American Geriatrics Society, 61(9), 1627-1629. National Institute on Deafness and Other Communication Disorders (2016, March). NIDCD Fact Sheet: Hearing and Balance: Hearing loss and older adults. NIH Pub. No. 01-4913. Washington, DC: U. S. Department of Health and Human Services. Retrieved from https://www. nidcd. nih. gov/health/hearing-loss-older-adults National Institutes of Health, National Institute on Deafness and Other Communication Disorders (2015a). NIDCD Fact Sheet: Hearing and Balance: Pendred Syndrome (NIH Publication No. 06-5875). November 2012, Reprinted December 2014. Washington, DC: U. S. Department of Health and Human Services. Retrieved from https://www. nidcd. nih. gov/health/pendred-syndrome National Institutes of Health, National Institute on Deafness and Other Communication Disorders (2015b). Quick statistics about hearing. Retrieved from https://www. nidcd. nih. gov/health/statistics/quick-statistics-hearing Poe, D., & Bassem, M. (2016). Eustachian tube dysfunction. In D. Deschler (Ed. ), Up To Date. Retrieved from http://www. uptodate. com/contents/eustachian-tube-dysfunction? source=search_result&search=eustachian+tube+dysfunction&selected Title=1%7E39 Roland, P. S. (2015). Presbycusis. Medscape. Retrieved from www. medscape. comarticle/855989-overview Schaefer, P., & Baugh, R. (2012). Acute otitis externa: An update. American Family Physician, 86 (11), 1055-1061. Tunkel, D. E., Bauer, C. A., Sun, G. H., Rosenfeld R. M., Chandrasekhar, S. S., Cunningham, E. R.,... Whamond, E. J. (2014). Clinical guidelines: Tinnitus. Otolaryngology Head Neck Surgery, 151(2 Suppl. ), S1-40. Retrieved from https://www. guideline. gov/content. aspx?id=48751&search=tinnitus 334 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
7Nasal Guidelines Allergic Rhinitis Jill C. Cash and Moya Cook Definition A. Allergic rhinitis is a chronic or recurrent condition characterized by nasal congestion, clear nasal discharge, sneezing, nasal itching, conjunctival itching, and periorbital edema. It usually occurs seasonally after exposure to allergens (same time every year, associated with pollen count), or it may be perennial (year-round, related to indoor inhalants, animal dander, and mold). “Allergic” suggests that a specific immunoglobulin E (Ig E) antibody mediates the condition. Incidence A. Prevalence varies according to geographic region; 20% to 25% of adults have allergic rhinitis. Pathogenesis A. This is an immunoglobulin E (Ig E) mediated inflammatory disease involving nasal mucosa; Ig E antibodies bind to mast cells in the respiratory epithelium, and histamine is released. This results in immediate local vasodilatation, mucosal edema, and increased mucus production. Predisposing Factors A. Genetic predisposition to allergy B. Exposure to allergic stimuli: Pollens, molds, animal dander, dust mites, 335 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
and indoor inhalants Common Complaints A. Nasal congestion B. Sneezing C. Clear rhinorrhea D. Coughing from postnasal drip E. Sore throat F. Itchy, puffy eyes with tearing Other Signs and Symptoms A. Dry mouth from mouth breathing, snoring B. Itchy nose C. Loss of smell and taste D. Eczema rash E. Shortness of breath, difficulty breathing, and wheezing F. Headache G. Halitosis Subjective Data A. Ask about onset, course, and duration of symptoms. B. Inquire about characteristics of nasal discharge. C. Inquire about exposure to people with similar symptoms. D. Ask about seasonal impact on symptoms. E. Inquire about other diseases caused by allergens, such as asthma, eczema, and urticaria. F. Rule out pregnancy. G. Ask female patients about their birth control method, specifically birth control pills. H. Review exposure to irritants. I. Ask about any past or recent nasal trauma. Physical Examination A. Vital signs: Temperature, blood pressure, pulse, and respirations B. Inspect 1. Examine face. Note Dennie's lines (skin folds under eyes) and allergic 336 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
salute (transverse crease on nose from chronic rubbing of nose). 2. Examine eyes and conjunctivae. a. Tearing; red, swollen eyelids; and allergic shiners (dark circles under eyes from venous congestion in maxillary sinuses) are seen with allergies. b. Palpebral conjunctiva pale and swollen, bulbar conjunctiva is injected. 3. Examine ears, nose, and throat. a. Red, dull, bulging, perforated tympanic membrane is seen with otitis media. b. Nasal redness, swelling, polyps, and enlarged turbinates are seen with upper respiratory infection (URI). Mucosa appears pale blue, and boggy with clear discharge in chronic allergy. c. Cobblestone appearance in pharynx, tonsils, and adenoids seen in chronic allergies. d. Use otoscope light to transilluminate under superior orbital ridge of frontal sinus cavity and also maxillary sinus cavity to assess for fluid in sinus cavity. Healthy sinuses contain air and light up symmetrically. C. Palpate 1. Palpate face and frontal maxillary sinuses for tenderness. 2. Examine the head and neck for enlarged lymph nodes. D. Percuss 1. Sinus cavities and mastoid bone 2. Chest for consolidation E. Auscultate heart and lungs. Diagnostic Tests Diagnosis may be made from history and physical. Other diagnostic tests include: A. Wright's stain of nasal secretions; eosinophils present confirm allergy B. Skin testing for allergies C. Radioallergosorbent test (RAST) D. Complete blood count (CBC) with increased eosinophils (confirm allergy) Differential Diagnoses 337 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Allergic rhinitis B. URI C. Medication-induced rhinitis D. Sinusitis E. Otitis media F. Deviated septum G. Nasal polyps H. Endocrine conditions such as hypothyroidism I. Influenza Plan A. General interventions 1. Avoid allergens (most effective treatment). 2. Keep bedroom as allergen free as possible. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Allergic Rhinitis. ” C. Pharmaceutical therapy 1. Antihistamines (H1 receptor antagonists) are drugs of choice. Several may need to be tried before an effective one is found. Drugs may also need to be switched occasionally to prevent tolerance. a. Azelastine hydrochloride (HCl; Astelin) metered nasal spray, 137 mcg per metered dose i. Children younger than 5 years: Not recommended ii. Children 5 to 11 years: One spray in each nostril twice daily iii. Adults: Two sprays per nostril twice daily b. Loratadine (Claritin) 10 mg by mouth daily (adults) i. Children younger than 2 years: Not recommended ii. Children 2 to 5 years: 5 mg daily iii. Children 6 years and older: 10 mg daily c. Fexofenadine HCl (Allegra) 60 mg capsules orally twice daily (adults) or 180 mg daily i. Children younger than 6 years: Not recommended ii. Children 6 to 11years: 30 mg twice daily d. Cetirizine HCl (Zyrtec) i. Adults and children 12 years and older: 5 to 10 mg by mouth 338 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
daily depending on symptom severity ii. Zyrtec 5 mg daily for patients with renal or hepatic impairment iii. Children 2 to 6 years: 2. 5 mg daily iv. Children 6 to 11 years: 5 to 10 mg (1-2 teaspoons) by mouth daily depending on symptom severity e. Montelukast (Singulair): Not recommended for children younger than 6 months i. Children 6 to 23 months: One 4-mg granule packet ii. Children 2 to 5 years: One 4-mg chewable tablet or granule packet iii. Children 6 to 14 years: One 5-mg tablet iv. Children older than 15 years and adults: One 10-mg tablet daily f. Levocetirizine dihydrochloride (Xyzal) i. Children younger than 6 years: Not recommended ii. Children 6 to 11 years: Maximum 2. 5 mg once daily in p. m. iii. Adults: 2. 5 to 5 mg daily in p. m. Precautions for renal impairment 2. Topical decongestants for significant congestion of the mucous membranes. These drugs may also stimulate the sympathetic nervous system and cause insomnia, nervousness, and palpitations. Use no longer than 3 to 5 days. Discontinuing these drugs after 5 days may result in a rebound effect. a. Oxymetazoline hydrochloride (Afrin) spray or drops i. Adults and children 6 years and older: 2 to 3 drops or sprays of 0. 05% solution in each nostril twice daily ii. Children 2 to 6 years: 2 to 3 drops of 0. 025% solution in each nostril twice daily b. Phenylephrine (Neo-Synephrine) spray or drops i. Adults and children 12 years and older: 2 to 3 drops or one to two sprays in each nostril, or small amount of jelly applied to nasal mucosa, every 4 hours as needed. Do not use for more than 3 to 5 days. ii. Children 6 to 12 years: 2 to 3 drops or one to two sprays of 0. 25% solution in each nostril every 4 hours as needed. Do not use 339 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
for more than 3 to 5 days. iii. Children younger than 6 years: 2 to 3 drops of 0. 125% solution every 4 hours in each nostril as needed. Contact physician if symptoms persist beyond 3 days. 3. Steroid sprays may be used to decrease nasal inflammation. Steroid sprays are not recommended in children younger than 6 years old unless there is an allergic component. Sprays do not cause significant systemic absorption in usual doses, but occasionally they may cause pharyngeal fungal infections. a. Beclomethasone dipropionate (Beconase AQ, Vancenase): Adults and children older than 6 years: One to two sprays in each nostril twice daily b. Fluticasone propionate (Flonase): Adults: Two sprays daily or one spray twice daily. Maintenance dosing: One spray in each nostril daily. Children younger than 4 years: Not recommended. Children 4 years and older: One spray in each nostril daily, may increase to two sprays each nostril once daily. Maintenance: One spray daily c. Triamcinolone acetonide (Nasacort AQ): Adults: Two sprays daily. Children 2 to 5 years: One spray in each nostril once daily. Children 6 to 12 years: One spray in each nostril once daily, maximum one spray in each nostril once daily. Reduce dose as condition improves. d. Mometasone furoate (Nasonex): Adults: Two sprays in each nostril once daily. Children 2 to 11 years: One spray in each nostril daily e. Fluticasone furoate (Veramyst) i. Adults: Two sprays each nostril daily 1)Maintenance: One spray in each nostril daily ii. Children 2 to 11 years: One spray in each nostril daily; may increase to two sprays daily if needed 1)Maintenance dose: One spray in each nostril daily f. Budesonide (Rhinocort Aqua): Children younger than 6 years: Not recommended. Adults and children 6 years and older: Two sprays twice daily g. Qnasl (beclomethasone dipropionate): Children: Not established. Adults: Two sprays in each nostril once daily; maximum four sprays per day 4. Saline spray 340 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
a. Saline spray is effective in liquefying thick secretions and helps keep mucosa moist. b. Use Neti pot to cleanse inside of nasal mucosa; daily use suggested. 5. Petroleum jelly applied with Q-tip to inside mucosa of nares three to four times a day helps to provide lubrication and hold in moisture to prevent nasal dryness and bleeding. Follow-Up A. Patient should return for follow-up visit in 2 to 3 weeks if necessary; earlier if symptoms worsen after 3 days of treatment. Consultation/Referral A. Refer the patient to an allergist if symptoms continue and interfere with daily activities. B. Allergist may prescribe immunotherapy following identification of offending allergens. Individual Considerations A. Pregnancy 1. Over-the-counter (OTC) antihistamines, such as diphenhydramine HCl (Benadryl), may be used for up to 5 days. 2. OTC decongestants, such as oxymetazoline HCl (Afrin), may be used up to 3 days. Epistaxis Jill C. Cash and Moya Cook Definition A. Epistaxis is a nosebleed or hemorrhage from the nose. Incidence A. About 11% of Americans have had at least one nosebleed. Pathogenesis 341 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Epistaxis is caused by disruption of the nasal mucosa. More than 90% of nosebleeds are related to local irritation rather than underlying anatomic lesions and are self-limiting. Most start in the anterior nasal cavity (Kisselbach's plexus). B. Posterior nasal bleeding usually originates from the turbinates or lateral nasal wall. Predisposing Factors A. Local trauma, usually from nose picking B. Acute inflammation from an upper respiratory infection (URI; e. g., common cold, acute sinusitis, and allergic rhinitis) C. Vigorous nose blowing D. Inhalation of chemical irritants E. Drying and crusting of nasal septum F. Trauma G. Cocaine use H. Pregnancy I. Neoplasm J. Systemic causes 1. Bleeding disorders (most common) 2. Hypertension 3. Arteriosclerosis 4. Renal disease Common Complaints A. Common complaint is unusually severe or frequent nosebleeds. Other Signs and Symptoms A. Anterior epistaxis 1. Unilateral 2. Continuous, moderate bleeding from septum of nose B. Posterior epistaxis 1. Brisk (arterial) bleeding 2. Blood flowing into pharynx (indicates a more serious problem) Subjective Data 342 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Inquire about amount, duration, and frequency of bleeding. B. Ask about use of oral anticoagulants, aspirin, or aspirin-containing compounds (e. g., Pepto-Bismol, aspirin, Excedrin). C. Ask about recent or current URIs, family history of abnormal bleeding, recent surgery, or trauma. D. Ask about the first day of female patient's last menstrual period (if appropriate). Determine if the patient is pregnant. E. Ask about a possible foreign body in the nose. F. Ask about cocaine use or occupational exposure to irritants or chemicals. G. If the patient has a history of nosebleeds, how did the patient treat previous nosebleeds? H. Has the patient ever been evaluated for a blood clotting abnormality, such as thrombocytopenia or platelet dysfunction? I. Does the patient complain of bruising easily, melena, or heavy menstrual periods? J. Ask about family history of bleeding disorders, such as hemophilia or von Willebrand's disease. Physical Examination A. Check temperature, blood pressure (check for orthostatic hypertension), pulse, and respirations. If nasal packing is required, take precaution and monitor patient closely for vasovagal episode during insertion of nasal packing. B. Inspect 1. Check airway patency with patient sitting and leaning forward. 2. Observe skin, mucous membranes, and conjunctiva for rash, pallor, purpura, petechiae, and telangiectasias. 3. Perform full eye examination, noting pupillary response. 4. Examine nose for septal perforation and ulcerations, which indicate cocaine use. Collagen diseases (such as lupus) are occasionally responsible for ulceration. Epistaxis is rare in hemophiliacs without trauma but is characteristic of von Willebrand's disease. 5. Examine nasal discharge: A unilateral foul discharge with blood indicates a foreign body in the nose. 6. After bleeding has stopped: a. Inspect nasal mucosa for color, discharge, masses, lesions, and 343 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
swelling of turbinates. b. Inspect nasal septum for alignment, septal perforation, and crusting. C. Auscultate heart and lungs. D. Palpate: Check for enlarged lymph nodes in the neck to rule out sarcoidosis, tuberculosis, or malignancy. E. Percuss sinuses. Diagnostic Tests A. None is required unless the patient has recurrent or severe blood loss. B. Perform drug screen, if indicated. C. Hematocrit and hemoglobin if bleeding is severe. D. Complete blood count (CBC) with differential. E. Platelets, prothrombin time (PT), and partial thromboplastin time (PTT) if bleeding disorder is suspected. F. Sinus films if recurrent sinus pain, tenderness, and bleeding. Differential Diagnoses A. Epistaxis B. Foreign body C. Septal deformity D. Perforated nasal septum E. Coagulation disorder (von Willebrand's disease) F. Nasal tumors G. Drug-induced coagulopathy H. Hypertension I. Pregnancy Plan A. General interventions: Main goal is to control episodes of bleeding. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Nosebleeds. ” C. Pharmaceutical therapy/medical/surgical management 1. To control anterior septal bleeding: a. Have patient sit and lean forward, apply pressure to reduce venous pressure, and prevent swallowing of blood. 344 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
b. Soak a cotton pledget in phenylephrine (Neo-Synephrine), oxymetazoline HCl (Afrin), or epinephrine 1:1,000, and apply with pressure against bleeding site for 5 to 10 minutes. c. Remove and check for bleeding after 10 minutes. d. If this fails, anesthetize mucous membrane by applying cotton soaked with a vasoconstrictor, such as 4% lidocaine (Xylocaine) plus topical epinephrine (1:10,000), cocaine 4%, or phenylephrine 0. 25% for 10 to 15 minutes. e. Then apply a silver nitrate stick to the bleeding site and any prominent vessels, until gray eschar appears. Warn the patient that this is painful. f. If bleeding still does not stop (rare), repeat last two steps. Then place a small amount of oxidized regenerated cellulose (Surgicel) against the bleeding artery, or pack a small petroleum gauze strip in the nasal vestibule for 24 hours. Monitor the patient for vasovagal episode during the insertion of packing. 2. To control posterior septal bleeding: a. Have the patient sit and lean forward. b. Control bleeding: Spray nose with topical anesthetic and vasoconstrictor, and apply pressure to the bleeding site. c. Consult a physician. The patient needs emergency department care immediately because of rapid blood loss. d. Take blood pressure and pulse; order hematocrit; blood type and cross-match may be needed. Follow-Up A. Anterior septal bleeding: Referral to otolaryngologist is recommended for unsuccessful cessation of hemorrhage. B. For posterior nosebleeds, admission to hospital and referral to otolaryngologist is recommended. Consultation/Referral A. Posterior epistaxis: Refer to a physician and/or otolaryngologist immediately. Individual Considerations 345 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Pregnancy 1. Nosebleeds are common. 2. Suggest use of saline spray to keep mucous membranes moist and use humidifier at bedtime. 3. Follow use of saline spray with Vaseline applied with Q-tip daily to prevent recurrent nosebleeds. B. Pediatrics 1. The most common cause of nosebleeds is trauma from nose picking or rubbing. 2. Advise parents to keep fingernails short. 3. Applying water-based lubricant on rims of nostrils to maintain mucosal moisture may cause lipoid pneumonia in infants and children. C. Geriatrics 1. Spontaneous posterior hemorrhage is more common in elderly patients. 2. Epistaxis is classically associated with hypertension or arteriosclerosis. 3. Airway obstruction from posterior packing is especially risky in the elderly. 4. Applying water-based lubricant on rims of nostrils to maintain mucosal moisture may cause lipoid pneumonia in the elderly. Nonallergic Rhinitis Jill C. Cash and Moya Cook Definition A. Nonallergic rhinitis is an inflammation of nasal mucous membranes, usually accompanied by a nasal discharge and mucosal edema. Nonallergic rhinitis disorder has no correlation to specific allergen exposures. It is classified in several ways: Vasomotor, perennial, atrophic, geriatric, drug induced, or rhinitis of pregnancy. Incidence A. Chronic or recurrent nasal congestion occurs in about 15% to 20% of the population. 346 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Pathogenesis A. Vasomotor and perennial nonallergic rhinitis results from hyperreactive nasal mucosa. B. Atrophic and geriatric rhinitis results from progressive degeneration and atrophy of the mucous membranes and bones of the nose. C. Overuse of topical nasal decongestants can worsen symptoms and cause severe rebound congestion. D. Cocaine abuse causes nasal congestion and discharge. E. Rhinitis in pregnancy results from hormonal increase; congestion abates with delivery. Predisposing Factors A. Adulthood B. Abrupt changes in temperature, odors, and emotional stress C. Other predisposing factors depend on type Common Complaints A. Nasal congestion B. Sneezing C. Clear rhinorrhea D. Coughing E. Sore throat F. Itchy, puffy eyes Subjective Data A. Ask about the onset, duration, and course of symptoms. B. Inquire about the color and other characteristics of nasal discharge. C. Ask about other discomforts and exposure to people with similar symptoms. D. Inquire about seasonal impact on symptoms, previous treatments, and results. E. Rule out pregnancy. Ask female patients about birth control method, specifically contraceptives. F. Ask about use of prescription drugs, over-the-counter (OTC) drugs (especially aspirin), and illicit drugs (cocaine). 347 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Review medical history for other respiratory problems, such as asthma, emphysema, or chronic bronchitis. H. With children, investigate possibility of a foreign object in nostrils. Physical Examination A. Check temperature and blood pressure. B. Inspect 1. Observe general appearance. 2. Inspect conjunctivae for “allergic shiners” (dark circles under eyes), tearing, and eyelid swelling. 3. Examine ears for signs of otitis media (red, bulging, perforated tympanic membrane, and purulent drainage). 4. Examine nose for redness, swelling, polyps (soft, pedunculated, nontender, pale-gray smooth structures), enlarged turbinates, foreign objects, septal deviation, septal perforation (sign of cocaine abuse), ischemia, mucosal injury, atrophy, and “cobblestoned” pharyngeal mucosa (sign of allergy). C. Auscultate heart and lungs. D. Percuss 1. Sinus cavities and mastoid process 2. Chest for consolidation E. Palpate 1. Face for sinus tenderness 2. Head and neck for enlarged lymph nodes Diagnostic Test A. Skin testing for allergies may be done. Differential Diagnoses A. Nonallergic rhinitis B. Allergic rhinitis C. Upper respiratory infection (URI) D. Foreign body E. Sinusitis F. Otitis media G. Deviated septum 348 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
H. Nasal polyps I. Endocrine conditions, such as hypothyroidism and pregnancy J. Drug use: Oral contraceptives, aspirin, alpha-adrenergic blockers, cocaine, and nasal decongestant overuse Plan A. General interventions 1. Avoid changes in temperature, odors, and emotional stress. 2. Identify triggers for condition and address alleviating triggers. B. Patient teaching 1. Teach the patient the significance of individual triggers for nonallergic rhinitis. Encourage use of a journal to learn personal triggers. 2. Avoid triggers, such as smoking, smoke-filled rooms, wood-burning stoves/fireplaces, sprays, and perfumes. 3. Other triggers may include weather changes, hormonal changes, and medications. 4. Teach methods of treatment and identify treatments that work best for the patient. 5. Encourage use of Neti pot daily to cleanse sinus cavity. Cleansing sinus cavity daily will help to remove foreign materials inhaled and will also help with tissue edema. Clean pot after each use and allow to air dry. C. Pharmaceutical therapy 1. Vasomotor rhinitis: Physiological saline solution as nasal spray, thorough cleansing of nares, topical ipratropium bromide, or inhaled ipratropium bromide (Atrovent) 3 to 6 puffs every 4 hours, not to exceed 12 inhalations per day 2. Atrophic rhinitis: Guaifenesin (Guiatuss) 200 mg/5 m L, 10 m L orally every 4 hours 3. Physiological saline nasal spray to nares three times a day 4. Nasal antihistamines: Azelastine (Astelin): Adults: Two sprays in each nostril daily. Children younger than 5 years: Not recommended. Children 5 to 11 years: One spray in each nostril daily. Olopatadine (Patanase): Adults: Two sprays twice daily. Children younger than 6 years: Not recommended. Children 6 to 11 years: One spray in each nostril twice daily 5. Nasal glucocorticoids: Fluticasone (Flonase): Adults: Two sprays daily 349 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
or one spray twice daily. Maintenance dosing: One spray in each nostril daily. Children younger than 4 years: Not recommended. Children 4 years and older: One spray in each nostril daily, may increase to two sprays in each nostril once daily. Maintenance: One spray daily. Mometasone (Nasonex): Adults: Two sprays in each nostril once daily. Children younger than 2 years: Not recommended. Children 2 to 11 years: One spray in each nostril daily. 6. Decongestants: Oral and nasal decongestants are not recommended unless the use of antihistamines and glucocorticoids failed. Examples may include: Oral pseudoephedrine or nasal oxymetazoline (Afrin) and phenylephrine (Neo-Synephrine). These should not be used longer than 2 to 3 days at a time for congestion due to the effects of rebound congestion with long-term use. Follow-Up A. Have the patient return in 2 to 3 weeks and for biannual examinations and/or as needed. Consultation/Referral A. Consult with a physician if symptoms continue despite treatment. B. If treatment fails, refer the patient to the allergist for testing. Individual Consideration A. Pregnancy: Reassure pregnant patients that rhinitis is a common hormonal response. Nonallergic rhinitis is not contagious and cannot cross the placenta. Sinusitis Jill C. Cash and Moya Cook Definition Sinusitis is the inflammation of mucous membranes lining paranasal sinuses. Sinusitis is often referred to as rhinosinusitis due to the inflammation of the nasal mucosa that almost always accompanies the inflammation of the sinus 350 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
cavity. It may be acute, subacute, or chronic. A. Acute sinusitis: Abrupt onset of infection with symptom resolution after therapy. Acute sinusitis lasts less than 4 weeks. B. Subacute sinusitis: Persistent purulent nasal discharge despite therapy C. Chronic sinusitis: Episodes of prolonged (greater than 3 months) inflammation and/or repeated or inadequately treated acute infections Incidence A. Sinusitis is very prevalent. However, true incidence is unknown because people with frontal headaches or congestion self-medicate with over-the-counter (OTC) decongestants and then request antibiotics if symptoms persist. Most cases of acute sinusitis are viral and last less than 10 days. Incidence increases in spring and fall (allergy seasons) and in winter (cold season). Pathogenesis A. One cause is obstruction of mucus flow due to edema of nasal mucosa from allergies and upper respiratory infections (URIs). B. Another cause is anatomical abnormalities that interfere with the normal mucocilliary clearance mechanism. C. Exposure to pathogens following URI also causes sinusitis. Pathogens include Staphylococcus aureus, Haemophilus influenzae, pneumococci, streptococci, and bacteroides. Incubation period depends on the pathogen. D. Dental abscess is a cause in 10% of cases. E. Fungi such as Mucor, Rhizopus, and Aspergillus can produce invasive sinusitis in poorly controlled diabetics or people with leukemia. F. Common cold is a cause in 0. 5% to 5. 0% of cases. Predisposing Factors A. Recent URI B. Allergens (pollens; molds; smoking; occupational exposure, such as coal mining; and animal dander) C. Nicotine/smoke exposure (first-or secondhand smoke) D. Air pollutants E. Deviated septum F. Adenoidal hypertrophy 351 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Dental abscess H. Diving and swimming I. Neoplasms J. Cystic fibrosis K. Trauma L. Medical disorders (diabetes, immune disorders, inflammatory disorders, mucosal disorders, cystic fibrosis, and asthma) M. Flying or rapid changes in altitude Common Complaints A. Yellow or green nasal discharge B. Fever C. Sore throat D. Facial pain, frontal pain, or pressure that worsens when patient bends forward E. Headache F. Toothache Other Signs and Symptoms A. Anosmia (loss of sense of smell) B. Nasal congestion C. Cough (worse when lying down); may be chronic D. Periorbital edema (especially early morning) E. Malaise or fatigue F. Halitosis G. Snoring, mouth breathing H. Nasal-sounding speech Potential Complications to Consider: Immediate Ear, Nose, and Throat Referral A. Meningitis (symptoms are increased fever, stiff neck) B. Subdural and epidural purulent drainage C. Brain abscess D. Cavernous sinus thrombosis (acute thrombophlebitis due to infection in the area where veins drain into cavernous sinus) E. Tender periorbital edema (orbital cellulitis) 352 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Subjective Data A. Elicit the onset, duration, and course of symptoms. B. Inquire whether seasons affect symptoms. C. Ask the patient about recent URI and how it was treated. 1. Did the patient receive antibiotics? 2. Did the patient finish the full course of antibiotics? D. Ask about allergies. E. Inquire about recent dental problems, especially dental abscesses. F. Find out what home therapies and OTC medications the patient tried before the office visit. G. Ask if the patient took a trip recently, especially by airplane. H. With a child, look for a foreign object up the nose. I. Inquire whether the patient was swimming or diving recently. J. Review the patient's medical history for cystic fibrosis, asthma, nasal abnormalities (e. g., deviated septum), and other respiratory problems. Physical Examination A. Check temperature, blood pressure, pulse, and respirations. B. Inspect 1. Observe eyes for periorbital swelling, “allergic shiners” (dark circles under eyes), tearing, and signs of orbital cellulitis (conjunctival edema, drooping lid, decreased extraocular motion, and vision loss). 2. Examine ears. 3. Inspect the nose for erythema, edema, discharge, lack of nostril patency, septal deviation and polyps, and presence of a foreign body. 4. Transilluminate maxillary and frontal sinuses in a darkened room. Absence of light reflection is not definitive. 5. Examine the mouth and pharynx for erythema and tonsillar enlargement, check teeth for uneven surfaces (sign of grinding), and check retropharynx for evidence of postnasal drip. C. Auscultate heart and lungs. D. Palpate 1. Neck for lymphadenopathy 2. Sinuses but do not press on eyes a. Frontal sinusitis: Pain and tenderness over lower forehead (worse 353 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
when bending forward) and purulent drainage from middle meatus of nasal turbinates b. Maxillary sinusitis: Pain and tenderness over cheeks from inner canthus to teeth (referred pain), edematous hard palate (severe cases), and purulent drainage in middle meatus c. Ethmoid sinusitis: Frontal or orbital headache, tenderness and erythema over upper lateral aspect of nose, drainage from anterior ethmoid cells through middle meatus, drainage of posterior cells through superior meatus d. Sphenoid sinusitis (uncommon): Frontal or orbital headache or facial pain (headache referred to top of head and deep into eyes), purulent drainage from superior meatus E. Percuss 1. Tap maxillary teeth to rule out dental cause. 2. Percussion maxillary and frontal sinuses and do chest percussion, if indicated. 3. Percussion over affected area exacerbates pain. F. Neurologic examination 1. Evaluate for signs of meningeal irritation, assessing for Brudzinski's sign, Kernig's sign, and nuchal rigidity. Diagnostic Tests A. Diagnosis is usually made through history and physical. B. Consider sinus x-ray films, which show air-fluid level and thickening of sinus mucous membranes with sinusitis for chronic or recurrent sinusitis or complicated cases. C. CT of sinuses if indications include chronic sinusitis, recurrent sinusitis, allergic fungal sinusitis, or osteomeatal complex occusion. Differential Diagnoses A. Sinusitis B. Headache (cluster, migraine) C. Rhinitis (allergic or vasomotor) D. Nasal polyps E. Tumor F. URI 354 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Trigeminal neuralgia Plan A. General interventions 1. Preventive techniques suggested to avoid sinus infections. 2. Patients with frequent sinus infections should be encouraged to keep a log of triggers, if present. Avoiding these triggers helps to prevent the onset of infection. Avoid smoking and secondhand smoke; use of nasal saline, Neti pot, and increased fluids also help prevent the onset of infection. 3. Recurrent frequent sinus infections should be further investigated for other causes, such as autoimmune diseases. B. Patient teaching 1. Teach patient to avoid smoking and secondhand smoke. 2. Drinking extra fluids helps to loosen secretions and hydrate the body. 3. Encourage the patient to use medications as prescribed. OTC medications, such as antihistamines and decongestants, should be used with caution. 4. Application of warm, moist compresses to the face several times a day will help with discomfort. 5. Humidifiers should be used daily. 6. Nasal saline to the nares three times a day will help to keep nasal passages moist. 7. See Section III: Patient Teaching Guide for this chapter, “ Sinusitis. ” C. Pharmaceutical therapy 1. Antibiotics for infection a. Drugs of choice for acute sinusitis: i. Children 1)First-line treatment: Augmentin 45 mg/kg/d in twice-daily dosing for 10 to 14 days. Second-line treatment: Augmentin 90 mg/kg/d in twice-daily dosing for 10 to 14 days 2)Beta-lactam allergy: Type I hypersensitivity: Levofloxacin 10 to 20 mg/kg/d orally every 12 to 24 hours for 10 days. Non-type I hypersensitivity: a)Cefpodoxime 10 mg/kg/d (for a maximum of 400 mg/d) in divided doses every 12 hours or 355 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
b)Cefdinir 14 mg/kg/d (for a maximum of 600 mg/d) in divided doses every 12 to 24 hours or c)Levofloxacin 10 to 20 mg/kg in divided doses every 12 to 24 hours 3)Risk for antibiotic resistance or failed initial therapy: a)Augmentin 90 mg/kg/d orally twice daily for 10 to 14 days b)Ceftriaxone 50 mg/kg intramuscular for 3 days followed by Augmentin 90 mg/kg for 10 to 14 days c)Cefpodoxime 10 mg/kg/d in divided doses every 12 hours d)Cefdinir 14 mg/kg/d in divided doses every 12 to 24 hours or e)Levofloxacin 10 to 20 mg/kg/d orally every 12 to 24 hours ii. Adults 1)First-line treatment: Augmentin 500 mg orally three times a day or 875 mg orally twice daily for 10 to 14 days. Second-line treatment: Augmentin 2,000 mg (two extended-release tablets) by mouth every 12 hours for 10 days or doxycycline 100 mg orally twice daily for 10 to 14 days 2)Beta-lactam allergy: Doxycycline 100 mg orally twice daily or 200 mg orally daily for 10 days, levofloxacin 500 mg orally daily for 10 days, or moxifloxacin 400 mg orally daily for 10 days. 3)Risk for antibiotic resistance or failed initial therapy: Augmentin 2,000 mg orally twice daily for 10 days, levofloxacin 500 mg orally daily for 10 days, or moxifloxacin (Avelox) 400 mg orally daily for 10 days. b. The same antibiotics can be used for chronic sinusitis, but treatment should last 3 to 4 weeks. Fluroquinolones should be reserved for those who do not benefit from other medication treatment as the risks associated with these antibiotics outweigh the benefits. D. Oral and topical decongestants to correct the underlying edematous mucosa (use cautiously with hypertension) 1. Adults and children older than 6 years: Pseudoephedrine sulfate 356 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
(Afrin) 0. 05% spray or drops, 2 to 3 drops or sprays per nostril twice daily; maximum for 3 to 5 days. 2. Adults and children older than 12 years: Phenylephrine (Neo-Synephrine) spray or drops, 2 to 3 drops or one to two sprays of 0. 25% solution per nostril, or small amount of jelly to nasal mucosa, every 4 hours as needed. Do not use for more than 3 to 5 days. 3. Pseudoephedrin HCl 30 to 60 mg every 4 to 6 hours as needed for congestion for adults. 4. Nasal saline to nares three times daily as needed for hydrating nasal mucosa: 0. 25% solution spray or drops, 2 to 3 drops or one to two sprays per nostril every 4 hours as needed. Do not use for more than 3 to 5 days. E. Steroid sprays may be used to decrease nasal inflammation. Steroid nasal sprays should only be used on children younger than 6 years of age if there is an allergic component: 1. Beclomethasone dipropionate (Beconase AQ, Vancenase AQ); fluticasone (Flonase): a. Adults: Two sprays daily b. Children 4 to 12 years: One spray daily 2. Mometasone furoate monohydrate (Nasonex): a. Adults: Two sprays daily b. Children 6 to 12 years: One spray daily F. Antihistamines are recommended to block histamine production in response to the allergy triggers and prevent allergy symptoms. 1. Loratadine (Claritin) 10 mg daily for children older than 6 years 2. Fexofenadine (Allegra) 180 mg daily in adults 3. Levocetirizine HCl (Xyzal) 5 mg daily for adults 4. Cetirizine HCl (Zyrtec) 10 mg oral or dissolve tab daily for adults and children older than 6 years; for less severe symptoms, 5 mg daily 5. Leukotriene inhibitors (Singulair, Accolate) for severe allergies and/or asthma G. Pediatric doses are available for all products. Follow-Up A. Recheck the patient in 3 to 4 days if signs and symptoms are not improving with the use of treatment prescribed. B. Recommend treatment for 10 to 14 days. Patients not improving may be 357 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
resistant to antibiotics and may be switched to a different antibiotic for 14 days. Consultation/Referral A. Admission to hospital is needed if the patient has fever with facial cellulitis and mental changes. B. Refer chronic sinusitis patients to an otolaryngologist if they do not improve in 4 weeks. C. Refer patients to a physician or ear, nose, and throat (ENT) specialist for suspected neoplasm, abscess, osteomyelitis, meningitis, or sinus thrombosis. Individual Considerations A. Pediatrics: Sinusitis may be considered for children who present with normal to low-grade temperature and green mucus from nose for longer than 2 weeks. B. Geriatrics 1. Precautionary measures should be used for patients with long-term nasogastric tubes. These patients are at higher risk for the development of occult sinusitis. 2. Precautions should be used with patients currently prescribed warfarin (Coumadin). 3. Avoid use of Bactrim DS (TMP-SMX) with warfarin because the medication can cause a significant increase in prothrombin time/international normalized ratio (PT/INR). Bibliography Adelson, R. T., & Adappa, N. D. (2013). What is the proper role of oral antibiotics in the treatment of patients with chronic sinusitis? Current Opinion in Otolaryngology & Head and Neck Surgery, 21(1), 61-68. Center for Disease Control and Prevention. (n. d. ). Pediatric treatment recommendations. Retrieved from https://www. cdc. gov/getsmart/community/for-hcp/outpatient-hcp/pediatric-treatment-rec. pdf De Muri, G. P., & Wald, E. R. (2012). Clinical practice. Acute bacterial sinusitis in children. New England Journal of Medicine, 367(12), 1128-1134. de Shazo, R., & Kemp, S. (2016). Pharmacotherapy of allergic rhinitis. In J. Corren (Ed. ), Up To Date. Retrieved from http://www. uptodate. com/contents/pharmacotherapy-of-allergic-rhinitis? source=search_result&search=Pharmacotherapy+of+allergic+rhinitis&selected Title=1%7E150 Messner, M. D. (2014). Management of epistaxis in children. In A. Stack & G. Isaacson (Eds. ), 358 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Up To Date. Retrieved from http://www. uptodate. com/contents/management-of-epistaxis-in-children?source=search_result&search=epistaxis&selected Title=2%7E150 Patel, Z., & Hwang, P. (2016). Acute sinusitis and rhinosinusitis in adults: Treatment. In D. Deschler & S. Calderwood (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/uncomplicated-acute-sinusitis-and-rhinosinusitis-in-adults-treatment?source=search_result&search=sinusitis&selected Title=1%7E150 Ramavaram, S., & Jones, S. M. (2012). Natural course and comorbidities of allergic and nonallergic rhinitis in children. Pediatrics, 130(Suppl. 1), S23-S24. Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Kumar, K. A., Kramper, M.,... Corrigan, M. D. (2015). Clinical Practice Guideline (Update): Adult sinusitis executive summary. Otolaryngology—Head and Neck Surgery, 152(4), 598-609. Retrieved from https://www. guideline. gov/content. aspx?id=49207&search=acute+rhinitis Wald, E. (2016). Acute bacterial rhinosinusitis in children: Microbiology and treatment. In S. Kaplan, G. Isaacson, & R. Wood (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/acute-bacterialrhinosinusitis-in-children-microbiology-and-treatment?source=search_result&search=sinusitis+children+treatment&selected Title=3%7E150 359 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
8Throat and Mouth Guidelines Avulsed Tooth Jill C. Cash and Moya Cook Definition A. A tooth that has been completely displaced from its alveolar socket. Incidence A. Avulsion accounts for 0. 5% to 16% of all dental injuries to the permanent teeth. It occurs predominantly in children between ages 7 and 10 years. The upper central incisor is the most frequent tooth that is avulsed. Pathogenesis A. Trauma causes a tooth to be completely displaced from its alveolar socket. Predisposing Factor A. Erupting teeth are most susceptible to avulsion due to immature periodontal ligaments. Common Complaints A. Tooth displaced B. Pain C. Bleeding Subjective Data 360 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Ascertain the patient's age, and note if the avulsed tooth is primary or permanent. B. Determine the time span for which the tooth has been avulsed (minutes or hours). C. Ask the patient about the underlying cause or trauma. Are there any other injuries that need assessment, such as lacerations or concussion? D. Did the tooth fall out of the mouth or remain in the mouth? Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Observe general appearance. a. Check for signs that are secondary to traumatic etiology, such as lacerations, concussion, facial injury, and eye injury. b. Keep the patient calm. Check to be sure that the patient is not in respiratory distress or has not aspirated the tooth. 2. Inspect gums and avulsed tooth, noting poor dental hygiene. Do not touch the root surface. 3. If the tooth is not in the mouth, rinse off briefly under cold running water (less than 10 seconds) and attempt to reposition the tooth into the socket if there is no concern of the child swallowing the tooth or dropping it. Diagnostic Tests A. Dental x-ray should be considered to assess for fracture. Immediate referral to dental specialist for emergency dental evaluation. Differential Diagnoses A. Avulsed tooth B. Luxation injuries: Concussion and subluxation Plan A. General interventions 1. Refer immediately for emergency dental evaluation and treatment. B. Patient teaching 1. Tell the patient not to let the tooth air dry; it may cause permanent 361 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
destruction of periodontal cells. 2. Instruct the patient to transport the tooth in the tooth socket and bite on gauze or a small handkerchief to help hold the tooth in position. 3. If unable to transport inside the tooth socket, use another medium to transport the tooth that may include saline, Hanks balanced storage medium, or milk. C. Pharmaceutical therapy 1. Consider administering oral antibiotics prophylactically. Consider tetracycline or doxycycline for adults. Amoxicillin may be used for children. 2. If the tooth had contact with soil, determine tetanus status and administer tetanus booster if necessary. Follow-Up A. Follow-up is done with the dentist until stabilization is complete. Consultation/Referral A. Immediately refer the patient to a dentist or an emergency department. Teeth replanted within 30 minutes have the best prognosis. Teeth avulsed longer than 2 hours have a poor prognosis. The American Academy of Pediatric Dentistry provides a free algorithm for the treatment of permanent tooth avulsion: www. aapd. org/media/policies_guidelines/rs_traumaflowsheet. pdf Individual Consideration A. Pediatrics: Primary teeth do not need to be replaced. Dental Abscess Jill C. Cash and Moya Cook Definition A. A dental abscess is a space infection of the gingival or periodontal tissues. Incidence 362 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Incidence is unknown. Pathogenesis A. An abscess occurs when bacteria gain access into the gingiva or periodontal tissues. Predisposing Factors A. Poor dental hygiene B. Dental caries Common Complaints A. Constant, severe jaw pain B. Swelling C. Difficulty in chewing with tooth due to pain Other Signs and Symptoms A. Fever B. Warmth, redness C. Loss of appetite D. Heat and cold sensitivity E. Halitosis Potential Complications Risk of complications increases with valvular disease. The following are complications: A. Sepsis B. Leukocytosis associated with facial cellulitis Subjective Data A. Elicit information from the patient regarding the onset, duration, location, and quality of pain. B. Note the radiation of pain as well as alleviating or aggravating factors. C. Note if pain is brought on by contact with hot, cold, or sweet substances; this may indicate periapical abscess or dental caries. D. Ask if the patient has a fever. If so, how high and for how long? E. Inquire about the history of mitral valve prolapse or rheumatic fever. 363 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Inspect teeth for caries, mobility of teeth, or protrusion from sockets, and gum disease. 2. Examine the teeth for erosion, enamel decalcification, diminished tooth size, discoloration, and sensitivity to temperature changes. C. Palpate neck and submental area for enlarged, tender lymph nodes. D. Percuss all teeth. Tenderness is diagnostic of an abscess. E. Auscultate heart, if indicated. Diagnostic Tests A. None usually required. B. White blood cell count (WBC), if cellulitis is suspected. Differential Diagnoses A. Dental abscess B. Periodontal disease C. Cellulitis Plan A. General interventions 1. Treat immediate infection. 2. Refer to the dentist for immediate evaluation and treatment. B. Patient teaching 1. Advise the patient to apply a heating pad to the painful facial area for comfort. 2. Advise soft diet until pain resolves. 3. Review daily dental care and hygiene with the patient. C. Pharmaceutical therapy 1. Drug of choice: Penicillin V potassium (Pen-Vee-K) 250 to 500 mg orally every 6 hours while the patient awaits dental consultation 2. Other medications a. Cephalexin (Keflex) 500 mg every 6 hours until dental consultation b. Clindamycin (Cleocin) 300 mg orally every 6 hours until dental 364 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
consultation 3. For discomfort and fever: Ibuprofen (Advil) 400 to 600 mg orally every 6 to 8 hours, not to exceed 1,200 mg/d Follow-Up A. Follow up 2 to 3 days after dental examination to evaluate results. Consultation/Referral A. Advise the patient to see a dentist promptly, even if pain resolves. Individual Considerations A. Pregnancy 1. It is safe for patients to have dental procedures during pregnancy. 2. X-ray films may be taken with a lead shield over patient's abdomen. 3. Epinephrine and nitrous oxide should not be used during dental procedures. 4. Tetracycline should not be used; it causes staining of fetal bones and teeth. Epiglottitis Jill C. Cash and Moya Cook Definition A. Epiglottitis is the inflammation and swelling of the epiglottis and is a medical emergency. Incidence A. Epiglottitis usually occurs in children between ages 2 and 8 years, but it may also occur in adults. Incidence has decreased dramatically since the Haemophilus influenzae vaccine was introduced. Pathogenesis A. Epiglottitis is almost always caused by H. influenzae, although Streptococcus pneumoniae and Streptococcus pyogenes have also been 365 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |