C. Lynn Besch, M.D.

Associate Professor of Medicine

1. age, immunocompromise
2. underlying disease

1. anatomic abnormalities can predispose to infection
2. abnormalities can be congenital or acquired

1. age: very young or very old
2. local conditions: allergy, smoking
3. systemic conditions: diabetes, HIV, Ig defects

1. share common organisms
2. anaerobes outnumber aerobes 10:1 (mucosa)

1. sterile at birth
2. colonize from mother, other humans, environment

1. adhesins, lectins, fibronectin
2. fibronectin crucial to adherence of protective strep spp

1. general health, age, diet, dentition
2. pregnancy, hospitalization
3. personal hygiene

1. mutans, salivarius
2. sanguis, pneumococcus

1. peptostreptococcus
2. Staph epidermidis

1. lactobacilli
2. corynebacteria
3. Bacteroides spp

1. Moraxella
2. Neisseria species
3. N. meningitidis

1. Haemophilus spp
2. H. influenzae

1. Gram-(-) cocci: Veillonella
2. Gram-(-) bacilli: fusobacterium, Bacteroides sp

1. can culture nasophayngeal organisms

1. aerobes > anaerobes in this locale
2. Staph epi (90%), diphtheroids (30%)
3. Pseudomonas (6%)

1. tortuous, thin-skinned (osseus portion), moist
2. desquamated skin & organisms trapped by hair
3. organisms invade macerated skin
4. symptoms: pain, itching
5. staph, diphtheroids, some Gram-negatives
6. localized, diffuse, acute or chronic

1. spread to adjacent soft tissues, bone, mastoid sinus and brain (CN IX, X, XII - facial paralysis)

1. One of most common reasons to see doctor

1. S. pneumoniae (39%)
2. H. influenzae (27%)
3. Gr A strep, Staph aureus (2-3%)
4. M. catarrhalis (2%)
5. None/non-pathogens (viral?) (28%)

1. look at tympanic membrane, find anatomical landmarks
2. look for fluid, pus, and bubbles
3. examine nose and throat

1. penicillins (amoxicillin DOC), cephalosporins
2. sulfa drugs (trimethoprim-sulfamethoxazole)

1. myringotomy, adenoidectomy, drainage tubes

1. redness over mastoid area
2. pinna displaced outward and downward

1. antibiotics, same as for otitis but IV at first
2. surgical drainage

-Includes anterior nares, nasopharynx, sinuses

-All spaces are connected by small tubes

-All have clearance mechanisms

-Material ultimately delivered to oropharynx

-All hollow organs are considered sterile

-Holloew organs are only sterile if they drain

1. Staphylococcus aureus and epidermidis

1. Strep pneumonia, 'Staph epi'
2. Moraxella, Haemophilus
3. Neisseria (meningitidis)

1. should be functionally sterile
2. can find organisms transiently
3. organisms include streptococci, Haemophilus, & anaerobes (Bacteroides, fusobacterium)
4. can find pathogens: H flu, Staph aureus, pneumococcus

1. occlusion of the osteomeatal complex, point of all sinus drainage (-10% due to tooth extraction)

1. viral infections or allergy
2. septal deviation, foreign body, nasal polyps

1. organisms can be introduced by sneezing, coughing
2. mucosa gets inflamed and pus forms inside sinus

1. Strep pneumonia (31/36)
2. H. influenzae (21/23)
3. M. catarrhalis (2/19)
4. Gram-negatives (9/2)
5. Chlamydia (?)
6. Viruses (2-3/0-2)

1. rhinovirus, influenza virus, adenovirus

1. purulent (colored) nasal discharge
2. respiratory symptoms > 1 week, cough
3. maxillary toothache, pain/pressure over sinus area

1. look in nose for discharge, look at teeth/throat
2. transilluminate sinuses
3. x-rays (plain, CAT scan)

1. normal ciliated lining replaced by squamous epithelium, due to repeated or inadequately treated acute sinusitis
2. no longer sterile because of structural damage

1. as for acute plus Gram-negatives, anaerobes and staph

1. cover S. pneumoniae and H. flu
2. starts with penicillins or cephalosporins
3. consider selecvted quinolones and sulfa's in penicillin allergy

1. meningitis (usually frontal or ethmoid)
2. brain abscess (frontal)
3. epidural abscess

1. orthomyxovirus: influenza (12%)
2. paramyxovirus: parainfluenza (17%), RSV (6%)
3. adenovirus (5%)
4. picornavirus; rhinovirus (38%), enteroviruses (4%)
5. coronavirus (4%)

1. children in the home
2. smokers - same rates as non-smokers, but more severe
3. tonsillectomy has no impact on attack rates

-Viral invasion of mucosa

-Swelling and sloughing of mucosa

-Eustachian tube infection

-Occlusion of osteomeatal area

-Possible viral invasion of sinuses and middle ear

-+/- bacterial superinfection

-Eventual resolution of infection and recovery

1. runny nose, scratchy throat, hoarse voice, sneezing
2. mild fever (adults <100, children higher)
3. loss of sense of smell and taste
4. pressure-feeling in sinuses and ears

1. what sounds like a cold usually is
2. rule out other causes of symptoms

1. decongest nose (antihistamines only if sneezing)
2. cough syrup (dextromethorphan) and cough drops
3. antipyretics for fever and headache
4. warm saline gargles
5. Vitamin C and echinaceae +/- beneficial

1. to rule out etiologies that require specific treatment
2. to confirm is not symptom of serious infection

1. Group A strep, non-Group A strep
2. Corynebacterium and Arcanobacterium
3. Treponema (syphilis) and gonorrhea
4. Mixed anaerobes
5. Mycoplasma

1. Candida

1. adenovirus
2. influenza and parainfluenza viruses

1. rheumatic fever and glomerulonephritis

1. Vincent's angina
2. Lemierre's disease: jugular vein septic thrombophlebitis
3. peritonsillar abscess (Quinsy)

1. Gr A Strep (exudate, perichiae, strawberry tongue, rash (Scarlet fever))
2. Anaerobes (gingivitis, foul odor, stiff swollen neck)
3. Candida (thrush)
4. Viruses

1. Adenovirus (conjunctivitis)
2. Enterovirus (herpengine (posterior pharyngeal ulcers))
3. Epstein-Barr (exudate, petichiae, previous amoxicillin)

1. other family members sick (viral)
2. season

1. History and physical
2. if ulcers => treat for herpes if anterior
3. if tonsils medially displaced => antibiotics (+/- admit)
4. rapid antigen test => treat for strep if (+), culture if (-)
5. check mono serology if generalized adenopathy and/or enlarged spleen

1. cellulitis of the epiglottis and adjacent tissue
2. occurs in children and adults

1. dysphonia, dysphagia, irritability and fever
2. sits forward, drools, breathes fast (tachypnea)
3. adult presentation more subtle - odynophagia

1. tongue depressor no further than anterior tonsillar pillars - look for big, cherry red epiglottis
2. or better yet,

1. intubate or perform tracheostomy

1. Haemophilus influenzae type b in children
2. Group A strep in adults (occasionally others)

1. cephalosporins, some penicillins
2. Bactrium (trimethoprim-sulfa) for pen-allergic

1. usually viral and/or part of the common cold
2. bacterial infection can cause supraglottitis
3. ~15% due to voice abuse

1. hoarseness, URI symptoms

1. 90% viral (most common: Parainfluenza types 1, 3)
2. occasionally by Mycoplasma

-Clinical signs and symptoms

-Rule out epiglottitis, foreign body

-May see "hourglass" shape of trachea on AP film of the neck

-Viral isolation or identification (special staining)