Morning conference at MGH

This morning’s excellent teaching conference was given by Dr. Miriam Barshak. A few notes I took are below, with my own commentary interspersed. Any errors are my own responsibility, and please do not use this for medical decision making. It is merely provided for education.

  • Sinusitis (Acute/chronic)
    • Sinuses are normally sterile but drain into the colonized nasal passage.
    • In the context of a viral URI, you can have mucopurulent rhinorrhea but that doesn’t mean bacterial infection.
    • Only 2% progress to bacterial sinusitis, but 80% of patients with “rhinosinusitis” get antibiotics. Antibiotics are very much overused in sinusitis.
    • Amoxicillin doesn’t help with sinusitis, said this important JAMA article
    • Be aware of the 2012 IDSA guidelines. They state that if it is bacterial in etiology, use amox-clav not amoxicillin.
    • Otolaryngology guidelines are different than IDSA guidelines. Many ENT patients still get amoxicillin.
    • Macrolides and TMP-SMX are not recommended empirically.
    • Second line treatment (included if penicillin allergy)- Doxy, respiratory quinolone, cephalosporin + clindamycin. No empiric treatment for MRSA. Adults should only receive 5-7 days and children 10-14.
    • If there’s an allergic rhinitis history- give intranasal saline irrigations/steroids but no decongestants/antihistamines.
    • If they get worse, check for resistant organisms. But nasopharyngeal swab isn’t necessarily representative of the sinuses.
    • These guidelines don’t apply if old/young, daycare exposure, recent antibiotics/hospiltilziations, immunocompromised, etc (Chow 2012 CID).
    • An elderly patient with an extensive sinus infection/ sinus surgery history s/p ethmoidectomy, frontal mucocele drainage, presents with pain and head CT shows a defect in the frontal sinus. The patient had a frontal sinus infection that ruptured posteriorly, and could have developed meningitis.
    • It is important to be aware of the sinus anatomy. (Go back and read your Netter!)
    • Rare complications of sinusitis include osteomyelitis (frontal sinus -. facial bones). There is no marrow in these bones, so maybe it should be called osteitis. Patients may have fever, soft swelling, and tender. “Potts puffy tumor.
    • Another complication is periorbital cellulitis and orbital infection. Exam the eye movements. Is there proptosis or changes in vision?
    • Invasive fungal sinusitis is possible in diabetics and the immunocompromised host. The clinical exam is more important than the imaging. Look for eschars, areas where the tissue is not well vascularized. Look for the turbinate destruction, prenatal swelling, cyanosis of the facial skin.  Cultures are often negative. Therefore, emergent/aggressive surgery may be needed. ENTs will usually act quickly if you tell them you are worried about invasive fungal sinusitis.
    • Chronic sinusitis is if symptoms last for more than 4 weeks. It’s more common than hypertension and generates more office visits than hypertension. Infectious diseases doctors see these patients frequently. There needs to be a CT done and ENT evaluation to exonerate the anatomy- no cancer or other obstruction (malignant).  Allergic fungal sinusitis, immune deficiency, Wegeners, and Cystic Fibrosis are possible. It is like “asthma in the sinuses.” Don’t give antibiotics. However, you can get a acute bacterial infection, so have an ENT evaluation of the sterile places to guide therapy. They may be colonized with resistant bacteria.
    • Sinus infections in hospitalized patients: are an uncommon cause of a nosocomial fever but worth considering if there’s an NG tube causing obstruction to outflow.
  • Pharyngitis
    • In adolescents/young adults, 62% of patients had no bacterial species identified.
    • Fusobacterium occurred in 20%, but group A strep, group G strep and Group C strep are very rare.
    • Fusobacterium is an emerging pathogen and Lemierre’s syndrome can be bad (Centor Annals 2015).
    • Why treat group A strep pharyngitis in adults? Decrease symptoms, prevent local/systemic spread of disease. But this is very rare. And prevent rheumatic fever, but it is exceedingly rare in the West. The strains don’t usually have cross reactivity with the antigens associated with rheumatic fever. Preventing transmission is important, however, and 25% of household contacts will get infected from an untreated family member.
    • Be aware of the Centor Criteria (Centor, Med Dec Making 1981).
    • Rapid antigen testing is not so helpful in children.
    • Treatment for GAS is Penicillin V 250 mg po aid x 10 days, and 500 mg BID is probably ok.
    • Macrolides are not effective for fusobacterium and it is difficult to culture from routine throat cultures.
    • Group A strep can be persistent in 15% but they don’t need more treatment, they are chronic carriers.
    • For GAS, post-exposure prophylaxis is not recommended.
    • Viral syndromes that cause influenza include influenza, adenovirus, herpetic, coxsackievurs herpangina, EBV, and acute HIV.
    • The most common testing for EBV is the mono spot (heterophile antibody). But for 2-3 days of sore throat and a negative monospot it is not so reliable. In those patients, you can either repeat the mono spot in 2 weeks and see if it has converted to positive, or send a more sensitive EBV serology panel looking for IgM from the viral capsid antibody.
    • Arcanobacterium haemolyticum is another etiology of pharyngitis, most often seen on the ID boards, and is treated with erythromycin. 
    • Thrush is due to candida albicans.
    • Uncommon causes include epiglottis, tularemia, diphtheria, deep neck space infections (ludwig’s angina, retropharyngeal/peritonsillar abscess, Lemierre’s syndrome).  Beta lactase effective, but metronidazole needed.
      • Peritonsillar abscess– due to group A strep, mouth anaerobes. There is severe, persistent pharyngitis, truisms, “hot potato” voice, dysphagia. There is unitonsillar peritonsillar swelling, displacement of the tonsil. 20% of our strep milleri can be resistant to clindamycin.
      • Retropharyngeal abscess is important to be aware of if they have sore throat, dysphagia, neck pain, stridor, drooling.  Group A strep and oral anaerobes are most common.
  • Otitis (acute, Malignant Otitis Externa, MOE)
    • Otitis media
    • “Chronic otitis” – perforated tympanic membrane with chronic intermittent drainage.
    • Mastoiditis is uncommon, although in ICU patients imaging can show mastoid opacification.
    • Malignant Otitis Externa is osteomyelitis of skull bace.
      • Risk factors include diabetes, immunodeficiency, age over 60, and is most common in men.
      • The earwax (cerumen) in diabetics have a higher pH and lower lysozyme concentration.
      • Just because they don’t have a high A1c doesn’t mean they aren’t at risk.
      • There is usually drainage (yellow/green, foul odor).
      • Fever is uncommon.
      • There can be cranial nerve defects, especially the 7th nerve leading to dysphagia and hoarseness.
      • The pain can be out of proportion.
      • Culture the ear canal.
      • Imaging is helpful. On head CT, you can see bony erosion.
      • Most commonly (>95%) it is due to pseudomonas.

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Thanks so much for reading. Reading/writing blog posts does take time and we all know that time is in short supply. You and I will both get much more out of this blog if it leads to discussion/dialogue. If you found this post useful and wouldn’t mind leaving a brief comment/sharing on social media, that would be great. Or if you’re shy but are willing to email me a comment that I can post anonymously, I’d appreciate it. As my posts are generally written quickly, if you find any factual errors, please do let me know. Best regards, Philip Lederer

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