Otitis Media

Otitis Media
Presentation by:Rick Newton, MD

Definition:inflammation of the middle ear

Why the Worry?
* Ear Pain
* Possible Complications
o Hearing Loss (esp. conductive)
+ Leading to speech, language, and cognitive abilities
o Ruptured TM
o Mastoiditis
o Meningitis
o Labyrinthitis
o Brain Abcess
o Lemierre’s Syndrome - anaerobic suppurative thrombophlebitis involving the internal jugular vein

Epidemiology
Risk Factors
Pathogenesis
* Typically follows URI or Allergy
* Congestion obstructs eustachian tube @ isthmus.
* Middle ear secretions accumulate
* Normal flora or new infections in upper respiratory tract to middle ear.

Bacteriology
3 bacteria remain most common isolates even in post-PCV7 & HIB vaccine era
Strep. pneumoniae
Haemophilus Influenzae
Moraxella catarrhalis


Symptoms/Signs
Otalgia
Otorrhea
Non-specific

o Fever
o Irritability
o HA
o Apathy
o Anorexia
o Vomiting
o diarrhea

Syndromes: Otitis-Conjunctivitis

* Symptom complex of otitis media and purulent conjunctivitis
* Classically nontypable H. influenzae (54% of all cases)
* inflammation of the TM in which bullae are present on the tympanic membrane
* occurs in ~ 5 percent of cases of AOM in children younger than 2 years
* Characterized by increased pain

Syndromes: Bullous Myringitis
Virology
* RSV
* Rhinoviruses
* Influenza

Other Microbes
* Mycoplasma pneumonniae
* Chlamydia trachomatis
* Tuberculous
* Ascaris lumbricoides
* Blastomyces dermatitidis
* Candida
* Aspergillus

Diagnosis

* Two diagnostic criteria for AOM
o Inflammation
o Fluid in middle ear
* Otoscopy
o TM erythematous, bulging, and immobile
* Techniques to Confirm Dx
o Pneumatic Otoscopy
o Culture

AAP Consensus Dx Criteria:
Nature of the Illness
Antibiotics & Otitis Media
The Controversy
Treatment Options
When to Consider Tympanostomy Tubes or Chemoprophylaxis
Tympanostomy Tubes
Complications of Tympanostomy Tubes
To Swim or Not to Swim
Management of Patients with Tympanostomy Tubes
* Otorrhea
* Tube Extrusion
* Cholesteatoma
* Persistent TM Perforation
* Tympanosclerosis

Otitis Media.ppt

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Cervical Rib Resection Procedure

Cervical Rib Resection Procedure
Presentation by:April Carter RN,MSN,CNOR
NorthWest Florida State College

Objectives

* Assess the related terminology and pathophysiology of the lungs.
* Analyze the diagnostic interventions for a patient undergoing a cervical rib resection
* Plan the intraoperative course for a patient undergoing
* Assemble supplies, equipment, and instrumentation needed for the procedure.
* Choose the appropriate patient position
* Identify the incision used for the procedure
* Analyze the procedural steps for cervical rib resection.
* Describe the care of the specimen

Terms and Definitions
* Thoracic outlet: formed by the first ribs, spine, and sternum
Definition/Purpose of Procedure

* Decompression of the thoracic outlet through partial or entire removal of the rib
* Surgical Goal: release compression of the neurovascular tissue and restore neurovascular function to the affected upper extremity, neck, or shoulder

Pathophysiology
* Thoracic Outlet Syndrome
o Compression of the subclavian vessels and the brachial plexus at the apex of the thorax.
o Other names: cervical rib syndrome, first thoracic rib syndrome, costoclavicular syndrome, hyperabduction syndrome
o Classifications
+ Arterial thoracic (result compression of subclavian artery and results in severe ischemia of arm)
+ Neurological
+ Venous thoracic

Surgical Intervention:
Special Considerations
Surgical Intervention: Positioning
* Position during procedure
Surgical Intervention: Special Considerations/Incision
Surgical Intervention: Supplies
Surgical Intervention: Instruments
Thoracic Instrumentation
Surgical Intervention: Equipment
Surgical Intervention: Procedure Steps
Surgical Intervention:
Procedure Steps
Specimen & Care
Resources
For visualization of the pleurae, lower and middle mediastinum, and pericardium, the surgeon would need a:

* Thorascope
* Mediastinoscope
* Bronchoscope
* Laryngoscope
As the STSR, with which of the following procedures would you anticipate the use of chest tubes and a water-seal drainage system?
* Lobectomy
* Scalene Node Biopsy
* Percutaneous Transluminal Coronary Angioplasty
* Cardiac Pacemaker Insertion

Which of the following retractors would be most useful in a posteriolateral Thoracotomy?
* Balfour
* O’Sullivan-O’Connor
* Davidson scapula
* Weitlaner

With which of the following procedures would you expect the greatest amount of bleeding?
* Wedge Resection of the Lung
* Decortication of the Lung
* Open Thoracotomy fro Closure of a Ruptured Bulla
* Closure of a Patent Ductus Arteriosus

The removal of a lung is referred to as a/an:
* Pneumonectomy
* Endarterectomy
* Blalock-Hanlon operation
* Cryoablation

Cervical Rib Resection is performed to relieve:
* Thoracic Inlet Syndrome
* Thoracic Outlet Syndrome
* Adult Respiratory Distress Syndrome
* pneumothorax

The procedure performed to remove a fibrous covering from the lung following empyema formation is:
* Aneurysmectomy
* Thoracostomy
* Thymectomy
* Pulmonary Decortication

When two chest tubes are placed into the pleural space, the uppermost tube is used to:
* Evacuate air/re-establish negative pressure
* Evaluate blood/re-establish positive pressure
* Evacuate serous fluid/re-establish positive pressure
* Evacuate pus/re-establish negative pressure

When a rib is removed, the remaining bone edges are trimmed with a:
* Doyen raspatory
* Bethune shear
* Lebsche knife
* Stille-Luer rongeur

When transporting a patient with a closed water-seal drainage:
* The bottle should be kept at or above the height of the patient’s chest
* The chest tube should always be clamped
* Chest tube clamps should accompany the patient at all times
* The patient should be placed in Trendelenburg position

Mediastinoscopy is usually performed with the patient in what position?
* Lateral
* Sims
* Dorsal recumbent
* prone

Removal of air or fluid from the pleural cavity via needle aspiration is:
* Thoracoscopy
* Thoracotomy
* Hemocentesis
* Thoracentesis

Cervical Rib Resection Procedure.ppt

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Infections of the Central Nervous System

Infections of the Central Nervous System
Presentation by:Charles S. Bryan, M.D.

* Pleocytosis: increased WBCs in the CSF
* Hypoglycorrhachia: low CSF glucose
* Meningitis: inflammation of meninges
* Encephalitis: inflammation of the brain
* Meningoencephalitis: both of the above
* Myelitis: inflammation of the spinal cord
* Encephalomyelitis: encephalitis + myelitis
* Parameningeal infection: localized infection “beside the meninges”, e.g. brain abscess, subdural empyema, epidural abscess,suppurative intracranial thrombophlebitis, mycotic aneurysm

The CSF formula
* Red cells (normally 0)
* WBCs (normally < 5/cmm)
* Differential (normally all mononuclear cells)
* Protein (normally 15 to 45 mg/dL)
* Glucose (normally 40 to 70 mg/dL or about 2/3 of simultaneous blood glucose)

Some pointers on the LP
* If you think of it, it’s generally best to do it!
* In chronic problems, rule out localized intracranial pathology; for acute problems, don’t delay if there are no localizing signs!
* Save an extra tube (the Golden Rule)!

Acute bacterial meningitis
* A MEDICAL EMERGENCY
* Consider in every patient with a history of URI interrupted by one of the “meningeal symptoms”: vomiting, headache, lethargy, confusion, stiff neck
* Clinical picture is often unimpressive when the patient is first seen

Triad of acute bacterial meningitis
* Fever (bacterial invasion of blood & CSF)
* Stiff neck (nuchal rigidity due to protective reflexes from inflammation of the subarachnoid space)
* Brain dysfunction (nausea/vomiting, headache, irritability/excitability; obtundation)

Kernig’ sign
Brudzinski’s sign
LP in acute bacterial meningitis
Gram’s stain of CSF in meningitis
Pathogenesis of meningitis
* Mucosal colonization
* Mucosal invasion
* Bacteremia
* Meningeal invasion
* Bacterial replication in CSF
* Host response to bacterial antigens
* Subarachnoid space inflammation

Pathogen offensive strategies in acute bacterial meningitis
* IgA protease secretion
* Ciliostasis
* Adhesive pili
* Evasion of alternative complement pathway by polysaccharide capsule

Host defensive strategies in acute bacterial meningitis
* Secretory IgA
* Ciliary activity
* Mucosal epithelium
* Complement (serum bactericidal system)
* Cerebral endothelium: Blood-brain barrier

The blood-brain barrier in meningitis
* 99% of bacteremic adults do not develop meningitis
* However, 1/3 of bacteremic infants develop meningitis suggesting immaturity of blood-brain barrier
* Barrier seems to function unidirectionally (inoculation of subarachnoid space causes bacteremia 1/3 of the time)
* Normal functions: active transport, facilitated diffusion, aqueous secretion of CSF, homeostasis
* Major sites: arachnoid membrane, choroid plexus, and endothelial cells of cerebral microvascular
* Meningitis: cytokines (especially interleukin-1) increase permeability

Cytokines in meningitis
Why is bacterial meningitis so devastating?
Complications of meningitis
Causes of bacterial meningitis by age
“The big three” of bacterial meningitis
Haemophilus influenzae meningitis
H. influenzae meningitis: current issues
Invasive meningococcal disease
Epidemiology of meningococcal disease
Meningococcal disease: indications for preventive
Pneumococcal meningitis
Neonatal meningitis due to gram-negative bacilli
Listeria monocytogenes meningitis
Epidemiology of bacterial meningitis: some associations
Aseptic meningitis: etiology of the term
Aseptic meningitis: current operational definition
Causes of viral meningitis
Pearls on viral meningitis
Other causes of aseptic meningitis syndrome
* Partially-treated bacterial meningitis
* Tuberculous or fungal meningitis
* Parameningeal infection
* Syphilis or leptospirosis
* Toxoplasmosis, amebiasis
* Sarcoidosis
* Drug reactions
The syndrome of chronic meningitis
Causes of chronic meningitis
Tuberculous meningitis
Cryptococcal meningitis
Syphilitic meningitis
Herpes simplex encephalitis
Brain abscess
Subdural empyema
Cavernous sinus thrombosis
Spinal epidural abscess

Infections of the Central Nervous System.ppt

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