Ep-PAINE-nym



Roth’s Spots

Other know aliasesLitten’s spots

Definitionexudative, edematous hemorrhagic lesions of the retina with pale, white centers that can be composed of coagulated fibrin, platelets, infectious organisms, or neoplastic cells

Clinical Significanceone of the classic physical examination findings in bacterial endocarditis seen on fundoscopy. Further research and analysis has shown these can be present in leukemia, diabetes, and hypertensive retinopathy

Historynamed after Mortiz Roth (1839-1914), who was a Swiss pathologist and recieved his medical doctorate from University of Basel in 1864. He practiced all around Switzerland before returning to Basel as professor extraordinary of pathology in 1872, when he published his now eponymous findings in an article entitled “Uber Netzhauteffecstionen bei wundfiebren [Retinal Manifestations of wound fever]”. Dr. Roth, though, never described the classic appearance of the retinal red spot with a white center. Dr. Moritz Litten described this finding 6 years later and would coin the term we still use today.


References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • Roth Spots – StatPearls. [article]
  • Roth M. Uber Netzhauteffecstionen bei wundfiebren [Retinal manifestations of wound fever]. Deutsch A Chir. 1872;1:471–84.
  • Litten M. Ueber akute maligne endocarditis
  • und die dabei vorkommenden retinal veranderungen.
  • Charite-Ann 1878;3:135.

Ep-PAINE-nym



Dix-Hallpike Manuever

Other known aliasesNylen-Barany test

DefinitionStarting supine, the patient’s head is rotated to one side and then quickly lowered to supine with the neck extended over the exam table.  Patient is observed for nystagmus for 30 seconds and then returned to supine and observed for another 30 seconds.  This is then repeated for the other side.

Clinical SignificanceThe Dix-Hallpike maneuver is the diagnostic maneuver to induce vertigo and nystagmus in patients with benign paroxysmal positional vertigo by relocating canaliths to the posterior semicircular canals.

HistoryNamed after Margaret Ruth Dix (1902-1991), a British neuro-otologist, and Charles Skinner Hallpike (1900-1979), an English otologist.  Dr. Dix earned her medical doctorate in 1937 from the Royal Free Hospital School of Medicine and Dr. Hallpike earned his from the University of London in 1926.  Dr. Dix was training to become a surgeon when she was injured during the World War II air raids of London and suffered facial and ocular injuries which forced her to change her medical career path.  It was during this time she was hired by Dr. Hallpike to pursue the field of neuro-otology.  Their work resulted in a landmark series in the Proceedings of the Royal Society of Medicine and Annals of Otology, Rhinology, and Laryngology.  It was this series in 1952 where one of the papers describing their eponymous finding  entitled “The Pathology, Symptomatology, and Diagnosis of Certain Common Disorders of the Vestibular System” was published.


References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • DIX MR, HALLPIKE CS. The pathology symptomatology and diagnosis of certain common disorders of the vestibular system. Proceedings of the Royal Society of Medicine. 1952; 45(6):341-54. [pubmed]
  • Margaret Ruth Dix – Royal College of Surgeons [link]

#45 – Preseptal vs Orbital Cellulitis



***LISTEN TO THE PODCAST HERE***



Definitions

  • Orbital Septum
    • Membranous structure that extends from orbit to the tarsal plate and is the anterior boundary of the orbital compartment
  • Preseptal Cellulitis
    • Infection of the soft tissues ANTERIOR to the orbital septum
  • Orbital Cellulitis
    • Infections of the soft tissues POSTERIOR to the orbital septum

Numbers

  • Preseptal cellulitis is much more common than orbital (>90%)
  • Both conditions are more common in children than adults

Pathogenesis

  • Preseptal
    • Usually due to superficial dermatologic infections (though the data has wide variability in reported causes)
  • Orbital
    • Bacterial rhinosinusitis
      • Due to perforations in the lamina papyracea
    • Other causes:
      • Ophthalmologic surgery
      • Dacrocystitis
      • Orbital trauma
      • Dental infections

Microbiology

  • Preseptal
    • Staphylococcus aureus (skin causes)
      • Increasing incidence of MRSA
    • Streptococcus pneumoniae (sinus/nasopharynx causes)
  • Orbital
    • Same as preseptal, but include:
      • Fungal (mucormycosis and Aspergillus spp.)

Signs and Symptoms

  • Both present with unilateral eyepain, erythema, and edema, but:
  • Preseptal
    • No pain with eye movement
    • Sclera is white
Preseptal Cellulitis (sclera is white and quiet)

    • Orbital
      • Painful eye movement
      • Vision changes (acuity, diplopia)
      • Proptosis
      • Sclera injection and chemosis
      • Decreased pupillary response
Orbital cellulitis (notice sclera is red and angry with chemosis)

Complications

  • Complications of preseptal cellulitis are rare, but orbital cellulitis can lead to:
    • Vision loss (3-11%)
    • Subperiosteal abscess
    • Orbital abscess
    • Cavernous sinus thrombosis

Diagnostic Studies

  • CBC with differential may be helpful in risk stratification or atypical presentation
  • Preseptal
    • None! –> Clinical diagnosis
  • Orbital
    • Indications for CT scan
      • Inability to assess vision or deteriorating vision
      • Double vision
      • Inability to examine due to age
      • Proptosis
      • Restricted, limited, and/or painfuleye movement
      • Edema extending beyond eyelid margin
      • Lack of improvement in 24 hours on antibiotics
      • Cyclical fevers
      • Signs of CNS involvement
      • ANC > 10,000 cell/microL
a. proptosis, b. soft tissue inflammation, c. choroidal detachment, d. retrobulbar inflammation, e. optic nerve sheet enhancement
medial orbital subperiosteal abscess with left sided ethmoid sinusitis
  • Blood cultures are not routinely recommended but should be entertained in ill appearing children prior to antibiotic administration

Treatment

  • Preseptal
    • Outpatient
      • > 1 year old and no signs of systemic toxicity
      • Treatment duration typically 5-7days, but treatment should continue until eyelid erythema and swelling have resolved
    • Inpatient
      • < 1 year old, children who can’t cooperate with exam, toxic appearance, or outpatient treatment failing to improve in 24-48 hours
      • Follow orbital cellulitis treatment
  • Orbital
    • Medical
      • Staphylococcal coverage
        • Vancomycin
      • Streptococcal coverage
        • Ceftriaxone
        • Cefotaxime
      • Anaerobic coverage
        • Metronidazole
      • Improvement should occur within24-48 hours
      • Transition to oral therapy when:
        • Afebrile and periorbital signs are resolving
        • Typically 3-5 days
        • Follow culture data (if obtained) or follow outpatient preseptal cellulitis regimen
      • Treat for a total of 2-3 weeks
    • Surgical indications
      • Radiographically identified abscess
        • Typically > 10mm, though small abscesses respond to antibiotics well
      • Intracranial extension
      • Failure to respond to antibiotic treatment
      • Threat to vision


References

  1. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatrics in review. 2010; 31(6):242-9. [pubmed]
  2. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. International journal of pediatric otorhinolaryngology. 2008; 72(3):377-83. [pubmed]
  3. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192011900
  4. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. The British journal of ophthalmology. 2008; 92(10):1337-41. [pubmed]
  5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. The New England journal of medicine. 2006; 355(7):666-74. [pubmed]
  6. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. The Laryngoscope. 1996; 106(8):1010-3. [pubmed]
  7. Erickson BP, Lee WW. Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis. Orbit (Amsterdam, Netherlands). 2015; 34(3):115-20. [pubmed]
  8. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clinical otolaryngology and allied sciences. 2004; 29(6):725-8. [pubmed]
  9. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010; 125(4):e719-26. [pubmed]
  10. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Archives of otolaryngology–head & neck surgery. 2008; 134(7):764-7. [pubmed]
  11. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 1998; 2(6):351-5. [pubmed]

PAINE #PANCE Pearl – HEENT



Question

Benign paroxysmal positional vertigo (BPPV) can be quite a debilitating condition for patient it effects.  What are the two maneuvers that are used at the bedside for this condition and how do they differ?


Answer

The two maneuvers used clinically in the evaluation and treatment of BPPV are:

  • Dix-Hallpike Maneuver (diagnosis)
    • This is used to diagnosis BPPV and is performed by having the patient starting sitting upright.  The head is then turned to one side and the patient is rapidly lowered to the supine position with their extended over the examination table.  The provider then watches for nystagmus or vertigo symptoms.  If this side is negative, then the maneuver is repeated on the other side.
Dix-Hallpike
  • Epley Maneuver (treatment)
    • This is used to treat active vertigo in BPPV by attempting to relocate the canalith back into the utricle by using a series of repositioning techniques.
Epley

References

  • Shim DB, Ko KM, Kim JH, Lee WS, Song MH. Can the affected semicircular canal be predicted by the initial provoking position in benign paroxysmal positional vertigo? The Laryngoscope. 2013; 123(9):2259-63. [pubmed]
  • Furman JM, Cass SP. Benign paroxysmal positional vertigo. The New England journal of medicine. 1999; 341(21):1590-6. [pubmed]
  • Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure for benign positional vertigo: a meta-analysis. The Laryngoscope. 2004; 114(7):1143-6. [pubmed]
  • White J, Savvides P, Cherian N, Oas J. Canalith repositioning for benign paroxysmal positional vertigo. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2005; 26(4):704-10. [pubmed]

Ep-PAINE-nym



Epley Manuever

Other known aliasescanalith repositioning manuever

Definitionseries of positions and manual manipulations used to reposition free-floating otoconia in the semicircular canals of the inner ear

Clinical SignificanceThe Epley maneuver is used to treat benign paroxysmal positional vertigo (BPPV) by relocating the otoconia back to the utricle where they can no longer stimulate the cupula of the semicircular canal and cause vertigo. 

HistoryNamed after John Epley, an American otolaryngologist from Portland, OR, who received his medical degree from the Oregon Health Sciences University and fellowship from Stanford Medical Center.  He pioneered the “canalith theory” of vestibular disease and published his eponymous maneuver in 1980 in the article entitled “New Dimensions of Benign Paroxysmal Positional Vertigo”.  Dr. Epley is still in practice today.


References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngology and head and neck surgery. 1980;88(5):599-605. [pubmed]


#37 – Conjunctivitis



***LISTEN TO THE PODCAST HERE***

 



Pathophysiology

 

The conjunctiva is a mucous membrane that that lines the surface of the eyelids (palpebral) and globe up to the limbus (bulbar).

 

The conjunctiva itself is made up of non-keratinized squamous epithelium with goblet cells and substantia propria, which is highly vascularized.

The important thing to remember is that the conjunctiva is transparent, unless inflamed (which is termed “injected”).


Bacterial Conjunctivitis

 

  • Bacterial conjunctivitis is more common in children than adults (though viral is most common overall).
  • Transmission is spread from direct contact with infected drainage or contaminated objects
  • Pathogens
    • S. aureus, S. pneumoniae, H. influenza, M. catarrhalis
  • Signs and Symptoms
    • Redness and drainage in one eye
    • Matted shut in the morning
    • Drainage
      • Continues throughout the day
      • Thick and purulent
  • Special Concerns
    • Neisseria gonorrhoeae
      • Concurrent STI symptoms
      • Rapid onset of symptoms (< 12 hours)
      • More pain and tenderness with marked chemosis and lymphadenopathy
      • Admission with emergency ophthalmology evaluation
        • Keratitis and perforation may occur

Viral Conjunctivitis

 

  • Most common cause of acute conjunctivitis
  • Highly contagious and is spread through direct contact with drainage or contaminated objects
  • Pathogens
    • Adenovirus is the most common
  • Viral prodrome
    • Fever, adenopathy, pharyngitis, URI, conjunctivitis
  • Drainage
    • Watery, mucoserous drainage
    • Matted/thick in the morning with scant, watery drainage throughout the day
  • Corneal injection with burning/gritty sensation
  • Starts unilateral and spreads to contralateral eye within 48 hours of symptoms onset
  • Follicular pattern on palpebral conjunctiva
  • Self-limiting process
    • Worsens for 3-5 days with gradual resolution over the next 7-10 days

Allergic Conjunctivitis

 

  • Caused by airborne allergens that initiate an IgE-mediated local response with mast cell degranulation and release of histamine
  • Drainage
    • Watery and stringy
  • Signs and Symptoms
    • Bilateral eye involvement
    • Periorbital edema
    • Allergic symptoms
      • Sneezing, coughing, rash, sore throat
    • Profuse itching
    • Marked chemosis and injection
      • Bullous chemosis may occur in severe causes or as a result of itching

Non-Infectious/Non-Allergic Conjunctivitis

 

  • Causes
    • Mechanical or chemical insult
      • Patients with chronic dry eyes
      • Patients s/p irrigation from chemical splash
      • Transient foreign body
  • Self-limiting and spontaneously improve within 24 hours

Distinguishing Between The Types

 


Special Considerations for Contact Lens Wearers

 

These patients are at an increased risk for Pseudomonas infections and should be advised to refrain from wearing their contacts and to have a formal evaluation by an ophthalmologist to rule-out serious infection.  Any antibacterial treatment in these patients should also cover for Pseudomonas.


Treatment

 

With the exception of gonococcal conjunctivitis, all types are self-limiting and will improve on their own.  Having said that, bacterial conjunctivitis will improve faster with topical antibiotics.

 

Bacterial

  • Erythromycin 5mg/gram ointment – 1cm ribbon 4x/day for 5-7 days
  • Trimethoprim-polymyxin B 0.1%-10,000 units/mL – 1-2 drops 4x/day for 5-7 days
  • Ciprofloxacin 0.3% – 1-2 drops 4x/day for 5-7 days

 

Viral and Allergic

  • Antihistamine/decongestant drops
    • Pheniramine/naphazoline – 1-2 drops 4x/day
    • Olopatadine 0.2% – 1 drop daily
    • Azelastine 0.05% – 1 drop 2x/day

 

Non-Infectious/Non-Allergic

  • Eye lubricants

Return to Work/School Issues

 

The safest recommendation is to be out until there is no longer any discharge, but this is not practical since it could last for up to 2 weeks.

 

Viral

  • I tell patients that you treat it like the common cold and practice good hand hygiene to limit the spread of any infectious drainage

Bacterial

  • Most schools require 24 hours of therapy before children are allowed to return to school

Cottage Physician

 


References

  1. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clinical therapeutics. 1995;17(5):800-10; discussion 779. [pubmed]
  2. Ullman S, Roussel TJ, Culbertson WW. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. 1987; 94(5):525-31. [pubmed]
  3. Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. American journal of ophthalmology. 1986; 102(5):575-83. [pubmed]
  4. Azar MJ, Dhaliwal DK, Bower KS, Kowalski RP, Gordon YJ. Possible consequences of shaking hands with your patients with epidemic keratoconjunctivitis. American journal of ophthalmology. 1996; 121(6):711-2. [pubmed]
  5. Roba LA, Kowalski RP, Gordon AT, Romanowski EG, Gordon YJ. Adenoviral ocular isolates demonstrate serotype-dependent differences in in vitro infectivity titers and clinical course. Cornea. 1995; 14(4):388-93. [pubmed]
  6. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. The Cochrane database of systematic reviews. 2012; [pubmed]
  7. Rose PW, Harnden A, Brueggemann AB. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet (London, England). ; 366(9479):37-43. [pubmed]