Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration

Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration

Otic Disorders: Acute Otitis Media (AOM) vs. Otitis Media with Effusion (OME)

Inflammation and fluid accumulation within the middle ear cleft are common primary care complaints. Differentiating acute infection from non-infectious fluid prevents inappropriate antibiotic overuse.

Acute Otitis Media (AOM)

AOM is an acute infection of the middle ear space, often precipitated by Eustachian tube dysfunction following a viral URI. Pathogens include Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella catarrhalis.

• Clinical Presentation: Rapid onset of otalgia (ear pain), fever, hearing loss, and otorrhea.
• Otoscopic Examination: Hallmark feature is a bulging tympanic membrane (TM) with marked erythema, loss of landmarks, light reflex displacement, and absent TM mobility on pneumatic otoscopy.
• First-Line Treatment: High-dose Amoxicillin 875 mg PO BID or 1000 mg PO TID for 7–10 days. Prescribe Amoxicillin-clavulanate 875/125 mg BID if amoxicillin was taken in the past 30 days or concurrent purulent conjunctivitis exists. Penicillin-allergic alternatives: Cefdinir, Cefpodoxime, or Azithromycin.

Otitis Media with Effusion (OME)

OME is middle ear fluid accumulation without acute inflammatory signs.

• Clinical Presentation: Ear fullness, popping, or mild conductive hearing loss without acute pain or fever. Follows resolved AOM or allergic rhinitis.
• Otoscopic Examination: TM is non-bulging, often retracted or amber/yellow, with visible air-fluid levels or bubbles. Pneumatic otoscopy shows decreased mobility.
• Management: Antibiotics and decongestants are NOT recommended. Managed with watchful waiting for up to 3 months. Audiometric evaluation is indicated if effusion persists beyond 3 months.

Otitis Externa ("Swimmer's Ear")

Infection of the external auditory canal caused by Pseudomonas aeruginosa or Staphylococcus aureus. Features severe tragal tenderness, canal edema, and purulent discharge. Treated with topical otic drops (Ciprofloxacin-dexamethasone).

Acute Bacterial Rhinosinusitis (ABRS)

Rhinosinusitis is mucosal inflammation of paranasal sinuses. Over 90% of cases are viral (AVRS). Antibiotics are indicated only when clinical criteria support ABRS.

Diagnostic Criteria for ABRS

ABRS is diagnosed when meeting at least one of three patterns:

1. Persistent Symptoms: Nasal congestion, purulent discharge, or facial pain lasting >= 10 days without clinical improvement.
2. Severe Onset: High fever (>= 39°C or 102°F) with purulent nasal discharge and severe facial pain for 3–4 consecutive days at illness onset.
3. "Double Sickening": Acute worsening of fever, headache, or discharge after initial 5–6 days of improvement.

Treatment Recommendations

• First-Line Antibiotic: Amoxicillin-clavulanate 875/125 mg PO BID for 5–7 days.
• Penicillin Allergy: Doxycycline 100 mg PO BID or Levofloxacin 500 mg daily.
• Adjunctive Therapy: Saline nasal irrigation, intranasal fluticasone, and analgesics. Limit topical decongestants (oxymetazoline) to 3–5 days maximum to avoid rebound congestion (rhinitis medicamentosa).

Pharyngitis & Group A Streptococcal (GAS) Infection

Pharyngitis is predominantly viral (adenovirus, EBV). Identifying Group A Beta-Hemolytic Streptococcus (Streptococcus pyogenes / GAS) is vital to prevent acute rheumatic fever and suppurative complications.

Centor and McIsaac Clinical Criteria

Assign 1 point for each:

• Absence of cough (+1)
• Tender anterior cervical lymph nodes (+1)
• Temperature > 38°C (100.4°F) (+1)
• Tonsillar exudates or swelling (+1)
• Age 3–14 (+1); Age 15–44 (0); Age >= 45 (-1)

Decision Protocol:

• Score 0–1: Low GAS probability; no testing or antibiotics.
• Score 2–3: Intermediate probability; perform Rapid Antigen Detection Test (RADT). Treat if positive.
• Score 4–5: High probability; perform RADT and treat if positive.

Pharmacological Treatment

• First-Line: Penicillin V 500 mg PO BID for 10 days OR Amoxicillin 500 mg PO BID for 10 days.
• Penicillin Allergy: Cephalexin 500 mg BID, Azithromycin 500 mg day 1 then 250 mg daily, or Clindamycin 300 mg TID.

Ophthalmic Disorders: Glaucoma, Macular Degeneration & Cataracts

Glaucoma

Progressive optic neuropathy with structural disc cupping and visual field loss, often linked to elevated intraocular pressure (IOP > 21 mmHg).

• Primary Open-Angle Glaucoma (POAG): Insidious, painless loss of peripheral vision ("tunnel vision"). Visual acuity is preserved until late stages.
  • First-Line Therapy: Topical Prostaglandin Analogs (Latanoprost, Bimatoprost) increase uveoscleral outflow.
  • Second-Line: Topical Beta-Blockers (Timolol) decrease aqueous humor production (contraindicated in severe asthma, COPD, bradycardia).
• Acute Angle-Closure Glaucoma (AACG): Ophthalmic emergency from physical blockage of trabecular meshwork by the iris.
  • Presentation: Severe eye pain, headache, nausea, blurred vision, and halos around lights. Exam shows a fixed, mid-dilated pupil, cloudy cornea, ciliary flush, and markedly elevated IOP (40–70 mmHg).
  • Management: Immediate emergency ophthalmology referral; topical timolol, apraclonidine, pilocarpine, and IV acetazolamide.

Age-Related Macular Degeneration (AMD)

Causes progressive breakdown of the macula, leading to loss of central vision while peripheral vision remains intact.

• Dry (Non-Exudative) AMD: 90% of cases. Cellular debris accumulates beneath retinal pigment epithelium forming yellow drusen. Causes gradual central vision loss and distorted straight lines (metamorphopsia) on Amsler grid. Slowed by antioxidant vitamins (AREDS2 formulation: vitamins C, E, zinc, copper, lutein, zeaxanthin).
• Wet (Exudative) AMD: Rapid, severe central vision loss due to choroidal neovascularization and capillary leakage. Treated with intravitreal anti-VEGF injections (ranibizumab, aflibercept).

Cataracts

Progressive lens opacification presenting with painless blurring of vision, increased glare sensitivity (especially night driving), halos, and faded color perception. Exam reveals an absent or blunted red reflex. Treated with surgical phacoemulsification and lens replacement.

Presbycusis, Presbyopia & Geriatric Red Flags

• Presbycusis: Age-related bilateral sensorineural hearing loss. High-frequency sounds (s, f, th) are lost first, making speech muffled. Managed with bilateral hearing aids.
• Presbyopia: Loss of lens elasticity impairing near-vision accommodation (starts around age 40–45). Corrected with reading glasses.
• Geriatric Red Flags: Sudden monocular vision loss (amaurosis fugax, retinal detachment, temporal arteritis), sudden sensorineural hearing loss (requires urgent ENT referral and oral steroids), and malignant otitis externa (Pseudomonas temporal bone invasion in elderly diabetics).