E

Ear Infection

What is acute otitis media?
What causes acute otitis media?
How does it cause disease?
How common is acute otitis media?
Who gets an ear infection?
Is an ear infection contagious?
How do you know if your child has an ear infection?
What does the eardrum look like when it is infected?
How is an ear infection treated?
What are the complications?
How can an ear infection be prevented?
What research is being done?

by Stan L. Block, M.D. Associate Clinical Professor of Pediatrics University of Louisville and University of Kentucky

What is acute otitis media?
Acute otitis media is an infection of the middle ear, generally caused by bacteria. In acute otitis media (i.e., an ear infection or an infection of the middle ear), pus and infected fluid accumulate in the middle ear space.
The tympanic membrane (eardrum) appears inflamed, reddened, and often protrudes outward. Usually, an ear infection begins after the eustachian tube (a small tube connecting the back of the nose to the middle ear space) has become swollen, congested, and closed, most commonly resulting from an ongoing viral respiratory infection.

Acute otitis media should not be confused with: 1) external otitis (“swimmer’s ear”)-a painful bacterial infection of the superficial skin of the ear canal, or 2) otitis media with effusion (secretory otitis or “fluid ears”)-an accumulation of non-inflamed fluid behind the eardrum. Otitis media with effusion is not considered infected, and most doctors do not treat it with antibiotics. This uninfected fluid in the middle ear is a remnant in 50% to 60% of resolved ear infections. It is frequently a mild complication of colds, respiratory illnesses, or nasal allergies.

What causes acute otitis media?
Acute otitis media usually is caused by one of four bacteria:
. Streptococcus pneumoniae (pneumococcus) in 30% to 45% of cases.
. Haemophilus influenzae (Haemophilus-but not the Haemophilus strain in the HIB or meningitis vaccine) in 20% to 30% of cases.
. Moraxella catarrhalis (Moraxella; sometimes called Branhamella catarrhalis) in approximately 10% of cases.
. Group A Streptococcus (like the strep bacteria of strep throat) in 5% of the cases.
The pneumococcus bacteria is now the most difficult to treat. Some strains have become very resistant to antibiotics by using their unique ability to transform their genes and cell wall into a bacterial form, which is resistant to most of the antibiotics that commonly are used to treat ear infections. These resistant strains frequently are cultured from children who do not respond to several courses of antibiotics. When a child has an ear infection that does not respond to antibiotics, resistant pneumococcus bacteria may cause it.
Pneumococcus has 90 different types, which are all genetically related; however, 7 types account for the majority of ear infections in childhood and nearly all of the antibiotic resistant strains. In addition, pneumococcus is the leading cause of meningitis, bloodstream infections, and serious pneumonia in children, sometimes as a result of a preceding ear infection.
Up to half of Haemophilus and nearly all Moraxella bacteria produce an enzyme (beta-lactamase), which makes these bacteria resistant to some of the commonly used antibiotics. This enzyme may destroy many antibiotics when they come in contact with the bacteria. Nonetheless, several available antibiotics are still quite effective against these strains.
Viruses play a critical role in the development of acute otitis media by enabling the bacteria to travel into the middle ear (see below). By themselves, though, viruses account for only 6% to 10% of ear infections.

How does it cause disease?
As long as air entering from the back of the nose is able to reach the middle ear space via the eustachian tube, the middle ear rarely becomes infected. The eustachian tube in younger children is flimsy and easily collapses. As the child grows, the cartilage tissue surrounding the eustachian tube becomes stiffer, longer, and more angulated inside the skull.
Pneumococcus, Haemophilus, and Moraxella commonly reside in the back of the nose, and do not infect the child. Once a child becomes infected with a respiratory virus, it not only causes congestion of the nose and the lungs, but also of the eustachian tube. When this tube becomes clogged, the cells in the middle ear space produce a fluid-like substance, which allows bacteria to grow and infect the middle ear space. A virus infection precedes up to 90% of cases of acute otitis media.
Respiratory virus infections also trigger ear infections by upsetting the body’s normal defenses in the nose and the eustachian tube, and allowing certain normal bacteria that reside in the nose to “stick” better to the lining of the nose and the eustachian tube. Certain viruses, such as the flu (influenza) and RSV (a respiratory syncytial virus, or the “bronchiolitis bug”), are more frequently associated with ear infections. Occasionally, the child’s nose becomes colonized by a new aggressive strain of bacteria, which rapidly invades the middle ear. Unfortunately, more exposures (e.g., via daycare attendance) to viruses and new strains of bacteria increase the likelihood of ear infections.

How common is acute otitis media?
Acute otitis media is predominantly an infection of young children, primarily occurring in the first three years of life. Children in the 1990s experience 30% more episodes of acute otitis media as compared with children in the 1970s, probably as a consequence of high rates of day care. Currently, acute otitis media accounts for one-fourth of all pediatric office visits in the first three years.
Nearly 94% of children will experience at least one ear infection in the first three years of life, with an average of about three episodes in the first and second years, and one and one-half episodes in the third year. As many as 5% to 8% of children will undergo the placement of ventilating tubes in their first 24 months of life. Much of this is related to the high rate of daycare attendance in the United States, with increased exposure to infectious agents.

Who gets an ear infection?
At the highest risk for ear infections include those children who:
Are male;
Are of the white, American Indian, or Eskimo races;
Attend daycare;
Have Downs syndrome;
Are immunocompromised;
Have a strong family history of otitis media;
Were not breastfed during the first 12 months of life; and/or
Reside in a smoking household.
Children with a cleft palate or HIV have particularly severe problems with recurrent ear infections.
Age affects the rate of acute otitis media, with a dramatic decline in frequency in children older than three years. However, some children with a history of ventilating tubes or frequent recurrent otitis media, severe allergies, or large adenoids may still be plagued with ear problems.

Is an ear infection contagious?
To some degree, the bacteria that cause ear infections are contagious because they may colonize, or set up residence, in the nose of children or close contacts. However, only a small proportion of children colonized with a new strain of bacteria will develop an ear infection. For example, in the case of pneumococcus, only about 15% of children colonized in the nose with a new strain of it will develop an ear infection, and usually only within the first month. Also, some bacterial strains appear more aggressive than others and will directly invade the middle ear.
What may be even more important than new bacterial colonization is the spread of respiratory viruses, particularly among children in daycare and pre-schools. Respiratory viruses are very contagious in close quarters. They frequently make a child more susceptible to an ear infection by upsetting the normal balance between the child’s local nose immunity and the co-inhabitant bacteria. When the child’s defenses are down, or the eustachian tube becomes clogged, the bacteria tend to infect the middle ear.

How do you know if your child has an ear infection?
Children with an ear infection display a wide range of symptoms, from none at all, to a high fever, to a screaming earache. Many infants and toddlers with an ear infection show less obvious symptoms, such as sleeplessness, irritability, decreased feeding, or a fever. Ear pain and ear tugging are helpful clues, but are fairly unreliable. Even in older children with a respiratory illness, mild to moderate ear complaints and earaches frequently occur in children with normal ears. In these children, a sore throat often causes the ear complaints. Fever occurs in only one-fourth of ear infections, and it does not signify an ear infection.
One of the more reliable indicators of an ear infection in younger children is when a child, who has had a cold and a runny nose for three to seven days, suddenly develops sleeplessness and inconsolability during the night, along with increasing fussiness throughout the day. Children with a persistent ear infection who have recently received antibiotics often show few symptoms.
Antibiotics should not be prescribed over the phone for a presumed ear infection, without an examination by a physician. Only a careful examination of the eardrum by a doctor can determine whether the ear is truly infected. Often, when the child is brought into the office in the early phase of a cold or a mild respiratory infection, the eardrum will be normal, only to become infected several days after the office visit. If the child has only a mild cough and a runny nose, it is best to wait at least five to seven days into the illness before making an office visit.
The new EarCheckTM (acoustic reflectometry instrument) may help parents to determine whether a young child is getting an ear infection. If a previously healthy child, who now has an illness, develops an abnormal reading on the instrument, parents can assume a 70% chance of fluid behind the eardrum. It will not distinguish between infected or uninfected fluid. More importantly, if the readings are normal and the child’s symptoms are mild, parents can assume that it is very unlikely that the child has an ear infection, and an office visit may be avoided.

What does the eardrum look like when it is infected?
When a doctor examines the eardrum through the otoscope instrument, the eardrum normally appears as a thin gray, translucent membrane (like wax paper). When infected, it will look opacified (cloudy), very reddened, and yellowish. Sometimes, it shows a small layer of pus-like material. During an infection, the eardrum usually becomes rigid because of the accumulation of fluid, and it will not wiggle when the doctor puffs a small amount of air against the eardrum with an otoscope. Use of tympanometry or acoustic reflectometry (i.e., the EarCheck instrument) may help to determine if there is fluid behind the eardrum. Neither instrument distinguishes between infected or uninfected fluid.
From the appearance of the eardrum, the doctor cannot determine the type of bacteria, or whether bacteria or viruses are causing the infection. The eardrum in children with otitis media with effusion appears as an orangish or dull, straw-colored fluid, and it also does not move when air is applied to it.

How is an ear infection treated?
The intense ear pain of acute otitis media can be partially relieved by adequate doses of ibuprofen or acetaminophen. For more severe earaches, some doctors may prescribe codeine. Numbing eardrops provide minimal relief, and only for a short time. A warm washcloth or sweet oil (olive oil) directly instilled in the ear canal may temporarily distract from the child’s ear pain.
Nearly all doctors in the United States believe that acute otitis media should be treated with antibiotics by mouth, particularly if the child has symptoms. Antibiotics generally provide prompt and dramatic relief of the ear pain. Oral antibiotics for acute otitis media are safe and effective, with exceedingly rare serious side effects.
In a few European countries, ear infections are not treated in children older than two years, unless symptoms persist for more than 48 hours. A few U.S. physicians recommend this same tactic.
Most experts in the United States are concerned about the tendency for pneumococcus in an ear infection to cause more serious infections. When pneumococcus causes an ear infection, if left untreated, it will persist in the ear of 80% of children for up to a week. However, most episodes of acute otitis media will resolve on their own from 3 to 10 days. Yet, non-treatment may be dangerous, not only because of the risk of serious pneumococcus infections, but also because of the possibility of other serious complications. Furthermore, few parents are willing to watch a child suffer with an earache, a fever, and crying for several days.
Amoxicillin (the “pink ink”) is the drug of choice for initial ear infections, except in the penicillin allergic child. In an attempt to enhance the effectiveness of this inexpensive and safe antibiotic, many doctors are now prescribing amoxicillin twice a day and in double the daily standard dose. Effectiveness for initial therapy with most antibiotics approaches 70% to 80%. There are other antibiotics to treat children who do not respond to amoxicillin or who never seem to respond to initial amoxicillin therapy.
Children who do not respond after two or more standard courses of antibiotics can be expected to respond to another antibiotic only about 50% to 60% of the time. Most children who fail antibiotic therapy are younger than 24 months, have poor eustachian tube function, and tend to be infected with more resistant bacteria. At this point, the easy-to-treat bacteria usually have been eliminated. The persistent bacteria are the most resistant strains of the three most common ear bacteria. The emergence of more resistant strains is outpacing the development of new effective drugs. A child’s doctor should be relied upon to select the most effective second-line antibiotic choices.
The new “one-shot” (ceftriaxone) for acute otitis media also is effective for simple cases of acute otitis media. However, “the shot” should only be used in select children, such as those with vomiting and diarrhea, very cantankerous toddlers, or children with an associated moderately serious illness. Three daily doses of ceftriaxone also may be very effective in children who have failed three to four consecutive courses of antibiotics, and are destined for tube placement.
The Centers for Disease Control (CDC) has convincingly pointed out that antibiotic overuse is one of the major culprits for the increasing antibiotic resistance problem. Parents should not insist on an antibiotic prescription for fevers, minor colds, and respiratory illnesses.
Physicians almost never know which bacteria they are treating. Thus, the CDC and other otitis experts advocate the use of tympanocentesis (lancing the ear or ear tap) for children who have failed antibiotic therapy.
Tympanocentesis:
Relieves instantly the pain of the child with a crying earache;
Enables the physician to culture the bacteria and to select the best antibiotic for the infection; and
Allows the ear infection (like an abscess) to drain, which may improve the healing process.
The procedure can be performed nearly pain free. Only physicians who have been trained in the procedure perform it.
No medication is currently available to treat viruses that precipitate ear infections, either before or during the illness. An exception is the flu virus. Anti-flu medications and the flu vaccine could help prevent some wintertime ear infections, but only for the small number of children with ear infections related to the flu.

What are the complications?
The most serious complications secondary to ear infections are mastoiditis (infection of the skull bone behind the ear) and meningitis (infection of the lining of the brain). Both are extremely rare.
Chronic draining ears and chronic perforations (holes in the eardrum) are uncommon, but occur more frequently as a result of resistant pneumococcus. However, these complications are commonly seen in developing countries where antibiotics are not readily available. Permanent hearing loss from very severe recurrent infections is a major concern, but is still rarely observed with effective antibiotic therapy. Children with an ear infection (even ones that rupture and drain) suffer only some temporary, low grade hearing loss. As the fluid resolves, which may take months, the hearing returns to baseline levels.
Your child’s doctor may work with an ear-nose-and-throat doctor to help treat the more severely afflicted child, or one who has suspected chronic hearing loss. Children with chronic fluid persisting for more than four months, or with more than five or six ear infections in a year, may require the insertion of “tubes.” This is most important during the first two years of life when hearing is critical for speech and language development. Chronic ear infections may aggravate learning and later school problems, but cause and effect on this issue remains speculative.
Severe complications from ear infections nearly have been eliminated, and there is an array of antibiotics to treat them; however, the rate of highly resistant bacteria infecting children has increased. Physicians cannot continue to wastefully prescribe antibiotics, and parents should not demand them to treat everyday colds and viral infections. Although the new Prevnar vaccine may prevent many strains of highly resistant pneumococcus, with continual antibiotic misuse, microbiologic history will repeat itself in other pneumococcal strains or in other bacteria.

How can an ear infection be prevented?
The simplest preventive measures include the following:
Breastfeed an infant during the first 12 months of life
For bottle-fed infants, never prop the bottle and wean off the bottle by 12 months
Do not smoke around the baby, particularly in the household or the car
Do not smoke during pregnancy
Consider a private sitter or a smaller daycare, instead of a high volume daycare
Avoid the introduction of solid foods in the first four months of life
Administer the flu vaccine annually after six months of age
Consider allergen avoidance and allergy shots in older children (over three years) with chronic fluid
Administer Prevnar vaccine to infants less than 24 months of age
More controversial preventive measures include the following:
Avoid the pacifier
Give the pneumococcal vaccine (Prevnar) to infants and children older than 24 months who are unvaccinated with Prevnar and still getting recurrent ear infections
Ineffective measures include the following:
Covering a child’s head with a hat during the winter
Using decongestants and antihistamines to “prevent” ear infections
Chiropractic manipulation
Herbal remedies

What research is being done?
The most important recent development to potentially reduce the frequency of ear infections is a new pneumococcal conjugate vaccine. A study from Northern California suggests that this vaccine could prevent about 7% of overall episodes of ear infections, and up to 23% of recurrent ear infections.
The new pneumococcal vaccine contains 7 of 90 types of pneumococcus, which are the most common and the most resistant bacteria. Elimination of these resistant types could have an impact on the number of antibiotic failures in children. This also could mean a reduction in the placement of tubes, possibly by one-fourth, as observed in the California study.
This vaccine is administered to infants at 2, 4, 6, and 12 months of age. Side effects have been minimal, and it has been a very safe vaccine. It uses the same technology as the universally administered HIB vaccine.
Some new antibiotics are about to undergo testing in children with acute otitis media. In preliminary testing, these drugs appear to work against the resistant pneumococcus.
In the future, there may be alternate ways of treating or preventing ear infections. A new antibiotic may be able to penetrate the eardrum directly by instilling eardrops. A nasal spray squirted in the nose of infants a few times a day may prevent the common bacteria of acute otitis media from gaining access to the nose. Some Scandinavian investigators have shown slight reduction in the number of ear infections in children who regularly used an experimental sugar called xylitol.

About the Author

Dr. Block is a full-time practicing pediatrician in rural Bardstown, Kentucky who serves on the clinical faculties at both the University of Kentucky and the University of Louisville as an Associate Clinical Professor of Pediatrics.
His pediatric practice is one of the leading pediatric research groups in the United States and, in fact, Dr. Block was awarded the American Academy of Pediatrics 1998 Practitioner Research Award.
He has authored and published over 20 articles and 40 abstracts on pediatric infectious diseases. He has also lectured on Otitis Media extensively to pediatricians and other physicians throughout the U.S. and Canada.
Copyright 2012 Stan L. Block, M.D., All Rights Reserved

Eating Disorder

http://win.niddk.nih.gov/publications/binge.htm

Eczema

What is dermatitis?
What is eczema?
What causes eczema?
What is ay?
What causes ay?
Why do aic people get eczema?
What are the common findings?
How is aic eczema diagnosed?
How is aic eczema treated?
What are the complications?
How is eczema prevented?
What research is being done?
Links to other information

by Paul Gillum, M.D. Aurora/Parker Skin Care Center Aurora, Colorado
What is dermatitis?
“Dermatitis” literally means “inflamed skin.” The term, dermatitis, is used to describe the skin when it is irritated, red, or inflamed. For example, sunburn, hives, or the rash of measles may be described as dermatitis.

What is eczema?
Eczema is a specific type of dermatitis. With eczema, the skin is not only inflamed (dermatitis), but it also is oozing. Early on, the oozing may show up as small blisters (“vesicles”). After a few days, the blisters usually break open and dry up, leaving scabs or crusts. After several weeks, the oozing is only visible under a microscope. At this stage, eczema looks dry and scaly.

What causes eczema?
Eczema is a reaction pattern of the skin. There are numerous causes, or triggers, of eczema. Some cases are triggered by contact allergy, such as poison ivy. More often, eczema is a reaction to external irritation. For example, rubbing the skin (scratching) may cause an eczema reaction. Harsh chemicals, detergents, and excessive washing also can cause it. Generally, eczema does not result from internal causes, such as foods or medications. More often, internal triggers cause a different type of inflammation (dermatitis), called hives or urticaria.

What is ay?
Ay, meaning “without a place,” is a word invented in 1923 by Drs. Cooke and Coca, who were classifying and categorizing different skin conditions and rashes. They had a group of patients who had unusually sensitive skin, and who were very susceptible to irritation and eczema. Most of these patients also had family members with hay fever, allergies, or asthma. Since this group of patients did not fit in Dr. Coca’s classification system, he made up the word, ay, to describe them. Today, ay is considered an allergic condition that a person may inherit.

What causes ay?
It is not known why aic people have sensitive skin. Most aic people begin having eczema by two years old. If one parent is aic (i.e., has hay fever, asthma, or allergies), there is a 20% chance that the child also will be aic; when both parents are aic, there is a 60% chance. However, to develop eczema, there must be a cause, such as irritation. Therefore, the skin sensitivity and easy irritation is inherited, while eczema is not.
Human skin is designed to act as a barrier to keep water inside the body and to keep irritants outside the body. In aic people, the barrier does not work correctly, and the water evaporates easily, leading to very dry skin. Aic people also perceive the sensation of itch more easily. When clothing slides across the skin, most people feel a sensation of touch or tickle, but aic people feel a sensation of itch. Skin sensitivity and skin barrier function generally improve with time. Fifty percent of people s having skin irritation and eczema by age 5, and 90% of people s by age 9. Sometimes, eczema reappears in adults, usually after age 60.

Why do aic people get eczema?
Aic people itch more easily, more intensely, and more frequently than other people. Scratching-which triggers a rash-is believed to be the cause of eczema in aic people. In fact, eczema in aic people has been called “the itch that rashes.” Two experiments support this theory. If you gently scratch anybody’s skin for 15 minutes every day, you will produce the eczema reaction. Once the eczema reaction appears, the skin usually itches so much that people will keep scratching. Unless you interrupt the itch/scratch cycle, eczema cannot heal. On the other hand, if you put a protective cast over the eczema, it will heal very quickly, even without any other treatment.
Eczema can be triggered by any kind of irritation, not just scratching. Since the skin barrier in aic people does not work correctly, rough wool clothing, strong soap, frequent bathing, or stress can easily trigger eczema. Because aic skin loses water easily, eczema is often worse in dry winter months. Generally, aic eczema is not caused by contact allergy or by food allergy.

What are the common findings?
Aic people often have a small crease on the lower eyelid near the nose (“Dennie’s Pleats”). They may have dark circles under the eyes, probably from the closely associated hay fever/allergies. They may have small acne-like bumps on the backs of the arms. The wart virus and the ringworm/athlete’s foot fungus grow more easily on aic skin. These findings help to identify aic people even if they never have skin irritation or eczema.
Eczema always looks the same, no matter what causes it. It is red, scaly, crusted, or blistered. In infants, eczema is usually located on the scalp (“cradle cap”), cheeks, elbows, and knees. These areas are most affected in infants, because they cannot directly scratch with their fingers, but they can rub against bedding or other surfaces. In toddlers, eczema mostly occurs on the areas where skin can touch itself, like the creases in front of the elbows or behind the knees. In adults, eczema is rare (they usually have only hay fever or asthma), but it may occur on the hands and feet.

How is aic eczema diagnosed?
For aic eczema to be diagnosed, itch and eczema must occur. Eczema also must last for a long period of time, or it must appear frequently. Eczema should be in the classic location for the age of the patient. When a person is diagnosed with aic eczema, another family member usually is aic.

How is aic eczema treated?
The goal in treating eczema is for a child to be comfortable and still be able to function; it is not as important to make every last spot of eczema disappear. To treat the inflamed, itchy rash areas, most pediatricians and dermatologists will use very mild prescription strength cortisone (steroid) creams. These creams are applied two to three times daily until the rash clears, or the itching ss. The cortisone will penetrate the skin better if a damp cloth is applied after the medicine. Damp pajamas or long john underwear also may be used. Oral antihistamines, such as Benadryl, reduce the sensation of itch and increase drowsiness to ensure restful sleep. ical antihistamines do not work. Occasionally, us will prescribe antibiotics when the raw, irritated skin gets infected. Dietary manipulation generally does not work. Severe cases may require a special kind of ultraviolet light treatment or powerful anti-inflammatory medicines.

What are the complications?
Eczematous skin gets infected more easily, especially by the cold sore virus. People with active eczema should not touch a cold sore. In darker skin, eczema and other skin irritation may leave dark spots. Dark spots always resolve without treatment, but it may take several months. The intensity of itching may prevent restful sleep; therefore, young patients may be tired or grouchy during the day.

How is eczema prevented?
Eczema cannot be completely prevented, but it can be less severe and less frequent. Dry skin always itches easier and more severely than moist skin. Humidifiers are helpful. Thick cream moisturizers, applied very frequently, and especially after bathing, also are beneficial. Young children should bathe less frequently with less soap. All soap is very irritating, especially Ivory and deodorant soaps. Soap substitutes, like Cetaphil, are excellent. Soap substitutes can be massaged gently onto the skin and simply wiped off. They do not need to be rinsed. In addition, cotton clothing is less scratchy than most synthetics or wool clothing. To remove irritating soap residue, clothing should be double rinsed in the laundry.

What research is being done?
Currently, most of the research on eczema is focused on developing better and safer anti-inflammatory medications, both ical and oral. Significant research also is underway to better understand and correct the barrier abnormality of the skin. To review recent research articles, go to http://www.nlm.nih.gov and search “pubmed” on your Internet browser.

Links to other information
A list server is available for patients with eczema. Send an e-mail to listserv@sjuvm.stjohns.edu and type “subscribe eczema” in the subject line.
For eczema support group information, call or write to:
National Eczema Society
163 Eversholt Street
London NW1 1BU, United Kingdom
hone: 0171 388 4097
Fax: 0171 388 5882
Web: http://www.eczema.org
For a pamphlet from the American Academy of Dermatology, go to http://www.aad.org/public/publications/pamphlets/skin_eczema.html

About the Author
After finishing medical school and dermatology training at the University of Oklahoma, Paul came to Colorado to further his knowledge in this specialty.
He is board certified in Dermatology and Dermaathology. He works at a busy private practice with offices in Aurora and Parker, Colorado. He also teaches at the University of Colorado Department of Dermatology.
Copyright 2012 Paul Gillum, M.D., All Rights Reserved

Enlarged Lymph Nodes

What are swollen glands?
What causes enlarged lymph nodes?
Who gets enlarged lymph nodes?
What are the common findings?
How is an enlarged lymph node diagnosed?
How is an enlarged lymph node treated?
What are the complications?
How can enlarged lymph nodes be prevented?

Edythe A. Albano, M.D. Associate Professor of Pediatrics University of Colorado Health Sciences Center Pediatric Oncologist The Children’s Hospital Denver, CO

What are swollen glands?
The lumps that you feel in your neck or under your jaw when you have a cold or a sore throat are called lymph nodes. Lymph nodes are part of the body’s immune system. They help to destroy infectious germs, such as viruses (e.g., the common cold virus) and bacteria (e.g., strep). The lymph nodes make antibodies that will help keep you from being infected with a particular germ in the future.
Lymph nodes are located in the areas beside the head and the neck region. They can be found in the armpits, the groin, above the elbow, and deep inside the chest and the abdomen (belly). Their function is the same regardless of their location.

What causes enlarged lymph nodes?
When lymph nodes are active in fighting infection, they may become swollen and painful. Usually, the pain is mild, and the lymph node does not get much bigger than 2 centimeters (slightly under 1 inch) in size.
While lymph nodes are the most common cause of a lump or a bump in the neck, there are other, much less common causes, e.g., cysts from abnormalities of fetal development or thyroid gland enlargement. Usually, us can tell the difference on a physical examination.

Who gets enlarged lymph nodes?
Frequently, children have enlarged lymph nodes. The immune system of a child is constantly being exposed to germs that it has never seen before, and the lymph nodes may swell in reacting to those germs. In contrast, the immune system of an adult has seen most of the common germs, and has developed immunity to them.
Therefore, the lymph glands do not need to work so hard, and they are much less likely to become swollen. In fact, a study published in 1975 showed that 100% of children who are under 12 years of age had lymph nodes that could be felt in the neck.

What are the common findings?
In children, once a lymph node becomes enlarged, it may stay enlarged for a long time. Sometimes, several lymph nodes can become enlarged at the same time. Usually, the lymph node will begin to decrease in size within two to three weeks, but a little bump (less than 1 centimeter, or 1/4 to 1/2 inches, in size) may be present for months.
However, lymph nodes should not continue to grow in size (especially grow greater than 1 inch in diameter). If they do, you should contact us. Your doctor may want to measure the lymph node and record the findings in your chart for accurate comparison on your next examination.
Typically, a fever accompanies enlarged nodes when it is part of an infectious process. You also may have a sore throat, enlarged tonsils, an earache, a dental problem, or skin irritation or infection. Often, the problem that caused the swollen gland will bring you to us and not the swollen lymph node.

How is an enlarged lymph node diagnosed?
Generally, enlarged lymph nodes are evaluated by a physical examination. Your doctor will note:
the size and the location of the enlarged lymph node;
if one or more lymph nodes are involved;
if the node is tender
if it is associated with redness of the overlying skin; and
how it feels, e.g., soft, firm, rubbery, or hard.
Your doctor will examine the areas that the lymph node drains. For example, a lymph node under the jaw should prompt a careful examination of the mouth and the throat. Your doctor also will look for abnormalities that often are seen with enlarged lymph nodes, such as a skin rash or a swollen liver and/or spleen.
Enlarged lymph nodes that grow progressively or are very large in size (generally more than 3 centimeters, or 1 1/4 inches) may require more extensive evaluations, to include a blood count; blood tests for infections, e.g., mono; a skin test for TB; or an x-ray. This is particularly true if you have been losing weight, have joint pain or swelling, have persistent fevers and/or night sweats, or have other abnormalities that are found on a physical examination.

How is an enlarged lymph node treated?
Sometimes, an enlarged lymph node needs no treatment at all, particularly if it is enlarged because it is fighting a viral infection. Occasionally, antibiotics will be prescribed if the lymph node is infected with a bacterial germ or is enlarged due to a bacterial infection (e.g., strep throat). If the lymph node tenderness is a problem, acetaminophen or ibuprofen can be taken to ease the discomfort.
Although steroids (prednisone) will cause the lymph nodes to decrease in size, regardless of the cause of the enlargement, it is strongly discouraged because it could mask a serious underlying cause of the enlarged nodes, delay the correct diagnosis, and, possibly, complicate the treatment.
Rarely, us may recommend surgery to remove the lymph node so that it can be examined under the microscope for the presence of cancer or unusual infections. Usually, a course of antibiotics is administered first, before surgery is recommended. However, surgery is most likely to happen if:
. the lymph node is large (greater than 3 centimeters, or 1 1/4 inches);
. there are other abnormal physical examination findings, e.g., an enlarged liver and/or spleen;
. the blood count is abnormal; or
. the chest x-ray shows enlarged nodes.
Most people worry that a persistently enlarged lymph node is something very serious, like cancer. In children, this is rare. Even if us recommends a lymph node biopsy, it is not very likely to show cancer. In fact, in one study of 239 children who underwent lymph node biopsy, only 13% of the removed lymph nodes showed cancer.

What are the complications?
The lymph node itself may become infected (called lymphadenitis), which can be very painful, and is associated with redness and swelling. Usually, it requires antibiotics for treatment. Infrequently, the lymph node may have a pus pocket inside of it (i.e., an abscess) that requires an operation to drain it.
An enlarged lymph node that is felt immediately above the collarbone is unusual and seldom is associated with infection. If it occurs, you should contact us, as it may be a sign of a more serious condition. For example, in teenagers, swollen glands felt right above the collarbone could be the first sign of Hodgkin’s disease, a type of cancer that occurs in the lymph nodes.

How can enlarged lymph nodes be prevented?
Enlarged lymph nodes cannot be prevented. The lymph node helps the body to fight infection, and, in the process, the lymph gland may increase in size. This is normal. The lymph tissue decreases in size after puberty, and it becomes less noticeable. However, you should contact us if:
the lymph nodes are larger than 3 centimeters, or 1 1/4 inches;
there are signs or symptoms of an infection, such as a sore throat, a fever, or an earache;
the lymph nodes are felt above the collarbone, regardless of their size; or
you have persistently enlarged nodes, lasting three or more weeks.

About the Author
Dr. Albano is a board certified pediatric hematologist/oncologist.
She graduated summa cum laude from Loyola University, Stritch School of Medicine and did both her pediatric residency as well as hematology/oncology fellowship at The Children’s Hospital National Medical Center in Washington, DC.
Besides a full time practice in clinical oncology, Dr. Albano is actively involved in research in infections that occur in immunocompromised patients and their treatment.
Copyright 2012 Edythe A. Albano, M.D., All Rights Reserved

Erythema Multiforme

What is Erythema Multiforme?
What causes Erythema Multiforme?
Who gets Erythema Multiforme?
How does the herpes simplex virus cause disease?
What are the common findings?
How is Erythema Multiforme diagnosed?
How is Erythema Multiforme treated?
What are the complications?
How can Erythema Multiforme be prevented?
What research is being done?

by William L. Weston, M.D. Professor of Dermatology University of Colorado Health Sciences Center
What is Erythema Multiforme?
Erythema Multiforme is an uncommon, self-limited symmetrical skin rash with target lesions that begins abruptly and heals in 7 to 14 days.

What causes Erythema Multiforme?
For most people, a herpes simplex virus infection causes Erythema Multiforme, such as an infection of the lip (i.e., a cold sore). Occasionally, Erythema Multiforme is caused by a herpes simplex virus infection of the genitals. Rarely, other viruses will cause it.

Who gets Erythema Multiforme?
Erythema Multiforme most commonly occurs in adolescents and, sometimes, in school age children.

How does the herpes simplex virus cause disease?
After growing at the site of a cold sore, the herpes simplex virus will travel through the bloodstream to the skin and then grow in the skin cells. The target lesions associated with Erythema Multiforme are the body’s attempt to eliminate the virus. People who are especially susceptible to the herpes simplex virus have difficulty clearing it from their skin.

What are the common findings?
The target lesion on the skin is the most common manifestation of Erythema Multiforme. Each target lesion has at least two zones of color change that resemble an archery target. The center of the target lesion always has some skin damage, such as a scab or a blister.
A herpes simplex virus infection on the lip (i.e., a cold sore) often precedes the appearance of the target lesion(s) by one to seven days. Sometimes, though, the preceding herpes simplex virus infection does not cause cold sores, and it is called a “subclinical infection.” Erythema Multiforme recurs in most people, but not necessarily after each cold sore.

How is Erythema Multiforme diagnosed?
Most physicians diagnose Erythema Multiforme from the target lesions on the skin. However, Erythema Multiforme is frequently overdiagnosed, as large hives are often confused for it. Large hives have normal skin in the center; Erythema Multiforme has damaged skin in the center. Large hives often are accompanied by swelling of the hands and feet; but, Erythema Multiforme is not accompanied by such swelling. Large hives will clear up with antihistamines; but, Erythema Multiforme will not clear up with such treatment.

How is Erythema Multiforme treated?
There is not an effective treatment at the time of the attack of Erythema Multiforme. If individuals experience an attack of Erythema Multiforme every three months or less, a preventative treatment with an oral antiherpes virus agent, such as Zovirax, Valvir, or Famvir, is effective.

What are the complications?
If untreated, the target lesions on the skin will heal within two weeks. Steroid treatments may prolong an attack of Erythema Multiforme. Healing usually occurs without scarring of the skin.

How can Erythema Multiforme be prevented?
Prevention of those factors that precipitate cold sores can be helpful. For example, sunscreen use is beneficial because sun exposure may activate the herpes simplex virus that causes Erythema Multiforme.

What research is being done?
Studies are currently being conducted to examine how the body eliminates the herpes simplex virus. These studies will aid in understanding why individuals who are susceptible to the herpes simplex virus cannot effectively eliminate it despite immune responses that are normal.

About the Author
Dr. Weston is a Professor of Pediatrics and Dermatology at the University of Colorado Health Sciences Center and Chair of the Department of Dermatology. His scientific and clinical interests include Cutaneous immunology, Cutaneous virology, and Pediatric Dermatology.
Dr. Weston is the primary author of the Color Textbook of Pediatric Dermatology (Weston, Lane, Morelli; Mosby, Inc.) which is used by clinicians worldwide and is published in 4 languages.
He created the Genetic Skin Disorders clinic at the University of Colorado in 1998.
Copyright 2012 William L. Weston, M.D., All Rights Reserved

Eye Problems Related to Headache

What is a headache?
What causes a headache related to the eye?
Who gets a headache?
How does it cause disease?
What are the common findings?
How is a headache diagnosed?
How is a headache treated?
What are the complications?
How is a headache prevented?

Robert A. King, M.D. The Children’s Hospital Denver, Colorado
What is a headache?
Commonly described, a headache is pain in the head. Generally, a headache is not dangerous; however, it can be a symptom of an underlying ocular problem or a serious neurological problem.

What causes a headache related to the eye?
The following conditions related to the eye may cause a headache:
. Convergence insufficiency: Difficulty converging both eyes simultaneously to focus on reading.
. Accommodative insufficiency: Difficulty focusing one eye at a time on reading, thereby requiring reading glasses.
. Migraine: Periodic attacks of a vascular headache.
. Strabismus: Any misalignment of the eyes.
. Refractive errors: Any need for glasses, for example, nearsighted (myopic), farsighted (hyperopic), or astigmatism.
. Increased intracranial pressure: Increased pressure around the brain caused by a neurological condition.
. Special conditions (for example, albinism or nystagmus): Most commonly, these conditions lead to focusing problems.
Typically, when a child complains of a headache to a pediatrician that may be attributed to eye fatigue and/or eyestrain, the child is referred to a pediatric ophthalmologist, a doctor who specializes in eye care and surgery for children. With the pediatrician, the pediatric ophthalmologist helps to diagnose and treat the child.

Who gets a headache?
Children often complain of headaches. Most commonly, these children are aged from 2 years to 19 years, with an average age of 10 years. Migraine headaches occur in 2.7% of children by age 7 and in 10.9% of children by age 14; onset in children by age 4 is not uncommon. Headaches caused by convergence or accommodative insufficiency usually do not occur until school age and often not until third or fourth grade when the reading print becomes smaller and it takes a longer time to finish assignments.

How does it cause disease?
A headache is a symptom of a problem, not a disease in its own right. The conditions listed above can be ocular causes of headaches. Headache itself does not cause medical damage, but one of the above listed conditions may cause it.

What are the common findings?
Convergence Insufficiency
Convergence insufficiency usually occurs in the school-aged child who complains of a chronic headache, typically for several months. The child may have difficulty with learning to read; in particular, the child may hold reading material close to the face in an attempt to overcome the blurry vision. This process usually overtaxes already weak convergence amplitudes, which are a measure of a person’s ability to focus both eyes simultaneously on a reading target. The problem may occur several times a week, if not daily, and may occur in school or with homework, with relief on weekends or vacations. The child does not complain of headaches that awaken the child from sleep or of headaches that occur upon awakening in the morning. Nausea and vomiting do not occur with this condition. The child may complain of double vision or may be seen closing or covering one eye, presumably to avoid double vision.
Accommodative Insufficiency
The signs and symptoms of this condition are exactly the same as convergence insufficiency. The child may complain of blurry vision or may simply complain of headache with or after reading. Sometimes, accommodative spasm may be the diagnosis. In this situation, the child becomes focused excessively at near, actually locking the eyes in this focused position. Blurry vision occurs when the eyes are raised to look in the distance.
Migraine
Migraine is a common form of headache in children. Because of the frequently associated visual disturbances, children with migraine often are referred to a pediatric ophthalmologist. Migraine is classified as classic migraine, or migraine with aura; common migraine, or migraine without aura; and complicated migraine.
Migraine with Aura
Migraine with aura begins with the appearance of focal neurologic symptoms, such as numbness in a limb or facial paralysis on one side. Typically, visual symptoms last from 4 to 60 minutes (not seconds or days). Classically described, these symptoms are jagged lines of light surrounding a central blind spot that expand to the peripheral visual field. A child may describe visual symptoms as colorful, bright, flickering, turning, and moving. Some children may describe a kaleidoscope-like effect. Younger children who may not be able to describe these findings should be encouraged to draw it.
Migraine auras generally are followed by an intense, pounding headache located on one side of the head that lasts from two to four hours. The child typically will seek rest, without encouragement, in a quiet, dark room.
Migraine Without Aura
This condition is not associated with preceding visual symptoms. Instead, poorly defined symptoms, generally characterized by behavioral or gastrointestinal disturbances, precede the headache attack by hours to days. The headache begins on one side of the head but often spreads to the whole head, typically lasting hours to several days. Nausea and vomiting, phohobia (avoiding light), and phonophobia (avoiding noise or even sound) are more frequent in this type of migraine than in migraine with aura.
Complicated Migraine
This condition is associated with other neurologic phenomenon, including the ophthalmoplegic migraine, where the patient is unable to move an eye from side to side. Such a condition can occur in children, and it is characterized by periodic episodes of ophthalmoplegia, beginning at the peak of the headache and involving all functions of the oculomotor nerve. The headache usually occurs on the same side and is located around the orbit of the eye. The weakness may last for several weeks after the resolution of the headache.
An unusual form of complicated migraine is the Alice in Wonderland syndrome. Alterations in time and body image, as well as visual distortions, such as shrinking, enlargement, inversion, and elongation, characterize this syndrome.
Strabismus
Strabismus is defined as misalignment of the eyes. With this condition, the eyes can cross (esotropia), turn out (exotropia), or undergo vertical deviation (hypertropia). Any strabismus may cause headaches, with the same signs and symptoms as convergence insufficiency; however, strabismus diagnosed by the ophthalmologist differentiates the two conditions. Frequently, the parents may notice that the child covers or squints one eye with either reading or distance activity or both. Presumably, this action occurs because the child is attempting to avoid having double vision. A history of head trauma or other specific inciting event may result in nerve palsy of one of the nerves (i.e., cranial nerves III, IV, and VI) that move the eye muscles.
Refractive Errors
Refractive errors are the optical condition of the eyes that cause blurry vision, which clears by wearing glasses. Astigmatism and farsightedness are the two refractive errors that may cause a child to experience focusing problems, leading to fatigue and then headache. Astigmatism is when the front surface of the eye is shaped less like a sphere and more like an egg when one meridian is distorted. Farsightedness (hyperopia) is the optical condition when the eye is too short for the focusing system, thereby forcing the patient to excessively focus the lens of the eye (accommodate) to bring images to focus on the retina of the eye. The child often complains of headaches on school days or after long periods of reading when focusing effort has been at a maximum; no headaches occur when the child is not reading. A child with significant astigmatic error may hold reading material too close to the face simply because the words look blurry. This action, in turn, demands that the child accommodate more and converge more to be able to read. If the child holds reading material too close for too long, even normal accommodative and convergence amplitudes are inadequate to sustain long periods of reading.
Increased Intracranial Pressure
A child experiencing a headache that is caused by a brain tumor is quite significant. Classic findings include headaches that awaken the child at night, nausea and vomiting with the headache, and frequently accelerating symptoms over a relatively short time. Recurring morning headaches may be significant; however, this finding also may be related to sinus disease. Additionally, the child may complain of double vision (diplopia), jiggling vision (oscillopsia), or blurry vision. Pseudotumor cerebri is elevated pressure in the head that is not associated with an anatomic cause, such as a brain tumor or hydrocephalus. It occurs in children with prior head trauma, in children who are taking Accutane for acne, or in children who are taking prednisone, for example as part of a chemotherapy regimen. In some teenagers, this condition may occur without any reason.
Special Conditions
A child may complain of headaches that result from an unusual diagnosis, such as albinism or nystagmus. Albinism is a specific ocular disorder caused by decreased body pigment in the skin and in the eye, where vision is decreased because the retina has a deficiency of cells. Nystagmus, which is best characterized as ” jiggling eyes,” results because the vision is poor or because of a primary motor instability that is congenital in nature. Nystagmus also can be caused by other entities.
The history is especially important in assessing whether the headaches occur with reading or other near effort. A child with albinism complaining of headaches may experience eyestrain by holding reading material close to the face, because of the poor vision. A child with nystagmus of any cause may hold reading material close to the face because it dampens the nystagmus (reduces the jiggling) and enlarges the print.

How is a headache diagnosed?
To determine the cause of a headache relating to each of the above listed conditions, a history of the circumstances surrounding the headache and associated symptoms, a physical examination for neurological abnormalities, and an ocular examination should all be performed. The history is very important from both the parents and the child. The time course of the headache should be recorded. The frequency and the circumstances in which the headache occurs also may be important; for example, a headache may occur in school after the child reads for 15 minutes.
Associated symptoms should be explored. The pediatric ophthalmologist should be informed of other physicians who have examined the child; other tests that have been performed; other medical problems of the child; and other signs or symptoms observed by the parents, such as abnormal head positions, closing one eye, vomiting, redness, or swelling.
The eye examination is important. The pediatric ophthalmologist will check the child’s visual acuity (how the child reads the eye chart) at distance and near, with one eye at a time (monocular) and with both eyes simultaneously (binocular). The child’s eye alignment will be recorded in all positions of gaze (looking in every direction) and with left and right head tilt. Accommodative and convergence amplitudes will be measured, and the refractive error will be determined frequently after using dilating drops. The pediatric ophthalmologist will perform a slit lamp examination and a funduscopic examination, with close observation of the optic nerve, examining it for evidence of increased intracranial pressure.
Further diagnostic testing generally is not necessary. However, in the case of complicated migraine, glucose tolerance testing to rule out diabetes or neuroimaging (a CT scan or MRI scan of the head) to rule out serious intracranial pathology may be required. With other conditions (for example, strabismus or increased intracranial pressure), neurological testing, including neuroimaging, may be required.

How is a headache treated?
Convergence Insufficiency
To treat this condition, the pediatric ophthalmologist may prescribe a trial of patching with reading. The patch overcomes any strain induced by attempting to use the eyes together. If reading improves or if the headaches decline in frequency, magnitude, or duration with an eye patch, then the eyestrain induced by the effort to focus is being relieved.
Treatment for this condition is aimed at avoiding the problem or increasing reduced convergence amplitudes. If the child holds reading material too close to the face, then the reduced convergence amplitudes will cause eye fatigue/headaches in a shorter time frame. Therefore, holding reading material further from the face often is helpful. Exercises can be done to improve reduced convergence amplitudes. Convergence amplitudes are measured using a prism bar. When the amplitudes fall well below the normal range, exercises should be done. The exercises normalize reduced amplitudes. Relieving convergence insufficiency is the single most useful application of eye exercises.
Parents can begin this exercise with the aid of an orthoptist, who can train and instruct both the parents and the child. The parents should record feedback from this exercise. Two sessions of exercises, each lasting six to eight weeks, usually is recommended. The exercise can be performed at home, 15 minutes per day, with the supervision of an orthoptist once a month. The child should not have to enroll for a year of vision therapy. The end point of treatment for this condition is normalization of convergence amplitudes and/or relief of symptoms.
Accommodative Insufficiency
Measuring accommodative amplitudes is part of the eye examination. The near point of accommodation can be excessively recessed. Reading glasses are used to move the near point of accommodation close to the face. To treat this condition, it is recommended that the parents buy an inexpensive pair of over-the-counter reading glasses for the child to wear when reading. The headaches may resolve by either the placebo effect of the glasses or true accommodative insufficiency. In either case, the parent may choose to have a formal pair of bifocal glasses prescribed by the pediatric ophthalmologist.
Migraine
The best treatment for migraine includes reassurance, avoidance of precipitating factors, abortive therapy, and prophylactic treatment. Abortive therapy includes rest with or without the use of acetaminophen, anti-inflammatory drugs, or antiemetics. Prophylactic treatment, including beta-blockers, calcium channel blockers, or antidepressants, may be indicated for frequent, incapacitating headaches.
Strabismus
Treatment is directed at alleviating strabismus with glasses (with or without a bifocal), prism glasses, occlusion (patching the eye), or surgery. When the patient has accommodative esotropia, a hyperopic glasses prescription will alleviate the crossing of the eyes and the headaches. Prism glasses are used occasionally to optically align the eyes for small amounts of strabismus. Surgery to realign the eyes is ultimately required in numerous strabismus conditions. The mechanical realignment by moving the muscles that move the eyes is often the only treatment to relieve double vision.
Refractive Errors
For a child who is farsighted (hyperopic) or nearsighted (myopic) or who has astigmatism, glasses are required. More complicated combinations of hyperopic, myopic, astigmatic, or anisometropic refractive error require formal glasses prescriptions from a pediatric ophthalmologist. Bifocal glasses rarely are needed outside of accommodative insufficiency or high accommodative convergence/accommodation ratio.
Increased Intracranial Pressure
For the conditions related to increased intracranial pressure, such as brain tumors or hydrocephalus, neurosurgical intervention is the ultimate treatment. Follow-up care with a pediatric ophthalmologist is recommended to ensure that the optic nerve returns to its normal appearance. Additionally, computerized visual field examinations are beneficial and should be performed on a periodic basis. Any ongoing loss of visual field indicates that the intracranial pressure is not being controlled; in this case, intracranial pressure monitoring is indicated.
Special Conditions
For the child with special conditions, such as albinism and nystagmus, strong reading glasses may relieve this relative accommodative insufficieny.

What are the complications?
In the case of increased intracranial pressure, the child may continue to complain of headaches even after the appropriate treatments have been performed. Failure to control the pressure can lead to ongoing optic nerve damage. Ultimately, the child can become blind if the intracranial pressure is not controlled or if the optic nerve is not protected.

How is a headache prevented?
Routine eye examinations with a pediatric ophthalmologist are recommended to ensure that any significant eye abnormalities are diagnosed and treated appropriately.
To prevent migraine headaches, such precipitating factors as stress, chocolate, nitrates, certain cheeses, and monosodium glutamate (flavor enhancer) should be avoided. Additionally, in girls, oral contraceptives may worsen migraine headaches.

References
Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child. 1982 Feb;136(2):121-4.
Hupp SL, Kline LB, Corbett JJ. Visual disturbances of migraine. Surv Ophthalmol 1989 Jan-Feb;33(4):221-36.
King RA. Common ocular signs and symptoms in childhood. Pediatr Clin North Am 1993 Aug;40(4):753-66.
Mapstone T. Brain tumors in children. In: Tomsak RT, ed. Pediatric Neuro-ophthalmology. Newton: Butterworth-Heinemann Medical; 1995:79.
McManaway JW. Management of common pediatric neuro-ophthalmology problems. In: Wright KW, ed. Pediatric Ophthalmology and Strabismus. St. Louis: Mosby-Year Book; l995:63.
Moore A. Hydrocephalus. In: Taylor D, ed. Pediatric Ophthalmology. London: Blackwell Scientific; 1990:499.
Nelhaus G, Stumpf DA, Moe PG. Neurologic and muscular disorders. In: Kempe CH, Silver HK, O’Brien D, eds. Current Pediatric Diagnosis and Treatment. Los Altos: Lange Medical Publishers; 1984:653.
Troost BT. Migraine and other headache. In: Duane TD, Jaeger EA, eds. Clinical Ophthalmology. Philadelphia: Harper and Row; 1997.
About the Author
Dr. King graduated from the United States Air Force Academy in 1972, with a Bachelor of Science degree. After spending 5 years in the Air Force, he went to medical school at the University of Colorado, graduating in 1981. He completed ophthalmology residency training at the University of Colorado in 1985, followed by a pediatric ophthalmology fellowship at Wills Eye Hospital in Philadelphia in 1986. Since then he has been in private practice in Denver, specializing in pediatric ophthalmology and adult strabismus.
He has been involved in resident training at The Children’s Hospital of Denver, and with other resident training programs as well. Past positions include co-director of pediatric ophthalmology at the Children’s Hospital in Denver, President of the Colorado Ophthalmological Society (now the Colorado Society of Eye Physicians and Surgeons), medical board member, and co-medical director of Anchor Center for Blind Children. He has been a regular contributor at the National Symposium for Nurse Practitioners, most recently chairing a symposium on the pediatric fundoscopic exam in July 2001. He has authored numerous articles in the field of pediatric ophthalmology.
Dr. King is married. He and his wife Carla have 2 children, Eric age 17 and Brian age 10.
Copyright 2012 Robert A. King, M.D., All Rights Reserved

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