head Im all ears Ashley Pinawin EM2 January 21 2016 Objectives To learn clinical signssymptoms of otitis media otitis externa and mastoiditis to be able to diagnose these conditions ID: 615103
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Slide1
Go ahead… I’m all ears
Ashley Pinawin, EM2January 21, 2016Slide2
Objectives
To learn clinical signs/symptoms of otitis media, otitis externa, and mastoiditis to be able to diagnose these conditions.To learn which organisms cause otitis
media, otitis externa, and mastoiditis
and therefore understand
management.
To learn about additional tests helpful in
diagnosing malignant otitis externa
To learn about perforation managementSlide3
AnatomySlide4
Otitis MediaSlide5
Otitis Media
Infection of the middle earModerate to severe bulging of the TMQuintessential sign
Most
common
diagnosis for children < 15 years old
80% of children will have at least one episode of AOMSlide6
Pathophysiology
Eustachian tube dysfunction Almost horizontal in childrenSlide7
Pathophysiology
URI
Inflammation
Accumulation of secretions
Acute Otitis Media
ObstructionSlide8
SymptomsOtalgia
Pulling at earsCoughURI symptomsPoor appetite, diarrhea, vomiting
F
everSlide9
EtiologyBacterial
Streptococcus pneumoniaeHaemophilus influenzae
Moraxella
catarrhalis
Viral
Respiratory syncytial virusSlide10
Risk factors Age
Peak between 6-18 months of age Lack of breastfeedingSeasonDay careEconomic Slide11
Physical ExamSlide12Slide13Slide14Slide15
ManagementAnalgesia
Acetaminophen IbuprofenAntibiotics vs follow upUnilaterel AOM in child > 6monthsSlide16
Antibiotic Treatment
7-10 daysAmoxicillin 80-90 mg/kg/day
Penicillin
allergy
Type I sensitivity (
urticaria
or anaphylaxis)
Azithromycin
(10 mg/kg for one day, then 5 mg/kg for an additional 5
days)
Clindamycin
(7.5 mg four times a day).
Non–type I sensitivity
Cefdinir
(14 mg/kg/day in one or two
doses)
Cefpodoxime
(10 mg/kg once a day
),Cefuroxime (30 mg/kg/day in two divided doses)Slide17
Tympanosotomy Tubes
Tubes patent?Little evidence for most effective treatmentOfloxacin
drops (5 drops BID)
C
iprofloxacin-dexamethasone (4 drops BID)
5 day courseSlide18
Complications
Mastoiditis and otic meningitisPrior to antibioticsIncidence 20%Use of
antibiotics
Incidence < 1% Slide19
Question
A 3-year-old boy is brought in by his mother for fever and right ear tugging for 2 days. He has also had 1 week of rhinorrhea on review of systems. His vaccines are up to date. His physical exam is remarkable only for a temperature of 38.8C and a bulging and erythematous right tympanic membrane. What is the most likely pathogen?
Haemophilus
influenzae
,
nontypeable
Moraxella
catarrhalis
Staphylococcus aureus
Streptococcus pneumoniaeSlide20
Question
A 3-year-old boy is brought in by his mother for fever and right ear tugging for 2 days. He has also had 1 week of rhinorrhea on review of systems. His vaccines are up to date. His physical exam is remarkable only for a temperature of 38.8C and a bulging and erythematous right tympanic membrane. What is the most likely pathogen?
Haemophilus
influenzae
,
nontypeable
Moraxella
catarrhalis
Staphylococcus aureus
Streptococcus pneumoniaeSlide21
Question
A 26-year-old man presents with 2 days of left ear pain. He notes that the symptoms started with an itchy ear that progressed to pain, discharge, and mild hearing loss. On examination, there is tenderness with manipulation of the auricle, edema, erythema, and narrowing of the tympanic canal. Which of the following is useful in treating this condition?
Acetic acid
otic
washes
Antihistamines
Oral amoxicillin
Tympanostomy
tubesSlide22
Question
A 26-year-old man presents with 2 days of left ear pain. He notes that the symptoms started with an itchy ear that progressed to pain, discharge, and mild hearing loss. On examination, there is tenderness with manipulation of the auricle, edema, erythema, and narrowing of the tympanic canal. Which of the following is useful in treating this condition?
Acetic acid
otic
washes
Antihistamines
Oral amoxicillin
Tympanostomy
tubesSlide23
Otitis ExternaSlide24
Otitis Externa
Inflammation of the external auditory canal Incidence- 10%Swimmer's ear or tropical ear
Bacterial
disease
P
. aeruginosa
S
. aureus
P
olymicrobialSlide25
Pathophysiology External
auditory canal lined with squamous epithelial cellsMacerationLocal traumaSlide26
SymptomsPruritus
OtalgiaHearing lossSlide27
Risk Factors
Water exposureTrauma (aggressive cleaning or scratching)
Devices occluding the ear canalSlide28
Physical ExamFindings
ErythemaEdema of canalPain with pulling on auricle or tragusSlide29
Differential
Otomycosis Contact DermatitisPsoriasis CarcinomaSlide30
TreatmentClean the canal
Cotton swab or gentle suctioning and irrigationTap water, sterile saline, 2% acetic acid, and Burow’s solution Topical antibiotics
Polymyxin
B/neomycin/hydrocortisone (3-4
drops
QID)
Ofloxacin
(
Ocuflox
) 5
drops BID
Ciprofloxacin/hydrocortisone (3
drops
BID)
Duration: 7 days
PrecautionsSlide31
ComplicationsPeriauricular
cellulitisMalignant Otitis ExternaSlide32
Malignant Otitis Externa
Necrotizing otitis externa Elderly diabetic patients or immunocompromisedSymptomsSevere otalgia and otorrhea
Pain out of proportion to exam findings
Granulation
tissue at the bony cartilaginous junction of the ear canal
floorSlide33
ManagementCiprofloxacin (400mg IV TID)
Poor prognosis = cranial nerve palsiesMRI or CT scanENT referralSlide34
MastoiditisSlide35
Mastoiditis
Infection of the mastoid air cells Middle ear cavity and mastoid air
spaces are continuous
Most frequent
complication of
AOM
Bacterial
Streptococcus pneumoniae
Streptococcus pyogenes
Staphylococcus
aureus
Slide36
SymptomsFever
HeadacheOtalgiaPainSlide37
Physical ExamNo specific
diagnostic criteriaMost common findingsPostauricular erythema and tenderness
Protrusion
of the
auricle
Abnormal TMSlide38
ManagementAntibiotics
Ceftriaxone or cefotaxime (50 mg/kg/day)Clindamycin (penicillin-allergic patient)Surgical
procedures
Myringotomy
Tympanostomy
tube placement
MastoidectomySlide39
Tympanic Membrane PerforationSlide40
SymptomsEar pain
Hearing lossNausea and vomitingSlide41
Risk FactorsAOM
TraumaBarotraumaSlide42
FindingsSlide43
ManagementWater precautions
Antibiotic ear drops Ofloxacin drops (5 drops in the affected ear BID for 3-5 days)
Follow up with PCP
ENT referral with persistent perforation > 4 weeks after injury
Perforation < 25% of TM will heal spontaneously within 4 weeksSlide44
SummaryModerate
to severe bulging of the TM = AOMThe diabetic patient with granulation tissue at the bony cartilaginous junction of the ear canal
floor (think malignant otitis externa)
Perforation < 25% of TM will heal
spontaneouslySlide45
Thank youSlide46
Questions?Slide47
References
Goguen, Laura. External otitis: Pathogenesis, clinical features, and diagnosis. Uptodate.Pfaff, J. and Moore, G (2013). Otolaryngology. Marx,
Rosen’s Emergency Medicine
(931-940). Philadelphia, PA: Saunders.
Rosh Review
Wald, Ellen. Acute
otitis media in children:
Diagnosis.
Uptodate