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COMMON E.N.T. PROBLEMS

COMMON E.N.T. PROBLEMS. B. WAYNE BLOUNT, MD, MPH PROFESSOR EMORY FAMILY MEDICINE. Learning Objectives. IN SYLLABUS. Acute Otitis Media. B. WAYNE BLOUNT, MD, MPH PROFESSOR, EMORY. Otitis Media - Classification. Acute OM - rapid onset of signs & sx , < 3 wk course

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COMMON E.N.T. PROBLEMS

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  1. COMMON E.N.T. PROBLEMS B. WAYNE BLOUNT, MD, MPH • PROFESSOR • EMORY FAMILY MEDICINE

  2. Learning Objectives • IN SYLLABUS

  3. Acute Otitis Media B. WAYNE BLOUNT, MD, MPH PROFESSOR, EMORY

  4. Otitis Media - Classification • Acute OM - rapid onset of signs & sx, < 3 wk course • Subacute OM - 3 wks to 3 mos • Chronic OM - 3 mos or longer

  5. Otitis Media et al • Acute otitis media (AOM) • Otitis media with effusion (OME) • Otitisexterna • Other ear findings, common and uncommon

  6. Recommendation #1 • To diagnose acute otitis media the clinician should confirm: • 1) a history of acute onset, • 2) identify signs of middle-ear effusion (MEE), and • 3) evaluate for the presence of signs and symptoms of middle-ear inflammation. AOM Guideline at http://www.aafp.org/x26481.xml

  7. Recommendation #2 • The management of AOM should include assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. AOM Guideline at http://www.aafp.org/x26481.xml

  8. Recommendation #3A • Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up. AOM Guideline at http://www.aafp.org/x26481.xml

  9. Recommendation 3B • If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. When amoxicillin is used the dose should be 80 to 90 mg/kg/day. AOM Guideline at http://www.aafp.org/x26481.xml

  10. Recommendation #4 • If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s). AOM Guideline at http://www.aafp.org/x26481.xml

  11. Acute Otitis Media - Risk Factors • Male gender • Sibling hx or recurrent otitis media • Early age of onset of AOM ( before 4 mo) • Bottle feeding, or breastfeeding for < 4 mo • Group day care • Exposure to tobacco smoke Swanson, Jill, Otitis Media in Young Children, Mayo Clinic Proceedings, 71(2), Feb 1996, pp 179-183

  12. Eustachian tube • Usually closed • Opens during swallowing, yawning, and sneezing

  13. Acute Otitis Media - Positive Predictive Value of TM Findings Finding PPV Bulging TM 89 Cloudy TM 80 Distinctly impaired mobility 78 Distinctly red TM 65 Slightly impaired mobility 33 Slightly red TM 16 Karma et al, Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media, Int J Pediatr Otolaryngol, 1989, 17, pp 37-49

  14. Normal Ear Drum

  15. Microbiology • S. pneumoniae - 30-35% • H. influenzae - 20-25% • M. catarrhalis - 10-15% • Group A strep - 2-4% • Infants with higher incidence of gram negative bacilli

  16. Virology • RSV - 74% of middle ear isolates • Rhinovirus • Parainfluenza virus • Influenza virus

  17. PCN-resistant Strep 1979 - 1.8% 1992 - 41% Altered PCN-binding proteins Lysis defective Age, day-cares, and previous tx H. flu and M. catarrhalis beta-lactamase production All M. catarrhalis + 45-50% H. flu Microbiology

  18. Acute Otitis Media - Pneumatic Otoscopy • Pneumatic otoscopy/insufflation will demonstrate decreased mobility of the tympanic membrane in cases of middle ear effusion with increased middle ear pressure. • Mobility of the TM is not consistent with a diagnosis of AOM.

  19. Acute Otitis Media - Tympanometry • This instrument is used to detect fluid within the middle ear. • Several types of tympanograms • Highly sensitive when disease present. • Lower specificity when disease absent - will be abnormal in children with normal TMs.

  20. Onusko, E, Tympanometry, AFP, Nov. 1, 2004, pp 1713-1720

  21. Acute Otitis Media - Acoustic Reflectometry • An instrument similar to the tympanogram is used to bounce sound waves off the TM. • More waves are reflected when the middle ear is full of fluid. • Sensitivity = 90% and specificity = 86% for middle ear effusion or abnormal pressure.

  22. Recommendation #2 • The management of AOM should include assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. AOM Guideline at http://www.aafp.org/x26481.xml

  23. Acute Otitis Media - Treatment • Ensure that the patient has adequate analgesia. • Tylenol • 10-15 mg/kg up to q4hr • Motrin • 5-10 mg/kg up to q6-8hr, max dose of 20 mg/kg/24hr • Don’t forget topical analgesia with Auralgan (topical benzocaine)

  24. Acute Otitis Media - Treatment • In the USA, one study has demonstrated that AOM due to S. Pneumonia spontaneously resolved in 20%, while 50% cases of H. influenza resolved spontaneously. McCracken, Considerations in selecting an antibiotic for treatment of acute otitis media, Pediatr Infect Dis J, 1994, 13(Suppl), pp 1054-1057 • The difficulty is in choosing which patient not to give antibiotics.

  25. Recommendation #3A • Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up. AOM Guideline at http://www.aafp.org/x26481.xml

  26. Recommendation 3B • If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. When amoxicillin is used the dose should be 80 to 90 mg/kg/day. AOM Guideline at http://www.aafp.org/x26481.xml

  27. Acute Otitis Media - Treatment • Amoxicillin is still the first line therapy. • $1.00 per bottle • May also consider Septra/Bactrim • $0.82 per bottle • Please remember this before writing for Zithromax, which costs WAY more. • $15.00 per bottle

  28. Acute Otitis Media -Treatment • Ceftriaxone has been shown in multiple studies to be equally efficacious when given as a one-time IM injection of 50 mg/kg (max). Comparison of Ceftriaxone and Trimethoprim-Sulfamethoxazole for Acute Otitis Media, Pediatrics, 99(1), January 1997, pp 23-28.

  29. Treatment - Recurrent AOM • Chemoprophylaxis • Sulfisoxazole, amoxicillin, ampicillin, pcn • less efficacy for intermittent propylaxis • Myringotomy and tube insertion • decreased # and severity of AOM • otorrhea and other complications • may require prophylaxis if severe • Adenoidectomy • 28% and 35% fewer episodes of AOM at first and second years

  30. Acute Otitis Media - Treatment • Antihistamines and decongestants are not established therapies for AOM. • However, remember that 70-90% of children with AOM have/had an antecedent URI/cold, so this may not really be bad medicine.

  31. Acute Otitis Media - Treatment Duration • The standard treatment is 10 days. • A study in Pediatrics demonstrated that treating for a full 20 day course was no more efficacious than treating for 10 days Efficacy of 20- Versus 10-Day Antimicrobial Treatment of Acute Otitis Media, Pediatrics, 96(1), July 1995, pp 5-13

  32. Acute Otitis Media - Follow-Up • Patients with AOM should have a decrease, if not resolution, in their symptomatology over the 48-72 hours after a diagnosis is made and treatment instituted. • If no resolution in symptoms, consider a beta-lactamase producing bacteria or other process, not to exclude poor patient compliance.

  33. Recommendation #4 • If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s). AOM Guideline at http://www.aafp.org/x26481.xml

  34. Acute Otitis Media - Follow-Up • The party line - 2 week ear check. • Hathaway et al found the following criteria to be 97% accurate in determining if a child had AOM at follow-up: • Parental impression of resolved AOM • Absence of symptoms • Age > 15 months • No family history of recurrent AOM in a sib. Hathaway et al, Acute Otitis Media: Who Needs Posttreatment Follow-Up?, Pediatrics, 94(2), August 1994, pp 143-147.

  35. Acute Otitis Media - Recurrence/Prophylaxis • In general 3 episodes in 6 months or 4 episodes in 1 year deserve consideration for antibiotic prophylaxis. • Knowledge at large, also in Conn’s 1998 • Drugs • Amoxil at 20 mg/kg qd • Gantrisin 50-75 mg/kg divided bid

  36. Acute Otitis Media - Recurrence/Prophylaxis • Follow-up is usually once per month, at least initially. • If a child had breakthrough infections on prophylaxis, consider an ENT referral. • How long to continue prophylaxis? Needham et al (unpublished data) 6-12 months minimum. Use your best judgement.

  37. Acute Otitis Media - Recurrence/Prophylaxis • The goal of prophylaxis is to allow the child to age enough so that his/her eustachian tube apparatus will become less likely become infected (usually age 3-ish, again, more unpublished data, i.e., opinion). • Use the antibiotic prophylaxis to avoid surgery, although the surgery takes all of 2 minutes.

  38. Otitis Media with Effusion “OME”

  39. Otitis Media with Effusion-Some Sticky Business • Simply defined as fluid in the middle ear without symptoms or signs of AOM. • Clinical Practice Guideline - expert panel comprised of members from AAP, AAFP, and American Academy of Otolaryngology-Head and Neck Surgery, with review and approval of the Agency for Health Care Policy and Research.

  40. OM - persistent middle ear effusion (MEE) • High incidence of MEE, avg of 40 days • Children less that 2 years much more likely to have persistent MEE • White children with higher incidence of MEE

  41. Chronic MEE • Previously thought sterile • 30-50% grow in culture • over 75% PCR + • Usual organisms

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