L10 Ear Infections Flashcards
Why are infants more likely to get ear infections?
Their eustachian tube is more horizontal (nose to ear drainage)
“Swimmers ear”
otitis externa
Cause of otitis externa
heat/moisture leads to swelling and maceration of EAC allowing bacteria to enter, trauma, skin diseases (eczema, psoriasis, seborrheic dermatitis)
Etiology of Otitis Externa
Bacterial (most common) or fungal
Bacteria causing otitis externa
pseudomonas aeruginosa (38%), staph epidermidis (9%), staph aureus (8%)
Fungus causing otitis externa
Asperigillus niger or Candida albicans
Clinical presentation of otitis externa
ostalgia (worse with movement of tragus and pinna), pruritus (mild/severe), discharge, EAC may be erythematous and edematous, decreased hearing or swelling (conductive due to d/c or swelling)
Yellow discharge with OE
staph infection
Green discharge with OE
pseudomonas infection
Fluffy white/black “bread mold” discharge with OE
fungal infection
Otomycosis
fungal OE
Tx for OE
Cortisporin otic suspension (polymixin B, neomycin, hydrocortison), Floxin otic solution (ofloxacin), ciprodex or CiproHC (ciprofloxacin + glucocorticoid)
First line treatment for OE
Cortisporin otic solution
Treatment of OE with perforated TM
floxin otic solution (ofloxacin)
Side effects of Cortisporin otic solution
allergic rxn.- contact dermatitis, DON’T USE WITH TM PERFORATION
Why are otic suspensions better than solution?
less acidic (pH 5 vs. pH 3.4), so less irritation to infected tissues
Tx for fungal OE
Clotrimazole 1% solution (BID x 14 days), Acidifying solution (acetic acid)
Tx for marked swelling in EAC
ear wick (Oto-wick)- apply medication to wick TID-QID; remove wick after 48-72 hours and continue meds as directed
Management of OE
pain control, keep canal dry (no swimming 7-10d, cotton in ear when bathing)
How soon do OE usually resolve
5-7 days
If no improvement of OE in 48-72 hours what do you consider?
noncompliance, otomycosis, periauricular cellulitis, or malignant otits externa
Prevention of OE
prophylaxis: 2% acetic acid (Vosol), vinegar soluiton, isopropyl alcohol or hair dryer; bathing cap or custom ear plugs
Malignant OE
necrotizing external otitis
Cause of MOE
infection spreads from skin of EAC to skull base (pseudomonas)
Who is most at risk for MOE
elderly diabetics & immunocompromised patients
Clinical presentation of MOE
otalgia and otorrhea not responsive to OE tx; pain nocturnal and with chewing; red granulation tissue in EAC; possible periauricular lymphadenopathy, edem and trismus; watch for CN involvement (indication of progressive osteomyelitis)
Dx of MOE
CT!!! (bone erosion), ESR and CRP elevated; MRI
Tx of MEO
ADMIT, C&S of ear discharge, IV Ciprofloxacin, possible debridement
Complications of MOE
intracranial spread leading to meningitis, brain abscess and sepsis; mortality 10-20%
OME
otitis media w/ effusion
other names of OME
serous, secretory or nonsuppurative OM
Middle ear effusion in the absence of acute sxs
Otitis Media w/ Effusion
acute illness with middle ear fluid and s/sx of middle ear inflammation
Acute otitis media (AOM, suppurative otitis media)
Chronic infection of middle ear with non-intact TM and otorrhea
Chronic otitis media
Sx of OME
ear fullness and decreased hearing; usually painless
Etiology of OME
recent AOM, URIs, allergies, eustachian tube dysfunction, barotrauma, or nasopharyngeal carinoma
Clinical presentation of OME
patient afebrile, amber-colored (straw) fluid behind TM, air-fluid levels and bubbles, neutral or retracted TM; possible conductive hearing loss, TM not moving with pneumatic otoscopy, Tympanogram (Type B Pattern)
Recurrent OME could be a sign of what
nasopharyngeal carcinoma - REFER TO ENT TO RULE OUT
Type B tympanogram
little to no movement of TM; suggests OME
Tx of OME
usually resolves spontaneously, re-evaluate in 4-6 weeks (“watchful waiting,” intranasal steroids if underlying allergic rhinitis; refer to ENT for tympanostomy “T-tubes” if: persistent fluid and/or hearing loss >3 months, child considered at risk for speech, language or learning problems
inflammation or blockage resulting in negative middle ear pressure
eustachian tube dysfunction
Sx of eustachian tube dysfunction
ear fullness, recurrent OME, hearing loss
Exam findings for eustachian tube dysfunction
retracted TM, prominent bony landmarks
Dx for eustachian tube dysfunction
clinical, tympanogram type C
Tympanogram type C
middle ear with negative pressure; eustachian tube dysfunction
Cause of eustachian tube dysfunction
inflammation or blockage
Tx of eustachian tube dysfunction
steroid nasal spray, management of allergies, decongestants, T-tubes; may use topical decongestants (phenylephrine or Afrin)- limit therapy to 3 days to avoid rebound congestions (Rhinitis medicamentosa)
Topical nasal decongestants
phenylephrine (neo-synephrine) or oxymetazoline (afrin)
AOM most common in
pediatrics (peak: 6-18 mo)
URI usually precipitates
AOM
Cause of AOM
eustachian tube becomes obstructed w/ fluid and mucus; becomes secondarily infected; mastoid air cells involved
Most common etiology of AOM
stretpococcus pneumoniae (50%), haeomphilus influenzae (40%), moraxella catarrhalis (10%)
Other pathogens causing AOM
strep pyogenes, strep viridans, staph aureus, pseudomonas aeuroginosa, viruses (RSC)
Risk Factors of AOM
young age/immature anatomy (horizontal eustachian tube, enlarged adenoids preventing drainage), second hand smoke, lack of breastfeeding, day care, use of pacifier, season (fall/winter)
Pediatric Clinical presentation of AOM
irritability/restless sleep, poor feeding/anorexia, fever, ear pain (tugging on ear), hearing loss/ear fullness
Associated sx with AOM
conjunctivitis, rhinorrhea, ear discharge, vomiting, diarrhea
Adult presentation of AOM
otalgia and decreased hearing; fever is rare
PE findings in AOM
TM bulging (distorted, loss of landmarks), signs of inflammation (reddening, purulent middle ear effusion), poor mobility (pneumatic otoscopy)
Standard of car in dx of AOM
pneumatic otoscopy- detects poor mobility of TM
Bullous myringitis
inflammation of the TM w/ bulla formation
Cause of bullous myringitis
manifests in 10-14 days after viral infection (mycoplasma pneumoniae)
Sx of bullous myringitis
sever localized ostalgia
Dx of AOM in children 6 mo - 12 years
moderate to severe bulging of TM, new onset of otorrhea not due to acute OE, mild bulging of TM and ear pain (<48 hrs) or intense erythema of TM; pneumatic otoscopy, tympanometry
Type A tympanogram
normal ear; pressure at 0, compliance normal
Type B tympanogram
little or no mobility; fluid or TM perforation; flat line
Type C
Retracted TM; eustachian tube dysfucntion; negative pressure
When to tx AOM w/ Abx
<6 mo, >6 mo: bilateral or unilateral AOM w/ severe signs or symptoms, non-severe, bilateral AOM in ages 6-24 mo
observation and follow up in 48-72 hours for AOM w/o abx if;
6-23 mo: unilateral AOM w/o severe s/sx
>24 mo: without sever s/sx
Sever s/sx of AOM
moderate/severe otalgia, otalgia for at least 48 hours, fever (102.2/39) or higher
Tx of AOM
amoxicillin (high dose): 90 mg/kg/day divided q 12 hours (max dose of 3g/day) x 7-10 days
When not to use amoxicillin for AOM
high risk for resistant organism (received abx in last 30 days, have concurrent purulent conjunctivitis (H.influenzae), hx of recurrent AOM resistant to amoxicillin)
2nd line tx for AOM (resistant organism)
Augmentin
Augmentin is composed of
amoxicillin and clavulanate
Augmentin dosage
90 mg/kg amoxicillin and 6.4 mg/kg clavulanate
Alternative tx for AOM
used if PCN allergy or tx failure
What are alternative tx for AOM
Oral: omnicef, ceftin, vantin, zithromax (only for severe PCN allerge, not for tx failure)
IM/IV: rocephin 50 mg IM or IV daily x 1-3 days
Tx duration for AOM
10 days if: <2 years old, AOM w/ TM rupture, hx of recurrent AOM
5-7 days if: >2 yo w/o TM rupture or hx of recurrent infection
Other tx of AOM
abx, sx tx of pain/fever (acetaminophen or ibuprofen), encourage oral fluids: NO VALUE of using decongestants or antihistamines (unless allergies), OTC cold preps NOT used in children <4 yo
Persistant/worseing of AOM after 48-72 hrs
repeat PE, initiate or change abx; if sx persist despite appropriate abx, consider IM Rocephin or refer to ENT for tympanocentesis
AOM patient education
pain/fever resolve after 3 days (if not, RTC for eval); recheck @ 7-14 days, hearing loss may take up to a month to resolve
Recurrent AOM
development of s/s of AOM soon after completion of successful tx
Tx for recurrent AOM
Rocephin
When to consider tympanostomy tubes
3 or more AOM in 6 mo,
>4 episodes of AOM in 12 mo.
complications of AOM
infratemporal: TM perforation, tympanosclerosis, chronic OM, mastoiditis, hearing loss, cholesteatoma, acute labyrinthitis
intracranial: meningitis, encepahlitis, brain abscess
Systemic: bacteremia
Chronic otitis media
drainage from middle ear >2 weeks and associated TM perforation that is painless
Etiology of chronic otitis media
recurrent AOM, trauma, or cholesteatoma; pseudomonas, MRSA
Sx of Chronic otitis media
conductive hearing loss
Tx for chronic otitis media
Refer to ENT
TM perforations
associated with acute/chronic OM
Sx of TM perforation
+/- pain, otorrhea, conductive hearing loss, no movement w/ pneumatic otoscopy, vertigo indicative of injury to inner ear, most heal spontaneously
Keratinized, desquamated epithelia collection in middle ear or mastoid
cholesteatoma
Mastoiditis
rare complication of AOM, post-auricular pain, edema and erythema; fluctuance or mass, fever, deep temporal pain, protrusion of pinna
Tx for mastoiditis
IV abx; ENT consult (mastoidectomy)
Mastoidectomy
removing diseased mastoid air cells
Labyrinthitis (vestibular neuritis/neuronitis)
benign, acute inflammation or infection of the vestibular system
Pure vestibular neuritis
hearing preserved
Labyrinthitis
unilateral hearing loss present
Cause of labyrinthitis
viral infections (URI); AOM or meningitis
Clinical presentation of labyrinthitis
acute onset of severe vertigo (1-2 days), N/V, gait instability, unilateral hearing loss, horizontal nystagmus, (+) head thrust (can’t maintain visual fixation), No CNS deficits
(+) Head thrust
unable to fixate vision on object when head is turned, eyes move with head the quickly saccade back to target; (+) finding = peripheral vestibular lesion (turn head to right/effected ear is the right, vice-versa)
Tx of labyrinthitis
symptomatic (bed rest, hydration, oral prednisone taper); antihistamines/anticholergics (Meclizine (Antivert 25 mg TID); antiemetics (compazine); benzodiazepines (valium, ativan) - least preferred due to sedation
“popping” in ears
OME/SOM
