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Y5 Ear > List I - Act Core Conditions > Flashcards

List I - Act Core Conditions Flashcards

1
Q

What is acute otitis media?

A
  • Presence of inflammation in the middle ear, associated with an effusion and accompanied by the rapid onset of symptoms and signs of an ear infection
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2
Q

How is AOM categorised?

A
  • Persistent AOM

* Recurrent AOM

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3
Q

What is persistent AOM?

A
  • Occurring when people return for medical advice with the same episode of AOM, either because symptoms persist after initial management or because symptoms are worsening
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4
Q

What is recurrent AOM?

A
  • Defined as three or more well-documented and separate AOM episodes in the preceding 6 months, or four or more episodes in the preceding 12 months with at least one episode in the past 6 months
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5
Q

What are the causes of AOM?

A
  • Most common bacterial causes are:
  • Haemophilius influenzae
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
  • Streptococcus pyogenes
  • Viral pathogens associated with AOM include:
  • Respiratory syncytial virus
  • Rhinovirus
  • Adenovirus
  • Influenza virus
  • Parainfluenza virus
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6
Q

In which populations in AOM more common?

A
  • Children from birth to 4 years

* Most frequently affects children between 6 and 24 months old with incidence peaking at 9-15 months

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7
Q

What are the risk factors for AOM?

A
  • Young age.
  • Male sex.
  • Smoking and/or passive smoking.
  • Frequent contact with other children such as daycare or nursery attendance or having siblings (increases exposure to viral illnesses).
  • Formula feeding — breastfeeding has a protective effect.
  • Craniofacial abnormalities (such as cleft palate).
  • Use of a dummy.
  • Prolonged bottle feeding in the supine position.
  • Family history of otitis media.
  • Lack of pneumococcal vaccination.
  • Gastro-oesophageal reflux.
  • Prematurity.
  • Recurrent upper respiratory tract infection.
  • Immunodeficiency
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8
Q

What is the prognosis of AOM?

A
  • Without antibiotic treatment, symptoms will improve within 24 hours in 60% of children with AOM, most will recover within 3 days
  • Recurrent episodes of AOM are not common but thought that recurrent AOM will resolved as the child gets older, often at 3-4 years of age
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9
Q

What are the possible complications of AOM?

A
  • Persistent otitis media with effusion
  • Recurrence of infection
  • Hearing loss (usually conductive and temporary)
  • Tympanic membrane perforation
  • Labyrinthitis
  • Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve paralysis
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10
Q

How is diagnosis of AOM made on the history?

A
  • Diagnose AOM if there is:
  • Acute onset of symptoms including:
  • Earache - older children
  • Holding, tugging, or rubbing of the ear, or non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea - younger children

Note that these non-specific symptoms do not help differentiate AOM from upper respiratory tract infection.

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11
Q

How is a diagnosis of AOM made on examination?

A
  • Distinctly red, yellow, or cloudy tympanic membrane
  • Moderate to severe bulging or the tympanic membrane with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicates a middle ear effusion)
  • Perforation of the tympanic membrane and/or discharge in the external auditory canal
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12
Q

When can examination findings indicate causes other than AOM?

A
  • Tympanic membrane which is not bulging (with or without erythema or cloudiness)
  • Air filled level without bulging tympanic membrane
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13
Q

What can make diagnosis of AOM in younger children (0-6 months) more difficult?

A
  • Coexisting systemic illness such as bronchiolitis or bacteraemia
  • Tympanic membrane may not be visible, often lies in an oblique position and the ear canal is small and tends to collapse
  • Symptoms are likely to be non-specific
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14
Q

What are the other causes of middle ear inflammation or effusion?

A
  • Otitis media with effusion (glue ear) - fluid in the middle ear without symptoms or signs of acute infection
  • Chronic suppurative otitis media - persistent inflammation and perforation of the tympanic membrane with draining discharge for more than 2 weeks
  • Myringitis - erythema and injection of the tympanic membrane, visibile on otoscopy but no other features of otitis media
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15
Q

What is the admission criteria for people with initial presentation of AOM?

A
  • Admit for immediate specialist assessment:
  • People with a severe systemic infection
  • People with suspected acute complications of acute otitis media, such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis
  • Children younger than 3 months of age with a temperature of 38c or more
  • Consider admitting
  • Children younger than 3 months of age
  • Children 3-6 months of age with a temperature of 39c or more
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16
Q

How should people with first presentation of AOM be managed in primary care?

A
  • Advise that the usual course of acute otitis media is about 3 days but can be up to 1 week
  • Advise regular doses of paracetamol or ibuprofen for pain using a dosing schedule appropriate for the age and weight of a child
  • Explain that there is no evidence to support the use of decongestants or antihistamines for the management of symptoms
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17
Q

What is the management for people who are systemically unwell with AOM but do not require admission to hospital?

A
  • Offer immediate antibiotic prescription
  • Advise them to seek medical advice if symptoms worsen rapidly or significantly then may become systemically very unwell
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18
Q

Which patients may be more likely to benefit from antibiotics for AOM?

A
  • Patients with
  • Otorrhoea
  • <2 years with bilateral infection
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19
Q

When prescribing patients with AOM with antibiotics, what are the options?

A
  • No antibiotic prescription - advice about antibiotic not being needed and seeking medical help if symptoms worsen or do not improve after 3 days or the person becomes systemically unwell
  • Back up antibiotic prescription - using if symptoms do not improve within 3 days or worsen significantly or rapidly at anytime
  • Immediate antibiotic prescription
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20
Q

If antibiotics are prescribed for AOM, what regime is recommended?

A
  • 5-7 day course of amoxicillin

* For people allergic to penicillin prescribe a 5-7 days course of clarithromycin or erythromycin

21
Q

How is follow up done for AOM?

A
  • Routine follow up is not required in the absence of persistent symptoms of AOM
  • Exceptions are for persistent symptoms despite antibiotic treatment and people with recurrent symptoms (3 or more separate episodes in the previous 6 months or 4 or more episodes in the previous 12 months with at least 1 episode in the past 6 months)
22
Q

If AOM fails to improve and there is hearing loss in the absence of pain or fever, which alternative diagnosis should be considered?

A
  • Otitis media with effusion
23
Q

If AOM fails to improve and there is discharge from the ear canal persisting for 2 weeks, which alternative diagnosis should be considered?

A
  • Otitis media chronic suppurative
24
Q

When should adults with persistent AOM be referred to an ENT specialist?

A
  • If symptoms last more than 6 weeks or associated with persistent hearing loss
25
Q

If admission or referral is not necessary and symptoms are worsening despite taking a first line antibiotic for at least 2-3 days, which antibiotic can be prescribed second line for persistent AOM?

A
  • 5-7 day course of co-amoxiclav

* If symptoms persist despite two courses of anti-biotics seek specialist advice from a local microbiologist

26
Q

How should a person with recurrent AOM be managed?

A
  • Refer urgently (within 2 weeks) to an ENT specialist if nasopharyngeal cancer (rare) is suspected, especially in the presence of any one of the following:
  • Persistent symptoms and signs of otitis media with effusion in between episodes (for example, conductive hearing loss) due to obstruction of the eustachian tube orifice
  • Persistent cervical lymphadenopathy (usually in the upper levels of the neck)
  • Epistaxis and nasal obstruction
  • Consider referral to an ENT specialist for all people with recurrent AOM, especially if:
  • Craniofacial abnormality (Down’s syndrome or cleft palate)
  • Recurrent episodes are unexplained, very distressing or associated with complications
  • An adult is affected
27
Q

If referral is not necessary for people with recurrent AOM, how should they be managed?

A
  • Manage acute episodes in the same way as for initial presentation
  • In people with grommets (tympanostomy or ventilation tubes) who present with acute discharge:
  • Consider taking an ear swab for culture and sensitivity
  • Treat for initial presentation or refer to ENT for advice
28
Q

What advice can be given to prevent recurrence of AOM?

A
  • In children
  • Avoiding exposure to passive smoking, use of dummies, and flat, supine feeding
  • Ensure they have completed course of routine childhood vaccinations, GORD is managed appropriately
  • In adults
  • Avoid smoking and/or passive smoking

(Do not start long term prophylactic antibiotics in primary care)

29
Q

What is otitis media with effusion?

A
  • Known as glue ear
  • Characterised by a collection of fluid within the middle ear space without signs of acute inflammation
  • OME my be associated with significant hearing loss, especially if it is bilateral and lasts for longer than one month
30
Q

What are the causes of OME?

A
  • Over 50% of cases are thought to follow an episode of acute otitis media especially in children under 3 years of age
  • Presence of OME may occur because of one or more of the following:
  • Impaired eustachian tube function causing poor aeration of the middle ear
  • Low grade viral or bacterial infection
  • Persistent local inflammatory reaction
  • Adenoidal infection or hypertrophy
31
Q

Who is affected by OME?

A
  • Most common cause of hearing impairment in childhood
  • Highest incidence in those aged 2 and 5 years
  • Most common in the winter months
32
Q

What are the risk factors for developing OME?

A
  • Cleft palate (causing impaired eustachian tube function)
  • Downs syndrome - impaired immunity and mucosal abnormality increasing susceptibility to infection
  • Primary ciliary dyskinesia
  • Allergic rhinitis

Other risk factors include:

  • AOM - more frequent after an episode of AOM
  • Household smoking
  • Exposure to other children
  • Sibling history of OME
  • Low socio-economic group
  • Frequent upper respiratory tract infections
  • Bottle feeding
  • Winter months
33
Q

What are the complications of OME?

A
  • Conductive hearing loss
  • Educational, developmental, behavioural and social difficulties
  • Chronic damage to the tympanic membrane
34
Q

What is the prognosis of OME?

A
  • Usually resolves spontaneously within 6-10 weeks and 50% of children are clear within 3 months and 95% within 1 year
35
Q

What should be asked about when taking the history from a patient with suspected OME?

A
  • Hearing loss
  • Aural discharge - persistent foul smelling discharge requires urgent referral
  • Recurrent ear infections, URTI or frequent nasal obstruction
  • Assess the severity of the hearing loss and the impact on the child’s life and developmental status by asking about the following:
  • Fluctuations in hearing
  • Lack of concentration or attention or being socially withdrawn
  • Listening skills and progress at school or nursery
  • Speech or language development
  • Balance problems and clumsiness
36
Q

How should the examination be conducted for a patient with suspected OME?

A
  • Examine the ears with an otoscope
  • Normal looking tympanic membrane does not exclude otitis media with effusion
  • There are usually signs of inflammation or discharge on examination
  • An effusion can be serous, mucoid, or purulent and is more likely if one or more of the following features are present:
  • Abnormal colour of the drum, such as yellow, amber or blue
  • Loss of light reflex or a more diffuse light reflex
  • Opacification of the drum (other than due to scarring)
  • Air bubbles or an air/fluid level
  • Retracted, concave or indrawn drum or less frequently fullness or bulging
  • Examine the nose and throat for factors which may predispose the child to OME
  • Refer for audiometry and tympanometry where appropriate
37
Q

What are the investigations for OME?

A
  • Tympanometry

* Audiometry

38
Q

What is tympanometry?

A
  • Assesses the ability of the eardrum to react to sound, and may be used to improve the accuracy of a diagnosis of OME
39
Q

What is audiometry?

A
  • Visual response audiometry is used to assess children aged 8 months to 2.5 years and has been shown to provide reliable results in infants as young as 6 months when performed by an audiologist
  • Conventional audiometry is usually appropriate for children aged 4 years or over
40
Q

Which children are assessed every 3-6 months for OME?

A
  • Children with Down’s syndrome or cleft palate
41
Q

What are the differential diagnoses for OME?

A
  • AOM - often precedes OME with symptoms of shorter duration
  • Mastoiditis - potentially serious complication of AOM which may precede OME
  • Otitis externa
  • More common in swimmers and adults
  • Pain or itching are the main symptoms and there are inflammatory changes in the ear canal or surrounding skin
  • Referred pain - TMJ, enlarged lymph nodes, salivary glands, sinuses or laryngeal, pharyngeal and neck problems (bilateral pain virtually excludes the possibility of referred causes)
  • Otitic barotrauma - usually seen in people who have recently travelled by aeroplane, been scuba diving or received a blow to the ear
42
Q

What other causes of hearing loss should be included in consideration of OME alternatives?

A
  • Foreign body in the ear canal
  • Impacted earwax
  • Perforated tympanic membrane
  • Sensorineural hearing loss
43
Q

What is the management of OME?

A
  • Active observation over 6-12 weeks is appropriate for most children, as spontaneous resolution is common
  • During this period re-evaluate for signs and symptoms of the effusion and concerns regarding the child’s hearing or language development
  • Ideally include two hearing tests using pure tone audiometry at least 3 months apart as well as tympanometry
  • Hearing test will determine the decision to refer to ENT
  • If signs and symptoms persist after a period of observation - refer to ENT
44
Q

Which children who are suspected of having OME require immediate referral for specialist assessment?

A
  • Children with Down’s syndrome or cleft palate
45
Q

What is chronic supparative otitis media?

A
  • Defined as a chronic inflammation of the middle ear and mastoid cavity which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation)
  • CSOM is assumed to be a complication of acute otitis media (AOM)
  • WHO definition states that AOM is defined to be CSOM after at least 2 weeks of discharge whereas some experts suggest that 6 weeks of discharge is the cut off point
46
Q

What are the complications of CSOM?

A
  • Hearing loss that can be a feature of CSOM may cause problems with language development in children
  • If left untreated, infection in CSOM may spread extra-cranially (causing facial paralysis or mastoiditis) or intra-cranially (causing meningitis or a cerebral abscess) although this is rare
47
Q

What are the symptoms that support a diagnosis of CSOM?

A
  • Ear discharge for more than 2 weeks without pain or fever
  • History of AOM (ear pain, fever and irritability), history of ear trauma, or a previous glue ear and grommet insertion
  • Painless ear examination (unlike AOM or acute otitis externa) with evidence of tympanic membrane perforation
  • Possible hearing loss
48
Q

What factors should be assessed for CSOM?

A
  • Checking for post auricular swelling (tenderness) facial paralysis or vertigo and signs or symptoms of intracranial infection (requiring admission)
  • Asking about hearing loss and if appropriate the effect of CSOM on daily activities (e.g. school or work) and language development
  • Excluding alternative causes for persistent ear discharge such as otitis externa (suggested by an inflammed, eczematous canal without a perforation), a foreign body (particularly in children), impacted ear wax, and neoplasm (ear canal swelling that bleeds on contact)
49
Q

Which patients should be admitted for CSOM?

A
  • Signs of infection beyond the ear e.g. postauricular swelling or tenderness, headache, facial paralysis or vertigo
  • If CSOM is suspected, referral to an ENT specialist should be made
  • Ears should not be swabbed
  • Treatment should not be initiated
  • Reassurance should be given that any hearing loss will usually return when the perforation heals but that a hearing test may be carried out in secondary care

Y5 Ear (4 decks)

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