Otitis

Question 1

Peak age of otitis externa

Answer 1

7-12

Question 2

Etiology of otitis externa

Answer 2

1- Acute: baterial (pseudomonas 50%, S.aureus); fungal 10%; herpes zoster
2- Chronic: fungal or allergic (cosmetic, shampoos), or atopic dermatitis, psoriasis

Question 3

Risk factors Otitis externa

Answer 3

Humidity
Warmer temperatures
Swimming
Local trauma (mechanical removal of cerumen)
Hearing aid
Immunocompromised

Question 4

Signs and symptoms Otitis Externa

Answer 4

Acute:
90% unilateral
Odourless secretion
Pruritus
Pain/otalgia
Erythema
Fullness
Late stage: edema, otorrhea, conductive hearing loss

Chronic:
Pruritus
Mild discomfort
Erythematous canal

Examine:
Ear
Sinus
Nose
Mastoids
TM joint
Pharynx
Neck
Lymph nodes
Skin

Question 5

Ddx Otitis Externa

Answer 5

Contact dermatitis

Psoriasis

Malignant external otitis (Severe pain, Fever, necrosis of the canal skin, auricular chondrites, cervical adenines, parotitis, facial paralysis, vertigo, profound hearing loss)

Otitis media

Question 6

Complications of otitis Externa

Answer 6

Life threatening temporal bone infection <0.5%

Question 7

How to prevent Otitis Externa

Answer 7

Dry ear canals after swimming
Avoid using cotton swabs
Daily acidifying- Alcohol drops during high risk times
Hair dryer on lowest setting to increase air flow after swimming

Question 8

Management of Otitis Externa

Answer 8

Clear any obstructing debris-Cerumen and check TM
- Suction-Curette-spoon rather than irrigation

Relieve pain with acetaminophen + NSAIDs (GRADE A)

Expect improvement in 2-3 days full response in 6 days

Minimal difference in cure rate by combining topical steroid with topical abx for AOE

If the TM not visible, use expandable wick to decrease edema and improve medication delivery

Question 9

Management Otitis Externa ATB

Answer 9

• If no perforation:
  Polysporin 1-2 drops QID

Perforation:
Ciprodex Otic suspension 4 drops BID

Fungal:
clotrimazole 1% cream BID for 1-3 weeks

Question 10

Reasons for failure of treatment Otitis Externa

Answer 10

Differential
Failure to adhere to preventive measures
Faulty-inadequate administration-penetration of ototopical treatment
Wrong ototoxic agent
Immunosuppression

Question 11

What is the difference between acute otitis media, myringitis, otitis media with effusion (OME), chronic suppurative otitis media

Answer 11

1- Acute otitis media: inflammation and pus in the middle ear accompanied by signs + symptoms of ear infection

2- Myringitis: red eardrum. Inflammation of the tympanic membrane alone or in associate with otitis external

3- Otitis media with effusion (OME): aka serous otitis media, fluid in the middle ear without symptoms of acute inflammation

4- Chronic suppurative otitis media: persistant inflammation process with perforated tympanic membrane and draining exudates for > 6 weeks

Question 12

What is the peak incidence of Otitis media?

Answer 12

peak incidence at 6-9 months, after age 6< 40% develop AOM

75% of children have on episode before age 2

Younger age = increased risk of reoccurrence and increased risk OME (increased risk of hearing loss)

Question 13

What is the etiology of otitis media

Answer 13

S. pneumonia (40%)
H influenza (25%)
Moraxella Catarrhalis (10%)
GAS (2%)
S.Aureus (2%)

Viral infection of the nasopharynx disrupts function of the Eustachian tube causing obstruction, stasis, colonization

Question 14

What are the Risk factors of Otitis media

Answer 14

Daycare
Nursery school
Boys, white, family Hx
Enlarged tonsils, adenoids, anatomic anomaly(cleft palate)
Shorter duration of breastfeeding, soother, prolonged bottle feeding, lying down
Exposure to cigarette smoke
First Nations or Inuit

Question 15

What is the DDX of otitis Media

Answer 15

Myringitis
Otitis media with effusion (TM not Buldging)
Chronic suppurative otitis media
Teething, ear wax, migraine

Question 16

Diagnosis of Otitis Media

Answer 16

1- Acute Symptoms: otalgia
2- Middle ear fluid
3- Significant inflammation of the middle ear

Earache
Fever
Vomiting
Poor feeding
Rhinitis

Inflammation + pus in the middle ear + Buldging TM
Immobilite TM
TM cloudy, Red TM
Loss of landmarks, light reflex
Visible air fluid level
Perforation

Question 17

Complications of Otitis Media

Answer 17

Mastoiditis
Meningitis
Intracranial abcess
Facial paralysis

Question 18

Preventive measures for otitis media

Answer 18

Hand washing
Breastfeeding until at least 3 months of age
Pacifiers increase the risk
Avoid tobacco exposure
Avoid feeding in supine-flat positions
Flu shot
Prevnar (limited efficacy)

Question 19

What are the alternatives to ATB in Otitis media?

Answer 19

1- Decongestants: no difference from placebo
2- Antihistamines
3- Antihistamines and decongestants
4- Acetaminophen and Ibuprofen

No combination of histamine-decongestant shown to be effective in treatment of AOM in children or OME

Question 20

ATB in AOM

Answer 20

1- Perforated purulent discharge
2- > 48 hours of illness, severe pain, difficulty sleeping, irritable
3- Less than 6 months ALWAYS treat

10 days if less than 2yo
5 days if more than 2yo

Question 21

Prognosis in AOM

Answer 21

• 90% fever resolution in 2-3 days
  Complete resolution in 7 days

2.7% will get worse without treatment

15% of all AOM will benefit from abx and benefit is modest and short term

Absence of signs + symptoms by day 7 –> NNT 8

Fever and pain decrease by day 2: NNT 21

Avoid contralateral: NNT 17

CAUSE diarrhea, vomiting, abdo pain, rash –> NNH 11

Question 22

When to do a F/U for AOM

Answer 22

Fu in 48-72 hours if symptoms persist

If watchful waiting –> Rx ATB
If already on Abx–> Change Abx to Amox-Clax

50% of children will have a persistent effusion x 1 mo –> No Abx needed

F/U 3 months post AOM to assess for persistent OME (can lead to hearing loss)
Perform hearing assessment if effusion is present at 3 months
Refer to ENT if hearing loss
Consider tympanovstomy if more than 4 per year and OME, or less than 4 per year and OME+ nasal obstruction, chronic adenoiditis

In children with recurrent ear infections test for hearing loss