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HEENT > Otitis media > Flashcards

Otitis media Flashcards

1
Q

otitis media

A

-infection of middle ear
-pain
-may result in hearing loss
-types:
-acute
-secretory
-chronic

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2
Q

otitis media causative organisms

A

-newborns- gram negative enteric bacilli -> escherichia coli and staphylococcus aureus
-older infants and children < 14 yr- streptococcus pneumoniae*****, moraxella catarrhalis, haemophilus influenzae; loss common -> causes are group-A beta-hemolytic streptococci and S. aureus
-in patients > 14 yr- S. pneumoniae, group A beta-hemolytic streptococci, S. aureus, H. influenzae

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3
Q

otitis media risk factors

A

-attendance in day care
-second hand cigarette smoke exposure
-craniofacial abnormalities (cleft plate)
-immunologic deficiencies
-pacifier use
-eustachian tube- structurally and functionally immature -> *angle of tube is more horizontal -> opening mechanism less efficient
-bottle fed while in a horizontal position

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4
Q

prevention of otitis media

A

-parents/caretakers should be counseled
-elimination of controllable risk factors
-hand washing
-ensure immunizations are up to date
-protective factors:
-breastfeeding
-immune factors (secretory IgA and IgG)
-breast fed while in a vertical or semi reclining position

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5
Q

acute otitis media

A

-any age
-common in 3 mo to 3 yrs
-peak age being between 6-18 mo of age
-incidence decreases after the first year of life
-increases when the child enters school
-becomes less common after 7 years of age

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6
Q

acute otitis media S/S

A

-infants- irritability or having difficulty sleeping
-baby pulling on ear
-fever, nausea, vomiting, diarrhea
-spontaneous perforation -> sero-sanguineous or purulent otorrhea
-severe headache, confusion, or focal neurologic signs
-facial paralysis or vertigo suggests local extension to the fallopian canal or labyrinth

-less common symptoms:
-vertigo
-nystagmus (unidirectional, horizontal, jerk type)
-tinnitus
-swelling in the posterior auricular area (associated with mastoiditis)
-facial paralysis (due to disease within the temporal bone)
-purulent conjunctivitis (non typeable Haemophilus influenzae)

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7
Q

acute otitis media diagnosis

A

-rapid onset
-presence of MEE (middle ear infection)
-signs and symptoms of middle ear inflammation
-otoscopic exam- erythematous tympanic membrane (TM) -> indistinct landmarks and displacement of the light reflex
-bulging on TM
-pneumatic otoscopy- poor mobility of the TM -> signs that fluid is preventing
-acoustic reflectometry- sound waves detect the probability of middle ear fluids

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8
Q

acute otitis management

A

-analgesics
-decongestants
-antihistamines
-observation OR antibiotics?
-myringotomy- small opening created to aspirate some fluid / reduce pressure
-tympanocentesis

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9
Q

diagnosing acute otitis media

A

-history of acute onset (otalgia, aural pressure)
-signs of middle ear effusion (MEE)_ bulging of TM
-signs and symptoms of middle ear infection (marked erythema of TM and lack of mobility, fever, otalgia, decreased hearing)
-management of AOM should include an assessment of pain*
-observation without use of antibacterial agents in child with uncomplicated AOM is an option for selected children based on diagnostic certainty , age, illness severity, and assurance of follow up

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10
Q

acute otitis media treatment

A

-acetaminophen, ibuprofen
-aspirin- avoid in children
-home remedies
-distraction- external application of heat or cold -> oil
-topical agents including- benzocaine (auralgan, americaine otic)
-naturopathic agents (otikon otic solution)
-homeopathic agents
-narcotic analgesia with codeine or analogs
-tympanostomy /myringotomy

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11
Q

approach to acute otitis media treatment

A

-observation is a appropriate option ONLY if:
-child is mildly symptomatic and has NO risk factors
-follow up can be ensured and antibacterial agents started if symptoms persist or worsen (not commended in acutely ill child)

-non-severe illness is - mild otalgia and fever < 39 in the past 24 hrs
-severe illness - moderate to severe otalgia or fever > 39 in children < 2 years
-treat -> children < 6 months STAT
-treat children 6 months to 2 years may be option to observe

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12
Q

risk factors for acute otitis media

A

-severity of symptoms
-age <2
-parental acceptance to call back if symptoms persist or worsen
-AOM meets ALL 3 criteria
-rapid onset, signs of MEE, s+s of middle ear infection
-for child with a draining ear, either from ventilation tube or perforation, -> nontoxic drop (such as ciprofloxin or ofloxacin) may be added to oral antibiotic treatment

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13
Q

resolution of otitis media

A

-defined as a return to normal on exam with no evidence of effusion or inflammation and/or normal mobility
-tympanometry is not routinely needed to document resolution

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14
Q

failure of initial treatment of acute otitis media with antibiotics

A

-defined as the persistence or worsening of moderately severe symptoms (pain and fever) after 3-5 days of antibiotic therapy with finding of continued pressure and inflammation (bulging) behind the tympanic membrane

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15
Q

first line antibiotics: acute otitis media

A

-IF low risk (> 2 years, no day care, and no antibiotics for the past 3 months)
-amoxicillin- 80-100 mg/kg/day ?? 5 day duration***
-IF high risk- (< 2 years, day care attendance, antibiotics used in last 3 months)
-Augmentin- 80-100mg/kg/day 10 day ** duration
-other first line antibiotics in resistant cases:

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16
Q

PCN allergies - acute otitis media treatment

A

-pts with immediate hypersensitivity reactions
-anaphylaxis, angioedema, bronchospasm, urticaria
-azithromycin
-macrolides or clindamycin
-pts with other types of allergic reactions may be treated safely with cefdinir, cefpodoxime, cefuroxime, or intramuscular ceftriaxone

17
Q

acute otitis media length of treatment

A

-uncertain*
-some studies have shown that 5 days (absolute minimum) therapy has equal efficacy to the standard 10 day regimen in children with uncomplicated AOM and is recommended in children greater than or equal to 2 age and over
-< 2 year or those who present with perforation of the tympanic membrane*, 10 days of antibiotic therapy are still recommended

18
Q

failure to respond to initial management within 48-62 hrs: acute otitis media

A

-reassessment to confirm AOM and exclude other causes of illness
-if AOM is confirmed in the pt initially managed with observation-> clinician should begin antibacterial therapy
-if pt was initially managed with an antibacterial agent(s) -> clinician should change antibacterial agent

19
Q

indications for second line medications AOM

A

-failure to respond to first line drugs
-history of lack of response to first line drug
-hypersentivity to first line medications
-presence of resistant organism determined by culture
-coexisting illness requiring a second line medication
-recommended second line medications include:
-amoxicillin/clavulanate potassium (augmentin)
-cefuroxime axetil (ceftin)
-azithromycin

20
Q

recurrent acute OM

A

-minimum of 3 or more episodes of AOM in 6 month period or during a respiratory season or 4 or more in a year
-elicited from hx
-if criteria of recurrent AOM are present prophylactic antibiotic regimen should follow treatment
-children in high risk categories- more aggressive or earlier intervention with prophylactic antibiotics
-decision for prophylaxis should be based on both the diagnostic criteria and child risk factors
-antibiotic- amoxicillin (20mg/kg QD)- usual duration of prophylaxis is 1-3 mo
-parents should be advised- shown to reduce the frequency of AOM by 40%-50% but will not eliminate its occurrence

21
Q

increased risk of recurrent AOM

A

-cleft palate, craniofacial abnormalities and down’s syndrome (very high risk)
-first episode early (under 6 mo)
-family hx of recurrent AOM in sibling or parent
-day care attendance
-exposure to tobacco smoke
-not breast fed
-ethnic origin- native american or innuit (eskimo)

22
Q

acute otitis media follow up

A

-recheck all children < 5 years old
-recheck children > or equal to 5 years old if risk factors identified
-history of previous ventilating tubes or ear surgery
-history of speech or developmental delay
-timing of rechecks:
-recheck in 3-4 weeks or at next well child visit if within next 4-6 weeks
-reassess for symptoms of unresponsive otitis- pain, fever, or irritability continuing after 3-5 days of treatment

23
Q

chronic otitis media

A

-usually present with:
-conductive hearing loss
-otorrhea
-pain is uncommon unless an associated osteitis of the temporal bone occurs -> acute exacerbations
-TM perforated and draining -> auditory canal is macerated and littered with granulation tissue
-+/- cholesteatoma- abnormal collection of skin cells deep inside

24
Q

chronic otitis media dx

A

-usually clinical
-drainage- cultured
-if cholesteatoma or other complications are suspected (as in febrile pt or one with vertigo or otalgia)
-CT or MRI performed- intratemporal or intracranial processes (labyrinthitis, ossicular, or temporal erosion, abscesses)

25
Q

chronic otitis media treatment

A

-ear canal irrigated
-granulations tissue removed
-severe exacerbations require systemic antibiotic therapy
-tympanoplasty indicated for pts with marginal or attic perforations and chronic central TM perforations
-pt not at risk of speech, language, learning problems associated with hearing loss of <20dB -> watchful waiting for 3 months
-use of earplugs
-topical antibiotic drops for exacerbations- ofloxacin or ciprofloxacin with dexamethasone
-oral ciprofloxacin- active against pseudomonas and may help dry a chronically discharging ear
-antihistamines, decongestants, and corticosteroids -> but these are not standard treatments
-surgical management in those with hearing impairment -> myringotomy, mastoidectomy, tympanic membrane repair
-up to 80% children with recurrent otitis media have food and/or inhalant allergies
-elimination diets shown to be effective in recurrent chronic otitis media

26
Q

otitis media with effusion

A

-presence of fluid in the middle ear without signs or symptoms of acute ear infection
-serous or mucoid, opaque or yellow, position neutral or retracted, decreased mobility or air fluid level
-may occur spontaneously because of poor eustachian tube function, or as an inflammatory response following AOM
-common in 6 mo - 4 yo
-in older pts- serous otitis media usually occurs with URTI, with barotrauma or with chronic allergic rhinitis -> consider nasopharyngeal carcinoma
-leads to chronic otitis media

27
Q

otitis media effusion symptoms

A

-most commonly in children
-resulting from incomplete resolution of acute otitis media
-obstruction of eustachian tube without infection
-symptoms:
-hearing loss
-effects on speech, language, learning, physiologic sequelae, heath care utilization (medical, surgical) and quality of life

28
Q

otitis media effusion treatment and dx

A

-DX- TM- dull and hypomobile “cloudy”
-air fluid level or air bubbles in middle ear*
-tympanometry or acoustic reflectometry
-treatment:
-corticosteroids
-decongestants
-antibiotics
-antihistamines
-tympanostomy tube insertion preferred initial procedure
-myringotomy for persistent cases

29
Q

strep throat and otitis media

A

-know medication dose??
-watch and wait
-

HEENT (18 decks)

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