otitis media + externa Flashcards
AOM
• In children younger than 6 months of age (and particularly younger than 3 months of age), diagnosis can be difficult because:
○ There may be coexisting systemic illness, such as bronchiolitis or bacteraemia.
○ Symptoms are likely to be non-specific.
○ The tympanic membrane may not be visible; it often lies in an oblique position and the ear canal is small and tends to collapse.
treatment for AOM
• If an antibiotic is required:
○ Prescribe a 5–7 day course of amoxicillin.
○ For people who are allergic to, or intolerant of, penicillin, prescribe a 5–7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).
• If admission or referral is not necessary and symptoms are worsening despite taking a first–line antibiotic for at least 2–3 days, offer a second–line antibiotic:
○ Prescribe a 5–7 day course of co-amoxiclav.
○ For people who are allergic to, or intolerant of, penicillin, seek specialist advice from the local microbiology department.
If symptoms persist despite two courses of antibiotics, seek specialist advice from a local microbiologist or an Ear, Nose and Throat specialist if the diagnosis is uncertain.
AOM: who would benefit from ABs
those with otorrhoea, or those aged less than 2 years with bilateral infection
recurrent AOM
• Refer urgently (within 2 weeks) to an ear, nose, and throat (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.
causes of AOM
• Bacteria ○ Haemophilus influenzae ○ Streptococcus pneumoniae ○ Moraxella catarrhalis ○ Strep pyogenes : group A • Viral ○ Resp syncytial virus (RSV) ○ Rhinovirus ○ Adenovirus ○ Influenza virus ○ Parainfluenza
causes of CSOM
○ Pseudomonas aeruginosa (most common). ○ Staphylococcus aureus. ○ Proteus species. ○ Aspergillus species. Candida albicans.
suspect CSOM
○ Ear discharge persisting for more than 2 weeks, without ear pain or fever.
○ Hearing loss in the affected ear.
○ A history of acute otitis media (AOM), ear trauma, or glue ear and grommet insertion.
○ A history of allergy, atopy, and/or upper respiratory tract infection.
○ Tinnitus and/or a sensation of pressure in the ear may also be present.
symptoms that can indicate serious complications (such as mastoiditis and/or intracranial infection) in a person with CSOM include:
○ Headache. ○ Nystagmus. ○ Vertigo. ○ Fever. ○ Labyrinthitis. ○ Facial paralysis. ○ Swelling/tenderness behind the ear.
causes of OME
- 50% of cases follow AOM in children < 3y/o
- Impaired eustachian tube function causing poor aeration of middle ear
- Low grade viral or bacterial infection
- Persistent local inflammatory reaction
- Adenoidal infection or hypertrophy
OME resolves
within 6-10 weeks and 50% of children are clear within 3 months and 95% within 1 year
• Active observation over 6–12 weeks is appropriate for most children, as spontaneous resolution is common. ○ Ideally, this should include two hearing tests using pure tone audiometry at least 3 months apart as well as tympanometry.
• Children who have had grommets (ventilation tubes) inserted should be followed up periodically and their hearing should be re-assessed.
○ Continue follow-up until the grommets have been extruded and the eardrum has healed.
Grommets usually stop functioning after an average of 10 months, and a third to half of the children who have grommets will need reinsertion within 5 years.
for OME, refer to ENT specialist
- Hearing loss of any level is associated with a significant impact on the child’s developmental, social, or educational status.
- Hearing loss is severe (61 dB or greater) and requires urgent referral within 2 weeks to exclude additional sensorineural deafness.
- Significant hearing loss persists on two documented occasions (usually following repeat testing after 6–12 weeks).
- The tympanic membrane is structurally abnormal (or there are other features suggesting an alternative diagnosis).
- There is a persistent, foul-smelling discharge suggestive of a possible cholesteatoma. Referral should be semi-urgent.
- The child has Down’s syndrome or has a cleft palate.
treatment options
non surgical: active observation, hearing aids for bilateral OME, autoinflation (valsalva manoeuvre)
surgical: myringotomy which can lead to complications -> otorrhoea, infection, cholesteatoma, bleeding, fibrosis, tympanosclerosis, perforation of tympanic membrane
signs of AOE
○ Itch (typical).
○ Severe ear pain, disproportionate to the size of the lesion (typical).
○ Pain made worse when the tragus or pinna is moved, or when an otoscope is inserted (typical).
○ Tenderness on moving the jaw.
○ Tender regional lymphadenitis — may be present (less common).
○ Sudden relief of pain if the furuncle in localized otitis externa bursts (rare).
○ Loss of hearing if there is sufficient swelling to occlude the ear canal (rare).
○ The ear canal or external ear, or both, are red, swollen, or eczematous with shedding of the scaly skin. ○ Swelling in the ear canal is typical of an early presentation of localized otitis externa; later the swelling has a white or yellow centre filled with pus; occasionally this progresses and the swelling eventually completely occludes the ear canal. ○ Discharge (serous or purulent) may be present in the ear canal. ○ Inflamed eardrum, which may be difficult to visualize if the ear canal is narrowed or filled with debris.
AOE give oral AB
Cellulitis extending beyond the external ear canal.
When the ear canal is occluded by swelling and debris, and a wick cannot be inserted.
People with diabetes or compromised immunity, and severe infection or high risk of severe infection, for example with Pseudomonas aeruginosa.
