Otolaryngology Flashcards
Define the following:
OM
AOM
OME
COM
ROM
Otitis media - inflammation of the middle ear
acute otitis media - presence of a middle ear effusion with signs and symptoms of an acute infection
Otitis media with effusion - is a middle ear effusion without signs or symptoms of acute infection
Chronic otitis media prolonged discharge from the ear through perforation of the tympanic membrane. Typically last six weeks or longer
Recurrent otitis media is three or more episodes of acute in six months or four episodes within one year
Age range for AOM
Peak 6 months 15 months years
Can be over 2 years
Less than 6 not common still have coverage from materal antibodies
5 risk factors for AOM? Two protective RF?
Modifiable - smoking, pacifier use, daycare
Not modifiable - poor, male, non hispanic white, family history, craniofacial abnormalities
Breastfeeding and pneumococcal vaccination protective
What does TM look like in AOM?
ditinctly erythemaous
Opacification
Bubbles
Air fluid levels
Buldging
Retraction or lack of movement with pneumatic otoscopy
remember the eustachaian tube is blocked creating negative pressure, why its retracted
I think AOM looks like a cervix
Treatment of choice AOM for:
standard
Mild to moderate pen allergic
Severe pen allergic
Amox 90mg/kg divided BID either 7 or 10 days
mild to mod - ceftriaxzone or cefuroxime
mod to severe - clinda or azithromycin
NSAIDs for everyone
What is considered treatment failure, 2 reasons why it happens in AOM, and what do they get?
Lack of improvement in signs and symptoms
Wrong disgnosis or antibiotic resistance
Amox/clav or ceftrixzone
Refferal to peds ID or ENT
Who can we use a watch and wait apporach in for AOM and antibiotics? Who can we not?
Older than 6 months and less than 2 years:
Healthy children
Unilateral
Dont have severe symptoms
Dont have ottorhea
Symptoms <48 hours
Dont have a temp over 39
Over 2 years:
Dont have severe illness
Dont have ottorhea
Can be seen in 2-3 days
All adults need to be treated
Who gets 10 days of antibiotics vs who might be able to get 7 days for AOM?
10 days
Younger than 2
Recurrent infection
TM perforations
7 days
Older than 2
First time infection
Does not have severe symptoms
*CPS guidelines say low risk duration is now 5 days
A kid has tubes
What are the 2 ways they present?
How do you treat them?
If tube is patent eythema plus discharge = infection
If tube is blocked same as other kids with buldging and imobility
Ciprodex BID 7 days
Who might you consider tubes in?
Reccurent or complicated AOM
Espcially if:
hearing loss, structural damage, concern about speech and language problems
What are two classifications of AOM complications? What is one complication unique to chronic cases?
Infratemporal - mastoiditis, facial nerve paralysis, conductive and perceptive hearing loss
Intracranial complications - meningitis, intracranial abscess
Cholesteatoma - mass of keratin producting sqaumous epithelial cells that migrate and accumulate in middle ear leading to rapidly expanding mass trapped behind TM
Needs to be removed surgically otherwise you get hearing loss, temporal bone destruction and cranial invasion (just gets going and going)
What is bullous myringitis?
Get bullae on TM, treat as regular AOM
What is ottitis conjunctivitis syndrome and the causative agent?
Get both at the same time
most common is influenza
What is the Rosens differential for AOM?
OME
OE
Otic FB
Trauma
Mastoiditis
Reffered pain
What do you do with small little perforations of TM?
Typically go away on their own
What are three discharge instructions for everyone?
One discharge consideration for adults?
NSAIDs for pain
Come back in 2-3 days if no improvement
See family doctor in 12 weeks to make sure effusion has resolved
Adults think about outpatient ENT - assess for ?carcinoma. Complications in kids also go to ENT
What is the pathophysiology of OE?
External auditory canal has sqamous epithelial cells and a layer of cerumen that is protective
Lots of humidity, high temp or maceration of the skin from trauma and this layers breaks down -> bacteria -> infection
What is your treatment approach for standard cases? Who requires systemic antibtiocs?
Standard:
Clean the ear canal
Ciprodex drops BID for 10 days
Systemic: PO Cipro BID 7 days if infections extends beyond the canal or patients are immunocompromised (including bad DM)
4 ways to improve delivery of drops in OE?
1 - clean out the ear with irrigation
2 - lay down for 5 minutes post drops
3 - use a wick, put drops on wick, leave in place 2-3 days then follow up
4 - consult ENT to come and debride if really bad
What antibiotics can you not give a perforated TM?
Aminoglycosides (the mycins - gent, tobra, streptomycin, neomycin)
3 varients of EOM that are not NMOE?
Otomycosis - fungal infection. Itching most common symptoms, candida and aspergillious most common bugs. Usually immunocompromised or tropical
Furunculosis - small erythematous and well circumscribed infections of cartilagenous external ear canal from staph aureus
Herpes zoster oticus aka ramsey hunt - Varicella zoster of auricle. Can have facial paralysis.
What is the severe OE you worry about? How does it happen? What are 2 chracteristic findings? How is it diagnosed? What is the management?
Necrotizing Malignant Otitis Externa
Agressive form of OE with high mortality in patients who are immunocompromised and DM (over 50% have DM)
Infection starts as per normal in external canal but then progresses through periauricular tissue to the cartilagenous-bony juntion of the external auditory meatus -> can keep going right into temporal bone
CN 7 facial paralysis (remember it sits right under the ear)
Granulation tissue on the floor of the ear canal
No single diagnostic crtieria - think about it if refractory, severe, looks bad. Can confirm bony involvement with CT
Cipro +/- Pip/tazo for 6-8 weeks
ENT consult if refractory for surgical management
What is most common supurlative complication of OM? Who are some special populations it can occur in? Most common bugs and physcial findings?
Mastoiditis
Leukemia, kawasaki, sarcoma of temporal bone, cochlear ear implant
Bugs - strep pneumo most common, psuedomonas, fusobacterium if recent abx
Exam - red, swollen, tender protuding ear
Why do you image mastoiditis? What is the management?
CT for intracranial involvement - a must if neurologic symptoms or failure to improve
Consult ENT, need IV antibiotics
without recurrent acute otitis media or recent antibiotic use, vancomycin at a dose of 15 mg/kg IV (uptodate says amp/sulbactam, vanco ceftrixzone probably reasonable)
Patients who have had an episode of acute otitis
media within the past 6 months, or in patients with recent antibiotic use need pseudo coverge:
cefepime, at a dose of 50 mg/kg IV (max 2 g) in pediatric patients, or 2 g IV in adults.
(up to date says do tazo vanco)
*Up to date says pip/tazo
