Temporal Bone infections, Vertigo Flashcards
According to the 2013 Pediatrics Guideline, what is the definition of Acute Otitis Media? 3
Acute otitis media:
1. Moderate to severe bulging of the TM; OR
2. New onset otorrhea not due to acute otitis externa; OR
3. Mild bulging of the TM and recent (< 48h) onset of ear pain (holding, tugging, rubbing)
Middle ear effusion MUST be present
What is the definition of severe vs. non-severe acute otitis media?
- Severe = Moderate to severe otalgia; OR temp ≥ 39 deg C
- Non-severe = Mild otalgia AND temp < 39 degC
What is the treatment of acute otitis media, according to the 2013 pediatric guidelines?
- Severe (moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C), bilateral or unilateral, ≥ 6 months old = Antibiotics
- Non-severe
A. < 24 months
- Bilateral = Antibiotics
- Unilateral = Observe, antibiotics if worsens or fails to improve within 24 hours
B. > 24 months
- Bilateral = observe
- Unilateral = observe
- Begin antibiotics within 48-72 hours if no improvement
CONSIDER:
- Myringotomy + tube or tympanocentesis if toxic
- Analgesics: Tylenol + Ibuprofen
- Decongestants not routinely recommended
- 60% of symptoms will resolve in 24 hours, 80% in 48-72 hours
What is the first line antibiotic for AOM? Why?
- High dose Amoxicillin 80-90mg/kg per day divided BID
Reason for high dose:
- Streptococcus resistance occurs through alteration of penicillin binding sites on penicillin binding proteins (leads to decreased antibiotic affinity)
- This can be overcome if the serum concentration of antibiotic exceeds the minimum inhibitory concentration (MIC)
- At high dose, the concentration in the middle ear becomes > MIC for most intermediate and high resistance strains
What are the indications to use Amoxicillin/Clavulanate as first line for AOM? 3
- Amoxicillin use in the past 30 days
- Concurrent purulent conjunctivitis
- Recurrent AOM unresponsive to Amoxicillin
CAR
What are the alternative antibiotics if patients have penicillin allergy for AOM?
Amoxicillin –> Cefuroxime
Clavulin –> Ceftriaxone
What is the definition of persistent AOM? 2
- Persistence of AOM symptoms/signs during antimicrobial therapy (treatment failure; AND/OR
- Relapse of AOM within 1 month
What is the definition of recurrent AOM?
- ≥ 3 AOM episodes in 6 months; OR
- ≥ 4 AOM episodes in 12 months with at least 1 in the past 6 months
Note: Antibiotic use may reduce the frequency of episodes, however it will build resistance
What is the definition of otitis media with effusion?
The presence of fluid in the middle ear without signs or symptoms of acute ear infection (AOM)
What is the definition of chronic otitis media with effusion?
OME persisting for 3 months or longer from the date of onset (if known), or from the date of diagnosis (if onset unknown)
What are the indications for tympanostomy tubes according to the 2022 tympanostomy guidelines, and the strength of recommendation? 4
- Bilateral OME for 3 months or longer and documented hearing difficulties (Recommendation)
- Recurrent AOM with unilateral or bilateral middle ear effusion at time of assessment (Recommendation - bilateral tubes)
- Unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms (e.g. vestibular problems, poor school performance, behavioral problems, ear discomfort, reduced QOL) - Option
- At-risk children with unilateral or bilateral OME that is likely to persist (Type B tymp, or documented effusion for 3 months or longer but does not have to be Chronic) - Option
According to the 2022 tympanostomy guidelines, which children are considered “At risk”? 8
- Permanent hearing loss independent of otitis media with effusion
- Suspected or confirmed speech and language delay or disorder
- Autism spectrum disorder
- Syndromes (e.g. Down) or craniofacial disorders that include cognitive, speech, or language delays
- Blindness or uncorrectable visual impairment
- Cleft palate, with or without associated syndrome
- Developmental delay
- Intellectual disability, learning disorder, or ADHD
According to the recent AAOHNS guidelines, are prophylactic water precautions recommended?
No (recommendation against)
What are indications that patients with tympanostomy tubes SHOULD have routine water precautions? 5
2022 guidelines:
1. Children with tubes and active episode of tympanostomy tube otorrhea or recurrent or prolonged otorrhea episodes (especially pseudomonal or staph infections)
2. History of problems with prior water exposure
3. Lake swimming or heavily contaminated water
4. Deep diving (>4feet)
5. Otalgia from water entry into canal
2013 guidelines:
1. Risk factors for infection/complications (e.g. immunosuppression)
What is the management of otitis media with effusion (OME) at the time of initial diagnosis according to 2016 AAO HNS guidelines? Make sure to differentiate between normal and at-risk kids
What is the rate of resolution?
Normal kids:
- Expectant management (no meds)
- Follow up at 3 months, if effusion still persists = audiogram
At risk kids:
- Audio ± tube without waiting for 3 months
Rate of Resolution:
- If OME following AOM, resolution rate at 3 months is 75% (usually up to 90%)
- If OME is spontaneous, resolution rate at 3 months is 56% (follow patients q3 months)
What classes of medications should not be prescribed for OME, according to 2016 AAO HNS guidelines? 4
- Steroids (systemic and topical) - may be beneficial for children with allergic rhinitis/OME
- Antihistamines
- Decongestants
- Antibiotics
DASA bad idea
According to 2016 AAO HNS guidelines, when should adenoidectomy be added to the treatment of chronic OME? When should it NOT? 4
In short, considered when above the age of 4 (unless high risk such as cleft palate)
Less than 4 years old - recommendation AGAINST adenoidectomy
Over 4 years old, 3 options:
1. Tympanostomy + adenoidectomy (recommended option as several systematic reviews have showed advantage of this option, but discuss with parents)
2. Tympanostomy
3. Adenoidectomy alone
According to 2022 Tympanostomy AAO HNS guidelines, what is the treatment of acute tympanostomy tube otorrhea? 2
What are the indications for systemic antibiotics? 4
- Complicates ~25% of tympanostomy tubes
- Usually a manifestation of AOM, caused by typical pathogens
TREATMENT:
1. Ciprodex drops x 10 days
- Instruct parents to clean the canal of debris or discharge before administering
- Water precautions during otorrhea
INDICATIONS FOR SYSTEMIC ANTIBIOTICS:
1. Children with complicated otorrhea or signs of severe infection
2. Cellulitis of adjacent skin/pinna
3. Concurrent bacterial infection requiring antibiotics (e.g. sinusitis, GAS throat, pneumonia
4. Immunocompromised children
2013 guidelines:
1. Acute otorrhea persists, or worsens, despite topical antibiotics
Outline the differential diagnosis of tube otorrhea that is refractory to topical therapy? 7
- Inadequate penetration of topical drops due to debris (blocked)
- Fungal overgrowth
- Antibiotic resistance (MRSA, multi-drug resistance Strep Pneumoniae)
- Granulation tissue
- Occult cholesteatoma
- Atypical infections: Candida, Actinomyces, Aspergillus
- Immunodeficiency (e.g. Histiocytosis, Cystic Fibrosis)
What is the management of tube otorrhea refractory to topical therapy? 5
- Microscopic examination
- Aural toilet (debridement)
- Culture
- Trial of oral antibiotics
- Water precautions
What are the host risk factors for developing AOM? Name 10
- Age (< 2 years, first onset < 6 months)
- Gender: Male
- Race (First nations)
- Genetic predisposition
- Ciliary dyskinesia
- Adenoids (resevoir of infection and mechanical ET obstruction)
- ET dysfunction (short, horizontal, compliant)
- Cleft palate
- Craniofacial anomalies
- Down’s syndrome
- Immune deficiency
- Atopy (Disputed)
- Family history
What are environmental risk factors of AOM? 10
- Day care attendance (2.6x)
- Season (fall/winter)
- URTIs
- Older siblings
- Parental history of otitis media
- Passive smoking
- Low SES (overcrowding, poor sanitation)
- Lack of breast feeding
- Night-time bottle (horizontal position)
- Pacifier use
How does acute otitis media symptoms and signs typically present? 3
- Pain
- Fever
- Bulging TM
List the top virology of acute otitis media 5
- Respiratory Syncytial Virus (paramyxovirus) - most common
- Rhinovirus
- Influenza
- Parainfluenza
- If immunocompromised - TB, mycoplasma, chlamydia
“RRIP”
What are the most common bacteriology of AOM?
- Streptococcus pneumonia
- Haemophilus influenza
- Moraxella Catarrhalis
- Streptococcus pyogenes
- Less common: staphylococcus aureus, gram negative bacilli
What are two vaccines that can prevent recurrent ear infections?
- Anti-pneumococcal vaccine
- Influenza vaccine
What are ten intratemporal complications of AOM?
- Chronic suppurative otitis media
- Adhesive otitis
- Tympanic membrane perforation
- Cholesteatoma
- Tympanosclerosis
- Fixation and discontinuity of ossicular chain
- Mastoiditis with or without abscess (postauricular, Bezold’s Zygomatic, parapharyngeal, retropharyngeal)
- Petrous apicitis (Gradenigro’s syndrome)
- Labyrinthitis - serous or suppurative (through oval window –> profound HL, then vestibular loss)
- Facial palsy
- Labyrinthine fistula
- CHL or SNHL
Intratemporal = within the temporal bone
What is the most common bacteriologies for acute mastoiditis (not due to cholesteatoma)? 6
- Most common: Streptococcus Pneumonia (unilateral, bulging TM, T >100.6° (38.1°C), perforation most common HL in 20%
- Haemophilus influenza (bilateral, dull TM, non-mobile, T > 37°C)
- Streptococcus pyogenes
- Coagulase negative Staph
- Staphylococcus Aureus
- Pseudomonas
Regarding acute mastoiditis, discuss:
1. Risk factors 2
2. Diagnosis
3. Treatment
Risk factors:
1. < 4 years old (25% < 1 year old)
2. AOM unresponsive to treatment
Diagnosis:
- CLINICAL signs, not radiologic
Treatment:
1. Broad spectrum IV antibiotics
2. Myringotomy + tube placement
3. I+D of abscess ± mastoidectomy (if coalescent)
What is the bacteriology of chronic otorrhea with or without cholesteatoma? 4
- Mixed flora including Streptococcus Pneumonia and Anaerobes (including Bacteroides)
- Pseudomonas (most common aerobe)
- Staphylococcus Aureus & Epidermidis
- Gram negatives – Klebsiella, E. coli, Proteus
What are 6 intracranial complications of AOM?
- Meningitis (#1 HiB > Pneumococcus, mondini)
- Epidural abscess/ subdural or cerebral abscess (LP contraindicated due to increased ICP, involve neurosurgery urgently)
- Focal encephalitis
- Lateral/sigmoid sinus thrombosis (Tobey-Ayer/Quesckenstedt’s test, Griesinger’s sign, Picket fence fevers, Headache) –> ID consult, IV antibiotics, ± anticoagulation; Diagnosis with MRV (CT may miss evolving clot)
- Otic hydrocephalus (progressive headache)
- Blindness with optic neuropathy
What are the top 3 bacteriology of bacterial meningitis?
- Haemophilus influenza (non-typable)
- Streptococcus pneumonia
- Neisseria Meningitidis
What are the risk factors for hearing loss in meningitis patients? 5
- Low glucose on LP (bacteria)
- Increased ICP noted on CT
- Streptococcus pneumonia
- Male
- Nuchal rigidity (need to rule out SNHL within 2 weeks)
Nuchal SLIMin
What are the common bacteriology of intracranial abscess? 4
- Streptococcus sp. (Pneumonia, Pyogenes)
- Staphylococcus sp.
- Proteus sp.
- Anaerobes (Peptococcus, Peptostreptococcus, B. fragilis
What are early signs of impending complication for AOM? 5
- Persistence of acute infection for 2 weeks
- Recurrence of symptoms within 2 weeks
- Malodorous discharge
- Acute exacerbation of chronic infection, especially if malodorous/purulent
- HiB or anaerobes
What is the criteria for 72 hour observation of AOM? 8
- Will not be lost to follow up
- Otherwise healthy
- Antibiotics started if presentation persists or worsens
- No immune deficiency or craniofacial anomalies
- No treatment failures/relapse within 30 days
- No co-existing acute sinusitis/streptococcal pharyngitis
- No underlying chronic OME
- No complicated AOM
What is the common pathogen that causes bilateral, dull TM, non-mobile TM, and T > 37deg?
Hemophilus influenza
What is the common pathogen that causes unilateral, bulging TM with T > 38.1 deg C
Streptococcus pneumoniae
What are the common pathogens that causes bullous myringitis? 6
- Streptococcus pneumoniae
- Mycoplasma
- Cover the above with Clarithromycin
- H. flu
- Beta-hemolytic strep
- M. Catarrhalis
- Parainfluenza & influenza virus
What is the most common pathogen that causes spontaneous perforation of TM?
Streptococcus pyogenes
What are indications for myringotomy tubes aside from AOM? 7
- Severe retraction pocket (± tinnitus, dysequilibrium/vertigo)
- Eustachian tube dysfunction with autophony, dysequilibrium/vertigo, tinnitus, or atelectatic TM/severe retraction pocket, unrelieved by medical management
- Patulous eustachian tube
- Barotitis media/hyperbaric oxygen therapy
- Suspected unusual pathogen
- Suppurative complication, present or suspected
- Unsatisfactory response to antibiotics
What are 5 indications for tympanocentesis/myringotomy?
- AOM in a toxic, newborn or immune deficient patient
- Severe pain
- Suppurative complications (e.g. facial paralysis, meningitis, etc.)
- Unsatisfactory response to antibiotics
- Suspected unusual pathogen (e.g. newborns, immunodeficiency)
What are 9 complications of tympanostomy tubes?
- Otorrhea (3.5% rate of persistent drainage)
- Granulation tissue formation
- Myringosclerosis
- TM perforation
- TM atrophy, retraction, atelectasis
- Cholesteatoma
- Loss of tube in the middle ear
- Early extrusion
- Plugged tube
What is the differential diagnosis of aural polyp in pediatrics? 3
- Cholesteatoma
- Eosinophilic granuloma (Type 1 LCH)
- Rhabdomyosarcoma
.
What are the most common causes of pediatric vertigo at ages 2, 5, and 13?
- 2 years old = AOM
- 5 years old = Recurrent vertigo of childhood
- 13 years old = Migraine associated vertigo
Describe recurrent vertigo of childhood:
1. What is the epidemiology?
2. Clinical presentation?
3. Diagnostic criteria?
Recurrent Vertigo of Childhood:
- 2021 replaces terminology of benign paroxysmal vertigo of childhoos
- Suggested to be a migraine precursor
Epidemiology:
- Approx 2.6% of children
Clinical presentation:
- Abrupt episodes of unsteadiness or ataxia
- May have bilateral migraine headache
DIAGNOSTIC CRITERIA:
1. At least 3 episodes with vestibular symptoms of moderate or severe intensity, lasting between 1 minute and 72 hours
2. None of the criteria B + C for vestibular migraine of childhood
3. Age < 18 years old
4. Not better accounted for by another headache disorder, vestibular disorder, or other condition
What is the diagnostic criteria for definite vestibular migraine of childhood?
A. At least five episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours
B. A current or past history of migraine with or without aura
C. At least half of episodes are associated with at least one of the following 3 migraine features:
1. Headache with at least two of the following four characteristics: unilateral, pulsatile, moderate or severe pain intensity, aggravation by routine physical activity
2. Photophobia and phonophobia
3. Visual aura
D. Age < 18 years
E. Not better accounted for by another headache disorder, vestibular disorder, or other condition
What is the criteria for Probable Vestibular migraine of Childhood?
A. At least 3 episodes with vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours
B. Only one of the criteria B+C for vestibular migraine of childhood
C. Age < 18 years
D. Not better accounted for by another headache disorder, vestibular disorder, or other condition
