Derrick Randall & Dieter Fritz Otolaryngology – Head and Neck Surgery PGY 5 ENT Potpourri.

Derrick Randall & Dieter FritzOtolaryngology – Head and Neck Surgery

PGY 5

ENT Potpourri

• No conflicts of interest to declare

• 8.17 years (collective) experience

Disclosure

Topics

• Otitis media

• The stuffy child

• Post T&A bleeding

• Nasal trauma

Does This Child Have AOM?

• 2 year female, crying, fever 38.3 C, pulling at ears

Objectives• Review new guidelines for diagnosis and

treatment of AOM

• Highlight the difficulty of diagnosing middle ear effusions in clinical practice & discuss the role of tympanometry

• Review new guidelines regarding tympanostomy tubes in the management of OM

What are the Diagnostic Criteria

for AOM?A). Bulging TM

B). Acute onset of ear pain accompanied by fever

C). Acute onset of ear pain and middle ear effusion without TM inflammation

D). Acute onset of ear pain and middle ear effusion with TM inflammation

• There is no gold standard for the diagnosis of AOM

Diagnostic Criteria for AOM

What Is AOM?

• The rapid onset of symptoms and signs of inflammation in the middle ear

• otalgia is useful in diagnosing AOM (positive LR 3.0-7.3)

• however, is only present 50% to 60% of children with AOM

• pain is not required for the diagnosis of AOM

Symptoms of AOM

• Restless sleep, ear rubbing and fever do not differentiate children with AOM from those without

Symptoms of AOM

Symptoms of AOM

• Symptoms such as ear rubbing, crying, irritability, difficulty sleeping and decreased appetite should be assessed

• they change appropriately in response to clinical change

Signs of AOM• Impaired TM mobility (95% sens, 85%

spec)

• Cloudy TM (74% sens, 93% specific)

• Bulging TM (51% sens, 97% specific)

• Strongly red or hemorrhagic TM correlates with AOM

• Slightly red TM not helpful

Signs of AOM• Bulging TM highly

associated with bacterial pathogen in ME

• Bulging TM represents the most important characteristic in the diagnosis of AOM

When To Diagnose AOM

• Children who present with moderate to severe bulging of the TM or new onset otorrhea not due to OE

When To Diagnose AOM

• Children with mild bulging of the TM and recent (<48 hrs) onset of ear pain or intense erythema of TM

When Not To Diagnose AOM

• Children who do not have MEE

Treat The Pain

Antibiotics in AOM

• Severe = moderate or severe otalgia, otalgia >48 hrs, or temp >39 °C

• Nonsevere = mild otalgia <48 hrs, temp <39 °C

Antibiotics in AOM

What Antibiotic?

What Antibiotic?

Note

• Change in recommendations regarding use of cephalosporins in patients with penicillin allergy

• Recommending against use of macrolides and TMP-SMX

Note• No role for ototopical antibiotic agents

(Ciprodex, Floxin) in AOM in the absence of tympanostomy tubes

• Topical benzocaine or lidocaine may be of limited benefit in children >5 years

• However, some OTC ototopical agents, antibiotic (Polymixin) or otherwise are potentially ototoxic

Patient Follow-Up• Following initial treatment of AOM, there will

be a MEE that can last up to 3 months

• Don’t treat MEE unless symptoms

• Re-assess status of the ME in 3 months

• 90% of children will clear the MEE within 3 months

• If MEE present, order audiogram and consider consulting ENT

What The Guidelines Don’t Address

• Antibiotic use in children with penicillin anaphylaxis

• Asymptomatic bulging TM following appropriate course of antibiotics

In The Future

• Levofloxacin and linezolid for treatment of AOM?

• Nasopharyngeal swab to identify middle ear pathogens?

SAOM with Tympanostomy Tubes

=

What About Pneumatic Otoscopy?

• Takata et al., 2003

• 93.8% sensitive and 80.5 specific for the diagnosis of OME as compared to myringotomy

Do Your Clinic Rooms Have Pneumatic

Otoscopes?

A). Always

B). Sometimes

C). Never

How Often Do You Perform Pneumatic Otoscopy for

AOM?

A). Always

B). Usually

C). Sometimes

D). Never

Do You Have Pneumatic Otoscopy Tips For Your

Otoscope?

A). Yes

B). No

Otoscopy in Real Life• Low intensity bulb

• Uncooperative patient

• Narrow EAC

• Cerumen

• Non-sealing tips

IS IT OK TO NOT KNOW WHAT I’M

LOOKING AT?

Can We Do Better?

The Hearing Professional: Ted Venema

The Hearing Professional: Ted Venema

Tympanometry

• Takata et al., 2003

• 89.1 % sensitive, 58.2% specific for diagnosis of OME

Type A Tympanogram

emedicine.com

Type B Tympanogram

emedicine.com

Type C Tympanogram

emedicine.com

Tympanometry

• Easy to learn and use

• Well tolerated by children

• Very useful when poor view on otoscopy

Our Original Case

• 2 year female, crying, fever 38.3 C, pulling at ears

Case #2

• 2 year female, crying, fever 38.3 C, pulling at ears

Case #2

Tympanometry

• Not perfect

• False-positives

• Useful when TM visualization limited

Ear Tubes

• most commonly performed ambulatory surgery in the US

• By age 3, 7% of US children will have ear tubes

Recurrent AOM

• 3 or more separate AOM in 6 mo or at least 4 in last year with at least 1 in the last 6 mo

Otitis Media With Effusion (OME)

• fluid in the middle ear without signs or symptoms of AOM

• Duration and symptoms are important

COME

• OME persisting for 3 months of longer

Ear Tubes

• The 3 most common reasons we insert ear tubes:

• COME with conductive hearing loss

• RAOM

The New Guidelines

• Ear tubes for COME > 3 mo with CHL

• When does the 3 mo time interval start?

Do Ear Tubes Prevent RAOM?

A. Yes

B. No

C. Maybe

Are We Over Treating RAOM?

• 7% of US kids have ear tubes

The New Guidelines

• Ear tubes for RAOM only if MEE is present in either ear at time of assessment for tube candidacy

The New Guidelines

• Do not encourage routine, prophylactic water precautions (ear plugs or swimming avoidance) in children with ear tubes

Topics

• Otitis media

• The stuffy child

• Post T&A bleeding

• Nasal trauma

Nasal Obstructio

n

Rhinitis

AR

NARObstructive Adenoid

Topics

• Otitis media

• The stuffy child

• Post T&A bleeding

• Nasal trauma

Nasal Fracture

Septal hematoma

Yes I&D

No

Obvious external

deformity

No

Yes

Closed reduction 7-10 days post

injury

Topics

• Otitis media

• The stuffy child

• Post T&A bleeding

• Nasal trauma

In My Head

Stable?

No Emergency

Yes Examine Fossae

No Clot/Bleed

ing

Clot/Bleeding

In My Head

No Clot/Blee

ding

Looks well

Observe x 6 hrs

Looks unwell

Observe o/n

Clot/Bleeding

Pt co-operativ

e?

No

Yes

In My Head

No OR

Yes

Feeling Lucky

Tonsil ball with epi in

ER

Feeling Unlucky OR

Post T&A Bleeding• 5 yr female, POD #4 T&A for SDB

• Spitting BRB this AM

• O/E:

• VSS

• Co-operative exam

• No bleeding/No Clot

What To Do?• Standard stuff

• IV

• CBC, INR/PTT, type & screen

• Bolus?

• Observe 6 hrs & if no further bleeding d/c home

Post T&A Bleeding• 5 yr female, POD #4 T&A for SDB

• Spitting BRB this AM

• O/E:

• VSS

• Co-operative exam

• Large clot left fossae

• Standard stuff

• I’m feeling lucky

• Suction clot (be prepared for frank hemorrhage)

• Apply tonsil ball containing epi

What To Do?

Post T&A Bleeding• 5 yr female, POD #4 T&A for SDB

• Spitting BRB this AM

• O/E:

• VSS

• Uncooperative exam

• Large clot left fossae

• Standard stuff

• OR for control

What To Do?