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

Disclosure No conflicts of interest to declare 8.17 years (collective) experience

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

Not at risk children age 6 mo to 12 years

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

Diagnostic Criteria for AOM There is no gold standard for the diagnosis of AOM

What Is AOM? The rapid onset of symptoms and signs of inflammation in the middle ear

Symptoms of AOM 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 - page e970

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 as the kid gets better so do non-specific symptoms

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 e971

Signs of AOM Bulging TM highly associated with bacterial pathogen in ME Bulging TM represents the most important characteristic in the diagnosis of AOM go back to the definition of AOM - it say inflammation, not infection, and it doesn’t differentiate between viral and bacterial

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? - Note the Pen Allergy suggestions. There has been a shift towards OK to use cephalasporins in Pen allergy, unless anaphylaxis. Likelihood of issue ~0.1%. - I’m using 7:1, I can’t get 14:1

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 =

Ciprodex 4 drops BID x 7 days Tragal pumping

-Increased emphasis by AAP on both otoscopy and pneumatics in diagnosing AOM - In particular, pneumatic otoscopy to aid in the recognition of MEE

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

- Reality check

These pictures are not taken with otoscope Captured using rigid endoscope

This picture was not taken with an endoscope

Otoscopy in Real Life Low intensity bulb Uncooperative patient Narrow EAC Cerumen Non-sealing tips It doesn’t matter how good your pneumatic skills are, if these are working against you

IS IT OK TO NOT KNOW WHAT I’M LOOKING AT? - I have a microscope, wax loops, and pediatric nurses - still, unsatisfactory view of TM ~20-30% of the time

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 Not perfect, will have some false positives

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 can not rule out possibility of MEE without AOM and separate cause for fever

Case #2

Tympanometry Not perfect False-positives Useful when TM visualization limited Not strictly in accordance with CPG

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? Yes No 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 Obstruction Rhinitis AR NAR Obstructive Adenoid

Topics Otitis media The stuffy child Post T&A bleeding Nasal trauma

Mike Tindall, married to Zara Phillips, eldest granddaughter of QEII

Nasal Fracture Septal hematoma Yes I&D No Obvious external deformity 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/Bleeding

In My Head No Clot/Bleeding Looks well Observe x 6 hrs Looks unwell Observe o/n Clot/Bleeding Pt co-operative? No Yes

Tonsil ball with epi in ER In My Head No OR Yes Feeling Lucky Tonsil ball with epi in ER Feeling Unlucky

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

What To Do? Standard stuff I’m feeling lucky Suction clot (be prepared for frank hemorrhage) Apply tonsil ball containing epi

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

What To Do? Standard stuff OR for control