1. Ashley Pinawin, EM2 January 21, 2016
Go ahead… I’m all ears
Ashley Pinawin, EM2
January 21, 2016

2. Objectives
To learn clinical signs/symptoms of otitis media, otitis externa, and mastoiditis to be able to diagnose these conditions.
To learn which organisms cause otitis media, otitis externa, and mastoiditis and therefore understand management.
To learn about additional tests helpful in diagnosing malignant otitis externa
To learn about perforation management

3. Anatomy

4. Otitis Media

5. Otitis Media Infection of the middle ear
Moderate to severe bulging of the TM
Quintessential sign
Most common diagnosis for children < 15 years old
80% of children will have at least one episode of AOM

6. Pathophysiology Eustachian tube dysfunction
Almost horizontal in children

7. Accumulation of secretions
Pathophysiology
Inflammation
URI
Accumulation of secretions
Obstruction
Acute Otitis Media

8. Symptoms Otalgia Pulling at ears Cough URI symptoms
Poor appetite, diarrhea, vomiting
Fever

9. Etiology Bacterial Streptococcus pneumoniae Haemophilus influenzae
Moraxella catarrhalis
Viral
Respiratory syncytial virus

10. Risk factors Age Peak between 6-18 months of age Lack of breastfeeding
Season
Day care
Economic

11. Physical Exam

15. Management Analgesia Acetaminophen Ibuprofen Antibiotics vs follow up
Unilaterel AOM in child > 6months

16. Antibiotic Treatment 7-10 days Amoxicillin 80-90 mg/kg/day
Penicillin allergy
Type I sensitivity (urticaria or anaphylaxis)
Azithromycin (10 mg/kg for one day, then 5 mg/kg for an additional 5 days)
Clindamycin (7.5 mg four times a day).
Non–type I sensitivity
Cefdinir (14 mg/kg/day in one or two doses)
Cefpodoxime (10 mg/kg once a day),
Cefuroxime (30 mg/kg/day in two divided doses)

17. Tympanosotomy Tubes Ofloxacin drops (5 drops BID) Tubes patent?
Little evidence for most effective treatment
Ofloxacin drops (5 drops BID)
Ciprofloxacin-dexamethasone (4 drops BID)
5 day course
no consensus for the most appropriate treatment in a patient with an acutely draining ear.
A meta-analysis concluded that there was little high-quality evidence available to identify the most effective treatment.
The organisms involved are the same ones that cause AOM acutely, particularly in children younger than 2 years, but Pseudomonas aeruginosa, S. aureus, and Staphylococcus epidermidis are also implicated.

18. Complications Mastoiditis and otic meningitis Prior to antibiotics
Incidence 20%
Use of antibiotics
Incidence < 1%

19. Question
A 3-year-old boy is brought in by his mother for fever and right ear tugging for 2 days. He has also had 1 week of rhinorrhea on review of systems. His vaccines are up to date. His physical exam is remarkable only for a temperature of 38.8C and a bulging and erythematous right tympanic membrane. What is the most likely pathogen?
Haemophilus influenzae, nontypeable
Moraxella catarrhalis
Staphylococcus aureus
Streptococcus pneumoniae

20. Question
A 3-year-old boy is brought in by his mother for fever and right ear tugging for 2 days. He has also had 1 week of rhinorrhea on review of systems. His vaccines are up to date. His physical exam is remarkable only for a temperature of 38.8C and a bulging and erythematous right tympanic membrane. What is the most likely pathogen?
Haemophilus influenzae, nontypeable
Moraxella catarrhalis
Staphylococcus aureus
Streptococcus pneumoniae

21. Question
A 26-year-old man presents with 2 days of left ear pain. He notes that the symptoms started with an itchy ear that progressed to pain, discharge, and mild hearing loss. On examination, there is tenderness with manipulation of the auricle, edema, erythema, and narrowing of the tympanic canal. Which of the following is useful in treating this condition?
Acetic acid otic washes
Antihistamines
Oral amoxicillin
Tympanostomy tubes

22. Question
A 26-year-old man presents with 2 days of left ear pain. He notes that the symptoms started with an itchy ear that progressed to pain, discharge, and mild hearing loss. On examination, there is tenderness with manipulation of the auricle, edema, erythema, and narrowing of the tympanic canal. Which of the following is useful in treating this condition?
Acetic acid otic washes
Antihistamines
Oral amoxicillin
Tympanostomy tubes

23. Otitis Externa

24. Otitis Externa Inflammation of the external auditory canal
Incidence- 10%
Swimmer's ear or tropical ear
Bacterial disease
P. aeruginosa
S. aureus
Polymicrobial
Inflammation of the external auditory canal
Incidence of 10%, and it accounts for 7.5 million annual ototopical prescriptions in the United States.
Occurring most often in the summer and in tropical climates, it is also known as swimmer's ear or tropical ear.
Bacterial disease
P. aeruginosa
S. aureus
Polymicrobial

25. Pathophysiology
External auditory canal lined with squamous epithelial cells
Maceration
Local trauma
The external auditory canal is lined with squamous epithelial cells and cerumen glands that provide a protective lipid layer.

26. Symptoms
Pruritus
Otalgia
Hearing loss

27. Risk Factors Water exposure Trauma (aggressive cleaning or scratching)
Devices occluding the ear canal

28. Physical Exam Findings Erythema Edema of canal
Pain with pulling on auricle or tragus

29. Differential
Otomycosis 
Contact Dermatitis
Psoriasis
Carcinoma

30. Treatment Clean the canal Topical antibiotics Duration: 7 days
Cotton swab or gentle suctioning and irrigation
Tap water, sterile saline, 2% acetic acid, and Burow’s solution
Topical antibiotics
Polymyxin B/neomycin/hydrocortisone (3-4 drops QID)
Ofloxacin (Ocuflox) 5 drops BID
Ciprofloxacin/hydrocortisone (3 drops BID)
Duration: 7 days
Precautions

31. Complications
Periauricular cellulitis
Malignant Otitis Externa

32. Malignant Otitis Externa
Necrotizing otitis externa
Elderly diabetic patients or immunocompromised
Symptoms
Severe otalgia and otorrhea
Pain out of proportion to exam findings
Granulation tissue at the bony cartilaginous junction of the ear canal floor
severe, potentially fatal complication of acute bacterial external otitis.
Most common in elderly diabetic patients or other immunocompromised individuals, it occurs when the infection spreads from the skin to bone and marrow spaces of the skull base (also involving soft tissue and cartilage of the temporal region). Granulation tissue at the bony cartilaginous junction of the ear canal floor is a classic finding. Edema, erythema, and frank necrosis of ear canal skin may be evident.

33. Management Ciprofloxacin (400mg IV TID)
Poor prognosis = cranial nerve palsies
MRI or CT scan
ENT referral
Cranial nerve palsies are a poor prognostic sign.
Patients generally have a markedly elevated erythrocyte sedimentation rate (ESR). Diagnosis is aided with an abnormal MRI or CT scan showing extension of infection into bony structures.

34. Mastoiditis

35. Mastoiditis Bacterial Infection of the mastoid air cells
Middle ear cavity and mastoid air
spaces are continuous
Most frequent complication of AOM
Bacterial
Streptococcus pneumoniae
Streptococcus pyogenes
Staphylococcus aureus
Complication of leukemia, mononucleosis, sarcoma of the temporal bone, and Kawasaki disease.

36. Symptoms
Fever
Headache
Otalgia
Pain

37. Physical Exam No specific diagnostic criteria Most common findings
Postauricular erythema and tenderness
Protrusion of the auricle
Abnormal TM
Pain is universally present. There are no specific diagnostic criteria, but the most common physical findings are postauricular erythema and tenderness, protrusion of the auricle, and an abnormal TM. The TM is similar to that in AOM (erythema, bulging, and decreased mobility) but may be normal in 10% of cases. Suspicion should be heightened if symptoms of AOM have lasted longer than 2 weeks. In chronic mastoiditis, symptoms include persistent drainage through the perforated TM, redness, edema, and retroauricular sensitivity.

38. Management Antibiotics Surgical procedures
Ceftriaxone or cefotaxime (50 mg/kg/day)
Clindamycin (penicillin-allergic patient)
Surgical procedures
Myringotomy
Tympanostomy tube placement
Mastoidectomy

39. Tympanic Membrane Perforation

40. Symptoms
Ear pain
Hearing loss
Nausea and vomiting

41. Risk Factors
AOM
Trauma
Barotrauma

42. Findings

43. Management Water precautions Antibiotic ear drops Follow up with PCP
Ofloxacin drops (5 drops in the affected ear BID for 3-5 days)
Follow up with PCP
ENT referral with persistent perforation > 4 weeks after injury
Perforation < 25% of TM will heal spontaneously within 4 weeks

44. Summary Moderate to severe bulging of the TM = AOM
The diabetic patient with granulation tissue at the bony cartilaginous junction of the ear canal floor (think malignant otitis externa)
Perforation < 25% of TM will heal spontaneously

45. Thank you

46. Questions?

47. References
Goguen, Laura. External otitis: Pathogenesis, clinical features, and diagnosis. Uptodate.
Pfaff, J. and Moore, G (2013). Otolaryngology. Marx, Rosen’s Emergency Medicine ( ). Philadelphia, PA: Saunders.
Rosh Review
Wald, Ellen. Acute otitis media in children: Diagnosis. Uptodate