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H A N S R O S E N B E R G M D C C F P ( E M )
OTOLARYNGOLOGICAL EMERGENCIESAHD JAN 31, 2013
OBJECTIVES
• Ear Anatomy• Otitis Media• Otitis Externa• Mastoiditis
ANATOMY
CLINICAL EXAMINATION
• Start with External: helix, antihelix, tragus, outer ear canal• Otoscope: external auditory canal, TM• Syringing• Pneumatoscopy
QUESTION 4
• What is the DDx of Ear pain, list 5 primary causes and 5 non-ear causes? (10)
DDX FOR EAR PAIN
Ear
• Otitis Media• Otitis Externa• Otitis Media with Effusion• Mastoiditis• Labyrinthitis • Dysbarism• Ramsay Hunt Syndrome• Malignant External Otitis
Non-Ear
• Pharyngitis• Sinusitis• Upper Respiratory Tract
Infection• Dental pain• Bell’s Palsy• Foreign bodies
CASE 6
• 4 year old brought in by mom because he has pain in his right ear, fever and coryza
OTITIS MEDIA
• #1 diagnosis in patients <15 yo• #1 reason for Rx of antimicrobials• Definitions:• Inflammation of the middle ear• AOM: signs and symptoms of an acute infection with an effusion• OM with Effusion: effusion without symptoms and signs of acute
infection• Recurrent AOM: 3 episodes in 6/12 or 4 in 1 year
QUESTION 5
• What are the 5 most common bacteria that cause AOM?
OTITIS MEDIA
• Bacteriology• S. pneumoniae, H. influenzae (primarily nontypeable), and M.
catarrhalis.• Streptococcus pyogenes, Staphylococcus aureus, and gram-negative
bacteria are much less common• Virology• RSV, parainfluenza, influenza, enterovirus, rhinovirus, and adenovirus
CLINICAL
• Hx• otalgia, fever, ear pulling, coryza, cough, anorexia, vomiting, diarrhea
• Risk Factors• 6m-3y, male, daycare, smoking,
pacifier, cleft palate, Downs• Sequelae• mastoiditis, bacterial meningitis,
H/L, labyrinthitis, CN VII palsy
TM ANATOMY
• P/E• TM• Normal: pars flaccida, malleus, light reflex, moves with insufflation
CLINICAL
• P/E• TM• AOM: bulging/retracted, erythematous*, effusion, A/F level, dull (loss of
anterior light reflex), no movement
OTITIS MEDIA
OTITIS MEDIA - GUIDELINES
1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE.
2. The presence of MEE that is indicated by any of the following: a. Bulging of the tympanic membrane b. Limited or absent mobility of the tympanic membrane c. Air fluid level behind the tympanic membraned. Otorrhea
OTITIS MEDIA
• 3. Signs or symptoms of middle-ear inflammation as indicated by either • a. Distinct erythema of the tympanic membrane OR • b. Distinct otalgia (discomfort clearly referable to the ear[s] that results
in interference with or precludes normal activity or sleep)
MANAGEMENT
• Pain Control• Tylenol• Advil• Narcotic Analgesics• Benzocaine-Antipyrene gtts (Auralgan)
MANAGEMENT
• Note: Nonsevere illness is mild otalgia and fever <39C in the past 24 hours. Severe illness is moderate to severe otalgia or fever >39C.
AGE CERTAIN DIAGNOSIS
UNCERTAIN DIAGNOSIS
<6 mo Antibacterial therapy Antibacterial therapy
6 mo–2 yr Antibacterial therapy Antibacterial therapy;
Observation option if nonsevere
>2 yr Antibacterial therapyObservation option if severe illness; observation option if nonsevere illness
MANAGEMENT
AT DIAGNOSIS FOR PATIENTS BEING TREATED INITIALLY WITH ANTIBACTERIAL AGENTS
CLINICALLY DEFINED TREATMENT FAILURE AT 48–72 HOURS AFTER INITIAL MANAGEMENT WITHOBSERVATION OPTION
CLINICALLY DEFINED TREATMENT FAILURE AT 48–72 HOURS AFTER INITIAL MANAGEMENT WITHANTIBACTERIAL AGENTS
TEMPERATURE ≤ 39C OR SEVERE OTALGIA OR BOTH
RECOMMENDEDALTERNATIVE FOR PENICILLIN ALLERGY
RECOMMENDEDALTERNATIVE FOR PENICILLIN ALLERGY
RECOMMENDEDALTERNATIVE FOR PENICILLIN ALLERGY
No Amoxicillin (80–90 mg/kg/day)
Non-type I: cefdinir, cefuroxime, cefpodoximeType I*: azithromycin, clarithromycinCeftriaxone—1 or 3 days
Amoxicillin (80–90 mg/kg/day)
Non-type I: cefdinir, cefuroxime, cefpodoximeType I*: azithromycin, clarithromycinCeftriaxone—1 or 3 days
Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate)
Non-type I: ceftriaxone—3 daysType I*: clindamycin
Yes
Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate)
Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate)
Ceftriaxone—3 days Tympanocentesis—clindamycin
<2yr old or complex case use 10 day course, otherwise may use 7 day course
MANAGEMENT
• Recurrent AOM• If > 6 weeks since last AOM use first line agents• If < 6 weeks since last AOM use second line agents• Consider ENT referral• OME for ≥ 3 months with bilateral hearing loss ≥ 20 dB.• ≥ 3 episodes in 6 months • ≥ 4 episodes in 12 months • Retracted tympanic membrane • Cleft plate or craniofacial malformations.
MANAGEMENT CONTROVERSIES
MANAGEMENT CONTROVERSIES
• Primary Outcome – not statistically significant• Changed protocol, from single Primary Outcome
to four primary outcomes• Lead author has received multiple honoraria from
makers of Amox-Clav ES• Make little to no mention of secondary outcome
which was statistically significant - Diarrhea
MASTOIDITIS
• Inflammation of mastoid air cells• commonly associated with AOM• Bacteriology• S. pneumoniae, group A streptococci, S. aureus, S. epidermidis, M.
catarrhalis, H. flu
CLINICAL
• Hx• PAIN, Fever, h/a, erythema posterior to auricle, AOM symptoms for >2 weeks
• P/E• tenderness, erythema• displaced auricle• TM erythema/bulging/fluid
• Complications• Subperiostial Abscess• Bezold Abscess – below pinna, behind SCM• Petrositis/Osteomyelitis
• Diagnostic Imaging• CT (Sens 87-100%)/MRI
MANAGEMENT
• Antibiotics: Ceftriaxone, Clindamycin + Gentamycin, Pip-Tazo• ENT for possible myringotomy, tympanostomy tubes,
mastoidectomy
CASE 7
• 23 year old male returns from his weekend at his cottage early due to unbearable pain in his right ear. His vital signs are all stable but when you touch his helix he screams out in pain.
OTITIS EXTERNA
• Infection of the external auditory canal• DDx• AOM• Otomycosis – Aspergillosis• Furunculosis – infection of cartilagenous portion of ext. canal• Herpes Zoster Oticus – Ramsay Hunt Syndrome
• Bacteriology• P. aeruginosa, S. aureus, and other gram-negative organisms often
occurring as polymicrobial infection.
CLINICAL
• Hx• otalgia, ear fullness, H/L, redness, swelling, jaw pain, discharge, pruritis
• Risks• moisture, maceration, trauma
• P/E• erythema, edema, narrowing of canal, discomfort with pulling on the
auricle or tragus
OTITIS EXTERNA
• Analgesia – NSAID’s, opiates• Ear Wick• Antifungals• Thimerosol gtts• Gentian Violet gtts
• Antimicrobials• Ciprodex 4gtts bid• Cortisporin 4gtts qid
NECROTIZING (MALIGNANT) EXTERNAL OTITIS
• Osteomyelitis of temporal bone secondary to OE potentially life threatening almost exclusively in immunocompromised Pseudomonas 50 % mortality if left untreated Hx: severe pain, h/a, discharge P/E: erythema, tenderness, edema of external ear or adjacent structures,
POOP, granulation tissue
MALIGNANT EXTERNAL OTITIS
• Oral Ciprofloxacin 750mg po bid if uncomplicated• IV Ceftazidime 1-2g IV q8h• Hyperbaric • ENT consultation• Treatment length guided by
bone scan
EPISTAXIS
EPISTAXIS
• Nasal Anatomy• Etiology• Management of Anterior Bleeds• Management of Posterior Bleeds
QUESTION
• What are the arteries which are involved in anterior epistaxis (ie. Kiesselbach’s Plexus)?(5)
EPISTAXIS
• Most cases in children although bimodal distribution• Anterior ~90% of cases in Kiesselbach’s Plexus• ant. ethmoid, sphenopalatine, greater palatine, superior labial arteries
• Posterior Epistaxis from posterior branch sphenopalatine artery
NASAL ANATOMY
EPISTAXIS
• Causes• TRAUMA – self, assault, surgical• Mucosal – URTI, allergies, cold/dry weather• Bleeding diatheses• Etc.• Hypertension – NOT a cause of bleeding but may worsen active
bleeding
EPISTAXIS
• Preparation, proper equipment and an organized step-wise approach will be the key to success or…
MANAGEMENT - ANTERIOR
• Clear clots• Apply pressure for 15-20 min with clips – over septum!!!• With nose parallel to ground use nasal speculum• Use headlight or assistant for light source• Suction as necessary• Check if continued bleeding…
MANAGEMENT - ANTERIOR
• Apply pledgets soaked in:• Lidocaine w/ Epi• Cocaine• Xylometazoline (Otrivin)
Re-examine if bleeding persists…
MANAGEMENT - ANTERIOR
• If light or no bleeding but identify source• Silver Nitrate• Outside to inside• Avoid on both sides of septum• Re-examine if bleeding persists…
MANAGEMENT - ANTERIOR
• Nasal Packing• Nasal Packing with Vaseline gauze• Nasal Tampon/Rhino-Rocket – 8 or 10cm sizes• May need bilateral packs
*warn patient that Nasal tampon insertion will be painful for about 10 seconds
MANAGEMENT - ANTERIOR
• If success leave packing in for 48hrs, consider antibiotic prophylaxis• Prevention: avoid blowing nose, picking, closed mouth
sneezing, apply Polysporin cream• If STILL bleeding• Consider posterior bleed
MANAGEMENT - POSTERIOR
• Commercial Balloon Cather – Epistat
• Foley Catheter • Prophylaxis with Keflex/Clavulin• ENT consultation
MANAGEMENT
• If all of above fails time to call ENT• In case of massive, life threatening bleed• ABC’s• Establish Advanced A/W• Nasal Packing• Fluids/Blood Products – PRBC’s, FFP, Plts, PCC• call ENT/IR/Vascular
SUMMARY
• AOM is common – be aware of treatment guidelines and rare complications including mastoiditis• OE is very painful but quite benign, be aware of
NOE as a complication• Have an approach to the patient with epistaxis,
consider posterior bleed if unable to achieve hemostasis with above techniques
REFERENCES
• American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media: Diagnosis and management of acute otitis media. Pediatrics 113:1451, 2004• eMedicine: Otitis Externa, Otitis Media• Guidelines for the Diagnosis and Management of
Acute Otitis Media. Towards Optimized Practice. Alberta Medical Association. 2008• Treatment of Acute Otitis Media in Children under
2 Years of Age. Alejandro Hoberman, M.D. et al. NEJM January 13, 2011