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Common Ear Common Ear DisordersDisorders and and their pharmacologictheir pharmacologic

managementmanagement

Joanne Stow CRNP, CORLNJoanne Stow CRNP, CORLN

ObjectivesObjectives

•• Identify the medication therapies used to Identify the medication therapies used to treat cerumen impaction and eardrum treat cerumen impaction and eardrum perforationperforation

•• Describe the practice guidelines for the Describe the practice guidelines for the management of acute otitis management of acute otitis externaexterna (AOE)(AOE)

•• Discuss the management of acute otitis Discuss the management of acute otitis media (AOM) based on the 2013 AAP/AAFP media (AOM) based on the 2013 AAP/AAFP guidelineguideline

Wax ImpactionWax ImpactionFactors contributing to Factors contributing to

wax impactionwax impaction

•• Use of cotton swabs (or other objects)Use of cotton swabs (or other objects)

•• Radiation to head/neckRadiation to head/neck

•• Lack of mandibular movementLack of mandibular movement

•• Hearing aidsHearing aids

•• Ear bud useEar bud use

•• GeneticsGenetics

Wax Impaction ManagementWax Impaction Management

•• Carbamide peroxide solution 1Carbamide peroxide solution 1--5 5 drops twice daily x 4 days (5drops twice daily x 4 days (5--10 10 dropsdrops--adult)adult)

•• ½ strength hydrogen peroxide 5 ½ strength hydrogen peroxide 5 drops twice daily x 4 daysdrops twice daily x 4 days

•• Pump the tragus!Pump the tragus!

•• Keep ear up for several minutes, use Keep ear up for several minutes, use cotton ball to absorb drainagecotton ball to absorb drainage

Wax Impaction ManagementWax Impaction Management

•• Gentle warm water Gentle warm water irrigationirrigation

•• Binocular microscopy Binocular microscopy with cerumen with cerumen removal by ENT MDremoval by ENT MD

–– Wax curretteWax currette

–– suctionsuction

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Eardrum perforationsEardrum perforations

tympanosclerosis

Ear Pain: Ear Pain: true ear disorder or referred?true ear disorder or referred?

•• Teething (cranial nerve V)Teething (cranial nerve V)–– Emerging teeth, impacted molars in teenEmerging teeth, impacted molars in teen–– AbscessAbscess

•• TMJ pain (malocclusion)TMJ pain (malocclusion)•• PreauricularPreauricular cervical adenitiscervical adenitis•• ParotitisParotitis, sinusitis, sinusitis•• Anterior tongue lesions, ulcersAnterior tongue lesions, ulcers

•• Posterior tongue, pharyngeal or laryngeal Posterior tongue, pharyngeal or laryngeal inflammation (post op T/A)inflammation (post op T/A)

•• Bell’s palsy or Ramsey Hunt (Herpes Zoster) Bell’s palsy or Ramsey Hunt (Herpes Zoster)

•• C1C1--C2 injuriesC2 injuries

Acute External OtitisAcute External Otitis

•• “Swimmer’s Ear”“Swimmer’s Ear”•• Most common presentationMost common presentation-- itching, pain itching, pain

when ear is touched, edema of ear canalwhen ear is touched, edema of ear canal

•• May have drainage, fever, enlarged lymph May have drainage, fever, enlarged lymph nodesnodes

•• Contributing factors:Contributing factors:

–– Absence of cerumenAbsence of cerumen–– Water retentionWater retention–– Trauma to skin of canalTrauma to skin of canal–– Change in skin pHChange in skin pH

•• Primary cause is bacterialPrimary cause is bacterial

Otitis Otitis ExternaExterna-- Differential Differential diagnosisdiagnosis

Herpes Zoster OticusHerpes Zoster Oticus

EczemaEczema

Contact DermatitisContact Dermatitis

FurunculosisFurunculosis

Acute Otitis Acute Otitis ExternaExternaAAOAAO-- HNS 2014 GuidelineHNS 2014 Guideline

•• Distinguish diffuse AOE from other causes of Distinguish diffuse AOE from other causes of otalgia, otalgia, otorrheaotorrhea, and canal inflammation, and canal inflammation

•• Assess for factors that would modify Assess for factors that would modify managementmanagement

•• Assess and treat painAssess and treat pain

•• No systemic antimicrobials unless there is No systemic antimicrobials unless there is extension outside canal or host factors that extension outside canal or host factors that indicate needindicate need

Acute Otitis Acute Otitis ExternaExternaAAOAAO-- HNS 2014 GuidelineHNS 2014 Guideline•• Clinicians should use topical preparations Clinicians should use topical preparations

for diffuse, uncomplicated AOEfor diffuse, uncomplicated AOE

•• Clinician should inform patients how to Clinician should inform patients how to administer topical drops. Debridement or administer topical drops. Debridement or wick may be needed.wick may be needed.

•• Non Non otooto--toxic topical preparation should toxic topical preparation should be used for known or suspected be used for known or suspected perforationperforation

•• Reassess if failure to respond in 48Reassess if failure to respond in 48--72 72 hrshrs

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External OtitisExternal Otitis-- treatmenttreatment

•• Pain managementPain management-- ibuprofenibuprofen•• Debridement is importantDebridement is important•• Prescribe an antibiotic ear drop (w or w/o Prescribe an antibiotic ear drop (w or w/o

corticosteroid) containing a mild acidcorticosteroid) containing a mild acid•• May need ear wick for 1May need ear wick for 1--2 days2 days•• Apply drops 4 times daily; treat 3Apply drops 4 times daily; treat 3--4 4 days beyond symptomatic improvement days beyond symptomatic improvement (usually for 5(usually for 5--7 days total)7 days total)

•• MustMust keep water out of ears! keep water out of ears! •• If severeIf severe-- may require oral or IV antibiotics may require oral or IV antibiotics

plus topical dropsplus topical drops

Ear wick

External OtitisExternal Otitis-- treatmenttreatment

•• 2% acetic acid w/wo hydrocortisone2% acetic acid w/wo hydrocortisone

–– ((VoSolVoSol, , AcetasolAcetasol, , VoSolVoSol HC)HC)

•• PolymyxinPolymyxin BB--hydrocortisonehydrocortisone

–– ((CorticosporinCorticosporin oticotic))

•• 0.3% Ciprofloxacin w hydrocortisone0.3% Ciprofloxacin w hydrocortisone

–– ((CiprodexCiprodex))

External OtitisExternal Otitis-- treatmenttreatment

•• OfloxacinOfloxacin 0.3%0.3%

•• Aminoglycoside w/wo hydrocortisoneAminoglycoside w/wo hydrocortisone

–– (Tobramycin, (Tobramycin, GaramycinGaramycin, , TobradexTobradex))

• For fungal: For fungal: ClotrimazoleClotrimazole ((LotraminLotramin))

Key teaching points for topical Key teaching points for topical ear dropsear drops

•• Warm the dropsWarm the drops

•• Clean the ear of debrisClean the ear of debris-- cotton ballcotton ball

•• Gently pull ear back to straighten Gently pull ear back to straighten canalcanal

•• Do Do notnot touch dropper to eartouch dropper to ear

•• Pump the tragus after instilling dropsPump the tragus after instilling drops

•• Keep ear up for several minutesKeep ear up for several minutes

Keep Ears dryKeep Ears dry--“Dry Ear Precautions”“Dry Ear Precautions”

•• External otitisExternal otitis

•• Draining earDraining ear

•• Major ear surgery in previous 2 weeksMajor ear surgery in previous 2 weeks

•• For frequent swimmers with For frequent swimmers with healthyhealthyearsears-- may use 50:50 mixture of white may use 50:50 mixture of white vinegar and isopropyl alcohol. Place 4vinegar and isopropyl alcohol. Place 4--5 5 drops in canal after swimmingdrops in canal after swimming

Bullous MyringitisBullous MyringitisPurulent secretionsPurulent secretionsdistending TMdistending TM

Acute Otitis Media (AOM)Acute Otitis Media (AOM)

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AOM mild symptomsAOM mild symptoms

•• Fever less than 102.2 F (39 C)Fever less than 102.2 F (39 C)

•• Mild otalgia less than 48 hoursMild otalgia less than 48 hours

AOM moderateAOM moderate--severe severe symptomssymptoms

•• Moderate or severe ear pain Moderate or severe ear pain •• Ear pain lasting > 48 hoursEar pain lasting > 48 hours•• Fever > 102.2 F / 39 CFever > 102.2 F / 39 C•• otorrheaotorrhea

AOM managementAOM management--2013 AAP guideline changes2013 AAP guideline changes

•• Change in diagnostic criteriaChange in diagnostic criteria

•• Option of “watchful waiting” added for Option of “watchful waiting” added for 6mos6mos--2yrs with mild AOM2yrs with mild AOM

•• Revision of recommendations regarding Revision of recommendations regarding therapy for patient with penicillin allergytherapy for patient with penicillin allergy

•• Change in duration of therapy based on Change in duration of therapy based on age and severityage and severity

•• Discussion of recurrent AOM managementDiscussion of recurrent AOM management

AOM managementAOM management--AAP guidelineAAP guideline

•• Treat painTreat pain

•• Watchful waiting for up to 3 days Watchful waiting for up to 3 days for the following patients:for the following patients:–– >6 >6 momo and older with unilateral AOM and older with unilateral AOM

and mild symptomsand mild symptoms

–– > 2yrs with bilateral AOM and mild > 2yrs with bilateral AOM and mild symptomssymptoms

•• May give an antibiotic prescription May give an antibiotic prescription and advise to wait to fill it and advise to wait to fill it

AOM pain managementAOM pain management

•• Acetaminophen or ibuprofen for Acetaminophen or ibuprofen for pain/feverpain/fever

•• Warm compresses may provide comfortWarm compresses may provide comfort

•• May use topical anesthetic (antipyrene May use topical anesthetic (antipyrene and benzocaine) if no perforation or and benzocaine) if no perforation or drainage (Auralgan, Aurodex) 4drainage (Auralgan, Aurodex) 4--5 gtts 5 gtts every 2every 2--3 hours3 hours

•• Antihistamines and decongestants are Antihistamines and decongestants are NOTNOT effectiveeffective

AOM managementAOM management--AAP guidelinesAAP guidelines

•• Do not wait! Give antibiotic for:Do not wait! Give antibiotic for:

–– < 6 < 6 momo child with unilateral or bilateral child with unilateral or bilateral AOM with severe symptomsAOM with severe symptoms

–– 6m6m--2 2 yoyo child with relapse of AOM within child with relapse of AOM within the past 30 days the past 30 days

–– Child with 2 concurrent illnesses (AOM with Child with 2 concurrent illnesses (AOM with streptstrept throat or sinusitis)throat or sinusitis)

–– Child with weak immune system, cleft Child with weak immune system, cleft palate, or head & neckpalate, or head & neck syndromesyndrome

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AOM Antibiotic therapy:AOM Antibiotic therapy:First line First line

•• #1#1-- AmoxicillinAmoxicillin 8080-- 90 mg/kg/day in 2 90 mg/kg/day in 2 divided doses (BID dosing)divided doses (BID dosing)

•• Child must not have received Amoxicillin in Child must not have received Amoxicillin in the past 30 daysthe past 30 days

•• Child must not have concurrent Child must not have concurrent conjunctivitis, sinusitisconjunctivitis, sinusitis

•• No penicillin allergyNo penicillin allergy

•• Length of treatment: Length of treatment:

–– 10 days if < 6 years10 days if < 6 years

–– 55--7 days for mild to mod. illness > 6 7 days for mild to mod. illness > 6 yrsyrs

AOM Antibiotic therapy:AOM Antibiotic therapy:Beta lactamase coverageBeta lactamase coverage

•• If amoxicillin was used in past 30 daysIf amoxicillin was used in past 30 days

•• If there is concurrent conjunctivitisIf there is concurrent conjunctivitis

•• If there is a history of recurrent AOM If there is a history of recurrent AOM unresponsive to Amoxicillinunresponsive to Amoxicillin

•• Then use Then use AugmentinAugmentin-- 90 mg/kg per 90 mg/kg per dayday-- amoxicillin component, 6.4 amoxicillin component, 6.4 mg/kg per day of mg/kg per day of clavulanateclavulanate in 2 in 2 divided doses.divided doses.

AOM treatmentAOM treatment--Amoxicillin allergy, not type 1Amoxicillin allergy, not type 1

•• Cefdinir 14 mg/kg/day in 1 or 2 divided Cefdinir 14 mg/kg/day in 1 or 2 divided doses (tastes good)doses (tastes good)

•• Cefpodoxime 10 mg/kg/day, once dailyCefpodoxime 10 mg/kg/day, once daily

•• Cefuroxime 30 mg/kg/day in 2 divided Cefuroxime 30 mg/kg/day in 2 divided dosesdoses

•• Length of treatment : Length of treatment :

–– 10 days if < 6 years10 days if < 6 years

–– 55--7 days for mild7 days for mild--mod. illnessmod. illness > 6 years> 6 years

AOM treatmentAOM treatment--Penicillin allergyPenicillin allergy-- type 1type 1

(urticaria, wheezing, anaphylaxis)(urticaria, wheezing, anaphylaxis)

•• AzithromycinAzithromycin-- 10mg/kg/day10mg/kg/day--day 1, then 5 day 1, then 5 mg/kg/day for 4 days, once daily dosemg/kg/day for 4 days, once daily dose

•• ClarithromycinClarithromycin-- 15 mg/kg/day in 2 divided 15 mg/kg/day in 2 divided doses. Length of treatment: doses. Length of treatment:

–– 10 days if < 6 years10 days if < 6 years

–– 55--7 days for mild to mod. illness7 days for mild to mod. illness > 6 > 6 yearsyears

If an oral antibioticIf an oral antibioticis not an option..is not an option..

•• Child is vomiting or Child is vomiting or won’twon’t swallow medsswallow meds

•• Ceftriaxone 50 mg/kg/day Ceftriaxone 50 mg/kg/day IMIM for 3 daysfor 3 days

Progression of AAP Recommended Progression of AAP Recommended Antibacterial AgentsAntibacterial Agents

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AOM and MRSAAOM and MRSA

•• Need Culture & sensitivity!Need Culture & sensitivity!•• If no ear tubesIf no ear tubes-- give oral antibioticgive oral antibiotic

–– TrimethoprimTrimethoprim-- sulfamethoxazole 8sulfamethoxazole 8--12 mg 12 mg TMP (40TMP (40--60 mg SMX)/kg/day in 2 divided 60 mg SMX)/kg/day in 2 divided doses for 7doses for 7--10 days10 days

–– Clindamycin 10Clindamycin 10--30 mg/kg/day in 330 mg/kg/day in 3--4 divided 4 divided dosesdoses

•• Ear tubes presentEar tubes present-- use topical dropsuse topical drops–– sulfacetamidesulfacetamide 10% ophthalmic solution10% ophthalmic solution 5 5

drops twice daily (drops twice daily (BlephBleph 10)10)–– SulfacetamideSulfacetamide and prednisolone (and prednisolone (VasocodinVasocodin, ,

BlephamideBlephamide)

Recurrent AOM Recurrent AOM recommendationsrecommendations

•• 3 episodes in 6 months or 4 episodes in 1 3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding monthyear with 1 episode in the preceding month

•• TympanostomyTympanostomy tubes may be offered for tubes may be offered for reccurentreccurent AOMAOM

Ear tube factsEar tube facts

•• Most common reason a child receives Most common reason a child receives anesthesiaanesthesia

•• 600,00 children in the US get ear tubes 600,00 children in the US get ear tubes placed annually (10,000 per week)placed annually (10,000 per week)

•• 2/3 of these children need only 1 set2/3 of these children need only 1 set•• The tubes are temporaryThe tubes are temporary

•• There are a variety of tubesThere are a variety of tubes•• Ear tubes enable Ear tubes enable topicaltopical antibiotic antibiotic treatment of AOM treatment of AOM

–– 1,000x stronger 1,000x stronger –– no systemic side effectsno systemic side effects

AOM management with ear tubesAOM management with ear tubes

•• ((FloxinFloxin) ) OfloxacinOfloxacin (0.3%) (0.3%) oticotic solution 5 solution 5 drops twice daily for 10 daysdrops twice daily for 10 days

•• ((CiprodexCiprodex) Ciprofloxacin (0.3%) with ) Ciprofloxacin (0.3%) with dexamethasone (0.1%)dexamethasone (0.1%)

5 drops twice daily for 7 days5 drops twice daily for 7 days

–– Use if Use if ofloxacinofloxacin fails to clear drainage by fails to clear drainage by day7day7

–– If there is documented granulation tissueIf there is documented granulation tissue

–– Most insurance co. require priorMost insurance co. require prior--authauth

Ear disorders are common in Ear disorders are common in childrenchildren

Appropriate pharmacologic managementAppropriate pharmacologic managementis the key to successis the key to success

ReferencesReferences•• The Diagnosis and Management of Acute Otitis media. 2013. The Diagnosis and Management of Acute Otitis media. 2013.

downloaded from downloaded from http://pediatrics.aappublications.org/content/131/3/e964.full.hthttp://pediatrics.aappublications.org/content/131/3/e964.full.htmlml

•• Clinical Practice Guideline: Acute Otitis Clinical Practice Guideline: Acute Otitis ExternaExterna executive executive summary. Otolaryngologysummary. Otolaryngology--Head and Neck Surgery 2014, Vol. Head and Neck Surgery 2014, Vol. 150 (2) 161150 (2) 161--168168

•• Acute Otitis Media Update: Update 2015 Acute Otitis Media Update: Update 2015 http://contemporarypediatrics.modernmedicine.com/issueDetailshttp://contemporarypediatrics.modernmedicine.com/issueDetails/CNTPED0315/CNTPED0315

•• RosenfieldRosenfield, R. (2005) . , R. (2005) . A Parent’s Guide to Ear Tubes .A Parent’s Guide to Ear Tubes . BC BC Decker, Inc.Decker, Inc.

•• Sandler, R. (2001) . Otitis Sandler, R. (2001) . Otitis ExternaExterna: A Practical Guide to : A Practical Guide to Treatment and Prevention. Treatment and Prevention. Journal of American Family Journal of American Family Physician.Physician. 63: (5) , 92763: (5) , 927--937.937.

•• Wetmore, R F. (2007) Wetmore, R F. (2007) Pediatric Otolaryngology The Requisite in Pediatric Otolaryngology The Requisite in Pediatrics. Pediatrics. Mosby.Mosby.