Page 1025 - TNFlipTest

Toronto Notes 2019 Pediatric Otolaryngology
Diagnosis
• history
■ acute onset of otalgia or ear tugging in a preverbal child, otorrhea, decreased hearing
■ unexplained irritability, fever, upper respiratory symptoms, poor sleeping, anorexia, N/V, and
diarrhea • physical
■ febrile
■ MEE on otoscopy: immobile tympanic membrane, acute otorrhea, loss of bony landmarks,
opacification of TM, air-fluid level behind TM
■ MEI on otoscopy: bulging TM with marked discolouration (hemorrhagic, red, grey, or yellow)
Management
• supportivecareandsymptommanagement:maintainhydration,analgesic,andantipyretic (acetaminophen, ibuprofen)
• watchfulwaiting:inagenerallyhealthychild>6moofagewithunilateral,non-severe,suspectedAOM ■ without MEE or with MEE but non-bulging or mildly erythematous TM
◆ consider viral etiology
◆ reassess in 24-48 h if not clinically improved (or earlier if worsening)
■ mildly ill (alert, responsive, no rigors, mild otalgia, fever <39 °C, <48 h illness) with MEE present
AND bulging TM
◆ recommend analgesia
◆ observe and follow-up in 24-48 h – if not improved or worsening, treat with antimicrobials
• antimicrobialindications:infants<6moofageorinagenerallyhealthychild>6moofagewith suspected AOM and the following features
■ moderately or severely ill (irritable, difficulty sleeping, poor antipyretic response, severe otalgia) OR fever ≥39 °C OR >48 h of symptoms
◆ treat with antimicrobials: 10 d course if 6-24 mo, 5 d if ≥2 yr old ■ perforatedTMwithpurulentdrainage
◆ treat with antimicrobials for 10 d
• referraltootolaryngologyformyringotomyandtympanostomytubesmaybewarrantedforrecurrent
infections
Treatment
• antimicrobialagentsforAOM
■ 5 d course of appropriate dose antimicrobial recommended for most ≥ 2 yr old with uncomplicated
AOM. 10 d course for 6-24 mo, perforated TM, or recurrent AOM
■ 1st line treatment (no penicillin allergy)
◆ amoxicillin: 5 d course of 45-60 mg/kg/d divided 3x/d, or 75-90 mg/kg/d divided 2x/d
■ 2nd line treatment
◆ cefprozil: 30 mg/kg/d divided 2x/d
◆ cefuroxime axetil: 30 mg/kg/d divided 2-3x/d (1st line for penicillin allergy) ◆ ceftriaxone: 50 mg/kg IM (or IV) x 3 doses (1st line for penicillin allergy)
◆ azithromycin: 10 mg/kg OD x 1 dose, then 5 mg/kg OD x 4 doses
◆ clarithromycin: 15 mg/kg/d divided 2x/d
■ if initial therapy fails (i.e. no symptomatic improvement after 2-3 d)
◆ amoxicillin-clavulanate: 45-60 mg/kg/d (7:1 formulation, 400 mg/5 mL suspension) for 10 d for
child weighing ≤35 kg, or 500 mg tablets tid for 10 d for child weighing >35kg
◆ if AOM-related symptoms do not resolve with amoxicillin/clavulanate, a course of ceftriaxone
50 mg/kg/d IM (or IV) OD x 3 doses could be considered
Complications
• extracranial
■ hearing loss and speech delay (secondary to persistent MEE), TM perforation, extension of
suppurative process to adjacent structures (mastoiditis, petrositis, labyrinthitis), cholesteatoma, facial nerve palsy, middle ear atelectasis, ossicular necrosis, vestibular dysfunction, persistent effusion (often leading to hearing loss)
• intracranial
■ meningitis, epidural/brain abscess, subdural empyema, lateral and cavernous sinus thrombosis,
carotid artery thrombosis, facial nerve paralysis • other
■ mastoiditis, labyrinthitis, sigmoid sinus thrombophlebitis
Otitis Media with Effusion
Definition
• presenceoffluidinthemiddleearwithoutsignsorsymptomsofearinfection
Epidemiology
• mostcommoncauseofpediatrichearingloss
• notexclusivelyapediatricdisease
• frequentlyfollowsAOMinchildren
• middleeareffusionshavebeenshowntopersistfollowinganepisodeofAOMfor1moin40%of
children, 2 mo in 20%, and >3 mo in 10% (i.e. 90% of children clear the fluid within 3 mo – observe for 3 mo before considering myringotomy and tubes)
Otolaryngology OT39
Antibiotics for Acute Otitis Media in Children
Cochrane DB Syst Rev 2013;1:CDOOO219
Study: Meta-analysis of Randomized Controlled Trials (RCTs) on children (1-15 mo) with acute otitis media comparing any antibiotic regime to placebo and expectant observation.
Data Sources: Cochrane Central Register of Controlled Trials (2012 issue 10), MEDLINE (1966 to October 2012), OLDMEDLINE (1958 to 1965), EMBASE (January 1990 to November 2012), Current Contents (1966 to November 2012), CINAHL (2008 to November 2012) and LILACS (2008 to November 2012) without language restrictions.
Main Outcomes: 1) Pain at 24 h, 2-3 d, and
4-7 d; 2) Abnormal tympanometry findings; 3)
TM perforation; 4) Contralateral otitis; 5) AOM recurrences; 6) Serious complications from AOM; 7) Adverse effects from antibiotics.
Results: Treatment with antibiotics had no significant impact on pain at 24 h. However, pain at 2-3 d and 4-7 d was lower in the antibiotic groups with a NNT of 20. Antibiotics had no significant effect on tympanometry findings, number of AOM recurrences, or severity of complications. Antibiotic treatment led to a significant reduction in TM perforations (NNT 33) and halved contralateral AOM (NNT 11). Adverse events (vomiting, diarrhea, or rash) occurred more often in children taking antibiotics.
Conclusion: The role of antibiotics is largely restricted to pain control at 2-7 d, but most (82%) settle without antibiotics. This can also be achieved by analgesics. However, antibiotic treatment can reduce risk of TM perforation and contralateral AOM episodes. These benefits must be weighed against risks of adverse events from antibiotics.