Acute Otitis Media&

Acute Otitis Externa

Grand RoundsPresented by: Cathleen McKnight, DNP, APRN, NP-C

September 24, 2015

Objectives

• Learning objectives for respective condition– Identify incidence & risk factors– Explore causation– Review anatomy and pathophysiology– Recognize signs & symptoms– Distinguish appropriate diagnostic criteria & testing– Survey differential diagnoses– Evaluate best practice treatment modalities– Discover applicable ICD-10 coding

Acute Otitis Media(AOM)

AOM: Introduction

• Middle ear infection• >80% of children have ≥1 episode by age 2• Most common cause for abx administration• 80-90% cases occur in <6 years of age

Epidemiology

• Family hx• Day care • Race• > Fall/ winter• Tobacco smoke• Air pollution• Boys> Girls

• Lack of breastfeeding• Supine feeding• Pacifier use• Developing areas• ↓ Socioeconomic

status• Anatomic anomalies• Immunologic

deficiencies

Etiology

• Most viral & self-limiting• Bacterial AOM– S. pneumoniae (40%)– H. influenzae (25-30%)– M. catarrhalis (10-15%)

Pathophysiology• Eustachian tube in infants is shorter, > angle• Eustachian tube obstruction leads to negative

pressure within the middle ear and movement of capillary fluid into the space (OME)

Normal TM

• Transudation of inflammatory mediators into the middle ear may cause mucosal edema/ infection (AOM)

History & Exam

• History– Preceding coryza– Otalgia– Irritability– Sleep disturbance– Fever– Decreased appetite– N & V– Diarrhea

• Exam– Acute infection– Middle ear inflammation

& effusion

with perforation

Diagnostic Testing

– Clinical diagnosis*– Pneumatic otoscopy– Tympanometry– Acoustic reflectometry– Audiometry– Bacterial culture

Pneumatic Otoscopy

• 95% sensitive, 80% specific (with accurate execution)

• Assess mobility of TM• Seal is key!• Causes of immobility• Fluid in middle ear• Perforation• Poor seal

Video of Pneumatic Otoscopy

Differential Dx

• Otitis media with effusion• Myringitis• Mastoiditis• Cholesteatoma

Myringitis

Cholesteatoma

Prevention

• Primary prevention– Pneumococcal immunization– Influenza immunization– Probiotics

• Secondary prevention– Decreasing modifiable risk factors– No support for prophylactic abx– Pain control– Antibiotics

Pain Control

• Simple analgesics– NSAIDs– Tylenol

• Topical agents– Antipyrine/benzocaine otic• Limited benefit• Short duration

• Narcotics• Distraction

Antibiotics

– To prescribe or not to prescribe?• Limited effect• Shorten recovery by 1 day

– Delayed abx therapy• A place to SNAP?

– Optimal abx1) Amoxicillin-based therapy2) Cefdinir3) Azithromycin, Ceftriaxone

Follow-up

• Routine follow-up discouraged– Improvement in 2-3 days– Most asymptomatic at 1 week regardless of tx

• Recurrent/ resistant infections– Broader spectrum abx– Tympanostomy tubes

• Long-term complications rare

ICD-10

• Diseases of the middle ear H65-H75

ICD-10

• Documentation1) Type2) Infectious agent3) Temporal factors4) Laterality5) Tympanic membrane rupture6) Secondary causes

ICD-10

• Miscellaneous essential codes– W61.42 Struck by Turkey– Y93.D1 Accident while knitting or crocheting– W56.22 Struck by orca, initial encounter– V91.07 Burn due to water-skis on fire– V97.33XD: Sucked into jet engine, subsequent

encounter– Z63.1: Problems in relationship with in-laws

Acute Otitis Externa(AOE)

AOE: Introduction

• Superficial skin infection of the external auditory canal

• Bacteria most common cause*

Epidemiology

• 10% of people develop AOE in lifetime• Highest risk in childhood• Females > Males• Summer• Warmer temps• High-humidity• After swimming• Occlusive devices

Etiology

• Mostly bacterial– P. aeruginosa (20-60%)– S. aureus (10-70%)

• Often polymicrobial& multifactorial

• Fungal infections 2-10%

• Idiopathic• Trauma• Chemical irritants• Allergy• Dermatologic

conditions

Pathophysiology

• Obstruction• Absence of cerumen• Trauma • Alteration of the pH of the ear canal

History & Exam

• History– Acute onset otalgia– Pruritis– Fullness– Decreased hearing– Tender tragus/pinna

• Exam– Canal inflammation

& erythema– Drainage & debris– Regional

lymphadenopathy

Diagnostic Testing

– Clinical diagnosis*– Bacterial culture– Pneumatic otoscopy– Tympanometry– Microscopy– CT scan– MRI

Differential Dx

• AOM• Otomycosis• Psoriasis• Furunculosis• Contact dermatitis• Viral infections• Carcinoma of ear canal• Cholesteatoma• Malignant OE

Cholesteatoma

Prevention

• Primary prevention– Avoid risk factors– Preserve skin integrity

• Secondary prevention– Decreasing modifiable risk factors– Treat skin disorders– Pain control & antibiotics– Occlusive ear plugs for swimming– Use acetic acid-containing ear drops after swimming

Treatment

• Pain control• Clean canal• Treat inflammation &

infection• Topical therapy– Antiseptics– Abx– Glucocorticoids– Acidifying solutions

Video of Ear Wick Placement

Topical Therapy

Ciprofloxacin/ dexamethasone(Ciprodex 0.3%/0.1%)

4gtt BID x7-10 days

Ofloxacin 0.3%5-10 gtt QD x7 days

Acetic acid 2%-OR-

Acetic acid/ hydrocortisone 2%/1%

Neomycin/ polymixin D/ hydrocortisone

(Cortisporin otic)3-4gtt TID-QID x7-10 days

Oral abx therapy should be utilized if resistance to initial treatment, or high risk patient (ex. diabetic)

Ciprofloxacin 500-750mg BID-AND-

Topical therapy

Follow-up

• 60-90% resolution ≤ 10 days irrespective to agent choice

• Routine follow up not required

ICD-10

• Otitis externaH60

H60.11 Cellulitis of right external ear H60.312 Diffuse otitis externa, left ear H60.331 Swimmer’s ear, right ear H60.543 Acute eczematoid otitis externa, bilateral

ICD-10

R46.1 – Bizarre personal appearance

Questions/ Comments?

ReferencesCenters for Medicare & Medicaid Services. (2014). ICD-10 clinical concepts series: Clinical

concepts for pediatrics. Retrieved on September 1, 2015 from https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsPediatrics1.pdf.

Goguen, L.A. (2014). External otitis. UpToDate. Retrieved on September 1, 2015 from http://www.uptodate.com/contents/external-otitis-treatment?source=machineLearning&search=otitis+externa&selectedTitle=1~78&sectionRank=1&anchor=H13312385#references.

Limb, C.J., Lustig, L.R., & Klein, J.O. (2014). Acute otitis media in adults (suppurative and serous). UpToDate. Retrieved on September 1, 2015 from http://www.uptodate.com/contents/acute-otitis-media-in-adults-suppurative-and-serous?source=machineLearning&search=otitis+media&selectedTitle=1~150&sectionRank=1&anchor=H17#H17.

ReferencesRosenfeld RM, Schwartz SR, Cannon CR, et al. (2014). Clinical practice guideline: acute otitis

externa. Otolaryngol Head Neck Surg 150:S1. Society for Middle Ear Disease. (2014). Otitis media. Retrieved on September 1, 2015 from

https://societyformiddleeardisease.org/otitis-media/. The Univerisity of Chicago Pediatrics Clerkship. (2013). Acute otitis media and otitis media with

effusion. Retrieved on September 1, 2015 from http://pedclerk.bsd.uchicago.edu/page/acute-otitis-media-and-otitis-media-effusion.

Waitzman, A.A. (2015). Otitis externa. Medscape. Retrieved on September 1, 2015 from http://emedicine.medscape.com/article/994550-overview#a8.