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.

AGECERTAIN 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

NoAmoxicillin (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 daysTympanocentesis—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

CASE 8

• http://www.youtube.com/watch?v=S3Mrh52-pzs

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