1. ENT Potpourri Derrick Randall & Dieter Fritz
Otolaryngology – Head and Neck Surgery
PGY 5

2. Disclosure No conflicts of interest to declare
8.17 years (collective) experience

3. Topics
Otitis media
The stuffy child
Post T&A bleeding
Nasal trauma

4. Does This Child Have AOM?
2 year female, crying, fever 38.3 C, pulling at ears

5. Objectives Review new guidelines for diagnosis and treatment of AOM
Highlight the difficulty of diagnosing middle ear effusions in clinical practice & discuss the role of tympanometry
Review new guidelines regarding tympanostomy tubes in the management of OM

7. Not at risk children age 6 mo to 12 years

8. What are the Diagnostic Criteria for AOM?
A). Bulging TM
B). Acute onset of ear pain accompanied by fever
C). Acute onset of ear pain and middle ear effusion without TM inflammation
D). Acute onset of ear pain and middle ear effusion with TM inflammation

9. Diagnostic Criteria for AOM
There is no gold standard for the diagnosis of AOM

10. What Is AOM?
The rapid onset of symptoms and signs of inflammation in the middle ear

11. Symptoms of AOM
otalgia is useful in diagnosing AOM (positive LR )
however, is only present 50% to 60% of children with AOM
pain is not required for the diagnosis of AOM

12. Symptoms of AOM
Restless sleep, ear rubbing and fever do not differentiate children with AOM from those without
- page e970

13. Symptoms of AOM
Symptoms such as ear rubbing, crying, irritability, difficulty sleeping and decreased appetite should be assessed
they change appropriately in response to clinical change
as the kid gets better so do non-specific symptoms

14. Signs of AOM Impaired TM mobility (95% sens, 85% spec)
Cloudy TM (74% sens, 93% specific)
Bulging TM (51% sens, 97% specific)
Strongly red or hemorrhagic TM correlates with AOM
Slightly red TM not helpful
e971

15. Signs of AOM
Bulging TM highly associated with bacterial pathogen in ME
Bulging TM represents the most important characteristic in the diagnosis of AOM
go back to the definition of AOM - it say inflammation, not infection, and it doesn’t differentiate between viral and bacterial

16. When To Diagnose AOM
Children who present with moderate to severe bulging of the TM or new onset otorrhea not due to OE

17. When To Diagnose AOM
Children with mild bulging of the TM and recent (<48 hrs) onset of ear pain or intense erythema of TM

18. When Not To Diagnose AOM
Children who do not have MEE

19. Treat The Pain

20. Antibiotics in AOM
Severe = moderate or severe otalgia, otalgia >48 hrs, or temp >39 °C
Nonsevere = mild otalgia <48 hrs, temp <39 °C

21. Antibiotics in AOM

22. What Antibiotic?
- Note the Pen Allergy suggestions. There has been a shift towards OK to use cephalasporins in Pen allergy, unless anaphylaxis. Likelihood of issue ~0.1%.
- I’m using 7:1, I can’t get 14:1

23. What Antibiotic?

24. Note
Change in recommendations regarding use of cephalosporins in patients with penicillin allergy
Recommending against use of macrolides and TMP-SMX

25. Note
No role for ototopical antibiotic agents (Ciprodex, Floxin) in AOM in the absence of tympanostomy tubes
Topical benzocaine or lidocaine may be of limited benefit in children >5 years
However, some OTC ototopical agents, antibiotic (Polymixin) or otherwise are potentially ototoxic

26. Patient Follow-Up
Following initial treatment of AOM, there will be a MEE that can last up to 3 months
Don’t treat MEE unless symptoms
Re-assess status of the ME in 3 months
90% of children will clear the MEE within 3 months
If MEE present, order audiogram and consider consulting ENT

27. What The Guidelines Don’t Address
Antibiotic use in children with penicillin anaphylaxis
Asymptomatic bulging TM following appropriate course of antibiotics

28. In The Future Levofloxacin and linezolid for treatment of AOM?
Nasopharyngeal swab to identify middle ear pathogens?

29. SAOM with Tympanostomy Tubes=

30. Ciprodex 4 drops BID x 7 days
Tragal pumping

31. -Increased emphasis by AAP on both otoscopy and pneumatics in diagnosing AOM
- In particular, pneumatic otoscopy to aid in the recognition of MEE

32. What About Pneumatic Otoscopy?
Takata et al., 2003
93.8% sensitive and 80.5 specific for the diagnosis of OME as compared to myringotomy

33. Do Your Clinic Rooms Have Pneumatic Otoscopes?
A). Always
B). Sometimes
C). Never

34. How Often Do You Perform Pneumatic Otoscopy for AOM?
A). Always
B). Usually
C). Sometimes
D). Never

35. Do You Have Pneumatic Otoscopy Tips For Your Otoscope?
A). Yes
B). No

36. - Reality check

38. These pictures are not taken with otoscope
Captured using rigid endoscope

39. This picture was not taken with an endoscope

40. Otoscopy in Real Life Low intensity bulb Uncooperative patient
Narrow EAC
Cerumen
Non-sealing tips
It doesn’t matter how good your pneumatic skills are, if these are working against you

41. IS IT OK TO NOT KNOW WHAT I’M LOOKING AT?
- I have a microscope, wax loops, and pediatric nurses
- still, unsatisfactory view of TM ~20-30% of the time

42. Can We Do Better?

43. The Hearing Professional: Ted Venema

44. The Hearing Professional: Ted Venema

45. Tympanometry Takata et al., 2003
89.1 % sensitive, 58.2% specific for diagnosis of OME
Not perfect, will have some false positives

46. Type A Tympanogram
emedicine.com

47. Type B Tympanogram
emedicine.com

48. Type C Tympanogram
emedicine.com

49. Tympanometry Easy to learn and use Well tolerated by children
Very useful when poor view on otoscopy

50. Our Original Case
2 year female, crying, fever 38.3 C, pulling at ears

51. Case #2 2 year female, crying, fever 38.3 C, pulling at ears
can not rule out possibility of MEE without AOM and separate cause for fever

52. Case #2

53. Tympanometry Not perfect False-positives
Useful when TM visualization limited
Not strictly in accordance with CPG

55. Ear Tubes most commonly performed ambulatory surgery in the US
By age 3, 7% of US children will have ear tubes

56. Recurrent AOM
3 or more separate AOM in 6 mo or at least 4 in last year with at least 1 in the last 6 mo

57. Otitis Media With Effusion (OME)
fluid in the middle ear without signs or symptoms of AOM
Duration and symptoms are important

58. COME
OME persisting for 3 months of longer

59. Ear Tubes The 3 most common reasons we insert ear tubes:
COME with conductive hearing loss
RAOM

60. The New Guidelines Ear tubes for COME > 3 mo with CHL
When does the 3 mo time interval start?

61. Do Ear Tubes Prevent RAOM?
Yes No
Maybe

62. Are We Over Treating RAOM?
7% of US kids have ear tubes

63. The New Guidelines
Ear tubes for RAOM only if MEE is present in either ear at time of assessment for tube candidacy

64. The New Guidelines
Do not encourage routine, prophylactic water precautions (ear plugs or swimming avoidance) in children with ear tubes

66. Topics
Otitis media
The stuffy child
Post T&A bleeding
Nasal trauma

68. Nasal Obstruction
Rhinitis AR
NAR
Obstructive Adenoid

72. Topics
Otitis media
The stuffy child
Post T&A bleeding
Nasal trauma

73. Mike Tindall, married to Zara Phillips, eldest granddaughter of QEII

74. Nasal Fracture Septal hematoma Yes I&D No Obvious external deformity
Closed reduction 7-10 days post injury

75. Topics
Otitis media
The stuffy child
Post T&A bleeding
Nasal trauma

76. In My Head Stable? No Emergency Yes Examine Fossae No Clot/Bleeding

77. In My Head No Clot/Bleeding Looks well Observe x 6 hrs Looks unwell
Observe o/n
Clot/Bleeding
Pt co-operative? No
Yes

78. Tonsil ball with epi in ER
In My Head No OR
Yes
Feeling Lucky
Tonsil ball with epi in ER
Feeling Unlucky

79. Post T&A Bleeding 5 yr female, POD #4 T&A for SDB Spitting BRB this AM
O/E:
VSS
Co-operative exam
No bleeding/No Clot

80. What To Do? Standard stuff IV CBC, INR/PTT, type & screen Bolus?
Observe 6 hrs & if no further bleeding d/c home

81. Post T&A Bleeding 5 yr female, POD #4 T&A for SDB Spitting BRB this AM
O/E:
VSS
Co-operative exam
Large clot left fossae

82. What To Do? Standard stuff I’m feeling lucky
Suction clot (be prepared for frank hemorrhage)
Apply tonsil ball containing epi

83. Post T&A Bleeding 5 yr female, POD #4 T&A for SDB Spitting BRB this AM
O/E:
VSS
Uncooperative exam
Large clot left fossae

84. What To Do?
Standard stuff
OR for control