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

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Presentation on theme: "Derrick Randall & Dieter Fritz Otolaryngology – Head and Neck Surgery PGY 5 ENT Potpourri."— Presentation transcript:

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

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

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

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

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

11 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 Symptoms of AOM

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

13 Symptoms such as ear rubbing, crying, irritability, difficulty sleeping and decreased appetite should be assessed they change appropriately in response to clinical change

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

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

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?

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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 =

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32 What About Pneumatic Otoscopy? Takata et al., % 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

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40 Otoscopy in Real Life Low intensity bulb Uncooperative patient Narrow EAC Cerumen Non-sealing tips

41 IS IT OK TO NOT KNOW WHAT I’M LOOKING AT?

42 Can We Do Better?

43 The Hearing Professional: Ted Venema

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45 Tympanometry Takata et al., % sensitive, 58.2% specific for diagnosis of OME

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

52 Case #2

53 Tympanometry Not perfect False-positives Useful when TM visualization limited

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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? A.Yes B.No C.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

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

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68 Nasal Obstruction RhinitisARNAR Obstructive Adenoid

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

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74 Nasal Fracture Septal hematoma YesI&DNo Obvious external deformity NoYes 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?NoEmergencyYes Examine Fossae No Clot/Bleeding Clot/Bleeding

77 In My Head No Clot/Bleeding Looks well Observe x 6 hrs Looks unwellObserve o/nClot/Bleeding Pt co- operative? NoYes

78 In My Head NoORYesFeeling Lucky Tonsil ball with epi in ER Feeling Unlucky OR

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

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 Standard stuff OR for control What To Do?


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