1. HANS ROSENBERG MD CCFP(EM) OTOLARYNGOLOGICAL EMERGENCIES AHD JAN 31, 2013

2. OBJECTIVES Ear Anatomy Otitis Media Otitis Externa Mastoiditis

3. ANATOMY

4. CLINICAL EXAMINATION Start with External: helix, antihelix, tragus, outer ear canal Otoscope: external auditory canal, TM Syringing Pneumatoscopy

5. QUESTION 4 What is the DDx of Ear pain, list 5 primary causes and 5 non-ear causes? (10)

6. 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

7. CASE 6 4 year old brought in by mom because he has pain in his right ear, fever and coryza

8. 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

9. QUESTION 5 What are the 5 most common bacteria that cause AOM?

10. 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

11. 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

12. TM ANATOMY P/E TM Normal: pars flaccida, malleus, light reflex, moves with insufflation

13. CLINICAL P/E TM AOM: bulging/retracted, erythematous*, effusion, A/F level, dull (loss of anterior light reflex), no movement

14. OTITIS MEDIA

15. 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 membrane d. Otorrhea

16. 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)

17. MANAGEMENT Pain Control Tylenol Advil Narcotic Analgesics Benzocaine-Antipyrene gtts (Auralgan)

18. MANAGEMENT Note: Nonsevere illness is mild otalgia and fever 39C. AGE CERTAIN DIAGNOSIS UNCERTAIN DIAGNOSIS <6 moAntibacterial therapy 6 mo–2 yrAntibacterial therapyAntibacterial therapy; Observation option if nonsevere >2 yrAntibacterial therapy Observation option if severe illness; observation option if nonsevere illness

19. MANAGEMENT AT DIAGNOSIS FOR PATIENTS BEING TREATED INITIALLY WITH ANTIBACTERIAL AGENTS CLINICALLY DEFINED TREATMENT FAILURE AT 48–72 HOURS AFTER INITIAL MANAGEMENT WITH OBSERVATION OPTION CLINICALLY DEFINED TREATMENT FAILURE AT 48–72 HOURS AFTER INITIAL MANAGEMENT WITH ANTIBACTERIAL AGENTS TEMPERATURE ≤ 39C OR SEVERE OTALGIA OR BOTH RECOMMENDED ALTERNATIVE FOR PENICILLIN ALLERGY RECOMMENDED ALTERNATIVE FOR PENICILLIN ALLERGY RECOMMENDED ALTERNATIVE FOR PENICILLIN ALLERGY No Amoxicillin (80– 90 mg/kg/day) Non-type I: cefdinir, cefuroxime, cefpodoxime Type I*: azithromycin, clarithromycin Ceftriaxone—1 or 3 days* Amoxicillin (80– 90 mg/kg/day) Non-type I: cefdinir, cefuroxime, cefpodoxime Type I*: azithromycin, clarithromycin Ceftriaxone—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 days Type I*: clindamycin* Yes Amoxicillin- clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) Ceftriaxone—3 days Tympanocentesis— clindamycin <2yr old or complex case use 10 day course, otherwise may use 7 day course

20. 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.

21. MANAGEMENT CONTROVERSIES

22. 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

23. MASTOIDITIS Inflammation of mastoid air cells commonly associated with AOM Bacteriology S. pneumoniae, group A streptococci, S. aureus, S. epidermidis, M. catarrhalis, H. flu

24. 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

25. MANAGEMENT Antibiotics: Ceftriaxone, Clindamycin + Gentamycin, Pip- Tazo ENT for possible myringotomy, tympanostomy tubes, mastoidectomy

26. 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.

27. 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.

28. 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

29. OTITIS EXTERNA Analgesia – NSAID’s, opiates Ear Wick Antifungals Thimerosol gtts Gentian Violet gtts Antimicrobials Ciprodex 4gtts bid Cortisporin 4gtts qid

30. 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

31. 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

32. CASE 8 http://www.youtube.com/watch?v=S3Mrh52-pzs

33. EPISTAXIS

34. Nasal Anatomy Etiology Management of Anterior Bleeds Management of Posterior Bleeds

35. QUESTION What are the arteries which are involved in anterior epistaxis (ie. Kiesselbach’s Plexus)?(5)

36. 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

37. NASAL ANATOMY

38. 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

39. EPISTAXIS Preparation, proper equipment and an organized step-wise approach will be the key to success or…

40. 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…

41. MANAGEMENT - ANTERIOR Apply pledgets soaked in: Lidocaine w/ Epi Cocaine Xylometazoline (Otrivin)  Re-examine  if bleeding persists…

42. 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…

43. 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

44. 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

45. MANAGEMENT - POSTERIOR Commercial Balloon Cather – Epistat Foley Catheter Prophylaxis with Keflex/Clavulin ENT consultation

46. 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

47. 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

48. 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