Ear Infections and Other Common Pediatric ENT Issues

Transcription

1 Ear Infections and Other Common Pediatric ENT Issues Warren Yunker, MD, PhD, FRCSC Pediatric Otolaryngology Head & Neck Surgery Alberta Children s Hospital

2 Disclosure No conflicts of interest to declare

3 Ear Infections & Ear Tubes

4 Does This Child Have AOM? 2 year female, crying, fever 38.8 C, pulling at ears

5 Objectives Acknowledge that diagnosing AOM can be difficult! Review the Canadian Pediatric Society s recommendations for the treatment of otitis media Review non antibiotic treatments Identify when antibiotics are recommended

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13 Otoscopy in Real Life Low intensity bulb Uncooperative patient Narrow EAC Cerumen Non-sealing tips So How can we Choose Wisely if we can t see the TM?

14 We need to honest about the fact that it can be difficult to diagnose just an ear infection What else can we do?

15 The Hearing Professional: Ted Venema

16 The Hearing Professional: Ted Venema

17 Type A Tympanogram emedicine.com

18 Type B Tympanogram emedicine.com

19 Type C Tympanogram emedicine.com

20 Our Original Case 2 year female, crying, fever 38.8 C, pulling at ears

21 Case #2 2 year female, crying, fever 38.8 C, pulling at ears

22 Case #2

23 Tympanometry Not perfect False-positives Well tolerated Useful when TM visualization limited, especially for ruling out AOM Provides feedback

24 Tympanometry Tympanometry is briefly addressed in the CPG s, but it s role is not well defined In % of GP s in Denmark reported using tympanometry in clinical practice Denmark has one of the lowest rates of antibiotic use as compared to other European countries

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26 Treat The Pain

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29 What Antibiotic?

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32 Note Using cephalosporins in patients with penicillin allergy, or clindamycin (30-40 mg/kg/day div TID) Recommending against use of macrolides and TMP-SMX No role for ototopical antibiotic agents (Ciprodex, Floxin) in AOM in the absence of tympanostomy tubes

33 Note Topical benzocaine or lidocaine may be of limited benefit in children >5 years as a pain control adjunct However, some OTC ototopical agents, antibiotic (Polymixin) or otherwise, are potentially ototoxic

34 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

35 What The Guidelines Don t Address Duration of antibiotic use 7 to 10 days Management of patients with an uncertain diagnosis Tympanometry The risks of not treating AOM

36 Effects of Antibiotics for AOM on Mastoiditis Most children with mastoiditis have not seen their doctor for AOM Antibiotics halve the risk of mastoiditis (decrease from 3.8 per 10,000 episodes to 1.8) Doctors would need to treat 4831 AOM episodes with antibiotics to prevent 1 child from developing mastoiditis

37 Effects of Antibiotics for AOM on Mastoiditis This precludes the treatment of AOM as a strategy for preventing mastoiditis Reassuring for observation in cases of uncertain diagnosis, especially in cases where patient is non-toxic with low grade fever and mild otalgia (Group 1)

38 Effects of Antibiotics for AOM on Mastoiditis The challenge is Group 2 (sick patients) with uncertain diagnosis Tympanometry can help decrease the number of patients with an uncertain diagnosis Type A tympanogram = No AOM

39 Someone else telling me to buy more equipment for my office

40 SOMB Automatic tympanometry 09.49A - $2.17

41 ebay Welch Allyn Microtymp 1 - $595 USD Grason-Stadler GSI38 - $899 USD Madsen Otoflex $8300 USD

42 SOMB $595 USD = $740 CDN $740 / $2.17 = 341 In one year do you (or your group) see 341 patients (children and/or adults) with ear symptoms?

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

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48 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

49 Otitis Media With Effusion (OME) fluid in the middle ear without signs or symptoms of AOM

50 COME OME persisting for 3 months of longer

51 Ear Tubes The 2 most common reasons I insert ear tubes: COME with conductive hearing loss RAOM

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

53 Do Ear Tubes Prevent RAOM? Yes No Maybe

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

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

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

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59 SAOM with Tympanostomy Tubes =

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61 Epistaxis Nose Bleeds

62 Approach to epistaxis can vary widely among practitioners This is my approach Pediatric focus Level IV evidence

63 Epistaxis 60% of the population will have a nosebleed at some point in their lifetime bimodal distribution young children years of age 6% will require medical intervention Numbers are higher if their is an underlying coagulopathy

64 Anatomy

65 Anatomy

66 Anatomy

67 Causes of Epistaxis Traumatic* Neoplastic Hematologic* Structural* Drug-Induced Inflammatory

68 Vast majority of nosebleeds are anterior (90 to 95%) A difficult to control nosebleed does not mean it s a posterior nosebleed

69 Epistaxis Management

70 Epistaxis Prevention Nasal Care & Moisturization Humidifier in bedroom Nasal lubrication Nasogel/Rhinaris Sinus Rinse Nozoil

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72 Avoid Polysporin (long term) Vaseline Q-tip applications

73 If despite all that there are ongoing problems

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75 The Pediatric Nose Nasal obstruction/rhinitis/adenoiditis/sinusitis?

76 The Pediatric Nose Can be very difficult to differentiate nasal obstruction/adenoiditis/rhinitis/sinusitis Need to differentiate obstruction, from inflammation, from viral infection, from bacterial infection Based primarily on history, physical exam is of limited benefit

77 The Pediatric Nose Nasal Obstruction & Clear Rhinorrhea Rhinitis Obstructive Adenoid AR NAR

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80 Treatment of Rhinitis Symptomatic Nasal saline irrigation Intranasal corticosteroids (mometasone) Consider allergy testing esp if receiving benefit from OTC antihistamines

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82 The Pediatric Nose New onset congestion, rhinorrhea Sinusitis or Adenoiditis

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84 Acute Rhinosinusitis (ARS) < 4 weeks of purulent (not clear) nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness or both

85 Diagnosing Rhinosinusitis

86 Viral Rhinosinusitis (VRS) Symptoms or signs of ARS for < 10 days and the symptoms are not worsening

87 Treatment of VRS Symptomatic Analgesic and antipyretic Nasal saline irrigation Consider topical or systemic decongestants Minimal evidence for INCS, no evidence for systemic CS No evidence for antihistamines

88 Diagnosing Rhinosinusitis

89 ABRS Symptoms or signs of ARS for 10 days or more beyond the onset of upper respiratory symptoms or Symptoms or signs of ARS worsen within 10 days after an initial improvement (double worsening) No role for DI in patients who meet diagnostic criteria unless a complication or alternative diagnosis is suspected

90 Treatment of ABRS Symptomatic Analgesic and antipyretic Nasal saline irrigation Topical or systemic decongestants INCS (mometasone) No studies examining role of systemic CS No evidence for antihistamines Insufficient evidence to make recommendations regarding mucolytics

91 The Antibiotic Option After you have made the diagnosis of ABRS, need to differentiate severe disease from non-severe disease Non-severe ABRS Mild pain and temperature <38.3 C and assurance of follow-up Symptomatic therapy and observation (antibiotics optional) Severe ABRS Moderate to severe pain or temperature 38.3 C Symptomatic therapy and antibiotics

92 Antibiotics for ABRS 1st Line Amoxil x 10 d 2nd Line Cefuroxime x 10 d Amoxil-clavulanate x 10 d β-lactam Allergy Clarithromycin x 10 d

93 What About Recurrent and Chronic Sinusitis? These conditions do exist in children, but are much less frequent that in the adult population Controversy exists over role of sinus surgery In my practice... prior to considering sinus surgery for CRS or RABRS the adenoid must be addressed

94 Tonsils and Adenoid

95 Tonsil Size Grading Surgically Removed <25% of OP 25 to 50% of OP 25 to 50% of OP > 75% of OP

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97 Tonsillectomy 2 most common indications SDB/OSA with adenotonsillar hyperplasia Recurrent infections

98 Tonsillectomy for SDB/OSA In the pediatric population, adenotonsillar hyperplasia is the primary etiology of sleep disordered breathing (SDB)/obstructive sleep aprnea (OSA) Adenotonsillectomy is standard of care CPAP is viable alternative

99 SDB Snoring is present in ~20% of children Is this a normal variant? However, 10% of children who snore have SDB/OSA The difficulty - differentiating snoring from SDB/OSA

100 SDB/OSA vs. Snoring 2 methods: History Sleep study Snoresat, Noonin, etc. PSG

101 Snoring History Features suggestive of SDB/OSA AM fatigue Daytime sleepiness Nocturnal enuresis Psychosocial disturbances Behavioural problems Poor concentration

102 SDB/OSA vs. Snoring Overnight pulseoximetry study Relatively easy to obtain High PPV, but very low PPV Can not be used to rule out SDB/OSA

103 SDB/OSA vs. Snoring PSG Gold standard for diagnosing OSA More difficult to obtain Harder for kids to tolerate

104 Surgical Management of SDB/OSA History suggestive for OSA and tonsillar hyperplasia on exam PSG demonstrating OSA

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106 Tonsillectomy for Recurrent Tonsillitis Frequency 7 episodes/yr x 1 yr 5 episodes/yr x 2 yrs 3 episodes /yr x 3 yrs With one for more of the following with each episode Temp > 38.3 Cervical LA Tonsillar exudate GABHS +

107 A Word About Tonsillectomy Technically a simple procedure, but it is not a simple operation Significant post-op morbidity Very real mortality risk 5 children a year die of complications following tonsillectomy in the US

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109 Questions & Comments Warren Yunker Pediatric Otolaryngology - Head & Neck Surgery Alberta Children s Hospital / University of Calgary Clinic: Fax: warren.yunker@albertahealthservices.ca