Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 22

Ear Disorders

Jane A. Fox

I. FOREIGN BODY

Decreased hearing, 389.9

Otitis externa, 380.1

Discharge from ear, 388.6

Pain or itching, 388.7

Foreign body, ear, 931

 

A. Etiology.

1. Usually results from young children or their companions placing stones, erasers, vegetables (beans, peas, string beans), paper, jellybeans, toy parts, or small alkaline batteries in their ear(s).

2. Insects may become lodged in ear.

3. Chronic irritation or inflammation (e.g., otitis externa may result from putting objects in ear).

B. Occurrence.

1. Most common between 2 and 4 years of age.

C. Clinical manifestations.

1. Presenting complaints may include:

a. Pain or itching.

b. Decreased hearing.

c. Buzzing if insect is in ear canal.

d. Feeling of fullness in ear or pressure.

e. Discharge from ear.

D. Physical findings.

1. Foreign object or insect visualized on otoscopic exam.

2. Check all body orifices if foreign body found in one.

3. Carefully check ear after removal of foreign object for additional ones.

E. Diagnostic tests.

1. Usually none.

F. Differential diagnosis.

Contact dermatitis and eczema, 692.9

Otitis media, 382.9

Impacted cerumen, 380.4

Psoriasis, 696.1

Otitis externa, 380.1

Trauma, 959.09

1. Foreign body: object or insect is visualized on otoscopic exam.

2. Otitis media (OM).

3. Otitis externa.

4. Trauma.

5. Impacted cerumen.

6. Dermatologic disorders (psoriasis or eczema).

G. Treatment.

1. Remove foreign body. If bleeding occurs, object must be removed.

2. Have child lie down, restrain head if needed.

3. Do not irrigate if foreign body is vegetable or wood and/or suspect perforation of tympanic membrane.

4. Insect in ear: Kill insect by filling ear canal with mineral oil or alcohol before removal. Ticks: Dislodge ticks by filling canal with 70% alcohol and then remove.

5. Removal of objects.

a. Best: Remove objects using an otoscope with an opening head for visualization.

b. Objects that are soft and unwedged.

• Remove by irrigation with tepid water (body temperature) and water pik on low setting or an 18-gauge butterfly catheter with needle cut off. Pulsating water should help dislodge object.

• Insert pliable tubing into ear canal behind foreign body.

6. If object does not completely occlude canal, can use ear loop, curette, forceps for removal.

7. Refer to otolaryngologist if:

a. Object is an alkaline battery.

b. Object cannot be easily removed.

c. Ear canal is swollen or bleeding.

d. Object is tightly wedged in canal.

e. Child is unable to cooperate.

H. Follow up.

1. Generally none, well-child care.

I. Complications.

Perforation of tympanic membrane, 384.2

1. Perforation of tympanic membrane (TM).

J. Education.

1. Advise parents not to attempt to remove foreign body.

2. Tell parents some bleeding may occur after removal.

3. Cleaning ear canal is not necessary.

II. HEARING LOSS: CONDUCTIVE, SENSORINEURAL

Allergies, 477.9

Hearing loss, sensorineural, 389.1

Anomalies of external ear, 744.3

Impacted cerumen, 380.4

Cholesteatoma, 385.3

Middle ear anomalies, 744.03

Decreased hearing, 389.9

Middle ear effusions, 389.03

Delayed language development, 315.39

Neck anomalies, 744.9

Foreign body, ear, 931

Otitis externa, 380.1

Head and ear trauma, 959.09

Otitis media, 382.9

Head anomalies, 756

TM perforation, 384.2

Hearing loss, conductive, 389

 

A. Etiology.

1. Genetic or hereditary factors, environmental or acquired diseases, malformations.

2. Trauma.

3. Congenital perinatal infections.

4. About 33% of cases of hearing impairment: cause unknown.

B. Occurrence.

1. About 15% of school-age children have significant conductive hearing losses.

2. OM and its sequelae most common cause of conductive hearing losses during childhood.

3. Acquired conductive hearing losses most common types of hearing loss in childhood.

C. Clinical manifestations.

1. Conductive hearing loss (middle ear hearing loss).

a. Decreased hearing.

b. May have history of middle ear effusions.

c. OM and its sequelae.

d. Foreign body and/or impacted cerumen.

e. May report delayed language and speech development or parental concern about child's ability to hear.

f. Allergies.

g. Head or ear trauma.

h. Middle ear anomalies.

i. Cholesteatoma can cause hearing loss.

2. Sensorineural hearing loss (perceptive or nerve deafness) may report distortion of sound and problems in discrimination of sounds. Hearing loss often involves high-range frequencies, speech difficulties.

D. Physical findings.

1. Conductive hearing loss (middle ear hearing loss).

a. Possible:

• Otitis externa.

• OM.

• Foreign body.

• Impacted cerumen.

• Growths or tumors, cholesteatomas.

• TM perforation.

b. Rinne test on affected side; bone conduction (BC), air conduction (AC).

c. Weber test sounds lateralized to involved side.

d. Average hearing loss 27-31 dB (mild), may be intermittent, may occur in one or both ears.

2. Sensorineural hearing loss (perceptive or nerve deafness).

a. Possible dysmorphic facial features suggesting presence of syndrome.

b. Head and/or neck anomalies.

c. Anomalies of pinnae and external ear canals.

d. Weber test sounds louder in unaffected ear.

e. Rinne test: in normal ear or ear with sensorineural hearing loss, AC, BC.

3. Audiometric testing: soft sounds not well perceived, loud sounds perceived almost normally. In older children, if normal in high and low frequencies but poor in middle frequencies, suspect congenital hearing loss.

4. Acquisition of language skills affected.

E. Diagnostic tests.

1. Evoked otoacoustic emissions (EOAE) testing (can be performed on children of all ages): newer type of newborn screening, 10 minutes.

2. Automated auditory brainstem response (AABR): for newborn screening, 10 minutes.

3. Brainstem auditory evoked response (BAER): newborn screening, 90 minutes; often used in children of all ages who are unable to cooperate for audiometry testing.

4. Behavioral observation audiometry.

5. Pure tone audiometry for children 5 years of age.

6. Tympanometry identifies a middle ear effusion.

7. Impedance audiometry.

8. Language screening: Early Language Milestone Scale.

F. Differential diagnosis.

Hearing loss, conductive, 389

Hearing loss, sensorineural, 389.1

Mixed conductive sensorineural loss, 389.2

1. Careful history and thorough physical examination, including screening and laboratory data, essential in identifying those at risk and in early detection of hearing losses.

2. Hearing disorders classified into three categories:

a. Conductive hearing loss.

b. Sensorineural hearing loss.

c. Mixed conductive sensorineural loss.

G. Treatment.

1. Refer for audiologic testing.

2. Surgery for conductive hearing loss (usually bilateral myringotomy with tubes).

3. Refer to multidisciplinary team, hearing center, or ENT specialist if hearing impairment detected.

4. For sensorineural loss:

a. Amplification (hearing aids; bilateral is best) benefits most children.

b. Cochlear implants with sensorineural loss, if done within 4 years of hearing loss.

c. Clarion CII Bionic Ear System for deafness.

H. Follow up.

1. Determined by type and cause of hearing loss.

2. Well-child care.

I. Complications.

Speech and language disorder, 315.39

1. Speech and language disorders.

J. Education.

1. Early detection imperative to minimize negative consequences for language, other development.

2. Disease process, type of loss, causes. Conductive loss usually reversible, sensorineural loss often irreversible.

3. To decrease incidence of communication disorder in child with middle ear disease:

a. When speaking to child, turn off sources of background noise (e.g., dishwasher, television, radio, stereo, computer games, etc.).

b. Make sure child is looking directly at speaker and that speaker has child's attention.

c. Speak louder than normal.

d. Child should sit in front of classroom (may need referral for full evaluation of hearing needs).

4. Effects on child.

a. Speech and language development.

b. Social development.

c. Learning process.

5. Needs of child.

a. Emotional.

b. Social.

c. Educational.

6. Parents' role.

a. Care and function of hearing aids, if indicated.

b. Medic alert bracelet.

7. Parent support groups.

8. Support groups for the child.

9. Prevention: Limit exposure to loud noise.

III. OTITIS EXTERNA

Contact dermatitis and eczema, 692.9

Psoriasis, 696.1

Otitis externa, 381.1

Seborrhea, 706.3

Perforation of the tympanic membrane, 384.2

 

A. Etiology.

1. Bacteria: Pseudomonas aeruginosa (most common); Streptococcus species, Staphylococcus epidermidis, Proteus species, Mycoplasma species.

2. Fungi: Aspergillus species, Candida organisms.

3. Excess cerumen or loss of protective cerumen from exposure to excess moisture.

4. Trauma to the ear canal caused by overzealous cleaning with a cotton-tipped applicator or a foreign body.

5. Allergic reaction to chemical or physical agents; contact dermatitis.

6. Excessive wetness from swimming, bathing, or high humidity.

7. Excessive dryness; child or family history of eczema, psoriasis, seborrhea.

8. Purulent otitis media with perforation of the tympanic membrane and drainage may masquerade as otitis externa, usually painless with no swelling of the canal.

B. Occurrence.

1. Most common in hot, muggy weather, summer months.

2. Persons who are swimmers or divers are more susceptible.

3. Higher incidence in those with smaller ear canals.

4. Males and females equally affected.

5. Affects all ages.

C. Clinical manifestations.

1. Ear pain and itching (common in fungal infections) in the ear, especially when chewing or pressure on tragus.

2. Feeling of fullness or obstruction of ear.

3. Frequently, a history of exposure to water.

4. Purulent discharge and hearing loss (conductive) possible.

D. Physical findings.

1. Pain on movement of pinna or tragus.

2. Periauricular adenitis may occur, but not necessary for diagnosis.

3. External canal: gross edema and erythema of canal, accumulation of moist debris in canal. Patient may resist insertion of ear speculum.

4. Tympanic membrane often difficult to visualize and may be mildly inflamed but is mobile on insufflation.

D. Diagnostic tests.

1. No tests specific to diagnosing otitis externa.

2. Gram stain and culture of discharge may be helpful, particularly when fungal cause is suspected.

F. Differential diagnosis.

Abscess of otitis externa, 380.1

Furuncle of otitis externa, 680

Contact dermatitis and eczema, 692.9

Mastoiditis, 389.3

Cyst of otitis externa, 382

Otitis externa, malignant, 160.1

Dental infection, 522.4

Otitis media with perforation, 384

Foreign body, ear, 931

Postauricular lymphadenopathy, 289.3

1. Cyst, furuncle, or abscess.

2. Foreign body.

3. Otitis media with perforation.

4. Dental infection.

5. Mastoiditis.

6. Postauricular lymphadenopathy.

7. Eczema or other dermatologic condition.

8. Malignant otitis externa.

G. Treatment.

1. Clean debris from canal: Insert small gauze wick or absorbent sponge into external canal to carry antibiotic corticosteroid solution into canal if needed (severe swelling).

2. Ciprofloxacin hydrochloride/hydrocortisone otic suspension (Cipro HC Otic Suspension) has broad spectrum for covering resistant organisms or combination eardrops of antibiotics, hydrocortisone, propylene glycol.

a. Not recommended for children younger than 1 year of age.

b. Advise parents to warm bottle in hands for 1-2 minutes before use and then place 3 drops in affected ear(s) 2 times a day for 7 days.

3. Ofloxacin solution 0.3% otic drops (Floxin) every 12 hours.

a. Highly effective if Pseudomonas aeruginosa and Staphylococcus aureus are causes in patients 1 year of age and older.

b. Age 1-12 years: 5 drops in affected ear(s) 2 times daily for 10 days.

c. Older than 12 years of age: 10 drops in affected ear(s) twice daily for 10 days.

4. Analgesics for pain.

5. Oral antibiotics only if signs of invasive infection.

a. Cellulitis of auricle.

b. Fever.

c. Tender postauricular lymph nodes.

6. Topical treatment is always needed to treat otitis externa.

7. Keep ear dry.

8. Do not use cotton swabs.

H. Follow up.

1. Mild cases: none.

2. Immediate recheck: pain worsens or sensitivity to eardrops.

3. Return visit in 2-3 days if marked cellulitis or tympanic membrane was not visualized.

4. Return visit if symptoms worsen, do not improve in 48 hours, or recur.

5. Telephone if severe pain.

6. Recheck in 10 days and continue treatment, if not completely resolved.

I. Complications.

Cellulitis of surrounding tissue, 380.1

Stenosis of auditory canal, 380.5

Irritated furunculosis, 680

Transient conductive hearing loss, 388.02

Malignant otitis externa, 172.3

 

1. Cellulitis of surrounding tissue.

2. Irritated furunculosis.

3. Malignant otitis externa (uncommon) seen in chronically ill or immuno-suppressed children.

4. Stenosis of auditory canal.

5.  Transient conductive hearing loss.

J. Education.

1. Explain cause and treatment plan.

a. Keep ear dry: no swimming during acute phase, can use cotton coated with petroleum jelly or lamb's wool when showering or shampooing to occlude canal; remove immediately when finished.

b. Side effects of eardrops: local stinging or burning sensation and rash where drops have come in contact with skin.

c. Avoid earplugs and use of cotton swabs.

d. Acute pain should subside within 48 hours.

2. Keep foreign objects out of ears.

3. Prevention of recurrence (common): Instill 2-3 drops of isopropyl alcohol in ear canals after swimming, showering, or during hot, humid weather; shake excess water out of ears.

IV. ACUTE OTITIS MEDIA (AOM)

Enlarged tonsils (pharyngitis), 462

Otitis media, chronic, 381.01

Fever, 780.6

Perforation of tympanic membrane, 384.2

Influenza virus (types A and B), 487.1

Respiratory syncytial virus (RSV), 079.6

Otitis media, 382.9

Upper respiratory infection, 465.9

Otitis media, acute, 392.9

 

A. Etiology.

1. Streptococcus pneumoniae (most common causative organism).

2. Nontypeable Haemophilus influenzae causes about 27% of the bacterial otitis.

3. Less frequent pathogens include Moraxella (Branhamella) catarrhalis and Group A beta-hemolytic streptococci.

4. Staphylococcus aureus and Pseudomonas aeruginosa: common in chronic serous otitis media, especially if perforation of tympanic membrane present.

a. Group A beta-hemolytic streptococci, Escherichia coli, S. aureus: more common in neonates.

5. Viruses, particularly respiratory syncytial virus (RSV), influenza virus (types A and B), and adenovirus, increase the risk, possibly by impairing eustachian tube function. Infants have increased susceptibility to OM, possibly due to short horizontal position of eustachian tube.

6. Viruses may be involved in about 40% of cases of AOM.

7. Bacterial resistance is increasing problem: Certain strains of H. influenzae and most strains of M. catarrhalis are resistant to amoxicillin because of beta-lactamase production. Another concern is drug-resistant S. pneumoniae (DRSP).

8. The groups most at risk for DRSP are:

a. Children younger than 24 months of age.

b. Those who have recently received beta-lactam drugs, were recently treated with antibiotics, and/or had a recent ear infection.

c. Children exposed to large numbers of other children (e.g., daycare attendance in children 2 months to younger than 5 years of age, or household crowding in children older than 2 years of age).

d. Those with immune deficiencies (e.g., sickle cell disease, HIV, malignancy). The proportion of penicillin-resistant S. pneumoniae strains may be 40-50% and half of these may be highly resistant.

B. Occurrence.

1. After upper respiratory infection (URI), OM most common disease of childhood; peak prevalence from 6 to 36 months of age. Incidence declines at about 6 years of age.

2. Incidence has dramatically increased since 1985; greatest in children younger than 2 years of age.

3. By 3 years of age, most have had at least 1 acute infection; 33% have had 3.

4. Those with first episode early in life have increased risk for developing chronic ear disease.

5. More common in boys than in girls.

6. Caucasians, Native Alaskans, Native Americans have higher incidence than African Americans.

7. More frequent in low-income and large families and those children in group daycare settings.

8. Those immunocompromised, including those with AIDS, have higher incidence.

9. Smoking in household increases incidence.

10. Bottle-fed infants have higher incidence than breastfed infants.

11. Incidence, prevalence of otorrhea: tympanostomy tubes in place longer.

C. Clinical manifestations.

1. Diagnosis of AOM requires:

a. History of acute onset of signs and symptoms.

b. Presence of middle ear effusion.

c. Signs and symptoms of middle ear inflammation.

d. Distinct erythema of TM or distinct otalgia (discomfort clearly related to the ear[s] that causes sleep disturbances and/or interferes with normal activity).

2. Most common younger than 2 years of age.

3. Acute onset of ear pain and fever; pulling, tugging, rubbing at infected ear.

4. Occasionally asymptomatic.

5. Fever in 50% of cases.

6. Other associated symptoms: irritability, disturbed sleep, restlessness, rhinorrhea or URI, cough, malaise, sore throat, stiff neck, refusal of bottle, change in eating habits, vomiting, diarrhea.

7. May report recent URI, previous ear infections, allergies, taking bottle to bed, infant supine when feeding from bottle, attending daycare, other siblings sick.

8. Hearing loss.

D. Physical findings.

1. Fever is common.

2. Signs of URI or allergies.

3. Possible red, enlarged tonsils (pharyngitis).

4. Cervical nodes often enlarged.

5. Otoscopic findings: Middle ear effusion must be present as evidenced by any of the following: bulging TM, decreased or absent mobility of the TM as noted with pneumatic otoscopy, air fluid level behind the TM, otorrhea reflectometry.

E. Diagnostic tests.

1. Pneumatic otoscopy to assess mobility of TM.

2. Tympanometry: to supplement but not replace pneumatic otoscopy, for children older than 6 months of age.

3. Acoustic reflectometry.

4. Tympanocentesis with culture and sensitivity testing is diagnostic of organism.

Table 22-1 Recommended Antibacterial Agents for Patients Who Are Being Treated Initially with Antibacterial Agents or Have Failed 48 to 72 Hours of Observation or Initial Management with Antibacterial Agents

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F. Differential diagnosis.

Dental abscess, 522.5

Mastoiditis, 389.3

Dysfunction 524.6

Otitis externa, 380.1

Eustachian tube dysfunction, 381.81

Otitis media, acute with effusion, 381

Foreign body, ear, 931

Sinusitis, 473.9

Furuncle, 680

Temporomandibular joint (TMJ)

Immune deficiency, 279.3

Tonsillitis, 463

Impacted teeth, 520.6

Lymphadenitis, 289.3

1. Otitis externa, otitis media with effusion (OME), sinusitis.

2. Mastoiditis, furuncle.

3. Foreign body, trauma.

4. Eustachian tube dysfunction.

5. Lymphadenitis.

6. Dental abscess, tonsillitis, impacted teeth.

7. Temporomandibular joint (TMJ) dysfunction.

8. Immune deficiency.

G. Treatment (Table 22-1).

1. Pain management, especially during the first 24 hours, is a priority regardless of whether antimicrobial agents are prescribed. Acetaminophen and ibuprofen are the mainstays. Adequate dosage is important.

2. Observation involves deferring treatment for 48-72 hours in otherwise healthy children 6 months to 2 years of age with nonsevere illness at presentation and uncertain diagnosis and in children ages 2 years and older who present without severe symptoms or an uncertain diagnosis. There should also be a reliable parent or caregiver able to obtain medication if needed and adequate facilities for follow up and reevaluation.

3. Prescribe antibiotics with caution. More than 80% of cases resolve spontaneously.

4. For children age 2 years and older who appear well, discuss treatment options with parents which include:

a. Safety-net antibiotic prescription (SNAP) is a prescription for an appropriate antibiotic written to be filled within 5 days of the office visit. Parents are instructed not to fill the SNAP unless symptoms worsen at any time or symptoms do not improve during the waiting period of 48-72 hours. Instruct parents that child's condition may quickly progress to a more severe case and to call and make a return visit if this occurs.

b. 5-day course of high-dose amoxicillin (if no history of allergy).

5. Begin antimicrobial therapy (Box 22-1) if no improvement or condition has worsened within 24-72 hours.

6. Antibiotic therapy is indicated for symptomatic AOM, particularly in children younger than 2 years of age.

7. Prescribe amoxicillin (drug of choice) or ampicillin if causative organism unknown (most cases).

8. Initially prescribe amoxicillin 40-45 mg/kg per day for 5-7 days in uncomplicated cases in children younger than 2 years of age who do not attend daycare, have not taken antibiotics within the past 3 months, except in areas of high resistance. This dose may fail to eradicate DRSP.

9. If child attends daycare, has taken antibiotics recently, or has history of recent AOM, prescribe amoxicillin 80-90 mg/kg per day in 2 divided doses for 10 days.

10. Prescribe adequate dose for initial treatment of symptomatic children. If allergic to penicillin, treat with azithromycin (for children allergic to beta-lactam).

11. Not recommended in children younger than 6 months of age: 30 mg/kg (max 500 mg) once daily for 3 days; or 10 mg/kg (max 500 mg) once, then 5 mg/kg (max 250 mg) once daily for 4 days. Can also prescribe oral cephalosporins, macrolides, or trimethoprim-sulfamethoxazole (TMP-SMX; rates of resistance to pneumococci are high). Treat for 10 days.

12. Begin second-line therapy in cases of documented amoxicillin failure (e.g., persistent fever, ear pain, irritability, TM findings after 3 days of treatment of redness, bulging, or otorrhea). Drug must be active against beta-lactamase-producing strains of H. influenzae or M. catarrhalis, DRSP (e.g., oral amoxicillin-clavulanate [Augmentin]); give in higher doses of 80-90 mg/kg per day of amoxicillin component, clavulanate dose remains at 10 mg/kg per day or ceftriaxone (Rocephin) 50 mg/kg (max 1 g) IM once for severe infections and/or if compliance is concern.

13. If recurrence of acute symptoms after full course of amoxicillin, retreat with second-line antibiotic. First drug of choice is amoxicillin-clavulanate. Oral cephalosporins (except cefuroxime axetil) and macrolides do not provide adequate coverage against resistant strains of S. pneumoniae.

14. Pain control (see beginning of section): warm compresses, an analgesic with antipyretic effects (e.g., acetaminophen or ibuprofen), and eardrops with benzocaine and antipyrine (Auralgan). Immediate treatment for pain is very important.

Box 22-1 Antibiotics Labeled for the Treatment of Acute Otitis Media

Penicillins

Amoxicillin (first-line therapy)

Amoxicillin-clavulanate (Augmentin) (second-line therapy)

Sulfa-based combinations

Erythromycin-sulfisoxazole (Pediazole)

Trimethoprim-sulfamethoxazole (Bactrim, Septra)

Macrolide/azalide (second-line therapy)

Azithromycin (Zithromax)

Clarithromycin (Biaxin)

Second-generation cephalosporins

Cefaclor (Ceclor) Cefprozil (Cefzil) Cefuroxime axetil (Ceftin) Loracarbef (Lorabid)

Third-generation cephalosporins

Cefdinir (Omnicef)

Cefixime (Suprax)

Cefpodoxime proxetil (Vantin)

Ceftibuten (Cedax)

Ceftriaxone (Rocephin)

Topical antimicrobial agents (approved for use with tympanostomy tubes or nonintact tympanic membrane

Ciprofloxacin/dexamethasone (Ciprodex Otic Suspension) Ofloxacin (Floxin Otic Solution)

Source: Pichichero ME. Acute otitis media: Part II. Treatment in an era of increasing antibiotic resistance. Am Fam Phys. 2000;61:2410-6,. American Academy of Family Physicians website: www.aafp.org/afp/20000415/2410.html. Accessed June 16, 2011.

15. Children with frequent AOM: evaluate for anemia. If iron deficiency is diagnosed (hemoglobin 10 g/dL), begin iron supplementation to achieve at least a hemoglobin level of 11 g/dL.

16. Persistent AOM likely caused by different pathogen than initial infection: treat with antibiotic (e.g., cefaclor, TMP-SMX, erythromycin-sulfisoxazole, amoxicillin-clavulanate potassium, cefixime).

17. Recurrent AOM: American Academy of Pediatrics and the CDC suggest placement of tympanostomy tubes rather than antibiotic prophylaxis. If must prescribe antibiotics: sulfisoxazole most effective at preventing recurrences.

18. Pneumococcal vaccine (PCV 13, Prevnar) in children during first year of life, as well as high-risk children younger than 1 year of age.

19. Influenza vaccine in high-risk children.

20. Surgical intervention: tympanostomy tubes (performed by an ENT surgeon) possible in children with chronic middle ear fluid (3 months or 4 persistent episodes) who fail to respond to antimicrobial therapy; children with recurrent AOM; suppurative complications; those with eustachian tube dysfunction.

21. Adenoidectomy in children younger than 4 years of age with recurrent AOM may be performed as substitute for, or in conjunction with, insertion of tympanostomy tubes.

22. Tympanocentesis (performed by an ENT specialist) and culture of exudate: if diagnosis is uncertain, child is seriously ill or toxic, response to antibiotic therapy is unsatisfactory, suppurative complications develop, otitis media in newborn or in immunologically deficient patients, or AOM develops despite receiving antibiotic therapy.

23. Refer for audiologic testing if fail hearing screen.

24. Consult/refer to physician: infant younger than 2 months of age, signs of meningitis.

25. ENT referral: hearing loss or delayed speech, 3 infections in 6 months or 4 in 12 months.

H. Follow up.

1. Younger than 3 months of age: revisit 1 to 2 days (higher incidence of treatment failure).

2. Children 3 months of age and older: revisit in 48-72 hours if no improvement or condition worsens (need to change antibiotics).

3. Return visit 4-8 weeks to evaluate for OME and reinforce teaching.

4. Persistent AOM: prescribe second-line antibiotic (e.g., amoxicillin-clavulanate, cefuroxime, or ceftriaxone IM); recheck every 2-4 weeks until resolved.

5. Return visit if signs or symptoms of ear infection, trouble hearing, fever with/without ear pain.

I. Complications.

Cerebral thrombophlebitis, 325

Meningitis, 322.9

Cholesteatoma, 385.3

Ossicle necrosis, 385.24

Facial nerve paralysis, 767.5

Otitis media, acute, 382.9

Hearing loss, 389.9

Otitis media, acute with effusion, 381

Labyrinthitis, 386.3

Perforation of tympanic membrane, 384.2

Language delay, 315.39

Pseudotumor cerebri, 348.2

Mastoiditis, 389.3

Tympanosclerosis, 385.09

1. Perforation of TM.

2. Hearing loss, language delay.

3. Persistent AOM, persistent OME.

4. Mastoiditis, cholesteatoma.

5. Meningitis.

6. Facial nerve paralysis.

7. Labyrinthitis.

8. Tympanosclerosis.

9. Ossicle necrosis.

10. Pseudotumor cerebri.

11. Cerebral thrombophlebitis.

J. Education.

1. Causes of ear infections.

2. Risk factors/modification: passive smoke, bottle propping, allergies, sinusitis, use of pacifier after age 6 months, breastfeeding (may protect), immunizations.

3. Treatment plan: If antibiotics prescribed, call if symptoms worsen or do not improve in 48 hours; give exactly as prescribed.

4. Pain relief measures.

5. Importance of follow-up.

V. OTITIS MEDIA WITH EFFUSION (OME)

Allergies, 477.9

Otitis media, 382.9

Cervical lymphadenopathy, 785.6

Otitis media, acute, 382.9

Enlarged tonsils, 474.11

Otitis media with effusion, chronic, 380.23

Eustachian tube dysfunction (ETD),

Perforated tympanitic membrane, 384.2

381.81 Hearing loss, 389.9 Irritability, 799.2

Sleep disturbances, 780.5 Speech and language disorder, 315.39

A. Etiology.

1. Multifactorial: eustachian tube dysfunction (ETD), infection, allergies.

2. Bacteria are same as for AOM, except frequency of H. influenzae is greater in OME.

3. If TM perforated in chronic OME: S. aureus and P. aeruginosa most likely causative organisms.

B. Occurrence.

1. See AOM section earlier in this chapter.

2. Usually follows episode of AOM.

3. Children who are diagnosed with AOM during the first year of life are much more likely to develop chronic OME.

4. Sixty-six percent of children with AOM have middle ear effusion or high negative middle ear pressure 2 weeks after diagnosis; 33% have middle ear effusion 1 month after diagnosis, regardless of antibiotic therapy.

5. OME most common cause of hearing loss in children.

C. Clinical manifestations.

1. May be asymptomatic.

2. Complaint of hearing loss (older children).

3. Possible language delay.

4. Feeling of fullness in affected ear, clogged/crackling sensation in ear, “talking in tunnel.”

5. Irritability.

6. Sleep disturbances.

7. Poor school performance.

8. Allergies.

9. Frequent episodes of otitis media.

D. Physical findings.

1. Possible indicators of allergies.

2. Possible enlarged tonsils.

3. Possible cervical lymphadenopathy.

4. External canal may have discharge.

5. TM: often retracted or convex, opaque; diffuse light reflex; may be translucent with air-fluid level or air bubbles present or amber with blue-gray fluid noted, no visible landmarks.

6. Pneumatic otoscopy: decreased or irregular mobility to both negative and positive pressure.

7. Weber test: lateralization to involved ear.

8. Rinne test: BC AC (abnormal).

9. Hearing impairment.

10. Tympanometry: fluid present.

E. Diagnostic tests.

1. Pneumatic otoscope for primary diagnosis, confirmed by tympanometry.

2. Tympanometry: tympanogram is flat with an effusion.

3. Audiometry.

4. Acoustic reflectometry.

5. Otoacoustic emissions.

6. Tympanocentesis.

F. Differential diagnosis.

Anatomic abnormalities, 759.9

Nasopharyngeal carcinoma, 147.9

Hearing loss, 389.9

Otitis media, acute, 382.9

1. All possible causes of hearing loss.

2. Anatomic abnormalities.

3. AOM.

4. Nasopharyngeal carcinoma (if unilateral OME).

G. Treatment.

1. Most cases of OME resolve spontaneously within 3 months.

2. Document at each visit: laterality, duration of effusion, and presence and severity of associated symptoms.

3. Distinguish the child who is at risk for speech, language, or learning problems from other children with OME and more quickly evaluate hearing, speech, and language and need for intervention in children at risk.

4. Refer for hearing evaluation when OME persists for 3 months or longer or at any time there is a language delay, learning problems, or a significant hearing loss is suspected in a child with OME.

5. Not recommended for treatment of OME in an otherwise healthy child 2 months through 12 years: Antihistamines and decongestants are ineffective for OME and should not be used for treatment. Antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

6. Observation or antibiotic therapy treatment options for children with effusion less than 4-6 months and any time in children without a 20-dB hearing threshold level or worse in the better hearing ear.

7. Antibiotics: consider beginning with a beta-lactamase-resistant antibiotic (e.g., amoxicillin-clavulanate potassium) for 2-3 weeks.

8. Myringotomy and tympanostomy tubes: consider if bilateral effusion for a total of 3 months and bilateral hearing deficiency (defined as a 20-dB hearing threshold level or worse in the better hearing ear). Recommendedafter a total of 4-6 months of bilateral effusion with a bilateral hearing deficit.

H. Follow up.

1. Return visit in 1 month, sooner if acute symptoms develop.

I. Complications.

Hearing loss, 389.9

Otitis media, acute, 382.9

Speech delay, 315.39

1. Hearing loss, speech delay.

2. Recurrent AOM.

J. Education.

1. Diagnosis; OME usually resolves spontaneously without treatment in 3 months.

2. Treatment plan.

3. Signs of hearing loss.

4. Modify risk factors.

5. Relationship between speech and language development and hearing.

6. Importance of follow up.

VI. EUSTACHIAN TUBE DYSFUNCTION (ETD)

A. Etiology.

1. Eustachian tube (ET) is narrower and oriented horizontally in children which predisposes them to ventilation and drainage problems.

2. Upper respiratory infections.

3. Pressure changes that occur, such as with plane travel, may lead to acute ETD.

4. Otitis media, serous effusions, cholesteatoma may cause chronic ETD from negative middle ear pressure.

5. Gastroesophageal reflux (GERD).

6. Enlarged adenoids.

7. Allergies.

8. Down syndrome (associated with small ETs).

9. Smoking.

B. Occurrence.

1. Most common in children younger than 5 years.

2. Usually decreases with age but may persist to adulthood.

C. Clinical manifestations.

1. Presenting complaints may include:

a. Fullness, clogged feeling in ear.

b. Ear discomfort (may be relieved by “popping ears”).

c. Hearing loss.

d. Symptoms can be unilateral or bilateral.

e. Allergic symptoms.

f. Dizziness or lightheadedness.

D. Physical findings.

1. Retracted TM, effusion, decreased movement on pneumoscopy.

2. Nasal obstruction.

3. Tuning fork test lateralizes to the affected ear if conductive hearing loss present.

E. Diagnostic tests.

1. Usually none.

2. Tympanography will confirm diagnosis.

3. Audiometry may be needed to determine hearing loss.

F. Differential diagnosis.

1. Otitis media.

2. Otitis media with effusion (OME).

3. Otitis externa.

4. Sinus infection.

5. Perforation of the TM.

6. Bullous myringitis.

7. Patulous eustachian tube (ET remains open for a prolonged period of time).

G. Treatment.

1. Decongestants.

a. Pseudoephedrine (Sudafed, Actifed), OR:

b. Topical nasal sprays (avoid use longer than 3 days)–phenylephrine (Neo-Synephrine topical), oxymetazoline (Afrin).

2. Nasal steroids (especially helpful to those with allergic rhinitis, most approved for children 6 years and older).

a. Beclomethasone (Beconase).

b. Budesonide (Rhinocort).

c. Fluticasone (Flonase) approved for those 4 years of age and older.

d. Fluticasone furoate (Veramyst) approved for those 2 years of age and older.

e. Mometasone (Nasonex) approved for those 2 years of age and older.

3. Second generation H1 antihistamines (may be beneficial for those with allergic rhinitis).

a. Loratadine (Claritin).

b. Desloratadine (Clarinex).

c. Fexofenadine (Allegra).

d. Cetirizine (Zyrtec).

4. Antibiotics: not usually indicated unless AOM present. a. Amoxicillin for 10 days–most effective.

a. Tympanic perforation or ventilation tubes present.

5. Topical antibiotic drops with topical steroid if discharge present.

a. Topical antibiotic drops with topical steroid if discharge present.

b. Neomycin-polymyxin-hydrocortisone (Cortisporin) otic drops.

c. Ciprofloxacin-hydrocortisone (Cipro HC).

6. Pain management.

a. Anti-inflammatories such as acetaminophen or ibuprofen, others.

7. GERD–omeprazole (Prilosec).

8. Patulous (abnormally open) ET–Premarin nose drops or nasal spray.

H. Follow up.

1. Check tubes every 3 months, if present.

2. If OME present, check for resolution in 3 months.

3. Return visit if symptoms worsen or change.

I. Complications.

1. TM perforation.

2. Hearing loss.

3. Cholesteatoma.

4. Meningitis.

5. Brain abscess.

6. Labyrinthitis.

7. Subdural empyema.

8. Subperiosteal abscess.

9. Facial paralysis.

10. Death.

J. Education.

1. Diagnosis: importance of treating cause.

2. Treatment plan.

3. Modification of risk factors.

4. Importance of follow up.

5. Relationship between speech, language and hearing.

BIBLIOGRAPHY

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Clinical practice guideline: Otitis media with effusion. Published May 3, 2004: http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/clin_recs/ome.Par.0001.File.dat/öMEFinal.pdf. Accessed June 6, 2011.

American Academy of Pediatrics and American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451-1465.

Corbeel L. What is new in otitis media? European J Pediatrics. 2007;166:511-519.

Daly KA, et. al. Epidemiology, natural history, and risk factors: Panel report from the ninth International Research Conference on otitis media. Int J Pediatr Otorhinolaryngol. 2010;74(3):231-240.

Gunasekera H, Morris P, McIntyre P, et al. Management of children with otitis media: A summary of evidence from recent systemic reviews. J Pediatr Child Health. 2009;45(10):554-563.

Leo G, Piacentini E, Incorvaia C, et al. Sinusitis and eustachian tube dysfunction in children. Pediatric Allergy Immunol. 2007;18(Suppl. 18):35-39.

Meropol S. Valuing reduced antibiotic use for pediatric acute otitis media. Pediatrics. 2008;12:669-673.

Rosenfeld RM. Antibiotic use for otitis media: Oral, topical, or none? Pediatr Ann. 2004;33:833-842.

Stool SE, et al. Managing otitis media with effusion in young children. In: Quick Reference Guide for Clinicians. AHCPR Publication 94-0623. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.

Takata G, et al. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics. 2003;112:1379.

Vernacchio L, Vezina R, Mitchell A. Management of acute otitis media by primary care physicians: Trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline. Pediatrics. 2007;120:281-287.



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