Otitis & pharyngitis in children

1. Otitis & pharyngitis in children Chap. 121

2. Otitis media • Acute OM (suppurative, purulent, bacterial) - Inflammation of middle ear • OM with effusion (serous, secretory, nonsuppurative, mucoid) – relatively asx collection of fluid in middle ear • Acute( < 3 wks), subacute (3 wks – 3 mos), & chronic (> 3 mos) • Hearing loss can be present with either

3. Acute OM • Middle ear effusion can persist for wks to mos • Axbx just gently sterilize the effusion but do not clear it from the middle ear space • Most common orgs • S. pneumo • H. flu • M. cat • Dz can occur as a result of eustachian dysfxn • Obstruction • Abnormal patency

4. Acute OM • Clinical features • Otalgia • Otorrhea • Fever • Remove cerumen before visualizing external canal & TM • TM is usually opaque, pale yellow, red, bulging, bony landmarks obscured • Loss of or decrease in mobility of TM • Aspiration of middle ear is definitive (not practical in ED)

6. Acute OM • Treatment (table 121-1 & 2) • Amoxicillin (still the DOC); CDC recommends high dose therapy b/c of emerging resistance (80-90 mg/kg/d) • Fig 121-1 (algorithm for guiding drug therapy for AOM) • If infant < 2 wks, then full sepsis w/up and admission for IV axbx • 5-7 d course if > 2 yo • 10 d course if < 2yo, TM perforation, coexisting medical problems, pts at high risk for treatment failure, pts with chronic or recurrent OM • Topical analgesic (Auralgan); do not use if TM perforation present • Acetaminophen & ibuprofen PO

7. Recurrent AOM • 3 or more episodes of AOM in 6 mos; or, 4 episodes in 12 mos w/ at least 1 episode in last 6 mos • These pts at high risk for hearing loss & speech impairment • Require thorough work-up (ENT ref.) • Prophylaxis w/ axbx (amox, sulfasoxazole); esp in fall/winter

8. Persistent AOM • AOM w/in 3 days of initiating therapy or recurrence of s/sx w/in a few days of completing 10 day course of axbx • Refer to ENT for tympanocentesis with culture ID

9. Chronic Suppurative OM • Persistance (>6 wks) of chronic inflammation of middle ear & mastoid in the presence of perforated or non-intact TM • +/- purulent ear discharge • Tx with meticulous cleaning and aspiration of external & middle ear, topical axbx ear drops, oral axbx • If this fails, then IV axbx with admission • Complications • Hearing loss, perforation or retraction pocket of TM, tympanosclerosis, adhesive OM, CSOM, cholesteatoma, mastoiditis, extradural abscess, subdural empyema, focal encephalitis, brain abscess, lateral sinus thrombosis, otic hydrocephalus

10. OM with effusion • Hearing loss is most prevalent complication • Tx to reduce risk of hearing loss • If occurs in young infants • Assoc with purulent URI • Permanent conductive or sensorineural hearing loss • Vertigo • Alterations in TM • Middle ear changes • Persistence of effusion for > 3 mos • Occurrence of episodes close together • Presence of craniofacial abnormalities • Impaired or deficient immunologic states

11. OM with effusion • Tx is observation or axbx • Surgical options like myringotomy or tympanostomy tubes; adenoidectomy

12. Otitis externa • Inflammatory condition of the auricle, external ear canal or outer surface of the TM • Causes: • Infection • Inflammatory dermatoses • Trauma • Most common orgs • Normal flora (Staph epi, Corynebacterium sp., alpha hemolytic strep) • P. aeruginosa • S. aureus • Fungi

13. Otitis externa • Clinical features • Itching or sense of fullness in ear • Pain, itching, edema, redness, tenderness of canal • Cheesy or purulent discharge • Pain with pressure on tragus or pulling up the auricle • TM will be red, thick & covered w/ flat vesicles • Disseminated infxn w/ tender, enlarged lymph nodes • If there is abscess, suspect S. aureus • If there is c/o intense itching, suspect Aspergillus niger (fungi) • Inspect for FB

15. Otitis externa • Treatment • Thorough & atraumatic cleaning of ear canal • Acetic acid eardrops (3-4x/d for 1 wk) • If canal edematous, place wick so drops can be passed in canal • Axbx drops • Cortisporin opthalmic suspension, • Ofloxacin (preferred for non-intact TM) • Ciprofloxacin with hydrocortisone • Oral axbx can be added if fail to respond w/in 48 h • Parenteral axbx in pts w/ progressive, unresponsive, sev. Infxn • Need cxs of canal secretions • No swimming while tx, encourage ear plugs even after tx

16. Pharyngitis • Infxn of pharynx & tonsils • Non-streptococcal • Most cases caused my viruses • Adenovirus • EBV • Influenza • Parainfluenza • Rhinovirus • HSV • Enterovirus • Sxs include sore throat & fever w/ cough, coryza, conjunctivitis or mucosal ulcerations

17. Pharyngitis • Non-streptococcal • Corynebacterium diphtheriae • Pseudomembrane can progress to airway obstruction, exotoxin that can cause myocarditis, cardiac dysrhythmias, neuritis w/ bulbar & peripheral paralysis, nephritis, hepatitis; tx w/ PCN or ERY & horse serum antitoxin • N. gonorrhoeae • If in young children, suspect abuse; throat cxs along w/ vaginal, rectal, urethral swabs & serum to test for hep B and syphillis; tx w/ ceftriaxone 125mg IM • EBV • Infectious mononucleosis; splenomegaly & hepatomegaly; malaise, fatigue, LAD & fever; serum for heterophil Ab • HIV type 1

19. Pharyngitis • Streptococcal • GABHS • Jan-May • Ages 4-11 yo; uncommon before age 3 • Sore throat & fever • Table 121-5 • RST, throat cx (mainstay of lab dx) • False neg. rate about 10% • Tx w/ PCN (no development of resistance even after decades of using) • PCN G 600,000u IM (if pt weighs <26 kg); 1.2 millionu (if > 26kg) • PEN VK or Amoxicillin oral • Table 121-6

21. Pharyngitis • Tx aimed at: • Preventing rheumatic fever • Preventing suppurative complications (PTA, cellulitis) • Hasten clinical recovery • Complications • Rheumatic fever • Post-streptococcal glomerulonephritis (not preventable w/ axbx; related to infxn w/ nephrogenic strains of strep) • Invasive GABHS (septicemia, TSS, pneumonia, cellulitis, lymphangitis, necrotizing fasciitis)