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Pediatric ENT in 40 Minutes

Pediatric ENT in 40 Minutes. Gil C. Grimes, MD Assistant Professor Family Medicine Texas A&M HSC COM Scott and White Family Medicine Residency April 6 th 2005. Objectives. Describe criteria for diagnosing Acute Otitis Media Describe rationale for therapy for Acute Otitis Media

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Pediatric ENT in 40 Minutes

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  1. Pediatric ENT in 40 Minutes Gil C. Grimes, MD Assistant Professor Family Medicine Texas A&M HSC COM Scott and White Family Medicine Residency April 6th 2005

  2. Objectives • Describe criteria for diagnosing Acute Otitis Media • Describe rationale for therapy for Acute Otitis Media • Describe Therapy for Serous Otitis Media • Describe the role of Tympanostomy Tubes • Describe the strategies for diagnosing Strep Pharyngitis • Describe Treatment options for Strep Pharyngitis

  3. My Bias • I am a minimalist • If the evidence for intervention is not good I do nothing

  4. Acute Otitis Media • A diagnosis of AOM requires • a history of acute onset of signs and symptoms • the presence of middle ear effusion (MEE) • signs and symptoms of middle-ear inflammation. Pediatrics 2004 May;113(5):1451-65 Level 1a

  5. Acute Otitis Media • The presence of MEE that is indicated by any of the following: • Bulging of the tympanic membrane • Limited or absent mobility of the tympanic membrane • Air-fluid level behind the tympanic membrane • Otorrhea

  6. Acute Otitis Media • Signs or symptoms of middle-ear inflammation as indicated by either • Distinct erythema of the tympanic membrane or • Distinct otalgia • discomfort clearly referable to the ear(s) and • interference with or precludes normal activity or sleep

  7. Acute Otitis Media • Otitis Media? • Yes • No http://www.otol.uic.edu/research/microto/Microtoscopy/Case10origweb.jpg

  8. Acute Otitis Media • Otitis Media? • Yes • No www.orldoc.ch/index

  9. Acute Otitis Media Prevalence • Prevalence • 10% US children diagnosed by 3 months • 90% by 2 years (1) • Prospective cohort of children (2) • 62% with AOM by 1 year • 83% with AOM by 3 years • 9th most common diagnosis during FM visits(3) • Coded 3.2% visits (3) 1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b 2)J Infect Dis 1989 Jul;160(1):83 Level 2b 3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c

  10. Acute Otitis Media Etiology • Viral pathogens found Tympanocentesis and Nasal Aspirate in AOM • RSV and coronavirus RNA in 75% children • 5% dual viral infections • Bacterial pathogens detected 62% • Viral RNA detected in 57% bacteria-negative and 45% bacteria-positive samples Pediatrics 1998 Aug;102(2):291 Level 1c

  11. Acute Otitis Media Etiology • Bacteria shifts • Streptococcus pneumoniae • S. pneumoniae is the most common bacterial organism identified • non-typeable Haemophilus influenzae • H. flu identified primarily in children < 5, but reduced with routine immunization • Moraxella (Branhamella) catarrhalis • may be changing due to heptavalent pneumococcal vaccine • decrease in S. pneumoniae and increase in H. influenzae Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b

  12. Acute Otitis Media Risk Factors • Formula feeding • incidence of otitis media is higher in formula-fed infants vs. breast-fed infants • incidence of prolonged ear infections was 5x higher among formula-fed infants • Duration OM episodes longer (8.8 vs. 5.9 days) J Pediatric 1995 May;126(5 Pt 1):696 Level 2b

  13. Acute Otitis Media Risk Factors • Day Care Attendance • day care associated with increased risk of upper and lower respiratory tract illnesses in first year of life for children with familial history of atopy • prospective birth cohort study of 498 children with parental history of allergy or asthma followed prospectively for first year of life Pediatrics 1999 Sep;104(3):495 Level 2b

  14. Acute Otitis Media Risk Factors. • Associated with 2 or more doctor-diagnosed ear infections (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.7-3.6) • For children attending day care independent predictors of 2 or more doctor-diagnosed ear infections included • exposure to pets in day care • presence of rug or carpet in area where child slept in day care • nonresidential setting for day care Pediatrics 1999 Sep;104(3):495 Level 2b

  15. Acute Otitis Media Risk Factors • Passive Smoking • 625 Children Calgary first graders • Middle ear disease • 2 or more household smokers (crude odds ratio) [OR], 1.85; 95% confidence interval [CI], 1.15-2.97 • 10 or more cigarettes smoked by the mother per day (crude OR, 1.68; 95% CI, 1.12-2.52) • 10 or more cigarettes smoked in total in the household per day (crude OR, 1.40; 95% CI, 0.98-2.00) during the first 3 years of life Arch Pediatric Adolescent Med. 1998 Feb;152(2):127 Level 2c

  16. Acute Otitis Media • History • Poor predictive value • Studies are not good • Statistics • LR+ greater than 5 good • LR- less than 0.5 good • Specificity to rule in • Sensitivity to rule out Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

  17. Acute Otitis Media Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

  18. Acute Otitis Media • Physical Findings • Based on prospective study of 8,859 ear-related visits among children 0.5-2.5 years with acute symptoms • myringotomy performed if middle ear effusion suspected on exam • 51.5% had acute otitis media (i.e. middle ear effusion confirmed on myringotomy) • Color not particularly helpful but cloudy membrane predictive • red color was not highly predictive • cloudy tympanic membrane had 80-96% positive predictive value • normal color dramatically reduces likelihood of AOM (2-5% probability of middle ear effusion if normal color) Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b

  19. Acute Otitis Media • Physical Continued • Position helpful if clearly bulging • bulging tympanic membrane had 89-96% positive predictive value • retracted tympanic membrane had 47-50% positive predictive value • normal position had 22-32% probability of AOM Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b

  20. Acute Otitis Media • Mobility helpful if distinctly impaired or clearly normal • distinctly impaired mobility had 78-94% positive predictive value • slightly impaired mobility had 33-60% positive predictive value • normal mobility dramatically reduces likelihood of AOM (2-5% probability of middle ear effusion if normal mobility)

  21. Acute Otitis Media

  22. Acute Otitis Media • Type A pattern is normal • Type B pattern is consistent with MEE • Type C is seen with retracted TM

  23. Acute Otitis Media Prognosis • Spontaneous resolution is the norm • 81% spontaneously resolve (1) • 5000 children with otitis(2) • >90% resolved with supportive care • 2.7% had a severe course (required antibiotics or myringotomy at 5 days) • Pediatrics 5 May 2004 113:1452 Level 1a • Br Med J (Clin Res Ed). 1985 Apr 6;290(6474):1033 Level 1b

  24. Acute Otitis Media Prognosis • Recurrent otitis media no long term consequences • usually spontaneous recovery • study of 222 children with recurrent otitis media who received no prophylaxis • 4% developed chronic otitis media with effusion • 12% continued having recurrent episodes • most significant risk factor for continued recurrence was age < 16 months (1) • Pediatrics 5 May 2004 113:1452 Level 1a

  25. Acute Otitis Media Prognosis • Persistent effusion • Watchful Waiting recommended in children without the following: • Permanent hearing loss independent of OME • Suspected or diagnosed speech and language delay or disorder • Autism-spectrum disorder and other pervasive developmental disorders syndromes (e.g., Down) • Craniofacial disorders that include cognitive, speech, and language delays • Blindness or uncorrectable visual impairment • Cleft palate with or without associated syndrome • Developmental delay Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a

  26. Acute Otitis Media Prognosis • Persistent effusion • Change from B to non-B tympanogram favorable • 25% of OME of unknown duration resolves in 3 months • Warn parents of decreased hearing while effusion present • Recheck every three months Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a

  27. Acute Otitis Media Treatment • Treat Pain • Acetaminophen and ibuprofen (1) • 219 children treated with cefaclor evaluated pain at 2 days • Ibuprofen 7% with pain NNT 5 • Acetaminophen 10% with pain NNT 6 • Placebo 25% • Fundam Clin Pharmacol. 1996;10(4):387 Level 1c

  28. Acute Otitis Media Treatment • Initial treatment options are observation or antibiotics • for children < 6 months old, antibiotics recommended • for children 6 months to 2 years old observation option recommended only if all of the following are present • otherwise healthy child • uncertain diagnosis • non-severe illness • follow-up can be ensured so antibiotics can be started if symptoms persist or worsen • antibiotics recommended if certain diagnosis of AOM, severe illness, or follow-up cannot be ensured

  29. Acute Otitis Media Treatment • For children > 2 years old • Observation option recommended only if the following are present • otherwise healthy child • uncertain diagnosis OR non-severe illness • follow-up can be ensured so antibiotics can be started if symptoms persist or worsen • Antibiotics recommended if certain diagnosis of AOM and severe illness, or follow-up cannot be ensured DynaMed Acute Otitis Media Accessed March 19 2005

  30. Acute Otitis Media Treatment • No improvement in 48-72 hours • Confirm the diagnosis • If AOM certain then begin antibiotics if not already started • Change antibiotics if already started

  31. Acute Otitis Media Treatment • Antibiotics • CDC guidelines for management and surveillance of acute otitis media in era of pneumococcal resistance • You must know your community • Pediatrics 5 May 2004;113(5):1452 Level 1a

  32. Acute Otitis Media Treatment • Amoxicillin 80-90 mg/kg/day divided TID for 10 days • Failure at 3 days switch to one of the following • cefuroxime axetil (Ceftin) 15 mg/kg BID for 10 days • amoxicillin-clavulanate (Augmentin) Augmentin 45 mg/kg/day divided BID or 40 mg/kg/day divided TID, both for 10 days • ceftriaxone (Rocephin) IM 50mg/kg for 3 days • Pediatric Infect Dis J. 1999 Jan;18(1):1 Level 1a

  33. Acute Otitis Media Treatment • Penicillin Sensitive patients • Not Type I reaction (no urticaria or anaphylaxis) (1) • Cefdinir (Omnicef) 14 mg/kg divided once daily or BID for 5 days (BID dosing) or 10 days (once daily dosing) slightly better taste (2) • Cefpodoxime (Vantin) 10 mg/kg once daily for 10 days or divided BID for 5 days • Cefuroxime (Ceftin or Zinacef) 30 mg/kg divided BID for 10 days • Ceftriaxone (Rocephin) 50mg/kg IM once • Pediatrics 5 May 2004;113(5):1452 Level 1a • Pediatric Infect Dis J 2000 Dec;19(12 Suppl):S181 Level 3

  34. Acute Otitis Media Treatment • Penicillin Sensitive Patients • Type I reaction • Azithromycin (Zithromax) 10 mg/kg day one then 5 mg/kg days 2-5 • Clarithromycin (Biaxin) 15 mg/day divided BID for 10 days • Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg daily of erythromycin divided TID to QID for 10 days • Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10 mg/kg daily of trimethoprim divided BID for 10 days Pediatrics 5 May 2004;113(5):1452 Level 1a

  35. Acute Otitis Media Reality • Shorter therapy 5 days is likely as beneficial as longer therapy (1) • Early treatment with antibiotics may lead to increased resistance (2) • Side effects are as common as benefit • NNT 15-17 at 1 week • NNH 17 at one week • Delayed antibiotics result in decreased use and decreased likelihood of asking for antibiotics in the future (3) • JAMA. 1998 Jun 3;279(21):1736 Level 1a • J Infect Dis. 2001 Mar 15;183(6):880 Level 4 • BMJ 2001 Feb 10;322:336 Level 1c

  36. Acute Otitis Media • Guideline Review • Pediatrics 2004 May;113(5):1451 • Summary can be found in Am Fam Physician 2004 Jun 1;69(11):2713 • editorial can be found in Am Fam Physician 2004 Jun 1;69(11):2537 • commentary can be found in Pediatrics 2004 Sep;114(3):898 • commentary can be found in Pediatrics 2005 Feb;115(2):513

  37. Serous Otitis Media www.pedisurg.com/ PtEducENT/Default.htm

  38. Serous Otitis Media Causes • Causes • Overgrowth of lymphoid tissue in the nasopharynx • Chronic sinus infection • Allergies of nose and nasopharynx • Gastric reflux implicated • Pepsin seen in MEE 45 of 54 children with SOM (1) • Pepsin seen in MEE 59 of 65 children with SOM (2) • Lancet 2002 Feb 9;359(9305):493 Level 4 • Laryngoscope. 2002 Nov;112(11):1930 Level 4

  39. Serous Otitis Media Complications • Permanent hearing loss (?) (5) • Tympanosclerosis • Fibrosis of middle ear space • Balance problems (1) • Minor language deficits (+/-) (2) • No association with attention or behavior in first 6 years of life (3) • Possible behavior problems in teens (4) • Pediatrics. 1997 Mar;99(3):334 Level 4 • Pediatrics. 2000 May;105(5):1119 Level 2c • Pediatrics. 2001 May;107(5):1037 Level 1b 4) Arch Dis Child. 2001 Aug;85(2):91 Level 1b 5) Pediatrics. 2000 Sep;106(3):E42 Level 1c

  40. Serous Otitis Media Physical • Physical examination • Pearly gray • Minimal dullness • Minimal retraction • Presence of effusion

  41. Serous Otitis Media Tests • Key tests • Pneumo-otoscopy with limited movement (1) • Sensitivity of 94% (95% CI: 92%-96%) • Specificity of 80% (95% CI: 75%-86%) • Tympanogram B-curve (2) • 81% sensitivity • 56% specificity • Audiometry Carhart Notch (2) • 77% sensitivity • 98% specificity • Pediatrics. 2003 Dec;112(6 Pt 1):1379 Level 1a • Clin Otolaryngol. 2003 Jun;28(3):183 Leve 1c

  42. Serous Otitis Media Prognosis • High rate of spontaneous resolution (1) • Most resolve in 3 months • Meta-analysis 11 trials (2) • No significant hearing loss • No speech/language delay • Tubes have consequences (3) • 140 children followed 8 years • Sequela higher at 3-5 years • 47% for retraction pocket • 67% for tympanic membrane atrophy • 40% for myringosclerosis • 23% for hearing loss • Pediatrics 2004 May 5;113(5):1412 Level 1a • Pediatrics 2004 March; 113(3): e238 Level 1a • Arch Otolaryngol Head Neck Surg. 2003 May;129(5):517 level 1b

  43. Serous Otitis Media Treatment • Medications • Antibiotics not beneficial (1) • Most rigorous meta-analysis find no benefit long-term • Some short-term benefit may exist • Steroids • Nasal steroids no evidence of benefit (2) • Systemic steroids no difference long term (3) • J Fam Pract. 2003 Apr;52(4):321 FPIN network answer • Cochrane Library 2002 Issue 4:CD001935 Level 1a • Pediatrics. 2002 Dec;110(6):1071 Level 2b

  44. Serous Otitis Media Treatment • Surgery no clear evidence of benefit • RCT of a birth cohort that developed MEE (1) • Randomized to early tube placement or delay of 6 months (unilateral MEE) to 9 months (bilateral MEE) • Delayed group had better outcomes cognition, language (not significant) at age 3 • Reduced time with MEE but no change in language or hearing (2) • No change in quality of life • N Engl J Med. 2001 Apr 19;344(16):1179 Level 1b • Cochrane Library 2005 Issue 1:CD001801 Level 1a

  45. Serous Otitis Media Treatment • Surgery no clear evidence of benefit • Cohort 30,099 children born in the Netherlands • Routine hearing screening at age 9 months • 1,081 who failed 3 successive hearing screens were referred to ENT surgeon • 386 found to have persistent bilateral otitis media with effusion for 4-6 months • 187 children (mean age 19.5 months) were randomized to ventilation tubes vs. watchful waiting and followed for 1 year with language tests • Ventilation tubes reduced diagnoses of bilateral otitis media with effusion at all measurements (NNT 2-4), • No differences in language development Pediatrics 2000 Sep;106(3):e42 Level 1c

  46. Serous Otitis Media Treatment • Post-tube precautions • unrandomized trial in 533 children who underwent tympanostomy tube placement • parents self-selected into 1 of 3 "treatments" to prevent complications of swimming • no additional precautions • antibiotic drops following swimming • ear molds worn during swimming • control group consisted of children who never went swimming • all were given precautions against deep water swimming (> 180 cm), diving and soapy water in ears during bathing • no benefit was noted from antibiotic ear drops or ear plugs Arch Otolaryngol Head Neck Surg. 1996 Mar;122(3):276 Level 2b

  47. Strep Pharyngitis http://web.indstate.edu/thcme/micro/strep/sld009.htm

  48. Strep Pharyngitis Basics • Bacteria Streptococcus pyogenes • AKA Group A beta-hemolytic streptococcus (GABHS) • More than 80 sero-types based on M protein • Transmission • Person-person • Aerosol • Water • NOT household pets (1) • Incubation period 2-4 days Pediatric Infect Dis J 1995 May;14;372

  49. Strep Pharyngitis Risk Factors • More common during school year • Crowded living situation • Exposure to GABHS • Youth • Immunosuppression • Smoking • Excessive alcohol consumption • Diabetes mellitus • Recent illness Griffin's 5 Minute Clinical Consult from InfoRetriever Level 5

  50. Strep Pharyngitis Complications • Acute Rheumatic Fever (1) • Develops in 1-3% children with GABHS • Only throat infections not skin • Common in developing nations (2) • 30 million children in the developing world have heart disease due to rheumatic fever • 70% of whom will die prematurely at average age of 35 • Acute Glomerulonephritis • Less common than rheumatic fever • Most patients recover • Tonsillitis • Peritonsillar Abscess • Pediatrician. 1986;13(4):180 Level 3 • Tropical Doctor 1999 Jul;29(3):129 Level 5

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