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756 SECTION 12: Pediatrics a WBC count and blood culture and give ceftriaxone if the WBC count is ≥15,000/mm3. Arrange 24-hour follow-up either in the ED or with the child’s primary provider. THE CHILD PRETREATED WITH ANTIBIOTICS Children who have signs or symptoms of meningitis but who have been pretreated with antibiotics present an important challenge. In one study, after receiving ≥50 milligrams/kg of a third-generation cephalosporin, sterilization of the CSF occurred as early as 15 minutes in meningococ cal meningitis, about 4 hours in pneumococcal meningitis, and about 8 hours in group B streptococcal meningitis. Blood cultures obtained prior to antibiotic treatment were positive in 74% of cases. 34 Antibiotic pretreatment was examined in another study, which showed that CSF WBC count and absolute neutrophil count were unaffected by antibiotic administration, but patients had higher CSF glucose levels and lower protein levels after about 12 hours of antibiotic administration. 35 In the situation where a child has been pretreated, CSF assays with multiplex polymerase chain reaction may be helpful for the diagnosis of meningitis. As mentioned before, procalcitonin is emerging as a useful test for differentiating bacterial from viral meningitis. WBC count, C-reactive protein, lactate, and erythrocyte sedimentation rate have not performed as well. THE CHILD WITH CSF LEAK CSF leaks can occur spontaneously or in association with head trauma or surgical procedures. They can also occur as a complication of hydrocephalus. Children with CSF rhinorrhea or otorrhea are most likely to develop meningitis from S. pneumoniae . The signs and symptoms of meningitis tend to be milder in this group than in children with pneu mococcal meningitis from bacteremia. Therefore, this is a situation in which meningitis is still a possibility despite a somewhat well-appearing child. Recommended treatment is with a third-generation cephalospo rin and vancomycin. THE CHILD WITH PENETRATING HEAD TRAUMA Children who have experienced penetrating head trauma can get meningitis from S. aureus, coagulase-negative staphylococci such as S. epidermidis, and gram-negative rods. Initial therapy should consist of a combination of drugs including vancomycin; cefepime, ceftazidime, or meropenem; plus an aminoglycoside such as gentamicin or amikacin. THE CHILD WITH A COCHLEAR IMPLANT A cochlear implant increases the risk of meningitis in children. In most cases, the initial event is an acute episode of otitis media in the side with the implant, followed by the development of meningitis. In the first 2 months after cochlear implant surgery, treat otitis media with parenteral antibiotics. After 2 months, treat nontoxic children with otitis media with oral antibiotics. S. pneumoniae is the most common cause of men ingitis in children with implants. Obtain cultures of middle ear fluid and CSF in children with suspected meningitis. Children with meningitis in the first 2 weeks after implantation are at risk of a greater range of pathogens than patients presenting later and should receive broad-spectrum antibiotics, such as meropenem and vancomycin. Children with symptoms of meningitis developing later than 2 weeks after implantation should receive the standard empiric treatment for meningitis. Consult ear, nose, and throat specialists for imaging recommendations and possible surgical management.
eceive broad-spectrum antibiotics, such as meropenem and vancomycin. Children with symptoms of meningitis developing later than 2 weeks after implantation should receive the standard empiric treatment for meningitis. Consult ear, nose, and throat specialists for imaging recommendations and possible surgical management. For further discussion of cochlear implant complications, see Chapter 242, “Ear Disorders. ” THE CHILD WITH A FEBRILE SEIZURE Children with meningitis can present with seizures. However, simple febrile seizures are more common. Simple febrile seizures occur in up to 5% of children between 6 and 60 months of age. About one third of children will experience a recurrence. The American Academy of Pediatrics defines simple febrile seizures as seizures that are generalized, last less than 15 minutes, and do not recur within 24 hours. Routine lumbar puncture is not indicated for simple febrile seizures, but should be performed if the child has an examination consistent with meningitis. Children between 6 and 12 months of age should be con sidered for a lumbar puncture if they are missing immunizations against H. influenzae type b or S. pneumoniae or if their immunization status is not known. Clinicians should be able to recognize meningitis clinically after 12 months of age. A lumbar puncture should also be considered in children pretreated with antibiotics because antibiotics can mask the development of meningitis. Routine blood work, imaging, and electro encephalogram are not recommended. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Ear and Mastoid Disorders in Infants and Children Carmen M. Coombs INTRODUCTION Ear pain, or otalgia, is one of the most common pediatric outpatient chief complaints. The differential diagnosis is listed in Table 121-1. This chapter discusses acute otitis media, otitis media with effusion, otitis externa, acute mastoiditis, and foreign body. The ear is divided into three major parts: (1) the outer ear, which includes the auricle/pinna and the external auditory canal; (2) the middle ear, which is bound by the tympanic membrane laterally, contains the auditory ossicles, and is connected to the nasopharynx via the eustachian tube; and (3) the inner ear, which includes the semicircular canals, the cochlea, and the audi tory nerve (Figure 121-1). ACUTE OTITIS MEDIA EPIDEMIOLOGY Acute otitis media (AOM) is the acute onset of signs and symptoms of middle ear inflammation. Although the incidence is decreasing in the postpneumococcal vaccine era, otitis media remains the third most CHAPTER TABLE 121-1 Differential Diagnosis of Acute Ear Pain Common • Acute otitis media • Otitis externa • Foreign body in the external ear canal • Impacted cerumen Less common • Cholesteatoma • Referred pain from oral cavity pathology (e.g., dental caries and infections, pharyngitis) • Cellulitis of the auricle/pinna • Contact dermatitis (e.g., earrings) • Trauma to the auricle/pinna (e.g., hematoma with pressure necrosis of cartilage) • Physical trauma or barotrauma to the tympanic membrane and middle ear Rare • Mastoiditis • Herpes zoster oticus (Ramsay Hunt syndrome) • Hemotympanum due to basilar skull fracture • Rhabdomyosarcoma of the ear or temporal bone Tintinalli_Sec12_p0669-0996.indd 756 8/2/19 7:50 PM
essure necrosis of cartilage) • Physical trauma or barotrauma to the tympanic membrane and middle ear Rare • Mastoiditis • Herpes zoster oticus (Ramsay Hunt syndrome) • Hemotympanum due to basilar skull fracture • Rhabdomyosarcoma of the ear or temporal bone Tintinalli_Sec12_p0669-0996.indd 756 8/2/19 7:50 PM CHAPTER 121: Ear and Mastoid Disorders in Infants and Children 757 FIGURE 121-1. Anatomy of the outer, middle, and inner ear. Outer ear Middle ear Eardrum (tympanic membrane) Auditory bones Stapes Incus Malleus Semicircular canals Auditory nerve Cochlea Eustachian tube Ear canal Inner ear common diagnosis for ED visits in children under 15 years old, accounting for 6.1% of all ED visits.1 The peak incidence of AOM is between 6 and 12 months of age. 2 Recent U.S. studies found that 23% to 46% of children had at least one episode of AOM by the age of 1 year, 2,3 and this rate increased to 60% by the age of 3 years.2 Risk factors include male sex, non-Hispanic white race, family history of recurrent AOM, day care attendance, and early occurrence of the first episode of AOM before 1 year of age. 2 The incidence is also higher in children with atopy,2 craniofacial anomalies, and immunodeficiency syndromes. Breastfeeding in infancy is protective and decreases the risk of AOM. 2,3 PATHOPHYSIOLOGY In the healthy state, the middle ear is aerated via the eustachian tube and its connection to the nasopharynx (Figure 121-1). If the eustachian tube becomes obstructed due to inflammatory edema and/or mucus (often associated with a viral upper respiratory infection), middle ear secre tions build up and create conditions favorable to the development of AOM. Compared with adults, the eustachian tube in children is shorter and more horizontally oriented. This orientation is the anatomic ratio nale for the increased incidence of middle ear disease seen in children. Microorganisms responsible for AOM originate from the nasophar ynx and enter the middle ear space via the eustachian tube. Bacteria can be isolated in 55% of cases of AOM in young children. The most common bacterial pathogens include Streptococcus pneumoniae (23.6%), nontypeable Haemophilus influenzae (29.1%), Streptococcus pyogenes (3.7%), and Moraxella catarrhalis (2.8%). 4 Common viruses identified in cases of AOM include picornaviruses (e.g., rhinovirus, enterovirus), respiratory syncytial virus, and parainfluenza virus. CLINICAL FEATURES The classic symptom is rapid-onset ear pain. Y oung or nonverbal chil dren may hold, tug, or rub the ear or be fussy and irritable. Fever is present in many but not all cases. Fever ≥40.5°C (104.9°F) is rare and should prompt consideration of alternative diagnoses. 6 Older children may complain of decreased hearing due to conductive hearing loss from middle ear effusion. An antecedent history of rhinorrhea, congestion, and/or cough is common because an upper respiratory tract infection creates conditions favorable to the development of AOM. The most common acute complication is tympanic membrane per foration, which typically heals spontaneously after the AOM resolves. More serious acute complications are rare and include mastoiditis, spread to the intracranial cavity (meningitis, encephalitis, abscess, sinus thrombosis, otitis hydrocephalus, or facial or abducens nerve palsy), and involvement of the inner ear (labyrinthitis). Acquired sensorineural hearing loss can result from chronic or recurrent AOM and secondary inflammatory changes in the inner ear. DIAGNOSIS The diagnosis is clinical. Tympanocentesis is the gold standard for diagnosis, but is outside the scope of most pediatricians and emergency providers. The three different clinical scenarios that meet the criteria for diagnosis are listed in Table 121-2.
AOM and secondary inflammatory changes in the inner ear. DIAGNOSIS The diagnosis is clinical. Tympanocentesis is the gold standard for diagnosis, but is outside the scope of most pediatricians and emergency providers. The three different clinical scenarios that meet the criteria for diagnosis are listed in Table 121-2. 7 Erythema of the tympanic membrane alone is insufficient for the diagnosis of AOM because erythema can be caused by middle ear inflammation, crying, or fever. For proper otoscopic examination, use a bright light source, clean otoscope head, and properly fitting speculum. To immobilize the child’s head, have the caregiver hold the child’s head against the caregiver’s shoulder or chest or place the child supine with the examiner controlling the head of the child and the parents holding the child’s arms. Remove impacted cerumen with a soft speculum or by gently irrigating the canal with warm water. Both procedures can cause pain and/or traumatic perforation of the tympanic membrane and must be done carefully. Adjunctive use of a topical ceruminolytic agent such as docusate may be helpful in some cases. Assess for the presence or absence of discharge in the ear canal and the tympanic membrane’s position, color, and degree of translucency. TABLE 121-2 Clinical Criteria for the Diagnosis of Acute Otitis Media (AOM) Scenario 1 Moderate to severe bulging of the tympanic membrane Scenario 2 Mild bulging of the tympanic membrane and at least 1 of the following: Acute onset of ear pain (<48 h) Intense erythema of the tympanic membrane Scenario 3 New onset of otorrhea not due to otitis externa or foreign body (indicating perforation of the tympanic membrane or AOM in a child with tympanostomy tubes) Tintinalli_Sec12_p0669-0996.indd 757 8/2/19 7:50 PM
t least 1 of the following: Acute onset of ear pain (<48 h) Intense erythema of the tympanic membrane Scenario 3 New onset of otorrhea not due to otitis externa or foreign body (indicating perforation of the tympanic membrane or AOM in a child with tympanostomy tubes) Tintinalli_Sec12_p0669-0996.indd 757 8/2/19 7:50 PM 758 SECTION 12: Pediatrics FIGURE 121-2. Normal right tympanic membrane (TM). TM is flat, pearly gray, and translucent. [Image used with permission of Dr. Shelagh Cofer, Department of Otolaryngol ogy, Mayo Clinic.] AB C FIGURE 121-3. Tympanic membrane findings consistent with acute otitis media. A. Severe bulging and opaque. B. Moderate bulging and opaque with intense erythema. C. Mild bulging with intense erythema. [Photos used with permission of Alejandro Hoberman, Department of Pediatrics, Children’s Hospital of Pittsburgh.] A normal tympanic membrane is flat, pearly gray, and translucent (Figure 121-2) . Erythema and bulging of the tympanic membrane are consistent with AOM ( Figure 121-3) . TREATMENT Most cases of AOM resolve spontaneously and without complications. Antibiotics are recommended for some but not all cases of AOM. 7 Pain control, however, is an essential treatment modality and should be provided whether or not antibiotics are prescribed. PAIN CONTROL The medications most commonly used to treat ear pain are shown in Table 121-3. Ibuprofen and acetaminophen are the first-line agents and have the added benefit of also being antipyretics. Opioid medications such as oxycodone and hydrocodone may be considered for severe ear pain, but should be used rarely and reserved as second-line agents. Topical otic analgesic drops may be used in combination with systemic analgesics because they have a rapid onset and may provide temporary relief of ear pain, but they have a short duration of action. 9,10 Topi c a l analgesics are contraindicated in patients with perforation of the tympanic membrane and those with tympanostomy tubes. OBSERVATION OR ANTIBIOTICS Some but not all cases of AOM require treatment with antibiotics . Consensus guidelines from the American Academy of Pediatrics and American Academy of Family Physicians recommend an initial obser vation option (defined as withholding immediate antibiotics) for select children with AOM. 7 An observational approach for AOM has been used successfully in areas of Europe with similar rates of mastoiditis (the primary suppurative complication of AOM) compared to the United States, 11 and this approach is now supported by several randomized controlled trials, systemic reviews, and observational studies.7 Tables 121-4 and 121-5 describe which children can initially be observed without antibiotics and which children require initial antibiotics. If acceptable to both the provider and caregivers, initial observation is appropriate for otherwise healthy children with uncomplicated AOM without severe signs or symptoms (mild ear pain for <48 hours and temperature <39°C [102.2°F]) who are 6 to 23 months old with unilateral AOM and children ≥24 months old with unilateral or bilateral AOM (Table 121-4). 7 Provide follow-up in 48 to 72 hours, and initiate anti biotics only for worsening symptoms or lack of improvement. A waitand-see antibiotic prescription can be provided at the initial visit with instructions for the caregiver to initiate antibiotics if the child worsens or fails to improve. Patients who do not meet the criteria for an initial period of observation require prompt treatment with antibiotics and include children who are <6 months old, have severe signs or symptoms, are <24 months old with bilateral AOM, have recurrent AOM, have AOM with perforation, have myringotomy tubes, and/or have underly ing craniofacial abnormalities or immunodeficiencies (Table 121-5).
ation require prompt treatment with antibiotics and include children who are <6 months old, have severe signs or symptoms, are <24 months old with bilateral AOM, have recurrent AOM, have AOM with perforation, have myringotomy tubes, and/or have underly ing craniofacial abnormalities or immunodeficiencies (Table 121-5). CHOICE OF INITIAL ANTIBIOTICS Initial antibiotic treatment for AOM in which antibiotics are prescribed is shown in Table 121-6. High-dose amoxicillin (45 milligrams/kg per dose PO twice daily) for 5 to 10 days is the first-line treatment. 7 The higher dose achieves concentrations in the middle ear that exceed the minimum inhibitory concentration for highly resistant forms of S. pneumoniae . Alternative regimens are appropriate for children with penicillin aller gies, children who have received amoxicillin in the past 30 days, children with concurrent conjunctivitis, children with myringotomy tubes, and those unable to tolerate oral treatment (Table 121-6). With initiation of appropriate antibiotics, fever and ear pain should be expected to persist for 24 to 48 hours. If symptoms persist Tintinalli_Sec12_p0669-0996.indd 758 8/2/19 7:50 PM
s, children with concurrent conjunctivitis, children with myringotomy tubes, and those unable to tolerate oral treatment (Table 121-6). With initiation of appropriate antibiotics, fever and ear pain should be expected to persist for 24 to 48 hours. If symptoms persist Tintinalli_Sec12_p0669-0996.indd 758 8/2/19 7:50 PM CHAPTER 121: Ear and Mastoid Disorders in Infants and Children 759 TABLE 121-3 Treatment of Ear Pain From Acute Otitis Media Medication Comments Systemic Ibuprofen (10 milligrams/kg PO every 6 h PRN) First-line agents Also work as an antipyretic Acetaminophen (15 milligrams/kg PO/PR every 4 h PRN) Oxycodone (0.1 milligram/kg PO every 4 h PRN) Second-line agents Consider for severe otalgia Hydrocodone (0.2 milligram/kg PO every 6 h PRN) Topical Antipyrine/benzocaine (2–3 drops every 1–2 h PRN) Apply drops to a small piece of cotton and place in external ear canal Provide rapid but short-term relief Contraindicated with perforation or tympanostomy tubes Lidocaine (2% aqueous) (2–3 drops every 1–2 h PRN) Abbreviation: PRN = as needed. TABLE 121-4 Indications for Consideration of Initial Observation for Acute Otitis Media (AOM)7 Children 6–23 mo old with unilateral AOM without severe signs or symptoms • Mild ear pain for <48 h • Temperature <39°C (102.2°F) Children ≥24 mo old with unilateral or bilateral AOM without severe signs or symptoms • Mild ear pain for <48 h • Temperature <39°C (102.2°F) Note: When observation is used, a mechanism must be in place to ensure follow-up and initiation of antibiotics if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms.
ith unilateral or bilateral AOM without severe signs or symptoms • Mild ear pain for <48 h • Temperature <39°C (102.2°F) Note: When observation is used, a mechanism must be in place to ensure follow-up and initiation of antibiotics if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. TABLE 121-5 Indications for Initial Antibiotic Use for Acute Otitis Media (AOM): No Observation Period7 • All infants <6 mo old • All children with severe signs or symptoms • Moderate or severe ear pain or • Ear pain for ≥48 h or • Temperature >39°C (102.2°F) • Children <24 mo old with bilateral AOM • Recurrent AOM (prior episode of AOM within 2–4 wk) • AOM with perforation • Patients with myringotomy (pressure-equalizing) tubes in place • Patients with craniofacial abnormalities • Immunocompromised patients • Any child with AOM if the provider or caregiver is not comfortable with initial observation TABLE 121-6 Initial Antibiotic Treatment for Uncomplicated Acute Otitis Media (AOM)7 Antibiotic Dosing First-line treatment AOM (with or without tympanic membrane perforation) Amoxicillin 40–45 milligrams/kg/dose PO 2 times daily for 5–10 d Special situations Penicillin allergy Cefdinir 7 milligrams/kg/dose PO 2 times daily for 5–10 d Cefuroxime 15 milligrams/kg/dose PO 2 times daily for 5–10 d Cefpodoxime 5 milligrams/kg/dose PO 2 times daily for 5–10 d Clindamycin 10 milligrams/kg/dose PO 3 times daily for 5–10 d Amoxicillin received in past 30 d Concurrent purulent conjunctivitis History of recurrent AOM unresponsive to amoxicillin Amoxicillinclavulanate 45 milligrams/kg/dose PO of amoxicillin with 3.2 milligrams/kg/dose of clavulanate 2 times daily for 5–10 d Myringotomy tubes Ofloxacin otic drops 5 drops in affected ear twice daily for 5–10 d Unable to tolerate PO antibiotics Ceftriaxone 50 milligrams/kg/dose IM or IV once daily for 1–3 d TABLE 121-7 Management of Acute Otitis Media After Failure of Antibiotic Regimen7 Management Dosing Failure of initial antibiotic (amoxicillin) First-line treatment Amoxicillin-clavulanate 45 milligrams/kg/dose of amoxicillin with 3.2 mg/kg/d of clavulanate 2 times daily for 10 d Ceftriaxone 50 milligrams/kg/dose IM or IV once daily for 3 d Penicillin allergy Clindamycin 10–12 milligrams/kg/dose PO 3 times daily for 10 d Failure of second antibiotic Treatment options Clindamycin + third-generation cephalosporin 10–12 milligrams/kg/dose PO 3 times daily for 10 d Consult an otolaryngologist for tympanocentesis and culture >48 or 72 hours after antibiotic therapy has been initiated, however, reevaluate and consider adjusting antibiotics. Management of AOM after failure of initial antibiotic is shown in Table 121-7. If high-dose amoxicillin fails, change to amoxicillin-clavulanate or ceftriaxone to provide coverage against β-lactamase–producing M. catarrhalis and nontypeable H. influenzae. If the second antibiotic regimen fails, treat with clindamycin and a third-generation cephalosporin, or consult ear, nose, and throat for tympanocentesis and culture (Table 121-7). A suggested algorithm for the diagnosis and treatment of AOM is illustrated in Figure 121-4. OTITIS MEDIA WITH EFFUSION Otitis media with effusion (OME) is fluid in the middle ear space with out clinical signs of inflammation or acute symptoms of illness. OME can occur spontaneously as a result of poor eustachian tube function, but more commonly results from an inflammatory response after an episode of AOM. More than 2 million episodes of OME are diagnosed annually in the United States, with an estimated annual cost of $4 bil lion. 12 The peak incidence is between 6 months and 4 years of age, and 90% of children will be affected at some time before school age. 13 Many children with OME are asymptomatic.
an episode of AOM. More than 2 million episodes of OME are diagnosed annually in the United States, with an estimated annual cost of $4 bil lion. 12 The peak incidence is between 6 months and 4 years of age, and 90% of children will be affected at some time before school age. 13 Many children with OME are asymptomatic. In some children, however, the effusion can cause mild intermittent ear pain, fullness, or a popping sensation. Because the effusion can impair the mobility of the tympanic membrane, mild to moderate conductive hearing loss in the range of 10 to 20 dB can occur and can have adverse effects on speech, language, and learning in the developing child. Children at higher risk of complications of OME include those with permanent hearing loss (independent of OME), speech and language delays, autism or other developmental disorders, Down syndrome, craniofacial abnormalities (e.g., cleft palate), and blindness. Tintinalli_Sec12_p0669-0996.indd 759 8/2/19 7:50 PM
g child. Children at higher risk of complications of OME include those with permanent hearing loss (independent of OME), speech and language delays, autism or other developmental disorders, Down syndrome, craniofacial abnormalities (e.g., cleft palate), and blindness. Tintinalli_Sec12_p0669-0996.indd 759 8/2/19 7:50 PM 760 SECTION 12: Pediatrics FIGURE 121-5. Well-appearing toddler with middle ear effusion. Note slight bulging of tympanic membrane and visible fluid level. [Image used with permission of Dr. Shelagh Cofer, Department of Otolaryngology, Mayo Clinic.] DIAGNOSIS Diagnosis is by pneumatic otoscopy. A cloudy tympanic membrane often with a visible effusion (visualized as either an air-fluid level or bubbles) and with significantly impaired mobility is the classic otoscopic finding of OME (Figure 121-5). Although there is overlap of some of the otoscopic findings of OME and AOM, it is important to remember that the disorders are separate entities and distinguishing between the two is essential. The critical distinguishing feature is that AOM has acute signs and symptoms of inflammation and OME does not. TREATMENT Close to 90% of episodes of OME resolve spontaneously and without complications. 14 Management depends on whether or not children are at risk for complications. Watchful waiting is appropriate for children with OME who are not at risk for complications. 13 Intranasal or systemic steroids, antibiotics, antihistamines, and decongestants can cause more harm than benefit and should not be used. 13 Children should follow up with their pediatrician and be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected. Hearing and language testing is recommended if OME lasts >3 months FIGURE 121-4. Algorithm for management of acute otitis media (AOM). TM = tympanic membrane. Does the patient have reliable access to follow-up? AND Are the provider and caregiver comfortable with initial observation? Treat with analgesics & defer antibiotics Reassess within 48–72 hours Do the symptoms worsen or persist beyond 48–72 hours? Follow-up as needed
f acute otitis media (AOM). TM = tympanic membrane. Does the patient have reliable access to follow-up? AND Are the provider and caregiver comfortable with initial observation? Treat with analgesics & defer antibiotics Reassess within 48–72 hours Do the symptoms worsen or persist beyond 48–72 hours? Follow-up as needed Acute Otitis Media (diagnosed by one of the following) 1. Moderate to severe bulging of the TM 2. Mild bulging of the TM and ≥1 of the following: - Acute onset of ear pain - Intense erythema of the TM 3. Acute otorrhea not due to otitis externa or foreign body High-Risk Factors (any one of the following) 1. Se vere signs or symptoms 2. Bilateral AOM and age <24 months 3. Recurrent AOM 4. AOM with perforation 5. Myringotomy tubes 6. Craniofacial abnormalities 7. Immunocompromised Treat with antibiotics & analgesics Reassess in 72 h if not better Consider initial observation without antibiotics Age <6 months Age >6 months Yes Yes Yes Tintinalli_Sec12_p0669-0996.indd 760 8/2/19 7:50 PM
3. Recurrent AOM 4. AOM with perforation 5. Myringotomy tubes 6. Craniofacial abnormalities 7. Immunocompromised Treat with antibiotics & analgesics Reassess in 72 h if not better Consider initial observation without antibiotics Age <6 months Age >6 months Yes Yes Yes Tintinalli_Sec12_p0669-0996.indd 760 8/2/19 7:50 PM CHAPTER 121: Ear and Mastoid Disorders in Infants and Children 761 or at any time that hearing loss or language delay is suspected in a child with OME.13 Otolaryngology referral is important for all at-risk children with OME and any child with a complication from OME, recurrent OME, or symptomatic OME lasting >3 months. Tympanostomy tube placement may be indicated. 13,15 ACUTE OTITIS EXTERNA Acute otitis externa is an infection of the external ear canal associated with diffuse inflammation and often significant edema. The peak inci dence occurs in children between 7 and 12 years of age, and cases are more common in the summer than in the winter. 16 The most common risk factor is hyperhydration and maceration of the epithelial layer lining the canal, often induced when a child is submerged during swimming (“swimmer’s ear”). Mechanical debridement of the epithelial layer (e.g., as can occur with a cotton swab inserted in the canal to clean to the ear) is also an important risk factor. Approximately 98% of cases in North America are due to invasive bacteria, the most common of which is Pseudomonas aeruginosa followed by Staphylococcus aureus and Staphylococcus epidermidis. 17-19 Polymicrobial infection is common, and different bacteria often coexist. Fungal infection is rare in primary acute otitis externa and is more commonly associated with chronic otitis externa. CLINICAL FEATURES The early stages of otitis externa are characterized by a sense of ear full ness and itching. As the disease progresses, pain becomes prominent and is often severe and exacerbated by manipulation of the auricle as well as by any movement of the jaw. A purulent and sometimes foul-smelling discharge can develop and fill the canal. Because the discharge and canal edema can obstruct sound waves, temporary hearing loss may be present. In the severe form of otitis externa, further anterior spread can cause tenderness and inflammation of the surrounding lymphoid and subcutaneous tissue. Rarely, posterior spread can involve the mastoid or can cause osteomyelitis of the skull. Malignant otitis externa is osteomyelitis of the ear canal and should be suspected with the presence of fever >38.9°C (102°F), severe otalgia, and/or facial paralysis or meningeal signs. DIAGNOSIS Diagnosis is clinical. According to the American Academy of Otolaryngology–Head and Neck Surgery Foundation, a diagnosis of otitis externa requires the rapid onset (within 48 hours) in the past 3 weeks of at least one primary symptom (otalgia, itching, or fullness) and one primary sign (tenderness of the tragus/pinna or diffuse ear canal edema/erythema) of ear canal inflammation (Table 121-8). Acute otitis externa must be distinguished from other causes of ear pain, otorrhea, and inflammation such as foreign body and AOM with perforation of the tympanic membrane. Placing the speculum of the otoscope into the external ear canal may induce pain and should be done gently. TREATMENT PAIN CONTROL Analgesic therapy should be based on the severity of the pain. Ibuprofen or acetaminophen is sufficient to reduce pain in most cases. ANTIBIOTICS AND STEROIDS Topical fluoroquinolone drops, such as ofloxacin or ciprofloxacin, instilled into the ear canal two to four times daily, are the standard treatment. Ciprofloxacin drops are also available in preparations that include hydrocortisone or dexamethasone, which help relieve itching and pain.
cases. ANTIBIOTICS AND STEROIDS Topical fluoroquinolone drops, such as ofloxacin or ciprofloxacin, instilled into the ear canal two to four times daily, are the standard treatment. Ciprofloxacin drops are also available in preparations that include hydrocortisone or dexamethasone, which help relieve itching and pain. Polymyxin B/neomycin/hydrocortisone preparations have also been traditionally recommended as first-line therapy, but they are not as effective as ciprofloxacin/hydrocortisone in eradicating P . aeruginosa 19 and neo mycin hypersensitivity is common, so fluoroquinolone drops are preferable. Acidifying agents, such as 2% acetic acid drops, are also approved for treatment of otitis externa, but are painful upon application and are contraindicated in the presence of a suspected tympanic membrane perforation or tympanostomy tubes. Do not give systemic antibiotics for uncomplicated cases of acute otitis externa. Consider systemic antibiotics only if there is extension of the disease outside of the ear canal and/or there are specific host factors (e.g., immunocompromised) that indicate a need for systemic therapy. 18 Parenteral therapy may be required in severe cases and should involve otolaryngology consultation. When instilling antibiotic drops, lie the child down with the affected ear upward and have the child remain in this position for 5 minutes after application. Fill the ear with the topical agent and gently move the pinna back and forth to improve delivery throughout the entire external canal. If the external canal is extremely edematous and obstructed, perform aural toilet and/or place an ear wick to improve delivery of the drops (the wick should be removed in 3 days if it has not fallen out on its own as the edema improves). Reexamine children who fail to improve within 48 to 72 hours of initial therapy and consider other diagnoses. 18 Cultures of the external canal may be useful in such cases. SUPPORTIVE MEASURES Avoid swimming until the canal heals. Gentle cleaning and drying of the ear canal may be helpful but should be done cautiously to avoid secondary trauma. With repeated infections in children who swim, use of earplugs while swimming and daily prophylaxis with acidifying and drying drops (e.g., vinegar and isopropyl alcohol as 1:1 solution) during at-risk periods such as swimming season may prevent infection. ACUTE MASTOIDITIS Acute mastoiditis is a bacterial infection of the mastoid that almost always develops as a complication of AOM. The initial diagnosis of AOM may occur prior to or at the same time that mastoiditis is diag nosed. At birth, the mastoid consists of a single cell called the antrum, but air cells quickly develop during the first few years of life, and most children have well-developed mastoids by 3 years of age. The incidence of mastoiditis is highest in children younger than age 2 years. 20 Risk factors for acute mastoiditis include recurrent AOM, immunocompromise, or the presence of a cholesteatoma. Cholesteatomas are destructive, expanding growths in the middle ear consisting of keratinizing epithelial cells and can be congenital or acquired (Figure 121-6). The relationship between antibiotic usage for AOM and the incidence of mastoiditis is not clear. 21-29 PATHOPHYSIOLOGY Acute mastoiditis develops when inflammation and infection in the middle ear spread into the cells of the mastoid through the aditus ad antrum. This process can induce destruction of the mastoid bone and periosteum. The same bacterial organisms most commonly associated with AOM (S. pneumoniae, nontypeable H. influenzae, and S. pyogenes) are common causes of acute mastoiditis, but other important bacteria implicated include S. aureus and P . aeruginosa.
antrum. This process can induce destruction of the mastoid bone and periosteum. The same bacterial organisms most commonly associated with AOM (S. pneumoniae, nontypeable H. influenzae, and S. pyogenes) are common causes of acute mastoiditis, but other important bacteria implicated include S. aureus and P . aeruginosa. 30,31 CLINICAL FEATURES In addition to the signs and symptoms of AOM, patients with mas toiditis have erythema, edema, and/or tenderness of the mastoid area posterior to the auricle. Mastoiditis is rare if the tympanic membrane TABLE 121-8 Diagnostic Criteria for Acute Otitis Externa18 Rapid onset (within 48 hours) in the past 3 weeks of • At least 1 primary symptom of ear canal inflammation AND • At least 1 primary sign of ear canal inflammation Primary Symptoms of Otitis Externa Primary Signs of Otitis Externa Otalgia (often severe) Itching Sense of ear fullness Tenderness of the tragus and/or pinna Diffuse ear canal edema and/or erythema Tintinalli_Sec12_p0669-0996.indd 761 8/2/19 7:50 PM
inflammation AND • At least 1 primary sign of ear canal inflammation Primary Symptoms of Otitis Externa Primary Signs of Otitis Externa Otalgia (often severe) Itching Sense of ear fullness Tenderness of the tragus and/or pinna Diffuse ear canal edema and/or erythema Tintinalli_Sec12_p0669-0996.indd 761 8/2/19 7:50 PM 762 SECTION 12: Pediatrics is normal, but can occur if there is obstruction of the aditus ad antrum and the fluid in the middle ear has drained through the eustachian tube. As the inflammation and infection in the mastoid progress, the auricle becomes visually protruded outward ( Figure 121-7). Advanced disease may cause palsies of the VI (abducens) or VII (facial) nerves. Complications include subperiosteal abscess, facial nerve palsy, osteomyelitis of other parts of the skull, direct extension into the intracranial cavity (e.g., intracranial abscess, meningitis), venous sinus thrombosis, hematogenous spread of infection to separate sites, and otitic hydro cephalus. Otitic hydrocephalus is due to thrombosis of the transverse sinus of the dura and should be suspected in children with mastoiditis with signs and symptoms of elevated intracranial pressure. DIAGNOSIS The diagnosis is clinical. Confirmation is by CT (with IV contrast) of the mastoid but is usually reserved for cases with suspected complications. MRI may be preferred in children with suspected intracranial com plications, but is usually only obtained after CT if more information is needed. 32 Laboratory tests rarely change outcome. Consider blood cul tures in children with fever. Aspiration and culture of middle ear fluid by tympanocentesis are useful to identify the specific organism. TREATMENT Treatment for uncomplicated cases involves broad-spectrum IV anti biotics and drainage of middle ear and mastoid fluid. Direct initial antibiotic therapy toward the most common bacteria ( S. pneumoniae, nontypeable H. influenzae, S. pyogenes, S. aureus , and P . aeruginosa). Piperacillin-tazobactam plus vancomycin is an example of an appropriate regimen. Antibiotic therapy can be narrowed once a specific organism is identified. Drainage is usually accomplished by myringotomy with or without placement of tympanostomy tubes. Mastoidectomy and more aggressive surgical intervention are typically reserved for cases in which there is no significant clinical improvement within 48 hours and for complications. FOREIGN BODY IN THE EAR CANAL Foreign bodies in the ear canal are a relatively common occurrence. The foreign body can be anything from a bead to a small toy to a corn kernel to a piece of paper to a button battery. On occasion, a live insect will crawl into the ear during sleep. Some children will report putting something in their ear and come to medical attention before symptoms are present. Others will develop ear pain and/or discharge as the ear canal becomes inflamed and may also complain of hearing loss. In the case of an insect, acute onset of extreme pain often with the sensation of something moving in the ear is classic. Diagnosis is confirmed by direct visualization with otoscopy. Most foreign bodies can be easily removed at the bedside. An anxiolytic medication such as intranasal midazolam may be helpful in young children. Many foreign bodies can simply be grasped and extracted with alligator forceps. An otoscope with an operational head through which the instrument can be introduced is helpful to allow direct visualization throughout the procedure. Foreign bodies that do not have easily graspable parts but are not deeply embedded can usually be removed with an ear curette, suctioning, or irrigation with warm water.
An otoscope with an operational head through which the instrument can be introduced is helpful to allow direct visualization throughout the procedure. Foreign bodies that do not have easily graspable parts but are not deeply embedded can usually be removed with an ear curette, suctioning, or irrigation with warm water. 20 For irrigation, thread a thin catheter attached to a syringe filled with warm water into the ear canal posterior to the foreign body, so that irrigation pushes the foreign body out of the canal. Live insects should be killed by instilling mineral oil into the ear canal prior to removal. Consult otolaryngology if the foreign body is a hazardous material (e.g., button battery); if there is concern for associated injury to the canal, tympanic membrane, and/or middle ear; or if the above techniques are not successful. If inflammation is noted after removal of any foreign body, a short course of topical antibiotic-steroid otic drops (e.g., ciprofloxacin 0.3% and dexamethasone 0.1%) is indicated to prevent otitis externa. Acknowledgments: We are grateful to Dr. Shelagh Cofer for her otoscopic pictures and photographs of mastoiditis and Dr. Alejandro Hoberman for his otoscopic pictures. REFERENCES The complete reference list is available online at www.TintinalliEM.com. FIGURE 121-7. Acute mastoiditis with postauricular erythema and edema and outward protrusion of the auricle. [Image used with permission of Dr. Shelagh Cofer, Department of Otolaryngology, Mayo Clinic.] FIGURE 121-6. Cholesteatoma. Cholesteatomas are destructive, expanding growths in the middle ear and/or mastoid that consist of keratinizing squamous epithelial cells. Note the yellow epithelial debris and distortion of anatomy. Cholesteatomas can be congenital or acquired. [Image used with permission of C. Bruce Macdonald, MD; reproduced with permis sion from Knoop et al: Atlas of Emergency Medicine , 2nd ed. Jauch et al: Chapter 5, Ear, Nose, and Throat Conditions, Figure 5-9.] Tintinalli_Sec12_p0669-0996.indd 762 8/2/19 7:50 PM