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Flashcards in 2: Otitis Media Deck (52)
1

increased risk of OM with?

-age

2

decreased risk of OM with?

breastfeeding - may be position of infant or the passive Ab's from mom

3

incidence of OM?

-most common reason for abx therapy
-most common diagnosis in sick children in US

-highest incidence 6-18 mo/o
-by 1y, 60-80% affected
-by 3y, 90% affected

4

how does blockage of the eustachian tube cause middle ear infections?

-

5

describe respiratory epithelium - why is it important?

-pseudostratified ciliated columnar epithelium with goblet cells
-lines eustachian tube, mastoid air cells, and down into lungs

6

what three functions does the eustachian tube serve for the middle ear?

-protection
-drainage
-ventilation

7

pathogenesis of OM (factors associated)

1. inflammation (URI, allergies)
2. Eustachian tube obstruction (mass, anatomy, smoke)
3. middle ear effusion (barotrauma)
4. (nasopharyngeal contamination) -> AOM
5. can go to OME or become complicated
6. OME resolves or becomes complicated

8

can you catch OM?

no - it is not contagious, BUT the respiratory infection that caused it IS contagious

9

big 3 for OM

S. pneumoniae
H. influenzae (non-typable)
M. catarhallis

10

what are some other bugs that cause OM?

-GAS, S. aureus, anerobes (more common in patients w/ tubes and chronic drainage)
-mycoplasma, Chlamydia
-TB, diphtheria, tetanus, fungus

11

some viruses associated with OM

-HPIV
-RSV
-Human metapneumovirus
-Rhinovirus
-Adenovirus
-Coronavirus

12

how do you get a sample of purulent fluid in OM if necessary?

tympanocentesis - needle through tympanic membrane

13

AOM history -what will you see?

-PAIN
-URI
-fever (only in about 1/3 of patients)
-headache
-irritability, apathy
-anorexia/ decreased appetite
-vomiting
-diarrhea

14

OME history - what will you see?

-behavior changes
-communication problems (not hearing well due to fluid)
-plugged ears
-popping ears
-recent URI or allergy symptoms

15

ddx: other options for otalgia

-otitis externa
-Ramsay-Hunt (VZV)
-TMJ
-dental problems
-pharyngitis

16

ddx: other options for ottorhea

-otitis externa

17

ddx: other options for hearing loss

-EAC (external auditory canal) impaction (could be wax)
-sensorineural

18

ddx: other options for vertigo, nystagmus, tinnitus

-eustachian tube dysfunction
-labyrinthitis

19

ddx: other options for postauricular swelling

-mastoiditis
-lymphadenitis

20

ddx: other options for facial paralysis

Bell's palsy

21

what to look for on physical exam:
-general appearance
-head
-eyes
-nose
-throat
-neck

-gen: sepsis
-head: craniofacial abnormalities
-eyes: drainage
-nose: polyps (allergies, chronic infection), septal deviation, congestion, drainage - purulent?
-throat**: LOOK AT LAST - bifid uvula (submucosal cleft palate), redness, drainage, masses
-neck: masses, lymph nodes, meningismus

22

what to look for on ear exam:
-external
-otoscopic
-AOM TM triad?

external: tenderness, swelling
otoscopic: tympanic membrane
-landmarks
-position
-color
-translucency
-mobility

triad: bulging, immobile, red***

23

tympanic membrane abnormalities

-bulging
-bubbles
-air fluid levels
-perforation
-ottorhea
-bullae (blisters/vesicles) - very painful
-tympanosclerosis
-atrophy
-retraction pockets
-cholesteatoma (keratin accumulation - can erode through ossicles and TM in chronic OM)

24

micro associations w/ fever and earache

suspect pneumococcal infection

25

micro associations w/ otitis conjunctivitis syndrome or bilateral otitis

suspect H. flu

26

micro associations w/ membrane perforation or mastoiditis

suspect GAS

27

landmarks in posterosuperior quadrant

-incudostapedial joint
-pars flaccida

28

landmarks in anterosuperior quadrant

-lateral process
-manubrium of malleus

29

landmarks in posteroinferior quadrant

-pars tensa
-umbo

30

landmarks in anteroinferior quadrant

- light reflex

31

treatment of AOE

-roll of cotton w/ a wick containing meds: hydrocortizone and antibiotics

don't give drops if suspect perforation of TM

32

how predictive is redness of OM? what else can it indicate?

-redness along only predictive about 25%
-can also get redness w/ crying, cerumen removal, (baro)trauma

33

special studies: tympanometry

-measures impedance of TM - if there is fluid, there will be no TM movement

34

special studies: acoustic reflectometry

-sound stimulus to see if TM will move

35

special studies: audiometry

-use this to monitor hearing if 3 ear infections in a row

36

special studies: CT/MRI

-look for masses, including infectious abscesses

37

other special studies you can do

-tympanocentesis/myringotomy
-CBC
-blood culture
-sed rate

38

AAP guidelines for AOM diagnosis:

-acute history (recent URI, congestion)
-evidence of middle ear effusion (drainage, bulging TM, abnormal tympanometry)
-signs and/or symptoms (fever, pain)

39

AOM tx: symptomatic relief

-topical anesthetic
-analgesics
-local heat

40

AOM tx: antimicrobial therapy
-med options
-how long
-when you see response
-when to recheck

-amoxicillin!!
-amoxicillin clavulanate
-cephalosporins
-macrolides
-erythromycin sulfisoxazole
-TMX (when allergic to penicillins)

-10d
-short course if > 2y/o and no risk factors
-response in 24-48h
-recheck in 10-14d

41

treatment for recurrent OM

-treat for AOM
-antibiotic prophylaxis (amoxicillin or sulfisoxasole at 1/2 dose) or ENT referral
-adults - image for masses
-surgery (myringotomy w/ tympanostomy tubes - young age or frequent infections)
-monitor hearing, speech, and language

42

AOM tx: observation

many of these cases resolve on their own - but can treat b/c there can be severe complications and it keeps patients happy

43

OME treatment

-observe unless infant
-trial of full course antibiotics if effusion > 3 mo
-surgery (tubes, adenoidectomy - remove lymphadenopathy next to eustachian tube) - due to concern for hearing loss affecting language
-effusion > 4-6 mo
-bilateral effusion
-> or = 21dB hearing loss
-high risk
-monitor hearing, speech, and language

44

speech and language at risk

-infant

45

timeline of OME resolution

-70% still have effusion at 2 w
-most clears by 4-6 w

anything remaining in there creates risk of another infection

46

type and placement of tubes in TM

-grommet tubes (to help it stay in TM)
-placed inferiorly

47

AOM prognosis

-20% resolve spontaneously
-effusion remains in 40% at 1 mo after AOM
-effusion remains in 10% at 3 mo after AOM
-20% will have recurrent episodes

48

AOM complications (long list)

-hearing loss (most common)**
-mastoiditis
-perforation
-chronic supporative OM (could be due to chronic mastoid infection)
-cholesteatoma (keratin tumor, appears white on TM)
-facial paralysis
-supporative labyrinthitis and petrositis (Gradenigo syndrome - signs of increased ICP: papilledema, headache)
-meningitis
-extradural abscess
-subdural empyema
-lateral sinus and carotid artery thrombosis
-brain abscess
-otitic hydrocephalus

49

prevention of AOM

-parental education:
-NO smoking
-breastfeeding
-vaccines
-fewer children in care setting for higher risk children
-chemoprophylaxis
-surgery

50

developments

-observation instead of therapy
-decreased length of therapy
-vaccinations
-xylitol sugar dosed with a gum
-probiotics, other complementary medical therapies not proven

51

where is one susceptible to cholesteatomas?

at areas of retraction in the TM

52

how to differentiate tympanosclerosis from cholesteatoma

tympanosclerosis doesn't change movement of TM, whereas cholesteatoma will cause a mass behind TM that prevents movement of TM