What is the most common age group for AOM?
18 months to 6 years
What are the common causative organisms for AOM in children?
- Streptococcus pneumoniae
- Hemophilus influenzae (non-typable)
- Moraxella catarrhalis
- Group A streptococcus
- Staphylococcus aureus
>> Most common due to bacterial/viral co-infection
What are the signs of AOM on otoscopy?
- Bulging tympanic membrane (TM)
- TM with marked discoloration (erythematous, hemorrhagic etc.)
- Acute otorrhea
- Opacification of TM
- Loss of bony landmarks
- Air-fluid level behind TM
- Immobile TM
What is the management approach for a child with AOM?
>80% of AOM resolve spontaneously
- Hydration and rest
- Symptomatic relief
- Watchful waiting in certain cases
>> Child >6 months old
>> Severity of AOM is mild: U/L, otorrhea is mild and temperature is <39C
>> Child has no history of immunosuppression, anatomical abnormalities of the head and neck, chronic cardiac or pulmonary diseases, history of severe/complicated AOM, or Down syndrome
>> Parents educated and alert to signs of worsening illness
>> Medical help readily available
- Otherwise, consider starting antibiotics
>> First-line: amoxicillin: 75-90mg/kg/day
>> Second-line: cefuroxime, ceftriaxone (1 dose), azithromycin or clarithromycin
>> Mainly to hasten resolution
If initial therapy fails with no symptomatic improvement after 2-3 days:
- Augmentin for 10 days
- IM ceftriaxone
For future prevention
- Encourage exclusive breastfeeding until 6 months
- Recommend annual influenza (and pneumococcal -- now part of the immunization programme) vaccine to all children
- Avoid tobacco smoke
- Tympanostomy tubes for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year)
What are the complications of AOM?
- TM perforation
- Extension of suppurative process to adjacent structures
- Ossicular necrosis
- Vestibular dysfunction
- Facial nerve palsy
- Hearing loss and speech delay
- Epidural and brain abscess
- Subdural empyema
- Lateral/cavernous sinus thrombosis
- Carotid artery thrombosis
What are the common presenting features of AOM?
- Conductive hearing loss
+/- Facial nerve palsy
>> Ear-tugging: NOT a good indicator of pathology
>> Poor sleeping
>> Poor feeding
>> Vomiting and diarrhea
What is recurrent AOM?
3 episodes in 6 months, or 4 episodes in 1 year
What is otitis media with effusion (OME)?
Presence of fluid in the middle ear without signs or symptoms of an ear infection
What is the most common cause of hearing loss in children?
How does it present
Otitis Media with Effusion (OME)
>> Hearing loss
>> Fullness from blocked ear
>> +/- Pain and low grade fever
What are the physical examination findings of OME?
- Discolouration of TM -- amber/dull grey ("glue ear")
- Meniscus fluid level behind TM
- Air bubbles
- TM atelectasis/retraction bubbles
- Immobility with pneumotoscopy
What are the common causative organisms of acute tonsilitis?
- Group A streptococcus
- Other bacteria: S. pneumoniae, S. aureus, H. influenzae, M. catarrhalis
What investigations would be useful in diagnosing the cause of acute tonsilitis?
- CBC with d/c
- ESR, CRP
- Throat swab for C/ST
- Monospot test (less accurate in <2 years; try EBV titre)
- +/- ASOT; may not be elevated that early on
- NPA for latex agglutination test/PCR virology
What are the presenting features of quinsy?
(Quinsy = Peritonsillar abscess)
1. Trismus -- involvement of the motor branch of CNV
2. Uvular deviation
3. Dysphonia ("Hot-potato" voice)
>> Sore throat
>> Edema of the soft palate
>> Unilateral referred otalgia
>> Cervical lymphaednitis
How does one manage a case of quinsy?
- Surgical drainage >> C/ST
- IV penicilin G x 10 days (if cultures are positive for GAS)
- IV/PO metronidazole/clindamycin x 10 days (if cultures are positive for Bacteroides)
What are some common causative organisms for quinsy?
Group A streptococcus (50%)
- Staphylococcus aureus
- H. influenzae
NEONATES ARE OBLIGATE NOSE BREATHERS.
The narrowest portion of the pediatric airway is CRICOID RING.
How does croup present?
- Usually preceded by URITI symptoms
- Symptoms usually occur at night
- The three Ses of croup:
2. Subglottic swelling
3. Seal-like barking cough
>> Appears less toxic than epiglottitis
>> Rule out foreign body and subglottic stenosis
>> Steeple sign on AP X-ray of NECK
What are the common causative organisms for croup?
- Parainfluenza I, II and III
- Influenza A and B
What is the common age for croup?
4 months to 5 years
How does one manage a case of croup?
- Adequate hydration
- Close observation: BP/P, temperature, RR, SaO2, signs of respiratory distress
- Systemic corticosteroids (e.g. dexamethasone, prednisone)
- Racemic epinpehrine via nebulizer Q1-2H PRN (if respiratory distress present)
Hospitalize if poor response to steroids after 4 hours and persistent stridor at rest
How does manage a case of acute epiglottitis?
- Secure airway
- IV access and fluids
- IV antibiotics: cefuroxime, cefotaxime or ceftriaxone
>> Common organisms: H. influenzae type B, beta-hemolytic strep (pneumococcus)
- Moist air supplement
- Watch out for meningitis
What is subglottic stenosis?
Diameter of subglottis <4mm in a neonate
>> Due to thickening of soft tissue of subglottic space
>> OR due to maldevelopment of the cricoid cartilage
>> OR due to prolonged, repeated, or traumatic (endotracheal) intubation
>> OR due to foreign body
This is why nasal intubation is preferred in neonates if prolonged tubing is neededd
What is the most common cause of stridor in infants?