Transcript File - CCFP-EM

OTOLARYNGOLOGICAL
EMERGENCIES
AHD JAN 31, 2013
HANS ROSENBERG MD CCFP(EM)
OBJECTIVES
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Ear Anatomy
Otitis Media
Otitis Externa
Mastoiditis
ANATOMY
CLINICAL EXAMINATION
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Start with External: helix, antihelix, tragus, outer ear canal
Otoscope: external auditory canal, TM
Syringing
Pneumatoscopy
QUESTION 4
• What is the DDx of Ear pain, list 5 primary causes
and 5 non-ear causes? (10)
DDX FOR EAR PAIN
Ear
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Otitis Media
Otitis Externa
Otitis Media with Effusion
Mastoiditis
Labyrinthitis
Dysbarism
Ramsay Hunt Syndrome
Malignant External Otitis
Non-Ear
• Pharyngitis
• Sinusitis
• Upper Respiratory Tract
Infection
• Dental pain
• Bell’s Palsy
• Foreign bodies
CASE 6
• 4 year old brought in by mom because he has pain in his right
ear, fever and coryza
OTITIS MEDIA
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#1 diagnosis in patients <15 yo
#1 reason for Rx of antimicrobials
Definitions:
Inflammation of the middle ear
• AOM: signs and symptoms of an acute infection with an effusion
• OM with Effusion: effusion without symptoms and signs of acute
infection
• Recurrent AOM: 3 episodes in 6/12 or 4 in 1 year
QUESTION 5
• What are the 5 most common bacteria that cause
AOM?
OTITIS MEDIA
• Bacteriology
• S. pneumoniae, H. influenzae (primarily nontypeable), and M.
catarrhalis.
• Streptococcus pyogenes, Staphylococcus aureus, and gram-negative
bacteria are much less common
• Virology
• RSV, parainfluenza, influenza, enterovirus, rhinovirus, and adenovirus
CLINICAL
• Hx
• otalgia, fever, ear pulling, coryza, cough, anorexia, vomiting, diarrhea
• Risk Factors
• 6m-3y, male, daycare, smoking,
pacifier, cleft palate, Downs
• Sequelae
• mastoiditis, bacterial meningitis,
H/L, labyrinthitis, CN VII palsy
TM ANATOMY
• P/E
• TM
• Normal: pars flaccida, malleus, light reflex, moves with insufflation
CLINICAL
• P/E
• TM
• AOM: bulging/retracted, erythematous*, effusion, A/F level, dull (loss of
anterior light reflex), no movement
OTITIS MEDIA
OTITIS MEDIA - GUIDELINES
1. Recent, usually abrupt, onset of signs and symptoms of
middle-ear inflammation and MEE.
2. The presence of MEE that is indicated by any of the
following:
 a. Bulging of the tympanic membrane
 b. Limited or absent mobility of the tympanic membrane
 c. Air fluid level behind the tympanic membrane
 d. Otorrhea
OTITIS MEDIA
• 3. Signs or symptoms of middle-ear inflammation as indicated
by either
• a. Distinct erythema of the tympanic membrane OR
• b. Distinct otalgia (discomfort clearly referable to the ear[s] that results
in interference with or precludes normal activity or sleep)
MANAGEMENT
• Pain Control
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Tylenol
Advil
Narcotic Analgesics
Benzocaine-Antipyrene gtts (Auralgan)
MANAGEMENT
AGE
CERTAIN
DIAGNOSIS
UNCERTAIN
DIAGNOSIS
<6 mo
Antibacterial therapy
Antibacterial therapy
6 mo–2 yr
Antibacterial therapy
Antibacterial therapy;
Observation option if
nonsevere
>2 yr
Antibacterial therapy
Observation option if
severe illness; observation
option if nonsevere illness
• Note: Nonsevere illness is mild otalgia and fever <39C in the past 24 hours. Severe
illness is moderate to severe otalgia or fever >39C.
MANAGEMENT
AT DIAGNOSIS FOR PATIENTS BEING
TREATED INITIALLY WITH
ANTIBACTERIAL AGENTS
TEMPERATURE ≤
39C OR SEVERE
RECOMMENDED
OTALGIA OR BOTH
CLINICALLY DEFINED TREATMENT
FAILURE AT 48–72 HOURS AFTER
INITIAL MANAGEMENT WITH
OBSERVATION OPTION
CLINICALLY DEFINED TREATMENT
FAILURE AT 48–72 HOURS AFTER
INITIAL MANAGEMENT WITH
ANTIBACTERIAL AGENTS
ALTERNATIVE FOR
PENICILLIN
RECOMMENDED
ALLERGY
ALTERNATIVE FOR
PENICILLIN
RECOMMENDED
ALLERGY
ALTERNATIVE FOR
PENICILLIN
ALLERGY
No
Amoxicillin (80–
90 mg/kg/day)
Non-type I: cefdinir,
cefuroxime,
cefpodoxime
Amoxicillin (80–
Type I*: azithromycin,
90 mg/kg/day)
clarithromycin
Ceftriaxone—1 or 3
days
Non-type I: cefdinir,
cefuroxime,
cefpodoxime
Type I*: azithromycin,
clarithromycin
Ceftriaxone—1 or 3
days
Amoxicillinclavulanate
(90 mg/kg/day of
amoxicillin with
6.4 mg/kg/day of
clavulanate)
Non-type I:
ceftriaxone—3 days
Type I*: clindamycin
Yes
Amoxicillinclavulanate
(90 mg/kg/day of
amoxicillin with
6.4 mg/kg/day of
clavulanate)
Amoxicillinclavulanate
(90 mg/kg/day of
amoxicillin with
6.4 mg/kg/day of
clavulanate)
Ceftriaxone—3 days
Tympanocentesis—
clindamycin
<2yr old or complex case use 10 day course, otherwise may use 7 day course
MANAGEMENT
• Recurrent AOM
• If > 6 weeks since last AOM use first line agents
• If < 6 weeks since last AOM use second line agents
• Consider ENT referral
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OME for ≥ 3 months with bilateral hearing loss ≥ 20 dB.
≥ 3 episodes in 6 months
≥ 4 episodes in 12 months
Retracted tympanic membrane
Cleft plate or craniofacial malformations.
MANAGEMENT CONTROVERSIES
MANAGEMENT CONTROVERSIES
• Primary Outcome – not statistically significant
• Changed protocol, from single Primary Outcome to
four primary outcomes
• Lead author has received multiple honoraria from
makers of Amox-Clav ES
• Make little to no mention of secondary outcome
which was statistically significant - Diarrhea
MASTOIDITIS
• Inflammation of mastoid air cells
• commonly associated with AOM
• Bacteriology
• S. pneumoniae, group A streptococci, S. aureus, S. epidermidis, M.
catarrhalis, H. flu
CLINICAL
• Hx
• PAIN, Fever, h/a, erythema posterior to auricle, AOM symptoms for >2
weeks
• P/E
• tenderness, erythema
• displaced auricle
• TM  erythema/bulging/fluid
• Complications
• Subperiostial Abscess
• Bezold Abscess – below pinna, behind SCM
• Petrositis/Osteomyelitis
• Diagnostic Imaging
• CT (Sens 87-100%)/MRI
MANAGEMENT
• Antibiotics: Ceftriaxone, Clindamycin + Gentamycin, PipTazo
• ENT for possible myringotomy, tympanostomy tubes,
mastoidectomy
CASE 7
• 23 year old male returns from his weekend at his
cottage early due to unbearable pain in his right
ear. His vital signs are all stable but when you touch
his helix he screams out in pain.
OTITIS EXTERNA
• Infection of the external auditory canal
• DDx
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AOM
Otomycosis – Aspergillosis
Furunculosis – infection of cartilagenous portion of ext. canal
Herpes Zoster Oticus – Ramsay Hunt Syndrome
• Bacteriology
• P. aeruginosa, S. aureus, and other gram-negative organisms often
occurring as polymicrobial infection.
CLINICAL
• Hx
• otalgia, ear fullness, H/L, redness, swelling, jaw pain, discharge, pruritis
• Risks
• moisture, maceration, trauma
• P/E
• erythema, edema, narrowing of canal, discomfort with pulling on the
auricle or tragus
OTITIS EXTERNA
• Analgesia – NSAID’s, opiates
• Ear Wick
• Antifungals
• Thimerosol gtts
• Gentian Violet gtts
• Antimicrobials
• Ciprodex 4gtts bid
• Cortisporin 4gtts qid
NECROTIZING (MALIGNANT) EXTERNAL
OTITIS
• Osteomyelitis of temporal bone secondary to OE
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potentially life threatening
almost exclusively in immunocompromised
Pseudomonas
50 % mortality if left untreated
Hx: severe pain, h/a, discharge
P/E: erythema, tenderness, edema of external ear or adjacent structures,
POOP, granulation tissue
MALIGNANT EXTERNAL OTITIS
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Oral Ciprofloxacin 750mg po bid if uncomplicated
IV Ceftazidime 1-2g IV q8h
Hyperbaric
ENT consultation
Treatment length guided by
bone scan
CASE 8
• http://www.youtube.com/watch?v=S3Mrh52-pzs
EPISTAXIS
EPISTAXIS
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Nasal Anatomy
Etiology
Management of Anterior Bleeds
Management of Posterior Bleeds
QUESTION
• What are the arteries which are involved in anterior
epistaxis (ie. Kiesselbach’s Plexus)?(5)
EPISTAXIS
• Most cases in children although bimodal distribution
• Anterior ~90% of cases in Kiesselbach’s Plexus
• ant. ethmoid, sphenopalatine, greater palatine, superior labial arteries
• Posterior Epistaxis from posterior branch sphenopalatine
artery
NASAL ANATOMY
EPISTAXIS
• Causes
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TRAUMA – self, assault, surgical
Mucosal – URTI, allergies, cold/dry weather
Bleeding diatheses
Etc.
Hypertension – NOT a cause of bleeding but may worsen active
bleeding
EPISTAXIS
• Preparation, proper equipment and an organized step-wise
approach will be the key to success or…
MANAGEMENT - ANTERIOR
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Clear clots
Apply pressure for 15-20 min with clips – over septum!!!
With nose parallel to ground use nasal speculum
Use headlight or assistant for light source
Suction as necessary
Check  if continued bleeding…
MANAGEMENT - ANTERIOR
• Apply pledgets soaked in:
• Lidocaine w/ Epi
• Cocaine
• Xylometazoline (Otrivin)
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Re-examine  if bleeding persists…
MANAGEMENT - ANTERIOR
• If light or no bleeding but identify source
• Silver Nitrate
• Outside to inside
• Avoid on both sides of septum
• Re-examine  if bleeding persists…
MANAGEMENT - ANTERIOR
• Nasal Packing
• Nasal Packing with Vaseline gauze
• Nasal Tampon/Rhino-Rocket – 8 or 10cm sizes
• May need bilateral packs
*warn patient that Nasal tampon insertion will be painful for about 10 seconds
MANAGEMENT - ANTERIOR
• If success leave packing in for 48hrs, consider antibiotic
prophylaxis
• Prevention: avoid blowing nose, picking, closed mouth
sneezing, apply Polysporin cream
• If STILL bleeding
• Consider posterior bleed
MANAGEMENT - POSTERIOR
• Commercial Balloon Cather – Epistat
• Foley Catheter
• Prophylaxis with Keflex/Clavulin
• ENT consultation
MANAGEMENT
• If all of above fails time to call ENT
• In case of massive, life threatening bleed
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ABC’s
Establish Advanced A/W
Nasal Packing
Fluids/Blood Products – PRBC’s, FFP, Plts, PCC
call ENT/IR/Vascular
SUMMARY
• AOM is common – be aware of treatment
guidelines and rare complications including
mastoiditis
• OE is very painful but quite benign, be aware of
NOE as a complication
• Have an approach to the patient with epistaxis,
consider posterior bleed if unable to achieve
hemostasis with above techniques
REFERENCES
• American Academy of Pediatrics Subcommittee on
Management of Acute Otitis Media: Diagnosis and
management of acute otitis media. Pediatrics 113:1451, 2004
• eMedicine: Otitis Externa, Otitis Media
• Guidelines for the Diagnosis and Management of
Acute Otitis Media. Towards Optimized Practice.
Alberta Medical Association. 2008
• Treatment of Acute Otitis Media in Children under 2
Years of Age. Alejandro Hoberman, M.D. et al.
NEJM January 13, 2011