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Ears, Aussie Style

Casey Parker, MD, Rob Orman, MD, and Andrew Buelt, DO
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Casey Parker sees more than his fair share of acute otitis media in the Australian hinterlands. Here are his tips and tricks for smooth as silk managment.

 

Pearls:

  • When examining the ear, don’t forget to check for mastoiditis as it  requires IV antibiotics and hospitalization. Otitis externa (OE) and otitis media (OM) can be easily distinguished on physical exam. Tugging on the ear does not tend to cause pain in OM.

  • Treatment mainstay is supportive (analgesic ear drops, ibuprofen, acetaminophen, chewing gum, autoinsufflation) +/- antibiotics to avoid long-term complications from chronic OM.

    • Treat with antibiotics: less than 6 months of age, high-risk populations (poor social support, crowded living conditions) and medically fragile children (ie: immunocompromised, baseline hearing loss).

    • Greater than 6 months, practice style varies but you may observe and decide to treat those who have severe disease or don’t respond in 24-72 hours.

  • Consider aural toilet for chronic suppurative OM: betadine or iodine dilute solution in ear with ciprofloxacin 0.3% drops at least daily for 2-3 weeks.

 
  • Ear infections are common and the long-term sequelae from these infections is common.

  • Approach to the child complaining of acute ear pain:

    • History (in addition to the regular questions): Do they have a history of ear infections? Do they have any other chronic predisposing conditions?

    • Physical exam:

      • External ear: if swollen it may be either otitis externa (OE) or skin infection.

      • Tug on the ear: if painful, less likely otitis media (OM) and more likely OE.

      • Mastoid: swollen or sore → think mastoiditis. Although rare it is easily missed if you don’t look. Recommended treatment is IV antibiotics/hospitalization.

      • Internal ear:

        • 1. Normal canal and tympanic membrane (TM)

        • 2.  Equivocal findings such as slightly injected, slightly dull, mildly erythematous tympanic membrane in child with fever is often  diagnosed as OM without excluding other potential causes of fever.  

        • 3. Pus = OM

    • Treatment:

      • Analgesics:

1. Ear drops: 2% lidocaine or xylocaine drops (ears up, 4-5 drops).

  • Effective around 30-minute mark, supported by evidence.

  • Bharti B, et. al. Is topical lignocaine for pain relief in acute otitis media really effective? Arch Dis Child. 2008 Aug;93(8):714. PubMed PMID: 18644939

2. Ibuprofen: 3-4 times per day, does not impact asthma risk in short, sharp bursts unless child has aspirin-sensitive type asthma. Does not need to be taken with food.

3. Acetaminophen: perhaps not as effective as ibuprofen.

4. Mild opiate: oxycodone elixir around 0.1mg/kg. Not standard in North America. However, AAP recommended against specifically CODEINE in children because of varying metabolism and bad outcomes in children such as death.

5. Chewing gum: chewing action may help empty middle ear contents into the Eustachian tube.

  • Cochrane review showed xylitol containing gum, lozenges or syrup may be helpful for preventing  OM among healthy children attending daycare.

6. Autoinsufflation “popping your ears”: can encourage kids to blow up a balloon or office gloves.

  • Antibiotics:  while we generally treat to avoid complications of OM such as chronic hearing loss, chronic suppurative OM, mastoiditis, meningitis, evidence doesn’t show antibiotics actually prevent those things. Roughly, NNT to prevent mastoiditis is 4000 in the general population.

    • You can start with supportive/conservative management and then if not improving give antibiotics (or an Rx to fill in 24-72 hours).

    • RCT of “wait and see” approach in emergency room there was roughly a 50% reduction in antibiotics Rxs filled (62% in the standard supportive measures group v. 13% in the wait and see with antibiotics group).

    • Spiro DM et. al.  Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41. PubMed PMID: 16968847.

    • Who to treat? Those from high-risk backgrounds (underserved backgrounds), those with congenital problems (cleft palate, chronic ear problems, deafness in one ear already, cystic fibrosis or other immunocompromise), those under 6 months of age and those with severe bilateral disease (inline with AAP and AAFP guidelines).

    • If an effusion: follow closely for resolution in a couple of months, test with audiometry, consider tympanostomy tubes.

    • If drainage from chronic perforation consider aural toilet.

Aural toilet: tissue spears in child’s ear to get out debris and then gentle syringe with warm dilute solution of iodine or Betadine (1:20) to wash out more debris and clean. Dry the ear again, instill ciprofloxacin (0.3% without steroid) at least daily if not 2-3 times daily for 2-3 weeks. Can be done with a chronic tympanic perforation.

Betadine (1:20) to wash out more debris and clean. Dry the ear again, instill ciprofloxacin (0.3% without steroid) at least daily if not 2-3 times daily for 2-3 weeks. Can be done with a chronic tympanic perforation.

Ian L., Dr -

An interesting review by a Aussie doctor practising in the Kimberly Area with a high indigenous population very challenging work .
Indeed the Royal Children Hospital Melbourne regards antibiotics as a guideline to prescribe in any child that is sicker than mildly unwell over 12 months but what is moderately unwell.?
Certainly with a high fever pain and a red bulging tympanic membrane almost all doctors would prescribe antibiotics and analgesics and review daily by phone or patient attendance .
Another worry is parents who smoke at home not common but a danger even if they smoke in a different room .
Another diagnostic difficulty is wax obscuring the ear .
Do antibiotics prevent tympanic membrane perforation ?

Casey P. -

Hi Ian
The Royal children's analgesic guidelines are here: http://www.rch.org.au/clinicalguide/guideline_index/Analgesia_and_sedation/
Dosing is as per the table
I believe there is clinical equipoise when it comes to moderate otitis media- antibiotics will shorten duration a bit, but aggressive pain control will help immediately
There is not much evidence that antibiotics reduce complications like effusion, perforations, CSOM or deafness

Agree it is good practice to review children within 24 hours- especially if parents are concerned

Wax can be removed if you really need to see the TM - however this is rarely necessary in practice
Pain gets analgesics either way.

Great point about parents smoking - should be part of any Paeds history
Thanks
Casey

Ian L., Dr -

Caution : In high risk children in the Chronic Otitis Media Intervention Group :103 Aboriginal Children with first detection of Otits Media randomised to Amoxycillin 50mg/kg/dBD long term for 24 weeks or placebo for 24 weeks :Amoxycillin group vs Placebo : Perforation 12% vs 27% Recurrent Perforation 4% Amoxycillin Treated 18% Placebo Treated Perforation during Therapy Amoxycillin 8% Placebo 20% .BMC paediatric 2008 8 23 Amanda Leach Peter S Morris John D Mathews

Heidi J., MD -

Here's a question from Lisa F:

Hi there - relatively new listener and am DEVOURING episodes. You guys are fabulous and thank you so much.
Just a quick question, recently listened to December 2016 episode 29 segment "Ears, Aussie Style", and when Dr. Parker discusses what you will see when you look in the pediatric ear with fever and pain, he lists three things: 1) normal ear, 2) floridly infected/ pus filled ear, 3) slightly injected TM consistent with viral AOM. Here is my question: I also often see a fourth thing - a tiny pediatric ear canal filled with cerumen such that I cannot see the TM. My residency preceptor felt that if a child had AOM, their fever would be high enough to "melt" the wax out, and as such cerumen in the canal would indicate no AOM (I seriously doubt this is evidence-based...). I guess I was just wondering what Dr. Parker's approach is if he cannot visualize the TM in a child with fever and ear pain.
Thanks!
Lisa

Casey P. -

Hi Lisa
Ear wax... ahhhh! It is the bane of us ED docs.

My approach is to look at the kid. Do they look a little crook, or more than a bit sick?

If the child is well-appearing, I suspect a non-severe infection, then I will treat symptomatically as I do not feel the risk:benefit for ABs will pay off for a relatively well kid.

However, if the kid looks unwell. Give some analgesia, review and try hard to push past the wax... if you still cannot see, and the child looks unwell then you might want to reframe the scenario as "PUO" or "possible sepsis" without obvious focus. Especially in the kids under 18 months I would say this is the safest option. To be honest I rarely diagnose AOM in kids who look unwell, with persistently abnormal Obs. It is kinda like calling "GERD on chest pain" - it is a throw away diagnosis that can lead to serious misses. SO I reserve it for clear cases where I can see the TM bulging in the "worryingly, sick-looking group of kids"

I have no idea about the fever, melting wax theory... it may be true. However, any kid with a high fever will have 'hot ears' - so I am not sure if this is a useful discriminator. Still your preceptor's strategy does err on the side of caution. e.g.. fever + wax means you need to keep looking for the source. I agree with that as a strategy.

Thanks for listening. Casey

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Ear Pain is but a Memory Full episode audio for MD edition 183:12 min - 86 MB - M4AHippo Primary Care RAP December 2016 Summary 305 KB - PDF

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