cholesteatoma with cystic white mass.
BAL HARBOUR, Fla. - There are six steps physicians can take to improve the diagnosis and treatment of otitis media (OM), said Joseph Haddad Jr., MD at the 34th Annual Postgraduate course, Perspectives in Pediatrics.
The first step is to visualize the tympanic membrane before making a diagnosis. "This seems obvious, but many of us are tempted by parents on the telephone to make a diagnosis over the telephone," said Haddad, vice chairman of the department of otolaryngology at Columbia University College of Physicians and Surgeons in New York City. "This should really be avoided. You are not doing the child a service in that situation. And unless the parents are calling by portable phone from Bora Bora or Timbuktu, it really makes sense to see the child."
One can see the malleus clearly in the center of a normal eardrum. When there is an acute infection, there will be some bulging or thickening of the tympanic membrane, and the annulus is difficult to find. The eardrum changes color when fluid is present in the middle ear. It can take on a white or a yellow appearance with pus.
"The light reflex is something that we were all taught about in medical school. But it is really a very nonspecific finding. And you see a light reflex usually in acute otitis media, as well as in the normal ear," he said.
The biggest enemy to visualizing the tympanic membrane is wax. "Wax removal is a real challenge," said Haddad, who added that a helpful tool for removing wax is to put a surgical head on an otoscope.
Haddad advised telling parents that wax removal may cause some bleeding so they will be prepared for the possibility. "If bleeding occurs, you can use an antibiotic-cortisone eardrop combination for a few days, just to clean out any left over blood."
There are other tools for cleaning the ear including a water pick or irrigating syringe, but Haddad said he does not irrigate the ears of young children.
"I think that there is a potential for perforating the eardrum. Generally, you should reserve irrigation for the older child," he suggested. "An ounce of prevention is worth a pound of cure. Discourage the parents from cleaning the ears with cotton swabs. This is probably the single greatest reason that I see children with wax impacted."
Sometimes Haddad said he will use eardrops to soften the wax, either an antibiotic-steroid combination or peroxide and water. Liquid Colace, a stool softener, also melts the wax acutely in the office.
Step two is to consider whether an underlying problem may be contributing to the infections. "When you are talking about ear infections, whatever happens in the nose tends to have an impact on the ears. So, think about what is going on in the nose. If there are infections like chronic sinusitis, you need to clear them. And that should have a positive impact on the ears."
In older children, who may suffer from allergic rhinitis, a nasal steroid spray may decrease inflammation in the eustachian tube as well as the sinuses.
The adenoids can impact middle ear disease in two ways: by obstructing the eustachian tube, or contributing to chronic fluid in the ears. "And, whenever you have fluid in the middle ear, that is going to be a good culture medium for infection," Haddad explained.
Immunodeficiencies are probably rare. However, they can occur in children because the immune system is not fully mature.
The environment also plays a role. Discussing the environment gives pediatricians a chance to empower parents. "Every parent wants to know, what can they do to help their child, to prevent or decrease the problem of ear infections," he said. Day care is one of the greatest contributing factors. Haddad recommends a smaller day care setting, rather than a large center.
Smoking should not take place in the home. "It does not count if the parents say that they only smoke in one room of the house. As long as they are smoking in the house, that child is going to be exposed to tobacco," he said.
Bottle habits can also be important. Breastfeeding helps prevent middle ear disease, but if a child does use a bottle, discourage parents from allowing the child to fall asleep while drinking a bottle. There is debate about whether pacifiers contribute to middle ear disease.
---Chronic ear fluid
with a retracted eardrum and prominent ossicles.
Step three is to try to improve the diagnosis of an acute infection. "It is helpful to categorize in your mind, what are the specific signs and symptoms that would go on with acute infection," he said. Any child with an acute otitis media should have fluid in the middle ear. A pneumatic otoscope can help determine if fluid is present.
"In addition to the effusion, there should be a recent or concurrent history of ear pain, or at least by looking at the ear, in the younger child, one should see redness, fullness and bulging of the tympanic membrane," Haddad said.
Nonspecific symptoms may include fever, irritability and diarrhea. Remember that every upper respiratory tract infection does not mean that there is an ear infection.
Step four is to recognize pathology. Some of the entities include bullous myringitis, facial nerve paralysis, acute mastoiditis, cholesteatoma and retraction pocket. In all of these instances, except bullous myringitis, consider referring to a specialist for care.
With bullous myringitis, one sees a bulla on the tympanic membrane, and the children usually present with significant pain. "Do not pop the bulla. These children need significant pain relief during the first few days of the infection," Haddad said. Antibiotics will clear this infection.
The facial nerve runs through the middle ear space. In the face of an acute infection, there can be inflammation of the facial nerve, which can lead to the acute onset of facial nerve paralysis. The treatment for facial nerve paralysis is to drain the ear. Most practitioners will insert a tube to allow rapid decompression, and relief of inflammation of the facial nerve. The facial nerve paralysis will usually clear within a month. Antibiotics and ear drops should be prescribed.
With acute mastoiditis, the auricle is jutting away from the skull. There is some redness and swelling behind the ear. A characteristic finding of the ear canal is swelling and bulging of the posterior superior part of the canal. Pus leaks from the mastoid bones, into the potential space between the bone and the skin. In addition, these are signs of an acute middle ear infection in most cases.
Tap the ear for culture before starting antibiotics. A tube is inserted to allow therapeutic drainage of the middle ear and mastoid system. Intravenous antibiotics are started. If the condition does not resolve with this therapy or a complication develops, a mastoidectomy can be performed, Haddad said.
A cholesteatoma, a cyst of keratinizing squamous epithelium, is problematic because it can destroy bone. Congenital cholesteatoma has a typical round, very bright white, pearl-like appearance. This often presents asymptomatically in the child in the first year or two of life. "This should be removed to avoid enlargement and bone disruption," he said.
Step five is to quantify the number of times a problem occurs. In a large group practice, several different physicians may be treating one child and they may fail to recognize a pattern.
"The child may be having frequent ear infections, and each time they come back, they are seeing a different person, and there may not be any one practitioner saying, `Well, gee, this child is having too many problems. Maybe there is an underlying fluid problem that is contributing to it.'"
Haddad recommended a cover sheet on the front of the chart that briefly lists each problem at every visit, so any pediatrician can see if there is a history. "And what would be particularly indicative of chronic fluid would be the child who is showing up every three to four weeks with a new infection. That might mean that the fluid is not resolving in between infections," he explained.
Step six is to recommend treatment. Antibiotics are usually prescribed for AOM, but use antibiotics judiciously because of growing antibiotic resistance. One should restrict the use of prophylactic antibiotics, curtail the use of antibiotics for effusion without infection and know local resistance patterns.
Individualized treatments for acute otitis are best, he said. Consider the child's age, the season of the year, and the child's history.
"Children generally have a track record. And some you know will clear up quickly, and you may be able to use a shorter course of antibiotic. And you should always try to follow the child's response during treatments, because that will help guide future therapy," he said.
For more information:
- Haddad J Jr. Improving the diagnosis and treatment of otitis media. Presented at the 34th Annual Postgraduate Course Perspectives in Pediatrics. Feb. 5-11. Bal Harbour, Fla.
- Haddad J Jr. Treatment of acute otitis media and its complications. The Otolaryngologic Clinics of North America 1994;27:431-441.
- Dowell SF, Marcy SM, Phillips WR., et. al. Otitis media-principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(1)Suppl.:165-166.
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