Pediatric Primary Care (48 page)

c.  Educational.

6.  Parents' role.

a.  Care and function of hearing aids, if indicated.

b.  Medic alert bracelet.

7.  Parent support groups.

8.  Support groups for the child.

9.  Prevention: Limit exposure to loud noise.

III. OTITIS EXTERNA

A.  Etiology.

1.  Bacteria:
Pseudomonas aeruginosa
(most common);
Streptococcus
species,
Staphylococcus epidermidis, Proteus
species,
Mycoplasma
species.

2.  Fungi:
Aspergillus
species,
Candida
organisms.

3.  Excess cerumen or loss of protective cerumen from exposure to excess moisture.

4.  Trauma to the ear canal caused by overzealous cleaning with a cotton-tipped applicator or a foreign body.

5.  Allergic reaction to chemical or physical agents; contact dermatitis.

6.  Excessive wetness from swimming, bathing, or high humidity.

7.  Excessive dryness; child or family history of eczema, psoriasis, seborrhea.

8.  Purulent otitis media with perforation of the tympanic membrane and drainage may masquerade as otitis externa, usually painless with no swelling of the canal.

B.  Occurrence.

1.  Most common in hot, muggy weather, summer months.

2.  Persons who are swimmers or divers are more susceptible.

3.  Higher incidence in those with smaller ear canals.

4.  Males and females equally affected.

5.  Affects all ages.

C.  Clinical manifestations.

1.  Ear pain and itching (common in fungal infections) in the ear, especially when chewing or pressure on tragus.

2.  Feeling of fullness or obstruction of ear.

3.  Frequently, a history of exposure to water.

4.  Purulent discharge and hearing loss (conductive) possible.

D.  Physical findings.

1.  Pain on movement of pinna or tragus.

2.  Periauricular adenitis may occur, but not necessary for diagnosis.

3.  External canal: gross edema and erythema of canal, accumulation of moist debris in canal. Patient may resist insertion of ear speculum.

4.  Tympanic membrane often difficult to visualize and may be mildly inflamed but is mobile on insufflation.

D.  Diagnostic tests.

1.  No tests specific to diagnosing otitis externa.

2.  Gram stain and culture of discharge may be helpful, particularly when fungal cause is suspected.

F.  Differential diagnosis.

1.  Cyst, furuncle, or abscess.

2.  Foreign body.

3.  Otitis media with perforation.

4.  Dental infection.

5.  Mastoiditis.

6.  Postauricular lymphadenopathy.

7.  Eczema or other dermatologic condition.

8.  Malignant otitis externa.

G.  Treatment.

1.  Clean debris from canal: Insert small gauze wick or absorbent sponge into external canal to carry antibiotic corticosteroid solution into canal if needed (severe swelling).

2.  Ciprofloxacin hydrochloride/hydrocortisone otic suspension (Cipro HC Otic Suspension) has broad spectrum for covering resistant organisms or combination eardrops of antibiotics, hydrocortisone, propylene glycol.

a.  Not recommended for children younger than 1 year of age.

b.  Advise parents to warm bottle in hands for 1-2 minutes before use and then place 3 drops in affected ear(s) 2 times a day for 7 days.

3.  Ofloxacin solution 0.3% otic drops (Floxin) every 12 hours.

a.  Highly effective if
Pseudomonas aeruginosa
and
Staphylococcus aureus
are causes in patients 1 year of age and older.

b.  Age 1-12 years: 5 drops in affected ear(s) 2 times daily for 10 days.

c.  Older than 12 years of age: 10 drops in affected ear(s) twice daily for 10 days.

4.  Analgesics for pain.

5.  Oral antibiotics only if signs of invasive infection.

a.  Cellulitis of auricle.

b.  Fever.

c.  Tender postauricular lymph nodes.

6.  Topical treatment is always needed to treat otitis externa.

7.  Keep ear dry.

8.  Do not use cotton swabs.

H.  Follow up.

1.  Mild cases: none.

2.  Immediate recheck: pain worsens or sensitivity to eardrops.

3.  Return visit in 2-3 days if marked cellulitis or tympanic membrane was not visualized.

4.  Return visit if symptoms worsen, do not improve in 48 hours, or recur.

5.  Telephone if severe pain.

6.  Recheck in 10 days and continue treatment, if not completely resolved.

I.  Complications.

1.  Cellulitis of surrounding tissue.

2.  Irritated furunculosis.

3.  Malignant otitis externa (uncommon) seen in chronically ill or immuno-suppressed children.

4.  Stenosis of auditory canal.

5.   Transient conductive hearing loss.

J.  Education.

1.  Explain cause and treatment plan.

a.  Keep ear dry: no swimming during acute phase, can use cotton coated with petroleum jelly or lamb's wool when showering or shampooing to occlude canal; remove immediately when finished.

b.  Side effects of eardrops: local stinging or burning sensation and rash where drops have come in contact with skin.

c.  Avoid earplugs and use of cotton swabs.

d.  Acute pain should subside within 48 hours.

2.  Keep foreign objects out of ears.

3.  Prevention of recurrence (common): Instill 2-3 drops of isopropyl alcohol in ear canals after swimming, showering, or during hot, humid weather; shake excess water out of ears.

IV. ACUTE OTITIS MEDIA (AOM)

A.  Etiology.

1.  
Streptococcus pneumoniae
(most common causative organism).

2.  Nontypeable
Haemophilus influenzae
causes about 27% of the bacterial otitis.

3.  Less frequent pathogens include
Moraxella (Branhamella) catarrhalis
and Group A beta-hemolytic streptococci.

4.  
Staphylococcus aureus
and
Pseudomonas aeruginosa:
common in chronic serous otitis media, especially if perforation of tympanic membrane present.

a.  Group A beta-hemolytic streptococci,
Escherichia coli, S. aureus:
more common in neonates.

5.  Viruses, particularly respiratory syncytial virus (RSV), influenza virus (types A and B), and adenovirus, increase the risk, possibly by impairing eustachian tube function. Infants have increased susceptibility to OM, possibly due to short horizontal position of eustachian tube.

6.  Viruses may be involved in about 40% of cases of AOM.

7.  Bacterial resistance is increasing problem: Certain strains of
H. influenzae
and most strains of
M. catarrhalis
are resistant to amoxicillin because of beta-lactamase production. Another concern is drug-resistant
S. pneumoniae
(DRSP).