Pediatric Primary Care (50 page)

Amoxicillin-clavulanate (Augmentin) (second-line therapy)

Sulfa-based combinations

Erythromycin-sulfisoxazole (Pediazole)

Trimethoprim-sulfamethoxazole (Bactrim, Septra)

Macrolide/azalide (second-line therapy)

Azithromycin (Zithromax)

Clarithromycin (Biaxin)

Second-generation cephalosporins

Cefaclor (Ceclor) Cefprozil (Cefzil) Cefuroxime axetil (Ceftin) Loracarbef (Lorabid)

Third-generation cephalosporins

Cefdinir (Omnicef)

Cefixime (Suprax)

Cefpodoxime proxetil (Vantin)

Ceftibuten (Cedax)

Ceftriaxone (Rocephin)

Topical antimicrobial agents (approved for use with tympanostomy tubes or nonintact tympanic membrane

Ciprofloxacin/dexamethasone (Ciprodex Otic Suspension) Ofloxacin (Floxin Otic Solution)

Source:
Pichichero ME. Acute otitis media: Part II. Treatment in an era of increasing antibiotic resistance.
Am Fam Phys.
2000;61:2410-6,. American Academy of Family Physicians website:
www.aafp.org/afp/20000415/2410.html
. Accessed June 16, 2011.

15.  Children with frequent AOM: evaluate for anemia. If iron deficiency is diagnosed (hemoglobin 10 g/dL), begin iron supplementation to achieve at least a hemoglobin level of 11 g/dL.

16.  Persistent AOM likely caused by different pathogen than initial infection: treat with antibiotic (e.g., cefaclor, TMP-SMX, erythromycin-sulfisoxazole, amoxicillin-clavulanate potassium, cefixime).

17.  Recurrent AOM: American Academy of Pediatrics and the CDC suggest placement of tympanostomy tubes rather than antibiotic prophylaxis. If must prescribe antibiotics: sulfisoxazole most effective at preventing recurrences.

18.  Pneumococcal vaccine (PCV 13, Prevnar) in children during first year of life, as well as high-risk children younger than 1 year of age.

19.  Influenza vaccine in high-risk children.

20.  Surgical intervention: tympanostomy tubes (performed by an ENT surgeon) possible in children with chronic middle ear fluid (3 months or 4 persistent episodes) who fail to respond to antimicrobial therapy; children with recurrent AOM; suppurative complications; those with eustachian tube dysfunction.

21.  Adenoidectomy in children younger than 4 years of age with recurrent AOM may be performed as substitute for, or in conjunction with, insertion of tympanostomy tubes.

22.  Tympanocentesis (performed by an ENT specialist) and culture of exudate: if diagnosis is uncertain, child is seriously ill or toxic, response to antibiotic therapy is unsatisfactory, suppurative complications develop, otitis media in newborn or in immunologically deficient patients, or AOM develops despite receiving antibiotic therapy.

23.  Refer for audiologic testing if fail hearing screen.

24.  Consult/refer to physician: infant younger than 2 months of age, signs of meningitis.

25.  ENT referral: hearing loss or delayed speech, 3 infections in 6 months or 4 in 12 months.

H.  Follow up.

1.  Younger than 3 months of age: revisit 1 to 2 days (higher incidence of treatment failure).

2.  Children 3 months of age and older: revisit in 48-72 hours if no improvement or condition worsens (need to change antibiotics).

3.  Return visit 4-8 weeks to evaluate for OME and reinforce teaching.

4.  Persistent AOM: prescribe second-line antibiotic (e.g., amoxicillin-clavulanate, cefuroxime, or ceftriaxone IM); recheck every 2-4 weeks until resolved.

5.  Return visit if signs or symptoms of ear infection, trouble hearing, fever with/without ear pain.

I.  Complications.

1.  Perforation of TM.

2.  Hearing loss, language delay.

3.  Persistent AOM, persistent OME.

4.  Mastoiditis, cholesteatoma.

5.  Meningitis.

6.  Facial nerve paralysis.

7.  Labyrinthitis.

8.  Tympanosclerosis.

9.  Ossicle necrosis.

10.  Pseudotumor cerebri.

11.  Cerebral thrombophlebitis.

J.  Education.

1.  Causes of ear infections.

2.  Risk factors/modification: passive smoke, bottle propping, allergies, sinusitis, use of pacifier after age 6 months, breastfeeding (may protect), immunizations.

3.  Treatment plan: If antibiotics prescribed, call if symptoms worsen or do not improve in 48 hours; give exactly as prescribed.

4.  Pain relief measures.

5.  Importance of follow-up.

V.  OTITIS MEDIA WITH EFFUSION (OME)

A.  Etiology.

1.  Multifactorial: eustachian tube dysfunction (ETD), infection, allergies.

2.  Bacteria are same as for AOM, except frequency of
H. influenzae
is greater in OME.

3.  If TM perforated in chronic OME:
S. aureus
and
P. aeruginosa
most likely causative organisms.

B.  Occurrence.

1.  See AOM section earlier in this chapter.

2.  Usually follows episode of AOM.

3.  Children who are diagnosed with AOM during the first year of life are much more likely to develop chronic OME.

4.  Sixty-six percent of children with AOM have middle ear effusion or high negative middle ear pressure 2 weeks after diagnosis; 33% have middle ear effusion 1 month after diagnosis, regardless of antibiotic therapy.

5.  OME most common cause of hearing loss in children.

C.  Clinical manifestations.

1.  May be asymptomatic.

2.  Complaint of hearing loss (older children).

3.  Possible language delay.

4.  Feeling of fullness in affected ear, clogged/crackling sensation in ear, “talking in tunnel.”

5.  Irritability.

6.  Sleep disturbances.

7.  Poor school performance.

8.  Allergies.

9.  Frequent episodes of otitis media.

D.  Physical findings.

1.  Possible indicators of allergies.

2.  Possible enlarged tonsils.

3.  Possible cervical lymphadenopathy.

4.  External canal may have discharge.

5.  TM: often retracted or convex, opaque; diffuse light reflex; may be translucent with air-fluid level or air bubbles present or amber with blue-gray fluid noted, no visible landmarks.

6.  Pneumatic otoscopy: decreased or irregular mobility to both negative and positive pressure.

7.  Weber test: lateralization to involved ear.

8.  Rinne test: BC AC (abnormal).

9.  Hearing impairment.

10.  Tympanometry: fluid present.

E.  Diagnostic tests.

1.  Pneumatic otoscope for primary diagnosis, confirmed by tympanometry.

2.  Tympanometry: tympanogram is flat with an effusion.

3.  Audiometry.

4.  Acoustic reflectometry.

5.  Otoacoustic emissions.

6.  Tympanocentesis.

F.  Differential diagnosis.

1.  All possible causes of hearing loss.

2.  Anatomic abnormalities.

3.  AOM.

4.  Nasopharyngeal carcinoma (if unilateral OME).

G.  Treatment.

1.  Most cases of OME resolve spontaneously within 3 months.

2.  Document at each visit: laterality, duration of effusion, and presence and severity of associated symptoms.