Pediatric Primary Care (51 page)

3.  Distinguish the child who is at risk for speech, language, or learning problems from other children with OME and more quickly evaluate hearing, speech, and language and need for intervention in children at risk.

4.  Refer for hearing evaluation when OME persists for 3 months or longer or at any time there is a language delay, learning problems, or a significant hearing loss is suspected in a child with OME.

5.  Not recommended for treatment of OME in an otherwise healthy child 2 months through 12 years: Antihistamines and decongestants are ineffective for OME and should not be used for treatment. Antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

6.  Observation or antibiotic therapy treatment options for children with effusion less than 4-6 months and any time in children without a 20-dB hearing threshold level or worse in the better hearing ear.

7.  Antibiotics: consider beginning with a beta-lactamase-resistant antibiotic (e.g., amoxicillin-clavulanate potassium) for 2-3 weeks.

8.  Myringotomy and tympanostomy tubes:
consider
if bilateral effusion for a total of 3 months and bilateral hearing deficiency (defined as a 20-dB hearing threshold level or worse in the better hearing ear).
Recommended
after a total of 4-6 months of bilateral effusion with a bilateral hearing deficit.

H.  Follow up.

1.  Return visit in 1 month, sooner if acute symptoms develop.

I.  Complications.

1.  Hearing loss, speech delay.

2.  Recurrent AOM.

J.  Education.

1.  Diagnosis; OME usually resolves spontaneously without treatment in 3 months.

2.  Treatment plan.

3.  Signs of hearing loss.

4.  Modify risk factors.

5.  Relationship between speech and language development and hearing.

6.  Importance of follow up.

VI. EUSTACHIAN TUBE DYSFUNCTION (ETD)

A.  Etiology.

1.  Eustachian tube (ET) is narrower and oriented horizontally in children which predisposes them to ventilation and drainage problems.

2.  Upper respiratory infections.

3.  Pressure changes that occur, such as with plane travel, may lead to acute ETD.

4.  Otitis media, serous effusions, cholesteatoma may cause chronic ETD from negative middle ear pressure.

5.  Gastroesophageal reflux (GERD).

6.  Enlarged adenoids.

7.  Allergies.

8.  Down syndrome (associated with small ETs).

9.  Smoking.

B.  Occurrence.

1.  Most common in children younger than 5 years.

2.  Usually decreases with age but may persist to adulthood.

C.  Clinical manifestations.

1.  Presenting complaints may include:

a.  Fullness, clogged feeling in ear.

b.  Ear discomfort (may be relieved by “popping ears”).

c.  Hearing loss.

d.  Symptoms can be unilateral or bilateral.

e.  Allergic symptoms.

f.  Dizziness or lightheadedness.

D.  Physical findings.

1.  Retracted TM, effusion, decreased movement on pneumoscopy.

2.  Nasal obstruction.

3.  Tuning fork test lateralizes to the affected ear if conductive hearing loss present.

E.  Diagnostic tests.

1.  Usually none.

2.  Tympanography will confirm diagnosis.

3.  Audiometry may be needed to determine hearing loss.

F.  Differential diagnosis.

1.  Otitis media.

2.  Otitis media with effusion (OME).

3.  Otitis externa.

4.  Sinus infection.

5.  Perforation of the TM.

6.  Bullous myringitis.

7.  Patulous eustachian tube (ET remains open for a prolonged period of time).

G.  Treatment.

1.  Decongestants.

a.  Pseudoephedrine (Sudafed, Actifed), OR:

b.  Topical nasal sprays (avoid use longer than 3 days)–phenylephrine (Neo-Synephrine topical), oxymetazoline (Afrin).

2.  Nasal steroids (especially helpful to those with allergic rhinitis, most approved for children 6 years and older).

a.  Beclomethasone (Beconase).

b.  Budesonide (Rhinocort).

c.  Fluticasone (Flonase) approved for those 4 years of age and older.

d.  Fluticasone furoate (Veramyst) approved for those 2 years of age and older.

e.  Mometasone (Nasonex) approved for those 2 years of age and older.

3.  Second generation H1 antihistamines (may be beneficial for those with allergic rhinitis).

a.  Loratadine (Claritin).

b.  Desloratadine (Clarinex).

c.  Fexofenadine (Allegra).

d.  Cetirizine (Zyrtec).

4.  Antibiotics: not usually indicated unless AOM present. a. Amoxicillin for 10 days–most effective.

a.  Tympanic perforation or ventilation tubes present.

5.  Topical antibiotic drops with topical steroid if discharge present.

a.  Topical antibiotic drops with topical steroid if discharge present.

b.  Neomycin-polymyxin-hydrocortisone (Cortisporin) otic drops.

c.  Ciprofloxacin-hydrocortisone (Cipro HC).

6.  Pain management.

a.  Anti-inflammatories such as acetaminophen or ibuprofen, others.

7.  GERD–omeprazole (Prilosec).

8.  Patulous (abnormally open) ET–Premarin nose drops or nasal spray.

H.  Follow up.

1.  Check tubes every 3 months, if present.

2.  If OME present, check for resolution in 3 months.

3.  Return visit if symptoms worsen or change.

I.  Complications.

1.  TM perforation.

2.  Hearing loss.

3.  Cholesteatoma.

4.  Meningitis.

5.  Brain abscess.

6.  Labyrinthitis.

7.  Subdural empyema.

8.  Subperiosteal abscess.

9.  Facial paralysis.

10.  Death.

J.  Education.

1.  Diagnosis: importance of treating cause.

2.  Treatment plan.

3.  Modification of risk factors.

4.  Importance of follow up.

5.  Relationship between speech, language and hearing.

BIBLIOGRAPHY

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media with Effusion.
Clinical practice guideline: Otitis media with effusion.
Published May 3, 2004:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/clin_recs/ome.Par.0001.File.dat/öMEFinal.pdf
. Accessed June 6, 2011.

American Academy of Pediatrics and American Academy of Family Physicians Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media.
Pediatrics
2004;113(5):1451-1465.

Corbeel L. What is new in otitis media?
European J Pediatrics.
2007;166:511-519.

Daly KA, et. al. Epidemiology, natural history, and risk factors: Panel report from the ninth International Research Conference on otitis media.
Int J Pediatr Otorhinolaryngol.
2010;74(3):231-240.