How to Treat Otitis Media
Children between the ages of 6 months and 2 years are at highest risk of developing acute otitis media (AOM). Children at increased risk of recurrent AOM contract their first episode prior to 12 months, have a sibling with a history of recurrent AOM, are in day care, or have parents who smoke. The pathogenesis of AOM is eustachian tube dysfunction, allowing retention of secretions (serous otitis) and seeding of bacteria. Patient presentations and complaints vary with age. Infants with AOM have vague, nonspecific symptoms (irritability, lethargy, and decreased oral intake). Young children can be irritable, often febrile, and frequently pull at their ears, but they may also be completely asymptomatic. Older children and adults note ear pain, decreased auditory acuity, and occasionally otorrhea.
The most common cause of pain in the external ear is acute otitis externa. It affects 3 to 10 of the patient population. The pain is caused by inflammation and edema of the ear canal skin, which is normally adherent to the bone and cartilage of the auditory canal. The inflammatory reaction can be caused by bacteria, fungi, or contact dermatitis (see eTable 19-2 online). Cerumen protects the canal by forming an acidic coat that helps prevent infection. Factors that predispose to otitis externa include absence of cerumen, often from excessive cleaning by the patient water, which macerates the skin of the auditory canal and raises the pH and trauma to the skin of the auditory canal from foreign bodies or use of cotton swabs. Fungal infections compose less than 10 of external otitis cases. The most common fungi are Aspergillus niger and Candida species and are more prevalent in tropical climates. Itching is a more common complaint than pain in fungal ear infections. Thorough cleaning of...
Otitis externa (OE), or swimmer's ear, is an inflammation and infection (bacterial or fungal) of the auricle and external auditory canal (EAC). Typical symptoms include otalgia, pruritus, otorrhea, and hearing loss. Physical examination reveals EAC hyperemia and edema, otorrhea, malodorous discharge, occlusion from debris and swelling, pain with manipulation of the tragus, and periauricular lymphadenopathy.
Acute Otitis Media The most common infection for which children are seen in a physician's office is acute otitis media (AOM). The annual cost of AOM in the United States is an estimated 5 billion (Bondy et al., 2000). By age 7 years, 93 of children have had at least one episode of AOM, and 75 have had recurrent infections. AOM can occur at any age, but the highest incidence is between 6 and 24 months in the United States. The primary cause of bacterial colonization of the middle ear is eustachian tube dysfunction. Abnormal tubal compliance in addition to delayed innervation of the tensor veli palatini muscle leads to collapse of the eustachian tube. Aerobic and anaerobic organisms, as well as viruses, can contribute to middle ear infection (Heikkinen et al., 1999). The three most common bacteria involved in AOM are S. pneumoniae (25 -40 of cases), H. influenzae (10 -30 ), and Moraxella catarrhalis (2 -15 ) (Klein, 2004). Risk factors most often associated with AOM are child care...
Resident work schedules first received widespread public attention in 1984 after the death of Libby Zion, an 18-year-old woman treated in the emergency department of a New York hospital for fever and earache. Her family charged that she died due to the poor care by overworked and un-dersupervised medical residents (no attending physician saw her, although one was consulted by phone). Upon investigation of her death, a grand jury in 1986 exonerated the doctors involved in the case (Ludmerer, 1999) and, instead, faulted the broader system of graduate medical education (New York Supreme Court, 1986)
Action Your doctor will examine your child's ears. If there is an outer ear canal infection, he or she may prescribe ear drops containing an antifungal drug and or a corticosteroid drug. You should also follow the self-help advice for relieving earache (below). Possible cause and action An infection of the middle ear may have caused your child's eardrum to rupture. This relieves the pressure built up within the ear. Your doctor will examine your child and may prescribe antibiotics. Self-help measures for relieving earache (below) may relieve your child's pain. The eardrum will heal within a few days. There will be no lasting effect on your child's hearing. self-help Relieving earache The following self-help measures may help to ease the pain of your child's earache Easing earache Resting the ear against a covered hot-water bottle with the head slightly raised may help to ease the pain of earache. Does your child have (VcSI earache at the moment Did your child have an earache when...
The audiogram is the single most useful test in the patient with a hearing disorder and or vertigo. In hearing disorders, the audiogram is crucial in defining the degree and type of loss. In patients with vertigo, abnormalities in the audiogram usually narrow the differential diagnosis down to otological vertigo. Accompanying the audiogram is a battery of related measures. The tympanogram measures middle ear pressure, and tympanometry is helpful in identifying a perforated ear drum or middle ear infection. Acoustical reflexes measure the stapedius and tensor tympani reflex-generated ear drum movement in
Similar symptoms may be seen with other etiologies. Meniere's disease is usually recognized by the episodic pattern (see later). Herpes simplex virus infection of the vestibular nerve is recognized by a combination of ear pain and the presence of vesicles on the external canal. Acoustic neuroma (discussed later) is recognized by a slower course and the occurrence of hearing loss. Vascular disorders such as a labyrinthine artery infarction are generally impossible to exclude, and their diagnosis is suggested by an identical symptom complex combined with vascular risk factors.
Heterozygous and homozygous deficiency of MBL has been shown to be associated with several types of immunodeficiencies. A primary immunodeficiency characterized by defective yeast opsonization was described 20 years before the molecular defect that was identified as the codon 54 mutation in the MBL (3,4). Many studies have now been published, including two large studies that included 229 and 345 children with unknown primary immunodeficiencies (5,6), which have demonstrated significant associations for both homozygous and heterozygous MBL mutations with increased risk of infection. In the largest study, of the 17 homozygous MBL deficient patients identified, 13 presented with severe infections including septicemia, cellulitis and boils, severe tonsillitis, and otitis media. Homozygous MBL mutations have also been reported to be a factor in susceptibility to Mycobacterium tuberculosis and avium, Trypanosoma cruzi, Klebsiella, Ctyptococcus neoformans, other fungal infections, hepatitis...
The geniculate ganglion level grow into the middle fossa, and those with proximal origin extend into the internal auditory meatus and cerebellopontine angle. Mean age of patients is approximately 40 years.8,10 Facial palsy occurs in most, but not all, cases it can be absent in up to one quarter. Severity of facial weakness ranges from mild paresis to total palsy. It is usually progressive, often proceeded by periods of facial twitching. Sensorineural deafness is usually present. It can be severe or total. However, it is conductive in some cases and rarely the patient can have intact hearing.8 Other symptoms may include vertigo, tinnitus, or ear pain.10 There is a long interval between onset of symptoms and diagnosis.
Ear Infections The Fear Not to Hear I've yet to meet a parent who doesn't dread the feverish, ear-tugging terrors that ear infections can bring to an otherwise happy baby. Otitis media (middle ear infection) is the most common form of ear infection. There were 30 million doctor visits for otitis media in 1997, which is up three-fold since 1975. Your conventional physician monitors your child's ears for any sign of fluid, redness, or inflammation, which could signal an increase in harmful bacteria. Antibiotics are usually the standard treatment in these situations. The American Academy of Pediatrics distinguishes between two kinds of otitis media Acute otitis media. Symptoms include fever, ear pain, and pus behind the eardrum. Most doctors use antibiotics to treat this type. - Otitis media with effusion. This condition involves fluid in the middle ear, which can cause temporary hearing loss that will return as the fluid drains. Antibiotics are not necessary to treat this. Your...
Routine neurosurgical examination in which all neurological signs and symptoms are tested for. Time constraints alone would preclude such an approach. In practice, neurosurgical history taking and examination is not routine or list based, but more heuristic, that is, goal directed, testing one hypothesis after another. For example, in a patient with a purulent middle ear infection and symptoms of intracranial infection (headaches, neck stiffness, disturbance of conscious level), history taking and examination should be directed initially at detecting signs of a lesion, such as cerebritis or abscess, in the area of brain most likely to be affected. Thus, a middle ear infection can spread superiorly to the temporal lobe, giving rise to a contralateral hemiparesis, visual field defect and, in the dominant hemisphere, dysphasia or infection can spread posteriorly into the posterior fossa, producing cerebellar signs such as ataxia, nystagmus and ipsilateral incoordination. Therefore these...
Conductive hearing loss is the most common manifestation of temporal bone metastasis. It is present in approximately 30 to 40 of symptomatic patients and is almost always the result of dysfunction of the eustachian tube with secondary serous otitis media.9,26,61 Sensorineural hearing loss, if it occurs, is usually due to involvement of the cochlear fibers in the internal auditory meatus.61 Maddox emphasized the triad of symptoms of otalgia, periauricular swelling, and facial nerve paresis as being the most suspect for malignant involvement of the temporal bone.41 He reported an incidence of facial nerve paralysis of 34 in his series. Schuknecht et al also reported a high incidence of facial palsy.63 Saito et al found that only 50 of patients with invasion of the facial canal manifested facial paralysis, although 100 of those who had tumors extending beyond the epineural sheath had complete paralysis.60 Much less common findings are otorrhea, vertigo, tinnitus, or a middle ear...
This procedure is used in some cases of chronic ear infection in which the vertical canal has become chronically inflamed and narrowed. In this situation it is important that owners do not believe that this will provide a miracle cure for their animal - usually it just makes treatment of the underlying condition easier and allows air to circulate in the ear canal. Another indication for this surgery is an animal with polyps or a tumour affecting just the vertical canal. It is more commonly carried out in dogs than cats, particularly animals with 'floppy' ears where air circulation is reduced and infection more likely, e.g. labradors and spaniels.
When my son is frustrated or upset he scratches the side of his facesometimes to the point where he bleeds What can I
Sometimes medication (such as beta-endorphin inhibitors) is used to help decrease self-injurious behaviors. If you suspect that your child's self-injurious behavior is the result of a subclinical seizure (which is not associated with typical seizures but are characterized by abnormal EEG patterns), your child must see a specialist for an extensive EEG workup. If you suspect that the behavior may be the result of illness or pain (e.g., excessive and constant ear swatting may be the result of a chronic ear infection), bring your child to see the pediatrician.
Streptococcus pneumoniae is the most common bacterial cause of community-acquired respiratory tract infections. Spneumoniae causes approximately 3,000 cases of meningitis, 50,000 cases of bacteremia, 500,000 cases of pneumonia, and over 1 million cases of otitis media each year. The increasing prevalence of drug-resistant S pneumoniae has highlighted the need to prevent infection through vaccination. Both licensed pneumococcal vaccines are highly effective in preventing disease from the common S pneumoniae sero-types that cause human disease.
A recent review evaluated various mouse models for the study of mucosal vaccination against otitis media, a common infectious disease in humans (Sabirov and Metzger, 2008). Murine antibody responses are similar to those in humans and, therefore, the mouse model is useful for testing hypotheses regarding immune responses. The authors discussed the mechanisms for mucosal immunization at one site leading to the secretion of specific IgA antibodies at other mucosal tissues and the preferential distribution of responding cells to sites that are anatomically related to the inductive sites that received the original antigenic stimulation. Although various rodents have been used in the induction ofotitis media, the mouse is a more advantageous study animal because mice are inexpensive and there is an extensive genetic toolkit available for manipulating the mouse genome. The mouse model has been used to assess the role of T- and B-cell-dependent mechanisms in protection against respiratory...
The host is an important determinant of susceptibility to meningitis. Obvious risk factors include a history of recent open trauma, surgery (especially neurosurgery), and burns. Closed-head trauma can cause cerebrospinal fluid (CSF) leaks, which have been associated with pneumococcal meningitis. Common predisposing factors include otitis media (most common), sinusitis, mastoiditis, alcoholism, perinatal exposure, and nonimmunized, immunocompromised, or asplenic status (Swartz, 1997).
Tomic sites, producing otitis media, mastoiditis, tonsillar abscesses, or osteomyelitis. Puerperal sepsis, or childbed fever, occurs when streptococci, introduced at delivery, invade the internal lining of the uterus. Group A streptococci can cause impetigo (a superficial skin infection), cellulitis, and erysipelas (a life-threatening, rapidly progressing soft tissue infection).
Over 50 of children younger than 5 years of age live in homes with at least one adult smoker. Children of smoking parents have more bronchitis and pneumonia during their first year of life and more otitis media when older. They have increased incidence of cough, bronchitis, and pneumonia proportional to the number of cigarettes smoked by the parents, particularly the mother. In fact, children of parents who smoke at least a half-pack a day have almost twice the risk of hospitalization for a respiratory illness. Secondhand smoke causes new-onset asthma in exposed children, and young persons with asthma have more asthma episodes (Charlton, 1994 Rantakallio, 1978 USHHS Report of the Surgeon General , 2006).
Acute suppurative thyroiditis is more common in children and young adults and occurs equally in both sexes. The disease is often preceded by an upper respiratory tract infection or otitis media. It is characterized by severe neck pain radiating to the jaws or ear, fever, chills, odynophagia, and dysphonia. Infants may present with respiratory distress and stridor secondary to tracheal compression caused by a thyroid abscess.12 Rarely, acute suppurative thyroiditis may cause transient vocal cord palsy.13
Cerebral venous thrombosis (CVT) is an uncommon condition. Basic mechanisms of CVT include venous stasis, increased clotting tendency, and traumatic or infective changes in the venous walls. Various endocrine, hematological, immunological, vasculitic, infective, and neoplastic diseases may be associated with CVT. y In neonates and children, regional infections (otitis media and mastoiditis), neonatal asphyxia, severe dehydrations, and congenital heart diseases are common associated diseases. In young women, pregnancy, puerperium, oral contraceptive pills, and various connective tissue diseases like systemic lupus erythematosus are the major causes. Other causes include malignancies, antithrombin III protein C and protein S deficiencies, and Behcalet's disease. y , y
Hearing loss is highly prevalent, especially in the older population, and three types are commonly encountered conductive, sensorineural, and central hearing loss. In conductive hearing loss, sound is not transmitted into the inner ear. Diagnosis is ordinarily made via observation of an air-bone gap on audiometry, meaning that hearing is superior when sound is transmitted in such a way that it bypasses the middle ear ossicular chain. Causes include a buildup of ear wax, foreign body in the ear canal, otosclerosis, external or middle ear infections, allergy with serous otitis, and perforation of the tympanic membrane. Characteristically, hearing aids work well for this population. Chronic, acute otitis media (bacterial)
A brain abscess (or subdural empyema) may occur as a result of direct spread from infected sinuses, otitis media or a penetrating wound, or by the haematogenous route (Fig. 19.3). Haematogenous brain abscesses are more likely to be multiple and are thought more likely in patients with a cardiac septal defect that allows the normal bacterial filtering action of the lung to be bypassed.
The toxicity of all aminoglycosides is similar--mainly ototoxicity and neuromuscular blockade (llTable.lll55z7.). Acute ototoxicity is based on calcium antagonism and blockade of ion channels, and chronic mechanisms are related to tissue-specific toxicity of a noxious metabolite. The frequency of ototoxicity ranges from 2 to 4 percent in retrospective studies and up to 25 percent in studies with specialized testing. The incidence and severity of damage appear to increase with patient age, total drug dose, and concomitant use of other ototoxic drugs. y Auditory toxicity is more common with the use of amikacin and kanamycin, whereas vestibular toxicity predominates following gentamicin and streptomycin therapy. Tobramycin is associated equally with vestibular and auditory damage. Cochlear toxicity is more often silent, as the hearing loss first affects the high frequencies (greater than 4000 Hz) before involving the speech frequencies. Cochlear toxicity presents clinically as deafness,...
Purulent otitis media with progressive destruction and coalescence of air cells. Medial wall erosion can cause cavernous sinus thrombosis, facial nerve palsy, meningitis, brain abscess, and sepsis. With the use of antibiotics for acute otitis media, the incidence of mastoiditis has fallen sharply. Patients present with fever, chills, postauricular ear pain, and frequently discharge from the external auditory canal. Patients may have tenderness, erythema, swelling, and fluctuance over the mastoid process proptosis of the pinna erythema of the posterior-superior external auditory canal wall and purulent otorrhea through a tympanic membrane perforation.
Measles, also known as rubeola, is characterized by a rash that is often complicated by diarrhea, middle ear infection, or pneumonia. Encephalitis occurs in 1 of every 1,000 reported cases. Individuals who recover from encephalitis usually have permanent brain damage. Death occurs in 1 to 2 of every 1,000 reported measles cases.11
Is the palate intact Figure 12-32 shows a severe cleft palate. Clefts of the palate and lips are distinct entities but are closely related embryologically, functionally, and genetically. The incidence of an isolated cleft palate is 1 per 1000 births. Clefts of the palate vary widely in size and shape. They can extend from the soft palate, to the hard palate, and to the incisive foramen. Recurrent otitis media, hearing loss, and speech defects are frequent complications.
The examination proceeds with an inspection of the external ear and ear canal looking for malformations, infections, masses, or asymmetry. Next, the tympanic membranes should be inspected for wax, perforation, otitis, or mass lesions. It is usually prudent to remove wax before embarking on more sophisticated diagnostic procedures. The tympanic membranes contribute about 20 db to the hearing level. Disorders such as perforation, scarring, fluid accumulation, or wax impaction can cause a conductive hearing loss. A normal tympanic membrane is translucent. Fluid behind the tympanic membrane imparts a straw color.
Subdural empyema is a pyogenic infection in the space between the dura mater and the arachnoid and represents 13 to 20 percent of localized intracranial infections. The arachnoid is not a very strong barrier, and subdural empyema may breach the arachnoid and cause subpial infection. y The most common predisposing condition that leads to the development of a subdural empyema is paranasal sinusitis, especially frontal sinusitis. Paranasal sinusitis is the primary cause of a subdural empyema in 50 to 80 percent of patients, and otitis media is the primary cause in 10 to 20 percent. y , y Superficial infections of the scalp and skull, craniotomy, or septic thrombophlebitis from sinusitis, otitis, or mastoiditis may extend to the subdural space causing empyema. y Subdural empyema in infants usually represents an infected subdural effusion complicating a bacterial meningitis. y , y An empyema may rarely develop in the subdural area of the spinal cord....
Specific treatments for facial palsy are aimed at the underlying etiology. Consultation with the appropriate specialist is necessary for facial palsy caused by tumors, cholesteatoma, skull base osteomyelitis, or middle ear infection. Infectious, metabolic, collagen vascular, or toxic causes should be corrected as required by the particular disease. Prompt surgical consultation is needed for patients with facial nerve paralysis after either blunt or penetrating trauma. y
Infectious, inflammatory, traumatic, and neoplastic diseases are common in the organs of the ear and nose. Some of the more common ear infections are discussed in this section. Acute otitis externa is a common inflammatory condition of the external ear canal, most often caused by Pseudomonas aeruginosa. The prominent symptom is severe ear pain (otalgia) accentuated by manipulation of the pinna and especially by pressure on the tragus. Edema of the external ear canal, erythema, and a yellowish-green discharge are prominent signs of this disease. Commonly, the canal is so tender and swollen that adequate visualization of the entire canal and tympanic membrane is impossible. ''Swimmer's ear'' is a form of otitis externa in which there is a loss of the protective cerumen, and chronic irritation and maceration by water and bacteria occur. Itching is a common precursor of otalgia. Figure 11-26 shows the external ear canal of a patient with acute otitis externa. Notice the follicular...
Although the most common cause of facial paralysis is indeed Bell's palsy, it is incumbent to rule out other potentially serious causes of facial paralysis before making this diagnosis of exclusion. Initially, a complete history and physical examination are required, including otologic and neurologic evaluation. The patient should be questioned regarding history of recurrent cold sores, which suggest her-petic involvement. Recent travel (especially camping) should be noted because Lyme disease is an often-overlooked cause of facial paralysis. Involvement of facial nerves is a concern in patients with a history of chronic otitis media or choles-teatoma. Other symptoms should be noted. Otalgia is common with Bell's palsy and does not always imply that the ear Evaluation of facial nerve function requires careful attention and comparison between the two sides of the face. The patient should be evaluated at rest and with voluntary movement. The patient should be asked to wrinkle the nose,...
The pathogens involved are similar to those causing tonsillitis, especially streptococcal species, but many infections are polymicrobial and involve anaerobic bacteria. Patients present with a fever, severe sore throat that is often out of proportion to physical findings, localization of symptoms to one side of the throat, trismus, drooling, dysphagia, dysphonia, fetid breath, and ipsilateral ear pain.
S. pneumoniae is the most common causative organism of community-acquired bacterial meningitis in the adult. Pneumonia and acute and chronic otitis media are important antecedent events. Chronic disease, specifically alcoholism, sickle cell anemia, diabetes, renal failure, cirrhosis, splenectomy, hypogammaglobulinemia, and organ transplantation are predisposing conditions for pneumococcal bacteremia and meningitis. The pneumococci are a common cause of recurrent meningitis in patients with head trauma and cerebrospinal fluid (CSF) rhinorrhea. In the older adult (50 years of age and older), S. pneumoniae is likely to cause meningitis in association with pneumonia or otitis media, and gram-negative bacilli are the likely organisms to cause meningitis in association with chronic lung disease, sinusitis, a neurosurgical procedure, or a the clinical symptoms and signs may vary depending on the age of the patient and the duration of illness before presentation. The symptoms and signs of...
The clinical presentation of an intracranial epidural abscess is an unrelenting hemicranial headache or persistent fever that develops during or after treatment for frontal sinusitis, mastoiditis, or otitis media. Focal neurological deficits, seizures, and signs of increased ICP do not develop until the infection extends into the subdural space. y Approximately 10 percent of epidural abscesses are associated with a subdural empyema. y An epidural abscess that develops near the petrous bone and involves the fifth and sixth cranial nerves presents with ipsilateral facial pain and lateral rectus weakness (Gradenigo's syndrome). A spinal epidural abscess presents as fever and pain at the affected spinal level. Heusner y described a characteristic clinical pattern of symptom progression. Back pain is
Immunizations may prevent AOM in certain patients, such as those with recurrent infections. Influenza vaccine is more effective in preventing AOM in children older than 2 years of age than in younger patients possibly from impaired immune responses and immature host defense in infants and toddlers.20 Pneumococcal conjugate vaccine is protective against infection by vaccine serotypes only with a limited overall benefit for AOM.21 Antibiotic prophylaxis is no longer recommended for otitis-prone children because of increasing resistance. Avoidance or minimization of risk factors associated with otitis media, such as tobacco smoke and bottle feeding, is advised, but the effects of these interventions remain unproven.
There is growing evidence that MBL deficiency is associated with increased susceptibility to many infectious diseases. In a study involving 228 patients with clinical symptoms such as recurrent lung infections, recurrent otitis media, diarrhoea and septicaemia were examined and their MBL genotype analyzed (Garred et al., 1995). The results showed a significantly higher incidence of patients with homozygous mutations in the mbl2 gene
Infectious CVT requires immediate broad antibiotic treatment and - often - surgical treatment of the underlying disease (e.g. otitis, sinusitis, mastoiditis). Until the results of microbiological cultures are available, third-generation cephalosporins (e.g. cefaloxim 2 g tid or ceftriaxone 2 g bid i.v.) should be given. As in aseptic CVT, anticoagulation should be initiated immediately and symptomatic therapy of septic CVT should adhere to the principles outlined for aseptic CVT, although controlled studies on the efficacy of these measures in septic CVT are lacking.
BB is now 23 months old, brought by his father to the pediatrician. He has a 4-day history of left ear pain, excessive crying, decreased appetite, and difficulty sleeping over the past 2 days. The child's temperature last night was 39 C (102.2 F) by electronic axial thermometer. The father gave the child several doses of acetaminophen drops (80 mg 0.8 mL), but the pain or temperature did not improve and none was given this morning. His immunizations are up to date. He was last treated for acute otitis media 4 months ago using oral amoxicillin 40 mg kg day divided every 12 hours. He has no known drug allergies. Diagnosis Acute otitis media, left ear
Prior to the introduction of the Hib conjugate vaccine, H. influenzae type b was the most common cause of bacterial meningitis in the United States.5 Routine inoculation of pediatric patients against Hib since 1991 has reduced the incidence of invasive Hib disease (i.e., meningitis and sepsis) in children younger than 5 years of age by 99 ,6 with mortality from Hib meningitis now less than 5 . The Hib vaccine is also recommended for patients undergoing splenectomy. Hib meningeal disease is often associated with a parameningeal focus such as a sinus or middle ear infection. Increases in -lactamase-mediated resistance have changed the empirical treatment of choice from ampicillin to third-generation cephalosporins (e.g., ceftriaxone and cefotaxime). Treatment should be continued for 7 days, after which no further maintenance therapy is required.
O The majority of uncomplicated AOM cases resolve spontaneously without significant morbidity. Untreated AOM improves in 80 of children between days 2 and 7 of illness without increasing the risk of complications.13 Antibiotics improve ear pain in only 7 of children between days 2 and 7 of therapy and significantly improve recovery in children younger than 2 years of age and in those with severe AOM symptoms.13 Therefore, antibiotics should be reserved for children most likely to benefit from therapy and is dependent upon patient age, illness severity, and diagnostic certainty. Children younger than 2 years of age have a higher incidence of penicillin-resistant pneumococcal infections and have higher clinical and bacteriolo-gic failure rates and complications when not treated initially with antibiotics as compared with older children.4 Patients with severe illness, defined by degree of fever and
Otitis media is most common in children between 6 months and 2 years of age but can occur in all age groups, including adults. By age 3 years, up to 85 of children have had at least one episode of otitis media, and up to 20 have recurrent infections by age 12 months. At least 13 million antibiotic prescriptions are written annually in the United States for otitis media, resulting in 2 billion in direct costs.4 Many risk factors (Table 72-1) predispose children to otitis media and can be associated with microbi-al resistance, such as daycare attendance, prior antibiotic exposure, and age younger than 2 years.3,5,6
The onset of AOM in childhood is often associated with fever, lethargy, and irritability. Older children may experience earaches and decreased hearing. Examination with a hand-held otoscope demonstrates tympanic membrane redness, opacity, bulging, and poor mobility when pneumatic pressure is applied. However, there is considerable variability in the symptoms and signs of acute otitis media.
If there is a question of middle ear infection, pneumatic otoscopy should be performed. This technique requires the use of a speculum large enough to fit snugly into the external canal to establish a closed air chamber between the canal and the interior of the otoscopic head. A rubber squeeze bulb is attached to the otoscopic head. By squeezing the bulb, the examiner can increase the air pressure in the canal. Pneumatic otoscopy must be performed gently, and the patient should be informed that he or she may experience a blowing noise during the procedure. When the pressure in the otoscopic head is increased by squeezing the bulb, the normal tympanic membrane shows a prompt inward movement. In patients with an obstructed eustachian tube, the tympanic membrane moves sluggishly inward. If fluid is present in the middle ear, a marked decrease or absence of movement is detected. The reduction of movement of the tympanic membrane increases the probability of middle ear infection by as much...
And suppurative adenitis of the lymph nodes located in the prevertebral fascia and is seen on a soft tissue lateral x-ray of the neck as prevertebral soft tissue thickening. The RPA may be preceded by an upper respiratory infection, pharyngitis, otitis media, or a wound infection following a penetrating injury into the posterior pharynx. It is helpful for the examiner to be familiar with the normal laryngeal structures. The differential diagnosis includes pharyngitis, acute laryngotracheobronchitis, epiglottitis, membranous (bacterial) tracheitis, cervical adenitis, infectious mononucleosis, peritonsillar abscess, foreign body aspiration, and diphtheria. These patients may present with stiff neck mimicking meningitis.
Treatment of acute TM perforations is tailored to the mechanism of injury. All easily removable foreign bodies should be extracted. Corrosive exposures require face, eye, and ear decontamination. Antibiotics and irrigation do not improve the rate or completeness of healing unless the injury is associated with OM. Systemic antibiotics should be reserved for perforations associated with OM, penetrating injury, and possibly water-sport injuries (see Otitis Media above). Topical steroids impede perforation healing.
Headache in WG is due to sinusitis, pachymeningitis, or cerebral vasculitis. Multiple forms of cranial nerve problems occur. Exophthalmos, ophthalmoplegia, and optic nerve involvement due to granulomatous involvement may be a presenting symptom of WG. y Ocular symptoms are present in 15 percent of patients at onset and 52 percent of patients during the disease course. The most helpful diagnostic finding is proptosis (2 percent at onset, 15 percent overall), since it is highly suggestive of WG when associated with upper or lower airway disease. Proptosis is usually painful and leads to visual loss owing to anterior ischemic optic neuropathy in about half of affected patients. Extraocular muscle entrapment can cause diplopia. y Recurrent serous or suppurative otitis media may cause partial (33 percent) or total unilateral (1 percent) or bilateral (1 percent) hearing loss. y Multiple cranial neuropathies rarely occur as a result of pachymeningitis. y
Patients may also experience headache, ear pain, or neck pain. Symptoms such as hoarseness, difficulty swallowing, bronchial aspiration, aspiration pneumonia, shoulder weakness, tongue atrophy, and tongue fasciculation suggest the involvement of the lower cranial nerves. Deficits of these nerves are usually associated with large tumors. Patients with giant tumors may have facial palsy, Horner's syndrome, diplopia from invasion of the cavernous sinus, and posterior fossa symptoms such as ataxia, nystagmus, intracranial hypertension, papilledema, and occasionally paresis or plegias from brainstem compression.
Distinguishing between vestibular neuronitis and bacterial labyrinthitis or labyrinthic ischemia is important. The diagnosis of bacterial labyrinthitis is based on hearing loss and otitis media or meningitis, and labyrinthic ischemia can be distinguished by hearing loss plus associated neurologic symptoms with a history of vascular disease.
As a group, these diseases are marked by striking somatic dysplasia, slowly deteriorating neurological and systemic symptoms, storage of mucopolysaccharides in the lysosomes, and excretion of mucopolysaccharides in the urine (see Iabje.30-4 ). Although each type has a specific enzyme deficit, the similar spectrum of clinical manifestations in all MPS disorders makes biochemical differentiation essential. For many reasons, Hurler's disease has become the prototypical MPS. Patients who have this syndrome in early infancy may appear reasonably normal, but by 6 months of age it is obvious that a severe disorder is present. Ihe abnormal facial appearance is one of the first signs noted, and hepatosplenomegaly and umbilical and inguinal hernias are soon detected. Affected infants may have chronic rhinorrhea associated with frequent colds, recurrent airway infections, and otitis media. When children with Hurler's disease attempt to sit, a characteristic kyphoscoliosis is often observed,...
Numerous pathological processes occurring within the middle cranial fossa can result in trigeminal dysfunction by affecting the gasserian ganglion. In children, osteitis of the petrous apex following suppurative otitis media or mastoiditis, which leads to inflammation and infection affecting the trigeminal ganglion, may result in Gradenigo's syndrome. The syndrome is characterized by facial pain, headache, or sensory loss and a sixth cranial nerve palsy, facial palsy (due to seventh nerve involvement), and deafness (due to eighth nerve involvement). The pain is described as boring or throbbing, worse at night. Pain is aggravated by jaw or ear movement. It has been hypothesized that some of the dysesthetic sensation patients experience before or during episodes of Bell's palsy may reflect involvement of the trigeminal ganglion or nuclei in the brain stem. y A benign, self-limited trigeminal sensory neuropathy has been reported in children 7 to 21 days following a nonspecific febrile...
Most of the acute effects of radiotherapy resolve within 1 to 2 months. However, the majority of patients will have some degree of permanent xerostomia, dental problems, skin hyperpigmentation, and soft-tissue fibrosis.35 Efforts to reduce long-term xerostomia include the use of radioprotectors such as amifostine or salivary stimulants such as pilo-carpine.36,37 Meticulous dental care and daily fluoride therapy are effective in minimizing the risk of serious dental complications. Approximately one-third of patients will eventually develop hypothy-roidism. This is usually subclinical and detected by annual screening with thyroid function tests. Thyroid hormone replacement should be prescribed in this setting. Chronic serous otitis media occurs in approximately 15 percent of patients and may be managed
Traumatic perforation of the tympanic membrane may result from barotrauma (water skiing diving injuries, blast injuries, blows to side of head), ear canal instrumentation (cotton-tipped applicators, bobby pins, paper clips, cerumen curettes), or otitis media (see earlier discussion). The patient usually complains of acute pain that subsides quickly, associated with bloody otorrhea. Severe vertigo can occur but is transient in most cases. Persistent vertigo suggests inner ear involvement (perilymphatic fistula). Hearing loss and tinnitus are also common.
Clinical signs Upper respiratory tract infection is usually characterized by a serous exudate from the eyes and nose, which later becomes a mucopurulent discharge. Infection may manifest as any of the following rhinitis (snuffles), pneumonia, otitis media, conjunctivitis, abscesses, genital infections or septicaemia.
VWhen the pharyngeal tonsil (adenoids) is infected and swollen, it can completely block airflow through the nasal cavity so that breathing through the nose requires an uncomfortable amount of effort. As a result, inhalation occurs through an open mouth. Surgical removal of the adenoids (adenoidectomy) may be necessary if infections, earaches, or breathing problems become chronic.
Temporal arteritis is a systemic autoimmune disorder. Pathologically, there is a granulomatous inflammation of large and medium-sized arteries. It generally occurs in patients older than 55 years, with no gender predilection. Involvement may occur in any organ system. Ocular involvement is generally associated with inflammation of the posterior ciliary arteries. General symptoms include amaurosis fugax, headaches, scalp tenderness, jaw claudication, occasional ear pain or arthralgias, pain and tenderness on one or both temples, malaise, and intermittent fevers. Ocular symptoms include loss of vision, diplopia, pain, red eye, and ocular-ischemic syndrome. The workup of patients suspected to have giant cell arteritis includes a careful history of nonvisual symptoms, examination, and laboratory studies to include erythrocyte sedimentation rate (ESR), C-reactive protein, and complete blood count with differential. Using the Westergren method, the value for a normal ESR is 30 mm hr for a...
Precipitating elements Alcoholism, diabetes mellitus, autoimmune diseases, malignancy, hypertension, sarcoidosis, acute porphyria, hyperthyroidism, and pregnancy have been associated with facial palsy. In addition, many infectious diseases can cause CN VII palsy, such as tuberculosis, mononucleosis, poliomyelitis, syphilis, and human immunodeficiency virus. A recent ear infection, with or without otorrhea, is suspicious for an otological infection or cholesteatoma as the possible etiology. An upper respiratory infection commonly precedes Bell's palsy. Facial palsy has been seen after immunizations for polio and rabies and after exposure to toxins like arsenic, carbon monoxide, and ethylene glycol. A family history of facial nerve palsy is seen with Melkersson-Rosenthal syndrome and occasionally with Bell's palsy. Maternal infections (e.g., rubella), drugs used during pregnancy (e.g., thalidomide), and a difficult delivery, especially if forceps were used, have been associated with...
A brain abscess is a focal, intracerebral infection that develops into a collection of pus surrounded by a well-vascularized capsule. Although fungi and protozoa (particularly Toxoplasma) can also cause brain abscesses, bacterial causes are much more common. Streptococci are found in 70 of bacterial abscesses and are usually from oropharyngeal infection or infective endocarditis, whereas Staphylococcus aureus accounts for 10 to 20 of isolates and is more often found after trauma. Community-associated MRSA strains have been increasing. Enteric gram-negative bacilli (e.g., E. coli Proteus, Klebsiella, and Pseudomonas spp.) are isolated in 23 to 33 of patients, often in patients with ear infection, septicemia, or immunocompro-mise and those who have had neurosurgical procedures.
In most people, cleaning the external meatus with a finger in a washcloth while bathing is sufficient to maintain the ear canals. Treatment of cerumen impaction by the clinician may involve ceruminolytic agents, irrigation, or manual removal. Ceruminolytic agents include water-based, oil-based, and non-water-, non-oil-based solutions. A Cochrane review found that any type of ear drop (including water and saline) is more effective than no treatment, but study quality was lacking. Office irrigations may be performed using a large syringe with a large angiocath-eter tip. The type of irrigant solution used is probably not critical, although a tepid or warm temperature is important to prevent the patient from becoming vertiginous from a labyrinthine caloric response. Instilling a ceruminolytic 15 minutes before irrigation may improve the success rate. Irrigations should not be performed in those with tympanic membrane perforations or previous ear surgery. Of note, irrigation with tap water...
Adenoid hypertrophy is common in children. If identified in an adult, adenoid hypertrophy could indicate a lymphopro-liferative disorder or HIV infection. The patient may present with nasal symptoms or symptoms of eustachian tube dysfunction. In the pediatric population, adenoid hypertrophy causes chronic or recurrent nasal obstruction, rhinorrhea, snoring, cough, or otitis media. The diagnosis is usually clinical but can be confirmed with lateral neck radiograph. If symptoms are severe or persistent, adenoidectomy is indicated improvement is usually dramatic.
This chapter covers plasticity in the central auditory system, most notably in the auditory cortex, from a variety of viewpoints. Neuroanatomical and neuro-physiological studies in animals as well as behavioral and functional imaging studies in humans will be considered. Plasticity in the auditory system will be compared to plasticity in other sensory systems, and the reorganization of the central auditory system during early blindness and deafness will be discussed. The findings from research in auditory cortical plasticity have important implications for the design of auditory prostheses, such as cochlear implants, in the deaf, and visual prostheses in the blind using nonvisual modalities. They also further the understanding and treatment of common ailments, including hearing loss and tinnitus in an aging population as well as the effects of otitis media in young children.
Twenty-three patients have been identified with homozygous factor I deficiency (121). Recurrent infections and meningitis infections with S pneumoniae, N meningitidis, H influenzae, and otitis media were reported in 21 of the patients (122,123). One patient was asymptomatic and one patient had a
In many studies, a range of outcome measures is recorded but not all are reported (Pocock 1987, Tannock 1996). The choice of outcomes that are reported can be influenced by the results, potentially making published results misleading. For example, two separate analyses (Mandel 1987, Cantekin 1991) of a double-blind placebo-controlled trial assessing the efficacy of amoxicillin in children with non-suppurative otitis media
Septic thrombosis of other sinuses is found as a complication of bacterial infection (e.g. otitis, mas-toiditis, bacterial meningitis), and is always accompanied by symptoms and signs of systemic infection. Septic CVT accounts for about 5 of all cases of cerebral thrombosis, but its mortality remains extremely high.
The baby wakes and cries. Do you nish in, or let him cry What is causing the baby to wake Are you spoiling him if you go in every time he cries On the other hand, he may have an earache and be sick, and really need you. How do parents decide
The evaluation of a child who has had a febrile seizure should begin with a careful history and physical examination. The history should include symptoms of infection, medication use, toxic ingestions, developmental and health problems, prenatal birth and family history, and detailed description of the seizure by witnesses. The physical examination should pay particular attention to signs of severe illness, including petechiae, meningismus, tense or bulging fontanelle, Kernig's and Brudzinski's signs, and signs of neurologic abnormality, including decreased alertness or cognition and deficits of motor strength or tone. Even in children with a previous history of febrile seizures, a seizure associated with fever may be a sign of an intracranial infection. If intracranial infection is suspected, a lumbar puncture (LP) should be performed. Otherwise, LP is not necessary. Children older than 18 months who have meningitis or encephalitis usually demonstrate typical clinical signs and...
In children, the nasopharyngeal tonsil, or adenoid, can occupy almost all of the nasopharyngeal space. Acute respiratory infections can cause acute adenoiditis with mucopurulent postnasal discharge, nasal obstruction and fever. Such episodes of acute infective adenoiditis are common in childhood and may lead to chronic adenoidal hypertrophy, mouth breathing, nasal obstruction and chronic mucopurulent postnasal discharge. The juxtaposition of the eustachian tubes to hypertrophied and inflamed adenoids is thought to be important in the causation of middle-ear effusions. The adenoid may therefore be important in the most common cause of hearing impairment in childhood - otitis media with effusion, more frequently known as 'glue ear'. Children with enlarged and inflamed adenoids often have difficulty eating because they are obligate mouth breathers. Symptoms include disturbed sleep, nocturnal cough and middle-ear effusions. Adenoidectomy offers an effective treatment in such children.
A 4-year-old boy is taken to the pediatrician because of recurrent ear infections. Tubes were placed in the tympanic membranes in the boy's ears 3 days ago, and he is now complaining of difficulty in tasting sweet foods. Which nerve was most likely disrupted during the insertion of the tubes that resulted in these findings 86. A 4-year-old girl is brought to the pediatrician because she has pain in the left ear. Examination reveals acute otitis media. Which nerve is responsible for conducting the painful sensation from the internal surface of the tympanic membrane to the brain
As with vestibular neuronitis, labyrinthitis causes sudden and severe vertigo. In contrast to vestibular neuronitis, the patient also has tinnitus and hearing loss. The hearing loss is sensorineural, is often severe, and can be permanent. Laby-rinthitis is caused by inflammation within the inner ear. The cause is most often a viral infection but can be bacterial. Bacterial labyrinthitis usually results from extension of a bacterial otitis media into the inner ear. A noninfectious serous labyrinthitis can also occur after an episode of acute otitis media. Other, less common causes include treponemal infections (syphilis) and rickettsial infection (Lyme disease). Symptomatic treatment of labyrinthitis is similar to that for vestibular neuronitis. Antibiotics are recommended if a bacterial cause is suspected. As with acute otitis media, bacterial labyrinthitis can, in rare cases, lead to meningitis. Few other conditions cause the constellation of hearing loss, tinnitus, and vertigo, but...
Bullous myringitis refers to painful inflammatory bullae on the tympanic membrane. The blebs appear hemorrhagic. It was formerly thought that bullous myringitis was caused by Mycoplasma pneumoniae infection. Roberts (1980), however, summarized six studies involving 858 patients with bullous myringitis, and M. pneumoniae was isolated from only one. The cause is usually viral but can be bacterial in some cases. Studies have confirmed that bacterial cultures from bullous fluid are similar to cultures from middle ear fluid taken from patients with acute otitis media. The main isolates are Streptococcus pneumoniae, Haemophilus influenzae, and beta-hemolytic streptococci. The tympanic blistering is probably a nonspecific reaction and simply a variant of acute otitis media that should be treated as such. It is important to distinguish bullous myringitis from acute otitis externa, which requires topical treatment, and from herpes zoster oticus, which can lead to cranial neuropathy and...
Otoscopy is one of the most difficult skills to learn to perform in infants and toddlers, and it is also one of the most important because these are the ages when otitis media is most prevalent. Is the tympanic membrane erythematous Is it bulging Check for a light reflex. Its presence, however, does not rule out otitis media. Are air-fluid levels visible behind the drum These signs are suggestive of fluid in the middle ear. Pneumatic otoscopy (see Chapter 11, The Ear and Nose) is an important skill for detecting mobility of the ear drum. In many young children, the ear drum may be red from crying or fever without middle ear infection. Decreased mobility is indicative of middle ear fluid, which is characteristic of otitis media the presence of pus behind an immobile ear drum (opaque yellow fluid) is the best evidence of bacterial otitis (see Fig. 11-29). Figure 24-37 shows the ear specula designed to facilitate pneumatic otoscopy the flared portion near the tip is coated with soft...
CVT may be due to infectious and non-infectious causes. Septic CVT is observed as a complication of bacterial infections of the visceral cranium, namely otitis, sinusitis, mastoiditis and bacterial meningitis. The infectious agents reach the cerebral sinuses ascending Otitis, mastoiditis, sinusitis Septic CVT may be caused by bacterial infections of the visceral cranium, e.g. otitis, sinusitis, mastoiditis and bacterial meningitis. Aseptic CVT may be caused by the same causes as extracranial thrombosis (see Table 11.1).
Examination of the ears together with myringotomy and insertion of grommets is carried out commonly in children who have secretory otitis media. This operation is usually performed as a day case. Either inhalation or i.v. induction, following the application of EMLA cream, may be used and anaesthesia is maintained with
Poliomyelitis acute coalescent mastoiditis, 209 acute epiglottitis, 81-82 acute granulocytic leukemia, 197 acute laryngotracheitis, 82 acute lymphatic leukemia, 197 acute lymphoblastic leukemia (ALL), 197 acute lymphocytic leukemia, 197 acute myeloblastic leukemia, 197 acute myelocytic leukemia, 197 acute myelogenous leukemia, 197 acute myeloid leukemia (AML), 197 acute nonlymphocytic leukemia (ANLL), 197 acute otitis media (AOM), 208-11 acute pulmonary histoplasmosis, 163 adult T-cell leukemia, 197 Aedes aegypti, 35, 36, 85-87, 365-66, 368-69 Aedes africanus, 365 glomerulonephritis chronic lymphatic leukemia, 197 chronic lymphocytic leukemia (CLL), 197 chronic lymphogenous leukemia, 197 chronic myelocytic leukemia, 197 chronic myelogenous leukemia, 197 chronic myeloid leukemia (CML), 197 chronic schistosomiasis, 291 chronic suppurative otitis media (CSOM), 209 Chrysops discalis, 343-44 chyluria, 125-27 cicatrizing trachoma, 231 cinchona, 206 cirrhosis, 79-81, 100, 173 citreoviridin...
Presenting symptoms may include a neck mass, epistaxis, nasal obstruction, a change in voice quality, pain, otalgia, decreased hearing, or cranial neuropathies. Approximately 85 percent of patients have cervical adenopathy and 50 percent have bilateral neck involvement.6 Serous otitis media may occur due to eustachian tube obstruction. Cranial nerve VI is most frequently affected but multiple cranial nerves may be involved. Common combined neurologic findings are described as petrosphenoid or
While the vast majority of patients with otalgia have an otologic cause, the clinician must recognize that otalgia may be referred. Sensory innervation of the ear includes cranial nerves V, VII, IX, and X, and therefore disorders of structures with similar innervation can cause otalgia. It is imperative that the physician not simply attribute otalgia to an ear infection unless the physical examination supports this diagnosis. Otalgia can result from dysfunction of the nose, sinuses, oral cavity, pharynx, larynx, dentition, temporo-mandibular joints, and salivary glands. These structures
Lymphopenia and neutropenia are common laboratory findings with measles infection. Complications of measles include primary infections such as pneumonia, gastroenteritis, encephalitis, and the rare subacute sclerosing panenceph-alitis. Secondary infections such as otitis media, pneumonia, and adenitis may also occur.
The turbinates are usually swollen and edematous and may be mistaken for nasal polyps, which are pearl-gray gelatinous masses and unusual in uncomplicated allergic rhinitis. Below the turbinates, the floor of the nostril is often prominent as a result of mucosal edema. One third to one half of children with allergic rhinitis have eustachian tube obstruction and resultant serous otitis. Otoscopy reveals a retracted or bulging