Module 11 DACCP ENT 2024 PDF

Diplomate Australian College of Chiropractic Paediatrics Year 2 2024 Module 11 Dr Braden Keil BAppSc(Chiro) MCSc(Paediatrics) FICC DACCP Dr Christian Fludder BChiroSc MChiro DACCP Dr Jenelle Bourgeois BHSc(Hons) DC DACCP Module 11 The child’s ear, nose and throat Acute otitis media C...

Diplomate Australian College of Chiropractic Paediatrics Year 2 2024 Module 11 Dr Braden Keil BAppSc(Chiro) MCSc(Paediatrics) FICC DACCP Dr Christian Fludder BChiroSc MChiro DACCP Dr Jenelle Bourgeois BHSc(Hons) DC DACCP Module 11 The child’s ear, nose and throat Acute otitis media Chronic otitis media Serous otitis media Nose and throat issues with children Tonsillitis, epiglottitis, coup and neck abscesses Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Otitis Media Should medical practitioners be treating this condition? or is it a chiropractic issue? 3  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 4 Anatomy of the ear Anatomy of the ear – older child Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Anatomy of the ear. A, A normal external ear (auricle or pinna) is shown, with its various landmarks labeled. B, This coronal section shows the various structures of the hearing and vestibular apparatus. The three main regions are the external ear, middle ear, and inner ear. The eustachian tube connects the middle ear and the pharynx and serves to vent the middle ear. 5  Note the different angle of 1. The external ear canal 2. The tympanic membrane Infant tympanic membrane 3. The eustachian tube Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Angulation of the tympanic membrane in infancy. The relationship between the ear canal and eardrum is different in the infant, with the drum being tilted at an angle of 130 degrees. Greater care is required in examining an infant's eardrum because of this angulation and because the landmarks are less promi nent. 6  Older child Note the different angle of 1. The external ear canal 2. The tympanic Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 membrane 3. The eustachian tube Infant 7 Anatomy of the tympanic membrane Chorda tympani nerve Pars flaccida Malleolar prominence Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Malleus Tip of malleus (Umbo) Pars tensa of tympanic membrane Incus 8 Anatomy of a perforated ear drum This picture demonstrates a large chronic unhealed perforation of the tympanic membrane Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  The smooth margins of the perforation indicate that the perforation is chronic 9  Examination of the ear and middle ear in infants and children Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 10  Pneumatic otoscopy equipment insufflator Small and medium Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 rubber tip “Sofseal” to assist air tight seal when using specula Paediatric (2.75mm) and adult (4.25mm) disposable specula Pneumatic otoscope head with hole for insufflator https://www.docstock.com.au/ 11  How would you examine a resistant 3-year-old? Examination position ▪ The child can be examined on an examination table or in the parent's lap. ▪ The presence of a parent or assistant is usually necessary to help restrain the baby and child as any undue movement may prevent Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 adequate evaluation and may result in injury to the child ▪ When necessary, a child may be restrained firmly on an adult's lap if the parent folds the child's wrists and arms over the child's own abdomen with one hand and holds the child's head against the parent's chest with the other hand. ▪ Some infants can be examined by placing their head on the parent's knee. 12  Examination technique The examiner should hold the otoscope with the hand or finger placed firmly against the child's head or face, so that the otoscope moves with the head rather Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 than causes trauma or pain to the ear canal if the child moves suddenly. Pulling up and out on the pinna usually straightens the ear canal enough to allow exposure of the tympanic membrane. In young infants, the tragus must be moved forward and out of the way. 13  Using the insufflator Using the bulb with the opposite hand Using the bulb with the same hand (Preferred option) (Tends to cause image shake) Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 14  Examination procedure 1. Test hearing 2. Assess external ear visually 3. Check external ear in not tender to touch before using otoscope Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 4. Pull pinna posterior and inferior in the infant and laterally in the primary school aged child 5. Gently insert otoscope looking at external canal first 6. Assess tympanic membrane  Intact  Colour  Contours  Movement The motility of and presence of fluid cannot be assessed without using a pneumatic otoscope 15  Otoscopic Inspection of the Drum the tympanic membrane should be examined for; intactness  intact  central perforation (usually benign)  marginal perforation (maybe associated with cholesteatoma) Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 colour  normal pearly grey  red (associated with otitis media and other infections)  dull (serous otitis media)  blue (blood behind TM, may occur with fracture of base of skull) contour  normal  bulging (acute otitis media)  retraction (negative pressure in the middle ear, serous otitis media) mobility  normal  decreased  immobile (perforation, grommet, otitis media)  immobile and retracted (chronic secretory otitis media) 16  Tympanic membrane appearance - normal The normal tympanic membrane has a ground-glass or waxed paper appearance A normal tympanic membrane is also translucent, allowing the observer to look through it to visualize the Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 middle-ear landmarks— incudostapedial joint, promontory, round window niche, and frequently the chorda tympani nerve. Note the: 1. Intactness 2. Colour 3. Contour 4. Mobility 17  The bulging tympanic membrane Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 A, Normal TM. B, TM with mild bulging. C, TM with moderate bulging. D, TM with severe bulging. 18  Tympanic membrane appearance – middle ear effusion A blue or yellow appearance usually indicates a middle-ear effusion. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Note the: 1. Intactness 2. Colour 3. Contour 4. Mobility 19  Tympanic membrane appearance – middle ear effusion with air bubbles and air fluid level If a middle-ear effusion is present medial to a translucent drum, an air- fluid level or bubbles of air mixed with Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 the fluid may be visible. Note the: 1. Intactness 2. Colour 3. Contour 4. Mobility 20  Tympanic membrane appearance – retracted membrane due to eustachian tube dysfunction Retraction of the tympanic membrane occurs when the eustachian tube is blocked and air pressure within the middle ear cannot be equalised Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 There will be no movement with positive pneumatic otoscopy but there maybe mild to moderate movement with negative pneumatic otoscopy Note the: 1. Intactness 2. Colour 3. Contour 4. Mobility 21  Red membrane and light reflex A red tympanic membrane alone may not indicate pathology, because the blood vessels of the drum head may be engorged as Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 a result of crying, sneezing, or blowing the nose. Assessment of the light reflex is generally not helpful, as a middle ear full of fluid reflects the light at least as well as a normal middle-ear space without fluid. 22  Inter-rater reliability of the diagnosis of otitis media based on otoscopic images and wideband tympanometry measurements International Journal of Pediatric Otorhinolaryngology 153 (2022) 111034 Results:  All four ENTs agreed on the diagnosis in 57% of the cases, with a pairwise agreement of 74%, and a Light’s Kappa of Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 0.58.  There are, however, large differences in agreement and certainty between the three diagnoses.  Acute otitis media yields the highest agreement (77% between all four ENTs) and certainty (0.90)  No effusion shows much lower agreement and certainty (34% and 0.58, respectively).  There is a positive correlation between certainty and agreement between the ENTs across all cases, and both certainty and agreement increase for cases where a WBT measurement is shown in addition to the otoscopy image. 23  Update of the consensus document on the aetiology, diagnosis and treatment of acute otitis media and sinusitis Anales de Pediatría 98 (2023) 362---372 The 2022 update of the clinical practice guideline on tympanostomy tubes in children published by Rosenfeld et al. states that pneumatic otoscopy is the method of choice when there are doubts Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 regarding the presence of effusion in the middle ear Watchful waiting or delayed antibiotic prescribing, after educating caregivers appropriately, could be adequate strategies for the management of AOM in children aged more than 6 months if there are no risk factors. The first step in the management of recurrent AOM should be the detection of predisposing factors, promoting protective factors and avoiding risk behaviours. 24  What are the medics currently doing? Acute otitis media management: A survey of European primary care pediatricians Global Pediatrics 4 (2023) 100057 Results:  Otoscope device used varied, including  conventional (89%), Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  fiber-optic (19%) and  pneumatic (4.9%) otoscopes.  Decision to treat:  78.1% (63.8–90.5%) would immediately initiate antibiotics for a 6-month-old with bilateral Acute Otitis Media;  73.2% (47.6%-82.9%) would use a delayed antibiotic therapy in a 25-month-old with bilateral Acute Otitis Media;  50.2% would immediately initiate antibiotic treatment in a first episode of Acute Otitis Media for a 3-year- old and 31.5% would defer antibiotics.  Younger pediatricians tend to prescribe more antibiotics: 87.6% vs 77.2%, OR: 2.08 (1.31–3.29). 25  Otoscopy review Note the: 1. Intactness 2. Colour 3. Contour 4. Mobility 26 Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 27 Tympanometry  Tympanometry Used to assess the compliance of the tympanic Tympanometric readings may be influenced by the membrane (movement) examiner and/or instrument:  Loss of compliance may indicate middle ear effusion  Proper calibration of the tympanometer is essential for  Loss of compliance will occur with tympanosclerosis accurate results.1 and tympanic atrophy  A low equivalent ear canal volume can be caused by improper placement of the probe (e.g. pressing against the Always needs to be compared to visual ear canal) or by obstructing cerumen. The ear canal should be cleaned and the probe repositioned before retesting. 1 assessment and pneumatic otoscopy Current guidelines outline: Less reliable in infants due to increased movement Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 of the external ear canal tissues  Pneumatic otoscopy is the primary tool for diagnosing middle ear effusion in acute otitis media or otitis media  Not reliable in infants under 7 moa with effusion.  The biggest changes occur during the first three years  Tympanometry is an optional tool that can be used to of life confirm suspected otitis media with effusion. Results may be affected by The success rate for performing Tympanometry is  ear wax between 74 and 94% compared with a success rate for  crying 84 – 91% for pneumatic otoscopy.2  moving  not cooperating  otitis externa 1. Rosenfeld et al. Clinical Practice Guideline: Tympanostomy Tubes in Children. American Academy Of Otoralyrgology-Head and Neck Surgery 149 (IS) S1 – S35. Wan and Wong (2002) found that 48% of Chinese children failed tympanometry screening when 2. Engel J, Anteunis L, Chenault M, Marres E. Otoscopic findings in relation norms developed on Caucasians were used to tympanometry during infancy. Eur Arch Otorhinolaryngol 2000;257:366-71. 28 Tympanometry Tympanometric patterns of various conditions of the middle ear. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 29  Useful to monitor child with chronic otitis media (middle ear effusion) Helps to document response to chiropractic care Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Tympanometry Always compare tympanogram with pneumatic otoscopy Often measured three monthly with chronic otitis media with effusion Used by ENT specialist to determine need for grommets 30  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 31 Otitis externa Otitis externa Often fungal Acute external otitis is Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 characterized by  intense pain that is worsened by traction on the pinna  purulent exudate  intense canal wall inflammation 32  Otitis externa The predominant symptom is ear pain, often severe, accentuated by manipulation of the pinna and especially by pressure on the tragus Itching is a frequent precursor of pain and is usually characteristic of chronic inflammation of the canal or resolving acute otitis externa. Conductive hearing loss may result from edema of the skin and tympanic membrane, serous or purulent secretions, or the progressive meatal skin thickening associated with long-standing external otitis. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 The canal frequently is so tender and swollen that the entire ear canal and tympanic membrane cannot be adequately visualized, and complete otoscopic examination may be delayed until the acute swelling subsides Other physical findings may include palpable and tender lymph nodes in the periauricular and, especially, preauricular areas. Rarely, facial paralysis, other cranial nerve abnormalities, vertigo, or sensorineural hearing loss is present. How would you test for conductive hearing loss in your office? 33  Treatment and management Only use ear drops if sure tympanic membrane is intact  need special drops if TM is perforated Can use 50/50 mixture of tea tree oil and olive oil heated to body temperature Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Avoid swimming (also called swimmer’s ear) or block external canal to prevent water entering. Adjust the subluxation Support child's immune system How would you support the child’s immune system? 34  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 35 Mastoiditis  Mastoiditis – clinical presentation Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Mastoiditis. A, This frontal photograph clearly shows the left auricle displaced anteriorly and inferiorly. B, In another patient, viewed from the side, erythema can be appreciated over the mastoid process. C, On otoscopy, erythema and edema of the canal wall are evident, and the posterosuperior portion of the canal wall sags inferiorly. 36  Look for: Mastoiditis 1. Head tilt (torticollis) 2. Ear prominence 3. Redness and/or swelling over mastoid process or behind ear 4. Tenderness of mastoid process 5. Unilateral cervical lymphadenopathy Test for sensitivity of the mastoid air cells by tapping firmly with your finger over the mastoid process, compare response with the unaffected side. Infection is associated with a very strong pain response Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 37  Pediatrics February 2009, VOLUME 123 / ISSUE 2 Effect of Antibiotics for Otitis Media on Mastoiditis in Children: A Retrospective Cohort Study Using the United Kingdom General Practice Research Database RESULTS. There were 2 622 348 children within the CONCLUSIONS. General Practice Research Database; 854 had mastoiditis, only one third of whom (35.7%) had Most children with mastoiditis have not seen their antecedent otitis media. general practitioner for otitis media. Mastoiditis incidence remained stable between 1990 Only one third with mastoiditis (35.7%) had antecedent and 2006 (∼1.2 per 10 000 child-years). otitis media. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Risk of mastoiditis, after otitis media, was 1.8 per 10 Antibiotics halve the risk of mastoiditis, but the high 000 episodes (139 of 792 623) after antibiotics number of episodes needing treatment to prevent 1 compared with 3.8 per 10 000 (149 of 389 649) without case precludes the treatment of otitis media as a antibiotics, and increased with age. strategy for preventing mastoiditis. Antibiotics halved the risk of mastoiditis. Although mastoiditis is a serious disease, most children make an uncomplicated recovery after mastoidectomy General practitioners would need to treat 4831 otitis or intravenous antibiotics. media episodes with antibiotics to prevent 1 child from developing mastoiditis. Treating these additional otitis media episodes could pose a larger public health problem in terms of If antibiotics were no longer prescribed for otitis media, antibiotic resistance. an extra 255 cases of childhood mastoiditis would occur, but there would be 738 775 fewer antibiotic prescriptions per year in the United Kingdom. 38 Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study Br J Gen Pract 2020; DOI: https://doi.org/10.3399/bjgp20X708821 The incidence of brain abscess and acute mastoiditis following Conclusion AOM, and of brain abscess and orbital cellulitis following AS, were calculated, as was the association between antibiotics and the development of these complications and numbers needed to treat Serious complications following AOM and AS are (NNT) rare. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Results Antibiotics are associated with lower odds of developing complications, but the NNT are large. The incidence of brain abscess and acute mastoiditis following AOM were 0.03 and 5.62 per 10 000 AOM episodes, respectively. Antibiotic prescription for AOM was associated with lower odds of developing acute mastoiditis (odds ratio [OR] 0.54); NNT to prevent one case was 2181. The incidence of brain abscess and orbital cellulitis following AS was 0.11 and 1.50 per 10 000 AS episodes, respectively. Antibiotic prescribing for AS was associated with lower odds of subsequent brain abscess (OR 0.12); NNT to prevent one case was 19 988. 39  Prevention and Management Mastoiditis is a rare condition where the mastoid air cells become Treatment with antibiotics is infected. indicated when mastoiditis is diagnosed. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Prophylactic treatment of otitis media with antibiotics to try to prevent mastoiditis has been shown to be unnecessary as well as not effective. Cochrane Summaries  There was not enough information to know if antibiotics reduced rare complications such as mastoiditis (infection of the bones around the ear).  VenekampRP, SandersSL, GlasziouPP, RoversMM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2023, Issue 11. Art. No.: CD000219. DOI: 10.1002/14651858.CD000219.pub5 40  Basilar skull fracture 41 Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  Basilar fracture Basilar skull fracture. A, The presence of a basilar skull fracture involving the temporal bone is often signaled by postauricular ecchymotic discoloration, termed the Battle sign. B, The force of the blow may also cause tearing of the ear canal or middle ear hemorrhage with hemotympanum. Depending on timing of examination, this may appear red or blue. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 42  Otitis media OM can be further divided into Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 1. Acute OM (AOM) without effusion with effusion 2. OM with effusion (OME) or serous otitis media 3. Chronic suppurative OM with or without cholesteatoma Other descriptions of OME include serous, secretory, mucoid, nonsuppurative, and “glue ear.” Chronic suppurative OM implies a nonintact tympanic membrane (perforation or tympanostomy tube present) with 6wk or more of middle-ear drainage. 43  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 44 Acute otitis media Normal tympanic membrane A normal tympanic membrane.  The drum is thin and translucent, and the ossicles are readily visualized. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  It is neutrally positioned with no evidence of bulging or retraction. What do we assess the ear drum for? 45  Acute Otitis media Examination with a pneumatic otoscope reveals a tympanic membrane which is 1. hyperaemic 2. opaque 3. bulging Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 4. poor mobility Purulent otorrhea with tympanic membrane perforation may be present The usual middle ear landmarks frequently are obscured 46  Epidemiology After respiratory tract infections, inflammation of the middle ear, otitis media (OM), is the most prevalent disease of child hood. The natural history is that about 85% will resolve spontaneously after 2 to 7 days. Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children (Cochrane Review). The Cochrane Library, 2001(2). Nearly two thirds of children have at least one episode of AOM by 3yr of age; 50% of children have two or more episodes. Infants and young children are at highest risk for OM, with the peak between 6 and 13mo of age. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 After a single episode of AOM,about 1. 40% of children have OME that persists for 4wk, 2. 10% have an effusion that is still present at 3mo. The incidence of the disease tends to decrease as a function of age, with a marked decrease after age 6yr. The incidence is higher in: 1. Boys 2. children in large day care settings 3. those exposed to second hand smoke 4. non–breast-fed infants 5. those with HIV or biologic siblings or parents with a significant history of OM OM is most common during the winter months because many episodes are associated with an upper respiratory tract infection (URI). 47  Otitis media and development There is no sound evidence that untreated otitis media results in speech/language delays or deficits. Stool SE, Berg AO, Berman S, Carney CJ, Cooley JR, Culpepper L, Eavey RD, Feagans LV, Finitzo T, Friedman E, et al. Managing Otitis Media with Effusion in Young Children. Quick Reference Guide for Clinicians. AHCPR Publication 94-0623. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of He alth and Human Services., 1994. July. 35,946 children without malformations and their parents completed a questionnaire at age 11 years. No associations were observed between number of OM episodes and school performance, even in children with 7 OM episodes. Early childhood otitis media and later school performance - A prospective cohort study of associations.(2017) http://dx.doi.org/10.1016/j.ijporl.2017.01.016 Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 A number of medical factors related to language delay were assessed – hearing loss, persistent otitis media, seizure disorder, birth asphyxia, low birth weight, preterm birth, and physical (oro-pharyngeal) deformity. Birth asphyxia, seizure disorder, and physical (oro-pharyngeal) deformity were found to be statistically significant risk factors. (Not persistent otitis media) Speech and language delay in children: Prevalence and risk factors. J Family Med Prim Care 2019;8:1642-6 Findings of Paradise et al. (2005, 2007) from a large-scale longitudinal study suggest that otitis media with effusion and associated hearing loss are not associated with Speech Sound Disorder in otherwise healthy individuals. Children with OM detected at 6 years of age in this cohort had average language development scores within the normal range at 6 and 10 years of age. Does otitis media affect later language ability? A prospective birth cohort study. Journal of Speech, Language and Hearing Research, published 15 June, 2020 48  Venekamp RP, Sanders SL, Glasziou PP, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Summaries Cochrane Database of Systematic Reviews 2023, Issue 11. Art. No.: CD000219. DOI: 10.1002/14651858.CD000219.pub5. The results of the trials revealed that by 24 hours from the start of treatment, 60% of the children had recovered whether or not they had placebo or antibiotics. Pain  Antibiotics do not reduce pain at 24 hours; (high-certainty evidence), or at four to seven days  result in almost a third fewer children having pain at two to three days (NNTB 20; high-certainty evidence),  likely result in two-thirds fewer having pain at 10 to 12 days (NNTB 7; moderate-certainty evidence). Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Antibiotics did reduce the number of children with abnormal tympanometry findings at two to four weeks (NNTB11) However, antibiotics neither reduced the number of children with abnormal tympanometry findings at six to 8 weeks or three mo nths nor the number of children with late AOM recurrences when compared with placebo. Antibiotics did slightly reduce the number of children with tympanic membrane perforations (NNTB33) Antibiotics halved contralateral otitis episodes (NNTB 11) compared with placebo. Severe complications were rare and did not differ between children treated with antibiotics and those treated with placebo. Antibiotics increase the risk of adverse events such as vomiting, diarrhoea or rash (NNTH 14; high certainty evidence). For most children with mild disease in high-income countries, an expectant observational approach seems justified. Therefore, clinical management should emphasise advice about adequate analgesia and the limited role for antibiotics 49  Antibiotics for Acute Otitis Media in Young Hoberman A, Paradise JL, Rockette HE, et al. Treatment of Children: The Case of the Shifting End Points acute otitis media in children under 2 years of age. N Engl J American Family Physician January 15, 2012 Med. 2011;364(2):105-115. Volume 85, Number 2 There were four primary outcomes. Having four primary outcomes is odd.  Clinical trials should be designed to have one predesignated primary outcome, with all 1. The first shows no difference in time to initial other outcomes considered secondary. resolution of symptoms in children who received antibiotics versus those who did not.  This end point is what we are most concerned with— When you look up this study on the ClincialTrials.gov Web site, you find that when does the child finally stop crying or fussing, or there were only three primary outcomes planned and the fourth outcome, when does the child’s fever go away? otoscopic resolution, was one of many planned secondary outcomes 2. The second outcome (sustained resolution of  You can’t switch a planned secondary outcome and make it a primary Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 symptoms) documents a slightly greater outcome just because you like the way the result turned out likelihood of two consecutive days of resolution of symptoms with antibiotics compared with  What is even more concerning is that the otoscopic findings are only one of placebo. 22 secondary outcomes evaluated in this study. It amazes me that a significant number of these findings, the ones that just happen to support 3. The third outcome was the mean AOM severity of placebo, were never reported symptoms score (a 14-point scale) at seven days.  In the group that received antibiotics, the mean score was  The secondary outcomes that demonstrated no difference between 2.79, whereas the mean score in the placebo group was placebo and amoxicillin/clavulanate were analgesia requirements in these 3.42.  These two end points, although statistically significant, children; number of needed follow-up visits to a primary care physician; are clinically insignificant; do you think a child or the number of visits to the emergency department; missed hours of work by child’s parents can tell a 0.63 difference on a 14-point the parents; and parental satisfaction. scale? 4. Lastly, the presence of more persistent findings It is disconcerting to see studies spun so positively when the original on otoscopy in the placebo group in follow-up has primary outcome, time to resolution of symptoms, demonstrated no no clinical effect. improvement with amoxicillin/clavulanate.  This is what we call disease-oriented evidence; it is not a patient-oriented outcome that we care about. In this study, the lead author and a colleague each received honoraria from 50 the manufacturer of the drug used in the study  Expectant observation of AOM  A study of 4,860 children with acute Otitis media treated with nose drops and pain relievers for four days revealed that more than 90% recovered within a few days with no further need for treatment. 3% of these children required antibiotics. Van Buchem FL, Peeters M, Van't Hof MA. Acute Otitis Media: a new treatment strategy. Br Med J, 1985. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 290(6):1033-37. In numerous studies, only approximately one-third of children initially observed received a rescue antibiotic for persistent or worsening AOM suggesting that antibiotic use could potentially be reduced by 65% in eligible children. Given the high incidence of AOM, this reduction could help substantially in curtailing antibiotic-related adverse events. The Diagnosis and Management of Acute Otitis Media Pediatrics; February 25, 2013 51  Close Follow-up in Children With Acute Otitis Media Initially Managed Without Antimicrobials JAMA Pediatr. 2016;170(11):1107-1108. 158 children between 6 and 35 moa with AOM were given placebo  104 overall condition improved after 48-72 hours without relapse over 1 week  54 overall condition did not improve after 48-72 hours or deteriorated over 1 week Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Otoscopy without symptomatic Otoscopy with symptomatic improvement improvement 3% perforation or worse signs 30% perforation or worse signs 2 perforations (2%) 3 perforations (6%) 14% no improvement 48% no improvement 83% improved or complete 22% improved or complete resolution resolution 52  In 2014, at least one course of antibiotics was dispensed to 46% of Australians Australian Commission on Safety and Quality in Health Care. Antibiotic use for OM AURA 2016 - First Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC, 2016 Antibiotic use varies from country to country: 31% in the Netherlands, 98% in Australia and 98% in the USA. Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children (Cochrane Review). The Cochrane Library, 2001(2). Antibiotic prescription for AOM in Australia for 1-4 yoa  2003-2007 84% Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  2007-2011 80%  2011-2015 80% General practice antibiotic prescribing for management of otitis media in children AFP VOL.45, NO.6, JUNE 2016  Use of antibiotics does not have a measurable effect on deafness due to Otitis media.  Use of antibiotics results in antibiotic resistant bacteria: 44% of cases of Otitis media in the USA involve antibiotic resistant infections against 1% in the Netherlands. Antimicrobial use and resistance in Australia Aust Prescr 2017;40:2-3 Matz PS. Acute Otitis Media. Pediatric Case Reviews, 2002. 2(4):209-219. 53  Assessing the appropriateness of the management of otitis media in Australia: A population-based sample survey Journal of Paediatrics and Child Health (2019) The percentage of children who received appropriate care for otitis media over all indicators was 58.0% Overprescribing of antibiotics was more common than underuse Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Estimated adherence to CPGs was higher for care provided in EDs (72%) and to hospital inpatients (78%) than in GPs (57%). 54  Rethinking Our Approach to Management of Acute Otitis Media JAMA Pediatrics Published online February 21, 2022 Current American Academy of Pediatrics guidelines for the management of AOM recommend that most children with non-severe AOM be treated with observation or a delayed prescription (a prescription to be filled only if the child’s health worsens or is not improved), rather than an immediate antibiotic. When an antibiotic is prescribed, amoxicillin is recommended as first line therapy for most Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 children, and 5 to 7days of therapy is recommended for children 2 years or older Despite these recommendations, more than 95% of children with AOM are prescribed an antibiotic of which more than 95% are immediate and 94% are for a duration of 10 days, including for those 2 years or older. Clinical data indicate that 78% to 85% of AOM episodes in the post-PCV era self-resolve  Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219. For clinicians and parents, the framework needs to shift to defaulting to symptom management with no antibiotic, with an antibiotic required only in select circumstances, or if a child’s health does not improve. This could be practically accomplished by routine use of observation or delayed prescribing 55  Effect of Antibiotics on the immune system and the GIT Use of antibiotics destroys the helpful intestinal bacteria which affects digestion, immune function and synthesis of certain vitamins. Use of antibiotics inhibits immune function, increasing the likelihood of further infections. 1. Antibiotics prevent white blood cell movement to the site of infection, Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 2. Antibiotics reduce the ability of white blood cells to attack bacteria and suppress the activity of bacteria killing neutrophils. 3. Antibody production is also decreased for up to 20 days after use. Certain antibiotics reduce the absorption of nutrients such as vitamin K, B12, folic acid, calcium and magnesium. ◼ In a study of 3,660 children with Otitis media, antibiotic treated children recovered at a slightly slower rate than children not receiving antibiotics.  Froom J, et al. Diagnosis and antibiotic treatment of acute otitis media: report from the international primary care network. Br Med J 1990. 300:582-6. 56  Anti-biotic resistance 26 April 2012 the National Prescribing Service Data suggest that antibiotic resistance ranks low on (NPS), a government body formed in 1998 to the list of factors influencing GP’s decisions regarding give health professionals and consumers AB use access to information for good prescribing and medicine use decisions, called on the Government to take the lead on tackling the anti-biotic resistance crisis facing the Prescribing routine course of antibiotics significantly Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Australian community increases the likelihood of an individual carrying a resistant bacterial strain. Aim of NPS is to reduce AB prescribing by 25% in 5 years to bring Australia in line with Previous use of AB during the previous two month OECD average. period doubles the chance of carrying AB resistant bacteria AB resistance from use of beta-lactam AB persisted Chiropractors may play a significant role in for at least 2 months assisting this process. B resistance from macrolide use persisted for at least six months 57  What every parent should know Fact sheet MedicineWise 2019 MODULE 11 AUTHORED BY DR BRADEN KEIL ©DR B KEIL 2024 58  Eustachian tube development o A child's eustachian tubes are different from an adult's in that they are o more horizontal and their nasopharyngeal opening, the torus tubarius, is likely to have numerous lymphoid follicles surrounding it. Also in a child, adenoids may fill the nasopharynx, mechanically blocking Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 o the nose and eustachian tube orifice or acting as a source of infection that may contribute to edema and dysfunction of the eustachian tube. o The eustachian tubes are normally closed at rest and open with swallowing by action of the tensor veli palatini, which extends from the skull base and inserts laterally into the soft palate. o The eustachian tubes protect the middle ear from nasopharyngeal secretions, provide drainage into the nasopharynx of secretions produced within the middle ear, and permit equilibration of air pressure with atmospheric pressure in the middle ear. 59  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 60 Nasopharynx adenoids  Presentation Children with an URI often develop the symptoms of AOM: 1. otalgia 2. fever 3. hearing loss 4. generalized malaise Other symptoms may include 1. otorrhea 2. irritability 3. lethargy 4. less often anorexia, nausea, vomiting, diarrhea, and headache. Fever occurs in approximately 30–50% of patients; temperatures exceeding 40°C are uncommon Older children may complain of  tinnitus,  vertigo, and  hearing loss  smaller children may not be able to complain about these specific symptoms but may appear to be off balance. Any child with a fever without a focus should be evaluated for a middle-ear infection 61 Module 11 authored by Dr Braden Keil ©Dr B Keil 2024  Sequelae of AOM - Bullous myringitis Acute otitis media with bullous myringitis. The bullous lesion commonly ruptures spontaneously, providing Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 immediate relief of pain. 62 Sequelae of AOM - Perforation Acute otitis media with perforation. Spontaneous healing is expected in 1-2 days Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Increased middle ear pressure with acute otitis resulted in perforation of the tympanic membrane. 63  Traumatic tympanic membrane perforation Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Traumatic perforations of the tympanic membrane. A, This 8-year-old boy's tympanic membrane was perforated by a forceful slap on the ear. B, Even more severe damage with thickening and hemorrhage is seen in this victim of a blast injury caused by an explosion. 64 Sequelae of perforation - Dimerism Dimerism of the tympanic membrane. Primarily occurs post grommets Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Otoscopy demonstrates a severely retracted atrophic segment of the eardrum that also has multiple white scars. The thinned portions are the result of abnormal healing of perforations and tend to be hypermobile on otoscopy. Why does this happen? What does it suggest we need to do? 65  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 66 (Serous otitis media) Otitis media with effusion  Otitis media with effusion The tympanic membrane is often retracted and moves poorly or not at all with pneumatic otoscopy. If a significant amount of middle-ear fluid is found, the Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 middle-ear landmarks may be obscured; if the tympanic membrane is very retracted, the malleus may be very prominent, and the incudostapedial joint may be seen as the eardrum drapes tightly over it. The tympanic membrane is usually opaque but may also be translucent, with an air-fluid level or air bubbles seen behind it. The middle-ear fluid may be whitish, yellow, or almost bluish. 67 Serous otitis media This patient has a chronic serous middle ear effusion. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 The tympanic membrane is retracted, thickened, and shiny. Behind it is a clear yellow effusion. Mobility was decreased and primarily evident on negative pressure. The child was not acutely ill but did have decreased hearing 68  Otolaryngology– Head and Neck Surgery 2016, Vol. 154(2) 201– 214 Clinical Practice Guideline: Otitis Media with Effusion Executive Summary (Update) 90% of children have OME before school age. When children aged 5 to 6 years in primary school are screened for OME, about 1 in 8 are found to They develop, on average, 4 episodes of OME every have fluid in one or both ears. year. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 The prevalence of OME in children with Down Mandel EM, Doyle WJ, Winther B, Alper CM. The incidence, prevalence and burden of OM in unselected children aged 1-8 years followed by weekly otoscopy syndrome or cleft palate is much higher, ranging through the “common cold” season. Int J Pediatr Otorhinolaryngol. 2008;72:491- from 60% to 85%. 499. Most episodes (75%) of OME resolve OME may occur spontaneously within 3 months, but 1. during an upper respiratory infection  about 30% to 40% of children have repeated OME 2. spontaneously because of poor eustachian tube episodes, function  5% to 10% of episodes last ≥1 year 3. as an inflammatory response following AOM, most often between the ages of 6 months and 4 years.  25% of OME episodes persist for ≥3 months 69  Viral infection in chronic otitis media with effusion in children (2023) Front. Pediatr. 11:1124567. doi: 10.3389/fped.2023.1124567 Background:  The role of respiratory viruses in chronic otitis media with effusion (COME) in children is not clearly defined.  In our study we aimed to investigate the detection of respiratory viruses in middle ear effusions (MEE) as well as the association with local bacteria, respiratory viruses in the nasopharynx and cellular immune response of children with COME. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Results:  Respiratory viruses were detected in MEE of 44 children (64%).  Rhinovirus (43%), Parainfluenzavirus (26%) and Bocavirus (10%) were detected most frequently.  Higher detection rates correlated with elevated BMI.  Monocytes were elevated in MEE (9.5 ± 7.3%/blood leucocytes).  Exhaustion markers were elevated on CD4+ and CD8+ T cells and monocytes in MEE. Conclusion:  Respiratory viruses are associated with pediatric COME.  Elevated BMI was associated with increased rates of virus associated COME.  Changes in cell proportions of innate immunity and expression of exhaustion markers may be related to chronic viral infection. 70  The Prevalence and Association of Biofilms With Otitis Media With Effusion: A Systematic Review and Meta-Analysis Annals of Otology, Rhinology & Laryngology (2023) 1–10 We performed a comprehensive search of electronic databases, and eight studies with a total of 402 patients, and 504 samples, were found to fulfill our eligibility criteria and included in this meta-analysis. Bacterial biofilms were found in 84% to 92% of chronic OME middle ear biopsies, but not in Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 controls. The presence of biofilm has no statistically significant relationship with the results of MEE culture. Only 23.8% of patients with biofilm had a positive culture. Conclusion:  The data presented in this study coincide with the significant role of bacterial biofilms in the pathogenesis of chronic otitis media with effusion.  The involvement of bacterial biofilm as a component of the OME pathogenic process can help us to explain why antimicrobial therapy is not always effective in the eradication of the disease process and, also explain the recurrence of middle ear effusion after treatment with tympanostomy tubes either with or without adenoidectomy. 71  Autoinflation for otitis media with effusion (OME) in children Cochrane Database of Systematic Reviews 2023, Issue 9. Art. No.: CD015253. DOI: 10.1002/14651858.CD015253.pub2. Due to a lack of robust evidence, we are uncertain whether autoinflation has any effect on hearing. Using autoinflation two to three times per day may slightly reduce the number of children with OME after three months follow-up. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 Scores on a questionnaire that looked at quality of life for people with OME were also better for children who carried out autoinflation. However, some children may experience pain whenm using autoinflation. 72  Antibiotics for otitis media with effusion (OME) in children Cochrane Database of Systematic Reviews 2023, Issue 10. Art. No.: CD015254. DOI: 10.1002/14651858.CD015254.pub2. We included 19 studies involving over 2500 children. Many different types of oral antibiotics were used and the duration of treatment varied a lot between the studies. It is unclear whether antibiotics have any effect on hearing, as the evidence was not robust. Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 When compared to no treatment, antibiotics might slightly reduce the number of children who have OME after three months of follow up. Only two studies looked at the number of children with OME after a longer follow-up time, so we are uncertain whether this is a long-lasting effect, as OME may recur. We do not know if treatment with antibiotics has any effect on quality of life as none of the studies included in this review assessed this outcome. We were unable to find much evidence on the occurrence of anaphylaxis - a rare but very serious allergic reaction. 73  Adenoidectomy for otitis media with effusion (OME) in children. Cochrane Database of Systematic Reviews 2023, Issue 10. Art. No.: CD015252. DOI: 10.1002/14651858.CD015252.pub2. We are uncertain whether surgery to remove the adenoids (adenoidectomy) improves hearing for children with glue ear, because the evidence is not robust. Adenoidectomy may slightly reduce the number of children who have glue ear after Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 one to two years of follow-up, but we do not know the effect of this on hearing or quality of life. We know that there may be harms from surgery, such as a risk of bleeding. However, there was not enough information in the studies to know how often this may occur. 74  Otolaryngology– Head and Neck Surgery Clinical Practice Guideline: Otitis Media 2016, Vol. 154(2) 201– 214 with Effusion Executive Summary (Update) PNEUMATIC OTOSCOPY: The clinician should document the presence of middle ear effusion with pneumatic otoscopy when OME may be associated diagnosing OME in a child. Strong recommendation with PNEUMATIC OTOSCOPY: The clinician should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both. Strong recommendation 1. hearing loss 2. Balance (vestibular) TYMPANOMETRY: Clinicians should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy. Strong recommendation problems Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 3. poor school performance WATCHFUL WAITING: Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown). Strong recommendation 4. Behavioral problems STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong 5. ear discomfort recommendation against 6. recurrent AOM ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation against 7. reduced Quality of life ANTIHISTAMINES OR DECONGESTANTS: Clinicians should recommend against using antihistamines, decongestants, or both for treating OME. Strong recommendation against HEARING TEST: Clinicians should obtain an age-appropriate hearing test if OME persists for ≥3 months OR for OME of any duration in an at-risk child. Recommendation SPEECH AND LANGUAGE: Clinicians should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development. Recommendation SURVEILLANCE OF CHRONIC OME: Clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle e ar are suspected. Recommendation 75  Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 76 Tympanostomy tubes Tympanostomy tube A, Tympanic membrane of patient with a history of chronic otitis media, with tympanostomy tube in place. The tube serves to vent the middle ear, improve hearing, and reduce Module 11 authored by Dr Braden Keil ©Dr B Keil 2024 the frequency of infection. B, The tympanic membrane is about the size of a dime. A typical tube takes up approximately 15% of the tympanic membrane's surface area. There are many different types in a variety of shapes, materials, sizes, and colors. Selection is based on specific pathology and surgeon preference. 77  Otolaryngology– Head and Neck Surgery Clinical Practice Guideline: Otitis Media 2016, Vol. 154(2) 201– 214 with Effusion Executive Summary (Update) OME may be associated SURGERY FOR CHILDREN