BEAUTY IS IN THE EAR OF THE BEHOLDER

Transcription

1 BEAUTY IS IN THE EAR OF THE BEHOLDER ANNE SPICER, DC, DACCP ASSOCIATE PROFESSOR/CLINICAL MENTOR NORTHWESTERN HEALTH SCIENCES UNIVERSITY OTITIS MEDIA Ò Incidence Ò Risk Factors Ò Signs and Symptoms Ò Exam Ò Treatment Ò Home Care Ò Outcomes Ò Complications 1

2 ACUTE OTITIS MEDIA Ò AAP Definition (Pediatrics 2013, Feb) É 1. acute onset of symptoms É 2. presence of middle ear effusion (MEE) É 3. signs of acute middle ear inflammation INCIDENCE INCIDENCE Ò 60% of children will have at least 1 ear infection by age 3 Ò 30% will have more than 1 ear infection by age 1 Ò Acute otitis media is most common diagnosis during pediatrician visits other than for wellchild reasons 2

3 PHYSICAL PREDISPOSITIONS Ò Eustachian tubes are short, wide, straight and horizontal Ò Cartilaginous lining is underdeveloped Ò Temporal bone flare may distort tube Ò Cervico-cranial myospasm may alter cervical biomechanics RISK FACTORS 3

4 RISK FACTORS Ò Older siblings RISK FACTORS Ò Older siblings Ò Daycare RISK FACTORS Ò Older siblings Ò Daycare Ò Family history 4

5 RISK FACTORS Ò Older siblings Ò Daycare Ò Family history Ò Pacifier use RISK FACTORS Ò Older siblings Ò Daycare Ò Family history Ò Pacifier use Ò Second hand smoke RISK FACTORS Ò Older siblings Ò Daycare Ò Family history Ò Pacifier use Ò Second hand smoke Ò Allergy Ò Low socioeconomic status 5

6 SIGNS AND SYMPTOMS COMMON SIGNS AND SYMPTOMS Ò Tugging ears Ò Pulling ears Ò Holding ears COMMON SIGNS AND SYMPTOMS Ò Irritability Ò Excessive crying 6

7 COMMON SIGNS AND SYMPTOMS Ò Changes in behavior pattern COMMON SIGNS AND SYMPTOMS Ò Change in appetite COMMON SIGNS AND SYMPTOMS Ò Disturbed sleep 7

8 COMMON SIGNS AND SYMPTOMS Ò +/- fever DDX TEETHING Ò Drooling Ò Fingers in mouth Ò Inflamed gums Ò Red cheeks Ò Appetite change Ò Loose stools DDX TOPICAL IRRITATION Ò Excessive cerumen Ò Soap residue 8

9 DDX URI Ò Runny nose Ò Puffy eyes Ò Sneezing Ò Coughing DDX REFERRED PAIN Ò SCM Ò TMJ Ò Teeth Ò Upper cervicals EXAMINATION 9

10 EXAMINATION EXAMINATION EXAMINATION Ò Color Ò Contour É Shape and position of light reflex É Clarity of ossicles É Bulge Ò Translucency Ò Fluid lines 10

11 EXAMINATION Ò Color of tympanic membrane É Grey EXAMINATION Ò Color of tympanic membrane É White Ð otosclerosis EXAMINATION Ò Color of tympanic membrane É White Ð cholesteatoma 11

12 EXAMINATION Ò Color of tympanic membrane É White Ð purulence EXAMINATION Ò Color of tympanic membrane É Yellow É Amber EXAMINATION Ò Color of tympanic membrane É Pink É Red 12

13 EXAMINATION Ò Contour of the tympanic membrane Ò Shape and position of light reflex É cone in anterior/inferior quadrant is normal Ð loss of cone shape Ð change in position EXAMINATION Ò Contour of the tympanic membrane Ò Clarity of ossicles É malleus Ð normally easily visible Ð protrudes with retraction EXAMINATION Ò Contour of the tympanic membrane Ò Clarity of ossicles É obliterated with bulge 13

14 EXAMINATION Ò Assessment of contour Ò A. Normal Ò B. Mild bulge Ò C. Moderate bulge Ò D. Severe bulge Alejandro Hoberman, MD (AAP Publications) EXAMINATION Ò Integrity of tympanic membrane EXAMINATION Ò Integrity of tympanic membrane 14

15 TREATMENT TREATMENT Ò Medical É Watchful waiting: Considered when AOM is questionable, there is no pain, the signs are unilateral and/or the child is older than 2 TREATMENT Ò Medical É Antibiotics Ð under age 2 antibiotics are most appropriate. Ð After age 2 antibiotics with diagnostic certainty 15

16 TREATMENT CONSIDERATIONS Ò 80+% of all ear infections improve with no treatment at all Ò Use of Amoxicillin for treatment of the first episode of ear infection results in an increased likelihood of recurrence Ò Use of antibiotics in general is associated with healing of the ear infection 1 day sooner than no pharmaceutical treatment at all. Ò Overuse of antibiotics has resulted in spontaneous development of antibiotic resistant strains of organisms TREATMENT Ò Medical É Tubes Ð Single episode lasting 3+ months Ð 6 episodes in 1 year Ð 6 months symptomatic over 24 months TREATMENT OPTIONS Ò Chiropractic adjustment-is there evidence? Ð Fallon, JM. The Role of the Chiropractic Adjustment in the Care and Treatment of 332 Children with Otitis Media. Journal of Clinical Chiropractic Pediatrics 1997 Vol 2, No. 2 p (Pilot study: improvement in otoscopic findings and tympanograms in 4-8 visits) Ð Sawyer CE, et al Feasibility Study of Chiropractic Spinal Manipulation versus Sham Spinal Manipulation for Chronic Otitis Media with Effusion in Children. J Manipulative Physiol Ther 1999 (June);22(5): (Single blind pilot studyattaining outcome measures challenging) Ð Mills et al, The Use of Osteopathic Manipulative Treatment as Adjuvant Therapy in Children With Recurrent Acute Otitis Media. JAMA 2003 Sept; 157:9 (Single blind RCT. 57 children: fewer episodes of AOM, fewer surgeries and improved tympanograms) Ð Low level research: case series/studies 16

17 TREATMENT OPTIONS Ò Chiropractic adjustment É most common C0-C4 TREATMENT OPTIONS Ò nutritional considerations É Vit A ( IUs/day) É Vit C (to gut tolerance) É Zinc (5-15mg/day) É Omega 3 Fatty acid supplement Ð Coromega Ð EPA/DHA Junior Ð Krill oil Ð Cod liver oil É Probiotics TREATMENT OPTIONS Ò Cranial techniques 17

18 Ò Sinus/lymphatic stimulation É stroke gently from superior to inferior along the anterior and posterior SCM SINUS/LYMPHATIC MASSAGE Ò Oral sweep É stroke gently at the junction of the hard and soft palate É this contracts the tensor veli palatini muscle which aids eustachian tube opening É the TVP is innervated by CN V- mandibular branch, which also serves muscles of mastication ORAL SWEEP ORAL SWEEP 18

19 TREATMENTS Ò Homeopathic remedies Ò acupuncture HOME CARE HOME CARE Ò Ear drops É Garlic and Mullein 19

20 HOME CARE Ò Essential Oils É Calendula É Lemon É Rosemary É Lavendar HOME CARE Ò Lymphatic stripping Ò Oral sweep HOME CARE Ò Heat application 20

21 HOME CARE Ò Inclined sleep position HOME CARE Ò Discontinue pacifier use and bottle propping Ò Eliminate dairy É 75% persistent OM cases show improvement É substitution of Ca+/A/D fortified almond/coconut milk or add Calcium supplement OUTCOME ASSESSMENT 21

22 SYMPTOM IMPROVEMENT Ò Reduced/eliminated pain Ò Improved/normal disposition Ò Improved/normal sleep Ò Afebrile Ò Improved/normal appetite Ò Improved/normal play behavior OTOSCOPIC EXAM FINDINGS Ò Reduced grade of bulge Ò 0-normal 1- erythema only 2-erythema+fluid 3-erythema+effusion Ò Possible Acute Otitis Media High confidence Acute Otitis Media Ò 4-opaque, fluid, 5- (4) + complete 6-(5) + donut bulge 7- (5) + bulla bulge, erythema effusion COMPLICATIONS 22

23 COMPLICATIONS Ò Ò É É Mastoiditis Sx Ð Dull ache and tenderness at mastoid Ð Low grade fever Ð Ear flaring Tx Ð Antibiotics (4,831 cases of OM treated with abx to prevent 1 case of mastoiditis) Ð Surgical draining of the mastoid Ð Surgical removal of damaged bone (mastoidectomy) Meningitis COMPLICATIONS Ò Adenoidal tonsillar hypertrophy COMPLICATIONS Ò Adenoidal tonsillar hypertrophy É Sx Ð persistent mouth breather Ð Snoring Ð Apnea Ð chronic OM Ð may be assoc with behavioral disorders Autism ADHD LD EBD 23

24 COMPLICATIONS Adenoidal Tonsillar Hypertrophy-Treatment Ò Conservative É Adjust É Lymphatic massage É Vit C É Remove allergens/irritants É complications/indications for medical referral Ò Ð Cyanosis Ð Apnea Medical Tonsillectomy adenoidectomy É É REFERENCES Ò Sexton S, Natale R, Risks and Benefits of Pacifiers, Am Fam Physician Apr 15;79(8): Ò Owen MD et al, Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life, JAMA 1993 Nov 123; 5 : Ò AAP, Clinical Practice Guidelines: The Diagnosis and Management of Acute Otitis Media, Pediatrics 2013;131:e964-e999 Ò Harmes KM et al. Otitis Media: Diagnosis and Treatment, Am Fam Physician Oct 1;88(7): Ò Zhang Y et al, Risk Factors for Chronic and Recurrent Otitis Media- a metaanalysis, PLoS One 2014 Jan 23;9(1):e86397 Ò Gottlieb A, Rupert R, Chiropractic manipulation in pediatric health conditions an updated systematic review, Chiropractic and Osteopathy :11 Ò ICPA4Kids.com: Pediatric chiropractic resources and research citations. RESOURCES Ò Practice/exercises.htm Ò grading.htm 24