ENT approach to middle ear disease in children: the evidence. Dr Trish MacFarlane MBBS, FRACS.

ENT approach to middle ear disease in children: the evidence. Dr Trish MacFarlane MBBS, FRACS.

Outline: Extent of the problem. Defining the problem. Tips to improving diagnostic accuracy. Review of current recommended treatment guidelines Surgical interventions

Extent of the problem: Otitis Media in Aboriginal Children: Earlier onset of disease Higher rates of OM (all types) in remote and urban Aboriginal children Higher rates of progression to chronic disease Longer duration of disease Cumulative duration of 2.5-3 years during childhood Jervis-Bardy J, Sanchez L, Carney AS. Otitis Media in Indigenous Australian children: review of epidemiology and risk factors. J Laryn Otol 2014. 128:S17-27

Extent of the problem: Hearing Variable rates of hearing impairment in literature: 6-70% Initially conductive hearing loss, may fluctuate Aboriginal children have 2.5x the rate of hearing aid use/cochlear implantation Persists into adulthood

Extent of the problem: Thinking (cognitive) skills Psychological issues BRAIN localisation Social Emotional attention EAR pain hearing loss sound distortion PERSON understanding speech in background noise Speech and language skills Ref: Linnett Sanchez

Common consequences of hearing loss in school-age children HL leads to: negative self-image lack of regard for external rules and constraints poor school attendance slow school progress or failure lack of basic literacy and numeracy prevents progress to secondary and post-secondary education Ref: Linnett Sanchez

Comparison of hearing screening test results with other groups Ref: Linnett Sanchez

Definitions

Normal Normal or Healed OM Variable appearance Tympanosclerosis = white patches Healed perforation = thin drum Retracted drum = short handle of malleus

Acute Otitis Media Middle ear effusion with rapid onset of one or more signs of inflammation of the middle ear (fever, otalgia, irritability with bulging, cloudy/ opaque drum with or without otorrhoea.) Not red ear

Otitis Media with Effusion Effusion without signs of acute inflammation Dull, opaque, retracted, yellow fluid or air-fluid levels >3 months duration = Persistent OME

Chronic Suppurative OM Persistent otorrhea through a non-intact tympanic membrane (perforation or grommet) for > 3 months duration

Perforation Acute or Chronic Inactive (dry) or active (discharging)

Retracted Drum Persistent OME or poor ET function can lead to collapse of ear drum May result in hearing loss by erosion of ossicles May result in Cholesteatoma formation

Fungal Otitis Externa May be associated with use/overuse of topical antibiotic drops Treatment Topical locacorten vioform drops (2 drops, BD for 7 days)

Improving diagnostic accuracy Because sometimes you just can t tell..

Diagnostic Accuracy Otoscopy findings: GP ~ 40% Paediatrican ~ 50% ENT Surgeon ~ 70% Wax impaction: Wax softening drops Dilute betadine irrigation 1:20 solution

Tissue Spears

Improving diagnostic accuracy

Pneumatic Otoscopy Improves accuracy of diagnosis of fluid behind an intact drum Looking for movement of drum with alternating pressure Reduced or no movement of drum = fluid Normal movement = air

Tympanometry Quick, painless, simple to use Measure of the compliance of the ear drum and ossicles 3 results: A = Normal B = Perforation or fluid C = Eustachian Tube Dysfunction

Tympanometry Additional info: Canal volume Normal Kids - < 1ml Adults < 1.5ml

RECOMMENDATIONS FOR CLINICAL CARE GUIDELINES ON THE MANAGEMENT OF OTITIS MEDIA in Aboriginal and Torres Strait Islander Populations updated 2010 OM Guidelines Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations (2010) http://www.healthinfonet.ecu.edu.au/key-resources/promotion-resources?lid=22141

AOM: Non ATSI children Watchful waiting Resolution of symptoms: 70-80%% untreated 92% of treated children 7-14 days 60-70% resolve OME by 30 days follow up 8-15% have persistent OME at 12 weeks. Antibiotics: Children < 6 months. Children >6/12 with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours or temperature > 39 C, with unilateral or bilateral disease. Children < 2 with bilateral AOM At risk children. AAP Guidelines, SA Health, RCH Melbourne

AOM: ATSI Guideline Treat with antibiotics if <2 years of age with bilateral disease, and those with a history of AOM with ear discharge. Amoxycillin 50mg/kg 2-3 times daily for 7 days). Referral to ENT raom - > 4 episodes/year or 3 in 6 months My Recommendations Treat with antibiotics. Amoxycillin 50mg/kg 2-3 times daily for 7 days). 2 nd Line agents: Amoxycillin+clavulanate 22.5+3.2 mg/kg up to 500+125 mg orally, 8-hourly for 5 to 7 days. Cefuroxime (child 3 months to 2 years: 10 mg/kg up to 125 mg; 2 years or older: 15 mg/kg up to 500 mg) orally, 12-hourly for 5 days

OME Referral for ENT assessment: Unilateral/Bilateral OME: Normal hearing regular review until resolved Unless severe retraction pocket present Mild HL (20-35dB) ENT referral If present for > 3 6 months Moderate HL (>35dB) ENT referral If present for > 3 months Antibiotics, steroids, antihistamines, autoinflation devices and decongestants are NOT recommended Intervention: Ventilation Tubes +/- Adenoidectomy

CSOM Treatment: Topical Ciloxcin drops 5 drops, twice a day for 7-10 days Regular reviews to ensure ear becomes dry When to refer to ENT: Persistent discharge despite topical drops May require IV antibiotics or mastoidectomy Chronic perforation that intermittently discharges

Dry Perforation Water precautions: Treat acute infections aggressively with topical drops (Ciloxcin) When to refer: Recurrent discharge Swimming/water sports Normal-Mild-Mod Hearing Loss ENT referral for consideration of myringoplasty

Surgical Interventions

Ventilating Tubes Indications: Recurrent AOM Persistent OME Discharging grommet: Treat topically Ciproxcin HC or Ciloxcin 0.3% ear drops (authority script) Water Precautions

Adenoidectomy Indications 2 nd or subsequent set of grommets Chronic Suppurative Otitis Media Prior to Myringoplasty Chronic nasal discharge Chronic Eustachian Tube dysfunction

Myringoplasty Indications: Dry Perforation Prevent further infections Improve hearing

Mastoidectomy Rarely required Indications: Chronic Suppurative Otitis Media unresponsive to medical therapies Failed myringoplasty Cholesteatoma

Take home messages: Encourage opportunistic surveillance (look early, look often!). Add tympanometry or pneumatic otoscopy to diagnostic workup. Treat middle ear disease in Aboriginal and Torres Strait Islander children aggressively. Refer for hearing assessment, speech pathology assessment early, +/- DECD and Australian Hearing (Sensorineural HL) Refer children with middle ear pathology EARLY for ENT intervention.

Questions?