Dine & Learn - Victoria May 2015 Otolaryngology Allergic rhinitis Allergic rhinitis guidelines (Otolaryngology Head and Neck Surgery 2015) Diagnosis: history: allergen + either nasal congestion or runny nose or itchy nose or sneezing exam: clear rhino, nasal congestion, pale turbinates, red watery eyes Treatment: avoid allergen intranasal steroid all are of equivalent efficacy all have negligible systemic absorption, except Triamcinolone (Nasacort) beclomethasone, dexamethasone caused adrenal suppression, no longer in use, in children Triamcinolone (Nasacort) may slow growth velocity (0.5cm/y) ok to use for decades in adults find min effective freq and dose rare septal perf., aim away from septum Have nose examined yearly by ENT antihistamine (2 nd gen) intranasal steroid + antihistamine may consider turbinate reduction may consider acupuncture Allergist referral if: not responding to treatment uncertain of diagnosis need to know allergen immunotherapy (if not responding to meds +/- environment change) Also look for: asthma atopic dermatitis rhinosinusitis conjunctivitis Otitis media sleep disordered breathing Do Not: Xray use Oral leukotriene
Rhinosinusitis Pearls: don't trust patient's self diagnosis tapping sinuses not sensitive or specific Xrays not sensitive or specific (unless there is A/F level) Sinus cyst/polyp reported on CT is of no significance most times rare to smell well during sinusitis Sinusitis Guidelines (Otolaryngology Head and Neck Surgery 2015) Acute rhinosinusitis (<4weeks) Diagnosis Purulent discharge (ant and/or post) + (nasal obstruction and/or facial pressure) For 10 days with no improvement or worsen within 10 days after an initial improvement No imaging, unless complication suspected Treatment For symptom relief: analgesia, topical steroids +/- saline irrigation Initial abx or watch up to 7 days, unless worsens Amoxil +/- Clav for 5-10 days (Penn allergy: use doxycycline or levofloxacin or moxifloxacin) Treatment failure If worsens or fails to improve by 7 days, reassess, change antibiotic: clavulin, doxycycline, levofloxacin, moxifloxacin, clindamycin plus 3 rd -gen oral cephalosporin Chronic rhinosinusitis (>12 weeks) and recurrent Acute rhinosinusitis (4+ episodes/y) Diagnosis Confirm with objective evidence of inflammation (by ant rhinoscopy, endoscopy, CT) consider asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. Consider allergy test Check for polyps Treatment for symptom relief: topical steroids and/or saline irrigation no antifungal rinse consider ref to ENT
Acute otitis media (AOM) Exam Pearls (contemp concepts in AOM, Oto Clinic N AM 2015) don't trust parents' diagnosis: 50% wrong when they think there is an ear infection red drum, fluid not sufficient for diagnosis positive exam mild bulging TM + pain + intense erythema. or mod/severe bulging TM, or otorrhea Treatment guidelines - Canadian Pediatric society 2009 Use Abx in all cases except: child >6 months with mild otalgia, temp < 39, and fu at 48-72h no history of: pulm/cardiac disease, anatomical anomaly, Down syndrome, prev perforation Consider Abx more readily in Aboriginal Child Abx: Amoxil 75-90 mg/kg div bid for 10 days Cefprozil 30 mg/kg/day divided twice per day Cefuroxime axetil 30 mg/kg/day divided twice per day Ceftriaxone 50 mg/kg intramuscularly (or intravenously) x 1 dose Azithromycin 10 mg/kg once per day x 1 dose, then 5 mg/kg once per day x 4 doses Clarithromycin 15 mg/kg/day divided twice per day Amoxicillin-clavulanate 90 mg/kg/day amoxil+ 6.4 mg/kg/day clav div bid for 10 days Treatment guidelines - American Academy Pediatrics 2013 Use Abx for all cases except: child 6-23/12 mild unilat AOM and fu at 48-72h, child 2y+ not severe AOM, and fu at 48-72h. Parental agreement needed too. Antibiotics shown to reduce pain faster middle ear effusion post infection last 2.7 weeks instead of 4.7 weeks Amoxil if: no amoxil in prev 30 days, no purulent conjunctivitis, not allergic AOM when to refer to ENT (contemp concepts in AOM, Oto Clinic N AM 2015) can't examine ear unexplained progressive TM change poor response to therapy recurrent AOM, esp in child with co-morbidity progressive/persistent AOM suspected complication of AOM (FN palsy, mastoiditis, meningitis, abscess) NB: 'mastoiditis' on a CT report doesn't mean a mastoid infection. With an infection the radiologists should describe a coalescent mastoiditis with breakdown of bony septations +/subperiosteal abscess.
AOM prevention vaccination no smoke around child exclusive breastfeeding to age 4-6 months. Tubes indication 3 AOM in 6 months 4 AOM in 12 months, with 1 in past 6 months when to worry about an infected ear not responding to treatment immunocompromised pt intractable pain poorly controlled glucose complication of AOM persistent purulent discharge
What not to miss in ENT Ramsey hunt syndrome (Ear pain, Hearing loss, Facial Paralysis, Vesciles in ear, palatal petechiae) Sudden sensorineural hearing loss (Hearing loss over 3 days, N TM, Weber opposite side) Unilateral hearing loss, or Tinnitus (refer to either fix conductive loss, or r/o retrocochlear tumor) Malignant otitis media (Immunocompromised, High blood glucose, intractable pain, out of keeping with findings, if missed lower cranial nerve paralysis) Cholesteatoma (white pearly lesion superior drum, granulation, chronic draining ear, hearing loss) Battery in ear, nose throat (requires immediate removal) Juvenile angiofibroma (severe epistaxis, nasal obstruction, teen male) Nasopharyngeal cancer (unilateral ear effusion, epistaxis, supraclavicular node, in South East asian, portuguese, inuit) Subglottic stenosis (inspiratory and expiratory stridor, often mistreated as asthma) Aspirated FB (toddler often treated for asthma, recurrent pneumonia) Peritonsilar abscess (unilateral tonsil pain, swelling fails to resolve with abx, also trismus, voice change, otalgia) Epiglottitis (stridor/hoarse, severe sore throat no physical finding on exam) Ludwig's angina (dental infection/work done, bilat sublingual and submand swelling) Deep neck space abscess (following URTI, severe pain, neck swelling/severe stiffness) Lemierre syndrome (neck infection + dyspnea) Angioedema in ACE (minor lip swelling etc if on ACE, assume it's ACE no matter how long pt's been on it) Unilateral nasal obstruction, discharge, bleed (tumor, foreign body) Periorbital swelling/erythema, exophthalmos with sinusitis (infection spread to orbit through bony erosion) Cough on ACE (need 4 weeks off, don't replace by ARB) Stridor (noise on inspiration, ominous sign -->ER right away)