Pediatric HEENT / Dental

ENT Emergencies

Strep Throat

Epistaxis

ask child which finger he picks his nose with

Otitis Media

(everything above the clavicles is Pneumo, H. Flu or B. Catarrhalis)

to look in the ears of an infant, put them in a prone position.

Certain Dx of AOM

Up to 23 months, give 10 day course of ABX

Greater than 24 months, with severe illness, should get 5-10 days of ABX

>24 months without severe illness may be observed for 2-3 days provided adequate follow-up is possible

Uncertain Dx of AOM

<6 months old, give 10 days of antibiotics

6 months-2 years with severe illness, give antibiotics

6 months-2 years without severe illness, give antibiotics or observe, return in 72 hours

>2 years treat only with certain diagnosis and severe illness.

Have patient return in 72 hours if no improvement

(Br Med J 322:336, 2001)

ANTIBIOTIC TREATMENT IN ACUTE OTITIS MEDIA PROMOTES SUPERINFECTION WITH RESISTANT STREPTOCOCCUS PNEUMONIAE CARRIED BEFORE INITIATION OF TREATMENT (Dagan, R., et al, J Infect Dis 183(6):880, March 15 2001 )

Parent Information Sheet

Pediatricians are doing a crappy job assessing for AOM (Pediatrics 112(1):143, 2003)

Give them Augmentin and they get diarrhea (J Ped Gastroent Nutr 37(1):22, 2003)

Best review article (NEJM 347:15, Oct 10, 2002)

1. Recommendation: To diagnose acute otitis media, the clinician should confirm a history of acute onset, identify signs of middle ear effusion, and evaluate for the presence of signs and symptoms of middle ear inflammation.1 The first recommendation concerns the critical step of being certain about the diagnosis of acute otitis media. This certainty is established with 3 elements on examination. First, there is an abrupt onset of symptoms such as fever, irritability, and excessive crying. Second, there is presence of middle ear effusion. Fullness or bulging of the tympanic membrane (this disrupts the normal light reflex) is the best predictor of middle ear effusion. Pneumatic otoscopy will help confirm decreased mobility. Distinguishing otitis media with effusion versus acute otitis media is a challenge. Remember that otitis media with effusion is more common than acute otitis media and can be a chronic sequela of acute otitis media or can be present in children with a cold. At times, the tympanic membrane is retracted and an air fluid level might even be seen, but with evidence of some mobility and/or no inflammation or pain the diagnosis of acute otitis media should not be given. Third, there should be signs of inflammation of the tympanic membrane or, if the child is old enough to communicate, evidence that there is ear pain. Obviously, these observations require clearing the external canal of cerumen, proper positioning, and gentle restraint; for pneumatic otoscopy, proper speculum size and technique will be necessary. This can be a challenge at times! Therefore, the 8-month-old child with fever who is well appearing, with an upper respiratory infection and red tympanic membranes bilaterally and no evidence of middle ear effusion (normal mobility and/or normal-appearing tympanic membrane), does not meet the criteria for acute otitis media, and antibiotics should not be prescribed. 2. Strong recommendation: The management of acute otitis media should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.1 Pain management, regardless of antibiotic use, is of critical importance in the first 24 to 36 hours after diagnosis. If pain is present, acetaminophen at an oral dose of 15 mg/kg per dose every 4 to 6 hours provides adequate analgesia. An alternative is ibuprofen given orally at a dose of 10 mg/kg per dose every 6 hours. 3A. Option: Observation without use of antibacterial agents in a child with uncomplicated acute otitis media is an option for selected children on the basis of diagnostic certainty, age, illness severity, and assurance of follow-up.1 The most controversial recommendation seems to be the option to withhold antibiotics and observe the patient for 48 to 72 hours. This option can be considered for those children aged 6 months to 2 years if the diagnosis is uncertain or, in other words, if the signs and symptoms of acute otitis media are not met. The option to withhold antibiotics is also allowed for children older than 2 years with an uncertain diagnosis or if the diagnosis is certain but the illness is not severe.1 Remember, for those children younger than 6 months, treatment with antibiotics is recommended for suspicion of acute otitis media even if the diagnosis is not absolutely certain. There are some experts who question the scientific data that support the nontreatment/observe option in children older than 2 years with acute otitis media. It is important to understand that the guidelines do not suggest that providers stop using antibiotics; rather, there is now an option to withhold and observe for 48 to 72 hours. How will these guidelines fare in the emergency department (ED) setting? Each ED will have to assess its practice environment and consider adapting the guidelines to fit its situation. Some families may find it difficult to get follow-up visits with their primary care providers in 48 to 72 hours. It seems to me that there are ways to use these guidelines that benefit our patients but recognize the unique practice of emergency medicine. For example, emergency physicians who serve families where assuring follow-up is a problem might opt to treat all children older than 6 months with certain acute otitis media and withhold therapy in those with uncertain diagnoses. Another physician group could decide to withhold antibiotics for the observation period but provide a prescription for antibiotics with instructions to start the therapy if the child’s symptoms don’t resolve. Another group may want to discuss the option to withhold antibiotics in the 2 year old with acute otitis media with the family given concerns for the overuse of antibiotics. 3B. Recommendation: If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. Option: When amoxicillin is used, the dose should be 80 to 90 mg/kg per day.1 High-dose amoxicillin is recommended as first-time therapy for children with acute otitis media. Why? Recall that the most common bacterial pathogens in acute otitis media are S pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.5H influenzae and M catarrhalis are resistant to antibiotics primarily because of their ability to produce β-lactamase. The mechanism of penicillin resistance for isolates of S pneumoniae is different and based on alternations of penicillin-binding proteins. It is known that even S pneumoniae isolates that are resistant to penicillin will respond to high-dose amoxicillin. The higher dose (90mg/kg/day) yields middle ear fluid levels of amoxicillin that approach or exceed the minimum inhibitory concentration of many of the resistant strains of S pneumoniae. It is therefore recommended as first-line therapy. The length of therapy for acute otitis media remains 10 days, except for children 6 years of age and older with mild to moderate disease, in which a 5 to 7 day course is appropriate.1 4. Recommendation: If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm acute otitis media and exclude other causes of illness. If acute otitis media is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent.1 This recommendation reminds us of the importance of follow-up and reassessment. If symptoms compatible with acute otitis media continue for 2 to 3 days after therapy has begun, then a change in therapy should be considered. It is recommended that high-dose amoxicillin be replaced with amoxicillin/clavulanic acid if symptoms and signs continue. A new preparation of amoxicillin/clavulanic acid has 600 mg of amoxicillin combined with 42.9 mg of clavulanic potassium in a 5-mL suspension. This preparation provides the high-dose amoxicillin while inhibiting β-lactamase with clavulanic acid. The clavulanic acid concentration is low enough to reduce the common side effect of diarrhea. A confusing aspect of these guidelines is the suggestion that there should be a different initial antibiotic choice if the child has a temperature greater than or equal to 39°C and/or severe otalgia. It is recommended that first-line therapy for these patients should be amoxicillin-clavulanate (as above). Why the distinction? Perhaps to provide better coverage for the β-lactamaseproducing pathogens? There is some evidence to suggest that, with the use of the heptavalent pneumococcal vaccine, there is a relative reduction in S pneumoniae and an increase in H influenzae isolates in acute otitis media.6 Despite these data, it is not clear why amoxicillin-clavulanate should be the first choice for therapy. For those patients allergic to amoxicillin without a history of urticaria or anaphylaxis (ie, not a type 1 hypersensitivity reaction), cefuroxime, cefdinir, or cefpodoxime may be used. For those children with a type 1 reaction, azithromycin, clarithromycin, and sulfamethoxazole-trimethoprim are possible choices. 5. Recommendation: Clinicians should encourage the prevention of acute otitis media through reduction of risk factors.1 There are things that parents can do to reduce the child’s risk for developing acute otitis media. Discussions with the family should include discussions about immunizations. The heptavalent pneumococcal vaccine is responsible for a 6% reduction in the incidence of acute otitis media.7 Mention that there is a new recommendation from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices for universal influenza vaccine for all children between 6 months and 2 years.8 On the basis of earlier studies, it is anticipated that increased use of the influenza vaccine will have a significant effect in preventing acute otitis media.9 Environmental changes can also help to reduce acute otitis media. Parents should be counseled to avoid bottle propping10; reduce or eliminate pacifier use in the second 6 months of life11; and eliminate exposure to passive tobacco smoke.12 Breast feeding for the first 6 months also appears to reduce the incidence of acute otitis media.13 6. No recommendation: There is insufficient evidence to make a recommendation regarding the use of complementary and alternative medicine for acute otitis media.1 Therefore, the new acute otitis media guidelines leave me with the following points to remember. Convince yourself of the diagnosis of acute otitis media using history, observation, and pneumatic otoscopy. If you use antibiotics, use high-dose amoxicillin initially. If the patient is allergic to penicillin, consider cefuroxime or azithromycin depending on the past history and the severity of the allergy. Pain control is important. If you are not sure of the diagnosis in children older than 6 months, then don’t treat with antibiotics, but Have a discussion with the family about what to expect and what to look for during the next 48 to 72 hours, and Make sure that the family has a place to follow up or an alternative plan if the child is not improving in 48 to 72 hours. Encourage the use of the influenza vaccine in children aged 6 months to 2 years. The clinical practice guidelines for acute otitis media provide a framework in which to manage this common childhood disease and are a welcome contribution. I suspect that, after careful consideration, many of us in emergency medicine will choose to adapt the guidelines with the goal to provide the best care for the children and families we serve in our unique practice environment. References 1 American Academy of Pediatrics and American Academy of Family Physicians, Clinical Practice Guidelines, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media, Pediatrics 113 (2004), pp. 14511465.

Otitis Externa

corticosporin

Foreign Body

Laceration

Perfed Tympanic Membrane-corticosporin or floxin

Labrynthitis

Endolymphatic Fistula

Ophthalmologic Emergencies

conjunctivitis in newborns if >48 hrs after birth=gonorrhea, chlamydia, strep, staph or herpes. If patient was in hospital, also consider pseudomonas

Pre/Orbital Cellulitis

Test EOM, should be pain free in preorbital. Vision must be normal. Can differentiate with CT with axial and coronal thin cuts.

To examine the reluctant child’s eye, roll them open with Q-Tips

Conjunctivitis

Corneal Abrasion

Foreign Body

Eye Trauma-dont patch, sub-conjunctival hemorrhage 360°, abnormal pupil shape

Nasal Lachrymal Duct Stenosis

Glaucoma->12mm pupil diameter, >20 on tonometry, 1 eye bigger, epiphora, photophobia, blephorospasm

Dental Emergencies

Full bevy of primary teeth by age 2

Secondary teeth are often heralded by the 1st molars (6 yr molars)

Eruption cysts-blue black, sometimes blood filled cyst over new tooth, bengin.

Teething can cause fever.

Ellis Class

I-only enamel

II-through enamel and dentin, will see yellow dentin in enamel

III-to pulp of tooth, will see bleeding

IV-involve the root, need x-ray to dx

Treat class I with filing, II and III should be covered with dental foil or commercial coating and sent to see a dentist within 24 hours (12 hours for <12 y/o)

Luxation Injuries

Intrusion-tooth impacted into alveolar socket

Extrusion-vertically dislodged from the socket

Lingual Luxation-displacement of the tooth towards the tongue

Labial Luxation-towards the lips

Lateral Luxation-occurs within the plane of the tooth.

Avulsion is a tooth knocked completely out of the socket. Put in mouth of parent or child, or hanks solution, or milk or saline. Never reimplant a avulsed primary tooth as ankylosis, a bony fusing of tooth to the ridge may occur

Permanent tooth luxations need immediate treatment.

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