Drug for Ears

acute otitis media (OAM) is defined as

infection, inflammation and fluid in the middle ear

AOM develops after a

viral upper respiratory infection, which can cause inflammation and swelling of the Eustachian tube. the swelling can lead to blockage= negative pressure in the middle ear that in turn leads to fluid accumulation in the middle ear

how do you diagnose AOM? the three elements must be present

acute onset of s/s

middle ear effusion [bulging TM with limited mobility or if the TM is perforated, purulent otorrhea] or TM ruptured, purulent otorrhea

middle ear inflammation

**MEE is the best predictor of AOM

otitis media with effusion differs from AOM is that OME

have fluid in the middle ear but no signs of local or systemic illness.

prolonged OME is common after resolution of AOM

What is the usual standard for AOM & if there is an indicator for abx what is the choice of treatment

pain medication—tylenol or ibuprofen

high dose of amoxicillin—40-45mg/kg BID for 5-10 days

for moderate to severe pain what can be given

codeine

for children older than 5 yo the AAP guideline also recommended for pain

topical anesthetic like procain or lidocaine drops for pan relief

what is contraindicated for TM that is perforated

topical analgesics in the external auditory canal (EAC)

if pt has a penicillin allergy what abx should be given (yes depending on severity)

if the allergy is NOT severe (type II allergy) cephalosporin may be used (ie: cefdinir, cefpodoxime, cefuroxime)

if allergy IS SEVERE (type I allergy, causing urticaria or anaphylaxis): give azithromycin and clarithromycin

if not prescribing abx what is the treatment? and actually the preferred treatment

observation rather than immediate treatment with antibiotics

observation- management by symptomatic relief along for 48-72 hours, allowing for AOM to resolve on its own. BUT if symptoms persist or worsen, abx may be started

what is the criteria for choosing initial abx therapy vs observation in children with AOM: less than 6 months

certain dx: abx therapy

uncertain: abx therapy

what is the criteria for choosing initial abx therapy vs observation in children with AOM: 6months -2 years

certain dx: abx therapy

uncertain dx: abx therapy if illness Is severe; observation if illness Is not severe

**2 yr old and older: abx therapy if severe pain >48hrs, fever >39 during the preceding 48 hr or if there is a possibility that the caregiver may not reliably arrange for followup if needed.

For mild earache <48hrs of if temp <39 observation is appropriate

what is the criteria for choosing initial abx therapy vs observation in children with AOM: 2years and older

certain dx: abx thrapy if illness is severe; observation if illness is not severe

uncertain dx: observation, regardless of symptom severity

what does it mean if there is abx resistance and what can be given if your pt still isn’t feeling better

persistence of s/s like fever, earache, otorrhea, and a red and bulging TM for 2 to 3 days despite abx therapy

high dose of amoxicillin increases activity against resits S. pneumoniae

for H. influenza and M. catarrhalis the preferred approach is oral therapy with high dose of amoxicillin/clavulanate bc the clavulanate in the combo inhibits b-lactamase

what are the risk factors for resistant AOM

day care

<2 yo

exposure to abx in the prior 1-3 months

winter and spring seasons

for recurrent AOM: yes there are disagreements about abx therapy, some say that abx should be given for each recurrent episode. other says give abx for episodes in which s/s are severe; in both situations what would you give?

high doses of amoxicillin

if resistance is indicated: amoxicillin/clavulanate

recurrent arm: prophylactic abx therapy; yes not normally recommended. BUT if elected it should be done only during upper respiratory infection szn; what is the drug of choice

amoxicillin

what are other modalities to help prevent AOM

prevention and treatment of influenza (vaccinate)

tympanostomy tubes

most otic preparation are contraindicated for pts who do not have intact TMs, exceptions is

fluoroquinolones and fluoroquinolone/glucocorticoid combination products.

for AOE the treatment usually is

analgesics

cleaning and using topical antimicrobial

if infection is extensive then oral abx

to help with healing, ear should be kept dry

what is the abx treatment for AOM for pts with tympanostomy tube

combo product ciprofloxacin/dexamethasone (ciprodex) and ciprofloxacin/fluocinolone acetonide (Otovel) are topical solutions approved specifically for treatment of AOM in pts with tympanostomy tubes.

what is commonly the cause of acute otitis external (AOE)

AOE: also known as swimmers ear—-bacterial infection of the EAC. the most common pathogens are pseudomonas aeruginosa and staphylococcus aureus

treatment of AOE consists of

analgesics

topical antimicrobials—2% solution of acetic acid; alcohol plus acetic acid offers benefit of promoting tissue drying

if infection is extensive and acetic acid and alcohol has not helped; topical antibiotics": hydrocortisone, neomycin, polymyxin B (hydrocortisone decreases inflammation and neomycin and polymyxin B kills bacterial pathogens)

AE of neomycin: ototoxic and causes local swelling and erythema

quinolones like ciprofloxacin are preferred bc they’re highly effective but do not cause local reactions and are not ototoxic.

Fluoroquinolone and glucocorticoid combo have added benefit of decreasing pain and reducing swelling caused by inflammation

tips of giving ear drops

warm ear drops before installation (cold can cause dizziness)

wiggling the earlobe can help facilitate transit of solutions down the EAC

IF swelling is bad and can’t give medication, using a wick can help

Oral medications are indicated for infection that extends beyond the EAC to involve the pinna for adults you give what and for kids what

adults: ciprofloxacin (Cipro)

2/2 oral quinolones can cause tendon rupture in younger patients, this drug should not be given to patients younger than 18 years of age.

Children: cephalexin

Necrotizing otitis externa is rare but fatal complication of AOE that develops when bacteria in the EAC invade the mastoid or temporal bone. Spread of infection to the skull base can affect what ___and spread to the dura mater can cause meningitis and possibly lateral sinus thrombosis.

cranial nerves

the usual pathogen is P. aeruginosa

patients typically present with progressive severe otic pain, purulent discharge from the ear and granulation of tissue in the EAC;

occurs most with high risk people; OA with diabetes and people who are immunocompromised especially ppl with HIV ALL pts should receive antipseudomonal ear drops like ofloxacin solution + oral ciprofloxacin

Fungal otitis externa also called otomycosis

common pathogens are aspergillus. and candida

S/S intense pruritus and erythema with or without pain or hearing loss.

treatment: thorough cleansing and application of acidifying drops like 2% acetic acid solution must be applied 3-4x a day for 7 days.

OR antifungal drugs like 1% clotrimazole BID for 7 days. if the infection fails to respond, oral antifungal therapy may be needed. options are itraconazole or fluconazole

if patients with AOM has taken amoxicillin in the past 30 days what can be given

amoxicillin/clavulanate

should be given if H. influenza and M. catarrhalis Is suspected

if there has been three or more episodes of AOM in the past 6months or four episodes in the past year, consider referring to

otolaryngologist—-tympanostomy tubes may be indicated especially if hearing loss is a concern

is the TM intact? if not avoid

ototoxic drops like aminoglycoside preparation instead give quinolone or quinolone/ glucocorticoid combo bc these are safe for patients who have perforated TMs

patients with AOE who have DM or immune deficient they should receive

systemic therapy or a combination of systemic and topical therapy; systemic therapy or referral is indicated if the infection has spread beyond the EAC