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Common Otologic Problems. Diego A. Preciado MD PhD Children’s National Medical Center George Washington University Washington, DC. Impact of pediatric ear disease. Ear related diagnoses are the most common reason for toddler physician visits in the U.S.

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common otologic problems

Common Otologic Problems

Diego A. Preciado MD PhD

Children’s National Medical Center

George Washington University

Washington, DC

impact of pediatric ear disease
Impact of pediatric ear disease
  • Ear related diagnoses are the most common reason for toddler physician visits in the U.S.
  • Up to 10,000,000 OM visits/year for 1-4 yr olds

Freid, Vital & Health Stats, 1998

medical proverb
Medical proverb
  • A specialist is someone who learns more and more about less and less until he/she knows everything about nothing
  • A generalist is someone who learns less and less about more and more until he/she knows nothing about everything
pediatric residency training
Pediatric residency training
  • Accurate diagnosis is harder than we may think
  • Diagnostic accuracy by pediatric residents
    • CME workshop at 240 locations with 383 pediatric residents
    • Diagnostic accuracy – video sessions
      • Resident 41% +/-16
      • Pediatrician 51% +/-11

Pichichero ME et al., Pediatrics, 2002

pediatric residency training1
Pediatric residency training
  • Commitment to training
    • Survey involving 144 programs participated (64% of all programs)
    • Only 59% of programs had formal education related to the diagnosis and treatment of OM
  • Lack of training and availability of diagnostic tools
    • Survey of 28 family medicine programs
    • Only 2/3 use pneumatic otoscopy, 1/3 tympanometry
    • 50% insufficient criteria to diagnose OM
    • Residents perceived training was adequate

MacClements et al., Family Medicine, 2002

Steinbach WJ, Pediatr, 2002.

the otologic exam
The otologic exam
  • Goals for a successful otologic exam
  • Prevent trauma to the ear canal and tympanic membrane
  • Safely and effectively remove cerumen
  • Obtain airtight seal within the external auditory canal
  • Visualize the entire tympanic membrane
tools of the trade
Tools of the trade
  • Otoscope
    • Examination of the canal/ tympanic membrane
    • Cerumen removal
  • Pneumatic head
    • Allows for insufflation
  • Operating head
    • Foreign body/cerumen removal
    • Tympanocentesis or middle ear injection
otoscopic speculae
Otoscopic speculae
  • Ear speculae
    • Age-appropriate
    • Ear canal appropriate
    • Snug for a seal
    • Provide necessary exposure
    • Comfortable for the patient
patient positioning
Patient positioning
  • Gaining the child’s cooperation
    • Approach each child based on their cognitive developmental level
  • Distracting and engaging techniques
  • Positioning
    • Depends on the age of the patient
    • Use of ancillary staff and parents
maximizing exposure
Maximizing exposure
  • Cerumen removal
    • Optimize visualization of TM
    • Atraumatic
    • Know your limits
  • Mechanical
    • Ear curettes
  • Cerumenolytic drops
  • Irrigation
    • Not considered a safe method by AAO-HNS
the otoscopic exam
The otoscopic exam
  • Pneumatic Otoscopy
  • Insufflation
    • assess tympanic membrane mobility
    • Identification of middle ear fluid improves significantly when subjects were shown pneumatic otoscopy
the otoscopic exam1
The otoscopic exam


Pars Flaccida

Short process


Long process


Pars Tensa

what to look for
What to look for
  • Color of TM
    • Gray, White, Yellow, Pink, Red, Blue
  • Translucency
  • Integrity
  • Mobility of TM
  • Landmarks
  • Ear Canal
clinical stages of otitis externa

Acute OE




Chronic OE

Edematous skin

Erythema, edema of EAC, clear secretions

Inc. edema / pain; seropurulent secretions

Intense pain, draining secretions, obstructing debris; lymphadenopathy; cellulitis

Longer than 4 weeks; 4 infections in 1 year

Clinical stages of Otitis Externa

Beers & Abramo, Pediatric Emergency Care, 2004

4 d s of aoe therapy
4 D’s of AOE therapy
  • Diagnose
  • Debride
  • Dry
  • Drops
differential diagnosis of aoe
Differential diagnosis of AOE
  • Furunculosis / sebaceous cyst
  • Otitis media  otitis externa
  • Mastoiditis
  • “Wrestler’s ear” / “Cauliflower ear”
  • Branchial cleft cyst
  • Trauma
  • Sensitivity
  • Myringitis
bacteriology of aoe
Bacteriology of AOE

DelBeccaro et al, Drugs, 1999

Ototopicals are first line therapy for AOE

Oral antibiotics may contribute to emergence of resistance and have therapeutic role only in cases of invasiveness

McCoy SI et al 2004 studied the NHAMCS and found among all US visits for OE (1,716,048):

39% Rx topical Abx

25% Rx oral Abx

No change in treatment trends from 1995-2000

  • Diagnose, debride, dry, drops
  • Consider likely micro-organisms
    • Obtain culture when possible
  • Preparations for AOE appear equally effective
  • AOM is a ubiquitous condition of early childhood with up to 20 million office visits and national cost of $3-$6 billion

Grubb, MS and Spaugh DC. Clinical Pediatrics, 2010

acute om impact
Acute OM Impact
  • 42% of all antibiotics prescribed for children are given for the treatment of AOM
  • Natural history- 80% clinical resolution within first week without treatment
    • Rosenfeld RM and Kay D. Laryngoscope, 113:1645–1657, 2003
  • Increasing concerns about multi-drug resistance among AOM pathogens
to treat or not to treat
To treat or not to treat?
  • 18 mo old, otherwise healthy
  • 2 days of 38°C, fussy
  • Pulling on ears
  • Crying during the night time
  • First episode
  • Flat tymps
antibiotics in aom aap guidelines 2004
Antibiotics in AOMAAP guidelines 2004

AAP Subcommittee on Management of AOM, Pediatrics, 2004

antibiotics in aom aap guidelines 20041
Antibiotics in AOMAAP guidelines 2004

AAP Subcommittee on Management of AOM, Pediatrics, 2004

the otitis media continuum


Otitis Media



Otitis Media with Effusion


Otitis Media

90% No Rx

Intact TM

Spontaneous perforation

Existing perforation



Suppurative OM

NON Intact TM

The Otitis Media Continuum



Otitis Media


Difficult Rx

  • 3 main disease types
    • AOM with perf (non-intact TM)
    • Chronic Suppurative OM (CSOM)
bacteriology of aom
Bacteriology of AOM

Mandel et al. Pediatr, 1995

DelBeccaro et al, J Pediatr, 1992

bacteriology of csom
Bacteriology of CSOM

Bluestone CD. Pediatr Infect Dis J, 2001

aom tympanostomy tube
AOM tympanostomy tube
  • Clinically and bacteriologically different from AOM
  • Pathogens of AOM
    • 50.0% < 6yr
    • 4.4% > 6 yr
  • Pathogens of AOM
    • 52.2% winter months
    • 14.7% summer months
  • P. aeruginosa, S. aureus
    • 43.5% > 6 yr
    • 44.1% summer months

Mandel EM. Ann OtolRhinolLaryngol, 1994

potential complications of om



Subperiosteal abscess

Facial nerve paralysis




Epidural abscess


Lateral sinus thrombophlebitis

Brain abscess

Potential Complications of OM
congenital cholesteatoma
Congenital Cholesteatoma
  • Derlacki and Clemis (1965) - “epithelial inclusion behind an intact TM in patient without a history of OM”
  • Occur secondary to persistent/remnant embryologic epithelial foci in the ME
  • Usually anterior-superior (2/3)
cholesteatoma treatment
  • Surgical disease, Medical Rx only for infection
    • Eradication of disease
    • Provide a safe, trouble-free ear
    • Optimize hearing results
tube or not
Tube or not?

Equalisation of middle ear pressure?


Aggravation of atrophy?

contra indications to tubes


Stable, minimal symptoms/hearing loss



pars flaccida retraction

keratin accumulation

? Contra-indications to tubes

Cholesteatoma Incidence after

Ventilation Tube Insertion (VTI)

Spilsbury K, et al. Laryngoscope 2010.

conclusions summary
  • There is inadequate emphasis on proper otoscopic techniques in pediatric residency
  • Optimize otoscopic examination
    • Proper equipment
    • Positioning
    • Visualization
    • Pneumatic otoscopy
    • Patience!
  • Consider likely pathogens