Outpatient management of acute mastoiditis with periosteitis in children

Children with acute mastoiditis with periosteitis are conventionally hospitalized for parenteral antibiotics and/or surgical treatment. However, if possible, effective and safe outpatient treatment is desirable. During a 36-month period, outpatient parenteral antibiotic therapy (once daily i.m. ceftriaxone) was evaluated in 32 children with acute mastoiditis, with clinical evidence of periosteitis. Inclusion criteria included otomicroscopic evidence of acute otitis media (AOM), displacement of the pinna, retroauricular swelling, erythema and tenderness. The treatment consisted of wide myringotomy and administration of i.m. antibiotics. Daily visits, by a combined team of an otolaryngologist and pediatric infectious disease specialist, were considered essential. Fourteen children (43%) were treated initially in the hospital (and subsequently as outpatients) and 18 (57%) children were treated entirely as outpatients. Mean duration of outpatient treatment was 7 days (range: 4-10). The overall clinical cure rate was 96.8%. One child underwent simple mastoidectomy. No serious side effects were observed. Our data suggests that many children with acute mastoiditis with periosteitis can be managed successfully and safely as outpatients by a combined team of otolaryngologists and infectious disease specialists.     

Pediatric deaths due to otolaryngologic causes: a population-based study in Massachusetts, 1990-2002

OBJECTIVE: To identify the most common otolaryngologic causes of mortality in the 0 to 19 age group in the state of Massachusetts and to estimate the pediatric otolaryngologic mortality rate based on population data. STUDY DESIGN: Population-based retrospective cohort study. METHODS: The Massachusetts State Registry of Vital Records and Statistics electronic database was searched for all otolaryngology related causes of death from 1990 to 2002 for children aged 0 to 19. The individual death certificates were then reviewed, and a database of otolaryngology related pediatric deaths was created. RESULTS: A total of 59 otolaryngology related deaths were identified in the pediatric population from 1990 to 2002. Eighty-one percent of deaths occurred because of airway compromise caused by infection, anatomic obstruction, or congenital anomaly. The remaining 19% of deaths occurred because of aspiration, nonairway infections, and malignant neoplasms. Ninety-five percent of deaths in the children under age 10 were caused by airway compromise. Six of seven deaths (86%) in the age 15 to 19 group occurred because of malignant neoplasms. The overall mortality rate caused by otolaryngologic causes was estimated to be 0.28 per 100,000 population. CONCLUSIONS: The overall mortality rate for otolaryngology related deaths is low in the pediatric population. The vast majority of deaths are caused by airway compromise, primarily because of laryngotracheobronchitis or other upper airway obstruction. In older children (ages 15-19), malignant head and neck neoplasms are the leading cause of otolaryngology related deaths.     

Current therapeutical management, new antibiotics and treatment of Pseudomonas aeruginosa in bacterial ENT-infections

In bacterial infections of the sinuses and the middle ear Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Staphylococcus aureus are most frequently isolated, whereas in tonsillopharyngitis Streptococcus pyogenes is the most important pathogen. S. aureus is found in up to 40 % in acute and chronic sinusitis and causes severe complications in otitis media, therefore antibiotics used as empirical initial treatment should also be effective against this pathogen. To decrease duration of illness and to avoid serious complications antibiotic treatment of bacterial ENT-infections is necessary. The new ketolides and the third and fourth generation quinolones are very effective and the second generation cephalosporins like cefuroxime axetil have proven excellent clinical and bacteriological efficacy in numerous clinical trials combined with an excellent resistance pattern over the years. Efficacy of short course therapy (5 days) in sinusitis and tonsillopharyngitis has been proven in clinical trials and is cost saving. In more severe infections treated in hospital sequential i. v./oral therapy offers pharmaco-economical benefits. Both regimen demonstrate cost savings while maintaining high clinical efficacy. In more severe infections like otitis externa diffusa, otitis externa maligna, otitis media chronica and perichondritis Pseudomonas aeruginosa is a dangerous pathogen that has to be covered by initial antibiotic treatment. Ciprofloxacin and Ceftazidime are widely used and effective. Ciprofloxacin resistance has increased, while Ceftazidime susceptibility is unchanged (> 90 %). A dose reduction study with ceftazidime in severe ENT-infections showed equivocal efficacy between 3 x 1 g and 3 x 2 g daily that offers a cost benefit of 50 %.     

Ectodermal dysplasia: otolaryngologic manifestations and management

OBJECTIVE: To present the otolaryngologic manifestations and management of 12 patients with the rare presentation of ectodermal dysplasia. STUDY DESIGN: A retrospective chart review combined with a patient evaluation by the specialties of genetics, dermatology, dentistry, and otolaryngology. METHODS: A review of the head and neck manifestations of the spectrum ectodermal dysplasia was undertaken by a retrospective chart review performed at a tertiary care children's hospital combined with a multidisciplinary evaluation by specialties of genetics, dermatology, dentistry, and otolaryngology. RESULTS: All 12 patients had confirmed ectodermal dysplasia by genetic evaluation with strong familial manifestations of the spectrum. Seven of 12 patients presented with X-linked hypohidrotic ectodermal dysplasia. Three of these seven were femalepatients and presented with variable expression. Common otolaryngologic manifestations included eczematoid skin changes, unusual facies, hypodontia, sparse scalp hair, chronic infections (rhinitis, pharyngitis, otitis media), epistaxis, ocular drying with corneal injury, dysphagia, hearing loss, and dysphonia. Immune evaluation was normal. Nasal cilia were deficient. CONCLUSIONS: Ectodermal dysplasia is a rare syndrome with heterogeneous manifestations secondary to hypoplasia of the mucous glands of the upper aerodigestive tract and ectodermal abnormalities. The spectrum is marked byhypohidrosis, recurrent ocular infections, chronic rhinitis, hypodontia, dystrophic nails, alopecia, and atypical facies. The recognition of this syndrome allows early management of ocular, dental, infectious, and dermatologic concerns with a multidisciplinary approach to management. Direct otolaryngologic management includes ocular and oral lubrication, treatment of infectious complications, and intervention to prevent and address hearing loss.     

Moxalactam therapy. Its use in chronic suppurative otitis media and malignant external otitis

Moxalactam disodium is a new broad-spectrum antibiotic structurally related to the cephalosporins. Eleven patients with chronic suppurative otitis media with mastoiditis and four patients with malignant external otitis were treated with moxalactam. Pseudomonas aeruginosa was isolated from external ear or mastoid in all patients. Twelve of 15 patients had undergone prior surgical procedures and 11 of 15 had failed recent antibiotic therapy. Three patients with malignant external otitis did not respond to parenteral carboxypenicillin and aminoglycoside therapy. Success rate for chronic suppurative otitis media was 73% as judged by eradication of P aeruginosa and resolution of symptoms 30 days after moxalactam therapy. Two patients with malignant external otitis were cured, and two were unevaluable since they may have died of noninfectious causes. Moxalactam disodium, at a dosage of 9 g/day, may be useful for serious Pseudomonas ear infections, including those refractory to other antibiotic therapy.     

Otolaryngologic manifestations in HIV disease - clinical aspects and treatment

HIV is a pandemic infection with cases notified in almost all countries. The reported prevalence of symptoms in the head and neck is about 80%; otolaryngologists may be the first physician to see such patients. Oral manifestations are the most common, followed by neck and sinus manifestations. Otolaryngologic symptoms may be important signs of antiretroviral therapy failure. Symptoms are present in acute infections and advanced cases.ObjectiveTo describe new approaches in the past five years for the treatment of the most frequent otolaryngologic manifestations in HIV patients.MethodsSystematic reviews and case series published in English and Portuguese from January 2002 to October 2007 including the most common otolaryngology manifestations were selected.ConclusionOtolaryngologic manifestations are common and ENT specialists must be prepared to identify such cases.     

Medical management of chronic suppurative otitis media without cholesteatoma in children

Tympanomastoid surgery is considered standard management for chronic suppurative otitis media (CSOM) without cholesteatoma, which is unresponsive to ototopical/oral antimicrobial therapy. The following makes this sequence of management less attractive today: 1. potential ototoxicity of ototopical agents; 2. lack of oral antimicrobial agents effective against most common pathogens (e.g., Pseudomonas aeruginosa); 3. frequent occurrence in children who have tympanostomy tubes; and 4. failure of tympanomastoid surgery to eradicate the disease in all cases. We conducted a study in 36 pediatric patients with chronic suppurative otitis media, in which all received parenteral antimicrobial therapy and daily aural toilet (mean duration of treatment = 9.7 days). Thirty-two patients (89%) had resolution of their infection with medical therapy alone; four children required tympanomastoidectomy. Further investigation is needed to understand the etiology, pathogenesis, and most effective methods of management/prevention of CSOM in children.     

Pediatric human immunodeficiency virus infection: an otolaryngologist's perspective

Children with human immunodeficiency virus (HIV) frequently have recurrent otitis media, chronic rhinorrhea, parotitis, cough and other common pediatric otolaryngologic problems. As these complaints often occur before more unusual opportunistic infections or pulmonary conditions prompt a diagnosis of acquired immunodeficiency syndrome (AIDS), members of our specialty are liable to see HIV-positive children before infection with the virus has been recognized. Children with HIV infection are also likely to be referred to us after diagnosis, as is any immunosuppressed child with otolaryngologic infections. These children may require procedures such as bronchoscopy, sinus irrigations or tympanocentesis. The subject of this review is the natural history of pediatric HIV infection with special emphasis on otolaryngologic manifestations and recommendations for safe techniques of examination and treatment.     

Acute mastoiditis: increase in the incidence and complications

OBJECTIVE: Acute mastoiditis is a serious complication of acute otitis media, but it can be treated successfully in most of the cases with broad spectrum intravenous antibiotics and myringotomy. In the last 5 years we have perceived that there have been more complicated cases in the otic infectious pathology and the frequency was also higher. METHODS: We reviewed the cases of mastoiditis in the last 10 years (1996-2005) in The Ni?o Jesús University Children Hospital in Madrid to confirm the clinic impression, the bacteriology, treatments and evolution of the children and analyze the causes of this clinic situation. RESULTS: We have studied 215 cases of mastoiditis (0.6-17 years), 67.4% less than 3 years old and 69.3% males. The number of cases every year was the double since 1999 with the same percentage of admissions in the Pediatric service, and the triple in 2005. The percentage of surgical treatment grew from 4.3% to 33% in the last years and to 70% in 2005. Most cases (80%) have received prior antibacterial agent therapy, but individual pathogens and current complications of periostitis or subperiosteal abscess formation were equally distributed between the two groups. We have detected a 28.57% of Streptococcus pneumoniae and a significative high rate of Staphylococcus aureus (16.32%). A 53.68% of cases had negative cultures. CONCLUSIONS: There is a progressive increase in the incidence of acute mastoiditis in our medium, and an increase of the surgical treatments. Ten years ago the process was controlled with antibiotic therapy only, but now the number of interventions has been eight times the previous years. Most cases of acute mastoiditis have responded well to medical management alone. But if higher levels of resistance predominate, more severe forms of pneumococcal or other pathogen like S. aureus disease are likely to be seen, these would be less likely to respond to oral or parenteral antibiotic therapy, so, tympanocentesis for middle ear culture may become more valuable and more frequently used in cases of antibiotic treatment failures, and surgical therapy may be necessary more often in the future. Our hospital seems to be in this tendency now.     

Tobacco intervention teachable moments for pediatric otolaryngologists: Atopy and second hand smoke exposure among children

Objectives

Pediatric otolaryngology clinics have tremendous access to children with allergic conditions, yet no research has evaluated in this setting environmental tobacco smoke and the occurrence of atopic diseases.

Methods

Caregivers or parents of 201 consecutive patients in a Hungarian pediatric otolaryngology clinic were queried on otolaryngologic conditions; self-reported diagnoses of atopic diseases; and tobacco smoke exposure.

Results

A history of asthma was reported in 10.3% of children; 38.7% had at least one parent who smoked. Fifteen out of the 20 children with asthma (75.0%) had at least one parent who smoked. Having a diagnosis of hay fever and having a parent who smoked greatly increased the odds of having a diagnosis of asthma.

Conclusions

Second hand smoke exposure among children in an otolaryngology clinic was common, and was associated with co-existing atopic conditions. Pediatric otolaryngologists have an important opportunity to address parental smoking as part their care of children.     

Gastroesophageal reflux and pediatric otolaryngologic disease: the role of antireflux surgery

OBJECTIVE: To determine the role of antireflux surgery in the treatment of gastroesophageal reflux-induced otolaryngologic disease (GEROD). DESIGN: A retrospective medical record analysis was performed. Patient demographics, otolaryngologic disease secondary to gastroesophageal reflux (GER), method of GER diagnosis, medical treatment used before antireflux surgery, and response to surgical intervention were considered. SETTING: Tertiary care children's hospital. PATIENTS: Among patients undergoing antireflux surgery between January 1, 1996, and December 31, 1999, children with GEROD were included in the study. INTERVENTIONS: Children with GEROD who failed medical therapy underwent antireflux surgery. MAIN OUTCOME MEASURES: The demographics of patients requiring antireflux surgery for treatment of their otolaryngologic disease and their clinical response to surgery were reviewed. RESULTS: Fourteen (17%) of 82 children, ranging in age from 48 days to 3 years (mean age, 9.7 months), who underwent antireflux surgery for GER at our institution between 1996 and 1999 were diagnosed as having GEROD. Twelve (86%) of the 14 patients were found to have upper airway abnormalities, including subglottic edema, fixed subglottic stenosis, reflex apnea, and recurrent croup. Two patients (14%) had severe chronic sinusitis and otitis media. Nine (64%) of the 14 had normal neurologic function for their age vs 5 (36%) who had neurologic impairment. After antireflux surgery, all 14 patients with GEROD had complete resolution of clinical symptoms. CONCLUSIONS: Gastroesophageal reflux has an important role in the cause of numerous otolaryngologic disorders. Although medical management should remain the mainstay of GER therapy, antireflux surgery provided definitive and successful treatment of potentially life-threatening manifestations of GEROD.     

ENT antibiotic therapy: therapeutic guidelines. Part I.]

We discuss the variety of ear, nose and throat infections and then define the criteria for the choice of an adequate antibiotic. The importance of "supercalculated" therapy based on the results of Gram's stain is stressed, as it can save patients from over-treatment and adverse side-effects. Indications for Gram's stain in ENT as well as the value of the characteristics of the pus produced by different pathogens are described. The severity of the infection determines the choice between parenteral or oral therapy. The importance of the decision taken on the 1st and 3rd day of a severe infection is emphasised. Therapeutic principles in ENT infections are shown by grouping different infections with a similar spectrum of pathogens; also the indications for antibiotic therapy are outlined. Finally the priority of antibiotic treatment in some surgical infections is mentioned, and the peri-operative prophylaxis and treatment are described as well as the guidelines for treatment of infectious post-operative complications.     

A randomised controlled trial comparing Triadcortyl® with 10% glycerine–ichthammol in the initial treatment of severe acute otitis externa

Acute otitis externa is a common clinical condition accounting for a large proportion of patients attending the otolaryngology department, although milder cases are often managed in primary care. Treatment of the most severe forms of otitis externa involves aural toilet, followed by the application of a topical preparation, commonly in the form of an ear canal dressing. A prospective single-blind randomized controlled trial was performed to compare the efficacy of 10% glycerine-ichthammol (GI) solution and Triadcortyl((R)) (TAC) ointment, both applied as ear canal dressings, in the initial management of severe acute otitis externa. A total of 64 patients were studied. Both treatment modalities were proven efficacious in the treatment of severe acute otitis externa. Although there was a statistically significant improvement of pain parameters in the TAC group, we found no significant differences in clinical findings between the two groups. Therefore, it is recommended that GI dressing can be used instead of an antibiotic dressing as an initial treatment of severe acute otitis externa on the basis of cost, avoidance of resistance and toxicity.     

Tympanomastoidectomy versus parenteral antibiotic therapy for pediatric otorrhea

ObjectiveTo evaluate the efficacy of tympanomastoidectomy versus parenteral antibiotic therapy for otorrhea as a result of chronic suppurative otitis media (CSOM) without cholesteatoma in the pediatric population.MethodsA retrospective review of 221 patients treated for otorrhea at a tertiary academic pediatric hospital was performed to evaluate the impact of tympanomastoidectomy versus parenteral antibiotic therapy on resolution of otorrhea. Inclusion criteria were age 0–18 years, prior treatment with otic and/or oral antibiotic, prior history of tympanostomy tube placement for recurrent otitis media, history of otorrhea, treatment with tympanomastoidectomy or parenteral antibiotic therapy, and follow-up of at least 1 month after intervention. Time to resolution was compared between the two modalities adjusting for age, bilateral ear disease status, and comorbidities using a Cox proportional hazard model.ResultsEighty-three ears from 58 children met the inclusion criteria. Ears that initially underwent tympanomastoidectomy had a significantly shorter time to resolution of symptoms (median time to resolution) 9 months (95 % confidence interval CI: 6.2–14.8) vs. 48.5 months (95 % lower CI 9.4, p = 0.006). On multivariate analysis, however, only bilateral ear disease status was independently associated with time to resolution of symptoms (hazard ratio 0.4, 95 % CI 0.2–0.9, p = 0.03). There was no statistically significant difference in the rate of treatment-related complications when comparing tympanomastoidectomy to parenteral antibiotic therapy (p = 0.37).ConclusionWhen adjusting for age, bilateral ear disease status, and comorbidities, there does not appear to be a significant difference in time to resolution of symptoms when comparing parenteral antibiotic therapy to tympanomastoidectomy. An informed discussion regarding risks and benefits of each approach should be employed when deciding on the next step in management for patients with CSOM who have failed more conservative therapies.     

Methicillin-resistant Staphylococcus aureus: pediatric otitis

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a potentially lethal organism in pediatric patients. MRSA is an uncommon otologic pathogen that requires special diagnostic and therapeutic intervention. METHODS: Three pediatric patients with community-acquired MRSA otologic infections were identified during 1999. SETTING: Tertiary care ear institution. RESULTS: All patients required intravenous antibiotic therapy to achieve resolution of the infections. CONCLUSIONS: MRSA in children can be community acquired and can cause otitis externa, otitis media with otorrhea, or acute mastoiditis; intravenous therapy that includes vancomycin is necessary for resolution.     

Co-amoxiclav antibiotic therapy of acute otitis media, exacerbation of otitis media chronica and sinusitis in children]

A comparative trial was performed of two regimens of antibiotic therapy in acute otitis, exacerbation of otitis media chronica and sinusitis in children. 100 children received combined treatment with amoxycilline and clavulanic acid (amoxiclav and autmentin). 50 control children were i.m. injected ampicilline. Oral co-amoxiclavs proved highly effective in ENT diseases in children and are superior to intramuscular ampicilline.     

Necrotizing otitis externa: 19 cases’ report

Necrotizing otitis externa is an uncommon but severe infectious disease of the external auditory canal. Patients at risk are those immunodepressed or having diabetes. The causal germ is often Pseudomonas aeruginosa. Over a period of 10 years (1997–2006), we treated 19 patients: 94.7% had diabetes (insulin dependent in 6 cases). The causal germ was P. aeruginosa in 59% of cases. The pretherapeutic work-up included a computed tomography and a scintigraphy practiced in order to confirm diagnosis and assess the extension. Medical treatment was based on a parenteral antibiotic therapy using a third-generation cephalosporin and a fluoroquinolones. Local treatment of the auditory canal including cleaning and application of antimicrobial agents was performed in all the cases. Surgical debridement of soft tissue and infected bone was performed in one patient who did not respond to medical management. Repeated scintigraphies with gallium were used to follow the course under treatment in only three cases. We had a 89.4% cure rate with only three cases of recurrence. We reviewed the data in the literature on necrotizing otitis externa and present the important diagnostic, imaging, and therapeutic aspects of the disease.     

Acute otitis media: To follow-up or treat?

Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed in children. However, due to their widespread use, we are witnesses to increased development of bacterial resistance to antibiotics. The purpose of this study was to evaluate the necessity of antibiotic treatment in patients with AOM. Our study included 314 children, aged between 2 months and 6 years. Children were divided into two groups: the first group included children with less severe forms of AOM, who received symptomatic therapy and “wait-and-see” approach (237 children); the second group presented with purulent ear infection and received antibiotic treatment from the beginning (77 children). After symptomatic therapy, resolution of the disease, without use of any antibiotics, was established in 61% of patients, compared to the overall sample of children with AOM. None of the children developed complications that would require surgical treatment. In the second group of children, receiving antibiotics, almost the same therapeutic effects (80%) were achieved with the use of amoxicillin, amoxicillin-clavulanate and cefixime, while the worst results were obtained after using azithromycin.The wait-and-see approach is recommended in forms of AOM without serious signs and symptoms, because it significantly reduces the use of antibiotics and their potential adverse effects.     

Efficacy of oral ciprofloxacin plus rifampin for treatment of malignant external otitis

Malignant external otitis is an invasive pseudomonal infection characteristically afflicting the elderly patient with diabetes mellitus. Therapy has traditionally consisted of the long-term administration of combination parenteral antibiotics, but morbidity and mortality remain substantial despite this therapy. We treated 11 consecutive patients with the oral combination of ciprofloxacin (750 mg twice daily) and rifampin (600 mg twice daily) for 6 to 12 weeks (mean, 8 weeks). Pseudomonas aeruginosa was isolated from ear canal or mastoid, and bone destruction was documented by computed tomography in all patients. Seven patients (64%) had ear irrigation before onset of the infection. Ten patients fulfilled the criteria of both clinical and bacteriologic cure. No serious adverse reaction to either antibiotic was observed. Otalgia and otorrhea responded at a mean of 6 and 4 days, respectively, following the initiation of therapy. The erythrocyte sedimentation rate fell from a mean pretherapy value of 81 mm/h (range, 41 to 138 mm/h) to 18 mm/h (range, 3 to 45 mm/h) after the completion of antibiotic therapy. Minimum inhibitory and bactericidal concentrations established that all organisms were sensitive to ciprofloxacin. Time-kill curve and checkerboard assays failed to demonstrate either synergy or antagonism between ciprofloxacin and rifampin. Serum inhibitory and bactericidal titers showed minimal increase in inhibition and killing of the bacteria with the addition of rifampin. Rifampin did not alter the pharmacokinetics of ciprofloxacin. The successful use of oral antibiotics for this difficult infection may be a major advance. Reduction in antibiotic costs and hospitalization and convenience of oral administration were of notable benefit.