Acute Otitis Media&
Acute Otitis Externa
Grand RoundsPresented by: Cathleen McKnight, DNP, APRN, NP-C
September 24, 2015
Objectives
• Learning objectives for respective condition– Identify incidence & risk factors– Explore causation– Review anatomy and pathophysiology– Recognize signs & symptoms– Distinguish appropriate diagnostic criteria & testing– Survey differential diagnoses– Evaluate best practice treatment modalities– Discover applicable ICD-10 coding
Acute Otitis Media(AOM)
AOM: Introduction
• Middle ear infection• >80% of children have ≥1 episode by age 2• Most common cause for abx administration• 80-90% cases occur in <6 years of age
Epidemiology
• Family hx• Day care • Race• > Fall/ winter• Tobacco smoke• Air pollution• Boys> Girls
• Lack of breastfeeding• Supine feeding• Pacifier use• Developing areas• ↓ Socioeconomic
status• Anatomic anomalies• Immunologic
deficiencies
Etiology
• Most viral & self-limiting• Bacterial AOM– S. pneumoniae (40%)– H. influenzae (25-30%)– M. catarrhalis (10-15%)
Pathophysiology• Eustachian tube in infants is shorter, > angle• Eustachian tube obstruction leads to negative
pressure within the middle ear and movement of capillary fluid into the space (OME)
Normal TM
• Transudation of inflammatory mediators into the middle ear may cause mucosal edema/ infection (AOM)
History & Exam
• History– Preceding coryza– Otalgia– Irritability– Sleep disturbance– Fever– Decreased appetite– N & V– Diarrhea
• Exam– Acute infection– Middle ear inflammation
& effusion
with perforation
Diagnostic Testing
– Clinical diagnosis*– Pneumatic otoscopy– Tympanometry– Acoustic reflectometry– Audiometry– Bacterial culture
Pneumatic Otoscopy
• 95% sensitive, 80% specific (with accurate execution)
• Assess mobility of TM• Seal is key!• Causes of immobility• Fluid in middle ear• Perforation• Poor seal
Video of Pneumatic Otoscopy
Differential Dx
• Otitis media with effusion• Myringitis• Mastoiditis• Cholesteatoma
Myringitis
Cholesteatoma
Prevention
• Primary prevention– Pneumococcal immunization– Influenza immunization– Probiotics
• Secondary prevention– Decreasing modifiable risk factors– No support for prophylactic abx– Pain control– Antibiotics
Pain Control
• Simple analgesics– NSAIDs– Tylenol
• Topical agents– Antipyrine/benzocaine otic• Limited benefit• Short duration
• Narcotics• Distraction
Antibiotics
– To prescribe or not to prescribe?• Limited effect• Shorten recovery by 1 day
– Delayed abx therapy• A place to SNAP?
– Optimal abx1) Amoxicillin-based therapy2) Cefdinir3) Azithromycin, Ceftriaxone
Follow-up
• Routine follow-up discouraged– Improvement in 2-3 days– Most asymptomatic at 1 week regardless of tx
• Recurrent/ resistant infections– Broader spectrum abx– Tympanostomy tubes
• Long-term complications rare
ICD-10
• Diseases of the middle ear H65-H75
ICD-10
• Documentation1) Type2) Infectious agent3) Temporal factors4) Laterality5) Tympanic membrane rupture6) Secondary causes
ICD-10
• Miscellaneous essential codes– W61.42 Struck by Turkey– Y93.D1 Accident while knitting or crocheting– W56.22 Struck by orca, initial encounter– V91.07 Burn due to water-skis on fire– V97.33XD: Sucked into jet engine, subsequent
encounter– Z63.1: Problems in relationship with in-laws
Acute Otitis Externa(AOE)
AOE: Introduction
• Superficial skin infection of the external auditory canal
• Bacteria most common cause*
Epidemiology
• 10% of people develop AOE in lifetime• Highest risk in childhood• Females > Males• Summer• Warmer temps• High-humidity• After swimming• Occlusive devices
Etiology
• Mostly bacterial– P. aeruginosa (20-60%)– S. aureus (10-70%)
• Often polymicrobial& multifactorial
• Fungal infections 2-10%
• Idiopathic• Trauma• Chemical irritants• Allergy• Dermatologic
conditions
Pathophysiology
• Obstruction• Absence of cerumen• Trauma • Alteration of the pH of the ear canal
History & Exam
• History– Acute onset otalgia– Pruritis– Fullness– Decreased hearing– Tender tragus/pinna
• Exam– Canal inflammation
& erythema– Drainage & debris– Regional
lymphadenopathy
Diagnostic Testing
– Clinical diagnosis*– Bacterial culture– Pneumatic otoscopy– Tympanometry– Microscopy– CT scan– MRI
Differential Dx
• AOM• Otomycosis• Psoriasis• Furunculosis• Contact dermatitis• Viral infections• Carcinoma of ear canal• Cholesteatoma• Malignant OE
Cholesteatoma
Prevention
• Primary prevention– Avoid risk factors– Preserve skin integrity
• Secondary prevention– Decreasing modifiable risk factors– Treat skin disorders– Pain control & antibiotics– Occlusive ear plugs for swimming– Use acetic acid-containing ear drops after swimming
Treatment
• Pain control• Clean canal• Treat inflammation &
infection• Topical therapy– Antiseptics– Abx– Glucocorticoids– Acidifying solutions
Video of Ear Wick Placement
Topical Therapy
Ciprofloxacin/ dexamethasone(Ciprodex 0.3%/0.1%)
4gtt BID x7-10 days
Ofloxacin 0.3%5-10 gtt QD x7 days
Acetic acid 2%-OR-
Acetic acid/ hydrocortisone 2%/1%
Neomycin/ polymixin D/ hydrocortisone
(Cortisporin otic)3-4gtt TID-QID x7-10 days
Oral abx therapy should be utilized if resistance to initial treatment, or high risk patient (ex. diabetic)
Ciprofloxacin 500-750mg BID-AND-
Topical therapy
Follow-up
• 60-90% resolution ≤ 10 days irrespective to agent choice
• Routine follow up not required
ICD-10
• Otitis externaH60
H60.11 Cellulitis of right external ear H60.312 Diffuse otitis externa, left ear H60.331 Swimmer’s ear, right ear H60.543 Acute eczematoid otitis externa, bilateral
ICD-10
R46.1 – Bizarre personal appearance
Questions/ Comments?
ReferencesCenters for Medicare & Medicaid Services. (2014). ICD-10 clinical concepts series: Clinical
concepts for pediatrics. Retrieved on September 1, 2015 from https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsPediatrics1.pdf.
Goguen, L.A. (2014). External otitis. UpToDate. Retrieved on September 1, 2015 from http://www.uptodate.com/contents/external-otitis-treatment?source=machineLearning&search=otitis+externa&selectedTitle=1~78§ionRank=1&anchor=H13312385#references.
Limb, C.J., Lustig, L.R., & Klein, J.O. (2014). Acute otitis media in adults (suppurative and serous). UpToDate. Retrieved on September 1, 2015 from http://www.uptodate.com/contents/acute-otitis-media-in-adults-suppurative-and-serous?source=machineLearning&search=otitis+media&selectedTitle=1~150§ionRank=1&anchor=H17#H17.
ReferencesRosenfeld RM, Schwartz SR, Cannon CR, et al. (2014). Clinical practice guideline: acute otitis
externa. Otolaryngol Head Neck Surg 150:S1. Society for Middle Ear Disease. (2014). Otitis media. Retrieved on September 1, 2015 from
https://societyformiddleeardisease.org/otitis-media/. The Univerisity of Chicago Pediatrics Clerkship. (2013). Acute otitis media and otitis media with
effusion. Retrieved on September 1, 2015 from http://pedclerk.bsd.uchicago.edu/page/acute-otitis-media-and-otitis-media-effusion.
Waitzman, A.A. (2015). Otitis externa. Medscape. Retrieved on September 1, 2015 from http://emedicine.medscape.com/article/994550-overview#a8.