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Algorithm-Based Pediatric Otolaryngology Management During the COVID-19 Global 1
Pandemic: A Children’s Hospital of Philadelphia Clinical Consensus 2
Stephen R. Chorney, MD, MPH,1,2 Lisa M. Elden, MD, MSc, FRCS(C), FAAP,1,2 Terri 3
Giordano, DNP, CRNP, CORLN,1 Ken Kazahaya, MD, MBA, FACS,1,2 Mark D. Rizzi, MD,1,2 4
Karen B. Zur, MD,1,2 Kavita Dedhia, MD1,2 5
6
1 Division of Otolaryngology, Children’s Hospital of Philadelphia 7
Philadelphia, Pennsylvania, 19104, USA 8
2 Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at 9
the University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA 10
11
Corresponding author: 12
Kavita Dedhia, MD 13
dedhiak@email.chop.edu 14
Division of Otolaryngology, Children’s Hospital of Philadelphia 15
3401 Civic Center Blvd., 1 Wood ENT 16
Philadelphia, PA 19104 17
Phone: 215-590-3440 18
Fax: 215-590-3986 19
20
Funding: None 21
Conflicts of interest: None 22
Author contributions: Stephen R. Chorney, contributed to the conception and design of the 23
work, drafting and revising the manuscript, and final approval of the manuscript; Lisa M. Elden, 24
contributed to the conception and design of the work, drafting and revising the manuscript, and 25
final approval of the manuscript; Terri Giordano, contributed to the conception and design of 26
the work, drafting and revising the manuscript, and final approval of the manuscript; Ken 27
Kazahaya, contributed to the conception and design of the work, drafting and revising the 28
manuscript, and final approval of the manuscript; Mark D. Rizzi, contributed to the conception 29
and design of the work, drafting and revising the manuscript, and final approval of the 30
manuscript; Karen B. Zur, contributed to the conception and design of the work, drafting and 31
Complete ManuscriptClick here to access/download;Complete Manuscript;COVID19 Pediatric Otolaryngology Consensus Final Manb.docx
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revising the manuscript, and final approval of the manuscript; Kavita Dedhia, contributed to the 32
conception and design of the work, drafting and revising the manuscript, and final approval of 33
the manuscript. 34
Keywords: COVID-19, coronavirus, pediatric otolaryngology, consensus 35
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Abstract 36
Objective: The coronavirus disease 2019 (COVID-19) pandemic requires clinicians to explore 37
alternatives to routine patient management. Otolaryngologists caring for children commonly 38
depend on physical examination, laboratory data, and ambulatory surgical procedures. Limiting 39
patient care, mindful allocation of resources, and concern for safety have challenged all aspects 40
of our healthcare system. This evidence-based clinical consensus is designed to guide 41
practitioners of pediatric otolaryngology for common scenarios during this time. 42
43
Data Sources: Peer-reviewed literature, published reports, institutional guidelines, and expert 44
consensus. 45
46
Review Methods: A clinical consensus on six common clinical scenarios in pediatric 47
otolaryngology developed with evidence-based strategies. 48
49
Conclusions: Providers should suspend all in-person non-essential office visits and elective 50
surgical procedures. An emphasis on medical management and caregiver education will provide 51
reasonable approaches to many of the common outpatient concerns. Surgery for chronic otitis 52
media, obstructive sleep apnea, and acute rhinosinusitis should occur only in response to severe 53
complications or failure of medical regimens. The approach to the pediatric neck mass focuses 54
on timely management for oncologic etiologies and cautious surgical intervention for abscess 55
drainage or tissue sampling. Finally, epistaxis and otorrhea must be triaged and addressed 56
without the usual ambulatory procedures. 57
58
Implications for Practice: Adaptation of practice patterns during this unprecedented moment for 59
our healthcare system requires thoughtful planning. The strategies described allow for safe 60
handling of common pediatric otolaryngology diagnoses. Ultimately, otolaryngologists must be 61
stewards of our global health community while advocating for the care of individual pediatric 62
patients. 63
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Introduction 64
On March 11, 2020, the World Health Organization (WHO) declared coronavirus disease 65
2019 (COVID-19) a global pandemic1. Within seven days, The Centers for Medicare and 66
Medicaid Services (CMS) recommended deferring non-emergent, elective and preventive 67
medical services for patients of all ages2. In order to preserve equipment, ensure safety, and 68
expand capacity, the Centers for Disease Control and Prevention (CDC) has subsequently asked 69
healthcare facilities and clinicians to delay all elective ambulatory provider visits, reschedule 70
elective and non-urgent admissions, and delay inpatient and outpatient elective surgical 71
procedures3. The result has been a rapid evolution in practice management4-6, an adjustment of 72
clinical protocols7,8 and a growing role for telemedicine9. 73
Otolaryngologists caring for pediatric patients must adapt to these changes and reconsider 74
many routine management strategies. Determining which surgical procedures are elective 75
depends on many unique patient factors. An elective surgery, typically non-emergent and 76
scheduled in advance, should be considered on an assessment of all available medical and 77
logistical information10. As a result, organizations such as the American College of Surgeons 78
have worked toward clarifying urgency for specific interventions11,12. Among the nearly 1.5 79
million ambulatory otolaryngology procedures performed on children each year13, an interface 80
with the upper respiratory tract mucosa occurs with obvious regularity. The high viral load of 81
COVID-19 identified in the nasopharyngeal mucosa raises particular concern for airway 82
secretion exposure14. 83
The objective of this clinical consensus was to disseminate specific management 84
considerations for common scenarios in pediatric otolaryngology. An evidence-based opinion 85
among pediatric otolaryngologists at Children’s Hospital of Philadelphia (CHOP) provides an 86
algorithmic approach for clinicians across all practice settings. Limited patient contact will 87
influence screening, diagnostics, and management during the COVID-19 global pandemic. 88
Strategies for practitioners emphasize safety and resource conservation while concomitantly 89
providing exceptional care for children. 90
91
Methods 92
A group of six pediatric otolaryngologists and one pediatric otolaryngology nurse 93
practitioner developed a clinical consensus on six common clinical scenarios in pediatric 94
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otolaryngology. The group represented expertise across the subspecialties of pediatric otology, 95
sleep medicine, airway, head and neck, and rhinology. Peer-reviewed literature, published 96
reports, and institutional guidelines supplemented the approaches outlined. Algorithms were 97
created to allow for streamlined visualization. 98
99
Discussion 100
Otitis Media 101
Otitis media (OM) rarely requires urgent surgical intervention. Guidelines published by 102
the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) 103
recommend that clinicians offer tympanostomy tubes in the following situations: chronic 104
bilateral otitis media with effusion (COME) with hearing difficulty, COME with associated 105
symptoms, recurrent acute otitis media (RAOM) with middle ear fluid at time of consultation, or 106
at risk children with RAOM or OME on shared decision with the child’s caregiver15. Until it is 107
reasonable to consider elective tympanostomy tube surgery, otolaryngologists must triage by 108
otologic severity. As shown in Figure 1, urgent tympanostomy tube placement should be 109
reserved for clinical scenarios where the patient is particularly vulnerable to ongoing middle 110
effusions and their sequelae. This includes immunocompromised children, those with 111
exacerbating comorbidities, acute mastoiditis, facial nerve palsy, or intracranial complications. 112
Clinicians and caregivers can identify potential modifiable risk factors for OM. 113
Practicing good hand hygiene, avoiding second-hand smoke exposure, mitigating allergic 114
symptoms, limiting pacifier use, improving gastroesophageal reflux (GERD), reducing daycare 115
visits (albeit less common during this pandemic), and maintaining timely vaccination schedules 116
should be underscored15,16. Additionally, non-ventilated or under-ventilated bottles used for 117
feeding can generate negative pressure in the middle ear17 and supine feeding position may allow 118
aspiration of milk into the middle ear leading to abnormal tympanometry18. Certainly, these 119
strategies are not curative, but can offer actionable plans in anticipation of addressing OM 120
surgically. 121
There is some evidence that prophylactic antibiotics may be a reasonable alternative to 122
surgery. For example, amoxicillin (20-40 mg/kg/daily) for up to 6 weeks has been described. 123
The higher dose should be reserved for locations with a high prevalence of penicillin-resistant 124
Streptococcus pneumonia, sulfamethoxazole (50 mg/kg daily) may be offered if penicillin 125
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allergic19,20. Physicians must remind families of the risks of prolonged antibiotic use in children. 126
Prophylaxis may be of particular benefit in specific scenarios, such as following a course of 127
intramuscular ceftriaxone in children who initially fail oral antibiotics, infections causing 128
tympanic membrane perforation, or patients without contributing modifiable risk factors. 129
Children may have hearing loss with COME. Otitis media with middle ear effusion 130
produces average air conduction thresholds of 27 dB HL at 500, 1,000, and 4,000 Hz in 131
children21. Particularly as speech and language development occurs, parents should be offered 132
techniques to help with learning during this time. It is important to emphasize to the parent that 133
they should expose their child to as many words as possible while engaging the child to look at 134
the caregiver’s face. Parents can face the child with a book when reading so that the child can 135
look at both the words in the book and caregivers’ lips while reading. Frequently talking with 136
the child can be strategies to ensure that children are progressing during speech milestones even 137
when mild hearing loss may be temporarily present. If the family has significant speech 138
concerns, we also recommend referring the child for speech therapy, which can be done through 139
telemedicine in certain locations. 140
141
Sleep Disordered Breathing 142
The approach to children with sleep disturbances outlined in Figure 2 focuses initially on 143
stratification. If a polysomnogram (PSG) has been obtained, then this assessment commences 144
without uncertainty. Unfortunately, the ability to obtain a PSG will be challenging during this 145
time and highlights the need for a precise history. Despite poor correlation with obstructive 146
sleep apnea (OSA) severity, the OSA-18 survey does allow clinicians to obtain some quantitative 147
information based on a scoring scale. The OSA-18 survey is a disease-specific quality of life 148
survey, which helps quantify symptoms and impact of SDB, but does not replace PSG for 149
diagnosis of OSA22. It is tremendously important to ask about growth, history of failure to 150
thrive, somnolence, mouth breathing, apneic episodes, and obesity23-25. Despite a low OSA-18 151
score, if the provider has a high suspicion for severe OSA, it is judicious to place a sleep 152
medicine consult. 153
Several nonsurgical options may be considered for management of severe OSA. 154
Modifying risk factors such as weight, avoidance of smoke exposure, control of GERD that 155
includes dietary modifications (avoid eating 1.5-2 hours before bedtime, lower acidic intake in 156
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the diet, and alkaline water at night) and proper management of asthma or allergies may have a 157
role. There have been some anecdotal reports and limited data evaluating the efficacy of oral 158
steroids or antibiotics for decreasing tonsil and adenoid hypertrophy with using oral steroids or 159
antibiotics26. When considering the addition of oral steroids, it is important to weigh the benefits 160
given patient comorbidities and potential COVID-19 status. 161
Coordination with local or institutional sleep medicine specialists to create streamlined, 162
safe protocols customized for management of OSA during this unique time is advised. Standard 163
algorithms for proceeding to use of continuous positive airway pressure (CPAP) should be 164
modified while surgical options are limited. If the child cannot tolerate CPAP, then the 165
treatment group (consisting of at least the sleep medicine physician and otolaryngologists) must 166
determine whether or not the child’s symptoms are considered life-threatening. If so, then 167
surgery with proper precautions and preoperative viral testing should occur. At our facility, we 168
recommend obtaining outpatient COVID-testing 1-2 days preoperatively while practicing home-169
isolation and physical distancing. Surgical options include adenoidectomy, tonsillectomy, 170
adenotonsillectomy, and/or supraglottoplasty27,28. That being said, we highly recommend to 171
avoid any tonsil or adenoid surgery during the COVID-19 pandemic. 172
Children considered to have mild or moderate OSA should also be counseled regarding 173
the modifiable risk factors mentioned above. Intranasal corticosteroids27,29, such as fluticasone 174
propionate with or without montelukast30-32 are medical approaches that have been described to 175
manage mild OSA in prior studies. At this time, we will also extrapolate using these medications 176
for treatment of moderate OSA. It is important to counsel families regarding the side effects of 177
both medications, especially the aggressive behavior and nightmares reported with montelukast 178
use33. 179
180
Sinusitis 181
There are four sinusitis management algorithms (Figure 3): uncomplicated acute 182
rhinosinusitis (ARS), ARS with orbital involvement, ARS with intracranial complications, and 183
chronic sinusitis with acute exacerbation. During COVID-19, providers should contemplate 184
counseling families regarding risk factor modification, such as avoiding second-hand smoke 185
exposure, effective management of environmental allergies, and controlling asthma. 186
187
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Uncomplicated ARS 188
The approach to ARS in children begins with an accurate diagnosis. Severe, worsening 189
or persistent upper respiratory tract symptoms of greater than 10 days with no improvement, 190
worsening or new nasal discharge, daytime cough, fever after initial improvement, or severe 191
fever (at least 102.2°F (39° C)) with purulent nasal discharge for at least 3 days point toward 192
(ARS)34. If the child does not meet criteria for ARS, they should be referred to their pediatrician 193
for work up and management of a viral upper respiratory tract infection. 194
Children with severe, worsening or persistent ARS should start antibiotics. Antibiotic 195
regimens start with amoxicillin or amoxicillin-clavulanate. Intravenous (IV) or intramuscular 196
(IM) ceftriaxone (50 mg/kg) would be warranted if the child is vomiting, cannot take anything by 197
mouth, or not likely to take prescribed medication. If an amoxicillin allergy is known, then 198
providers should offer cefdinir, cefuroxime, or cefpodoxime. Providers should treat patients 199
until they are symptom-free for at least 7 days35. It is important to be aware that some symptoms 200
of ARS overlap with those of COVID-19. History should be aimed at identifying risk factors for 201
exposure to SARS-CoV2 and at identifying specific signs and symptoms, such as cough, fever, 202
fatigue, dyspnea, and acute anosmia. Direct patients to seek further evaluation and care for these 203
concerning features with their primary physician. 204
205
ARS with orbital involvement 206
In cases where there is concern for orbital involvement, one should assess for signs of 207
post-septal involvement, such as proptosis, ophthalmoplegia, visual complaint, or chemosis. 208
Cases of pre-septal cellulitis without signs of significant illness can be managed medically with 209
antibiotics, as listed in the Children’s Hospital of Philadelphia clinical pathway (Table 1). 210
Adjuvant medical treatments can be offered, however, there is limited data regarding their 211
efficacy36,37. Oral steroids, topical nasal steroids and oxymetazoline can be considered. In 212
children who are known or deemed at risk for COVID-19, or in all hospitalized patients, we 213
recommend against using nasal sprays and or irrigations due to risk of aerosolization of 214
potentially infectious nasal secretions. Efforts should be made to maintain care on an outpatient 215
basis with very close follow up as long as is safe. Telemedicine with video link can be utilized 216
to ensure recovery. 217
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Those with signs of post-septal involvement or pre-septal cellulitis with significant illness 218
should undergo a fine-cut contrast-enhanced sinus computed tomography (CT) scan (consider 219
scans compatible with image-guidance, if available). In the case where a subperiosteal (SPOA) 220
or orbital abscess is identified and in the absence of a cavernous sinus thrombosis, 221
ophthalmology should evaluate the need for operative intervention. In the case where cavernous 222
sinus thrombosis is identified, the child should undergo COVID-19 testing, if available, followed 223
by urgent surgery. Inpatient COVID-19 testing should be done within 24 hours of the 224
anticipated surgical intervention. In rare occasions where sight or life is imminently threatened, 225
surgery should proceed with presumption of COVID-19 positivity. For SPOA or intraorbital 226
abscess drainage, we recommend the procedure be performed by an external approach. 227
Endoscopic sinus surgery (ESS) should be avoided. If ESS is absolutely necessary, it should be 228
performed without the use of high-powered instruments, such as drills. In a recent report, cold 229
surgical instrumentation and suction-microdebrider pose significantly less aerosolization risk 230
than a high-speed drill, but still present a particular risk supporting the need for PPE (personal 231
protective equipment)38. We have found the sinus PROCISE EZ View Coblation Wand (Smith 232
& Nephew, Watford, UK) to be a useful replacement to the microdebrider and we consider it to 233
be lower risk for aerosolization as well as provide hemostasis. 234
235
ARS with intracranial complications 236
All patients with intracranial complications should have an urgent neurosurgery 237
consultation. If the child has a significant intracranial collection with minimal sinus disease, 238
intravenous antibiotics may be considered rather than ESS at the time of open neurosurgical 239
drainage. Furthermore, in the case where neurosurgery performs a craniotomy on a COVID-19 240
positive patient, intravenous antibiotics may be given after the procedure. The patient must be 241
closely monitored with serial examinations to ensure that the antibiotics are sufficient for 242
management. If the patient fails to improve, ESS without powered instruments and proper PPE 243
should be performed. Acute sphenoidal sinusitis with intracranial complication, such as 244
cavernous sinus thrombosis or meningitis, may require urgent endoscopic drainage. The most 245
experienced surgeon available should perform the sphenoidotomy as efficiently as possible with 246
minimal aerosolizing dissection. There are currently no published studies assessing nonsurgical 247
management of patients with intracranial complications of sinusitis; therefore, if the decision is 248
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to proceed with surgical intervention, it is very important to utilize the utmost care in protecting 249
yourself and others during the procedure. 250
251
Chronic sinusitis with acute exacerbation 252
Steroid nasal sprays, nasal and systemic antihistamines, optimal management of 253
underlying medical conditions, and saline nasal irrigations are reasonable for managing chronic 254
rhinosinusitis (CRS) medically39. With the use of saline nasal irrigations, there may be concern 255
with increasing the spread of SARS-CoV2 if the child is COVID-19 positive. Providers must 256
ensure that if they are doing the irrigations, gloves, facemask, and eye protection should be worn 257
by the caregiver who is performing the irrigations upon the child. Proper hand washing after 258
irrigations is required and washing all surfaces that are in the location of the irrigations, as well 259
as surfaces that may be exposed to respiratory tract secretions. If there are signs of acute 260
infectious exacerbation of CRS, we recommend a 20-day course of antibiotics. A reasonable 261
first line choice would be amoxicillin-clavulanate, with consideration for clindamycin, 262
levofloxacin, or second or third generation cephalosporin if penicillin allergic. A quinolone 263
should be considered in patients known or suspected to be colonized with Pseudomonas 264
aeruginosa. Culture data from prior procedures may be used to guide management if available. 265
266
Neck Masses 267
The pediatric neck mass algorithm (Figure 4) begins with a detailed history. The history 268
should include onset, characteristics of the mass, immunization status, systemic symptoms 269
(arthralgia, nasal/aural symptoms, oral ulcers, rash, enlarged lymph nodes in other locations), 270
recent food or animal exposures, sick contacts, treatment history and presence of constitutional 271
symptoms40,41. Based on the history, it may be determined whether an ultrasound (US) is 272
necessary. The US can reveal a solid, cystic or infected lesion. 273
If on US a solid lesion does not appear benign and the child does not have constitutional 274
symptoms, we recommend laboratory work up. The recommended lymphadenopathy lab panels 275
include complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), C-276
reactive protein (CRP), lactate dehydrogenase (LDH), purified protein derivative (PPD) test, 277
liver function testing (LFTs), blood culture and other serologic testing based on history, such as 278
Epstein Barr virus (EBV), cat-scratch, cytomegalovirus (CMV), and human immunodeficiency 279
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virus (HIV)40,41. Consultation with medical oncology may provide helpful guidance for the 280
workup. If the mass persists, progresses or if the child develops constitutional symptoms, we 281
recommend an US-guided core needle biopsy (CNB) after the patient undergoes testing for 282
COVID-19. Although open biopsy has the best diagnostic accuracy at 90%, CNB was a close 283
second with 80% accuracy42. CNB is the better option at this time, as the procedure is shorter, 284
has less resource utilization, and may be performed under IV sedation. If surgical excision is 285
required, we recommend the procedure be performed with full PPE and using general 286
endotracheal anesthesia to prevent aerosolization from coughing. There has been a suggestion 287
that a supraglottic airway might prevent less aerosolization compared to bag-mask-ventilation43; 288
however, a laryngeal mask airway (LMA) might not protect operating room staff from viral 289
spread44. 290
Patients with lesions that appear infected and are solid/phlegmonous in nature should 291
initially be treated with oral antibiotics that cover both Group A Streptococcus and Methicillin-292
Sensitive Staphylococcus aureus45. Intravenous antibiotics should be started in cases where 293
there is no improvement or with symptom progression. Surgery should be considered in cases 294
where there has been no improvement on IV antibiotics or if the initial ultrasound showed an 295
infected cystic mass that was fluctuant and pointing. Prior to any procedure, COVID-19 testing 296
is recommended to determine need for expanded PPE versus universal precautions. For resource 297
conservation, we recommend needle aspiration under sedation if possible. However, if the 298
patient is not amenable to this, or if the suspicion is high that symptoms will not resolve, then the 299
child may require a formal incision and drainage under general endotracheal anesthesia. In 300
either case, it is imperative that a culture is performed to allow narrowing the spectrum of 301
therapy. Once again, if the child is COVID-19 positive, we recommend endotracheal intubation 302
during any surgical procedure to decrease the risk of aerosolization. 303
304
Epistaxis 305
Epistaxis in children is rarely severe enough to require intervention beyond topical 306
therapeutics. This algorithm outlined in Figure 5 was adapted from the published epistaxis 307
consensus statement46. Ensuring that there is no concern for a sinonasal mass is the primary 308
objective. Beyond that, determine if there has been significant blood loss that might warrant 309
observation or admission for further work-up. If there is a concern for a bleeding disorder based 310
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on the history, laboratory testing should be performed for further evaluation47. The use of nasal 311
antibiotic ointment has been suggested for two weeks and pinching the nostrils together for a few 312
seconds has been shown to help as well48. The routine application of saline sprays or gel and 313
avoidance of nasal mucosal trauma are paramount. Given the proximity to possible high viral 314
particle shedding in the nose, avoiding close contact with the child’s nose for exam at this point 315
is crucial unless absolutely necessary. 316
317
Otorrhea 318
Treatment of pediatric otorrhea cannot rely on minor procedures such as binocular 319
microscopy and debridement during the COVID-19 crisis (Figure 6). A clear history focusing 320
on potential modifiable risk factors, information regarding color and type of drainage to 321
differentiate infection from cerumen are important. The providers must know if there is a history 322
of tympanostomy tubes or tympanic membrane perforation. 323
It is important to counsel families regarding modifiable risk factors. Although there has 324
been some recent controversy regarding the impact of water exposure in children with ear tubes, 325
we believe it is best to avoid water exposure in a child with active otorrhea. It is important to 326
emphasize that the family is vigilant about hand washing and hygiene. Due to current social 327
distancing mandates, children are not in daycare or school; however, it is important to remind 328
families to avoid large groups if possible. It is also important to ensure immunizations are up to 329
date, or check S. pneumonia titers in the case of suspected poor immune response, avoid smoke 330
exposure, limit pacifier use, and optimize both allergy and GERD management49. 331
In conjunction with counseling families about modifiable risk factors, the family should 332
perform aural toilet at home and start the child on ofloxacin drops after washing their hands. It is 333
important to guide families to use a washcloth with hydrogen peroxide to wipe off any excess 334
drainage at the entrance of the ear canal. In those patients with copious mucus, 3% hydrogen 335
peroxide can be squeezed from a cotton ball into the canal to help debride the discharge, then the 336
bubbly discharge can be swabbed out so antibiotic drops can then be effectively instilled into the 337
ear canal. Next, they should be given instructions regarding how to optimally instill ear drops 338
(Figure 7). The parents/caregivers should make sure to wash their hands before and after using 339
the drops. If the child fails ofloxacin ear drops, then they should be given a combination of 340
ciprofloxacin/dexamethasone drops with the same instructions. 341
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In the case of recalcitrant otorrhea, an initial trial of fluoroquinolone drops along with a 342
broad-spectrum oral antibiotic is recommended. If there is concern for Methicillin-Resistant 343
Staphylococcus aureus (MRSA), either from a previous culture or high community prevalence, 344
we recommend considering the following topical antibiotics drops: tobramycin/dexamethasone 345
(Tobradex), Chloramphenicol-containing solutions, or 1% hydrocortisone polymyxin-B sulfate-346
neomycin. Tobradex has the benefit of providing coverage for Pseudomonas as well. 347
Unfortunately, all of these drops have been found to be ototoxic in animal models50. One study 348
reported decreased ototoxicity with Tobradex due to the steroid component in the 349
preparation51,52. If the family is concerned regarding the ototoxicity or if the family does not 350
believe that the child will be compliant with drops, oral antibiotics with MRSA coverage such as 351
clindamycin or trimethoprim-sulfamethoxazole should be prescribed. 352
Topical antiseptic powders and solutions are reasonable if drainage persists after using 353
topical and oral antibiotics. At our institution, we use a compounded powder combination of 354
ciprofloxacin, clotrimazole, and dexamethasone in a boric acid base. The capsules can be 355
prepared by a compounding pharmacy and placed into an insufflator for application to the 356
external ear canal at home, two puffs to the affected ear twice a day for two weeks. The 357
solutions listed below have been used in cases of severe recalcitrant chronic suppurative otitis 358
media, but can cause pain when instilled into the canal. The following solutions have been 359
described in the literature for recalcitrant otorrhea: acetic acid with 1-part white vinegar to 1-part 360
distilled water, 3% hydrogen peroxide and one-half sterile water two times per day, and Burow’s 361
solution/Domeboro drops. The Domeboro drops increase the alkalinity of the external canal 362
while acetic acid drops are bactericidal. Although these treatment strategies have been used as 363
in-office procedures on patients for years, there is evidence that there is a potential for each 364
solution to be ototoxic in animal models49,53-58. It is important to counsel families regarding the 365
ototoxicity of these solutions prior to treatment. 366
In cases that continue to drain despite all measures mentioned above, we recommend 367
obtaining an ear culture. Typically, the culture should be performed much earlier; however, 368
given our current challenges and trying to decrease patient contact we have placed this step at the 369
end of the algorithm. The child should be treated based on the culture results; treatment should 370
be extended for persistent disease. 371
372
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Implications for Practice 373
Pediatric otolaryngology providers face particular challenges during the COVID-19 374
pandemic. The need for limited patient encounters and overall societal restrictions has tempered 375
the emphasis on physical examination, imaging, and adjunctive testing. Common ambulatory 376
surgeries cannot be performed at this time, which shifts the attention to mitigation strategies and 377
medical management. Both measures have a tremendous impact on conserving valuable 378
resources, particularly PPE. Finally, the safety of children, healthcare providers and caregivers 379
must be ensured. This is especially crucial given the common exposure to nasopharyngeal 380
secretions and the upper respiratory tract mucosa during aerosol producing procedures that are 381
inherent in the field of otolaryngology. Even after full operations resume, otolaryngologists may 382
still encounter situations where diagnostic and surgical routines are temporarily unavailable. 383
These alternative strategies allow clinicians to navigate these challenging times and to remain 384
focused on caring for their pediatric patients. 385
386
Funding: None 387
Conflicts of Interest: None 388
Acknowledgments: Drs. Kavita Dedhia (senior author) and Stephen R. Chorney (first author) 389
were the lead authors. All authors are listed in alphabetical order and have equally contributed to 390
the conception and design of the work, drafting and revising the manuscript, and final approval 391
of the manuscript. 392
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References 393
1. World Health Organization. Coronavirus disease 2019 (COVID-19): Situation Report, 51; 394
March 11, 2020. 395
2. Centers for Medicare & Medicaid Services. Non-Emergent, Elective Medical Services, and 396
Treatment Recommendations. March 18, 2020. https://www.cms.gov/files/document/31820-397
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Figure Legends 552
553
Figure 1. Management algorithm limiting patient contact for pediatric otitis media with effusion 554
(OME) during the COVID-19 pandemic. Extended PPE (Personal Protective Equipment) 555
includes: N95 mask/face shield/gown and gloves or PAPR (Powered Air-Purifying Respirator) 556
557
Figure 2. Management algorithm limiting patient contact for pediatric sleep disordered breathing 558
(SDB) during the COVID-19 pandemic. Extended PPE (Personal Protective Equipment) 559
includes: N95 mask/face shield/gown and gloves or PAPR (Powered Air-Purifying Respirator). 560
** Note: it is highly recommended to avoid tonsillectomy/adenoidectomy surgeries during the 561
COVID-19 crisis. 562
563
Figure 3. Management algorithm limiting patient contact for pediatric acute rhinosinusitis (ARS) 564
during the COVID-19 pandemic. Extended PPE (Personal Protective Equipment) includes: N95 565
mask/face shield/gown and gloves or PAPR (Powered Air-Purifying Respirator) 566
567
Figure 4. Management algorithm limiting patient contact for pediatric neck masses during the 568
COVID-19 pandemic. Extended PPE (Personal Protective Equipment) includes: N95 mask/face 569
shield/gown and gloves or PAPR (Powered Air-Purifying Respirator) 570
571
Figure 5. Management algorithm limiting patient contact for pediatric epistaxis during the 572
COVID-19 pandemic. 573
574
Figure 6. Management algorithm limiting patient contact for pediatric otorrhea during the 575
COVID-19 pandemic. 576
1. If Ciprodex is too expensive or not available, recommend family to use both 577
dexamethasone and fluoroquinolone drops simultaneously. 578
2. Other topical or oral antibiotics or solutions to consider in refractory disease (see text). 579
580
Figure 7. Children’s Hospital of Philadelphia Division of Pediatric Otolaryngology Patient 581
Family Education instructions on giving children otic drops. 582
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22
Important: Keep ears dry during an ear infection with drainage. It’s important to keep water out 583
of the ear canal during bathing, showing, and hair washing. You can put an ear plug in the ear 584
during showers, or cover the ear with a plastic cup when rinsing hair during bathing. No 585
swimming until the infection is gone. 586
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23
Table 1. Pathogens and Antibiotic Recommendations 587
Common Pathogens 588
Diagnosis
Orbital cellulitis Anginosus group Streptococci (S. anginosus, constellatus, & intermedius)
S. pneumonia (pneumococcus)
S. pyogenes (GAS)
S. aureus
Haemophilus influenzae
Anaerobes
Preseptal cellulitis1
1. H. influenza type B and S. pneumoniae rarely cause preseptal cellulitis in the post-
conjugate vaccine era.
S. pyogenes
S. aureus (if purulent)
Recommended Empiric Antibiotics 589 Recommendations are based on local susceptibility; antibiotics should be tailored to local resistance patterns. 590
Diagnosis First Line Therapy Allergy to first line agent Severe Type 1 Hypersensitivity
Duration Comments/Other Considerations
Orbital Cellulitis Ampicillin-
sulbactam IV Monotherapy
75 mg/kg/dose (max: 2 g/dose), q6hrs
History of MRSA: Clindamycin IV Monotherapy 14 mg/kg/dose (max: 900 mg/dose) q8hrs
Clindamycin IV Monotherapy
14 mg/kg/dose (max: 900 mg/dose) q8hrs
14-21 days If there is concern for CNS extension on imaging, change to ceftriaxone, metronidazole, and
vancomycin and consult neurosurgery
If surgery performed, tailor therapy based on operative culture results
1. History of Clindamycin-resistant MRSA
2. OR
3. Concern for imminent sight threatening infection based upon exam by Ophthalmology:
4. Vancomycin IV 15 mg/kg/dose (max: 750 mg/dose) q6 hrs
AND
5. Ampicillin-sulbactam IV 75 mg/kg/dose (max: 2g/dose), q6 hrs
Concern for imminent sight threatening infection based upon exam by Ophthalmology:
Vancomycin IV 15 mg/kg/dose (max: 750 mg/dose), q6 hrs
AND
Ceftriaxone IV 100 mg/kg/dose (max: 2g/dose) q24 hrs
AND
Metronidazole IV 10 mg/kg/dose (max: 2000 mg/day) q8 hrs
Preseptal Cellulitis
Outpatient Cephalexin PO
Outpatient Clindamycin PO
5-7 days
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Diagnosis First Line Therapy Allergy to first line agent Severe Type 1 Hypersensitivity
Duration Comments/Other Considerations
20 mg/kg/dose (max: 1 g/dose) TID
10 mg/kg/dose (max: 600 mg/dose) TID
Inpatient Cefazolin IV 35 mg/kg/dose (max: 2 g/dose) q8 hrs
Inpatient Clindamycin IV 10 mg/kg/dose (max: 900 mg/dose) q8 hrs
5-7 days
591
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Urgent
Yes
COVID-19 Testing
Positive/Unable to test
Surgery with extended PPE
Negative
Surgery with universal precautions
No
Counsel families regarding modifiable
risk factors
No modifiable risk factors/unlikely to
follow them
Consider prophylactic antibiotics
Hearing loss present
Counsel family regarding educating child with hearing
loss
Figure 1 Click here to access/download;Figure;COVID Figure 1.pdf
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OSA-18 Survey sent
to families prior to visit
Discuss modifiable
risk factors
Concern for severe
OSA
Yes
Consider oral
steroids, antibiotics
Severe symptoms
requring emergent mangement
Yes
Refer to Emergency
Department
No
Refer to sleep
medicine for CPAP trial
Tolerates CPAP
Yes
No further
intervention
No
Life threatening
**Yes
Test for COVID-19
Negative
Surgery with
universal precautions
Positive
Surgery with
extended PPE
Unable to test
Surgery with
extended PPE
No
Sleep medicine for
medical management
No
Medical
management
Figure 2 Click here to access/download;Figure;COVID Figure 2.pdf
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This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
Discuss modifiable risk factors
Acute sinusitis without complications
Meets criteria for acute sinusitis
Yes
Antibiotics
No
Conservative management of viral
upper respiratory infection
Acute sinusitis with orbital involvement
Preseptal cellulitis
Features of significant illness
No
Medical management
Yes
Postseptal involvement
CT sinus with IV contrast and image
guidance
Cavernous sinus thrombosis
No
Subperiosteal/Orbital abscess
No
Medical management
Yes
Consider open drainage
Yes
COVID-19 testing
Positive/Pending results
Surgery with extended PPE
Negative
Surgery with universal precautions
Acute sinusitis with intracranial
complications
Acute on chronic sinusitis
Ensure that child is complying with
medical management
Antibiotics for 20 days
Figure 3 Click here to access/download;Figure;COVID Figure 3.pdf
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HPI
Ultrasound not needed
Observe
Ultrasound needed
Solid
Oval, central hilum and
vasculature
Round, peripheral
vasculature, loss of hilum
Constitutional symptoms
Yes
Core needle biopsy
No
Lab work-up
Persist/progress
Cystic
Observe
Infected
Solid/phlegmon
PO antibiotics
Resolve
Observe
Progression/stable
IV antibiotics
Resolving
Transition to PO
antibiotics
Progress/stable
Consider I&D versus needle aspiration for
culture.
Preop COVID-10 testing and proper PPE
Cystic
Mild/not pointing Fluctuant/pointing
Figure 4 Click here to access/download;Figure;COVID Figure 4.pdf
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HPI
Concern for
sinonasal mass
No
Active nasal
bleeding
Yes
Oxymetazoline
spray and presure
No
Nasal
crusting/prominent blood vessel
Yes
Antibiotic ointmentNasal moisture
therapy
No
Do not pack/rub
nose
Correct location for
nasal pressure
Oxymetazoline spray
during active bleedingHumidification
Yes
Consider MRI
Negative findings Positive findings
Refer to sinonasal
team
Figure 5 Click here to access/download;Figure;COVID Figure 5.pdf
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History
Concern for ear infection
Yes
Discuss modifiable risk factors
Discuss aural toilet at home ofoxin otic drops
Resolved Persists
ofloxin/dexamethasone otic drops1
Resolved Persists
If patient had prior culture, use to direct therapy
Consider oral antibiotics and ear drops2
Resolved Persists
Obtain ear culture
Treat based on culture results
Resolved Persists
Consider extending course of antibiotics
No
Observe
Figure 6 Click here to access/download;Figure;COVID Figure 6.pdf
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Figure 7 Click here to access/download;Figure;COVID Figure 7.pdf
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