eent update for primary care

7/27/2019 EENT Update for Primary Care

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Sinusitis and Otitis Media for

Primary Care Providers

DeWitt Army Community Hospital

Fort Belvoir, VA

DeWitt Health Care Network

Alicia R. Sanderson, MDLCDR, MC, USN

Otolaryngology-Head and Neck SurgeryFacial Plastics & Reconstructive Surgery


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Sinusitis-Objectives

Define Adult Rhinosinusitis and subtypes Review evidence based medicine

Suggest a treatment algorithm

Review appropriate antibiotic selection and

adjuvant therapies


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Definitions

Rhinosinusitis- symptomatic inflammation ofthe paranasal sinuses and nasal cavity

Uncomplicated Rhinosinusitis- without

clinically evident extension of inflammationoutside the paranasal sinuses and nasal cavity (no

neurologic, opthalmologic or soft tissue

involvement)

Acute (12 weeks)


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Diagnosis-Acute

Up to 4 weeks ofpurulent nasal discharge

with nasal obstruction and/or facial pain

pressure

ABRS vs VRS

ABRS when sxs are present for10 days or

more OR symptoms worsen within 10 daysafter initial improvement (double worsening)*

*Purulent discharge can occur in viral or bacterial infections


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Evaluation-Acute

Imaging isNOT recommended in

uncomplicated acute rhinosinusitis


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Treatment-Acute Symptomatic relief of VRS

analgesics/antipyreticsTopical or systemic decongestants

NO benefit systemic steroids or antihistamines

Symptomatic relief of ABRSAnalgesics

Studies show benefit to use of topical Steroids

Saline irrigations (isotonic or hypertonic)Some benefit to topical decongestant, xylometazoline

(do not use >3 days)

Mucolytics (guaifenesin) No data

No benefit antihistamines


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Treatment-Acute

Watchful Waiting of ABRSobserve without Abx up to 7 days afterdiagnosis

Uncomplicated, mild illness (temp


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Treatment-Acute

Antibiotic use for ABRSStrep pneumoniae, Haemophilus influenzae,

Moraxella catarrhalis

First line therapy: Amoxicillin or trimethoprim-

sulfamethoxazole or macrolide for PCN allergic

in acute setting- Randomized Control Trials found no

benefit to other stronger abx

Amoxicillin is safe, effective, low cost and narrowspectrum

Common duration 10 days


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Treatment Failure ABRS

Sxs worsen or fail to improve by 7 days

after diagnosis

Decreased susceptibility to antibiotic

High-dose amoxicillin-clavulanate (4g/day) or

Flouroquinolone (levofloxacin, mocifloxacin,

gemifloxacin)Examine for complications


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Sinusitis

Antimicrobial EfficacyTherapy Clinical efficacyAmoxicillin/clavulanate 90-91%

Amoxicillin 87-88%

Cefpodoxime 87%

TMP/SMX 83%

Doxycycline 81%

Azithromycin 77%

Gatifloxacin/levofloxacin 92%

Clindamycin 92%

Antimicrobial Treatment Guidelines for ABR 2004, Otolaryngology-HN Surgery, January 2004


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Diagnosis-Chronic

Nasal obstruction, facial congestion-

pressure, decreased sense of smell, purulent

discharge for >12 weeks AND documentedinflammation (edema, polyps, radiographic

imaging)

Recurrent Acute- Four or more episodes inone year with symptom free intervening

periods


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Rhinology-Exam

Exam Polyps

Septal deviation/spurs

Rhinorrhea

Assess air flow

Polyps Polypoid changes

Septal spur


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Evaluation-Chronic

Nasal Endoscopy-polyps, mucopurulent discharge,edema, anatomy

Radiographic imaging-CT Sinus Gold Standard

NO benefit during acute infection Allergy and Immunology Evaluation (AR in 40-

84% patients with CRS)


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Comorbid factors-Chronic

Allergic rhinitis, cystic fibrosis,

immunocompromised state (IgA, IgG, IgM,

HIV), ciliary dyskinesia and anatomicvariation


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Treatment-Chronic Preventive measures

Good hygiene, avoid smoking

Saline irrigations (improved mucociliary ftn,

decreased edema, rinse debris and allergens)

Antibiotic use for CRS

Treatment for 3-6 weeks

Bacteria in ABRS less common, Staph aureus, S.epidermidis, Pseudomonas aeruginosa, Klebsiella

pneumoniae, Proteus mirabilis, Enterobacter spp,

Escherichia coli


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Antimicrobials for Rhinosinusitis

Adults

Respiratory Quinolones (95%)

HD Amoxicillin / clavulanate (94%)

Ceftriaxone (94%)

HD Amoxicillin (1.5-4 g/d) (90%)

Cefpodoxime proxetil (88%)

Cefuroxime axetil (85%)

Cefdinir (83%)

TMP/SMX (81%)

Doxycycline (79%)Telithromycin (77%)

Macrolides (73%)

Placebo (47-62%)

More effective

Less effective

Source: Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg2004;130(1Suppl 1):S1-45.


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Treatment-Chronic Adjuvant therapies

Smoking cessation

Saline irrigations

Nasal steroids

Short course systemic steroids (two weeks)

Surgical Intervention


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The Sinusitis Patient

Evaluate patient and proper diagnosis

Consider the timing

Treat symptoms Treat with appropriate antibiotics as

indicated for adequate duration

Obtain imaging only after adequate timeand treatment or if suspected complication

Consider modifying factors


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Otitis Media

Define otitis media and subtypes

Discuss natural course of disease

Treatment recommendations and indications

for surgical intervention


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Otitis Media-definitions

Acute Otitis (AOM)

Recurrent Acute Otitis (RAOM)

Chronic otitis (COM)

Otitis Media with Effusion (OME)


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Otitis Media Diagnosis AOM

Rapid/Recent onset signs/sxs or ME inflammation

(erythema of TM, otalgia interferes with activity) AND

Presence of MEE:bulging of TM, decreased TMmobility, air-fluid level in ME, Otorrhea

OME

Presence of MEE


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Diagnosis Acute Otitis Media Purulent, bulging TM

Serous effusion can persist for up to 3 months

Pneumatic otoscopy (88-99% sen, 56-90% spec)

Tympanometry (54-96% sen, 73-93% spec)

Serous effusionAcute Otitis media


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Acute Otitis Media Treatment

Treatment of pain

Acetaminophen, ibuprofen

Topical Benzocaine (Auralgan, Americaine Otic)

Observation of uncomplicated AOM

48-72hrs

Age (6m-2y, >2y), severity (temp >39 C), certainty

of dx

Assurance of follow-up


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Acute Otitis Media Observation

Age Certain

Diagnosis

Uncertain

Diagnosis

2y Antibacterial therapy

if severe, observe if

not severe

Observation option


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Acute Otitis Media By 24hr 61% improved +/- abx, by 7 days 75%

resolved

12.3% reduction in clinical failure rate 2-7 days if

tx amp or amox vs placebo

*Delay tx 72hrs- 76% never need abx, immediate

abx tx resulted in 1 day shorter illness & tsp/day

less acetaminophen

In children with more severe illness, abx tx has

greater benefit

No evidence for increased risk of complications

with initial observation *UK


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Otitis Media-Bacteria

Streptococcus pneumoniae, Haemophilusinfluenzae, Moraxella catarrhalis

Treatment

High dose Amoxicillin (80-90 mg/kg/day) first lineHigh dose Amoxicillin/clavulanate (90mg/kg amox,

6.4mg/kg/day clavulanate)

PCN allergy: cefdinir (14mg/kg/d), cefpodoxime

(10mg/kg/d), cefuroxime (30mg/kg/d) , azithromycin

(10mg/kg/d), clarithromycin (15mg/kg/d),

clindamycin (30mg/kg/d)

6yo 5-7 days (weak evidence)


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Otitis Media-Bacteria

If fails abx tx, change abx

Ceftriaxone (50mg/kg/d) IV or IM for 3

consecutive days

Tympanocentesis

MEE persists for up to 3 months and does

NOT need treatment


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Recurrent Acute Otitis Media

Reduce risk factorsAvoid tobacco smoke exposure, eliminate pacifier

after 6 months, day care

Breastfeeding, immunizations protective Tympanostomy tube placement

>3 episodes in 6 months

>4 episodes in 12 monthsComplications

Decrease rate of AOM 1 episode/child/yr or RR

reduction 56%


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Otitis Media with Effusion

Diagnosis with pneumatic otoscopy,

tympanometry

Document laterality, duration of effusion andseverity of sxs

Determine if child at risk for speech/learning

difficulty and evaluate hearing, speechPermanent hearing loss, language delay, autism,

syndromes, visual impairment, cleft palate


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Manage child with watchful waiting for 3

months from date of effusion or dx

75-90% of OME after AOM resolves by 3 months

Hearing testing when OME >3 months or

language delay or sig hearing loss suspected

Children not at risk should be monitored ever 3

to 6 months until effusion is gone

Treatment is tympanostomy tube insertion

(Adenoidectomy with second set of tubes)


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No benefit to the use of antihistamines and

decongestants

Antimicrobials and steroids do not have longterm efficacy


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Indication for ENT referral

Complications of acute/chronic otitis media facial nerve paralysis, meningitis, and intracranial

and/or neck abscess formation

Conductive hearing loss in a patient with otitis

media with effusion for > 3 months

Otitis media with effusion with associated speech

delay

History of more than 3 episodes of otitis media in6 months or more than ~4-5 episodes in 12 months

Chronic retraction of the tympanic membrane


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Summary Otitis Media

Onset and severity of symptoms

Observation without abx in a healthy child with

reassessment in 48-72hrs

Treat symptoms

High-dose Amoxicillin first line drug

MEE persists for up to 3 months, document Monitor for hearing loss or speech delay

Refer to ENT for MEE >3-6 months, hearing

loss, speech delay, RAOM or complications


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References Rosenfeld, RM et al. Clinical practice Guideline:Adult Sinusitis. Otolaryngol

Head Neck Surg. 2007. 137:S1-S31

Benninger, MS et al. Adult Chronic Rhinosinusitis: definitions, diagnosis,

epidemiology, pathophysiology. Otolaryngol Head Neck Surg. 2003. 129:S1-

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AAP. Clinical Practice Guidelines: Diagnosis and Management of Acute Otitis

Media. Pediatrics. 2004. 113:1451-1465

Lieberthal, AS Acute Otitis Media Guidelines: Review and Update. Current

Allergy and Asthma Reports. 2006. 6:334-341

Rosenfeld et al. Clinical Practice Guideline: Otitis Media with effusion.

Otolaryngol Head Neck Surg. 2004. 130:s95-118

AAFP, AAO-HNS, AAP. Subcommittee on Otitis Media with Effusion.

Pediatrics 2004. 113:1412-1429

Dietmer, T. Tympanostomy tubes: A review of recent studies. ENT Journal.

2004 83:7-9

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