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1

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

[email protected] 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

This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.


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2

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



3

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



4

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



5

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



6

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



7

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



9

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



10

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



11

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



12

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



13

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



14

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



15

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2020. 422



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11. American College of Surgeons. COVID-19: Guidance for Triage of Non-Emergent Surgical 423

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detect obstructive sleep apnea in children?. Pediatrics. 2010 Jan 1;125(1):e162-8. 463

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and meta‐ analysis. The Laryngoscope. 2016 May;126(5):1246-55. 471

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outcomes for mild OSA in children. Chest. 2014 Jul 1;146(1):88-95. 473

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obstructive sleep apnoea in children. Cochrane Database of Systematic Reviews. 2020(1). 475

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disorders in children. Pharmacoepidemiology and drug safety. 2009 Sep;18(9):858-64. 483



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34. Croke LM. AAP releases guideline on diagnosis and management of acute bacterial sinusitis 484

in children one to 18 years of age. American family physician. 2014 Apr 15;89(8):676-81. 485

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Abscess Secondary to Acute Sinusitis: A Systematic Review and Meta‐ analysis. The 489

Laryngoscope. 2020 Feb 17. 490

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abscesses. The Laryngoscope. 2013 Oct;123(10):2337-8. 492

38. Workman AD, Welling DB, Carter BS, Curry WT, Holbrook EH, Gray ST, Scangas GA, 493

Bleier BS. Endonasal instrumentation and aerosolization risk in the era of COVID‐ 19: 494

simulation, literature review, and proposed mitigation strategies. International Forum of 495

Allergy & Rhinology 2020 Apr 3. John Wiley & Sons, Ltd. 496

39. Brietzke SE, Shin JJ, Choi S, Lee JT, Parikh SR, Pena M, Prager JD, Ramadan H, Veling M, 497

Corrigan M, Rosenfeld RM. Clinical consensus statement: pediatric chronic rhinosinusitis. 498

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clinics of North America. 2015 Mar 1;23(1):15-20. 501

41. Rosenberg TL, Nolder AR. Pediatric cervical lymphadenopathy. Otolaryngologic Clinics of 502

North America. 2014 Oct 1;47(5):721-31. 503

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management for COVID-19 in Hong Kong. The Lancet Respiratory Medicine. 2020 Feb 24. 509

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Wyatt M, Hall A, Hall MA. Practical insights for paediatric otolaryngology surgical cases 511

and performing microlaryngobronchoscopy during the COVID-19 pandemic. International 512

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45. Healy CM, Isaacson GC, Edwards MS. April 26, 2018. Cervical lymphadenitis in children: 514

Diagnostic approach and initial management. UptoDate. Accessed April 1, 2020. 515

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Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B. Clinical practice guideline: 517

nosebleed (epistaxis). Otolaryngology–Head and Neck Surgery. 2020 Jan;162(1_suppl):S1-518

38. 519

47. Neutze D, Roque J. Clinical evaluation of bleeding and bruising in primary care. American 520

family physician. 2016 Feb 15;93(4):279-86. 521

48. Özmen S, Özmen ÖA. Is local ointment or cauterization more effective in childhood 522

recurrent epistaxis. International journal of pediatric otorhinolaryngology. 2012 Jun 523

1;76(6):783-6. 524

49. Oberman JP, Derkay CS. Posttympanostomy tube otorrhea. American journal of 525

otolaryngology. 2004 Mar 1;25(2):110-7. 526

50. Hartnick CJ, Shott S, Willging JP, Myer CM. Methicillin-resistant Staphylococcus aureus 527

otorrhea after tympanostomy tube placement: an emerging concern. Archives of 528

Otolaryngology–Head & Neck Surgery. 2000 Dec 1;126(12):1440-3. 529

51. Park SK, Choi D, Russell P, John EO, Jung TT. Protective effect of corticosteroid against the 530

cytotoxicity of aminoglycoside otic drops on isolated cochlear outer hair cells. The 531

Laryngoscope. 2004 Apr;114(4):768-71. 532

52. Jinn TH, Kim PD, Russell PT, Church CA, John EO, Jung TT. Determination of ototoxicity 533

of common otic drops using isolated cochlear outer hair cells. The Laryngoscope. 2001 534

Dec;111(12):2105-8. 535

53. Yamano T, Higuchi H, Nakagawa T, Morizono T. Ototoxicity of acetic acid on the guinea 536

pig cochlea. Journal of Otolaryngology-Head & Neck Surgery. 2015 Dec 1;44(1):54. 537

54. Marc-Elie N, Maria K, Daniel SJ. Hydrogen peroxide ototoxicity in unblocking ventilation 538

tubes: a chinchilla pilot study. Otolaryngology—Head and Neck Surgery. 2007 539

Feb;136(2):216-20. 540

55. Jinnouchi O, Kuwahara T, Ishida S, Okano Y, Kasei Y, Kunitomo K, Takeda N. Anti-541

microbial and therapeutic effects of modified Burow's solution on refractory otorrhea. Auris 542

Nasus Larynx. 2012 Aug 1;39(4):374-7. 543



20

56. Pitaro J, Mood ZA, Daniel SJ. Ototoxicity of aluminum acetate/benzethonium chloride otic 544

solution in the chinchilla animal model. The Laryngoscope. 2013 Oct;123(10):2521-5. 545

57. Sugamura M, Yamano T, Higuchi H, Takase H, Yoshimura H, Nakagawa T, Morizono T. 546

Ototoxicity of Burow solution on the guinea pig cochlea. American journal of 547

otolaryngology. 2012 Sep 1;33(5):595-9. 548

58. Serin GM, Çiprut A, Baylançiçek S, Sari M, Akdas F, Tutkun A. Ototoxic effect of Burow 549

solution applied to the guinea pig middle ear. Otology & Neurotology. 2007 Aug 550

1;28(5):605-8. 551



21

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



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



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



24

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



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




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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




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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




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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




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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




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