Chapter 6 – Ear, Nose, and Throat Emergencies




Chapter 6 Ear, Nose, and Throat Emergencies


Daran Kaufman and Jeffrey Keller



Acute Otitis Media


Acute otitis media (AOM) is a suppurative infection of the middle ear caused by bacteria and viruses. It accounts for up to one-third of pediatric acute health care visits. The incidence is highest during the winter months, secondary to the greater frequency of viral upper respiratory infections (URIs). Children with normal immunity may have multiple episodes in a year. Risk factors for AOM include daycare attendance, second-hand smoke exposure, use of a pacifier, bottle feeding, and a family history of ear infections. Children with Down syndrome or craniofacial abnormalities are at increased risk of otitis media.


The most common bacterial etiology identified is Streptococcus pneumoniae (30–40%), which is now decreasing in frequency secondary to vaccination, followed by nontypable Haemophilus influenzae (20–30%), Moraxella catarrhalis (10–20%), and Streptococcus pyogenes. Gram-negative enteric organisms (Escherichia coli, Klebsiella, Proteus, Pseudomonas) and Staphylococcus aureus are responsible for about 15% of cases in the first few months of life, but are exceedingly rare afterward. Viruses, including parainfluenza, respiratory syncytial virus, influenza, adenovirus, and enterovirus are common pathogens (up to 50% of cases).



Clinical Presentation


Acute otitis media is usually preceded by a URI with cough and rhinorrhea. Additional symptoms begin 2–3 days later and may include fever, pain, dizziness, buzzing in the ear, or decreased hearing. In infants, there are nonspecific symptoms, such as irritability, increased crying, decreased feeding, sleep disturbance, vomiting, or diarrhea. In younger patients there may only be fever, a persistent URI, or behavioral changes (cranky, not feeding or sleeping well). Ear tugging is an unreliable sign of AOM. Occasionally, there is a history of severe ear pain that improved abruptly when a bloody or yellowish discharge began to drain from the external canal (tympanic membrane perforation). In summary, clinical history alone is an inaccurate predictor of AOM; therefore, examine the ears of a patient with any of the symptoms mentioned above, even if otoscopy in the previous 24–36 hours did not reveal an otitis media.



Diagnosis


The American Academy of Pediatrics and the American Academy of Family Physicians practice guidelines state that the diagnosis of AOM must meet the following three criteria: rapid onset, the presence of middle ear effusion (MEE), and signs and symptoms of middle ear inflammation.


Examine the tympanic membrane (TM) for shape (concave, retracted, bulging), color (pearly gray, injected, erythematous, yellow), the presence of landmarks (light reflex, malleus), and mobility. Redness alone is not sufficient to make the diagnosis, since crying can cause erythema of the drum. Perform pneumatic otoscopy, focusing on the light reflex. Decreased mobility of the tympanic membrane, which can be confirmed by tympanometry (flat tympanogram), is the most sensitive indicator of a middle ear effusion. A combination of erythema, bulging with or without a purulent effusion, loss of normal anatomic landmarks and decreased mobility are characteristic of an acute otitis media. Tympanic membrane perforation with recent onset of bloody or purulent ear discharge is also diagnostic. The history of a recent URI, complaints of ear pain, and constitutional symptoms such as listlessness and fever are insufficient to make the diagnosis without the typical otoscopic findings. See Table 6.1 for the differential diagnosis of otalgia.




Table 6.1 Differential diagnosis of otalgia








































Diagnosis Differentiating features
Acute myringitis Inflammation of tympanic membrane
Bullae possible
Dental abscess Edema, erythema, or tenderness of gingiva
Otitis externa Pain on traction of pinna, tenderness over tragus
Parotitis Edema, tenderness over angle of mandible
Inflammation of Stensen’s duct
Pharyngitis Erythema, exudate, or herpangina on oropharyngeal examination
Serous otitis media Dark, retracted tympanic membrane
Air-fluid level or bubbles behind tympanic membrane
TMJ disease Pain with palpation of TMJ, especially with mouth opening/closing

The optimal position for examination varies with the age of the patient. Examine infants and young children supine on the table, restrained by an adult. Place an older child on the parent’s lap, seated face-to-face with the examiner. One of the parent’s arms can tightly embrace the child, while the other holds the patient’s head.


In some cases, there may be impacted cerumen in the ear canal obstructing the view of the tympanic membrane. Remove cerumen by curetting or irrigating with warm water 20 minutes after instilling several drops of hydrogen peroxide (if no tympanic membrane perforation is suspected).



ED Management


Despite the presence of an otitis media, perform a thorough physical examination to be certain that the patient does not have a more serious infection, such as meningitis. If the patient is toxic-appearing, admit for aggressive inpatient parenteral management.


The American Academy of Pediatrics practice guideline recommends a 48–72 hour period of observation, without antimicrobial treatment, for selected patients in whom follow-up can be assured if symptoms worsen (Table 6.2). See Table 6.3 for antibiotic choices and doses.




Table 6.2 Treatment guidelines for AOM by agea




























Age With otorrheaa Uni/bilaterala with severe symptomsb Bilateral without otorrheaa Unilateral without otorrheaa
6 months – 2 years Antibiotics Antibiotics Antibiotics Antibiotics or additional observationc
≥2 years Antibiotics Antibiotics Antibiotics or additional observationc Antibiotics or additional observationc




a Applies only to patients with well-documented acute AOM.



b A toxic-appearing patient, otalgia for >48 hours, temperature >102 °F (38.9 °C) in the past 48 hours, or if follow-up is uncertain.



c If observation is offered a mechanism must be in place to ensure follow-up and begin antibiotics if the patient worsens or fails to improve within 48–72 hours.


Adapted from Lieberthal AS, Carroll AE, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964–999.



Table 6.3 Antibiotic doses for otitis media and sinusitis






















































































Antibiotic Dose Notes
Amoxicillin 80–90 mg/kg/day div bid or tid First choice if not penicillin-allergic
Amoxicillin-clavulanate ESa 90 mg/kg of amoxicillin div q 12h Use for treatment failure after 3 days
Azithromycin: first day 10 mg/kg q day Use for type 1 penicillin hypersensitivityb
days 2–5
or
or
5 mg/kg q day
12 mg/kg × 5 days
20 mg/kg/day × 3 days
Cefdinir 14 mg/kg/day div q day or bid Use for non-type 1 penicillin
hypersensitivity
Cefpodoxime 10 mg/kg/day div q day or bid Use for non-type 1 penicillin
hypersensitivity
Ceftriaxone IM Unable to take PO: 50 mg/kg × 1
Treatment failure: 50 mg/kg/day × 3
Cefuroxime 30 mg/kg/day div q 12h Non-type 1 penicillin hypersensitivity
Clarithromycin 15 mg/kg/day div q 12h Use for type 1 penicillin hypersensitivityb
Clindamycin 20 mg/kg/day div tid or qid Use for type 1 penicillin hypersensitivityb
Erythromycin-sulfisoxazole 50 mg/kg/day of erythro div qid Use for type 1 penicillin hypersensitivityb
Trimethoprim/sulfamethoxazole 8–10 mg/kg of TMP div bid Use for type 1 penicillin hypersensitivityb




a Consider as first choice for otitis-conjunctivitis syndrome because of high prevalence of penicillinase resistance among non-typable H. flu (most common etiologic agent).



b Urticaria or anaphylaxis.


Regardless of the treatment option, pain management is critical. Use analgesics such as acetaminophen (15 mg/kg q 4h) or ibuprofen (10 mg/kg q 6h). In the ED, instilling a single dose of one to two drops of 2% viscous lidocaine may ameliorate extreme discomfort. Do not recommend antihistamine–decongestant combinations, which are of no benefit. Instruct the parents to return in 2–3 days if the child remains symptomatic (fever, ear pain, decreased hearing). If AOM is confirmed on re-examination, initiate antibiotic treatment. Patients whose symptoms are worsening at any time or who have continued symptoms at the completion of treatment require re-examination.



Under Two Months of age

Treat an afebrile, well-appearing infant <2 months of age with amoxicillin. However, if there is fever (>38.1 °C; 100.6 °F), toxicity, irritability, evidence of a systemic infection, a complicated neonatal course, or a previous hospitalization with antibiotic treatment, perform an evaluation for sepsis, treat with IV antibiotics, and admit the patient (see Evaluation of the Febrile Child, pp. 390394).


A sterile effusion occurs in more than 40% of children following an AOM. This usually resolves without intervention, although a temporary conductive hearing loss can persist until the effusion resolves.


Tympanocentesis with culture is indicated for systemic toxicity, severe unremitting pain, inadequate response to conventional therapy, or a suppurative complication (facial nerve paralysis, mastoiditis, meningitis, brain abscess), and may be necessary in some immunocompromised patients. Obtain an otolaryngology consult.



Follow-up





  • Patient not treated with antibiotics: 2–3 days



  • Patient treated with antibiotics: 2–3 days if still febrile or with persistent otalgia



Indications for Admission





  • Infant <1 month of age, with temperature over 38.1 °C (100.6 °F)



  • Toxic appearance



  • Immunocompromised patient with fever



  • Suppurative complication (mastoiditis, meningitis, brain abscess) or seventh nerve palsy



Bibliography

Ngo CC, Massa HM, Thornton RB, Cripps AW. Predominant bacteria detected from the middle ear fluid of children experiencing otitis media: a systematic review. PLoS One. 2016;11(3):e0150949.

Principi N, Marchisio P, Esposito S. Otitis media with effusion: benefits and harms of strategies in use for treatment and prevention. Expert Rev Anti Infect Ther. 2016;14(4):415423.

Schilder AG, Chonmaitree T, Cripps AW, et al. Otitis media. Nat Rev Dis Primers. 2016;2:16063.

Sjoukes A, Venekamp RP, van de Pol AC, et al. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children. Cochrane Database Syst Rev. 2016;12:CD011534.

Venekamp RP, Burton MJ, van Dongen TM, et al. Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev. 2016;6:CD009163.


Cervical Lymphadenopathy


Palpable cervical lymph nodes >1 cm in diameter are present in approximately 80–90% of preschool and young, school-age children, especially if they have had a recent upper respiratory tract infection. Nonetheless, consider cervical lymphadenopathy in three broad etiologic categories: reactive, adenitis, or associated with systemic illness.



Clinical Presentation



Reactive

Most enlarged cervical lymph nodes are reactive, found in conjunction with a viral or bacterial infection of the head or neck. These nodes are generally benign and no work-up or specific treatment is necessary.


Most often the presentation reflects the primary illness (URI, pharyngitis, etc.). Other complaints include pain, a neck mass, stiff neck (unwillingness to move the neck side to side), or torticollis. Reactive nodes are usually multiple, discrete, firm, smaller than 1–2 cm in diameter, nontender, and mobile. The overlying skin is neither erythematous nor adherent. In general, reactive adenopathy subsides in 2–3 weeks, but it can persist.



Adenitis

An adenitis is an infection of the lymph node itself, most commonly (60–85%) caused by Staphylococcus aureus or group A Streptococcus, although viral and anaerobic infections have been implicated. Atypical Mycobacterium and Mycobacterium tuberculosis can result in a node with all the signs of acute infection. Cat scratch disease (Bartonellosis) may cause cervical, axillary, or inguinal adenitis.


With an adenitis, the node becomes enlarged, tender, and fluctuant. The overlying skin can be warm, erythematous, and occasionally adherent. The hallmarks of an atypical Mycobacterium infection are the presence of skin erythema overlying a nontender lymph node in an afebrile, otherwise well-appearing child. The node often suppurates. Cat scratch disease is characterized by a papule at the site of the scratch, followed in 5–60 days by regional lymphadenitis. Despite the impressive lymphadenopathy, the patient usually appears well, although 30% may have fever.



Systemic Disease

Systemic diseases, especially infectious mononucleosis and mono-like syndromes (cytomegalovirus, toxoplasmosis, leptospirosis, brucellosis, and tularemia), sarcoidosis, Kawasaki syndrome, and HIV can cause cervical as well as generalized lymphadenopathy. Some medications, such as phenytoin and isoniazid, can cause generalized lymphadenopathy. Always consider the possibility of a malignancy (leukemia, Hodgkin’s disease, non-Hodgkin’s lymphoma, neuroblastoma).


Mononucleosis and mono-like illnesses (pp. 425427) can present with generalized tender lymphadenopathy, sometimes in association with an exudative pharyngitis, macular rash, and hepatosplenomegaly. These nodes are firm and mobile. Kawasaki disease (pp. 414417) and HIV (pp. 396399) are discussed elsewhere.


A malignant node is fixed, nontender, hard, and matted. It is frequently supraclavicular in location and may be described as persistent or continuously growing. Weight loss, weakness, pallor, night sweats, fever, petechiae, and ecchymoses are other possible findings.



Diagnosis


Perform a thorough examination of the head, neck, teeth, and gums to find a source of infection draining into the affected node(s). Weakness, fever, rash, hepatosplenomegaly, and generalized lymphadenopathy are all indicative of a systemic disease. See Table 6.4 for the differential diagnosis of cervical adenitis.




Table 6.4 Differential diagnosis of cervical lymphadenopathy and neck masses





























































Diagnosis Differentiating features
Branchial cleft cyst Smooth and fluctuant along the lower anterior border of SCM muscle
Cervical ribs Bilateral, hard, immobile masses
Cystic hygroma Soft, compressible
Usually transilluminates
Dermoid cyst Midline mass with calcifications on x-ray
Hemangioma Present at birth
Red or bluish color
Kawasaki Nonpurulent conjunctivitis and mucous membrane changes
Polymorphic rash
Edema of dorsum of extremities
Malignancy May have: weight loss, pallor, bleeding, fever, hepatosplenomegaly
Node is fixed, hard, matted, and persistent or growing
Meningitis Nuchal rigidity, photophobia, toxicity
Parotitis Swelling obscures the angle of the jaw
Intraoral exam: edema, erythema, or drainage from Stensen’s duct
Thyroglossal duct cyst Midline mass between thyroid bone and suprasternal notch
Moves up when patient sticks out tongue

There are seven features of the affected node(s) to consider.



Single or Multiple (Unilateral or Bilateral)

Enlargement of a single node generally occurs in an adenitis, although tuberculous adenitis causes bilateral involvement. Reactive adenopathy and systemic diseases most often result in multiple, bilateral involvement.



Location(s)

The location of a reactive node can suggest the site of the primary infection (preauricular–conjunctiva or external ear canal; occipital–scalp; submental and submandibular–intraoral). Supraclavicular adenopathy is suspicious for a malignancy, while occipital adenopathy suggests a viral illness (particularly roseola and rubella). Generalized lymphadenopathy most commonly occurs during mononucleosis or a mono-like infection, although leukemia is a possible etiology.



Size

Reactive nodes are typically small (<2 cm). Massive enlargement can occur with an atypical Mycobacterium infection.



Rate of Growth

Nodes that slowly enlarge suggest a malignancy, while rapid enlargement occurs in an infected or reactive node.



Mobility

In general, a freely movable node is benign. A node that is fixed to adjacent structures or matted to other nodes suggests a malignancy, mycobacterial infection, or cat scratch disease.



Consistency

Soft or firm nodes are benign, while fluctuance occurs in adenitis. A rubbery consistency is noted in sarcoidosis, and malignant nodes are usually rock hard.



Overlying Skin

Bacterial adenitis causes erythema and warmth of the overlying skin. However, adherence occurs in cat scratch disease and atypical Mycobacterium infection. A reactive node does not affect the overlying skin.



ED Management



Reactive

“Benign” reactive nodes found in conjunction with a head or neck infection require treatment of the primary illness only. If the pharynx is erythematous, obtain a rapid strep test or a throat culture. Benign nodes can be followed without intervention, although persistence for more than 4–6 weeks may indicate the need for further testing. Reassure the family and arrange for primary care follow-up.



Adenitis

When bacterial adenitis is diagnosed, obtain a throat culture or rapid strep test and give an oral antibiotic with staphylococcal and streptococcal coverage, such as amoxicillin-clavulanate (875/125 formulation; 90 mg/kg/day of amoxicillin div bid) or clindamycin (20 mg/kg/day div q 6h). Warm compresses, applied for 15–30 minutes every 3–4 hours, are a useful adjunct. Have the patient return in 2–3 days. If there is clinical improvement, or a positive strep test or culture, continue the antibiotics for a total of ten days. If the node has not responded to antibiotics and warm compresses, obtain an ultrasound and admit the patient for IV antibiotics. If, instead, the node has become fluctuant, also obtain an ultrasound and consult with an otolaryngologist or surgeon to arrange for an incision and drainage. Obtain Bartonella titers if the patient has had contact with a kitten.


Admit patients who are toxic or have nodes unresponsive to oral antibiotic therapy for parenteral treatment: nafcillin 150 mg/kg/day div q 6h, ampicillin-sulbactam (150 mg/kg/day div q 6h), or cefazolin 75 mg/kg/day div q 8h. Use clindamycin (40 mg/kg/day div q 6h) if MRSA is a concern. Obtain a CBC with differential, heterophile antibody, and a blood culture prior to starting intravenous therapy. Indications for a node biopsy include age greater than ten years, persistent and unexplained weight loss or fever, skin ulceration or fixation to the node, supraclavicular location, or continuously increasing size. If atypical mycobacterial infection is suspected, surgical curettage/excision is required as the infection is frequently resistant to antitubercular medication (pp. 428429), but avoid incision and drainage, which can result in a chronic fistula. If tuberculosis is suspected because of possible exposure or travel, place a 5 TU PPD. If the PPD is positive, consider Mycobacterium as the cause of the infection. Obtain a chest x-ray and admit the patient for surgical consultation, collection of culture specimens, and institution of antituberculous therapy (pp. 435439).



Systemic Disease

When a mononucleosis syndrome is suspected, obtain a heterophile antibody (≥5 years of age) or EBV titers (<5 years of age). Treatment is supportive. Note that the heterophile antibody may be negative early in the disease and in young or immunocompromised patients. If a malignancy is suspected, the initial evaluation includes a chest x-ray and CBC with differential and reticulocyte count prior to hematology consultation. See pp. 159160 for the treatment of parotitis.



Follow-up





  • Bacterial adenitis: 2–3 days



Indications for Admission





  • Cervical adenitis associated with toxicity or inadequate oral intake



  • Cervical adenitis unresponsive to outpatient treatment



  • Evaluation of a suspected malignancy



  • Institution of antituberculous therapy



Bibliography

Locke R, Comfort R, Kubba H. When does an enlarged cervical lymph node in a child need excision? A systematic review. Int J Pediatr Otorhinolaryngol. 2014;78(3):393401.

Meier JD, Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician. 2014;89(5):353358.

Rajasekaran K, Krakovitz P. Enlarged neck lymph nodes in children. Pediatr Clin North Am. 2013;60(4):923936.

Rosenberg TL, Nolder AR. Pediatric cervical lymphadenopathy. Otolaryngol Clin North Am. 2014;47(5):721731.


Epistaxis


Epistaxis usually originates from the anterior nasal septum (Kiesselbach’s area). Trauma (nose picking, punch, fall), URIs, environmental allergies, excessive use of decongestants or topical nasal steroids, an overly dry environment, and foreign bodies are predisposing factors. Rarely, structural abnormalities (hemangioma, telangiectasia, or angiofibroma), a bleeding diathesis (usually thrombocytopenia), or hypertension is involved. While children are often rushed into the ED because of “massive” blood loss, clinically significant bleeding is unusual.



Clinical Presentation


Usually an anterior septal source is evident. It is rare for the bleeding to be bilateral, but blood crossing behind the nasal septum can mimic a bilateral bleed. Sometimes, if the site is posterior or if the child is sleeping, the blood may present as hematemesis.



Diagnosis


Examine the nasal cavity with the child sitting on the parent’s lap, using a bright light (otoscope). If a bleeding source is found, the examination may be terminated, as multiple sites are unusual, except in the case of a fractured nasal septum. If the patient has suffered nasal trauma, look for a septal hematoma, which appears as a bluish-black mass on the anterior septum, filling the nasal cavity. Occasionally, a mucosal hemangioma or telangiectasia is seen. If no cause is found, but blood is noted trickling down the throat, assume that there is a posterior source.


Examine the skin for hemangiomata or telangiectasias, which may also be present in the nasal cavity. Pallor, tachycardia, gallop rhythm, or orthostatic vital sign changes suggest significant blood loss. Jaundice, petechiae, purpura, lymphadenopathy, and hepatosplenomegaly may reflect a bleeding diathesis.


In general, no work-up is required for a nosebleed in an otherwise well child with an anterior septal source. Obtain a hematocrit if anemia is suspected, but evaluate for a bleeding diathesis (pp. 353357) if the patient has any of the physical findings enumerated above, a long history of recurrent nosebleeds, easy bruising, hemarthrosis, multiple subconjunctival hemorrhages, or a family history of excessive bleeding.



ED Management


Most anterior bleeds respond to pressure. Pinch the nares together for a full five minutes with the child sitting upright leaning forward (to prevent swallowing of blood). If this is unsuccessful, soak gauze with 1:1000 aqueous epinephrine or 0.05% oxymetazoline solution and place it in the nasal cavity. Alternatively, if the bleeding remains brisk, pack the nose with petrolatum-impregnated gauze, merocel nasal packing, or Gelfoam. If the patient has recurrent bleeds, after hemostasis is obtained, apply topical anesthesia with 4% lidocaine or benzocaine and cauterize the site, if visible, for three seconds with a silver nitrate stick. Treat hemangiomata or telangiectasias in the same way, but do not use cautery if a bleeding diathesis is suspected (possible tissue slough). Humidification, saline nose drops during the day, and the application of petrolatum (Vaseline) to the septum at bedtime help reduce the recurrence of nose bleeds. If a nasal septal hematoma is suspected, consult an otolaryngologist for immediate drainage to prevent a septal abscess and subsequent nasal deformities.


If routine measures are ineffective or the source is posterior, either consult an otolaryngologist or place a posterior pack. Anesthetize the nose with a topical anesthetic (as above), insert a posterior nasal balloon pack (Epistat or Rapid Rhino, blow up the posterior balloon, pull anterior until it fits snugly in the nasopharynx, and then inflate the anterior balloon until the bleeding stops. Fill both balloons with saline solution. If nasal balloon packs are not available, pass an uninflated Foley catheter through the nose into the pharynx, inflate the balloon, and then pull the catheter back until it fits snugly posteriorly in the nose. Fill the nose with petrolatum-impregnated gauze up to the balloon and place a clamp across the catheter where it exits the nose. If an anterior or posterior nasal pack is placed, give the patient broad-spectrum antibiotics to prevent an acute sinusitis (see Table 6.3). Otolaryngology consultation is indicated.



Follow-up





  • Unilateral anterior pack: 48 hours for pack removal



Indications for Admission





  • Bilateral anterior pack



  • Posterior pack



  • Bleeding diathesis or significant blood loss



Bibliography

Béquignon E, Teissier N, Gauthier A, et al. Emergency Department care of childhood epistaxis. Emerg Med J. 2016. pii: emermed-2015-205528.

McGarry GW. Recurrent epistaxis in children. BMJ Clin Evid. 2013;2013:0311.

Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012;9:CD004461.

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Sep 22, 2020 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 6 – Ear, Nose, and Throat Emergencies

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