How to Treat Otitis Media

Natures Amazing Ear Infection Cures By Naturopath Elizabeth Noble

Little Known Secrets To Cure An Ear Infection Fast! Here's A Taste Of What's Revealed In The Nature's Amazing Ear Infection Cures e-book: What type of ear infection do you or your loved one have? The 9 ear infection symptoms you can't afford to ignore. Danger at the drugstore what drugs you should never buy. Why antibiotics are useless and possibly dangerous for most ear infections. The problems with surgery. The causes and triggers of an ear infection everything from viruses, bacteria and fungi to allergies, biomechanical obstruction, environmental irritants, nutrient deficiencies, poor infant feeding practices and more. How to relieve even the most excruciating ear ache with a hot onion poultice. An ancient Ayurvedic recipe to control an ear infection. The herbal ear drops you can make in your own kitchen that are renowned for soothing ear pain. The wonderful essential oil ear rubs you can make to ease ear congestion and discomfort. The simplicity of homeopathy for treating an ear infection great for babies and young children. User-friendly acupressure, massage and chiropractic to relieve ear pain, enco. How to relieve problem ears with air travel.

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Necrotizing otitis externa

Necrotizing otitis externa is also known as 'malignant otitis externa'. It is not that the condition may become malignant, but because of the occasional fatal outcome. This typically occurs in elderly patient who is diabetic or is immunocom-promised for other reasons. There is usually a long history of ear discharge and otalgia is frequently present and pronounced. The causative organism is Pseudomonas pyocyanea. The clinical features of 'necrotizing otitis externa' are often misleading and deceptive in the early phase of the disease. However, the response to standard treatment is poor and the condition may suddenly deteriorate. Ear examination often shows exuberant granulation tissue. A biopsy should be taken for microbiological work-up and for histological examination to exclude malignancy. Infection and the necrotizing process may spread to involved the temporal bone causing osteomyelitis. The first indication is often facial nerve palsy. In advanced disease, the jugular foramen...

TABLE 1161 Treatment Options for Acute Otitis Media

In areas where drug resistant Strep. pneumoniae has become a concern, amoxicillin remains the drug of choice for the treatment of acute otitis media. However, since the standard dose (40 mg kg day) may not eradicate penicillin resistant organisms, a higher dose, (80 to 90 mg kg day) has been recommended for high-risk patients. These include those less than 2 years of age, those with recent (prior month) antibiotic exposure, and attendance in day care. (Of note, the Food and Drug Administration has not approved amoxicillin at these higher doses.)16 Although there is recent literature to support a short-course (5-day) therapy for selected children (those > 2 years of age with a mild episode and an otitis-free history), the standard length of treatment remains 10 days, except for azithromycin, which is given for 5 days. I7 In the numerous trials of antibiotics in the treatment of otitis media, adverse reactions requiring the discontinuation of the drug have occurred in fewer than 5...

Chronic suppurative otitis media

Chronic suppurative otitis media (CSOM) is the commonest form of chronic otitis media. Clinically it is characterized by otorrhoea and conduction hearing loss of variable severity. Otoscopy reveals a perforated eardrum. The condition is classified into the safe (tubotympanic) and unsafe (atti-coantral) variety depending on the likelihood of coexisting cholesteatoma. The unsafe variety is CSOM with cholesteatoma (Fig. 20.4). The presence of cholesteatoma is usually obvious on otoscopy. Occasionally, cholesteatoma may be more difficult to diagnose. If otoscopy reveals granulation tissue, aural polyps or middle ear infection that is resistant to conservative treatment, cholesteatoma should be excluded. Traditionally, in the presence of a marginal perforation or a deep retraction pocket, CSOM is considered potentially unsafe. However with modern endoscopic equipment and CT, assessment of the middle ear becomes much more accurate than before. Diagnostic uncertainty occurs only rarely. The...

Otitis media with effusion

Otitis media with effusion (OME) is a condition with complex etiologies including anatomical variations, allergy, infections and inflammation. The interplay of these factors lead finally to structural and or functional abnormality of the Eustachian tube resulting in OME. The more horizontal lie of the Eustachian tube and frequent attacks of URTI contribute to the high prevalence of OME in infants and young children of any race. The reported cumulative incidence of first episode of OME reaches almost 100 by the age of 3 years. The incidence drops sharply after the age of 7 so much so that the condition is uncommon amongst teenagers and rare in adults. However, in places where nasopharyngeal carcinoma (NPC) is endemic, deafness associated with OME is a common presenting symptom of the disease. In these areas, NPC should be excluded in any adult with unilateral OME. Clinical diagnosis is straightforward when otological examination shows a fluid level (Fig. 20.2) or bubbles behind the...

Otitis Externa Pseudomonas gram negatives proteus

-Polymyxin B neomycin hydrocortisone (Cortisporin otic susp or solution) 2-4 drops in ear canal tid-qid x 5-7 days. otic soln or susp per mL neomycin sulfate 5 mg polymyxin B sulfate 10,000 units hydrocortisone 10 mg in 10 mL bottles) . The suspension is preferred. The solution should not be used if the eardrum is perforated. Malignant Otitis Externa in Diabetes (Pseudomonas)

Otitis Externa

External otitis (OE) is any inflammatory condition of the auricle, external ear canal, or outer surface of the TM. It can be caused by infection, inflammatory dermatoses, trauma, or combinations of the three. DIAGNOSIS The hardest part of the diagnosis is to distinguish between OE and otitis media. Ideally, clinical inspection of the TM with a pneumatic otoscope helps establish the diagnosis however, the TM of a child with OE may be as red and distorted as that of a child with otitis media, although mobility of the TM is normal or slightly decreased in OE. In addition, visualization of the TM may be difficult because of edema of the canal in OE. Tympanometry can be helpful if the canal is clear and a tight seal for the earpiece can be formed without too much discomfort. Parotitis, periauricular adenitis, mastoiditis, dental pain, and temporomandibular joint dysfunction should be considered when the discomfort is poorly localized and the ear canal and TM appear normal. In addition,...

Acute otitis media

Acute otitis media most commonly occurs in young paedi-atric patients less than 6-7-year old. It typically occurs, following an upper respiratory tract infection (URTI), as ascending infection through the Eustachian tube. The natural course of acute otitis media is best described in four stages hyperaemic, inflammatory, suppurative and resolution phases. In the hyperaemic phase, the patient has otalgia without hearing loss and otoscopy reveals a hyperaemic eardrum. The inflammatory phase that follows is characterized by increasing otalgia and hearing loss. Fever is usually present at this phase. Otoscopy reveals a hyperaemic eardrum and middle ear effusion. The disease reaches a climax at the suppurative phase. The patient often becomes irritable because of intense otalgia and hyperpyrexia is frequently present. Otoscopy reveals pus collecting behind a bulging and intensely hyperaemic eardrum. The eardrum is now under severe tension and may rupture spontaneously. Once the eardrum...

Otitis Media

Otitis media, or inflammation of the middle ear, is one of the most common pediatric diagnoses. Each year there are 24.5 million office visits and over 3.7 million emergency department visits, with direct and indirect costs of 5.7 billion a year.12 and3 Acute otitis media (AOM) (acute suppurative, purulent, or bacterial) is associated with signs and symptoms of inflammation of the middle ear, such as otalgia, otorrhea, fever, irritability, anorexia, or vomiting. 4 Otitis media with effusion (OME) (secretory, nonsuppurative, serous, or mucoid) is a relatively asymptomatic collection of fluid in the middle ear. The duration (not the severity) of OME can be divided into acute (< 3 weeks), subacute (3 weeks to 3 months), and chronic (> 3 months).5 The most important distinction between OME and AOM is that the signs and symptoms of acute infection (otalgia, otorrhea, and fever) are lacking in OME, but hearing loss may be present in both conditions. 5 ACUTE OTITIS MEDIA Infants and...

Table 4D3 Etiology of CNS abscess

Otitis media, pulmonary infection Endocarditis Other sources Neurosurgical procedure, penetrating head injury Antecedent infection recent otitis media, sinusitis, respiratory tract infection, pharyngitis, or intracranial abscess may suggest recent colonization with, or contiguous spread of, a particular organism. HEENT exam should include a search for evidence of trauma, surgery, infections (otitis, mastoiditis, sinusitis, pharyngitis), or pupillary abnormalities. Note that papilledema takes time to develop, and this finding can be absent in the majority of patients with bacterial meningitis. In infants < 12 mo of age, when meningeal signs are unreliable, the anterior fontanelle should be evaluated for bulging.

Clinical Features

The exotoxin tetanospasmin is responsible for the clinical manifestations of tetanus, which consist of generalized muscular rigidity, violent muscular contractions, and instability of the autonomic nervous system. Wounds that become infected with toxin-producing C. tetani are most often puncture wounds2 but vary in severity from deep lacerations to minor abrasions.25 Tetanus can also develop after surgical procedures, otitis media, and abortion and can develop in neonates through infection of the umbilical cord and in intravenous drug users. Cephalic tetanus follows injuries to the head or occasionally otitis media and results in dysfunction of the cranial nerves, most commonly the seventh. This form of tetanus has a particularly poor prognosis.

Peritonsillar Abscess

Peritonsillar abscess in children most commonly presents in adolescents with an antecedent sore throat. Often there is a period of improvement prior to the onset of progressive worsening symptoms. Peritonsillar abscess may rarely occur in the younger child. Most commonly, patients appear acutely ill with fevers, chills, dysphagia, trismus, drooling, or a muffled or hot potato voice. When present, trismus is thought to be due to secondary inflammation of the neighboring pterygoid muscles. These children may have ipsilateral ear pain and torticollis. Torticollis may represent an attempt to relax the ipsilateral sternocleidomastoid muscle so as to decrease pressure on the peritonsillar space.

Subacute Bacterial Endocarditis

Children with congenital heart disease are at great risk of developing endocarditis. Transient bacteremia produced by iatrogenic procedures such as dental work or gastrointestinal or urologic manipulation can lead to localized colonization and infection. Although the thrust of most primary care providers is toward prevention of this disease, cases still occur. Typically, the usual presentation is of unexplained fever in children with known congenital heart disease. Appropriate evaluation includes multiple blood cultures, urine culture and analysis, and complete blood count. Parenteral or oral antibiotics should be administered in consultation with a pediatric cardiologist familiar with the child's history. In cases of known source of infection, such as otitis media or pneumonia, multiple blood cultures should be obtained, and appropriate therapy should be directed at the site of primary infection.

Idiopathic facial dermatitis of Persian cats

The presenting clinical signs are observed in Persian cats and in an initial case series the age of onset ranged from 4 months to 5 years. The dermato-logical examination reveals black waxy material on the distal portion of the hairs in a symmetrical pattern on the face, particularly on the chin, perioral and periocular areas. There is bilateral erythematous otitis externa with black waxy material in some cases. Pruritus is minimal at the outset and becomes severe in some cases (Plate 6.21).

Macromolecular Composition

Infection is transmitted via respiratory secretions. After a variable incubation period of up to 4 weeks the disease begins with growing hoarseness and aching throat, mild cough, and fever and does later develop into an atypical pneumonia. 12,13 In rare cases infection may also present as sinusitis or otitis media or lead to the aggravation of asthma. 14 In immunocompetent individuals the infection is usually self-limiting, but may be complicated by superinfections. In immunocompromised persons infection may take a more severe course. Reinfections do occur but are generally milder than primary infections. 13

Otodectic mange Otodectes cynotis

This mite is the common cause of otitis externa and pinnal dermatitis in the cat. Otodectes is a free-living The mites are a major cause of otitis externa occasionally they can be found beyond the ear canal, including the head, neck, dorsum and tailhead regions, where they may cause pruritus and papular dermatitis. Acute signs of irritation may accompany the onset of infection. Some cats develop a profound hypersensitivity reaction to the feeding mites. Various treatment options are available. All of the cats and dogs in the home should be treated because of the potential for cross-infection. The copious quantities of wax that frequently accompany infestation should be removed with an ear cleaner before instilling ear medication that is licensed for mite therapy. Some vets use 1 week of therapy followed by a rest for 1 week then a further week of therapy to remove any mites that have emerged from residual eggs hatching. Cases that appear to fail therapy should be carefully evaluated...

TABLE 2311 Causes of Otalgia

Abscessed and impacted teeth, usually mandibular molars, frequently cause ear pain. Malocclusion, bruxism, mandibular trauma, temporomandibular joint (TMJ) disorders, and ill-fitting dentures are frequent causes of otalgia. 1 Trigeminal neuralgia, or tic douloureux, causes severe unilateral facial pain. Herpetic geniculate neuralgia, or Ramsay Hunt syndrome, is herpes simplex of the EAC and auricle with facial palsy which may persist long after the disappearance of the vesicles (postherpetic neuralgia).

The Course of Infectious Diseases

Infectious diseases can be followed by specific complications. Otitis, lymphadenitis or nephritis can complicate scarlet fever, while typhoid fever can be complicated by intestinal haemorrhage or perforation of the intestine some complications can be non-specific, i.e., caused by some other microorganisms. The most dangerous complications of infectious diseases are shock, renal encephalopathy (viral hepatitis), acute renal failure (meningococcal infection), brain oedema (meningitis), etc., which require intensive therapy.

Developing Countries Perspective

The significant precipitating risk factors for FS include the degree of fever20 and the frequency of febrile illnesses.21 The most commonly reported febrile illnesses are upper respiratory tract infections and otitis media.10 Children with primary infection with human herpes virus-6 (HHV6) often develop FS.2 The pattern of the underlying febrile illness is similar in both developed and developing countries.10,26 However, certain infections like exanthematous fevers and malaria are still endemic in the developing countries. In Central Africa, malaria accounts for five per cent of pediatric emergencies.27,28 Vivax malaria is a frequent cause of typical FS in the endemic regions and FS can be the presenting feature of Falciparum malaria.14,27

Erythema multiforme and toxic epidermal necrolysis

The usual course to establishing a diagnosis is to avoid the contact irritant and then do provocative challenge to repeat the clinical findings, or perform patch testing with suspected allergens and evaluate the cutaneous response. Patch testing is rarely carried out with cats one report used closed patch testing with a neomycin-based topical preparation. The cat had bilateral otitis externa, which improved when the ear medication was discontinued. There was an erythematous reaction at 5 days to the patch test, with no reaction to the petrolatum base. The histological findings included microvesicle formation and an eosinophilic infiltrate (Thoday, 1985).

Physiological Cross Species and Evolutionary Perspective

Although high-quality breast milk substitutes are available today for those with the knowledge and financial means to use them correctly, the importance of breastfeeding in human prehistory and for mothers and infants in most cultures today cannot be overemphasized. There is no question that, under most conditions and in most parts of the world, breast-fed babies are healthier than their bottle-fed counterparts. In addition to the immunological protection afforded by mother's milk, breast-fed babies are less likely to be exposed to environmental pathogens associated with unclean water, unsterilized bottles, and other equipment used in infant feeding. Even later in life, children and adults who were breast-fed as infants seem to be protected from a number of health insults, including otitis media (earache), sudden infant death syndrome (SIDS), gastrointestinal illnesses, atherosclerosis, and some cancers (Anonymous, 1997). Furthermore, cognitive and motor skill development seem to...

Retropharyngeal Abscess

Although a retropharyngeal abscess is relatively uncommon, it occurs most frequently in very young children. The majority of children treated for this infection are younger than 12 months of age, and almost one-third of cases occur in children less than 6 months of age.17 There is a higher incidence of retropharyngeal abscess in young children because of the prominence of several lymph nodes in the space between the posterior pharyngeal wall and the prevertebral fascia. By 3 to 4 years of age, these lymph nodes atrophy and are no longer functional.17 Predisposing factors for the development of a retropharyngeal abscess include a penetrating foreign body, such as a nasogastric tube or nasotracheal tube trauma pharyngitis tonsillitis otitis media nasal or dental procedures and tonsillectomy or adenoidectomy.

Fusobacterium Infection And Immunity

The spectrum of infections in which Fusobacterium spp. play a pathogenic role include bacteremia, head and neck infections (such as chronic otitis media, sinusitis and mastoiditis, peritonsillar and retropharyngeal abscesses, Vincent's angina, gingival and dental infections), pulmonary infections (aspiration pneumonia, lung abscesses and empy ema), intracranial infections (meningitis and intracranial abscesses), gastrointestinal infections (peritonitis, hepatic and abdominal abscesses), osteomyelitis, urogenital (prostatic and female genital abscesses, amnionitis) as well as skin and soft tissue infections, especially around the oropharyngeal area. F. necrophorum (currently divided into two subspecies) is the second most common pathogen in humans. It is found in pharyngeal and tonsillar infection associated with bacteremia, otitis, pneumonia, liver and colonic infections. It has a variety of virulence factors that makes it a potentially greater pathogen than other fusobacteria. These...

Libby Kumin PhD Cccslp

The most common risk factors that we see in infants and toddlers with Down syndrome that directly influence speech and language development are low muscle tone in the oral motor area, including the lips, tongue, and jaw (Kumin and Bahr, 1999), relative macroglossia (Desai, 1997), and otitis media with effusion (Roizen et al., 1992) resulting in fluctuating hearing loss. Because there is no one communication profile, there is no one treatment plan. Treatment should be individually designed to meet all of the communication needs of the child. The IEP is based on a remediation model. For each area in which the child will receive services, the IEP must document the child's present level of performance, annual goals, and short-term objectives, including how progress will be measured and benchmarks. Generally, present performance and progress are measured by test results, and test scores must indicate delays and deficits to qualify for services. When a child makes progress and reaches the...

Characteristics of the organism and its antigens

Is associated with an increased incidence of otitis media in children. Whether nasopharyngeal colonization is an immunizing process is not yet known. The most serious systemic disease caused by H. influenzae is meningitis. The incidence of invasive Hib disease, particularly meningitis, has decreased dramatically since the mid-1980s. This decrease is due to the widespread use of vaccines which are composed of Hib polysaccharide capsule conjugated to protein carriers. While Hib causes invasive infections, NTHI causes predominantly mucosal infections. NTHI causes 25-30 of all cases of otitis media. Approximately 80 of all children will experience at least one episode of otitis media by the age of 3 years. NTHI is a common cause of lower respiratory tract infections in adults with chronic obstructive pulmonary disease. More recently, NTHI has been recognized as an important cause of pneumonia in adults with acquired immune deficiency syndrome (AIDS) and in children in developing...

Effect of maternal immunity on the child

Protection in the breastfed infant against Vibrio cholerae, Shigella and Campylobacter relates to the content in the mother's milk of secretory IgA antibodies against these pathogens. Protection against severe rotavirus diarrhea is also suggested as is protection against Helicobacter pylori infections. Studies have also shown that breastfeeding can prevent otitis media and this protection may relate to the fact that the milk secretory IgA may decrease nasopharvngial colonization with Haemophilus influenzae.

TABLE 1221 Differential Diagnosis of Vomiting

Other causes of acute diarrhea are uncommon but must be considered. In agricultural areas, poisoning with anticholinesterase insecticides, organophosphates, and carbamates must be considered, especially if diarrhea is accompanied by profuse sweating, lacrimation, hypersalivation, and abdominal cramps. Vomiting and diarrhea may also be a nonspecific presentation for other infectious diseases, such as otitis media, urinary tract infection, or other more serious conditions, including intussusception, malrotation, increased intracranial pressure, and metabolic acidosis.

B cell deficiency diseases

The physiological importance of B cell function is revealed by diseases that result from selective B cell deficiencies and consequent lack of antibodies (agammaglobulinemia). Bruton's agammaglobulinemia (XLA) is an X-linked defect in B cell maturation in humans, with arrest at the Pre-B I stage and a resulting deficiency in all immunoglobulin classes. A corresponding B cell maturation defect, the Xid mutation, also occurs in CBA N mice. In male children with XLA, the maturation block results from deficiency of a B cell-specific protein tyrosine kinase, btk. With a profound lack of mature B cells but normal T cells, these children are particularly susceptible to infections by bacteria, mycoplasma, hepatitis virus and enteroviruses. They have recurrent middle ear infection, pneumonia, sinusitis and tonsillitis caused by Pneumococcus, Streptococcous and Hemophilus. Problems with infection begin several months after birth, when the pool of protective maternal antibody decreases. XLA...

Human Rhinovirus Coat Protein

The human rhinovirus (HRV) belongs to the family of picornaviruses and is the main cause for common colds and a variety of other respiratory illnesses, including otitis media and sinusitis, and for exacerbations of asthma and reactive airways disease. These illnesses still lack effective antiviral treatment. The viral capsid is a promising and intensively studied target for drug development. This protein shell encapsulates a single, positive RNA strand and consists of 60 copies of four different viral proteins. HRV coat protein inhibitors act as capsid-binding antiviral agents that block the uncoating of the viral particles and or inhibit cell attachment (Hadfield et al., 1999). Their binding site is located within a hydrophobic pocket situated at the bottom of a depression, a so-called canyon, on the capsid surface. In the absence of an inhibitor, this pocket can be empty or occupied by a pocket factor, a lipid or fatty acid. Structural conservation in this region among the different...

TABLE 2316 Some Common Topical Otic Preparations

Finally, all patients should be instructed to follow up with their primary physician or an otolaryngologist if the condition worsens at any time or does not respond to treatment in 1 week these patients must be evaluated for the more serious disease of malignant otitis externa. MALIGNANT OTITIS EXTERNA Definitions Malignant otitis externa (MOE) is a potentially life-threatening infection of the EAC with variable extension to the skull base. It is almost always caused by P. aeruginosa. The term MOE actually refers to a spectrum of disease. When it is limited to the soft tissues and cartilage, it is called necrotizing otitis externa (NOE). When there is involvement of the temporal bone or skull base it is called skull-base osteomyelitis (SBO). Pathophysiology MOE begins as a simple otitis externa that then spreads to the deeper tissues of the EAC and infects cartilage, periosteum, and bone, with the normal anatomy of the ear serving as the conduit for the spread of infection. The...

Nasopharyngeal cancer

The first sign of NPC is often an enlarged metastatic cervical node in the posterior triangle. Common local signs and symptoms include nasal (blood-stained discharge, obstruction), aural (serous otitis media, tinnitis, conductive hearing loss) and neurological symptoms (diplopia due to abducen nerve paralysis). Diagnosis is by flexible fibreoptic nasopharyn-goscopy and biopsy. Elevated blood levels of antibodies to Epstein-Barr virus capsid antigen (IgA-VCA) and early antigen (IgA-EA) are often seen. CT and MRI are useful in staging the disease and in detection of recurrence. Radiation is the firstline treatment for NPC of all stages because of the radiosensi-tivity of undifferentiated carcinoma. For recurrent disease after radiotherapy, surgical resection of the nasopharynx by the transoropalatal approach, mandibular swing or maxilla swing approach are recently established surgical salvage procedures that are preferred over re-irradiation which is associated with complications...

Presentation History

Again, the medical history and physical examination will frequently reveal the source of infection. Viral illnesses, including respiratory infections and gastroenteritis, account for the majority of febrile illnesses and usually have system-specific symptoms, such as vomiting, diarrhea, rhinorrhea, cough, or rashes. In this age group, such symptoms are more often indicative of an organ-specific infection. Bacterial infections of the respiratory tract include most notably otitis media, pharyngitis, and pneumonia. Otitis media is generally caused by Streptococcus pneumoniae or Haemophilus influenzae, and antibiotic therapy, such as amoxicillin, should be directed at these organisms.27 Although pneumonia is commonly of viral etiology, it is appropriate to institute antibiotic therapy with amoxicillin or erythromycin. The physical signs of meningitis, such as nuchal rigidity and Kernig or Brudzinski signs, may be inapparent in children even up to the age of 2 years. A bulging fontanelle,...

Disorders associated with food allergens

According to various reports, secretory otitis media, particularly in its chronic form, may possess an allergic component in some cases. This is especially true where there exists a known allergy to foods with respiratory and gastrointestinal symptoms. The verification of such a problem is usually indirect, e.g. a clinical improvement being observed following an exclusion diet. According to some studies, up to 80 of patients with secretory otitis media also have an allergic rhinitis therefore investigation of the rhinitis can eventually help to identify the food component of the otitis.

Controversies in Disease Evolution Studies

Evolutionary medicine has proposed explanations for an array of modern ailments ranging from obesity to lower back pain, asthma, otitis media, depression, and addictions. Allergies, for example, are thought to be related to originally adaptive responses to parasitic infections (Nesse & Williams, 1994). Even more problematic are evolutionary explanations for current behavioral aberrations, such as homicidal assault, sexual abuse and incest, depression, and infanticide. Intellectually it may be satisfying to link contemporary ills to past conditions, but the extent of genetic determinism is problematic.

Documenting a Diagnosis of Food Allergy

Another common problem is the misinterpretation of a sequence of events. For example, a child with an ear infection is given an antibiotic, and 3 days later gets diarrhea, so the parents come to believe the child is allergic to the antibiotic. In fact the cause of the diarrhea is far more likely to be either an underlying viral infection, or a disturbance of the gut flora. Another example is the report of a child who is believed to be allergic to sesame seeds because of reactions occurring after eating buns coated with sesame seeds many such children are in fact not allergic to sesame seeds but are reacting to the egg glaze that has been used as an adhesive for the seed coating. Another common example is the child with asthma who coughs and wheezes after drinking a diluted orange squash drink, with the result that it is believed that the child is reacting to the yellow-orange coloring agent tartrazine. If fact such reactions are more likely to be due to sulfite preservatives in the...

TABLE 11B5 Antibiotic Dosages for Bacteremia and Meningitis

The treatment of febrile infants 3 to 36 months of age remains a subject of considerable controversy. As for all infants, an ill-appearing febrile child should be stabilized with supportive care and fully evaluated for sepsis, and broad-spectrum intravenous antibiotics such as cefotaxime or ceftriaxone should be administered in the ED. Fortunately, most penicillin- and cephalosporin-resistant strains of S. pneumoniae demonstrate only intermediate resistance at this time and may be adequately treated with a third-generation cephalosporin. Treatment of focal SBI presumptively identified by diagnostic testing in the ED depends on the likely pathogens and is reviewed in subsequent chapters. Treatment of meningitis is reviewed later in this chapter. The optimal treatment for children at risk for OB has not been established. Published observational retrospective studies,2 30 prospective randomized trials,731 and meta-analyses of pertinent prior studies1 3334 have concluded that expectant...

Emergency Department Management

Fever should be controlled with acetaminophen or ibuprofen. Children with concurrent otitis media should receive the appropriate course of oral antibiotics. Those who appear toxic with temperature above 38.5 C should have a CBC drawn to rule out other intercurrent infections. A 9-year prospective study of 565 children with documented RSV showed the risk of secondary bacterial infection was low subsequent secondary bacterial infections were seen more frequently in the group treated with antibiotics.38 OTHER MODALITIES The anecdotal theory that mist helps to dilute secretions has not been proven in fact, very little water reaches the lower airways to begin with. Infants with high temperatures and documented RSV are unlikely to require workup for occult bacteremia unless they appear septic. Studies have failed to show any utility in obtaining blood cultures in children with fever attributable to RSV. Antibiotics should be reserved for concurrent otitis media or other identifiable...

Food allergyintolerance

Clinical signs include non-seasonal pruritus often affecting the head and neck, including otitis externa (Plate 6.9). Miliary dermatitis, symmetrical alopecia, eosinophilic plaque and ulcerative dermatitis secondary to severe self-trauma may also be seen. Gastrointestinal signs of vomiting or diarrhoea occur occasionally.

Cranial nerve VII facial

The facial nerve nucleus is located in the medulla. The nerve exits the brain close to the fifth and eighth nerves from the petrous temporal bone. Facial nerve palsies are common as the nerve is vulnerable to injury at several sites. The facial muscles are paralysed, the lip is loose and flaccid, the ear is immobile and the affected nostril does not dilate. There may be drooling from the mouth on the affected side. The cornea will dry and corneal ulceration is a consequence. Peripheral injury to the facial nerve from injury and otitis media are common. Central lesions (usually neoplastic) in the cerebellar pontine region frequently affect the seventh nerve.

Chapter References

Klein JO, Bluestone CD Management of otitis media in the era of managed care. Adv Pediatr Infect Dis 12 351, 1997. 3. Stool SE, Berg AO Clinical Practice Guideline Otitis Media with Effusion in Young Children. Publication 94-0622. Rockville, MD. Agency for Health Care Policy and Research, 1994. 4. Klein JO Otitis media. Clin Infect Dis 19 823, 1994. 5. Bluestone CD, Klein JO Otitis Media in Infants and Children, 2d ed. Philadelphia, Saunders, 1995. 6. Maxson S, Yamauchi T Acute otitis media. Pediatr Rev 17 191, 1996. 7. Steele RW Management of otitis media. Infect Med 15 174, 1998. 8. Block SL Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. Pediatr Infect Dis 16 449, 1997. 9. Paradise JL Otitis media in infants and children. Pediatrics 65 917, 1980. 10. Pichichero ME Assessing the treatment alternatives for acute otitis media. Pediatr Infect Dis J 13 S27, 1994. 11. Barnett ED, Teele DW, Klein JO, et al Comparison of ceftriaxone and...

Historical background

In 1952 Colonel Ogden C Bruton reported the case of an 8-year-old boy with a 4 year history of recurrent bacterial sepsis, osteomyelitis and otitis. This child failed to make antibodies to pneumococcus after repeated antigenic challenge. In a seminal observation, Bruton noted that the patient's serum lacked the gamma globulin fraction by electrophor-etic analysis but was otherwise normal. This was the first case in which an abnormal result in a laboratory study explained the clinical problems and dictated the therapy for an immunodeficient patient. The patient was treated with gamma globulin and had a marked decrease in the incidence of infection. In the next 5 years many similar patients were reported.

Bacterial encephalitis

Infection occurs most commonly as a sequela to chronic nasal infection, otitis media, otitis interna and penetrating bite wounds. Clinical signs reflect the site of infection. The cats are febrile and clinical signs progress rapidly. Culture of CSF may identify the causative organism. Effective treatment depends on appropriate antibiotic treatment. Sulfonamides, trimethoprim and the newer generation cephalosporins all penetrate the blood-brain barrier and should be effective in the treatment of bacterial meningitis. A better prognosis is expected with early treatment.

Breast feeding and Immunity to Infection

Additionally, cytokines and other growth factors in human milk contribute to the activation of the lactating infant's immune system, rendering breastfed infants less susceptible to diarrheal diseases, respiratory infections, otitis media, and other infections and may impart long-term protection against diarrhea. Breast feeding also reduces mortality from diarrhea and respiratory infections. However, human immunodeficiency virus (HIV) infection (and other viral infections) can be transmitted from a virus-positive mother to her child through breast milk, and breast-feeding is responsible for a significant proportion of childhood HIV infection.

The Challenge Of Integrating Genomic Innovation

Applied to genetic issues, however, these techniques are less useful and may even contribute to failure to detect genetic involvement or appropriately consider genetic influences, thereby resulting in misdiagnosis or mistreatment. Specific characteristics of genetics thwart the clinical utility of these clinical reasoning strategies that are designed to identify observable pathology (phenotype), determine a proximate cause (diagnosis), and prescribe appropriate treatment and management. In particular, scientists determined that one gene can affect more than one trait (pleiotropy), that any single trait can be affected by more than one gene, and that the majority of traits are affected by environmental factors as well as by other genes. Identifying the cause of a clinical symptom (or trait) is then far more complicated than identifying a symptom or determining that a number of symptoms indicate the presence of disease. Furthermore, determining the clinical significance of any genetic...

Posttransplant Lymphoproliferative Disease PTLD

PTLD can be a consequence of T-cell suppression with long-term cyclosporine use. The overall incidence in lung transplant patients is approximately 8 percent. The disease tends to occur with primary EBV infection following lung transplant. Because younger patients are more likely to be EBV-negative at the time of transplantation, they tend to develop EBV infection and PTLD at a higher rate. Presenting features include isolated lymphadenopathy, painful otitis media (secondary to tonsillar involvement), or a viral-like syndrome. PTLD within 1 year of transplantation is usually localized and can be successfully treated with reduced immunosuppression and high-dose acyclovir, with a relatively good prognosis. In contrast, PTLD after 1 year tends to be disseminated, unresponsive to treatment, and usually fatal.

Other Streptococcal Infections

Although Streptococcus pyogenes is found in the upper respiratory tract of many people, sometimes (virulent strains or weakened hosts) it causes the disease known as strep throat. In addition to a sore throat, this may lead to tonsillitis, and in some cases ear infections (otitis media). If not treated, some strains produce a toxin leading to damage of small blood vessels, a fever, and a rash, a disease known as scarlet fever. A few strains may produce rheumatic fever, which can lead to heart, kidney, and joint damage.

Immune responses of the host

Less is known about the host immune response to nontypeable strains of H. influenzae. A hallmark of infections caused by NTHI is the high rate of recurrences. Therefore, infection does not confer subsequent protection from infection by NTHI strains. Serum bactericidal antibody develops following otitis media due to NTHI and this antibody response is associated with protection. However, the immune response is specific for the infecting strain and the child remains susceptible to infection by other strains of NTHI. A similar scenario may occur with recurrent exacerbations of chronic obstructive pulmonary disease. The strain-specific immune response is directed at least in part to immunodominant surface epitopes on the P2 OMP. These observations regarding strain-specific immune responses may account for the observation that these apparently immunocompetent populations experience recurrent infections.

Lowered Anticonvulsant Blood Levels

Anticonvulsant levels fall during acute infections (viral or bacterial) with or without fever. Quite often, a child's seizure recurrence is an indication of the infection before the acute problem is evident, e.g., varicella or otitis media.

History

Question about respiratory infections (especially otitis media) for constipation, use aggressive dietary management and consider Hirschsprung disease if resistant to dietary changes and stool softeners. Solicit parental concerns regarding vision and hearing. General neurological, neuromotor, and musculoskeletal examination must visualize tympanic membranes or refer to ear, nose, and throat (ENT) specialist, especially if suspicious of otitis media.

Bullous Myringitis

TREATMENT As the etiologic agent of bullous myringitis remains elusive, treatment of the condition consists of warm compresses and systemic analgesia with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Oral antibiotics may be added in cases with an associated middle ear effusion, since some of these may represent a concomitant otitis media.

Dka In Pregnancy

Several physiologic changes in pregnant patients make them more prone to DKA. Maternal fasting serum glucoses are normally lower, which leads to relative insulin deficiency and an increase in baseline free fatty acid levels in the blood. Pregnant patients normally have increased levels of counterregulatory hormones. In addition, the chronic respiratory alkalosis seen in pregnancy leads to decreased bicarbonate levels due to a compensatory renal response resulting in a decrease in buffering capacity. Pregnant patients also have an increased incidence of vomiting and infections (e.g., urinary tract infections, sinusitis, otitis media), which are frequent precipitants of DKA. In addition, DKA is triggered at lower sugar levels in the pregnant population. 6 Maternal acidosis causes fetal acidosis and also decreases uterine blood flow and fetal oxygenation. Maternal hypokalemia can also lead to fetal dysrhythmias and death.

Topical Anesthetics

Lidocaine may be used as a topical anesthetic for a variety of painful conditions and procedures. It is marketed in solution, jelly, and ointment forms in concetrations from 2 percent to 10 percent. Viscous lidocaine solutions (2 percent) can be used for temporary relief of inflamed or irritated mucous membranes of the mouth and pharynx (viral stomatitis). A sterile preparation of the viscous solution can be used for insertion of Foley catheters and gastrostomy tubes. Strict instructions to the patient and caregivers about sparing use of the viscous oral solution must be given. Only a limited amount (about 2 ml) of the solution should be applied. Topical benzocaine anesthetic solutions such as Auralgan (antipyrene benzocaine) may be effective in temporarily alleviating pain due to acute otitis media or external otitis media.

Clinical pathology

Radiology is of limited value in the diagnosis of intracranial disease, but is most useful for spinal cord diseases. Skull radiography is helpful for the diagnosis of otitis media, fractures, bone proliferation and lysis, and abnormalities of the shape of the skull and vertebrae. Complete information on radiographic technique and positioning for skull and spinal column radiographs is available in radiology textbooks. Correct positioning is essential for accurate neurological interpretation. Contrast radiological techniques, especially myelography, have been applied to the diagnosis of spinal cord disease in the cat. Myelography is indicated to define the nature and location of a spinal cord condition when there is clinical evidence of a lesion that is not visible on plain radiographs, when there are multiple spinal column lesions and it is necessary to determine which are significant, and when the cat's neurological signs are not compatible with changes in plain radiographs. The...

Malassezia

Clinical signs may be either generalised, often with a ventral distribution, or localised to the feet, ears or chin. Pruritus is common and can be severe. Examination of the skin reveals erythema, scale, hyperpig-mentation, oily scale and malodour. A black waxy otitis externa can be a major sign of Malassezia infection a similar waxy exudate may be observed around the base of the claws in some cases. In recurrent infection the cat should be investigated for underlying disease, notably allergic disease, viral infections and neoplasia, to prevent recurrence. Otitis externa can be a frustrating manifestation of Malassezia infection in some cases. The ceruminous glands provide a lipid-rich medium for the organisms, which are commensals in this environment, to survive. In some cases topical or oral steroids will help to control the glandular hyperplasia and cerumen production within the ear canal and, consequently, 'starve' the yeast and improve the condition of the ear.

Demodicosis

Demodicosis has been reported as an uncommon disease associated with a variety of dermatological manifestations, including ceruminous otitis externa localised alopecia, erythema, scaling, crusting and pyoderma of the head, neck and ears and generalised alopecia, erythema, variable scaling, papulocrusting dermatitis and secondary pyoderma. Clinical disease has been reported in cases associated with two species of mite. The long, slender form, Demodex cati, has been reported since the mid-nineteenth century and inhabits the hair follicle. The second species of mite has a short abdomen and may be found in the stratum corneum. Previously termed the stubby feline demodex mite, it is called Demodex gatoi (Desch 8c Stewart, 1999).

Infectious Disease

Egyptian, and American Indian skulls, secondary to middle ear infection. The infected bone becomes necrotic and is surrounded by pus, which may drain to the surface through sinus tracts. Such infections can still be very difficult to treat and may persist for years. Pyogenic osteomyelitis is an ancient disease, having been described in dinosaur skeletons.

Bronchiolitis

Acute bronchiolitis presents in infancy with serous nasal discharge accompanied by sneezing. These symptoms are followed by diminished appetite, cough, dyspnea, irritability, and, commonly, periods of apnea. Apnea is more common in neonates and usually presents within the first 3 days of illness. Physical examination reveals a rapid respiratory rate (> 60 breaths per minute), cyanosis, air hunger, hyperinflation, intercostal and subcostal retractions, and a palpable liver and or spleen due to hyperinflation of the lungs. Fever is usually low grade or absent, except in the presence of otitis media, when a temperature as high as 40 C may be present. Chest x-rays usually show hyperinflation with patchy atelectasis.

Hyperbaric Oxygen

However, HBO is expensive and logistically cumbersome. It is contraindicated where closed air spaces in the body can cause damage due to expansion upon returning to normal atmospheric pressure, such as sinusitis, otitis media, asthma, and bullous pulmonary disease. Care should be taken with diabetic patients, as hy-poglycemia may be exacerbated by HBO.

Acquired deafness

Acquired deafness occurs with damage to the eighth nerve or its nuclei or sensory apparatus. In most cases vestibular signs are also seen as the vestibular branch of the nerve is also affected. Otitis media and interna can be accompanied by unilateral deafness, but auditory defects are less common.

Williams Syndrome

Characteristic facial features include a flat profile, a broad brow with bitemporal narrowing, a wide mouth with full lips, full cheeks, upturned nose with a bulbous nasal tip, asymmetry in the face, and a long philtrum. Children with WS often have chronic otitis media as well as ocular and visual abnormalities. Additionally, abnormalities in the respiratory system often lead to an idiosyncratic voice pattern. This voice pattern is described as being hoarse, low pitched, and flat. Complications of the renal, gastrointestinal, musclos-keletal, and neurological systems are present as well.

SIDS and Apnea

The syndrome is rare in the first month of life, probably because the neonate has a better anaerobic capacity for survival, and with a gasp may be able to raise his or her arterial Po2 over 20 mmHg and continue breathing. Of the infants who are otherwise healthy, 30 to 50 percent have some acute infection, usually of the upper respiratory tract, at the time of the event. Infection with respiratory syncytial virus has been associated with apnea, particularly in premature infants and those with an antecedent history of apnea.2 26 Otitis media and gastroenteritis have also been associated with SIDS. Infected infants tend to be older than noninfected infants, and males outnumber females in the infected group by 2 1. The sex ratio is equal in the noninfected group. There is a disproportionate number of babies from the lower socioeconomic group, although this is true for deaths in infancy from all causes. Mothers frequently are younger than 20 years of age and unwed, smoke, use drugs, and...

Lab and Consults

Evaluation by a pediatric cardiologist including echocardiogram (if not done in newborn period) remember to consider progressive pulmonary hypertension in DS patients with a ventricular septal defect or atrioventricular septal defect who are having few or no symptoms of heart failure in this age group. ABR by 3 months of age if not performed previously or if previous results are suspicious. Pediatric ophthalmology evaluation by 6 months of age (earlier if nystagmus, strabismus, or indications of poor vision are present). Thyroid function test (TSH and T4), at 6 and 12 months of age. Evaluation by ENT specialist for recurrent otitis media as needed.

Auditory Skills

Children with Down syndrome are at increased risk for hearing loss. It is essential to have the pediatrician and the audiologist monitor hearing on a regular basis and treat any hearing problems (Cohen et al., 1999, Roizen et al., 1994, Shott, 2000). Some kinds of tests can be used to test infants within the first week of life. Otitis media with effusion (OME), inflammation of the middle ear with fluid buildup behind the eardrum, is the most common problem related to hearing. The fluid interferes with sound transmission, and the result is a conductive hearing loss that is fluctuating. It is difficult for infants and toddlers to learn to listen and to attend to sounds when they sometimes can hear the sounds and other times cannot (Roberts and Medley, 1995).

Examination

Patients with perennial or seasonal rhinoconjunctivitis may have injected conjunctivae (visible small blood vessels), erythematous conjunctivae (reddened whites of eyes), puffy eyelids, and erythematous, oedematous nasal mucosa (the lining of the nose appearing swollen and red). Studies investigating any link between food allergy and otitis media with effusion (sometimes termed glue ear - long-standing fluid in the middle ear resulting in, albeit temporary, conductive hearing loss) have been poorly conducted.18 To date, there is no good evidence linking this condition with food allergy.

Patient Education

However, any ED encounter is a teachable moment.18 Because emergency physicians are more likely to provide acute care to injured patients than any other physician group, they should have a special stake in preventing and controlling injuries. The mother who brings her child to the ED for evaluation of a severe otitis can leave the department with information about the importance of child safety seats, bicycle helmets, and four-sided fencing around her swimming pool. Emergency physicians have the opportunity to motivate patients to change high-risk behaviors and modify their home environment to decrease injury risk. Unfortunately, the ability to influence behavior from these brief emergency setting encounters have not been well studied.

Hydrocephalus

Hydrocephalus is present in 70 to 90 percent of children with thoracic or lumbar level defects and in substantial numbers of those with sacral level defects. It is routinely treated with shunt placement early in life. Concerns regarding shunt function are common in patients presenting to the acute care setting. Signs and symptoms of shunt malfunction are lethargy, irritability, nausea, vomiting, visual problems, cognitive changes, neck pain, headache, swelling along the shunt path, or seizure.9 0 Not all symptoms need be present to indicate malfunction of the shunt. The symptomatology is nonspecific and can easily be due to a variety of other problems such as sepsis, urinary tract infection, otitis media, gastroenteritis, sinus infection, or viral syndromes. A number of children with massive constipation and a shunt may complain of similar symptomatology, which resolves when the fecal backup is relieved. Evaluation for shunt malfunction should proceed only after infectious and other...

Viral infections

The initial reports of FeLV and FIV infection associated with dermatitis and abscesses were lacking in clear evidence of a causal link between viral infection leading to the skin infection and the type of dermatitis. There have also been associations with otitis externa and notoedric mange. There is more likely to be a direct link between retrovirus infection and chronic dermatophytosis, mycobacterial infection and demodicosis, where immune suppression could promote persistent skin disease. It is prudent to evaluate cats with chronic infectious skin disease, including cowpox infection, for underlying immune suppression due to retrovirus infection.

Infections

There are possible epidemiologic associations between diabetes and urinary tract infections, candidal vulvovaginits, cystitis, and balanitis, pneumonia, influenza, chronic bronchitis, bacteremia, primary and reactivation tuberculosis, mucormycosis, malignant otitis externa, lower extremity skin and soft tissue structure infections, surgical wound infections, and Fournier gangrene. 23 However, only a few of these conditions have been shown to be more frequent in diabetics than in a nondiabetic control group in controlled studies. MALIGNANT OTITIS EXTERNA This infection almost exclusively occurs in elderly diabetic patients without ketoacidosis. Unlike other serious infections in patients with diabetes mellitus, well-controlled glucose levels are present in up to half and systemic toxicity is often absent. Microangiopathies in the external auditory canal of diabetics is thought to be a predisposing factor for this infection. Patients present with unilateral otalgia, purulent discharge,...