Sandbox:Amira Albawri

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common cold or upper respiratory tract infection..... PMID 21918146

Your otoscopic examination reveals that her left tympanic membrane looks redder and less reflective than her right one, but you do not see bulging, retraction, or fluid behind the eardrum. There is no perforation or discharge. Her face, mouth, and throat look normal. Your examination reveals no foreign body. There is no swelling in front of her ears; the mastoids, temporomandibular joints, and maxillary sinuses are not tender. Her cervical glands are normal in size and are not tender. Her teeth and mouth look normal, and you notice that during the examination Amy moves her neck freely.

cause

anatomic disorders of the nasopharynx such as cleft palate4 and Down syndrome.PMID: 2976173 PMID: 21918146

FIRE of ear pain

Ear pain

** Abnormal ear examination(otoscopy)

*primary otalgia)

** Normal ear examination(otoscopy)

*secondary otalgia

** imaging studies

IF Diagnosis is not clear from the history and physical examination.


FIRE of ear pain

** Abnormal ear examination(otoscopy)

*primary otalgia

*Otitis externa = A red and tender ear ,Hearing loss ,pruritus and oedema , discharge

*Otitis media= pain fever ,hearing loss,headache, anorexia, vomiting

** Normal ear examination(otoscopy)

*secondary otalgia

Complete Diagnostic Approch


Characterize the pain: PMID: 30572868

  • Usually the parents use pain scales to detect pain in their young children .
  • Ear-related symptoms: ear rubbing.
  • Non-specific symptoms: fever, irritability, excessive crying, decreased activity, poor appetite and restless sleep .
  • Respiratory symptoms: rhinitis, cough, hoarse voice, conjunctivitis, mucus vomiting and nasal congestion.
  • Gastrointestinal symptoms: vomiting, and diarrhea.

History

  • Enter into group child care and amounts of time spent.
  • Exposure of smoking.
  • Peroid of breastfeeding.
  • swimming
  • recurrent ear pain.
  • Skills developmental delay like (language delay) due to hearing loss.

Examination

  • Face ( lymph node, mastoids, temporomandibular joints, and maxillary sinuses ), mouth, and throat .
  • Skin especially aroud the ear (mastoiditis)
  • Myringotomy

It dose not do for children who have been diagnosed on the basis of assessment in the clinic.PMID: 14962529 / PMID: 24453496

  • Tympanic membrane.

If the tympanic membrane is abnormal the most cause of it by primary otalgia.The primary otalgia include

  • Acut otitis media.
    • Cloudy, bulging PMID: 22459064 erythema of the tympanic membrane. PMID: 24453496
    • Acute onset symptoms and signs fever, otalgia also see irritability, otorrhea, anorexia, and vomiting.
    • Usually affects children aged under 2 years,
  • Otitis media with effusion.

Retracted/concave tympanic membrane with change colour of tympanic membrane (yellow,amber,blue) , and air–fluid levels. absence of signs and symptoms (asymptomatic). Hearing loss lead to speech delays.It is detected on screening of asymptomatic children. PMID: 27604644/ PMID: 24453496



Treatment

  • Acut otitis media.

Symptomatic management like fever and ear pain.If severe,recurrent infections or persistent give antibiotic.

  • otitis media with effusion.

Table 2

Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)

Subject 2004 2013 Rationale for 2013 Changes
Children <6 mo Treat with antibiotic therapy No recommendations

Diagnosis of AOM Acute onset of signs and symptoms Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa 2004 criteria allowed less precise diagnosis, provided treatment recommendation when diagnosis was uncertain.
Presence of MEE Mild bulging of TM and recentb onset ear painc or intense TM erythema
Signs and symptoms of middle ear inflammationa Must have MEE

Uncertain diagnosis Expected and included in treatment guidelines Excluded Emphasized need for diagnosis of AOM for best management.

Initial observation option instead of initial antibiotic therapy Option for observation:
  • 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd
  • ≥2 y: Option if nonsevered and certain diagnosis
Option for observation:
  • 6 mo–2 y: Unilateral OM without otorrhea
  • ≥2 y: Unilateral or bilateral AOM without otorrhea
Favorable natural history overall.
Observation recommended:
  • ≥2 y and uncertain diagnosis
Observation recommended:
  • None
Evidence of small benefit of antibiotics in recent trials that used stringent diagnostic criteria.

Initial antibiotic therapy recommended Antibiotics recommended:
  • <6 mo: All cases
  • 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severee illness
  • ≥2 y: Certain diagnosis and severee illness
Antibiotics recommended:
  • 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea
  • ≥2 y: Otorrhea or severee illness
More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
Antibiotics an option:
  • 6 mo–2 y: Uncertain diagnosis and nonsevered illness
  • ≥2 y: Certain diagnosis and nonsevered illness
Antibiotics an option:
  • 6 mo–2 y: Unilateral without otorrhea
  • ≥2 y: Bilateral without otorrhea or unilateral without otorrhea
Greater antibiotic benefit for bilateral disease, AOM with otorrhea.
Two recent studies show small benefit of antibiotics for age 6–24 mo.

Recurrent AOM No recommendations Do not prescribe prophylactic antibiotics Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects).
May offer tympanostomy tubes Modest reduction in AOM with tubes.

Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.

aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep’).

bRecent: <48 hours.

cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.

dNonsevere illness defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature less than 39°C.”

eSevere signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours.

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65.



table

table

table


cause

  • genetic
    • BACA
      • brca1
      • brca2
  • family
    • first related


Synonyms and keywords: