MEI on otoscopy:bulging TM with marked discolouration (hemorrhagic,red,grey, or yellow)

Management

• supportive care and symptom management: maintain hydration, analgesic, and antipyretic

(acetaminophen, ibuprofen)

• watchful waiting:in a generally healthy child >6 mo of age with unilateral, non-severe,suspected

AOM

without MEE or with MEE but non-bulging or mildly erythematous TM

• consider viral etiology

• reassess in 24-48 h if not clinically improved (or earlier if worsening)

mildly ill (alert,responsive, no rigors,mild otalgia,fever <39°C, <48 h Alness) with MEE present

AND bulgingTM

• observe and follow-up in 24-48 h -if not improved or worsening, treat with antimicrobials

• antimicrobial indications: infants <6 mo of age or in a generally healthy child >6 mo of age with

suspected AOM and the following features

moderately or severely ill (irritable, difficulty sleeping, poor antipyretic response,severe otalgia )

OR fever >39°C OR >48 h of symptoms

immunocompromised, craniofacial abnormalities

perforated TM with purulent drainage

• referral to otolaryngology for myringotomy and tympanostomy tubes may be warranted for recurrent

infections

Treatment

• antimicrobial agents for AOM

5 d course of appropriate dose antimicrobial recommended for most 22 yr with uncomplicated

AOM; 10 d course for 6-24 mo, perforated TM, or recurrent AOM

1st line treatment (no penicillin allergy)

t high-dose amoxicillin:80-90 mg/kg/d divided BID

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0TI1 Otolaryngology Toronto Notes 2023

• 2nd line treatment

azithromycin: 10 mg/kg (first line for penicillin allergy)

clarithromycin: 15 mg/kg/d divided BID (first line for penicillin allergy)

cefprozil: 30 mg/kg/d divided BID

cefuroxime axetil: 30 mg/kg/d divided B1D-TID

ceftriaxone: 50 mg/kg IM (or IV ) x 3 doses

• if initial therapy fails (i.e. no symptomatic improvement after 2-3 d )

high-dose amoxicillin-davulanate: 45-60 mg/kg/d (7:1 formulation, 400 mg/5 ml.

suspension) for 10 d for child weighing 235 kg or 500 mg tablets '

l lD for 10 d for child

weighing >35 kg

myringotomy and tympanostomy, if >4 AOM episodes (with middle ear effusion) within 12 Indications for Myringotomy and

Tympanostomy Tubes in Recurrent

ADM and OME’

• Chronic bilateral OME and

documented hearing difficulties

>3 mo

• Unilateral or bilateral OME >3 mo and

symptoms likely attributable to OME

(c.g. balance problems, poor school

performance,car discomfort, etc.)

• At-risk children (permanent HI,

spcechdanguage delay, autismspectrum disorder, craniofacial

disorders,blindness, cleft palate,

developmental delay) with unilateral

or bilateral OME with type B

tympanogram or persistent effusion

>3 mo

• Recurrent AOM (>3 episodes in 6

mo or >4 in 12 mo) with unilateral or

bilateral MEE

XMulprarbu guMnrt:lyinpinioilomv lube,In

(War.Olotoiyng Head H«k 201J:1«:StS3$

mo

Complications

• extracranial

HI.and speech delay (secondary to persistent MEE), TM perforation, extension of suppurative

process to adjacent structures(mastoiditis, petrositis, labyrinthitis), cholesteatoma, facial nerve

palsy, middle ear atelectasis, ossicular necrosis, vestibular dysfunction

• intracranial

• meningitis, epidural/brain abscess,subdural empyema, lateral and cavernoussinus thrombosis,

sigmoid sinus thrombophlebitis, carotid artery thrombosis, facial nerve paralysis

postauricular abscess, Bezold’

s abscess

• other

Otitis Media with Effusion

Definition

• presence of fluid in the middle ear without signs or symptoms of ear infection

Epidemiology

• most common cause of paediatric HL

• not exclusively a paediatric disease

• frequently follows AOM in children

• MEE have been shown to persist following an episode of AOM for 1 mo in 40% of children, 2 mo in

20%, and >3 mo in 10% (i.e. 90% of children clear the fluid within 3 mo - observe for 3 mo before

- considering myringotomy and tubes)

Effectiveness of Tympanostomy Tubesfor Otitis

Media:A Meta-Analysis

Paedatncs 2017;139|6|:e20170125

Study: Systematic review evaluating the

effectivenessof lym pa nostomy tubesliuhildrr

with chronic OM with effusion and lecuuent AOM

compared to watchful waiting.

Oata Sources MEDLINE,Cochrane Central Reg ster of

Controlled Inals. EMBASE. CINAHl.

Results:Children treated with tymparostoeny tubes

compared with watchful waiting had a net decrease

(improvement) in mean hearing threshold of 9.1 d3et

T3moand 0.0 by12-24 nD.Children with recurrent

MM may have fewer episodes after tympanostomy

Risk Factors

• same as AOM

Clinical Features

• CHL ± tinnitus

confirm with audiogram and tympanogram (flat) (see Figure 16B, 0770 and Figure 17, 0777)

• fullness- blocked ear

• ± pain, low grade fever

• otoscopy of tympanic membrane

discolouration - amber or dull grey with “glue"

ear

meniscus fluid level behind '

EM

air bubbles

• retraction pockets/ I

'

M atelectasis

most reliable finding with pneumatic otoscopy is immobility

tut*

.

Conclusions Tympanostomy tubes improve heinng

it 1-3 mo compartd with watchful willing, with

noeidenceof benefit by 12-24 mo. Moreevidenc*

is netded foi recurrent ROM. Ihe benefits ol

tympanostomy tubes must be weighed agiinst i

variety ol associated adverse events.

Pharyngeal tonsil

(adenoid)

Upper midline

in nasopharynx

Treatment

• expectant:90% resolve by 3 mo

• watchful waiting for 3 mo from onset or 3 mo from diagnosis if onset unknown

• document HL with audiogram

• recommend against intranasal or systemic steroids,systemic antibiotics, antihistamines,

decongestants for OME treatment

• surgery:myringotomy ± ventilation tubes to equalize pressure and drain ear (tympanostomy tubes

recommended) ± adenoidectomy ( not recommended in <4 vr unless nasal obstruction, chronic

adenoiditis; recommended in >4 yr)

\

A!

a Tubal i

-tonsil 1x21

'

Around openings

if Euslachion tubus

4

!

*'

) ——Palatine

WM tonsil 1x21 law ' / Both sides 0

of oropharynx 5

CD

Lingual tonsil

Under mucosa of

^

posterior 1/3 of tongue

Figure 20. Waldeyer's ring

An interrupted circle of protective

lymphoid tissue at the upper ends of _j

_

the respiratory and alimentary tracts

Complications of OME

• HL,speech delay, learning problems in young children

• chronic mastoiditis

• ossicular erosion

• cholesteatoma, especially when retraction pockets involve pars flaccida

• retraction of tympanic membrane, atelectasis, ossicular fixation

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OT42 Otolaryngology Toronto Notes 2023

Adenoid Hypertrophy

Definition

• size peaks at age 5 and resolves by age 12

• increase in size with repeated URTT and allergies

Clinical Features

• nasal obstruction

adenoid facies (open mouth, high arched palate, narrow midface, malocclusion)

history of hypernasal voice and snoring

long-term mouth breather; minimal air escape through nose

• choanal obstruction

chronic rhinosinusitis/rhinitis

OSA

• chronic inflammation

nasal discharge, post- nasal drip, and cough

• cervical lymphadenopathy

Diagnosis

• enlarged adenoids on nasopharyngeal exam (usually with flexible nasopharyngoscope)

• enlarged adenoid shadow on lateral soft tissue x-ray (palate elevation can make adenoid look larger)

Treatment

• self-resolving due to age-related adenoid atrophy

• antibiotics, if infectious

uncomplicated:amoxicillin, clindamycin or azithromycin (penicillin allergies)

chronic or recurrent:amoxicillin-clavulanate

. adenoidectomy

Complications

• Eustachian tube obstruction leading to serous otitis media

• interference with nasal breathing, necessitating mouth breathing

• malocclusion

• sleep apnea/respiratory disturbance

• orofacial developmental abnormalities

Adenoidectomy

Indications for Adenoidectomy

• chronic upper airway obstruction with sleep disturbance/apnea ± cor pulmonale

« chronic nasopharyngitis resistant to medical treatment

• chronic serous OM and chronic suppurative OM (with second set of tubes)

• recurrent AOM resistant to antibiotics

• suspicion of nasopharyngeal malignancy

• persistent rhinorrhea secondary to nasal obstruction

• persistent adenoiditis after two courses of antibiotics

• hyponasal speech

• dental malocclusion or orofacial growth disturbance documented by orthodontist or dentist

Contraindications

• uncontrollable coagulopathy

• recent pharyngeal infection

• conditions that predispose to velopharyngeal insufficiency (cleft palate,impaired palatal function,or

enlarged pharynx)

Complications

• bleeding, infection

• velopharyngeal insufficiency'

(hypernasal voice or nasal regurgitation)

• scarring of Eustachian tube orifice

Sleep-Disordered Breathing in Children

Definition

• spectrum ofsleep-related breathing abnormalities ranging from snoring to OSA

Epidemiology

• peak incidence between 2-8 yr when tonsils and adenoids are the largest relative to the pharyngeal

airway

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OT43 Otolaryngology Toronto Notes 2023

Etiology

• due to a combination of anatomic and neuromuscular factors

• adenotonsillar hypertrophy

• craniofacial abnormalities

neuromuscular hypotonia (e.g. cerebral palsy, Down syndrome)

• obesity

Clinical Features

• nighttime symptoms: heavy snoring, pauses or apnea, sleeping with neck hyperextended, enuresis

• daytime symptoms: mouth breathing, excessive daytime sleepiness, behavioural/learning problems,

symptoms of ADHD (e.g. inattention, hyperactivity), morning headache,failure to thrive

Investigations

• flexible nasopharyngoscopy for assessment of nasopharynx and adenoids

• polysomnography (apnea-hypopnea index >l/h considered abnormal)

children: mild OSA 1 - <5/h; moderate OSA >5 - <10/h;severe OSA >10/h

adults:mild OSA 5.1-15/h; moderate OSA 15.1-30/h;severe OSA >30.1/h

Treatment

• nonsurgical:CPAP, BiPAP,sleep hygiene,weight lossin overweight/obese child with OSA

• medication: topical nasal steroids and leukotriene-receptor antagonists for mild OSA or residual

sleep-disordered breathing post-adenotonsillectomy

• surgical: bilateral tonsillectomy and adenoidectomy (T&A) is surgery of choice

if persistent OSA following tonsillectomy and adenoidectomy, consider adenoid regrowth

if these fail and patient not tolerant of positive airway pressure therapy, consider lingual

tonsillectomy, midline posterior glossectomy, tongue suspension or other surgeries targeting

areas of resistance as required;surgery may be guided by Drug-Induced Sleep Endoscopy or

cineradiography-MRI to localize site of resistance

Peritonsillar Abscess (Quinsy)

Definition

• cellulitis of space behind tonsillar capsule extending onto soft palate, leading to abscess

Etiology

• bacterial: group A Streptococcus(GAS) (50% of cases), S. pyogenes, S. aureus, H.influenzae,and

anaerobes

Epidemiology

• can develop from acute tonsillitis with infection spreading into plane of tonsillar bed (see Paediatrics,

P64 )

• unilateral

• most common in 15-30 yr age group

Clinical Features

• trismus (due to irritation and reflex spasm of the medial pterygoid) is the most reliable indicator of

peritonsillar abscess

• fever and dehydration

• sore throat, dysphagia, odynophagia, and drooling

• extensive peritonsillarswelling but tonsil may appear normal

• edema of soft palate

• uvular deviation

• dysphonia (edema -> failure to elevate palate) 2" to CN X involvement

• unilateral referred otalgia

• cervical lymphadenitis

Quinsy Triad

• Trismus

• Uvular deviation

• Dysphonia (“hot potato voice")

Complications

• aspiration pneumonia 2° to spontaneous rupture of abscess

• airway obstruction

• lateral dissection into parapharyngeal and/or carotid space

• bacteremia

• retropharyngeal abscess

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Treatment

• secure airway

• surgical drainage (incision or needle aspiration) with C&S

• warm saline irrigation

• IV penicillin G x 10 d if cultures positive for GAS

• add PO/1V metronidazole or clindamycin x 10 d if culture positive for Bacteroides

• consider tonsillectomy aftersecond episode

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Other Sources of Parapharyngeal Space Infections

• pharyngitis

• acute suppurative parotitis (see Salivary Glands,OT30)

. AOM

• mastoiditis (Bczold'

s abscess)

• odontogenic infection

Tonsillectomy

Absolute Indications

• most common indication:sleep-disordered breathing

• second most common indication:recurrent tonsillitis

• tonsillar hypertrophy causing upper airway obstruction, OSA,severe dysphagia,or cardiopulmonary

complications such as cor pulmonale

• suspicion of malignancy (e.g.lymphoma,SCC)

• orofacial/dental deformity

• hemorrhagic tonsillitis

Relative Indications (To Reduce Disease Burden)

• recurrent tonsillitis with a frequency of at least 7 episodes in the past yr, at least 5 episodes per yr for

2 yr, or at least 3 episodes per yr for 3 yr with documentation in the medical record for each episode

of sore throat, and I or more of the following: temperature >38.3*C, cervical adenopathy, tonsillar

exudate, or positive test for group A P-hemolytic Streptococcus (Paradise Criteria)

• chronic tonsillitis with halitosis (bad breath) or sore throat ± tonsiliths/tonsilloliths (clusters of

material that form in the crevices of the tonsils)

• complications of tonsillitis:quinsy/peritonsillar abscess, parapharyngeal abscess, retropharyngeal

abscess

• failure to thrive

Relative Contraindications

• velopharyngeal insufficiency: overt or submucous/covert cleft of palate, impaired palatal function due

to neurological or neuromuscular abnormalities

• hematologic:coagulopathy, anemia

• infectious: active local infection without urgent obstructive symptoms

Complications

• hemorrhage: primary (within 24 h); secondary (within first 7-10 d)

• odynophagia and/or otalgia; dehydration 2* to odynophagia

• infection

• atlantoaxialsubluxation (Grisel’ssyndrome) - rare

Airway Problems in Children

DIFFERENTIAL DIAGNOSIS BY AGE GROUP

Neonates (Obligate Nose Breathers)

• extralaryngeal

pyriform aperture stenosis

septal deviation

choanal atresia (e.g.CHARGE syndrome)

nasopharyngeal dermoid, glioma, encephalocoele

glossoptosis: Pierre-Robin sequence, Down syndrome, lymphatic malformation, hemangioma

• laryngeal

laryngomalacia: most common cause of stridor in children

saccular cyst/laryngocele

vocal cord palsy (due to trauma or Arnold-Chiari malformation)

glottic web

laryngeal cleft

laryngeal papillomatosis

subglottic stenosis

• tracheal

. TEF

compression by vascularstructure (e.g. left pulmonary artery sling, vascular ring)

tracheomalacia (anterior displacement of trachealis muscle)

complete tracheal rings

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IS Otolaryngology Toronto Notes 2023

2-3 Months

• congenital

laryngomalacia

• vascular:subglottic hemangioma (more common), innominate artery compression,double aortic

arch

• laryngeal papilloma

• acquired

subglottic stenosis: post-intubation

tracheal granulation: post-intubation

tracheomalacia:post-tracheotomy and TE1

;

repair

Infants - Sudden Onset

• foreign body aspiration

• croup

• bacterial tracheitis

• caustic ingestion

• epiglottitis

Children and Adults

• infection

• Ludwig’

s angina

• peritonsillar/parapharyngeal abscess

retropharyngeal abscess

• neoplastic

• SCC (larynx, hypopharynx (adults))

• retropharyngeal: lymphoma, neuroblastoma

nasopharyngeal: carcinoma,rhabdomyosarcoma

• allergic

angioneurotic edema

• polyps (suspect cystic fibrosis in children)

• trauma

laryngeal fracture, facial fracture

• burns and lacerations

post

-intubation

caustic ingestion

• congenital

lingual thyroglossal duct cyst

• lingual tonsil hypertrophy

• lingual thyroid

Signs of Airway Obstruction

Stridor

• note quality, timing (suggestssite of stenosis)

inspiratory: vocal cords or above

biphasic:subglottis and extrathoracic trachea

expiratory'

: distal tracheobronchial tree

• body position important

lying prone: double aortic arch

lying supine: laryngomalacia, glossoptosis

Respiratory Distress

• nasal flaring

• tracheal tug

• supraclavicular and intercostal indrawing

• sternal retractions

• use of accessory muscles of respiration

• tachypnea

• cyanosis

• altered LOC

Feeding Difficulty and Aspiration

• supraglottic lesion

• laryngomalacia

• vocal cord paralysis

• laryngeal deft > aspiration pneumonia

• TEF

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Acute Laryngotracheobronchitis (Croup)

Definition

• inflammation of tissues in subglottic space ± tracheobronchial tree

• swelling of mucosal lining associated with thick, viscous, mucopurulent exudate which compromises

upper airway (subglottic space is narrowest portion of upper airway)

• normal function of ciliated mucous membrane impaired

Etiology

• viral:parainfluenzae1 (most common), 11,111, influenza A and B, RSV

Clinical Features

• age: 6 mo-3 yr

• preceded by URT'

I symptoms

• generally occurs at night

• biphasic stridor and croupy cough (loud,sea-lion bark)

• appear less toxic than epiglottitis

• supraglottic area normal

• rule out foreign body and subglottic stenosis

• “steeple-sign"on AP x-ray of neck

• if recurrent croup, think subglottic stenosis

Signs of Croup

The 3Ss

St ridor

Subglottic swelling

Seal bark cough

Treatment

• racemic epinephrine via metered-dose inhaler ql

-2 h PRN (if severe croup, >2 Westley Croup Score)

• systemic corticosteroids (e.g. dexamethasone 0.5 mg/kg, prednisone)

• adequate hydration

• close observation for 3-4 h

• positive pressure ventilation, nasal trumpet,laryngeal mask airway, intubation ifsevere (use smaller

endotracheal tube than expected for age)

• hospitalize if poor response to steroids after 4 h and persistent stridor at rest

• consider alternate diagnosis if poor response to therapy (e.g.bacterial tracheitis)

• if recurrent episodes of croup-like symptoms, consider bronchoscopy for definitive diagnosis

Acute Epiglottitis

<8>

Definition

• acute inflammation causing swelling ofsupraglottic structures of the larynx without involvement of

vocal cords Acute epiglottitisis a medical emergency

Etiology

• H. influenzae type B

• relatively uncommon condition due to H. influenzae type B vaccine

• common causes now include S

'

, pneumoniae and S. aureus

When managing epiglottitis,it is

important not to agitate the child,asthis Clinical Features may precipitate complete obstruction

• any age, most commonly 1-4 yr

• rapid onset

• toxic-looking,fever, anorexia, restlessness

• cyanotic/pale, inspiratory stridor,slow breathing, lungs clear with decreased air entry

• prefers sitting up ("tripod" posture), open mouth, drooling, tongue protruding,sore throat, dysphagia Thumb sign: cherry-shaped epiglottic

swelling with loss of the normal air

space of the vallecula seen on lateral

Investigations and Management neck radiograph

• examining the throat may lead to potential laryngospasm and airway compromise; ensure an

anesthesiologist/otolaryngologist is present and make preparationsfor intubation or tracheotomy

prior to any manipulation

• WBC (elevated), blood, and pharyngeal cultures after intubation

• lateral neck radiograph (only done if patient stable) shows "thumb sign"

Treatment

• secure airway

• IV access with hydration

• antibiotics:IV cefuroxime, cefotaxime,or ceftriaxone (10-14 d course should be completed)

• moist air

• extubate when leak around tube occurs and afebrile

• watch for meningitis

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Subglottic Stenosis

Congenital

• diameter ofsubglottis <4 mm in neonate (due to thickening of soft tissue of subglottic space or

maldevelopment of cricoid cartilage), orsmaller than average size for age as determined by MyerCotton grading system

Acquired

• following prolonged, repeated,or traumatic intubation

most commonly due to endotracheal intubation; nasal intubation is less traumatic and preferred

in long-term intubation, as it puts less pressure on the subglottis (tube sits at different orientation)

and there is less movement

subglottic stenosis is related to duration of intubation and endotracheal tube size resulting in

pressure necrosis and subsequent scar formation

• can also be due to foreign body, infection (e.g. TB, diphtheria,syphilis), or chemical irritation

Clinical Features

• biphasic stridor

• respiratory distress

• recurrent/prolonged croup

Diagnosis

• rigid laryngoscopy and bronchoscopy

Treatment

• if soft stenosis:diside tissue with knife or laser,dilate with balloon ± steroids

• if firm stenosis:laryngotracheoplasty

Laryngomalacia

Definition

• short aryepiglottic folds,omega-shaped epiglottis, redundant mucosa over arytenoids

• caused by indrawing ofsupraglottis on inspiration, leading to breathing against closed glottis, causing

laryngopharyngeal reflux of acid

Clinical Features

• high-pitched inspiratory stridor at 1-2 wk

• stridor is constant or intermittent and more pronounced when supine or following URTI

• usually mild, but can be associated with cyanosis or feeding difficulties when severe, leading to failure

to thrive

Laryngomalada isthe most common

cause of stridor in infants

Treatment

• observation ± proton pump inhibitor (to break the acid reflux cycle that leads to edema and worse

airway obstruction) is usually sufficient, assymptomsspontaneously subside by 12-18 mo in >90% of

cases

• if severe, division of the aryepiglottic folds (supraglottoplasty) provides relief

Foreign Body

Ingested

• usually stuck at cricopharyngcus muscle

• coins, toys, batteries (emergency)

• presents with drooling, dysphagia,stridor if very large

Aspirated

• usually stuck at right main bronchus

• peanuts, carrot, apple core, popcorn, balloons

• presentation

stridor if lodged in trachea (beware of the silent child as there may be complete obstruction)

unilateral “asthma” if bronchial, therefore often misdiagnosed as asthma

if completely occluded airway:cough,lobar pneumonia, atelectasis, mediastinalshift,

pneumothorax, death

Diagnosis and Treatment

• sudden onset, not necessarily febrile or elevated WBC

• any patient with suspected foreign body should be kept NPO immediately

• older patient:inspiratory-expiratory'chest x-ray (if patient isstable)

• younger patient:right and left decubitus chest x-rays.Lack of lung deflation while resting on

dependentside suggests foreign body blocking bronchus

• bronchoscopy or esophagoscopy with removal

Foreign body inhalation is the most

common cause of accidental death In

children

Button batteries MUST be ruled out as a

foreign body (vs. coins) asthey are lethal

and can erode through the esophagus.

Batteries have a halo sign around the

rim on AP x-ray and a step deformity on

lateral x-ray r-i

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Deep Neck Space Infection

Definition

• most commonly arise from an infection of mandibular teeth, tonsils, parotid gland, deep cervical

lymph nodes, middle ear,or the sinuses

• often a rapid onset and may progress to fatal complications

Etiology

• usually mixed aerobes and anaerobes that represent the flora of the oral cavity, upper respiratory

tract, and certain parts of the ears and eyes

Clinical Features

• sore throat or pain and trismus

• dysphagia and odynophagia

• stridor and dyspnea

• late findings may include dysphonia and hoarseness

• swelling of the face and neck, erythema

• asymmetry of the oropharynx with purulent oral discharge

• fever, lymphadenopathy

Diagnosis

• CBC with differential

• lateral cervical view plain radiograph

• cr

• MRI

These investigationsshould be obtained

carefully and the surgeon should

consider accompanying the patient,

asthe worst place to lose an airway is

during imaging

Ludwig's angina is the prototypical

infection of the submandibular and

sublingual space

Treatment

• secure the airway

• surgical drainage

• maximum doses of IV systemic antimicrobials regimens according to the site of infection

Common Medications

Table 22. Antibiotics

Generic Name (Brand

Name)

Dose Indications Notes

amoxicillin (Amoxil '

. Amoxl®,

Amox 5)

Adult 500 mg PO TID

Children:75-90 mg/kg/d in

2 divided doses

3 g TO qG h

Streptococcus. Pneumococcus. H. May cause rash in patients with

influenzae.Proteus coverage infectious mononucleosis

Gram-posilivcand negative

aerobes and anaerobes plus

Pseudomonos coverage

Pseudomonas,Streptococcus.

methicillin-resistanl

Staphylococcus aureus (MBSA),

and most Gram- negative:no

anaerobic coverage

Alternative to penicillin

piperacillin with tarobadam

Itosyn®)

May cause pseudomembranous

colitis

ciprofloxacin (CiproCiloxan 500 mg P0 BID Animalstudiessuggest that

systemic quinolones may cause

cartilage necrosis in children

erythromycin (Erythrocin

EryPed®,Station3,Mat®,

Erybid '

, Hovorythro Encap '

)

500 mgPOQID Ototoxic

Table 23. Otic Drops

Generic Name (Brand

Name)

Dose Indications Notes

for 0E and complications of 0M

Pseudomonos,streptococci,

MUSA, and most

Gram-negative:no anaerobic

coverage

forOE

Used for inflammatory conditions

which are currently infected or at

risk of bacterial infections

ForOM

ciprofloxacin (Ciprodcx ) 4 gtl In allotted car BID

neomycin, polymyxin 8 sulfate, 5 git in affected ear IID May cause HI il placed in inner ear

and hydrocortisone (Cortisporin

Otic )

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hydrocortisone and acetic acid 5-10 git in affected ear TID

(YoSol HC ’)

tobramycin and dciamethasone

(TobraDex - )

Locacorten-Vioform Ear Drops '

Bactericidal by lowering pH

5-10 gllinaflected ear BID For chronic suppurative 0M Bisk ol vestibular or cochlear

toxicity +

2-3 gtt in affected ear BID ForOE,Otomycosis

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0TI9 Otolaryngology Toronto Notes 2023

Table 24. Nasal Sprays

Generic Name (Brand Name) Indications Notes

Steroid

flunisolide (Rhinalar -

budesonide (Rhinocort ),

triamcinolone (Nasacort '

)

beclomelliasonc (Beconase ’

).

mometasone furoate, monohydratc

(Nasonex '

>.

fluticasone luroale (Ayarnys ’.Flonase '

).

ciclesonide (Omnaris }

Allergic rhinitis

Chronic sinusitis

Requires up to 4 wk olconsistent use to have

effect

longtermusc

Dries nasal mucosa:may cause minor bleeding

Patient should stoprf cpistams

May sling

Flonase’

and Nasonei'not absorbed

syslemically

Antihistamine

levocabastine (Livostin:

) Allergic rhinitis Immediate effect

Discontinue if no effect by day 3

Use during allergy season

Occongcslant

xylomelazoline (Otrivin'

).

oxymelaaoline (Orislan ®).

phenylephrine (Neosynephrlnc )

Careful if patient has H1N

Short- term use (

'

5 d)

IIlong term use.cancausc decongestant

addiction (i.e.rhinitis medicamentosa)

Acute sinusitis

Rhinitis

Antibiotic!Decongestant

framycetin,gramicidin,

phenylephrine (Soframycin 5)

Acute sinusitis

Anticholinergic

ipratropium bromide (Atrovent ") Careful not to spray into eyes as it can cause

burning or precipitation olnarrow angle

glaucoma

Increased ralcof epislaiis when combined

with topicalnasal steroids

Vasomotor rhinitis

lubricants

saline.NeilMedRhinaris ®,

Secaris!

.Polysporin

’

.Vaseline!

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OT50 Otolaryngology Toronto Notes 2023

Landmark Otolaryngology - Head and Neck Surgery Trials

Trial Name Reference Clinical Trial Details

Acute Otitis Media

NEJM 2016:375:2446-2466 Title:Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children

Purpose:To study the potential of limiting the duration of antimicrobial treatment among children with acute otitis media to

prevent antimicrobial resistance.

Methods:Children with acute otitis media were assigned to 2 gioups.1group received amoxicillin-clavulanale for 10 d.the other

group received a reduced duration of 5 d. Rate of clinicalresponse,recurrence, and nasopharyngeal colonisation were measured.

Results:Children treated with amoxicillin-clavulanale for 5 d had higher rates of clinical failure than those treated lor the full

duration.Mean symptoms scores over Irom d 6 14 were 1.61in the 5 d group and 1.34 in the 10 d group.

Conclusions:10 d of amoxlcillln-clavulanate had more favourable outcomes and no increase in adverse events or antimicrobial

resistance compared to a 5 d course in children ages 6mo-2 yr.

Title:Meet olAntimicrobial Treatment of Acute Otitis Media on the Daily Disappearance on Middle Tar Illusion

Purpose:To study the effect of antimicrobial treatment on the duration olmiddle ear effusion|MTE) and hearing impairment.

Methods:Children were assigned to either have 40mg/kg of amoxicillin-clavulanale or a placebo miiture for 7 d.The primary

outcome measure was time till disappearance of MET.

Results:MEE disappeared 2 wk earlier in the antimicrobial group,than in the placebo group (2.7 wk vs.4.7 wk,respectively).

Conclusions:Treatment with amoxicillin-clavulanale reduced the duration of middle ear effusion compared toplacebo in children

vrith acute otitis media.

Shortened Antimicrobial Treatment

for AcuteOtitis Media in Young

Children

Effect of Antimicrobial Treatment

ol Acute Otitis Media on the Daily

Disappearance on Middle Ear

Effusion

JAMAPediatr.

2014;168(7):635- 641

Head and Heck Malignancy

NEJM 2015:373(6):521-9 Title:Elective versus Therapeutic Neck Dissection n Node-Negative Oral Cancer

Purpose:To evaluate survival after elective neck dissection vs.therapeutic neck dissection in patients withlateraliied stage 11 or

12 oval squamous- cell carcinomas.

Methods: Aprospedive,randomited,controlled trial that evaluated survival after elective node dissection vs.therapeutic node

dissection.Overall survival and disease-free survival were used asprimary and secondary endpoints,respectively.

Results:At 3 yr.elective node dissection resultedinmore survival (80%).than therapeutic neck dissection (67.5%).As well,at 3

yt. elective node dissection patients had a higher rate of disease free survival compared lo those in the therapeutic surgery group

(69.5% vs.45.9%).

Conclusions:Among patients with early-stage OSCC.electiveneck dissection resulted inhigher rates of overall and disease-free

survival.

NEJM 2016; 374:1444-1454 Title:PET-CT Surveillance versus Neck Oissection in Advanced Head and Neck Cancer

Purpose:To compare the usefulness of planned neck dissection versus PET-CT-guided surveillance in patients withnodal stage N2

or N3 SCC.

Methods:Patients with N2 or N3 neck disease were randomly assigned to either a neck dissection(planned surgery group) or PETCT 12 weeks after chemoradiotherapy completion (surveillance group).The primary endpoint was overallsurvival.

Results:The 2 yr survival rate was 84.9% (95% Cl.80.7 to 89.1) in the surveillance group and 81.5% (95% Cl.76.9 to 86.3) in the

surgery group. The hazard ratio slightly favored PET-CT- guided surveillance and indicated noninferiority (upper boundary of the

95% Cl lor the hazard ratio.- 1.50;P‘

0.004).

Conclusions: PET- CT-guided surveillance is noninferior to planned neck dissection for overall survival in N2 or N3 SCC of Ihe head

and neck.

NEJM 2016: 375:1856 -1867 Title:Nivolumab for Recurrent Squamous-Cell Carcinoma ol the Head and Neck

Purpose: To compare the overall survival of patients with plalinum-refiaclory SCC of the head and neck treated with nivolumab

versus standard therapy.

Methods:Patients with recurrent SCC of the head and neck and disease progression within 6 mo after platinum-based

chemotherapy received either nivolumab or standard systemic therapy (methotrexate,docetaxel.or celuximab).The primary

endpoint was overall survival.

Results:Median overall survival was 7.5 mo (95%Cl.5.5 to 9.1)in the nivolumab group compared to 5.1mo (95% Cl,4.0 to 6.0) in

the standard therapy group.Survival is significantly longer with nivolumab (hazard ratio for death.0.70:97.73% Cl.0.51 to 0.96:

P-0.01).

Conclusions:Treatment withnivolumab resulted inlonger overall survival than treatment with standard therapy in platinumrefractory.recurrent squamous-cell carcinoma of the head and neck.

Elective versus Therapeutic Neck

Dissection in Node-Negative Oral

Cancer

PET-NECK

CheckMale141

Sleep-Disordered Breathing

Title:Effectiveness ol Adenotonsillectomy vs.Watchful Wailing in Young Children Willi Mild to ModerateObstructive Sleep Apnea:

A Randomized Clinical Trial

Purpose: To determine whether adcnolonsillcclomy is more effective than watchful wailing for treatinghealthy children with mild

lo moderate 0SA.

Methods: 60 children ages 2 to 4 with mildlo moderate 0SA were randomized to cither adonotonsilledomy or watchlul walling.

Ihe primary outcome was Ihe difference inmean obstructive apnea hypopnea index (0AHI) score change between the two gioups.

Results:Both gioups had a reduced mean 0AHI score with a small intergroup difference (-1.0:95% Cl.-2.4 to 0.5).Children with

moderate 0SA showed a meaningful intergroup differencein mean 0AHI score change,favouring adenotonsilledomy (-3.1;95% Cl,

-5.71o -0.5).

Conclusions:Otherwise healthy children ages 2-4 withmild 0SA may benefit from watchful waiting,while children with moderate

OSA should beconsidered for surgical treatment.

Title:A Randomized Trial of Adenotonsilledomyfor ChildhoodSleep Apnea

Purpose:To investigate the benefits of adenotonsilledomy vs.supportive care on children withobstructive sleep apnea.

Methods:Children ages 5-9 yr,with obstructive sleep apnea syndrome were randomized to adenotonsilledomy or a strategy of

watchful waiting.Polysomnogiaphic,cognitive,behavioural,and health outcomes were assessed at baseline and again at 7 mo.

Results:Attention and executive function scores from baseline did not change significantly in theadcnolonsilledomy group vs.

the watchful waiting group (7.1x13.9 vs.5.1r13.4.respectively).Signilican!differences frombaseline in behavioural,and quality

of life were found in Ihe adenotonsilledomy group. Normalization olpolysomnogruphic findings were foundin more of Ihe

adenotonsilledomy than Ihe watchful waiting group (79% vs. 46%).

Conclusions:Surgical treatment for obstructive slcepapnea in children ages 5-9 did not significantly improve attention or

executive function but didimprove behaviour,quality of life,and polysomnogiaphic findings compared to watchlul waiting.

KATE JAMA Otolaryngol

Head Neck Surg.

2020;146|7|:647 654

CHAT NEJM 2019:20|9):1273-

1285

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0T51 Otolaryngology Toronto Notes 2023

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