Kimberly Moriarty
ENT case studies
1. The antibiotic management of OM centers on the idea that it is virtually impossible to discern a
viral or bacterial cause of the infection. Giving antibiotics for a viral cause does not help the
illness, and further contributes to antibiotic resistance. Plus it opens children up to diarrhea or
even allergies to these antibiotics. Usually the practitioner was to prescribe antibiotics in every
case. A large study was done from an emergency room which started the wait and see method.
Parents were given scripts and told to fill them if symptoms didn’t get better in 24-48 hours. In
most cases they did get better, and didn’t need to take the antibiotic unnecessarily. In addition,
no child suffered any ill effects from the wait and see method. The American Academy of Family
Physicians set up guidelines to help prescribers use antibiotics more efficiently. Any child under
6 months is to be given antibiotics, those older than that, unless a known cause of OM is known,
use the wait and see method, with appropriate follow up scheduled.
2. Antibiotics are only indicated if the prescriber is certain of the diagnosis, the child is under 6
months or the child’s illness is severe.
3. Things to recommend to the parents include: analgesic eardrops, and antipyretics. Also to bring
the child back if symptoms are not getting better or the child is doing worse.
4. The first line agent in a child with OM is amoxicillin, 80-90 mg/kg/day. If there is a true penicillin
allergy, azithromycin (10mg/kg on day 1, and 5mg/kg on days 2-5) if the child is older than 6
months.
5. Otitis media and otitis media with effusion vary from each other. AOM usually an acute onset,
accompanied by fever, and usually with or after a URI. The child usually has ear pain, ear pulling,
and irritability. The TM is usually bulging, has decreased mobility and may take on a red, yellow
or purple color. In contrast, in OME the child is usually asymptomatic, has popping or fullness in
the ear, or complains of hearing loss. The TM is less mobile and looks dull, with no landmarks or
is retracted with landmarks and a fluid air level. This distinction is important to know because
chronic OME can lead to developmental and learning delays, as well as impact on attention and
language. Antibiotic treatment is not indicated with OME. Persistent AOM can lead to hearing
loss; usually tubes are placed in those children with recurrent OM infections. OME is likely to
occur after resolution of OM. OM is just the generic term used to capture the presence of an
inflammation in the middle ear, without reference to cause.
6. The most common cause of otitis extera is swimming in a pool or lake which leaves moisture in
the ear canal, promoting bacterial growth. Treatment of the 7 year old would be cortisporin otic
4-5 drops every 6 hours in affected ear.
7. Rapid strep testing has a sensitivity of 75-85%, 75-85 of 100 people with strep will test positive.
The test needs to be sent for a culture to make sure those other 25 people are caught. The test
is also 98% specific, meaning 98 of those positive tests indicate the bacteria are present for
causing strep. Only 2 of these hundred will come back positive when they aren’t really infected
with the virus. This allows practitioners to quickly and efficiently test for strep throat in those
presenting with symptoms. If positive, the two choices for treatment include penicillin, and
erythromycin in those with an allergy to penicillin. Penicillin would be given 500 mg BID for 10
days in adults, 250mg BID for 10 days in children. Erythromycin would be given as 500mg BID for
10 days, children would take 50mg/kg BID for 10 days.
8. Sinusitis: Sinus headache, nasal discharge, headache, bad breath, fatigue, congestion, tooth
aches and cough. Lasts longer than 7-14 days without improvement. Diagnosed by exam of
redness and swelling of nasal passages, pain when bending forward or when sinuses are tapped,
swelling around eyes. It is mainly diagnosed by history of presenting symptoms. Can order a CT
if severe or indicated. No lab work would be necessary unless patient is severely ill.
URI: Cough, sore throat, body aches, runny nose, sneezing, congestion, rarely presents with
headache, fever. Usually lasts 7-10 days. Exam reveals redness and swelling of nasal mucosa,
nasal discharge. No lab work is indicated. May take a CBC which will show an elevated white
count. Usually has a sick contact.
Not much differentiates the two besides the sinus pressure and headaches. No lab work is
needed unless severely ill. If recurrent, may indicate need for CT scan. Antibiotics are not
necessarily indicated unless a bacterial sinus infection is suspected. I’ve had a million sinus
infections and never gotten antibiotics….I’m not bitter.
9. Bronchiolitis would typically present in an infant with common cold symptoms; mild cough,
sneezing, runny nose, decreased appetite. The breathing becomes faster and a more
pronounced cough develops over a couple of days. Eventually the child’s breathing becomes
wheezy and more in distress. The child will develop nostril flaring when breathing becomes too
difficult. Clinically one would see an infant that is tachypnic, possible dehydrated, using
accessory muscles to breath (intercostals retractions), tachycardia and a very worried parent.
The infant’s lungs will have audible wheezing, crackling and possibly sound moist. Diagnosis is
made solely on history and physical. Getting a pulse ox and chest x-ray if the oxygen level is low.
Ruling out pneumonia and asthma is also helpful to confirm diagnosis. Hospitalization criteria
includes: respiratory distress, ill appearance, inadequate oral intake, low pulse ox,
immunosuppression, and underlying respiratory issues. These infants can benefit greatly from
hydration and oxygen therapy in the hospital. Management of a non hospitalized child includes
maintaining good hydration, rest and knowledge of when to seek emergency treatment. An air
humidifier may help breathing as well. Since this is a virus, no medications can be given to help
shorten the course of illness.