PERSPECTIVES IN PEDIATRIC OTOLARYNGOLOGY
| CURRENT TRENDS IN OTITIS MEDIA —Jacqueline E. Jones, MD, Associate Professor of Clinical Otorhinolaryngology,
Joan and Sanford I. Weill Medical College of Cornell University, New York City
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| Microbiology: up to 12 mo of age, Streptococcus pneumoniae (pneumococcus) predominant; from 12 to 35 mo of age,
Haemophilus influenzae predominant; in older children, pneumococcus and Haemophilus predominate, with “small
smattering of Moraxella”; bacteria isolated in 70% of cases
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 | Role of viruses: incidence of acute otitis media (AOM) highest in winter, lowest in summer (reflects pattern of viral upper
respiratory tract infections [URIs]); in young children, risk for AOM peaks 3 to 4 days after onset of viral URI; biggest
viral culprit respiratory syncytial virus (RSV); influenza A, adenovirus, and parainfluenza type III also associated
with AOM; viruses promote bacterial propagation in middle ear through 3 mechanisms; eustachian tube
dysfunction—tube swells, cannot drain, creating medium for bacteria to thrive; altered host immune defense—seen
mostly with leukocyte dysfunction; increased bacterial adherence and colonization—occurs with mucosal disruption
and ciliary loss associated with repeated viral infections
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| Treatment: most frequently treated with antibiotics; raises concerns about resistance, but major worry for otolaryngologists
is risk for suppurative complications from lack of treatment; in study of mortality from AOM between 1936 and
1976, fatalities dropped from 2% to 0.01%, due to better diagnosis and treatment; however, one study showed increased
incidence of penicillin-resistant pneumococcus in nasopharyngeal cultures after 10-day course of amoxicillin; among
day-care population in New York City, pneumococcal resistance to penicillin 60%, compared to 1% in Finland, due to
overuse of antibiotics; most meta-analyses consisting of >5000 patients suggest spontaneous cure rate 80%; observation
indicated if child >6 mo of age and otherwise healthy with no obvious ear perforations, and when last episode of AOM
>3 mo ago; parents must agree and follow through with adequate medical follow-up; amoxicillin first-line therapy, with
trimethoprim–sulfamethoxazole as alternative for penicillin-allergic patients; consider 5-day course, extended to 10 days
in severe cases; during observation, prescribe analgesics, eg, ibuprofen (Motrin) or acetaminophen (Tylenol); educate
parents about warning signs of AOM; safety net prescription—given to parents if disease appears to be progressing;
Pittsburgh study suggests only 30% of parents fill them
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| Risk factors for recurrent AOM: first episode before 1 yr of age; male sex; sibling with recurrent disease
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| Evidence of genetic predisposition: animal studies correlate risk for AOM with gene for increased mucin production in
middle ear; mastoid pneumatization more common in monozygotic than dizygotic twins; racial differences in eustachian
tube structure also seen; radiologic evidence suggests that susceptible children have smaller nasopharynxes than
controls; multiple genes most likely
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| Lowering risk (study data): incidence of AOM highest in group day care, so small day-care settings preferable; in study
of children breast-fed exclusively during first 4 mo of life, mean incidence of AOM episodes one half that seen in bottle-fed
children, and 40% less than that in infants fed supplemented diets; maternal smoking >20 cigarettes/day associated
with 2-fold increase in AOM incidence (3-fold among low birthweight children)
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| Gastroesophageal reflux: inflammatory cofactor for development of AOM; gastric acid and pepsin can reflux into nasopharynx,
flow into middle ear, and cause inflammation in children with short straight eustachian tubes, leading to eustachian
tube dysfunction and infection; concentration of pepsin and pepsinogen 1000 times greater in middle ear fluid than in
serum; in one study, pepsin found in 81% to 83% of effusions
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Otitis Media with Effusion (OME)
| Treatment: no good treatments available; benefits of antibiotics, steroids, and antihistamines short-lived
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| Surfactant therapy: surfactant (lung phospholipid) exists in eustachian tube and middle ear; lowers passive opening pressure
of eustachian tube; in animal studies, aerosolized surfactant decreases duration of effusion, as well as severity and
duration of AOM; shortest duration and fastest resolution associated with combination of surfactant and betamethasone
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| Nature of infection: effusions formerly thought to be sterile, but recent polymerase chain reaction (PCR) studies suggest
effusions may harbor viable, metabolically active pathogens; new potential pathogen, Allococcus otitis, isolated in 54%
of specimens in one study, sole isolate in 19.4%; may promote colonization by other organisms; biofilm—community of
bacterial colonies encased in protective exopolysaccharide matrix; highly resistant to antibiotics and difficult to culture;
bacteria in biofilm grow slowly; treatment means restoring normal middle ear environment and debulking biofilm with
tympanostomy tubes (alter biofilm phenotype by ventilating middle ear and increasing O2 tension); suctioning disrupts
and debulks film and promotes regrowth of cilia; also decreases secretory cells, reducing growth medium for biofilm
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| OTITIS MEDIA AS A BIOFILM DISEASE IN HUMANS —Joseph E. Kerschner, MD, Division of Pediatric Otolaryngology,
Children’s Hospital of Wisconsin, and Division of Pediatric Otolaryngology and Communication Sciences, Medical
College of Wisconsin, Milwaukee
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| Biofilm: complex organization of bacteria within exopolysaccharide matrix; low metabolic rate; invisible to host immune
surveillance; organisms communicate through complex mechanisms and resist standard culture techniques; genetic expression
differs from that of planktonic bacteria
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| Support for concept of otitis media as biofilm disease: chronic infectious process; difficult to culture; recalcitrant to antibiotic
therapy; indirect evidence—1998 study showing that “sterile” effusions from patients with OME actually had
bacterial DNA and messenger ribonucleic acid (mRNA); biofilm demonstrated in 2002 study of animal model with H influenzae
infection
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| Study by speaker and colleagues: included 26 children receiving tympanostomy tubes for recurrent AOM and OME; cultured
effusions and performed PCR analysis for 3 main pathogens; used confocal laser scanning microscopy, vital
dyes, and bacteria-specific assays to assess very small biopsy specimens for biofilms; used PCR to confirm presence of
biofilm
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| Results: 13 of 26 patients diagnosed with OME; 52% had effusion, 19% of these culture-positive; all patients with effusion
PCR-positive for viable bacteria; some effusions tested positive for multiple organisms; confocal microscopy identified
biofilms in 90% of 49 specimens; when 3 methods of biofilm assessment used, 57% of specimens positive; point—
several studies suggest S pneumoniae can form biofilms; H influenzae is known biofilm former under right conditions
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| ADENOTONSILLAR DISEASE —Lianne de Serres, MD, Assistant Professor of Pediatric Otolaryngology, Columbia
University College of Physicians and Surgeons, and Pediatric Otolaryngologist, Children’s Hospital of New York-Presbyterian
Hospital, New York City
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| Adenotonsillar hypertrophy: major cause of sleep disordered breathing (SDB) in children; surgery always curative if
child anatomically normal and not obese; most children seen by otolaryngologists have upper airway resistance syndrome
(obstruction produces sufficient resistance to cause electroencephalographic changes, but not enough to yield abnormal
sleep study); diagnosed only through esophageal pressure monitoring (availability limited); ≈10% of children
have primary snoring (believed to be benign)
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| Effects of SDB in children: cardiovascular effects (pulmonary hypertension rare, but systemic hypertension often occurs
at night); nocturnal enuresis; poor growth; behavior disturbances and poor school performance; adenotonsillectomy improves
breathing, sleep, and academics; one study of 866 children showed higher incidence of snoring among children
with high hyperactivity index scores than controls; in other studies, respiratory distress decreases after surgery, while
slow-wave sleep, growth, and serum insulin-like growth factor (IGF) levels all increase; in other studies, SDB associated
with high levels of C-reactive protein; correlations seen with apnea-hypopnea and arousal indices, and with lowest nocturnal
O2 saturation (may help explain long-term morbidity associated with SDB)
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| Sleep studies: perform before surgery, as recommended by American Academy of Pediatrics and American Thoracic Society
guidelines; most otolaryngologists do not obtain polysomnography unless diagnosis in doubt; takes at least 3 to 6
wk to schedule; many children undergo surgery even if results negative (justified because test not perfect, eg, patients
with upper airway resistance may test negative); postoperative studies performed in <5% of cases
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| Postsurgical outcomes in children with negative polysomnography: in one study, symptom scores decreased by 50 points,
compared to 8 points among children who did not undergo surgery; 82% of surgery patients became asymptomatic,
compared to 22% of those who did not have surgery; conclusion—physical examination and good history sufficient
for appropriate clinical decisions
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| Surgery: in double-blind randomized comparison of harmonic scalpel (ultrasonic forces vibrate blade, provide simultaneous
cutting and coagulation) with standard “cold-knife” surgery in 54 patients, trend for better results with standard
technique (not statistically significant)
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| Coblation: saline flushed from head of wand creates ionized plasma layer that breaks molecular bonds upon hitting tissue;
much lower risk for thermal injury than with electrocautery; associated with faster return to normal diet and activity
levels; used for total or partial tonsillectomy
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| Partial tonsillectomy (tonsillotomy): surgical microdebrider shaves 80% to 90% of tonsil; remaining tissue acts as biologic
dressing to cover pharyngeal muscles and larger end vessels; protection of raw muscle means less pain and bleeding
during recovery; study of 874 patients—postoperative bleeding rate 0.7%, compared to 3% with standard
surgery; dehydration 1.3%, compared to 3%; regrowth occurred in 0.5% of cases; procedure indicated only for patients
with obstructive symptoms (do not leave tonsil behind in patients with chronic or recurrent tonsillitis); discuss possibility
of regrowth with parents; list of relative indications may grow because this procedure more benign than tonsillectomy;
candidates include children with primary snoring or mild SDB; also children with unintelligible speech or
dysphagia, or who are at high risk for postoperative bleeding
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| Electrocautery tonsillectomy vs microdebrider: microdebrider associated with more blood loss and longer surgery, but
faster resumption of normal diet; no differences in pain resolution or return to normal activities
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| Recommendations: cold technique, coblation, or electrocautery recommended for total tonsillectomy; electrocautery,
when used, should be at low setting (minimizes pain); relative risk of postoperative bleeding 2 to 3 times higher with any
electrocautery technique; microdebrider or coblation recommended for partial tonsillectomy (microdebrider blades less
expensive and better for adenoidectomy); intraoperative steroids reduce postoperative pain and nausea
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| SUBGLOTTIC STENOSIS —Robert F. Ward, MD, Clinial Associate Professor, Otorhinolaryngology, Joan and Sanford I.
Weill Medical College of Cornell University, New York City
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| Background: today, congenital cases account for ≈10% of total; most current cases due to trauma from endotracheal tubes
(creates mucosal injury, leading to deeper tissue injury, perichondritis, and cicatrix formation); third most common infant
airway abnormality; presentation—biphasic stridor; severe cases associated with respiratory distress
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| Diagnosis: in intensive care unit (ICU) patient, stridor and respiratory distress upon extubation; difficult to see subglottic
space with fiberoptics (mild cases missed on endoscopy); newer instruments, eg, telescopes, laryngoscopes have improved
diagnosis; bronchoscope side ports good for placing suction or laser devices
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| Treatment of congenital subglottic stenosis: observation reasonable in milder cases; dilation best as adjunctive, not sole,
therapy; for severe cases, open repair (augmentation or resection) currently gold standard
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| Augmentation: involves opening anterior and/or posterior larynx; grafting to anterior cricoid cartilage, using vertical incision
to open cartilage; valuable for severe cases; costal cartilage graft most common; done in single or multiple stages;
today, surgeons seldom open entire airway as done formerly; number of sutures now much smaller; failure rate and need
for repeat surgery relatively high
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| Posterior grafting: important in management of pediatric airway; however, difficult to place sutures in posterior trachea;
current modifications include less invasive and extensive airway opening, with one person watching while other places
grafts; methods include sutureless posterior graft technique, aided by mitomycin C (to minimize fibroblast proliferation)
and fibrin glue; graft has bilateral flanges placed in pocket under cricoid lamina (with fibrin glue, eliminates need for sutures);
glue also ensures airtight seal (use sparingly, adding droplets until airtight seal achieved)
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| Resection: grew in popularity beginning in late 1980s to early 1990s, after animal studies demonstrating normal cricoid
growth after trauma; cricotracheal resection now performed on children who weigh <10 kg; thought to reduce need for
repeat procedures and create good tracheal framework, permitting earlier removal (or complete avoidance) of stent and
earlier removal of tracheotomy tube; discourages development of granulation tissue; procedure now often done in multiple
stages and with placement of endotracheal tube; concerns include risk for injury to recurrent laryngeal nerve (avoid
by careful resection through trachea) and possibility of failure, especially with true laryngeal involvement
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Educational Objectives
| The goal of this program is to update the otolaryngologist on current trends in the management of pediatric disease. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Describe appropriate antibiotic therapy for otitis media.
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| 2. Identify the children at highest risk for recurrent otitis media.
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| 3. Discuss the evidence supporting the concept of otitis media as a biofilm disease.
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| 4. List the advantages and disadvantages of partial tonsillectomy.
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| 5. Describe 2 surgical approaches to the treatment of subglottic stenosis.
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Discussed on This Program
Acetaminophen [many preparations and trade names]
Amoxicillin [Amoxil, Amoxil Pediatric Drops, Trimox, Trimox Pediatric Drops]
Betamethasone [Celestone]
Ibuprofen [many preparations and trade names]
Mitomycin (mitomycin-C; MTC) [Mutamycin]
Penicillin V (phenoxymethyl penicillin) [Penicillin VK, Veetids]
Pentagastrin [Paptavlon] (discontinued)
Trimethoprim–sulfamethoxazole (co-trimoxazole; TMP-SMZ) [several trade names]
Suggested Reading
Daly KA et al: Recent advances in otitis media. 1. Epidemiology, natural history, and risk factors. Ann Otol Rhinol
Laryngol Suppl 194:8, 2005; De Serres LM et al: Impact of adenotonsillectomy on quality of life in children with obstructive
sleep disorders. Arch Otolaryngol Head Neck Surg 128:489, 2002; De Serres LM et al: Measuring quality of
life in children with obstructive sleep disorders. Arch Otolaryngol Head Neck Surg 126:1423, 2000; Hultcrantz E et al:
Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy. Int J Pediatr
Otorhinolaryngol 69:463, 2005; Kenna MA: Otitis media and the new guidelines. J Otolaryngol 34 Suppl 1:S24, 2005;
Koltai PJ et al: Intracapsular tonsillar reduction (patial tonsillectomy): reviving a historical procedure for obstructive sleep
disordered breathing in children. Otolaryngol Head Neck Surg 129:532, 2003; McCormick DP et al: Nonsevere acute
otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics
115:1455, 2005; Panda NK et al: Prognostic factors in complicated and uncomplicated chronic otitis media. Am J Otolaryngol
17:391, 1996; Pelton SI: Otitis media: Re-evaluation of diagnosis and treatment in the era of antimicrobial resistance,
pneumococcal conjugate vaccine, and evolving morbidity. Pediatr Clin North Am 52:711, 2005; Sorin A et al:
Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope 114:297,
2004; Straetemans M et al: Immune status and Eustachian tube function in recurrence of otitis media with effusion. Arch
Otolaryngol Head Neck Surg 131:771, 2005; Ward RF, Triglia JM: Airway growth after cricotracheal resection in a
rabbit model and clinical application to the treatment of subglottic stenosis in children. Laryngoscope 110:835, 2000.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reports nothing to disclose.
Dr. Kerschner spoke at the Annual Meeting of the American Society of Pediatric Otolaryngology, held May 27-30,
2005, in Las Vegas, and sponsored by the American Society of Pediatric Otolaryngology. Drs. de Serres, Jones, and
Ward were recorded at Management of Challenges in Otolaryngology-Head and Neck Surgery: An American-International
Perspective, held June 3, 2005, in New York City, and sponsored by Cornell University. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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