Otitis externa

Cite this article as:
Sinéad Davis. Otitis externa, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2867

A 7-year-old boy is brought to the ED by mum. He has ear pain (otalgia), reduction in his hearing and a little discharge from the ear. His symptoms have been getting worse over the last couple of days and now he is in a lot of pain despite analgesia, given by the parents. Mum thinks the infections might have started after he began his swimming lessons, 3 months ago.

 Is this history suggestive of otitis externa (OE) or acute otitis media (AOM)?

Bottom Line

  • Scanty white/yellowish discharge associated with an oedematous ear canal is otitis externa.
  • Pain often builds up over a couple of days and is increased on moving the pinna or pressing on the tragus.
  • Increased risk with exposure to water e.g. recent holidays, swimming lessons.
  • Treatment is with TOPICAL antibiotics (usually drops) and regular analgesia.

What is otitis externa?

It is acute inflammation and infection of the skin of the external auditory canal.

It might be localized, like a pimple, or more often is diffuse, involving all the skin of the ear canal. It might extend to involve the pinna, causing perichondritis, or infection of the side of the face, cellulitis or erysipelas.

from Hawke Library

Who gets it?

This condition is less common in children than acute otitis media, but certain conditions can predispose an individual to get this condition including:

  • Eczema, involving the skin of/near the ear
  • Psoriasis
  • Water exposure: recent holidays, regular swimming, frequent baths
  • Trauma, particularly from cleaning ears with cotton buds
  • Immunocompromised patients

What are the most common pathogens?

Otitis externa might be caused by bacterial, fungal, or viral infections.

Bacterial causes: Staphylococcus aureus, Pseudomonas aeruginosa
Fungal causes: Candida spp; Aspergillus niger
Viral causes: Varicella zoster; Herpes simplex

What are the clinical findings?

Patients will find it painful when you touch the pinna or if you push on the tragus. The ear canal is swollen and oedematous, to the point that it closes up in severe cases. White debris or yellowish discharge can be seen in the ear canal.

Signs of mucous, however, indicate a discharge from the mucosa in the middle ear, indicating a tympanic membrane perforation is present. In this case, the patient should be treated for AOM.

The patient will have reduced hearing. As the ear canal closes over from the swelling a conductive hearing loss develops.

from Hawke Library

How should I treat it?

If you can see into the ear canal, enough to see the discharge, then firstly treat with

TOPICAL antimicrobial agents: antiseptic  e.g acetic acid drops/spray, antibiotic e.g. aminoglycoside or fluoroquinolones (ciprofloxacin) drops

Steroids: topical – usually combined with the above drops.

Analgesia: this is a very painful condition – paracetamol/NSAIDS

If the canal is closed over, refer the patient to ENT for further management. This is likely to include micro-suction clearance of the ear canal debris and/or insertion of a dressing (wick) into the ear, onto which antimicrobial therapy can be instilled.

Side effects of the treatment

Aminoglycosides carry a risk of ototoxicity: the use of these agents is not advised if it is known that there is a tympanic membrane perforation.

Aminoglycosides, especially neomycin, can cause contact dermatitis in 15% of patients.

License for use of fluoroquinolone

Though the use of topical ciprofloxacin in the ear canal is licensed in the US and many countries worldwide, it is not licensed for this use in the UK. Despite this many clinicians, in the UK, will choose to prescribe this medication ‘off license‘; but in doing so should follow the published guidance of the General Medical Council, UK.

What are the other possible diagnoses?

In children, the most likely diagnosis is going to be AOM, with a TM perforation, so that the ear discharge has caused a secondary OE. In this case, the discharge will be mucoid (stringy) in consistency.

Selected references

Kaushik V, Malik T, Saeed S R. Interventions to treat acute otitis externa. Cochrane Database Syst Rev 2010;(1):CD004740

Marais J, Rutka J A. Ototoxicity and topical eardrops. Clin Otolaryngol Allied Sci 1998;23:360-367

GMC. Good practice in prescribing and managing medicines and devices.

ITP – Idiopathic Thrombocytopenic Purpura

Cite this article as:
Tessa Davis. ITP – Idiopathic Thrombocytopenic Purpura, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2865

A 4-year-old girl presents with bruising over her legs, trunk and face.  Mum has noticed them appear over the last week.  She has been completely well with no other symptoms.  There is no history of trauma.  After an anxious 1 hour wait, the bloods are back-Hb 113, WCC 7.3, Plt 8 x 109/L.

 

Bottom Line

  • Uncomplicated idiopathic thrombocytopenic purpura (ITP) is new-onset bruising and bleeding with a platelet count <100 x 109/L in the absence of other symptoms
  • It generally resolves itself in 80% by six months
  • 5% will have a recurrence
  • Only treat if there is active bleeding, not just because of a low platelet count
  • Advise parents to avoid NSAIDS and lookout for signs of bleeding
  • Follow up regularly for the first six weeks or until platelet count stabilises

 

What is it and how did she get it?

Idiopathic thrombocytopenic purpura (ITP) is a reduction in platelet count in the absence of any other cause (<100 × 109/L).  Whilst normal platelets last eight to ten days, in ITP there are autoantibodies that destroy them in the first few hours. It has a peak incidence of two to five years of age (chronic ITP peaks in adolescence).  There is often a recent history (one to six weeks) of a viral illness or immunisation.

What are the commons symptoms and signs?

The most common sign is petechiae (1-5 mm red or purple non-blanching spots) on the skin or mucosa – these indicate capillary haemorrhages.  Some mucocutaneous bleeding is often seen, but it is rare for this to be severe (<5%).

Other symptoms of autoimmune disorders should NOT be present in ITP – e.g. no weight loss, rashes, alopecia, joint swelling. The examination should be normal with no hepatosplenomegaly or lymphadenopathy.

How is it diagnosed?

It is diagnosed by having a low platelet count with a normal haemoglobin (unlike in leukaemia, TTP, HUS and DIC). If there is a history of previous bleeding then consider other diagnoses. Bone marrow aspirate is only recommended if there is persistent bleeding in spite of a platelet count >20 × 109/L.

 

What treatment should we use?

The answer is simple: treat the patient not the platelet count.  Assess if the patient has haematuria, melaena, menorrhagia, epistaxis, mucosal bleeding or tonsillar purpura/petechiae.

Although there is variation between specialists, they will all be more concerned with the signs of wet purpura or haematuria rather than just the petechiae on the skin.

Steroids

Prednisolone 1-2mg/kg OD for at least three weeks then taper

OR

Methylprednisolone 30mg/kg/day for three days, then 20mg/kg /day for four days

 

IVIG (intravenous immunoglobulin)

Consider where there is significant bleeding (0.8-1g/kg) – can rapidly raise the platelet count Effects takes place in one to five days and lasts for two to four weeks

 

Platelets

Only give platelets if there is an intracranial hameorrhage (ICG) or significant bleeding.  Can be effective after IVIG administration and this can prolong platelet survival (otherwise transfused platelets are quickly destroyed)

 

When to admit?

Admit if there is significant bleeding: epistaxis>1 hour; haematemesis; haemoptysis, intracranial haemorrhage, melaena.  Or if there is an unclear diagnosis or problematic social circumstances.

When will it go away?

Most ITP self resolves.  80% will have resolved by six months (with or without treatment).  5% of ITP patients will have a recurrence. Although it seems counterintuitive, the lower the platelet count at the beginning, the better.  Uncomplicated ITP normally has a platelet count of <20 × 109/L. Chronic ITP does not resolve within six months and accounts for 10% of ITP.

Could it be anything else?

Confirmation is based on excluding other differentials such as acute leukaemia, aplastic anaemia, HUS.  A full blood count and film us usually adequate to make the diagnosis.

What do you need to inform the parents to look out for?

While the platelets are low, the patient is at risk of bleeding.  ICH is a serious but rare (1%) side effect.  Parents should watch out for any signs of ICH, urinary bleeding, GI bleeding, excessive mucosal bleeding and menorrhagia (in older patients).

They should avoid NSAIDs while the platelet count is low.

Older children should avoid contact sports.  This is completely impractical for young children so is not helpful advice – will only stress out the parents!

When to follow up?

Patients should be reviewed within two weeks of initial presentation and have a repeat FBC. Aim for weekly GP follow up initially and then PRN until resolution.

Paediatric outpatient review at six weeks three months and six months. Refer to haematology if unclear diagnosis, unresolved after six months or a haematological malignancy is suggested by the blood count.

 

Selected references

Pediatric EM Morsels – Wet purpura and ITP

UMEM Educational Pearls – ITP

Royal Children’s Hospital, Melbourne – Guidelines for ITP

Princess Margaret Hospital for Children – ITP Guideline

BMJ BestPractice – ITP

Grainger JD, Rees, JL, Reeves M, Bolton-Maggs PHB.  Changing trends in the UK management of childhood ITP. Arch. Dis. Child. 2012;97:8-11.[/toggle]

Single ventricle physiology – functionally univentricular heart, parallel circulation

Cite this article as:
Marc Anders. Single ventricle physiology – functionally univentricular heart, parallel circulation, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3443

Definition: either natural or palliated situation where blood to the pulmonary circulation is supplied in parallel rather than serial to the systemic circulation by the same pumping chamber(s).

Pertussis

Cite this article as:
Henry Goldstein. Pertussis, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2722

Winston, a 4-month-old boy, presents to your emergency department after his mother noticed, during his last feed, that he appeared to stop breathing for around 15 seconds and turned blue.

He restarted breathing spontaneously. Further history reveals a two-day history of feeding difficulties, cough, irritability, and rhinorrhoea. He has also had a low-grade temperature (37.8 0C). There has been no diarrhoea and a few vomits, but only after coughing. He has no rashes. His oral intake has been reduced to about half normal, for the last 24 hours.

 

Bottom Line

  • Have a low threshold for suspicion in any child with a prolonged cough, especially those incompletely immunized
  • Pertussis has a non-typical presentation in infants
  • In clinically or laboratory diagnosed pertussis, antibiotics do not reduce the severity or frequency of coughing paroxysms.
  • Antibiotics do render the child noninfectious
  • Due to the high risk of morbidity and mortality in infants less than six months of age who are incompletely immunized, contact prophylaxis is recommended for families who have an infant less than six months of age

 

Further Assessment

Birth History

Winston was born at term weighing 3700g. Apgars were 91, 95 after an SVD without any risk factors for sepsis. His well neonate check and six week GP reviews were unremarkable. He is exclusively breastfed. He is up to date with his immunizations.

Family History

Of note, Winston’s 11-year-old brother has had two weeks of rhinorrhoea and cough but is clinically well.

Examination

You see a slightly tachypnoeic, thriving 4/12 male. Chest clear. Mildly dehydrated. Irritable. Normotensive fontanelle. No rashes. No focal findings on the chest. Unremarkable cardiovascular and abdominal examinations. ENT; TMs are mild erythematous bilateral without effusion, tonsils are also mildly erythematous, not overly enlarged.

 

What is the most concerning feature of this history?

Apnoea – apnea is a particularly concerning feature in infants.

 

What are your differentials and most likely diagnosis – why?

Whooping cough, caused by Bordetella pertussis, a gram-negative coccobacillus whose only reservoir is humans. It’s transmitted by respiratory secretions, particularly in the first few weeks after exposure.

Clinically, pertussis classically progresses in three stages.

  • Firstly, the catharrhal phase which consists of one to two weeks of nonspecific symptoms.
  • This is followed by the paroxysmal phase, in which the characteristic ‘whoop’ sound at the end of a coughing paroxysm may be heard (infants and older children are less likely to have typical whooping cough).
  • Finally comes the convalescent phase in which the coughing paroxysms become less frequent and less severe.

Notably, infants may manifest pertussis infection only as feeding difficulties, cough or apnoeas. Also, immunized children may manifest a more attenuated illness that doesn’t demonstrate the classic three phases of illness.

 

How is it diagnosed?

Laboratory diagnosis is by nasal swab or nasopharyngeal aspirate showing PCR positive for Bordetella pertussis.

Additionally, when considering which children to swab, there was a distinct paucity of evidence. There were several comparisons of PCR vs culture, but no firm criteria about who should score an NPA or flocked swab in the first place.

The US CDC recommends: “Early diagnosis and treatment might limit disease spread. When pertussis is strongly suspected, attempts to identify and provide prophylaxis to close contacts should proceed without waiting for laboratory confirmation. When suspicion of pertussis is low, the investigation can be delayed until there is laboratory confirmation of the diagnosis. However, prophylaxis of infants and their household contacts should not be delayed because pertussis can be severe and life-threatening to young infants.”

Ditte & colleagues’ excellent (but quite technical) 2004 article investigated a sample size of 3096 patients, swabbed for suspected pertussis.

PCR was superior for detection in patients aged 6 months – 3 years and was highly sensitive for the diagnosis of pertussis.

Also of note, pertussis serology may be of use to confirm diagnosis around the time a patient enters the catarrhal phase, but will unlikely change management as discussed above.

 

Who is at most risk?

Infants under six months have the highest mortality from pertussis; the mortality rate is estimated at around 1%, with 80% of these deaths occurring in infants under 2 months. Comorbid apnoea, pneumonia, and seizures may complicate pertussis infection. Less commonly, a leukocytosis >50,000×109/L or encephalopathy potentially caused by pertussis toxin may occur and is associated with a poor prognosis.

 

Treatment

Let’s have a look at the evidence around antibiotic management of whooping cough as well as the indications for prophylaxis. This Cochrane review (assessed as up to date in Jan 2011) is the basis for a number of current guidelines.

Altunaiji SM, Kukuruzovic RH, Curtis NC, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004404. DOI: 10.1002/14651858.CD004404.pub3.

The review looks at 13 RCTs regarding the efficacy of antibiotics for treatment & prophylaxis of pertussis. Eleven trials looked at treatment and had the following objectives:

 

Do antibiotics achieve microbiological eradication of B. pertussis?

  • Multiple studies showed a number of agents successfully eradicating b. pertussis, including erythromycin, oxytetracycline.
  • Azithromycin and clarithromycin as macrolides equivalent to erythromycin has been shown effective at eradicating B. Pertussis.
  • A number of head to head studies showed no superior agent. However, a 1997 study showed roxithromycin was two to four-fold less effective at B. pertussis eradication vs erythromycin.

Do antibiotics improve the clinical illness of whooping cough?

  • No difference in mortality.
  • With regard to clinical cure/ remission; erythromycin ethyl succinate (EES) vs erythromycin estolate. Patients judged they were equivocal re: frequency of cough, and that erythromycin estolate was slightly superior to EES, regarding clinical cure / remission.
  • Erythromycin & azithromycin had no relapses after proven negative culture post-treatment.

What is the appropriate dose and duration of therapy?

  • There was no benefit for a prolonged course of antibiotics vs a standard course.

What are the side effects profile of antibiotics used to treat whooping cough?

  • Regarding side effects, azithromycin 3/7 was superior to erythromycin ethyl succinate 14/7 and clarithromycin 7/7 was superior to erythromycin estolate 14/7
  • Compliance was best for azithromycin vs erythromycin estolate and clarithromycin vs EES

Additionally, Honien et al (1999) describe seven cases of infantile hypertrophic pyloric stenosis in a cohort of 200 neonates treated with erythromycin; a significantly increased risk or IHPS in this population.

 

Prophylaxis

Two trials (401 patients in total) reviewed prophylaxis:

Do antibiotics achieve microbiological eradication of B. pertussis?

As for treatment, above.

Do antibiotics prevent the clinical illness of whooping cough?

  • slightly less” but not statistically significant frequency of whooping cough, paroxysms in household contacts of the prophylaxis arm.
  • slightly lower” but not statistically significantly lowered attack rate in prophylaxis groups.

The appropriate dose and duration of therapy?

As for treatment, above.

The side effects profile of antibiotics used for prophylaxis of whooping cough?

  • Placebo was better than erythromycin estolate for compliance and side effect profile.

Of note, erythromycin estolate is not available in Australia.

The reviewers commented on the marked heterogeneity of studies with regard to the outcome measures and definitions. They note that treatment renders patients noninfectious but does not alter the clinical course. Consequently, they make the following recommendations.

The best regimens for microbiological clearance, with fewer side effects, are:

  • three days of azithromycin (10 mg/kg as a single dose);
  • five days of azithromycin (10 mg/kg on the first day of treatment and 5 mg/kg once daily on the second day to fifth days of treatment); or
  • seven days of clarithromycin (7.5 mg/kg/dose twice daily).

Seven days of trimethoprim/sulphamethoxazole (20 mg trimethoprim with 100 mg sulphamethoxazole per dose, twice daily, for children under six months of age; double this dose for older children) appears to be effective in eradicating B. pertussis from the nasopharynx and may serve as an alternative antibiotic treatment for patients who can not tolerate a macrolide.

Additionally, in Australia, a pertussis booster vaccine is recommended for close household contacts of newborns; this advice is part of a neonatal discharge check within the hospital.

 

Antibiotics for prophylaxis against whooping cough – summary

There is insufficient evidence to determine the benefit of prophylactic treatment of pertussis contacts. Prophylaxis with antibiotics was significantly associated with side effects and did not significantly improve clinical symptoms, whoop, paroxysmal cough, number of cases who develop culture-positive B. pertussis or paroxysmal cough for more than two weeks in contacts older than six months of age. Due to the high risk of morbidity and mortality in infants less than six months of age who are incompletely immunized, contact prophylaxis is recommended for families who have an infant less than six months of age. The recommended antibiotics and dosages for contact prophylaxis are the same as those recommended in the treatment of whooping cough.

Additionally, the American CDC guidelines written in 2006 were reviewed more recently and not rewritten. They were published prior to the 2007 Cochrane Review.

 

References

Altunaiji SM, Kukuruzovic RH, Curtis NC, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004404. DOI: 10.1002/14651858.CD004404.pub3.

Chan MH et al. The California Pertussis Epidemic 2010: A Review of 986 Pediatric Case Reports From San Diego County J Ped Infect Dis (2012) 1 (1): 47-54 doi:10.1093/jpids/pis007 Accessed 24/06/2013.

Ditte MD, Dohn B, Madsen J, Jensen JS, Comparison of culture and PCR for detection of Bordetella pertussis and Bordetella parapertussis under routine laboratory conditions. J Med Microbiol August 2004 vol. 53 no. 8 749-754.

Faulkner A, Skoff T, Martin S, Cassiday P, Lucia Tondella M, Liang J, Ejigiri OG, Surveillance Manual, 5th Edition, 2011 Pertussis: Chapter 10-1. 8 July 2011. Accessed 09/07/2013.

Snyder, J & Fisher, Pertussis in Childhood. Pediatrics in Review Vol. 33 No. 9 September 1, 2012 pp. 412 -421 (doi: 10.1542/pir.33-9-412).

 

Testicular trouble

Cite this article as:
Andrew Tagg. Testicular trouble, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2728

Jaxxon, a 13-year-old boy, forgot to wear his box whilst at cricket training and a high-speed ball swings in just before the crease and hits him in the groin. He thought nothing of it because the pain disappeared after an hour. The next day it was back and worse than before so he stumped up the courage to tell his Dad.

Bottom Line

  • Testicular torsion is a true surgical emergency
  • Do not neglect the inguino-scrotal exam in the inconsolable infant
  • No part of the history or clinical exam can rule out torsion with 100% reliability
  • Doppler US can aid diagnosis in equivocal cases but if not immediately available should not prevent a trip to the OR

What is your differential diagnosis?

What is the incidence of testicular torsion and who is at risk?

Torsion occurs in 1 in 4000 men less than 25 years old. It has a bimodal distribution. 65% of cases occur during puberty due to hormone-induced changes in size.

10% of cases occur in boys under one year of age. Some of these torsions may have occurred before delivery!

An undescended testis is at increased risk of torsion as is a testicle subjected to trauma.
 

What is a bell-clapper deformity?

The tunica vaginalis extends over the epididymis and spermatic cord forming a cavity in which the testicle can hang and swing freely – like the clapper of a bell.

They have an increased risk of torsion.

12% of men have this deformity at post mortem.

What factors on history or examination may help you rule out torsion?

Nothing in the history can reliably let you rule out a torsion. The pain is often acute in onset and unremitting. It may wake the patient in the middle of the night and be associated with nausea and vomiting.

Pain due to trauma should settle within an hour or so.

They may also give a history of previous similar incidents when the testis has torted and detorted spontaneously.

The classical exam finding is of an exquisitely tender, high riding testicle with a horizontal lie though  secondary hydrocele may mask this.

What is Prehn’s sign?

This is the absence of the cremasteric reflex on the side of the affected testicle. It was once thought that if the cremasteric reflex was present then it could not be torsion. Unfortunately, a number of case reports have since refuted this. Relying on the presence of the reflex to rule out torsion will lead to trouble.

What about imaging to rule out torsion?

Ischemia and infarction of the testis may occur within 4 hours of torsion though one study has suggested a 90% salvage rate if operated on within 6 hours of onset.

Rates of success drop to 50% by 12 hours.

Time is testicle and if you have a high degree of clinical suspicion then the patient should go to the operating room (regardless of fasting state) for surgical exploration.

If the history is greater than 12 hours and there is some diagnostic doubt then two methods of imaging modalities may be considered.

Colour-flow doppler ultrasound has a quoted sensitivity of 88% and a specificity of 90% and may also be useful in making alternative diagnoses such as epididymo-orchitis, rupture, or bleeding. However, if the testicle has spontaneously detorted the resultant hyperaemia on ultrasound can be confused for epididymo-orchitis. Tc-99 scintigraphy is 100% sensitive but is not widely available.

Is there anything I can try whilst waiting for the surgeons?

You could try to externally detort the testis.  This does not negate the need for scrotal exploration but may buy you some time.

The key is good procedural sedation and the rotating the affected testicle as if you were opening the pages of a book.

What about a torsion of the appendix of the testicle?

The hydatid of Morgagni (one of five possible testicular appendages) is an embryological remnant of the Mullerian system found in the upper pole of the testis. As puberty hits raging hormones make this, and other appendages swell.  This makes them more likely to twist on their precarious blood supply.

The pain of a torted hydatid is supposed to be more insidious in onset and less intense. As it becomes more ischaemic it can be visible as a small blue dot on the testicle though this may be masked by a reactive hydrocele.

Treatment is conservative with supportive underwear and NSAID’s but the diagnosis can be hard to make and so exploration is often needed.

Given the greater than 24 hour history and the possibility of testicular rupture, a colour-flow Doppler was performed. This confirmed the presence of a large haematocoele and a non-viable testis. It was removed in the operating room later the same day.

Selected references on testicular torsion

Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006 Nov 15;74(10):1739-43. Review. Free full text

Cuckow PM, Frank JD. Torsion of the testis. BJU Int. 2000 Aug;86(3):349-53.

Mellick LB. Torsion of the testicle: it is time to stop tossing the dice.Pediatr Emerg Care. 2012 Jan;28(1):80-6. Free full text