Team DFTB. Eric Levi: The wonderful world of ENT at DFTB17, Don't Forget the Bubbles, 2018. Available at:
This talk was recorded live on the first day at DFTB17 in Brisbane.
Krystal is seven going on seventeen and is brought in by her mother because she is unable to take her earrings out. She had her ears pierced a week ago..
Most high street piercers (as opposed to specialty piercing/tattooists) use a gun that fires a blunt stud through the lobe. This is then attached to a butterfly to keep the earring in place. Professional piercers use a hollow needle to form a track for the stud.
Early infection is common especially in children who may not be as fastidious as teenagers with hygiene. Lobe piercings may become infected leading to oedema and swelling around the retaining butterfly. Higher piercings through the cartilage are at risk from perichondritis. Both may lead to later piercing-related keloid formation.
Nickel alloy piercings can lead to contact dermatitis.
A piercing is also a great handle for bullies to grab and rip out.
The technique is essentially the same no matter what the age. The challenge is providing adequate pain relief and/or sedation to an inflamed ear. Younger children respond well to topical EMLA with adjunctive nitrous, whereas older children may need only need some EMLA and ice. Very occasionally true procedural sedation is required.
Using sterile technique identify the point where the back of the butterfly is nearest the surface of the skin on the back of the lobe and make a small nick. Then push on the front of the lobe to expose the butterfly, like shelling a pea. You should then be able to remove the backing without difficulty. There may be a small amount of bleeding that can be covered with a sticking plaster.
Thanks to @babydocmacski for this suggestion
High piercings can lead to infection of the cartilage and overlying soft tissue with possible disfiguring abscess formation. The commonest organisms involved are Pseudomonas and Staph. aureus.
They may require IV anti-pseudomonal antibiotics (such as piperacillin/tazobactam) as well as the removal of the foreign body.
She should wait until the wound has healed and choose an alternative site, ideally done by a professional piercer and be meticulous when it comes to hygiene.
Krystal screams when you try to remove the butterfly under nitrous so you elect to perform procedural sedation using intravenous ketamine and EMLA. Whilst adequately sedated and no longer wriggling, you manage to pop the butterfly out without further fuss.
Fijałkowska M, Pisera P, Kasielska A, Antoszewski B. Should we say NO to body piercing in children? Complications after ear piercing in children. Int J Dermatol. 2011 Apr;50(4):467-9
Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care. 2008 Jan;24(1):31-3
A 2-year-old presents to ED with pyrexia – he’s pulling at his ear constantly in the waiting room. You know where this heading, but are you supposed to treat him with antibiotics or not?
Do you know the difference between acute otitis media (AOM) and otitis media with effusion ?
Otitis media is a general term that has been used to describe multiple disorders of middle ear inflammation
Acute otitis media (AOM)
Otitis media with effusion (OME)
Chronic otitis media (COM)
Establishing the diagnosis is important as antibiotic treatment is not recommended for OME
The definition of acute otitis media requires three equally important components, which must all be present.
There is considerable overlap between presenting signs and symptoms of upper respiratory illnesses and acute otitis media, especially in the preverbal child.
The peak incidence of otitis media is between 6 and 18 months of age. Neonatal acute otitis media is uncommon. Most effusions of the middle ear in this age are sterile and develop in the in utero environment.
Environmental insults, such as tobacco smoke, lack of breastfeeding, and exposure to children in daycare who frequently receive antibiotics, may lead to episodes that would not otherwise occur.
Prevention of the disease burden is possible through the use of newer vaccines such as the contemporary pneumococcal vaccine that includes protection from seven serotypes of Streptococcus pneumoniae.
Bacteria from the nasopharynx are the most common cause of acute otitis media and can be isolated from middle ear fluid in a majority of cases. The most common pathogens in the post-pneumococcal vaccine era are:
Neonates may be affected by gram negative organisms and Staph aureus.
The role of viruses is unclear.
These data were obtained in the post-pneumococcal vaccine era and represent a change from before this vaccination program was initiated. Of importance is a major change in the increased prevalence of β-lactamase organisms such as M. catarrhalis (almost 100%) and non-typeable H. influenzae (35% to 40%).
OME usually follows an episode of acute otitis media, and both are processes of the same disease continuum. OME may persist for weeks to months after an episode of acute otitis media.
Close to 90% of episodes of OME resolve spontaneously after an acute otitis media episode is diagnosed.
Guidelines recommend watchful waiting without the immediate use of antibiotics for children with uncomplicated otitis media with effusion.
Children with permanent hearing loss, craniofacial anomalies, or underlying speech delays may receive immediate antibiotics or have close outpatient follow-up by the primary care clinician.
Consensus guidelines strongly recommend the treatment of pain associated with acute otitis media.
Prescribing only an antibiotic for the treatment of acute otitis media is inappropriate care, as antibiotics are not analgesic medications.
The primary systemic analgesics and antipyretics used to treat acute otitis media are ibuprofen and paracetamol. In one randomized trial comparing ibuprofen, acetaminophen, and placebo, only ibuprofen was found to be superior to placebo.
Opioid medications may be used at night during the sleeping hours, although no studies have demonstrated the effectiveness of this medication class for the treatment of acute otitis media.
High-dose amoxicillin, 80 to 90 mg/kg PO per day divided into two daily doses for 5 to 7 days, is the first-line recommended antibiotic for the treatment of uncomplicated acute otitis media.
The higher dose achieves concentrations in the middle ear that exceed the minimum inhibitory concentration for highly resistant forms of S. pneumoniae, the most common bacteria found in acute otitis media.
M. catarrhalis and non-typeable H. influenzae, although the addition of clavulanic acid increases the likelihood of vomiting and diarrhoea.
IM ceftriaxone for three daily doses may be considered if children cannot tolerate oral medications. Children with a known allergy to the penicillin class may consider the use of a macrolide agent, such as azithromycin.
A 10-day course of antimicrobials has been recommended for decades without any evidence to support an exact duration of therapy. Shortened treatment regimens (5 to 7 days) may reduce resistance to antibiotics and reduce side effects by decreasing total drug exposure.
Two randomized double-blinded placebo-controlled trials of young children diagnosed with AOM
Hoberman et al, University of Pittsburgh
Tahtinen et al, Turku University Hospital in Turku, Finland
In children between 6 months and 2 years of age with certain AOM, the use of antibiotics result in faster recovery and less treatment failure (reduced by 42-62% in the severe group)
Although a majority of patients receiving placebo also recovered spontaneously (53% in Hoberman et al, 55% in Tahtinen et al.), a physician cannot predict at the onset of illness which patients will improve without antibiotics.
Even in patients with non-severe illness, antibiotics were associated with a decrease rate of treatment failure.
Age 6 months onwards with uncertain diagnosis and follow up assured observation without antibiotics is an option for mild illness (no systemic features) with re-evaluation at 48 hours & antibiotics if no improvement
As in the photo below, there can still be a perforation that does not heal within a few weeks. This is considered to be a ‘natural myringotomy’ and usually heals well. Only GP follow-up is needed.
The facial nerve descends over the posterior wall (mastoid) of the middle ear and can be affected by OM
The infection can extend into the mastoid (posterior to the middle ear). It can cause bone destruction, brain abscess, meningitis, VI and VII nerve palsies, lateral venous sinus thrombosis. It is very unlikely if the ear exam is normal as it is linked to OM.
A CT is advised along for IV antibiotics (usually ampicillin)
Cystic cholesterol lesions are linked to chronic OM and can erode local structures.
Bacteraemia occurs in 3%.
Conductive deafness can follow a persistent effusion.
Fever and ear pain should be expected for 24 to 48 hours after an ED evaluation. If symptoms persist 72 hours after antibiotic therapy has been initiated, reevaluation is needed. Routine, scheduled visits are not recommended for uncomplicated acute otitis media if symptoms have resolved.
Improvement should be evident by 2-3 days. Treatment failure may indicate incorrect diagnosis, development of a complication or presence of a resistant organism. If the initial treatment was amoxicillin, change to amoxicillin/clavulanate.
All children should be reviewed by the local doctor at 2 weeks for the presence of a persistent effusion (glue ear) or healing of the tympanic membrane (if ruptured).
ENT consultation is advised for children with persistent hearing loss or speech delay, chronic effusion for more than 3 months, frequent episodes of otitis media or underlying pathologies such as cleft palate or adenoidal hypertrophy.
Hawke Library – otitis media guide