Infections in
ENT Field
Summarized by Kyung Shik Suh, M.D.
from Current Issues in
ENT Infectious Disease
editor Geroge A Gates, MD
Ann Otol Rhinol Laryngol 101:1992 Suppl
Antimicrobial use in
ORL infections: General considerations
Gerald Medof, MD
Antimicrobials-on the basis of therapeutic
efficacy, toxicity, and cost
1.restricted - can be obtained only with the control of
infectious disease
specialist
2.controlled - automatic 72-hour stop order
3.nonrestricted(unrestricted)
· unrestricted drugs
1.Cephalosporins
cefazolin sodium
2.Penicillins
ampicillin
amoxicillin
oxacillin sodium
carbenicillin indanyl sodium(oral)
3. Aminoglycosides
gentamycin sulfate
4. Miscellaneous
clindamycin hydrochloride(oral)
metronidazole
· Formulary restrictions, when
combined with strict enforcement
and
physician education, can achieve significant cost savings
with no negative effect on patient care.
Diagnosis and
management of anaerobic infections of the head and neck
Itzhak Brook, MD, MSc
Pathogenic anaerobes
Bacteroides group (Bacteroides melanogenicus and Bacteroides
oralis)
Peptostreptococcus species
Fusobacterium species
· Otitis media
AOM
90% of the cases - bacteria isolated
Peptostreptococcus sp. - 1/4
Mixed with aerobes and facultative bacteria - 1/3
anaerobes respond to penicillins well
OME
40% of the cases - bacteria isolated
anaerobes 17% of culture +
26% - mixed
most Peptostreptococcus and B melanogenicus
COM with mastoiditis
about 50 % of the cases
Bacteroides, Peptostreptococcus, and Fusobacterium
most produce beta-lactamase
· Chronic sinusitis
10% of the cases with acute sinusitis
2/3 of the cases with chronic sinusitis
inflammation --> reduced O2 tension --> anaerobic
growth
surgical drainage after 48 hr antimicrobial
therapy
· Pharyngotonsillitis
GABHS -group A beta hemolytic streptococcus
anaerobes mixed - 74% of GABHS group
- 40% of non-GABHS group
BLPB- beta lactamase producing bacteria: Hemophilus sp, S aureus,
Moraxella catarrhalis and Bacteroides
Penicillin failure - due to BLPB, degrading penicillin
· Head and neck abscess
aerobes - 67%
anaerobes - 19%
mixed - 14%
· Acute suppurative parotitis
anaerobes only - 43%
aerobes and facultative - 43%
mixed - 13%
Antibiotic prophylaxis in clean-contaminated head and neck
surgery
Randal S Weber, MD David L Callender, MD
· the drug should be given parenterally in adequate doses before
wound contamination occurs
· use of antibiotics beyond 24 to 48 hr postoperatively does not
appear to decrease the risk of infection and increases the risk
of superinfection with resistant organisms
Otitis media update:
pathogenesis and treatment
G Scott Giebink, MD
· Otitis media continuum
OME commonly follows AOM and that intractable COM usually follows
recurrent AOM and chronic OME
- these epidemiological clues suggest that the various
types of OM represents part of continuum of a single
disease process
OM continuum is illustrated by the overlap in types of
effusion
AOM -- 2 wk -- 40 -70% not
cleared
2 mo (8 wk)-- 20% still
OME
High risk group - bilateral disease
day-care
attendance
effusion present for at least 4 wk before the presenting
AOM episode -----> 80% still OME at 8 wk after AOM
episode
· OM and viral infection
RS, adeno, and influenza A and B viruses
· OM and bacterial infection
antimicrobial therapy
__________________________________________________
amoxicillin
amoxicillin-clavulanate potassium = Augmentin
cefaclor = Ceclor
erythromycin ethylsuccinate-sulfisoxazole acetyl = Pediazole
trimethoprim-sulfamethoxazole= Bactrim, Septra
cefuroxime axetyl = Ceftin
cefixime = Suprax
_________________________________________________
· Augmentin vs Ceclor
1. no difference in the symptomatic relief in 3-6 days of
treatment
2. difference in antibacterial efficacies
3% failure rate in Augmentin
25% failure rate in Ceclor
3. impaired distribution of antimicrobial drugs into the middle
ear and resulting subtherapeutic concentration of the
antimicrobials explain AOM bacteriologic Tx failure
· Clinical failure after 3 to 5 days of antimicrobial Tx should
not necessarily be assumed to indicate infection with a resistant
organism: instead, it may suggest failure of the drug to reach
effective concentrations in the middle ear.
· Aspiration of middle ear fluid, a simple office procedure, is
important in bacteriologic assessment of children who fail to
improve.
Adenoidectomy and
otitis media
George A Gates, MD, Harlan R
Muntz, MD, Brendan Gaylis, MD
· Adenoidectomy
Efficacy
2 different theories
1. Roydhouse, Fiellau-Nikolajsen et al, and Widemar et al - no
effect on OM
2. Maw, Gates et al, and Paradise et al - significant effect on
OM
e.g. Gates et al
2-yr. follow-up
the reduction in morbidity with time spent with recurrent
effusion was
29% with TT only
38% with adenoidectomy and myringotomy
47% with adenoidectomy and TT
the evidence supports the conclusion that adenoidectomy does not
modify the natural history of chronic secretory otitis media in
severely affected children of 4 years of age and older
a decision to use adenoidectomy in children in whom other forms
of therapy have failed must take into account whether the
magnitude of the effect is great enough to be clinically
significant
Indications
· 1st consideration
evidence of efficacy is necessary but not sufficient
condition for establishing the indication for a surgical
procedure
adenoid size does not appear to be the factor
submucous cleft palate- in the past surgery excluded the
risks and costs of the surgery must be balanced against its
benefits
tonsillectomy does not appear offer any benefit
controversy for indication
1. duration of ME effusion
2. whether persistent effusion
Gates et al - even mild conductive hearing loss is a risk
factor for impaired development so, indication for the
adenoidectomy
· 2nd consideration
after a decision to operate,
2nd decision regarding tube insertion vs adenoidectomy with or
without tube insertion is necessary
Gates et al - surgical removal of middle ear effusion,
adenoidectomy, and, in most instances, tympanostomy tube
placement for children with effusion and hearing loss persisting
more than 90 days despite adequate antimicrobial therapy
Adenoidectomy should be considered in the primary surgical
Tx of older children(4>) with chronic OM with effusion when
medical therapy has failed and prolonged observation confirms the
persistence of effusion and hearing loss.
The role of adenoidectomy in younger children is still
under study.
The effectiveness of adenoidectomy in prevention of AOM has
not been established.
Antimicrobial
prophylaxis for recurrent acute otitis media
Jack L Paradise, MD
Rationale
1. prevention of discomfort
2. prevention of conductive hearing loss
3. costs of physician visits and drug therapy.
4. lost time of both parents and children
5. anxiety of parents
6. avoidance of long term sequele of OME and surgical
procedures
Methods
1. polyvalent pneumococcal vaccine
2. surgical procedures- myringotomy c/s adenoidectomy c/s
TT
3. antimicrobial prophylaxis
Caution concerning sulfonamides
1. sulfonamides - toxic effects
2. TMP-SMX - long term use is not recommended
3. sulfisoxazole = Ganstrinâ - no limitation now, but lack
of supporting evidence
Remaining questions
unanswered questions:
1. which drug ?
2. at what dosage?
3. appearance of new resistance strains after prophylaxis?
4. if then, the risk of spread of these resistant strains to
other children?
Current recommendations
Ix - children with recurrent
AOM
= 3 episodes of AOM during preceding 6 mo
or 4
episodes --------------------- 12 mo
Drug - Amoxicillin 1. safe 2. low
cost
Sulfisoxazole - if allergic to penicillin
Duration - 1. a matter of judgment
2. until the beginning of following summer season
so a children who had episodes of AOM in summer season,
medication is continued about 1 yr.
Sinusitis in infants
and children
Ellen R Wald, MD
· Acute sinusitis
40%- spontaneous recovery
antimicrobial agents
1. Amoxicillin: 40mg/kg/day # 3
2. Erythromycin ethylsuccinate and sulfisoxazole acetyl:
50mg/kg,150mg/kg/day # 4
3. TMP-SMX: 8mg/Kg, 40mg/Kg/day #2
4. Cefaclor: 40mg/kg/day #3
5. Amoxicillin and clavulanate potassium:
40mg/kg, 10mg/kg/day #3
6. Cefixime: 8mg/kg/day #1
duration - 10-14 days
antihistamines and decongestants
effect not fully studied
topical vasoconstrictors- somewhat aids on ostial-drainage
antihistamine causes ciliostasis - delays ciliary clearance
irrigation and drainage
dramatic relief of Sx
oxygenation
flow improvement
local immunoglobulin and complement levels up after irrigation
proteolytic enzymes decrease
Surgical management of
sinus disease in children
Scott C Manning, MD
1. 7-10 days course antibiotic medication
2. refractory cases : 3-4 wk course of broad spectrum
antibiotics
effective against beta-lactamase-producing H influenzae
3. prophylactic therapy : once-a-day prophylactic antibiotics for
6 wks
4. nasal saline irrigation : twice-a-day
5. antihistamine and decongestant : useful in acute
congestion
· long-term using results mucosal drying and impairment of
mucociliary defense mechanism
Indications for surgery
· no agreed indication of surgery for child sinusitis
the average child has 6 to 8 episodes of viral URIs/yr.
if Sx and signs persists beyond 10 days, a sinusitis is
suspected
1. orbital complication occurs
2.underlying health-threatening conditions such as asthma, cystic
fibrosis and immunodeficiencies
3. when definite areas of anatomic obstructions which are
definite cause of disease
· True chronic disease is, by definition, less likely in younger
children.
Etiology and Management of pharyngitis
and pharyngotonsilltis in children: A current review
Jack L Paradise, MD
Tonsillectomy Ix
for recurrent tonsillitis
7 episodes per 1 yr.
5 episodes per 2 yrs
3 episodes per 3 yrs
Current indications for tonsillectomy and
adenoidectomy
Charles D Bluestone, MD
· Tonsillectomy
definite Ix
1. obstructive tonsils and adenoid that are unresponsive to
antimicrobial therapy
2. high suspicion of malignancy
3. persistent or recurrent of tonsillar hemorrhage
elective Ix
1. fetor oris( or absolute Ix?)
2. frequent acute tonsillitis
3. chronic tonsillitis
4. obstructive tonsils
5. peritonsillar abscess
* effect of tonsillectomy for recurrent acute episodes of
tonsillitis
1st yr. 1.24: 3.09
2nd yr. 1.61:2.66
3rd yr. 1.77:2.20 - statistically no
significance
· Adenoidectomy c/s myringotomy and/or TT(tympanostomy tube)
insertion
elective Ix
1. obstructive adenoids
2. recurrent or chronic adenoiditis
3. recurrent or chronic sinusitis
4. prevention of recurrent or chronic OM
· obstructive adenoids
a. at Children's Hospital of Pittsburgh, Paradise et al - under
study for the effectiveness
b. moderate and severe nasal obstruction, 2ndary to obstructive
adenoids, adenoidectomy should reduce morbidity, including mouth
breathing, snoring, and hyponasality
c. in the absence of sleep apnea, or alveolar hypoventilation
resulting in cor pulmonale, however, the operation still remains
of uncertain benefit.
d. the quality of life: 1. improvement of nasal airway
2. improvement of olfaction
3. help prevent dento-facial morphology
4. correct hyponasal speech
5. some parents and clinician believe that growth and
development improves possibly as a result of improved
olfaction
· paranasal sinusitis
1. the benefit of adenoidectomy for children with
frequently recurrent acute or chronic sinusitis remains
uncertain
2. there has been no randomized study
3. a improved nasal airway passage should be considered
· otitis media
1. OM - most common
diagnosis made by pediatric physicians
2. from birth to 7 yrs
of age, Teele et al
1st yr. of life: OM mean attack -
1.2 times/yr.
17% of children: 3 or more episodes in the 1st yr.
following 6 yrs: 75% of children had at least 1 episode
3. adenoidectomy and TT is
more effective than no surgery in preventing recurrent acute
OM, Gebhart and Gonzales et al
4. efficacy of tubes over no
tubes
5. antimicrobial prophylaxis
is effective against recurrent acute OM, Maynard et al and Perrin
et al
6. TT is superior to
Myringotomy or no surgery, Mandel et al
7. Maw, 1983, Bristol,
England, for 103 children, randomized study
chronic OM
with effusion, unfortunately not given antibiotics
before
randomized study
--->
adenoidectomy is more effective than no surgery
tonsillectomy: no effect
8. Gates et al, N Engl J Med
, 1987,317:1445-51
for 578, 4
to 8 yr.-old Texas children, 2/3 = Mexican-Americans
chronic
middle ear effusion who failed to respond to antibiotics
--->
adenoidectomy and myringotomy c/s TT was
more effective than myringotomy alone c/s TT
*still debates about when the initial
operation is performed,
myringotomy and adenoidectomy vs TT and
adenoidectomy
9. Paradise et al, JAMA
1990:263:2066-73
for 99 children
with previous tube insertion and recurrent OM
after pontaneous tube
extrusion= at risk group, Pittsburg Children's
Hospital
---> adenoidectomy
was effective over 2 years
the effect was greater
for middle ear effusion than recurrent OM
10. Bluestone's
approaches
* decision for or against
surgical intervention should be individualized
a. frequency,
duration, and severity of OM including HL
b. whether appropriate
and adequate medical Tx was provided
c. age
d. anesthetic
risks
e. time of year, eg.
summer - not suitable for children wants swim
f. other Ix for
surgery on ear or pharynx
g. whether a patient
is from high risk group for chronic ear disease
e.g.
Down's SD, cleft palate
h. whether a patient
may benefit more from timely tube insertion or from
wait-and-see
The symposium 'Current
Issues in ENT Infectious Disease' was held March 16-17, 1990,
Orlando, Florida