Sandbox:Amira Albawri

• Acut otitis media.
  • In general,approximately 80% of children have spontaneous relief of AOM within 2–14 days who absence of suspected complications it follow initial treatment of symptomatic (analgesia and antipyretics) as fever and ear pain.If severe,recurrent infections or persistent give antibioticor if there is complication may offer tympanostomy tubes.
  • If we use analgisic.
    • Oral acetaminophen and ibuprofen are commonly used to treat pain in children.
  • If we use antibiotics.
    • Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines.
    • Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin.
    • If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin.
    • Tympanocentesis use for drainage (theraby) and culture in difficult cases.
• Acute otitis externa.
  • American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or witout topical corticosteroids.
  • Oral antibiotics use for infection has spread beyond the ear canal.
• Otitis media with effusion.
  • Antibiotics, histamines or decongestants not effect at treatment.
  • In less sever case and without hearing problems the effusion can resolve spontaneously or with autoinflation.
  • In sever case or persistent symptomatic cases the treatment by tympanostomy with or without adenoidectomy.
• Tonsilitis
  • Treatment depends on to cause.
  • IF the cause is viral it is go by alone.
  • Antibiotics.
    • If the cause is group A streptococcus the first-line therapy antibiotics are useing is penicillin or amoxicillin .If there is alergic to pinicillin we can use a macrolide .If there is not response to penicillin therapy we can use clindamycin or amoxicillin-clavulanate .
  • Pain medication.
    • Paracetamol or ibuprofen.
  • Surgery.
    • Tonsillectomy . It is as a choice for treatment the chronic tonsillitis
• Ear wax
  • First-line treatmen is softening ear drops (oil or water).
  • Ear syringing.

.

Table

Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)

Subject	2004	2013	Rationale for 2013 Changes
Children <6 mo	Treat with antibiotic therapy	No recommendations
Diagnosis of AOM	Acute onset of signs and symptoms	Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa	2004 criteria allowed less precise diagnosis, provided treatment recommendation when diagnosis was uncertain.
	Presence of MEE	Mild bulging of TM and recentb onset ear painc or intense TM erythema
	Signs and symptoms of middle ear inflammationa	Must have MEE
Uncertain diagnosis	Expected and included in treatment guidelines	Excluded	Emphasized need for diagnosis of AOM for best management.
Initial observation option instead of initial antibiotic therapy	Option for observation: 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd ≥2 y: Option if nonsevered and certain diagnosis	Option for observation: 6 mo–2 y: Unilateral OM without otorrhea ≥2 y: Unilateral or bilateral AOM without otorrhea	Favorable natural history overall.
	Observation recommended: ≥2 y and uncertain diagnosis	Observation recommended: None	Evidence of small benefit of antibiotics in recent trials that used stringent diagnostic criteria.
Initial antibiotic therapy recommended	Antibiotics recommended: <6 mo: All cases 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severee illness ≥2 y: Certain diagnosis and severee illness	Antibiotics recommended: 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea ≥2 y: Otorrhea or severee illness	More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
	Antibiotics an option: 6 mo–2 y: Uncertain diagnosis and nonsevered illness ≥2 y: Certain diagnosis and nonsevered illness	Antibiotics an option: 6 mo–2 y: Unilateral without otorrhea ≥2 y: Bilateral without otorrhea or unilateral without otorrhea	Greater antibiotic benefit for bilateral disease, AOM with otorrhea.
			Two recent studies show small benefit of antibiotics for age 6–24 mo.
Recurrent AOM	No recommendations	Do not prescribe prophylactic antibiotics	Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects).
		May offer tympanostomy tubes	Modest reduction in AOM with tubes.

Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.

aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep’).

bRecent: <48 hours.

cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.

dNonsevere illness defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature less than 39°C.”

eSevere signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours.

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65

• Temporomandibular joint disorder (TMJ) PMID: 25822556

Condition	Management
Acute Otitis Media	mmmmmmmmmmmmmmmmm ,l,
Chronic Otitis Media
Acute Otitis externa
Malignant Otitis externa

common cold or upper respiratory tract infection..... PMID 21918146

Your otoscopic examination reveals that her left tympanic membrane looks redder and less reflective than her right one, but you do not see bulging, retraction, or fluid behind the eardrum. There is no perforation or discharge. Her face, mouth, and throat look normal. Your examination reveals no foreign body. There is no swelling in front of her ears; the mastoids, temporomandibular joints, and maxillary sinuses are not tender. Her cervical glands are normal in size and are not tender. Her teeth and mouth look normal, and you notice that during the examination Amy moves her neck freely.

cause

anatomic disorders of the nasopharynx such as cleft palate4 and Down syndrome.PMID: 2976173 PMID: 21918146

FIRE of ear pain

Ear pain

** Abnormal ear examination(otoscopy)

*primary otalgia)

** Normal ear examination(otoscopy)

*secondary otalgia

** imaging studies

IF Diagnosis is not clear from the history and physical examination.

FIRE of ear pain

** Abnormal ear examination(otoscopy)

*primary otalgia

*Otitis externa = A red and tender ear ,Hearing loss ,pruritus and oedema , discharge

*Otitis media= pain fever ,hearing loss,headache, anorexia, vomiting

** Normal ear examination(otoscopy)

*secondary otalgia

Complete Diagnostic Approch

Characterize the pain: PMID: 30572868

• Usually the parents use pain scales to detect pain in their young children .

• Ear-related symptoms: ear rubbing.

• Non-specific symptoms: fever, irritability, excessive crying, decreased activity, poor appetite and restless sleep .

• Respiratory symptoms: rhinitis, cough, hoarse voice, conjunctivitis, mucus vomiting and nasal congestion.

• Gastrointestinal symptoms: vomiting, and diarrhea.

History

• Enter into group child care and amounts of time spent.
• Exposure of smoking.
• Peroid of breastfeeding.
• swimming
• recurrent ear pain.
• Skills developmental delay like (language delay) due to hearing loss.

Examination

• Face ( lymph node, mastoids, temporomandibular joints, and maxillary sinuses ), mouth, and throat .
• Skin especially aroud the ear (mastoiditis)
• Myringotomy

It dose not do for children who have been diagnosed on the basis of assessment in the clinic.PMID: 14962529 / PMID: 24453496

• Tympanic membrane.

If the tympanic membrane is abnormal the most cause of it by primary otalgia.The primary otalgia include

• Acut otitis media.
  • Cloudy, bulging PMID: 22459064 erythema of the tympanic membrane. PMID: 24453496
  • Acute onset symptoms and signs fever, otalgia also see irritability, otorrhea, anorexia, and vomiting.
  • Usually affects children aged under 2 years,
• Otitis media with effusion.
  • Retracted/concave tympanic membrane with change colour of tympanic membrane (yellow,amber,blue) , and air–fluid levels. PMID: 24453496
  • Absence of signs and symptoms (asymptomatic).
  • Hearing loss.This is lead to speech delays.It is detected on screening of asymptomatic children. PMID: 27604644/ PMID: 24453496
  • Affects children between 3 and 7 years old

Treatment

• Acut otitis media.

Approximately 80% of children have spontaneous relief of AOM within 2–14 days.PMID: 24453496 Symptomatic management ( analgesia and antipyretics) like fever and ear pain.If severe,recurrent infections or persistent give antibiotic.

• otitis media with effusion

Table 2

Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)

Subject	2004	2013	Rationale for 2013 Changes
Children <6 mo	Treat with antibiotic therapy	No recommendations
Diagnosis of AOM	Acute onset of signs and symptoms	Moderate to severe bulging of TM, or new-onset otorrhea not owing to acute otitis externa	2004 criteria allowed less precise diagnosis, provided treatment recommendation when diagnosis was uncertain.
	Presence of MEE	Mild bulging of TM and recentb onset ear painc or intense TM erythema
	Signs and symptoms of middle ear inflammationa	Must have MEE
Uncertain diagnosis	Expected and included in treatment guidelines	Excluded	Emphasized need for diagnosis of AOM for best management.
Initial observation option instead of initial antibiotic therapy	Option for observation: 6 mo–2 y: Option if uncertain diagnosis and nonsevere illnessd ≥2 y: Option if nonsevered and certain diagnosis	Option for observation: 6 mo–2 y: Unilateral OM without otorrhea ≥2 y: Unilateral or bilateral AOM without otorrhea	Favorable natural history overall.
	Observation recommended: ≥2 y and uncertain diagnosis	Observation recommended: None	Evidence of small benefit of antibiotics in recent trials that used stringent diagnostic criteria.
Initial antibiotic therapy recommended	Antibiotics recommended: <6 mo: All cases 6 mo–2 y: Certain diagnosis, or uncertain diagnosis if severee illness ≥2 y: Certain diagnosis and severee illness	Antibiotics recommended: 6 mo–2 y: Otorrhea or severee illness or bilateral without otorrhea ≥2 y: Otorrhea or severee illness	More stringent diagnostic guidelines in 2013 should lead to greater antibiotic benefit.
	Antibiotics an option: 6 mo–2 y: Uncertain diagnosis and nonsevered illness ≥2 y: Certain diagnosis and nonsevered illness	Antibiotics an option: 6 mo–2 y: Unilateral without otorrhea ≥2 y: Bilateral without otorrhea or unilateral without otorrhea	Greater antibiotic benefit for bilateral disease, AOM with otorrhea.
			Two recent studies show small benefit of antibiotics for age 6–24 mo.
Recurrent AOM	No recommendations	Do not prescribe prophylactic antibiotics	Minimal benefit for prophylaxis and antibiotics come with risks (antibiotic resistance and adverse effects).
		May offer tympanostomy tubes	Modest reduction in AOM with tubes.

Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.

aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (‘discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep’).

bRecent: <48 hours.

cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.

dNonsevere illness defined as mild otalgia and fever <39°C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to “mild otalgia for less than 48 hours and temperature less than 39°C.”

eSevere signs or symptoms include moderate or severe otalgia or temperature ≥39°C in 2004 guideline; the 2013 guideline also includes otalgia for ≥48 hours.

Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–99; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):1451–65.

table

table

table

cause

• Genetics
  • BACA
    • brca1
    • brca2
• family

First related

Treat the underlying causes

Fatigue due to heart failure : ❑Diuretics ❑Vasodilator Therapy ❑Inotropic Therapy ❑Vasopressor Support ❑ACE Inhibition ❑Beta Blockers ❑Aldosterone Antagonism ❑Morphin

{{{ C02 }}}

{{{ C03 }}}

{{{ C04 }}}

{{{ C05 }}}

{{{ C06 }}}

{{{ C07 }}}

Box 2 in Row 2

Box 3 in Row 3

Box 4 in Row 4

amira

amira

lolah

Treat the underlying causes

Fatigue due to Acut otitis media ❑In general,approximately 80% of children have spontaneous relief of AOM within 2–14 days who absence of suspected complications it follow initial treatment of symptomatic (analgesia and antipyretics) as fever and ear pain.If severe,recurrent infections or persistent give antibioticor if there is complication may offer tympanostomy tubes. ❑If we use analgisicOral acetaminophen and ibuprofen are commonly used to treat pain in children. ❑ If we use antibiotics. Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines. Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin. If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin. Tympanocentesis use for drainage (theraby) and culture in difficult cases

Fatigue due toAcute otitis externa ❑American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or witout topical corticosteroids. ❑Oral antibiotics use for infection has spread beyond the ear canal.

Fatigue due to Otitis media with effusion. ❑Antibiotics, histamines or decongestants not effect at treatment ❑In less sever case and without hearing problems the effusion can resolve spontaneously or with autoinflation ❑In sever case or persistent symptomatic cases the treatment by tympanostomy with or without adenoidectomy.

Fatigue due to Tonsilitis ❑Treatment depends on to cause. ❑IF the cause is viral it is go by alone. ❑Antibiotics. If the cause is group A streptococcus the first-line therapy antibiotics are useing is penicillin or amoxicillin .If there is alergic to pinicillin we can use a macrolide .If there is not response to penicillin therapy we can use clindamycin or amoxicillin-clavulanate . ❑Pain medication. ❑Surgery. Tonsillectomy . It is as a choice for treatment the chronic tonsillitis

Fatigue due to Ear wax ❑First-line treatmen is softening ear drops (oil or water). ❑Ear syringing.