This guideline provides evidence-based recommendations to manage diffuse acute otitis externa (AOE), defined as generalized inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The primary purpose is to promote appropriate use of oral and topical antimicrobials and to highlight the need for adequate pain relief.In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) selected a development group representing the fields of otolaryngology-head and neck surgery, pediatrics, family medicine, infectious disease, internal medicine, emergency medicine, and medical informatics. The guideline was created with the use of an explicit, a priori, evidence-based protocol.The group made a strong recommendation that management of AOE should include an assessment of pain, and the clinician should recommend analgesic treatment based on the severity of pain. The group made recommendations that clinicians should: 1) distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the ear canal; 2) assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); and 3) use topical preparations for initial therapy of diffuse, uncomplicated AOE; systemic antimicrobial therapy should not be used unless there is extension outside of the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The group made additional recommendations that: 4) the choice of topical antimicrobial therapy of diffuse AOE should be based on efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost; 5) clinicians should inform patients how to administer topical drops, and when the ear canal is obstructed, delivery of topical preparations should be enhanced by aural toilet, placing a wick, or both; 6) when the patient has a tympanostomy tube or known perforation of the tympanic membrane, the clinician should prescribe a nonototoxic topical preparation; and 7) if the patient fails to respond to the initial therapeutic option within 48 to 72 hours, the clinician should reassess the patient to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. And finally, the panel compiled a list of research needs based on limitations of the evidence reviewed.This clinical practice guideline is not intended as a sole source of guidance in evaluating patients with AOE. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to the diagnosis and management of this problem.This is the first, explicit, evidence-based clinical practice guideline on acute otitis externa, and the first clinical practice guideline produced independently by the AAO-HNSF.
Pharyngitis is one of the most common childhood diseases worldwide. We intended to compare the performance of one such rapid antigen detection test (RADT) using lateral flow immunoassay technique, between 3- to 10-year-old (children and preadolescent) and 11- to 21-year-old (adolescents).
A 55-year-old woman with melasma develops biopsy-proved exogenous ochronosis in the setting of prolonged topical hydroquinone use. A limited number of similar reports exist in the US literature and are the basis for an FDA call to review hydroquinone-based products. This case underscores the difficult therapeutic dilemma which this diagnosis presents to dermatologists.
Vomiting is a common adverse event after emergency department ketamine sedation in children. We sought to determine if the rate of vomiting is dose related to intravenous ketamine.Treating physicians administered intravenous ketamine to children requiring sedation for a procedure in a pediatric emergency department using doses of their discretion in this prospective observational study. We compared initial and total ketamine doses between children with and without vomiting directly and after controlling for age and coadministered drugs using multiple logistic regression analysis.A wide range of initial (0.2 to 2.4 mg/kg) and total (0.3 to 23.8 mg/kg) ketamine doses were administered in the 1039 sedations studied. Vomiting occurred in 74 (7%) overall. Initial and total ketamine dose distributions were similar in children with and without vomiting (medians 1.6 vs 1.6 mg/kg and 2.2 vs 2.1 mg/kg, respectively). Our multivariate analysis found no significant association between emesis and initial dose; however, it did reveal an association with total dose that was explained by a minority (3.5%) of children who received high cumulative doses (>7 mg/kg). The rate of emesis was 7.0% when the total ketamine dose was 7 mg/kg or less and 11.1% when greater than 7 mg/kg.Within a wide range of intravenous doses, ketamine-associated vomiting is not related to either the initial loading dose or the total dose--except for a modest increase for those receiving high cumulative doses (>7 mg/kg).
A dislodged gastrostomy tube (GT) is a common complaint that requires evaluation in the pediatric emergency department (ED) and, on occasion, will require stoma dilation to successfully replace the GT. The objective of this study was to describe the frequency that stoma dilation is required, the success rate of replacement, complications encountered, and the techniques used to confirm placement of the GT after dilation.We conducted a retrospective medical record review of children 0-18 years who presented to the pediatric ED from February 2013 through February 2015 with a dislodged GT that required stoma dilation by pediatric emergency physicians with serially increasing Foley catheter sizes prior to successful placement of the GT.We reviewed a total of 302 encounters in 215 patients, with 97 (32%) of the encounters requiring stoma dilation prior to replacing a GT. The median amount of dilation was 2 French between the initial Foley catheter size and the final GT size. There was a single complication of a mal-positioned balloon that was identified at the index visit. No delayed complications were encountered. We performed confirmation of placement in all patients. The two most common forms of confirmation were aspiration of gastric contents (56/97 [58%]) followed by contrast radiograph in 39 (40%).The practice of serial dilation of a gastrostomy stoma site to allow successful replacement of a gastrostomy tube in pediatric patients who present to the ED with a dislodged gastrostomy tube is generally successful and without increased complication. All patients received at least one form of confirmation for appropriate GT placement with the most common being aspiration of gastric contents.
