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easeofdosing.IftheIOPdecreaseswithaprostaglandinbutfailstoreachthetargetIOP,anadditional
medicationfromadifferentclass(suchasabetablocker)shouldbeadded.
TABLE16.8
RecommendedOrderofTreatmentforGlaucoma
Order Agent Comments
First
line
Prostaglandinophthalmicsolution(bimatoprost,latanoprost,
tafluprost,ortravoprost)
Second
line
Substitutionofanophthalmicbetablocker(iffailureto
decreaseIOPtoasignificantextent)
or
Additionofanophthalmicbetablocker(ifIOPissignificantly
decreasedbutnottogoal)
Third
line
Additionofanophthalmiccarbonicanhydraseinhibitoror
additionofbrimonidine
Dorzolamideisavailableinacombination
productwithtimolol.
Third-LineTherapy
If a patient fails to reach the target IOP with the first-line and second-line therapies, a topical CAI
(usuallythefixedcombinationof timolol and dorzolamide to keep the dosing regimensimple) canbe
added.Ifthisfails,dorzolamideshouldbediscontinuedinfavorofbrimonidine.
MonitoringPatientResponse
PatientswithPOAGshouldreceivefollow-upevaluationsandcare fromtheireyecare professionalto
determinetheeffectivenessoftherapy.Inadditiontoarecenthistory,aphysicalexaminationincludinga
slit-lamp biomicroscopy and tests of visual acuity and IOP in each eye should be performed (AAO,
2020).ThepractitionermustdistinguishbetweentheimpactofaprescribedagentonIOPandordinary
backgroundfluctuationsofIOP.
PatientEducation
Patientsshould washtheir handsbeforeadministeringglaucoma medications.Patientsshouldbetaught
howtoapplythemedicationintheinneraspectofthelowereyelid.Thetipofthecontainershouldnot
touchtheeyelashesor anypartoftheeyebecausethismaycontaminatethemedication.Contactlenses
should be removed prior to administration, and patients should separate administration of different
glaucomamedicationsbyatleast10minutes.
CASESTUDY1
V.S.isa15-year-oldwhitefemalewhopresentswithafeelingthatthereissandinhereye.Shehada
coldoneweekago,whichrecentlyresolved.HermotherreportsthatV.S.wokeupthismorningwith
herlefteyelidcrustedwithyellowishdrainage.Onphysicalexamination,V.S.hasswollenconjunctiva
onherleftside,noadenopathy,andnovisionchanges.Hervisioniscorrectedto20/20withcontact
lenses, butshe was unable to insertthem this morningand is wearingglasses instead. Fluorescein
stainingrevealsnoabrasion.Sheisafebrile.Sheisallergictosulfonamides(LearningObjective2).
1.WhatisthemostlikelydiagnosisforV.S.?
Answer:V.S.ismostlikelysufferingfrombacterialconjunctivitis.Viralconjunctivitisisunlikely
duetothetypeofdischarge(viralconjunctivitisisassociatedwithwaterydischarge),andallergic
conjunctivitiscanberuledoutbecausethesymptomswereonlypresentinoneeye.
2.ListspecificgoalsoftreatmentforV.S.
Answer:Thegoalsoftherapyaretoeradicatethecausativeorganism,torelievepatientsymptoms,
andtoquickentheresolutionofthediseasebeforeitcanspreadtoothers.
3.Whatdrugtherapywouldyouprescribe?Why?
Answer: Five to seven days of therapy with erythromycin ointment or bacitracin–polymixin B
ointmentwouldbe appropriate.Ifthereisadesiretoutilizea solution,anewerfluoroquinolone
(suchasgatifloxacinorlevofloxacin)ortobramycinwouldbeappropriate.
4.DiscusstheeducationyouwouldgivetoV.S.’sparentsregardingtreatingthiscondition.
Answer: InstructV.S.’s mother to ensure thatV.S. andothers inthehousehold washtheir hands
carefullytopreventspreadinginfectionasorganismsinbacterialconjunctivitisremainactive(and
contagious)for24 to48 hoursaftertherapybegins.V.S. andher mother shouldbe taughthow to
apply the medication in the inner aspect of the lower eyelid. Inform them that the tip of the
medicationcontainershouldnottouchtheeyelashesasitmaycontaminatethemedicationandresult
intherapyfailureorreinfection.Whilehereyelidsremaincrusted,theyshouldbegentlycleansed
before instilling medication. V.S. should refrain from wearing contact lenses until she has
completedtreatmentandthesymptomshaveresolved.
CASESTUDY2
P.B. isa 71-year-oldretiredwhitemalewhocomplainsthat,over thepast6 months,his eyeshave
beenfeelingincreasinglydryandhehasbecomemoresensitivetobrightlightsandmiddaysunshine.
Uponquestioning,hereportsthathealsothinkshehasbeenblinkingmorefrequentlyoverthepast6
months.Hehaslimitedmobilityinhisleftlegduetoastroke10yearsagoandspendsmuchofhistime
indoorsinhisair-conditionedtownhouse,watchingcablenewsandreading.Hequitsmoking15years
ago,havingpreviouslysmokedhalfapackofcigarettesperdayfor40yearspriortoquitting;hiswife
continuestosmokebuthasbeencuttingbackrecentlyandisdownto5cigarettesperday.P.B.takes
gabapentintomanageneuropathicpainstemmingfromthestroke,metoprololandhydrochlorothiazide
forhypertension,metforminfortype2diabetes,andzaleplonforinsomnia.Hehasanegativehistoryof
autoimmunedisordersorsystemicviralinfections.YouinformP.B.thatheisexhibitingthesymptoms
ofdryeyedisease(LearningObjective3).
1.WhatfactorscanbecontributingtothedryeyediseasesymptomsP.B.isexperiencing?
Answer:TheonlyphysicalattributethatP.B.has,whichcouldbecontributingtohisdeveloping
dry eye disease symptoms, is his advanced age. P.B. is taking medications (the beta blocker
metoprolol and the diuretic hydrochlorothiazide) that could exacerbate dry eye symptoms.
Environmental exposureto secondhandsmoke, air-conditioning drafts,orbeing ina setting with
reducedhumidity(duetotheair-conditioning)canalsoexacerbatehissymptoms.
2.WhatnonpharmacologicinterventionsshouldyourecommendforP.B.?
Answer:P.B.shouldbeadvisedtoreducehistimespentreadingandwatchingtelevisionandto
schedule regular breaks from those activities; when reading, he can be advised to lower the
positionofthebook,whichcanreducehiseyelidapertureandhelpminimizeevaporativetearloss.
He should avoid drafts from his air conditioner and minimize exposure to secondhand tobacco
smoke.Lastly, he should be instructedto speak tohis primary careprovider to determineifhis
hypertensionregimencouldbechangedtootherclassesofmedicationsthatarenotassociatedwith
exacerbatingdryeyesymptoms.
3. P.B. returns to your practice 6 weeks later, and the nonpharmacologic interventions you made
previouslyonlyledtoaslightimprovementofhisdryeyesymptoms.Youdecidetoinitiatetherapy.
WhattherapywouldyoustartP.B.on?Why?
Answer: P.B. continues to exhibit symptoms of mild dry eye disease and should be started on
artificialtearsadministered four timesaday.Ifamenable,P.B.canalso be started onanocular
lubricantadministeredatbedtime.
4.HowwouldyoucounselP.B.onhisnewtherapy?
Answer:P.B.shouldbeadvisedthatdryeyediseaseischronic.IfP.B.increasestheadministration
of artificial tears more than four times a day, he should utilize preservative-free artificial tear
products.
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17
OtitisMediaandOtitisExterna
LauraL.Bio
LearningObjective
1. Compare andcontrastthe clinical presentations of acute otitis media (AOM) and otitis externa
(OE).
2.AscertainthenecessityforantibiotictherapybasedonthepresentationofapatientwithAOM.
3.DetermineappropriatemanagementstrategiesforAOMandOE.
INTRODUCTION
Infectionsoftheearareacommonprobleminchildrenduetoanatomicalpredisposition,butadultsare
susceptibletoearinfectionsaswell.Themostcommoninfectionsorinflammatoryconditionsoftheear
includeacuteotitismedia(AOM),otitismediawitheffusion(OME),andotitisexterna(OE;alsoknown
asswimmer’searor tropicalear). Although antibiotics andvaccinationprograms have decreased the
frequencyofthese typesofinfections,identification,diagnosis,andmanagementofthese infectionsare
essential to preventcomplicationssuchas permanenthearingloss, chronic orrecurrentearinfections,
mastoiditis,meningitis,andspeechorlanguagedelay.
OTITISMEDIAANDOTITISEXTERNA
Otitis media(OM)continuestoimpactantibiotic expendituresasthemostcommoninfectionforwhich
antibiotics areprescribed inchildren.However,notallcases of OMrequire antibiotic treatmentasit
dependsonthepresentationasAOMorchronicOME(Lieberthaletal.,2013).Despitethestringent2013
AmericanAcademyofPediatrics(AAP)AOM
guidelines,therateofantibioticprescribingforAOMhasremainedconstant;however,adownwardtrend
intheratesofAOMepisodes hasbeenobserved,resultinginreduceddirectmedical expendituresfor
AOM (Suaya et al., 2018). Judicious antibiotic prescribing for upper respiratory infections (URIs),
includingOM,isrequiredtoreducetheriskofantibioticresistanceandadverseeffects.
AOMisdefinedasanacuteonsetofsignsandsymptomsofamiddleearinfectionandinflammation,
suchasmiddleeareffusion(MEE)anderythema,respectively(Table17.1). AOMisthemostcommon
bacterialURIinchildrenandpredominantlyaffectsinfantsandchildrenaged6monthsto2years.AOM
posesamajorsocialandeconomicburden,occurringatanalarmingrateof709millioncasesworldwide
each year, with 51% of these occurring in children under 5 years of age (Monasta et al., 2012). In
contrast,OMEischaracterizedbyMEEwithoutfeverorotalgiaandtypicallyisnotcausedbybacterial
infection(Pelton,2012).OMEtypicallyprecedesorfollowsAOM.
OEisdefinedasaninflammationoftheouterearandearcanal,andmaypresentinacuteandchronic
forms.WhileAOMprimarilyaffectschildren,OEoccurswithsimilarfrequencyinchildrenandadults.
Acute OE roughly affects 1 in 123 persons in the United States based on the 2.4 million visits to
ambulatorycarecentersandemergencydepartmentsin2007(CentersforDiseaseControlandPrevention,
2011).Halfofthevisitsoccurredamongadultsagedmorethanorequalto20yearscomparedtochildren
5to14years ofage,accountingforapproximately34%ofall visits.OEis mostoftenassociatedwith
swimming,localtrauma,useofhearingaids,andhigh,humidtemperatures(Table17.1).UnlikeAOM,in
whichthemainstayoftreatmentissystemicantibiotics,topicalantibiotictherapyisusuallyadequatefor
thetreatmentofOE.
TABLE17.1
ComparingTypesofOtitis
Typeof
Otitis
Etiology Symptoms ClinicalFindings
AOM Streptococcus
pneumoniae
Haemophilusinfluenzae
nontypableMoraxella
catarrhalis
Otalgia
Earpulling
Upperrespiratoryinfectionsymptoms
Diffuseerythemaandbulgingof
theTMDecreasedmobilityofthe
TM
OME Eustachiantube
obstructioncausing
sterileeffusioninthe
middleear
Hearinglossthatmaybemanifestedby
delayedlanguagedevelopmentinyoung
childrenordecreasedschool
performanceinolderchildren
Feelingofearfullness
Poppingsensationwithswallowing,
yawning,orblowingthenose
Clear,yellowish,orbluishgrayfluid
behindtheTM,withorwithoutair
bubbles
TMmayberetractedwith
decreasedmovement
OE Pseudomonas
aeruginosa,
Staphylococcusaureus,
Streptococcusspecies
Erythemaandswellingoftheexternal
canalwithotalgiaanditching,muffled
hearing,wateryorthickdischargefrom
theear
Painwithmovementoftragus,
raisedareaofindurationonthe
tragus,swollenexternalauditory
canal,redpustularlesions
Necrotizing
(malignant)
OE
P.aeruginosa Persistentfoul-smellingdischarge,deep
otalgia
Progressivecranialnervepalsies,
granulationsintheexternalear
canal
AOM,acuteotitismedia;OE,otitisexterna;OME,otitismediawitheffusion;TM,tympanicmembrane.
CAUSES
AcuteOtitisMediaandOtitisMediawithEffusion
ThemostfrequentlyisolatedbacteriafrommiddleearfluidduringAOMareStreptococcuspneumoniae,
nontypable Haemophilus influenzae, and Moraxella catarrhalis, followed by the less common
StreptococcuspyogenesandStaphylococcusaureus.TheprecisefrequencyforeachAOMpathogenhas
changedovertimeduetochangesinvaccinationcoverage.Historically,S.pneumoniaedominatedAOM
etiology, but after implementation of the 13-serotype pneumococcal conjugate vaccine (PCV),
betalactamaseproducingH.influenzaeandM. catarrhalishasemergedasmore common(Kauret al.,
2017).
Although many cases are caused by bacterial pathogens, viruses play a significant role in the
pathogenesis and treatment decisions. Viral pathogens, such as respiratory syncytial virus (RSV),
influenza A and B, parainfluenza, enterovirus, and rhinovirus, have been studied extensively and
implicatedwithAOM(Marometal.,2012).Inflammatorychangesintheupperairwayscausedbyviral
URIfacilitatebacterialAOMbyimpairinglocalhostdefenses,enhancingthebacteria’sabilitytoascend
thenasopharynx,andinfectingthemiddleear.Forexample,RSVhasbeenrecoveredfrom2%to20%of
AOMtympanocenteses.
OtitisExterna
Ninety-eight percent of OE cases in the United States are caused by bacteria, most commonly
PseudomonasaeruginosaandS.aureus(Rosenfeldetal.,2014).TheetiologyofOEisdifferentthanthat
of OM because the flora of the external auditory canal is similar to that of the skin including
Staphylococcusepidermidis,S.aureus,Corynebacteriaspecies,andPropionibacteriumacnes.Fungal
OE,otomycosis,predominantlyAspergillusandCandidaspecies,causelessthan5%ofOEintheUnited
States(Boyce&Balakrishnan,2018)andmaybe associatedwithprolongeduseoftopicalantibiotics.
Chronic OE may be noninfectious but caused by inflammatory skin disorders and allergic reactions.
Necrotizing(malignant)OEresultsfrominvasiveinfectionoftheexternalearcanalandispredominantly
causedbyP.aeruginosa.
PATHOPHYSIOLOGY
OtitisMedia
AOM frequentlyfollows a URI (usually of viral etiology) in which the eustachian tube is obstructed
secondary to inflamed mucous membranes (Marom et al., 2012). The pathophysiology of AOM is
multifactorial but is mainly theresult of eustachian tubedysfunction. Theeustachian tubeprotects the
middleearfromnasopharyngealsecretions,providesdrainageofsecretionsproducedinthemiddleear
intothenasopharynx,andpermitsequilibrationofairpressuretoatmosphericpressureinthemiddleear.
Thestructureofachild’seustachiantubediffersfromthatofanadult’s.Theadulteustachiantubeliesat
45 degrees to the horizontal plane and allows for secretions to drain from the middle ear to the
nasopharynx.Thechild’seustachiantube,however,isshortandhorizontal.Whenachilddevelopsmild
inflammationoredemaoftheeustachiantube,theearhasdifficultyclearingsecretionsduetothealmost
horizontalplacementoftheeustachiantube.Persistentsecretions,incompletedrainage,andtheabsenceof
aerationpromoteanenvironmentforbacterialgrowthwithinthemiddleear,resultinginAOM(Maromet
al.,2012).TheincidenceofAOMpeaksduring6to12monthsofageandinthewintermonthsduetohigh
correlationwithURIs.RiskfactorsforAOMincludedaycareattendance,familyhistoryofAOM,male
sex(onlyin the first year of life), non-Hispanic whiterace, andchildren who attenddaycare or are
relatives of children in day care (Kaur et al., 2017). Exposure to secondhand smoke has also been
associated,howeverinconsistently,withanincreasedriskofAOM.
OMEoccurswhenfluidbuildsupinthemiddleearwhichmayoccurafterAOMorduringURIdueto
eustachiantubedysfunction,andcanbeassociatedwithconductivehearingloss(Rosenfeldetal.,2016).
ThemajordifferencebetweenOMEandAOMisthatinOMEthefluidisnotactivelyinfectiousandpain
maybeabsentorminimal.
OtitisExterna
OEiscellulitisoftheearcanalskinandsubdermis,whichistypicallyunilateralandassociatedwithhead
immersioninwater,especiallyfreshwaterorhottubs(Rosenfeldetal.,2014).Personsofallagesareat
riskfordevelopingthisinfection.Thecommonpredisposingfactorisswimming.Additionalriskfactors
forOEincludeeczemaorseborrhea,resultinginexcessivescratching,traumafromcerumenremoval,use
of hearing aids, and immunocompromised states such as diabetes (Boyce & Balakrishnan, 2018).
Disruptionoftheearcanalhomeostasisfromprolongedperiodsofwaterexposure,lossoftheprotective
cerumenbarrier,anddisruptionoftheepitheliumallresultinvariedpHandcompromisedlocalimmune
defenses,whichallowsbacteriaandotherpathogenstoproduceinfection.
Resistance
The increasing rates of antimicrobial resistance are a major concern worldwide and warrants the
judicioususeofantibiotics.Commonbacterial mechanismsofresistanceassociatedwithAOMinclude
production of antibiotic-inactivating enzymes, such as beta-lactamases, and alteration of drug-binding
sites,suchasmutationsinthepenicillin-bindingprotein.Beta-lactamaseproductionisthemechanismby
whichbacteriasuchasH.influenzaeandM.catarrhalisdevelopresistance,withaprevalenceof45%
and100%intympanocentesisspecimens,respectively(Kauretal.,2017).Productionoftheseenzymes
renders many betalactam antibiotics useless. Betalactamase inhibitors in combination with betalactam
therapy, such as amoxicillin—clavulanic acid or betalactamase stable cephalosporins (i.e., cefixime,
cefpodoxime), can overcome this mechanism of resistance. Therefore, these agents should be
recommendedfortreatmentifthesebacteriaaresuspected,specificallyinthesettingoftreatmentfailure
or recurrent infection. A detailed discussion of treatment options is presented in the Initiating Drug
Therapysectionofthischapter.
Historically, penicillin had been the mainstay of treatment against S. pneumoniae, but increasing
prevalenceofpenicillin-intermediateandpenicillin-resistantstrainshasdiscouragedtheuseofpenicillin
anditsderivatives.Themechanismofresistanceis alterationofthepenicillin-bindingsite,resultingin
elevatedminimuminhibitoryconcentration.Drug-resistantS.pneumoniae(DRSP)remainsathreatinthe
treatmentofAOM.However,followingtheintroductionofthePCVwith7serotypes(PCV-7)in2000and
subsequent13-serotypevaccine(PCV-13) in2010,notonlyhavethenumberofpneumococcalisolates
decreased but the incidence of DRSP strains isolated from cultures of children with OM has also
decreased,includingserotype19A(Kaplanetal.,2015).
DIAGNOSTICCRITERIAANDCLINICALPRESENTATION
AcuteOtitisMedia
ThedifferentiationbetweenAOMandOMEisdependentonanaccurateandconsistentOMdiagnosis,as
emphasized in the 2013 AAP guidelines. However, difficulties remain, and AOM diagnoses
unsubstantiated by physical examination findings result in inappropriate and overprescribing of
antibiotics. For example, cerumen or debris may impede otoscopic examination of the ear canal and
tympanic membrane (TM), and may require removal for visualization. Therefore, novel noninvasive
technologies are highly desirable and could improve thediagnosis of OM,such as optical coherence
tomography(Shirai& Preciado, 2019). However,thevalidityandreliability ofnew methods mustbe
provenpriortoadoption;athoroughpatienthistoryandphysicalexaminationremainthestandardofcare.
AOMpresentsabruptlywithsymptomssuchasfever,otalgia,andirritability.Theaverbalinfantmay
expressotalgiaandirritabilitybytugging,rubbing, orholdingtheaffectedear,andexcessive crying,or
changes in sleep or behavior pattern. Visualization of the TM via otoscope reveals a bulging and
erythematousTMthatisimmobiletopneumaticotos-copyindicatingMEE.Tipsforpneumaticotoscopy
canbefoundinthe“OtitisMedia withEffusion:Clinical Practice Guideline”(Rosenfeldetal.,2016).
Thediagnosis ofAOMrequires abruptonsetofsymptoms(lessthan48hours), presenceofMEE,and
signs or symptoms of middle ear inflammation (e.g., otalgia, erythema of the TM, hearing loss)
(Lieberthaletal.,2013).OtorrheamayalsobepresentandasignofTMperforationwhichwillgreatly
impactthedecisiontotreatwithantibiotics(Table17.2).
The differentiation between AOM and OME is imperative since OME should not be treated with
antibiotics due to nonin-fectious etiology. The absence of acute inflammatory signs and symptoms
presumesa diagnosis of OME.Patientswith OMEare usuallyasymptomatic butmay complainofear
fullnessandhearingloss.Uponotoscopic examination,theTMmayappear normalor withanair-fluid
levelbehindtheTMwithnosignsorsymptomsofmiddleearinflammation;theonlysignofeffusionis
reducedmobility(Rosenfeldetal.,2016).TympanometryisanobjectivetoolforthediagnosisofOME
as a confirmatory measure or alternative to pneumatic otoscopyby assessing TM mobility. When the
diagnosis of OME is uncertain after pneumatic otoscopy is used or attempted, tympanometry is
recommendedinspecificsituations,forexample,childintolerancetootoscopy,unreliableequipment,TM
obstruction.
TABLE17.2
DiagnosticCriteriaforAcuteOtitisMedia
1.Historyofacuteonsetofsigns/symptoms
2.Presenceofmiddleeareffusion(indicatedbyoneofthefollowing):
a.BulgingofTM
b.LimitedorabsentTMmobility
c.Otorrhea
d.Air-fluidinterfacebehindTM
3.Signsandsymptomsofmiddleearinflammation
a.ErythemaofTM
b.Otalgia
TM,tympanicmembrane.
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