Effective Inexpensive Management of Necrotizing Otitis Externa Is Possible in Resource-Poor Settings.

INTRODUCTION: Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well. MATERIALS AND METHODS: Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention. RESULTS: Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression. CONCLUSION: Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.

Retroauricular pain caused by Eagle syndrome: A rare presentation due to compression by styloid process elongation / Dor retroauricular causada pela síndrome de Eagle: uma apresentação rara por compressão pelo alongamento do processo estiloide

Summary Eagle syndrome is a rare condition presenting with retroauricular pain (usually as main symptom) associated with dysphagia, headache, neck pain on rotation and, much rarelier, stroke. This occurs due to styloid process elongation. Sometimes, there is also styloid ligament calcification, which can cause compression of nerves and arteries and the symptoms above. Treatment can be conservative with pain modulators (e.g. pregabalin) or infiltrations (steroids or anesthetics drugs). In refractory cases, surgical approach aiming to reduce the size of the styloid process can be performed. We present a rare case of Eagle syndrome (documented by computed tomography) with good response to clinical treatment.

Resumo A síndrome de Eagle é uma condição rara na qual ocorre dor retroauricular (usualmente é o principal sintoma) associada a disfagia, cefaleia, cervicalgia durante a rotação da cabeça e, mais raramente, a AVC. Isso ocorre por conta do alongamento do processo estiloide e, às vezes, há também calcificação do ligamento estiloide. Essas estruturas podem comprimir nervos e artérias causando os sintomas citados. O tratamento pode ser conservador com moduladores da dor, como pregabalina, ou com infiltrações (corticoides ou drogas anestésicas). Em casos refratários, cirurgia para reduzir o tamanho do processo estiloide pode ser realizada. É apresentado um caso raro de síndrome de Eagle (documentado com tomografia computadorizada) com boa resposta ao tratamento clínico.

ED triage pain protocol reduces time to receiving analgesics in patients with painful conditions.

BACKGROUND: Studies suggest that collaborative nursing protocols initiated in triage improve emergency department (ED) throughput and decrease time to treatment. OBJECTIVE: The objective of the study is to determine if an ED triage pain protocol improves time to provision of analgesics. METHODS: Retrospective data abstracted via electronic medical record of patients at a safety net facility with 67 000 annual adult visits. Patients older than 18 years who presented to the ED between March 1, 2011, and May 31, 2013, with 1 of 6 conditions were included: back pain, dental pain, extremity trauma, sore throat, ear pain, or pain from an abscess. A 3-month orientation to an ED nurse-initiated pain protocol began on March 1, 2012. Nurses administered oral analgesics per protocol, beginning with acetaminophen or ibuprofen and progressing to oxycodone. Preimplementation and postimplementation analyses examined differences in time to analgesics. Multivariable analysis modeled time to analgesics as a function of patient factors. RESULTS: Over a 27-month period, 23 409 patients were included: 13 112 received pain medications and 10 297 did not. A total of 12 240 (52%) were male, 12 578 (54%) were African American, and 7953 (34%) were white, with a mean (SD) age of 39 years (13 years). The pain protocol was used in 1002 patients. There was a significant change in mean time (minutes) to provision of analgesics between preimplementation (238) and postimplementation (168) (P < .0001). Linear regression showed the protocol-delivered medications to younger patients and of lower acuity in a reduced time. Variables not related to time to provision of medication included sex, payer, and race. CONCLUSION: Emergency department triage pain protocol decreased time to provision of pain medications and did so without respect to payer category, sex, or race.

An otalgia pain syndrome, the anterolateral tip of the mastoid syndrome (ATOMS): diagnosis and response to treatment.

INTRODUCTION: Otalgia is a common presenting disorder. We describe a pain entity characterized by localized pain at the anterolateral tip of the mastoid (ATOM), which can be diagnosed by location and response to lidocaine (Xylocaine) injection. Long-term therapeutic results are described following a single injection of lidocaine. We compared 11 patients with this pain location to 24 patients with nonspecific otalgia. MATERIALS AND METHODS: In a tertiary otology centre, patients with severe ATOM-related pain were treated using 3 cc of 1% lidocaine injection; pain scores were measured before and afterward with a questionnaire, which also probed the effects on general lifestyle or possible causative factors. A consecutive group of 64 patients referred to the clinic, who also filled out the questionnaire, were used as a reference group. RESULTS: The average severity of the pain was 7.6 of 10 prior to injection, and at 1 hour, this fell to 1.5, at 1 day to 2, at 1 week to 0.6, and to 1.9 at the 10-month follow-up. The duration of the pain, if intermittent, also fell significantly. Of the 11 patients, 9 had previous ear surgery. There was a higher incidence of females, tooth grinding, and ear surgery in the ATOM group than in the non-ATOM otalgia group. CONCLUSIONS: ATOM pain is another cause of otalgia symptoms that should be recognized and often responds to local anesthetic injection.

Sectioning the sensory auricular branch of the facial nerve to treat recalcitrant otalgia.

OBJECTIVE: To present a new surgical approach to treat idiopathic neuralgia of the sensory auricular branch of the facial nerve. PATIENTS: : Three patients with chronic ear pain resistant to medical therapy. INTERVENTION: Sectioning of the sensory auricular branch of the facial nerve along its course at the posterior wall of the external auditory canal by a retroauricular mastoidectomy approach. MAIN OUTCOME MEASURES: Resolution of otalgia. RESULTS: All the patients were relieved of their pain at their first follow-up visit, and they have remained symptom-free. The patients were followed at least for 1 year. CONCLUSION: The surgical treatment of idiopathic otalgia should be reserved for patients in whom medical treatment has failed. Finding the exact location of the ear pain is of utmost importance for a favorable outcome after surgery. If the origin of the otalgia is found to be the sensory auricular branch of the facial nerve, the section of this nerve offers favorable outcomes with no morbidity.

Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms.

BACKGROUND: Although the vast majority of respiratory tract symptoms are self-limiting, many patients visit their GP for these symptoms and antibiotics are over-prescribed. AIM: To explore determinants of patients visiting GPs for recent cough, sore throat, or earache; for being prescribed antibiotics; and for patients' satisfaction with visiting the GP. DESIGN OF THE STUDY: Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING: A total of 7057 adult patients of 163 GPs in the Netherlands. METHOD: Characteristics of patients and GPs as well as morbidity data were derived from the DNSGP-2 and a health interview. Characteristics of the symptoms, GPs' management and patients' satisfaction were measured by an additional written questionnaire. Data were analysed by means of multivariate logistic regression. RESULTS: About 40% of the responders (n = 1083) reported cough, sore throat, or earache in the 2 weeks preceding the interview and, of them, 250 visited their GP. Of this latter group, 97 patients were prescribed antibiotics. Apart from non-medical reasons, relevant medical factors played an important role in deciding to visit the GP. Smokers and patients with cardiac disease or diabetes mellitus were not especially inclined to see their GP. Smoking behaviour, fever, and views on respiratory tract symptoms and antibiotics of patients and GPs were associated with being prescribed antibiotics. Patients' perception of having been carefully examined was associated with their satisfaction, while receiving antibiotics was not. CONCLUSION: GPs should inform patients with clear elevated risk when to visit their GP in cases of cough, sore throat, or earache. There is still a need for GPs and patients to be better informed about the limited significance of single inflammation signs (for example, fever and green phlegm) as an indication for antibiotics. Careful examination of the patient contributes to patient satisfaction.

Views on respiratory tract symptoms and antibiotics of Dutch general practitioners, practice staff and patients.

OBJECTIVES: To explore views on respiratory tract symptoms (cough, sore throat and earache) and antibiotics of GPs, practice staff, and patients. METHODS: In a nationwide study, 181 GPs, 204 practice staff members and 1250 patients from 90 practices participated by answering 14 items relating to views on respiratory tract symptoms and antibiotics in a written questionnaire. Differences in means were compared. RESULTS: Patients more than GPs endorsed the seriousness of respiratory tract symptoms, the need to consult a GP, the need to prescribe antibiotics, and the ability of antibiotics to speed up recovery. GPs were more than patients convinced of the self-limiting character of respiratory tract symptoms and of the fact that antibiotics have side effects. Practice staff took a middle ground in most of these views. CONCLUSIONS: Differences between GPs, practice staff and patients must be taken into account when exploring patients' complaints and advising on treatment. Education and knowledge programmes for practice staff might be advocated.

Cervical spine meningioma presenting as otalgia: case report.

OBJECTIVE AND IMPORTANCE: Cervical spine meningiomas have not been reported to present as otalgia. It is important to include otalgia in the differential diagnosis and workup, especially when more common causes of ear pain have been excluded. CLINICAL PRESENTATION: A 66-year-old woman presented to her primary care physician with severe ear pain. She underwent routine diagnostic testing and eventually was referred to a neurologist. After conservative management failed, the patient underwent cervical spine magnetic resonance imaging, which revealed a large meningioma encompassing C2-C3. INTERVENTION: The patient underwent a cervical laminectomy with complete resection of the tumor. She experienced immediate postoperative resolution of her symptoms. CONCLUSION: This case illustrates the importance of aggressive evaluation of otalgia when routine diagnostic studies are inconclusive. Cervical meningiomas are associated with significant potential morbidity and should be excluded early in the diagnostic process.

Naturopathic treatment for ear pain in children.

OBJECTIVE: Otitis media is 1 of the most frequent diseases of early infancy and childhood and 1 of the most common reasons for children to visit a physician. In the past 2 decades, there has been a substantial increase in the diagnosis of otitis media worldwide. In the United States, 93% of all children have had at least 1 episode of acute otitis media (AOM) by 7 years of age. Otalgia is the hallmark of AOM. Most affected children either complain of earache or manifest behavior that the parents interpret as indicating ear pain. Treatment of the ear pain early in the course of AOM decreases both parental anxiety and the child's discomfort and accelerates the healing process. The objective of this study was to determine the efficacy and tolerability of naturopathic versus traditional treatment for the management of otalgia commonly associated with AOM in children. METHODS: The study was designed as a double-blind trial in an outpatient community clinic. A total of 171 children who were aged 5 to 18 years and had otalgia and clinical findings associated with middle-ear infection were studied. The children were randomly assigned to receive treatment with Naturopathic Herbal Extract Ear Drops (NHED) or anesthetic ear drops, with or without amoxicillin. On enrollment, the children were assigned by computer-numbered randomization to receive NHED (contents: allium sativum, verbascum thapsus, calendula flores, hypericum perfoliatum, lavender, and vitamin E in olive oil) 5 drops 3 times daily, alone (group A) or together with a topical anesthetic (amethocaine and phenazone in glycerin) 5 drops 3 times daily (group B), or oral amoxicillin 80 mg/kg/d (maximum 500 mg/dose) divided into 3 doses with either NHED 5 drops 3 times daily (group C) or topical anesthetic 5 drops 3 times daily (group D). A double-blind design was used, and all ear drops were placed in identical bottles. Treatment was initiated by the nurse in all cases. A single physician (M.S.) evaluated and treated all of the patients included in the study and recorded all of the data. The presence or absence of ear pain was assessed over 3 days with a visual analog scale. Ear pain was assessed by a specially devised observational instrument based on previous reports. One side of the instrument consisted of a linear numbered scale, from 1 (no pain) to 10 (worst possible pain), and a corresponding color scale, ranging from blue to dark red. The reverse side contained a scale of 5 facial expressions, ranging from broad smile (no pain) to a sad and crying face (worst possible pain), and a corresponding color scale, ranging from blue to dark red. RESULTS: There were no significant between-group differences in patient age or gender, degree of fever, main symptoms, associated symptoms, and severity or laterality of acute otitis media. Each group had a statistically significant improvement in ear pain over the course of the 3 days. Patients who were given ear drops alone had a better response than patients who were given ear drops together with amoxicillin. Results were better in the NHED group than in the controls. Nevertheless, the findings indicated that the pain was mostly (80%) self-limited and could be explained simply by the time elapsed. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend topical medications as the first line of treatment for ear pain in the absence of systemic infection or serious underlying disease. Because no evidence was found that systemic antibiotics alone improved treatment outcome, if antibiotics do not change the natural course of otitis media, then the main goal of treatment, as in the present study, should be to alleviate the ear pain. The alternative, naturopathic herbal extract medications, may offer many new possibilities in the management of ear pain associated with AOM. Primary care physicians should be aware that at least 10% of their patients may have tried 1 or more forms of alternative/complementary medicine before presenting for consultation. As it was widely reported in the medical literature, these herb, these herbal extracts have the potential to meet all of the requirements of appropriate medication that could be routinely used in the pediatric patient, namely in vitro bacteriostatic and bacteriocidal activity against common pathogens, immunostimulation ability, antioxidant activity, and anti-inflammatory effects. They are also well-absorbed with good penetration into the tissue surrounding the tympanic membrane. They have been found to enhance local immunologic activity. Finally, herbal extracts are well-tolerated (owing to their long elimination time), easy to administer, and less expensive than the new antibiotics. There are no documented side effects. On the basis of our findings that the group with the most significant treatment effects (NHED with topical anesthetic) explained only 7.3% of the total pain reduction, we propose that sometimes the general practitioner or pediatrician needs to give the human body a chance to repair itself. Nevertheless, if the physician believes that there is an indication for some treatment, especially if the parents are anxious, then a local treatment such as one used in our study might be adequate. CONCLUSIONS: This study suggests that in cases of ear pain caused by AOM in children in which active treatment, besides a simple 2- to 3-day waiting period, is needed, an herbal extract solution may be beneficial. Concomitant antibiotic treatment is apparently not contributory.

Crohn's disease and the Melkersson-Rosenthal syndrome.

A 30-year-old woman with a 10-year history of recurrent bloody diarrhea and documented colitis of the descending colon, consistent with Crohn's disease, presented with an exacerbation of her gastrointestinal disease and an 18-month history of recurrent facial and genital swelling. Her course evolved to include severe ear pain, dysphagia and colonic dysmotility. She was diagnosed with Melkersson-Rosenthal syndrome and treated with multiple agents. The neurological aspects of her presentation are highlighted, and the Melkersson-Rosenthal syndrome is reviewed.

¿Es necesaria la antibioterapía en el tratamiento de la otitis media aguda (OMA)? y ¿en qué momento?: valor del meta-análisis / Is antibiotherapy necessary in the treatment of acute otitis media (AOM)? when?: meta-analysis value

El autor plantea la pregunta sobre la utilidad de los antibióticos en el tratamiento de la otitis media aguda (OMA); para ello analiza primero la primordial importancia que tienen los ensayos randomizados controlados (ERC) para responder a está interrogante y en especial cuando se trata sobre el uso de fármacos, enfatizando la importancia actual del meta-análisis y del meta-análisis acumulativo. Posteriormente efectúa una revisión de un meta-análisis sobre este tópico. En dicho estudio se encontró que un 60 por ciento de los niños que sufrían de OMA estaban sin dolor a las 24 horas sólo con tratamiento sintomático, y que los antibióticos no influían sobre la aparición de nuevos brotes de OMA, concluyéndose que los beneficios de los antibióticos en la OMA son realmente modestos, recomendándose su uso sólo en forma opcional

Self-administration of over-the-counter medication for pain among adolescents.

OBJECTIVE: To examine over-the-counter (OTC) medication use and self-administration of medication among adolescents. DESIGN: In-person survey. SETTINGS: Three public junior high schools in Halifax, Nova Scotia. PARTICIPANTS: Six hundred fifty-one junior high school students (7th, 8th, and 9th grades). MAIN OUTCOME MEASURES: A questionnaire regarding OTC medication use and self-administration for head: stomach; ear and throat; muscle, joint, and back; and menstrual pains. RESULTS: Of those who reported taking medication, many adolescents (58.7%-95.9%) reported taking OTC medications for each pain. Medications and knowledge about medications were obtained from a variety of sources, primarily parents. Self-administration was widespread; 58.3% to 75.9% of adolescents reported taking an OTC medication for pain without first checking with an adult in the previous 3 months. Self-administration of medication without the knowledge of adults increased significantly from grades 7 to 9 for all types of pain. Girls tended to self-administer medication more than boys. Higher levels of pain frequency and intensity were related to higher levels of self-administration for all pains except muscle, joint, and back pain. Adolescents reported that they began to self-administer medication between the ages of 11 and 12 years. CONCLUSIONS: Although a relatively responsible picture of self-administration of medication emerges, some adolescents engaged in inappropriate OTC medication use (eg, the common use of aspirin), highlighting the importance of providing adolescents with correct information about these medications.

Cranial polyneuropathy--Ramsay Hunt's syndrome: case report and discussion.

Ramsay Hunt's syndrome is an infectious cranial polyneuropathy caused by varicella zoster, the herpetic virus that also causes chickenpox and shingles. Its symptoms include facial paralysis, ear pain, and an auricular rash. Oral lesions are also present in most cases. This syndrome can affect any cranial nerve and usually affects multiple nerves, causing central, cervical, and peripheral effects. This article reports the case of a 35-year-old white female who was treated by the oral surgery service of a large urban hospital, after first reporting to the emergency clinic. Her reported symptoms of unilateral left-side facial paralysis, auricular pain, and trigeminal hyperesthesia were confirmed by clinical examination. An initial short low-dose steroid regimen was unsuccessful. A second daily dosage of 50 mg of prednisone was successful in 21 days. No permanent sequelae were evident or reported after treatment.

Tratamento de processos inflamatórios das vias aéreas superiores e ouvido, sem componente infeccioso, com AINH: estudo randomizado comparando o nimesulide ao diclofenato potássico / The treatment of upper respiratory tract and ear inflammatory non-infectious conditions with NSAID: a comparative randomized trial with nimesulide and potassium diclofenac

Através de um estudo randomizado, foram comparados os efeitos do nimesulide, um novo antiinflamatório não-hormonal, e do diclofenato potássico em 36 pacientes de ambos os sexos (27 femininos e nove masculinos) e com mais de 12 anos de idade, portadores de processos inflamatórios do trato respiratotio superior e/ou do ouvido. Dezessete pacientes receberam o nimesulide (1 comprimido a cada 12 horas) e 19 o diclofenaco (1 drágea três vezes ao dia), durante sete dias. Com o diclofenaco, os resultados foram excelentes ou bons em 36,5 por cento dos casos e regulares em 26,3 por cento. O nimesulide proporcionou 94,1 por cento de resultados excelentes ou bons e 5,9 por cento regfulares, sem falha terapêutica. A tolerância foi boa em 100 por cento dos pacientes que receberam o nimesulide e em 89,5 por cento dos tratados com o diclofenaco potássico, que apresentou 10,5 por cento de efeitos adversos (enjôo, tonturas, azia). O nimesulide não induziu qualquer reação indesejável, destacando-se pela eficácia, rápido início de ação e segurança