Tuesday, June 25, 2013

Updated Sinusitis Guidelines

photo source: Shutterstock

This month the American Academy of Pediatrics updated the guidelines for management of sinus infections in children (1-18 years of age) in the June edition of Pediatrics, available online.

Many parents bring kids in to the doctor for green or yellow runny noses because they're worried about bacterial sinusitis. Sinuses can be infected with viruses or produce mucus from allergies, so not all sinus infections are bacterial. Most of these kids do not need antibiotics to get better, but the guidelines help determine who might benefit from them and when to change an antibiotic if not improving. The guidelines are based on duration of symptoms and severity, not the color of the drainage, how much drainage there is, or fancy testing. Only infections caused by bacteria need antibiotics. Overuse of antibiotics can lead to resistance (so when there is a severe infection it becomes more difficult to treat), side effects (such as diarrhea), or allergic responses.

Unfortunately, a physical exam is not helpful in distinguishing a simple viral cold and cough from a bacterial sinus infection, but is needed to identify other problems that might complicate the picture, such as pneumonia or an ear infection. The inside of the nose can be swollen and various shades of pink, red or blue in sinus infections from bacteria or other causes. How often have I palpated those sinuses to see if tender, yet I know from personal experience that mine hurt when my allergies flare-- certainly not a reason for antibiotics!

I wish there was a simple test, but nose swabs for culture have not been found to be accurate in predicting bacterial cause of the infection. Imaging studies are not needed to help diagnose sinusitis because the inflammation seen in pictures can be from other causes, not just bacterial.

Most cases of runny nose, fever, and/or cough are due to a viral illness. The nasal discharge usually starts clear, but can become thick and discolor over time for several days. It often goes back to a thinner, clear color before resolving without antibiotics. Fever in a typical viral illness tends to be the first several days, and may precede the other symptoms. Fever usually resolves by day 3, when the nasal discharge and cough tend to worsen.  Symptoms tend to peak between the 3rd and 6th day, then resolve after about 10 days. (Though some studies show longer.) Back to back infections are common in kids, especially during the winter months, which can be confused with one prolonged sinus infection.

Guidelines to diagnose and treat acute bacterial sinusitis in a nutshell:

  • Symptoms in a child with upper respiratory infection suggest acute bacterial sinusitis if: 
  • there is persistent illness (nasal discharge or daytime cough) of 10 days without improvement. This persistence can be difficult to distinguish from back to back viral illnesses, so a careful review of symptoms is important.
  • there are worsening symptoms (nasal discharge, cough, fever) after initial improvement. (New in the 2013 guidelines.)
  • there is severe onset (fever over 102.2F and discolored nasal discharge for at least 3 consecutive days). Several viral infections, notably influenza, can cause severe onset of symptoms, but a clue to the bacterial nature is the combination of fever with mucus in the initial days, since the fever usually comes before the mucus in many viral illnesses. 

  • Observation without antibiotic is acceptable with a persistent infection over 10 days for another 3 days if there was not a severe onset or worsening of symptoms. (This differs from the 2001 guidelines to use an antibiotic for symptoms of 10 days.)
  • Imaging is not recommended to diagnose routine sinusitis. Plain x-rays, computed tomography (CT), magnetic imaging (MRI), and ultrasounds (US) cannot distinguish between viral, bacterial, or allergic nature of the inflammation. 
  • If there is a suspicion of extension of the infection outside of the sinus cavities, such as into the eye orbit or central nervous system, a contrast-enhanced CT scan is indicated. These might be suspected if the eyelid is swollen and the mobility of the eye is decreased, sensitivity to light, severe headache, seizures, or other neurologic changes. 
  • When antibiotics are indicated, amoxicillin or amoxicillin with clavulanate (Augmentin) is the first line choice unless there are documented allergies to penicillins. If there are allergies or failure to respond to the amoxicillin, a cephalosporin may be used. There are other good choices, but studies do not show that azithromycin (Zithromax) or trimethoprim sulfamethoxazole (Bactrim) are good choices because they aren't effective against the most common bacteria of bacterial sinus infections. The duration to take an antibiotic is not well identified. Recommendations vary from 10 to 28 days, or 7 days from the time symptoms go away. This will vary by prescriber's preference and experience.
  • If there are worsening of symptoms or failure to improve within 72 hours of initial visit, a repeat evaluation is recommended. If no other source of symptoms is found on physical exam, adding an antibiotic (if not previously initiated during the observation period) or changing the antibiotic is recommended. 
  • There was not enough evidence to support other treatments, such as decongestants, antihistamines, nasal corticosteroids, or saline rinses. More studies in children are needed to validate whether these are effective or not. There's always more to learn!

Friday, June 14, 2013

Bicycle Safety

I like the simplicity of picture blogs. They make it easy to share a lot of information in an easy to see format, so when I decided to do a blog on bicycle safety, it was an obvious choice.

Bicycle Safety Tips

Teach kids to use hand signals to alert others where they are going:
From: http://www.nhtsa.gov/Bicycles

Use a properly fitted helmet:

From: http://www.nhtsa.gov/Bicycles
Help your kids learn about bike safety with these fun activities from the National Highway Traffic  Safety Administration.

Tuesday, June 4, 2013

Swimmer's Ear

Summer's here and that means we will soon start seeing a lot of older kids with earaches.

swimmer's ear, ear infections, earache

Swimmer's ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

Swimmer's ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin. Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer's ear.

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear. Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though -- it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Both Good and Bad.

Swimmer's ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal. Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer's ear due to canal irritation). Sometimes there is drainage of clear fluid or pus from the canal. If the canal swells significantly or if pus fills the canal, hearing will be affected. More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck. Swimmer's ear can lead to dizziness or ringing in the ear.

Prevention of swimmer's ear is possible for most people.

  • If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. (Wax does help keep your ears clean, so you don't want to clear it too much!)
  • Never put anything solid into the ear canal.
  • Dry the ear canals when water gets in. 
  • Tilt the head so the ear is down and hold a towel at the edge of the canal. 
  • Use a hair dryer on a cool setting several inches away from the ear to dry it. 
  • If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal. DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.
  • If your child has a scratch in the ear or a current swimmer's ear infection, avoid swimming for 3-5 days to allow the skin to heal. 
  • Avoid bubble baths and other irritating liquids that might get into ear canals.
  • If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming. 
Treating swimmer's ear:
  • If you think your child has swimmer's ear, start with pain control at home with acetaminophen or ibuprofen per package directions. Heating pads to the outer ear often help, but do not put any heated liquids into the ear. 
  • Most often swimmer's ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days. Bring your child to the office for an exam, diagnosis, and treatment as indicated. 
  • If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at our office or another urgent/emergent care setting. 
  • Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal. Never attempt this at home!
  • The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day. Have the patient lie on their side, put the drops in the ear and remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. Symptoms generally improve after 24 hours and the infection clears within a week.
  • Oral antibiotics are usually not required unless the infection extends beyond the ear canal.
  • If pain is very severe, ask about prescription pain relievers when your child is being seen and evaluated. Most often they are not needed, but if they are it is best to get them at the time of your visit so risks of these medications and how and when to use them can be discussed.
  • If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection, which requires an anti-fungal medication. 
  • No swimming until the infection clears. 
  • Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection. Visit your doctor early if you suspect a problem.

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