April-June 20132013 April-June
Dr Jasveer Singh
Asian Journal of
Online Submission
Ear, Nose Throat
IJCP Group of Publications Dr Sanjiv Chopra Prof. of Medicine and Faculty Dean Harvard Medical School Group Consultant Editor
Dr Deepak Chopra Chief Editorial Advisor Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal Group Editor-in-Chief
FROM THE DESK OF GROUP EDITOR-IN-CHIEF 4 Sore Throats Mostly Viral, Not Strep
Dr Veena Aggarwal MD, Group Executive Editor
April-June 2013
KK Aggarwal
REVIEW ARTICLE
Editor: Dr Jasveer Singh
5 Acute Otitis Externa: An Update
IJCP Editorial Board
Obstetrics and Gynaecology: Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj Cardiology: Dr Praveen Chandra, Dr SK Parashar Paediatrics: Dr Swati Y Bhave Diabetology: Dr CR Anand Moses, Dr Sidhartha Das, Dr A Ramachandran, Dr Samith A Shetty ENT: Dr Jasveer Singh Dentistry: Dr KMK Masthan, Dr Rajesh Chandna Gastroenterology: Dr Ajay Kumar
Paul Schaefer, Reginald F Baugh
CASE REPORT 12 Congenital Facial Palsy with Bilateral Anotia
Geeta Gathwala, Jagjit Singh, Poonam Dalal
EXPERT OPINION 14 What is the Role of Bioengineering Solutions for Hearing Loss? Raghunandhan
ALGORITHM 15 Diagnosis and Management of Sore Throat
Dermatology: Dr Hasmukh J Shroff Nephrology: Dr Georgi Abraham Neurology: Dr V Nagarajan
Advisory Bodies Heart Care Foundation of India
Journal of Applied Medicine & Surgery: Dr SM Rajendran, Dr Jayakar Thomas
Non-Resident Indians Chamber of Commerce and Industry World Fellowship of Religions
Asian Journal of Orthopedics: Dr J Maheshwari
Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1, New Delhi - 110 048, E-mail: editorial@ ijcp.com Printed at: New Edge Communications Pvt. Ltd, New Delhi, E-mail: edgecommunication@gmail.com Š Copyright 2013 IJCP Publications Ltd. All rights reserved. The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.
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FROM THE DESK OF GROUP EDITOR-IN-CHIEF Dr KK Aggarwal
Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)
Sore Throats Mostly Viral, Not Strep ÂÂ
Most throat infections are viral and should not be treated with antibiotics, according to new guidelines from the Infectious Diseases Society of America, reports Medscape in the journal Clinical Infectious Diseases.
ÂÂ
Seventy percent of Americans with a sore throat receive antibiotics. However, bacteria are responsible for only 20-30% of pediatric cases and 5-15% of adult cases.
ÂÂ
Although, bacterial and viral throat infections often have overlapping symptoms, other symptoms, such as cough, rhinorrhea, hoarseness and oral ulcers, strongly suggest a viral infection.
ÂÂ
A sore throat is more likely to be caused by Group A streptococci if the onset of pain is sudden, swallowing hurts and fever is present. Such cases can be evaluated using a stand-alone rapid antigen detection test. Because children younger than three years are unlikely to have strep throat, testing is unnecessary, with the exception of certain circumstances such as an infected older sibling.
ÂÂ
Throat cultures should only be used to confirm negative antigen tests in children and adolescents.
ÂÂ
They should be eschewed in adults because of their low-risk for strep throat and even lower risk for complications such as rheumatic fever.
ÂÂ
Once strep throat is confirmed, the treatment of choice remains a 10-day course of penicillin (or its congener amoxicillin), which has a narrow-spectrum of activity, is cheaply available and carries a low-risk for adverse events.
ÂÂ
Penicillin or amoxicillin is the choice for treating strep because they are very effective and safe in those without penicillin allergy, and there is increasing resistance of strep to the broad-spectrum — and more expensive — macrolides, including azithromycin.
ÂÂ
The guidelines also recommend against tonsillectomy for children with repeated throat infection, except in very specific cases (e.g., children with obstructive breathing), because the risks of surgery are generally not worth the transient benefit. ■■■■
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Asian Journal of Ear, Nose and Throat, April-June 2013
REVIEW ARTICLE
Acute Otitis Externa: An Update PAUL SCHAEFER, REGINALD F BAUGH
ABSTRACT Acute otitis externa is a common condition involving inflammation of the ear canal. The acute form is caused primarily by bacterial infection, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens. Acute otitis externa presents with the rapid onset of ear canal inflammation, resulting in otalgia, itching, canal edema, canal erythema, and otorrhea, and often occurs following swimming or minor trauma from inappropriate cleaning. Tenderness with movement of the tragus or pinna is a classic finding. Topical antimicrobials or antibiotics such as acetic acid, aminoglycosides, polymyxin B, and quinolones are the treatment of choice in uncomplicated cases. These agents come in preparations with or without topical corticosteroids; the addition of corticosteroids may help resolve symptoms more quickly. However, there is no good evidence that any one antimicrobial or antibiotic preparation is clinically superior to another. The choice of treatment is based on a number of factors, including tympanic membrane status, adverse effect profiles, adherence issues, and cost. Neomycin/ polymyxin B/hydrocortisone preparations are a reasonable first-line therapy when the tympanic membrane is intact. Oral antibiotics are reserved for cases in which the infection has spread beyond the ear canal or in patients at risk of a rapidly progressing infection. Chronic otitis externa is often caused by allergies or underlying inflammatory dermatologic conditions, and is treated by addressing the underlying causes.
Keywords: Acute otitis externa, bacterial infection, topical antimicrobials, tympanic membrane status, oral antibiotics
O
titis externa, also called swimmer’s ear, involves diffuse inflammation of the external ear canal that may extend distally to the pinna and proximally to the tympanic membrane. The acute form has an annual incidence of approximately 1 percent1 and a lifetime prevalence of 10 percent.2 On rare occasions, the infection invades the surrounding soft tissue and bone; this is known as malignant (necrotizing) otitis externa, and is a medical emergency that occurs primarily in older patients with diabetes mellitus.3 Otitis externa lasting three months or longer, known as chronic otitis externa, is often the result of allergies, chronic dermatologic conditions, or inadequately treated acute otitis externa. ETIOLOGY In North America, 98 percent of cases of acute otitis externa are caused by bacteria.4 The two most common isolates are Pseudomonas aeruginosa and Staphylococcus aureus. However, a wide variety of other aerobic and anaerobic bacteria have been isolated.5,6 Approximately one-third of cases are polymicrobial.4 Fungal pathogens, primarily those of the Aspergillus PAUL SCHAEFER, MD, PhD, is an assistant professor, clerkship director, and director for medical student education in the Department of Family Medicine at the University of Toledo (Ohio) College of Medicine. REGINALD F. BAUGH, MD, is a professor and chief of otolaryngology in the Department of Surgery at the University of Toledo College of Medicine. Source: Adapted from Am Fam Physicians. 2012;86(11):1055-1061.
and Candida species, occur more often in tropical or subtropical environments and in patients previously treated with antibiotics.7-9 Inflammatory skin disorders and allergic reactions may cause noninfectious otitis externa, which can be chronic. RISK FACTORS Several factors may predispose patients to the development of acute otitis externa (Table 1).4,10 One of Table 1. Predisposing Factors for Otitis Externa Anatomic abnormalities
Dermatologic conditions
Canal stenosis
Eczema
Exostoses
Psoriasis
Hairy ear canals
Seborrhea
Canal obstruction
Other inflammatory dermatoses
Cerumen obstruction
Water in ear canal
Foreign body
Humidity
Sebaceous cyst
Sweating
Cerumen/epithelial integrity
Swimming or other prolonged water exposure
Cerumen removal
Miscellaneous
Earplugs
Purulent otorrhea from otitis media
Hearing aids
Soap
Instrumentation/itching
Stress Type A blood
Information from references 4 and 10.
Asian Journal of Ear, Nose and Throat, April-June 2013
5
REVIEW ARTICLE Table 2. Diagnosis of Otitis Externa Onset of symptoms within 48 hours in the past three weeks and Symptoms of ear canal inflammation: Ear pain, itching, or fullness With or without hearing loss or jaw pain and Signs of ear canal inflammation: Tenderness of tragus/pinna or ear canal edema/erythema With or without otorrhea, tympanic membrane erythema, cellulitis of the pinna, or local lymphadenitis
the most common predisposing factors is swimming, especially in fresh water. Other factors include skin conditions such as eczema and seborrhea, trauma from cerumen removal, use of external devices such as hearing aids, and cerumen buildup.4 These factors appear to work primarily through loss of the protective cerumen barrier, disruption of the epithelium (including maceration from water retention), inoculation with bacteria, and increase in the pH of the ear canal.10-12
Figure 1. Otitis externa on otoscopic examination following debris removal. Note canal erythema and edema.
PREVENTION A number of preventive measures have been recommended, including use of earplugs while swimming, use of hair dryers on the lowest settings and head tilting to remove water from the ear canal, and avoidance of self-cleaning or scratching the ear canal. Acetic acid 2% otic solutions are also used, either two drops twice daily or two to five drops after water exposure. However, no randomized trials have examined the effectiveness of any of these measures. DIAGNOSIS Acute otitis externa is diagnosed clinically based on signs and symptoms of canal inflammation (Table 24; Figures 1 and 2). Presentation can range from mild discomfort, itching, and minimal edema to severe pain, complete canal obstruction, and involvement of the pinna and surrounding skin. Pain is the symptom that best correlates with the severity of disease.13 Mild fever may be present, but a temperature greater than 101째F (38.3째C) suggests extension beyond the auditory canal. Acute otitis externa should be distinguished from other causes of ear canal inflammation4 (Table 3). Proper evaluation includes a history of presenting and associated symptoms, water exposure, local trauma/
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Asian Journal of Ear, Nose and Throat, April-June 2013
Figure 2. Acute otitis externa on otoscopic examination. Note marked canal edema.
cerumen removal, inflammatory skin disorders, diabetes, ear surgeries, and local radiotherapy. Physical examination should include the auricle and surrounding lymph nodes, a skin examination, otoscopy of the ear canal, and verification that the tympanic membrane is intact. Tenderness with movement of the tragus or pinna is a classic finding. Because otitis externa can cause tympanic membrane erythema, pneumatic otoscopy or tympanometry
REVIEW ARTICLE Table 3. Conditions that may be Confused with Acute Otitis Externa Condition
Distinguishing characteristics
Acute otitis media
Presence of middle ear effusion, no tragal/pinnal Use pneumatic otoscopy or tympanometry, treat with tenderness systemic antibiotics
Chronic otitis externa
Itching is often predominant symptom, erythematous Treat underlying causes/conditions canal, lasts more than three months
Chronic suppurative otitis media
Chronic otorrhea, nonintact tympanic membrane
Contact dermatitis
Allergic reaction to materials (e.g., metals, soaps, Check for piercings, hearing aids, or earplug use; plastics) in contact with the skin/epithelium; itching discontinue exposure when possible is predominant symptom
Eczema
Itching is predominant symptom; often chronic; Consider treatment with topical corticosteroids history of atopy, outbreaks in other locations
Furunculosis
Focal infection, may be pustule or nodule, often in Consider treatment with heat, incision and drainage, distal canal or systemic antibiotics; can progress to diffuse otitis externa
Malignant otitis externa
High fever, granulation tissue or necrotic tissue in ear canal, may have cranial nerve involvement; patient with diabetes mellitus or immunocompromise, elevated erythrocyte sedimentation rate, findings on computed tomography
Myringitis
Tympanic membrane inflammation, may have Usually results from acute otitis media or viral infection vesicles; pain is often severe, no canal edema
Otomycosis
Itching is predominant symptom, thick material in Can coexist with bacterial infections; treat with acetic canal, less edema; may see fungal elements on acid, half acetic acid/half alcohol, or topical antifungals; otoscopy (Figures 3 and 4) meticulous cleaning of ear canal
Ramsay Hunt syndrome
Herpetic ulcers in canal; may have facial numbness/ Treatment includes antivirals, systemic corticosteroids paralysis, severe pain, loss of taste
Referred pain
Normal ear examination
Look for other causes based on patterns of referred pain
Seborrhea
Itching and rash on hairline, face, scalp
Treatment includes lubricating or moisturizing the external auditory canal
Sensitization to otics
Severe itching, maculopapular or erythematous Type IV delayed hypersensitivity reaction to neomycin rash in conchal bowl and canal; may have streak or other components of otic solutions; discontinue on pinna where preparation contacted skin; vesicles offending agent; treat with topical corticosteroids may be present
should be used to differentiate it from otitis media. Otomycosis is classically associated with itching, thick material in the ear canal, and failure to improve with use of topical antibacterials. Otomycosis can sometimes be identified during otoscopy (Figures 3 and 4), although nonpathogenic saprophytic fungi may also be found. Malignant otitis externa may be suspected in older patients with diabetes mellitus or immunocompromise who have refractory purulent otorrhea and severe otalgia that may worsen at night. Clinical findings include granulation tissue in the external auditory canal, especially at the bone-cartilage junction. Extension of the infection beyond the auditory canal can cause
Comment
Control otitis externa symptoms, then treat otitis media
Medical emergency with high morbidity rate and possible mortality; warrants emergent consultation with otolaryngologist, hospitalization, intravenous antibiotics, debridement
lymphadenopathy, trismus, and facial nerve and other cranial nerve palsies. In chronic otitis externa, the symptoms and signs listed in Table 24 occur for more than three months. Classic symptoms include itching and mild discomfort; there may also be lichenification on otoscopy. TREATMENT
Topical Medications Topical antimicrobials, with or without topical corticosteroids, are the mainstay of treatment for uncomplicated acute otitis externa. Topical
Asian Journal of Ear, Nose and Throat, April-June 2013
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REVIEW ARTICLE may help facilitate compliance with treatment recommendations. Commonly studied antimicrobial agents include aminoglycosides, polymyxin B, quinolones, and acetic acid. No consistent evidence has shown that any one agent or preparation is more effective than another.4,14-16 There is limited evidence that use of acetic acid alone may require two additional days for resolution of symptoms compared with other agents, and that it is less effective if treatment is required for more than seven days.15
Figure 3. Otomycosis caused by Candida. Note the characteristic white fungal elements on the debris.
Current guidelines recommend factoring in the risk of adverse effects, adherence issues, cost, patient preference, and physician experience. Some components found in otic preparations may cause contact dermatitis.17 Hypersensitivity to aminoglycosides, particularly neomycin, may develop in up to 15 percent of the population, and has been identified in approximately 30 percent of patients who also have chronic or eczematous otitis externa.17,18 Adherence to topical therapy increases with ease of administration, such as less frequent dosing.19 The addition of a topical corticosteroid yields more rapid improvement in symptoms such as pain, canal edema, and erythema.4,14-16 Cost varies considerably for the different preparations20,21 (Table 44,14-16,20,21).
Oral Antibiotics
Figure 4. Otomycosis caused by Aspergillus. Note the characteristic gray-black fungal elements on the debris.
antimicrobials are highly effective compared with placebo, demonstrating an absolute increase in clinical cure rate of 46 percent or a number needed to treat of slightly more than two.4,14-16 Topical agents come in a variety of preparations and combinations; a recent systematic review included 26 different topical interventions.15 In some studies, ophthalmic preparations have been used off-label to treat otitis externa.14,15 Ophthalmic preparations may be better tolerated than otic preparations, possibly due to differences in pH between the preparations, and
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Asian Journal of Ear, Nose and Throat, April-June 2013
Systemic antibiotics increase the risks of adverse effects, generation of resistant organisms, and recurrence. They also increase time to clinical cure and do not improve outcomes compared with a topical agent alone in uncomplicated otitis externa.1,6,16,22 Systemic antibiotics should be used only when the infection has spread beyond the ear canal, or when there is uncontrolled diabetes, immunocompromise, a history of local radiotherapy, or an inability to deliver topical antibiotics.4,14,16
Treatment Methods Use of a topical otic preparation without culture is a reasonable treatment approach for patients who have mild symptoms of otitis externa. If the tympanic membrane is intact and there is no concern of hypersensitivity to aminoglycosides, a neomycin/ polymyxin B/hydrocortisone otic preparation would be a first-line therapy because of its effectiveness and low cost. Ofloxacin and ciprofloxacin/dexamethasone are approved for middle ear use and should be used if the tympanic membrane is not intact or its status cannot be determined visually4; these also may be
REVIEW ARTICLE Table 4. Common Antimicrobial Otic Preparations for Otitis Externa Component
Cost of generic (brand)
Dosage
Use if tympanic membrane perforation?
Comments
Acetic acid 2%
$39 for 15 mL*
Four to six times daily
No
May cause pain and irritation; may be less effective than other treatments if use is required beyond one week; often used as prophylactic agent
($36 for 15 mL)*
Ciprofloxacin 0.3%/ dexamethasone 0.1%
Not available ($160 for 7.5 mL)*
Twice daily
Yes
Low risk of sensitization
Hydrocortisone 2%/ acetic acid 1%
$220 for 10 mL†
Four to six times daily
No
May cause pain and irritation
Neomycin/polymyxin B/ hydrocortisone, solution or suspension
$28 for 10-mL solution;
Three to four times daily
No
Ototoxic; higher risk of contact hypersensitivity; avoid in chronic/ eczematous otitis externa4
Once to twice daily
Yes
Low risk of sensitization
($215 for 10 mL)* $30 for 10-mL suspension† ($85 for 10-mL solution; $78 for 10-mL suspension)†
Ofloxacin 0.3%
$60 for 5 mL; $93 for 10 mL† ($80 for 5 mL; $143 for 10
mL)†
*Estimated retail price of one course of treatment (10 to 14 days) based on information obtained at Red Book Online at http:// aapredbook. aappublications.org (accessed April 5, 2012). †Estimated retail price of one course of treatment (10 to 14 days) based on information obtained at http://www.drugstore.com (accessed April 5, 2012). Information from references 4, 14 through 16, 20, and 21.
useful if patients are hypersensitive to neomycin, or if nonadherence to treatment because of dosing frequency is an issue. Use of a corticosteroid-containing preparation is recommended to provide more rapid relief when symptoms warrant.
that are inaccessible because of canal swelling. As the canal responds to treatment and patency returns to the ear canal, the wick often falls out.
Patients should be taught to properly administer otic medications. The patient should lie down with his or her affected side facing upward, running the preparation along the side of the ear canal until it is full and gently moving the pinna to relieve air pockets. The patient should remain in this position for three to five minutes, after which the canal should not be occluded, but rather left open to dry.4 It may benefit the patient to have another person administer the ear drops, because only 40 percent of patients selfmedicate appropriately.23 Patients should be instructed to minimize trauma to (and manipulation of) the ear, and to avoid water exposure, including abstinence from water sports for a week or, at minimum, avoidance of submersion.
Pain is a common symptom of acute otitis externa, and can be debilitating.12 Oral analgesics are the preferred treatment. First-line analgesics include nonsteroidal anti-inflammatory drugs and acetaminophen. When ongoing frequent dosing is required to control pain, medications should be administered on a scheduled rather than as-needed basis. Opioid combination pills may be used when symptom severity warrants. Benzocaine otic preparations may compromise the effectiveness of otic antibiotic drops by limiting contact between the drop and the ear canal. The lack of published data supporting the effectiveness of topical benzocaine preparations in otitis externa limits the role of such treatments.
When there is marked canal edema, a wick of compressed cellulose or ribbon gauze may be placed in the canal to facilitate antimicrobial or antibiotic administration. Wick placement permits antibiotic drops to reach portions of the external auditory canal
Analgesia
Cleaning the Canal Acute otitis externa can be associated with copious material in the ear canal. Consensus guidelines published by the American Academy of Otolaryngology recommend that such material be removed to achieve
Asian Journal of Ear, Nose and Throat, April-June 2013
9
REVIEW ARTICLE optimal effectiveness of the topical antibiotics.4,16 However, no randomized controlled trials have examined the effectiveness of aural toilet, and this is not typically done in most primary care settings.4,15 Topical medications rely on direct contact with the infected skin of the ear canal; hence, aural toilet takes on greater importance when the volume or thickness of the debris in the ear canal is great. Guidelines recommend aural toilet by gentle lavage suctioning or dry mopping under otoscopic or microscopic visualization to remove obstructing material and to verify tympanic membrane integrity.4 Lavage should be used only if the tympanic membrane is known to be intact, and should not be performed on patients with diabetes because of the potential risk of causing malignant otitis externa.4 Pain medications may be required during the procedure.
Chronic Otitis Externa The treatment of chronic otitis externa depends on the underlying causes. Because most cases are caused by allergies or inflammatory dermatologic conditions, treatment includes the removal of offending agents and the use of topical or systemic corticosteroids. Chronic or intermittent otorrhea over weeks to months, particularly with an open tympanic membrane, suggests the presence of chronic suppurative otitis media. Initial treatment efforts are similar to those for acute otitis media. With control of the symptoms of otitis externa, attention can shift to the management of chronic suppurative otitis media. FOLLOW-UP AND REFERRAL Most patients will experience considerable improvement in symptoms after one day of treatment. If there is no improvement within 48 to 72 hours, physicians should reevaluate for treatment adherence, misdiagnosis (Table 3), sensitivity to ear drops, or continued canal patency. The physician should consider culturing material from the canal to identify fungal and antibiotic-resistant pathogens if the patient does not improve after initial treatment efforts or has one or more predisposing risk factors, or if there is suspicion that the infection has extended beyond the external auditory canal. There is a lack of data regarding optimal length of treatment; as a general rule, antimicrobial otics should be administered for seven to 10 days, although in some cases complete resolution of symptoms may take up to four weeks.4,15 Consultation with an otolaryngologist or infectious disease subspecialist may be warranted if malignant
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Asian Journal of Ear, Nose and Throat, April-June 2013
otitis externa is suspected; in cases of severe disease, lack of improvement or worsening of symptoms despite treatment, and unsuccessful lavage; or if the primary care physician determines that aural toilet or ear wick insertion is warranted, but is unfamiliar with or concerned about performing the procedure. REFERENCES 1. Rowlands S, Devalia H, Smith C, Hubbard R, Dean A. Otitis externa in UK general practice: a survey using the UK General Practice Research Database. Br J Gen Pract. 2001;51(468):533-538. 2. Raza SA, Denholm SW, Wong JC. An audit of the management of acute otitis externa in an ENT casualty clinic. J Laryngol Otol. 1995;109(2):130-133. 3. Rubin Grandis J, Branstetter BF IV, Yu VL. The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations. Lancet Infect Dis. 2004;4(1):34-39. 4. Rosenfeld RM, Brown L, Cannon CR, et al.; American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2006;134 (4 suppl):S4-S23. 5. Ninkovic G, Dullo V, Saunders NC. Microbiology of otitis externa in the secondary care in United Kingdom and antimicrobial sensitivity. Auris Nasus Larynx. 2008;35(4):480-484. 6. Roland PS, Stroman DW. Microbiology of acute otitis externa. Laryngoscope. 2002;112(7 pt 1):1166-1177. 7. Martin TJ, Kerschner JE, Flanary VA. Fungal causes of otitis externa and tympanostomy tube otorrhea. Int J Pediatr Otorhinolaryngol. 2005;69(11):1503-1508. 8. Pontes ZB, Silva AD, Lima Ede O, et al. Otomycosis: a retrospective study. Braz J Otorhinolaryngol. 2009; 75(3):367-370. 9. Ahmad N, Etheridge C, Farrington M, Baguley DM. Prospective study of the microbiological flora of hearing aid moulds and the efficacy of current cleaning techniques. J Laryngol Otol. 2007;121(2):110-113. 10. Russell JD, Donnelly M, McShane DP, Alun-Jones T, Walsh M. What causes acute otitis externa? J Laryngol Otol. 1993;107(10):898-901. 11. Kim JK, Cho JH. Change of external auditory canal pH in acute otitis externa. Ann Otol Rhinol Laryngol. 2009;118(11):769-772. 12. van Asperen IA, de Rover CM, Schijven JF, et al. Risk of otitis externa after swimming in recreational fresh water lakes containing Pseudomonas aeruginosa. BMJ. 1995;311(7017):1407-1410.
REVIEW ARTICLE 13. Halpern MT, Palmer CS, Seidlin M. Treatment patterns for otitis externa. J Am Board Fam Pract. 1999;12(1):1-7.
eczematous external otitis. Asian Pac J Allergy Immunol. 2004;22(1):7-10.
14. Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(4 suppl):S24-S48.
19. Shikiar R, Halpern MT, McGann M, Palmer CS, Seidlin M. The relation of patient satisfaction with treatment of otitis externa to clinical outcomes: development of an instrument. Clin Ther. 1999;21(6):1091-1104.
15. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010;(1):CD004740. 16. Hajioff D, Mackeith S. Otitis externa. Clin Evid (Online). 2010. 17. Smith IM, Keay DG, Buxton PK. Contact hypersensitivity in patients with chronic otitis externa. Clin Otolaryngol Allied Sci. 1990;15(2):155-158. 18. Yariktas M, Yildirim M, Doner F, Baysal V, Dogru H. Allergic contact dermatitis prevalence in patients with
20. Drugstore.com. April 4, 2011.
http://www.drugstore.com.
Accessed
21. EverydayHealth.com. Drugs A-Z on everyday health. http://www.everydayhealth.com/drugs/. Accessed April 5, 2011. 22. Roland PS, Belcher BP, Bettis R, et al.; Cipro HC Study Group. A single topical agent is clinically equivalent to the combination of topical and oral antibiotic treatment for otitis externa. Am J Otolaryngol. 2008;29(4):255-261. 23. England RJ, Homer JJ, Jasser P, Wilde AD. Accuracy of patient self-medication with topical eardrops. J Laryngol Otol. 2000;114(1):24-25.
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Surgery may Hike Survival in Tonsil Cancer Tonsillectomy followed by radiation therapy led to better survival in patients with early-stage tonsil cancer compared with radiation alone, a retrospective analysis suggested. Overall survival at five years was 83.2% (95% confidence interval [CI] 76.8-88) for patients who underwent surgery before radiation compared with 63.6% (95% CI 54.5-71.4, p < 0.001) among those who had only a tonsillar biopsy prior to radiation, according to Michael A. Holliday, MD, and colleagues from Georgetown University in Washington, DC. In addition, 5-year disease-specific survival rates were 89.6% (95% CI 84.1-93.3) and 76% (95% CI 67.8-82.2, p < 0.001), respectively, the researchers reported in the April JAMA Otolaryngology–Head & Neck Surgery. Despite this apparent survival advantage, the researchers pointed out that their analysis was probably influenced by selection bias, and should not be considered definitive. “Whether to treat patients with early-stage tonsil cancer using surgery or (radiation therapy) remains controversial, and with the advent of new procedures to address the primary tumor, the debate is far from settled,” they stated. Current guidelines suggest that either surgery or radiation is appropriate for early tonsil cancer. Tumor margins may remain positive when a diagnostic procedure such as a needle biopsy is done, but tonsillectomy requires delay in potentially curative radiation while the wound heals. Therefore, to see if a combined approach would be superior, Holliday’s team analyzed data from the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program, identifying 524 patients diagnosed with stage T1 or T2 tonsil cancer in the years 1988 to 2006. T1 tumors were smaller than 2 cm, and T2 tumors were 2-4 cm. All cases were squamous or epithelial cell cancers, and 61% were stage T2. A total of 54% of patients had surgery plus radiation, while the remainder had only radiotherapy. In a univariate analysis, factors influencing overall and disease-specific survival were older age, having had surgery, and being diagnosed after 2004. In multivariate analyses, those factors remained significantly associated with death from tonsil cancer. (Source: Medpage)
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CASE REPORT
Congenital Facial Palsy with Bilateral Anotia GEETA GATHWALA*, JAGJIT SINGH**, POONAM DALAL**
ABSTRACT Congenital facial palsy is generally considered developmental or acquired. Most of the cases are related to birth trauma. Herein we report a case of congenital facial palsy with bilateral anotia and external auditory canal artesia.
Keywords: Congenital facial palsy, anotia
C
ongenital facial palsy (CFP) is generally considered to be either developmental or acquired in origin. Developmental facial paralysis is associated with other anomalies including those of pinna and external auditory canal, ranging from mild defects to severe microtia and atresia.1 Herein we report a rare case of congenital right facial paralysis associated with bilateral anotia and atresia of right external auditory canal. CASE REPORT A 6-month-old male infant was admitted to the pediatric ward with lower respiratory tract infection. There was history of facial asymmetry and absent ears since birth. There was no history suggestive of intrauterine infection or drug intake during pregnancy. The baby was full-term normal vaginal delivery. Physical examination showed bilateral anotia, preauricular tag was present bilaterally and right lower motor neuron type of facial palsy (Figs. 1-3). There was no other cranial nerve palsy and the rest of the examination including neurological examination was normal. Magnetic resonance imaging (MRI) brain was normal. High-resolution CT temporal bone done to define the etiology of facial nerve palsy revealed absence of pinna, right auditory canal was not visualized and the middle
*Senior Professor and Head **Assistant Professor Dept. of Pediatrics Pt. BD Sharma PGIMS, Rohtak, Haryana Address for correspondence Dr Jagjit Singh Flat No.15, Couple Hostel, Medical Enclave, Pt. BD Sharma PGIMS Rohtak - 124 001, Haryana Email: drjagjitsingh@hotmail.com
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Asian Journal of Ear, Nose and Throat, April-June 2013
ear ossicles were reported normal. Brainstem Evoked Response Audiometry (BERA) was normal. DISCUSSION Congenital facial nerve palsy is an infrequent condition with a reported incidence of 2.1 per 1,000 live births.2 In 78% of cases CFP is related to birth trauma. No such history was available in the index case. Other causes include, intrauterine posture, intrapartum compression, and familial and congenital aplasia of the nucleus; the last being most frequently reported for bilateral cases. There are a number of syndromes which encompass CFP as part of their symptoms, including the cardiofacial, Moebius, Polandâ&#x20AC;&#x2122;s, and Goldenhaarâ&#x20AC;&#x2122;s syndrome.1,3 Some cases of CFP have been attributed to agenesis of the petrous portion of the temporal bone, with resulting agenesis of the facial and auditory nerves, the external ear and the mastoid region.4 Most commonly, development facial paralysis is associated with other anomalies. The most common site reported is the maxilla, including defects such as cleft palate, hypoplastic maxilla and duplication of the palate. Others have demonstrated a propensity for anomalies of the pinna and external auditory canal, ranging from mild defects to severe microtia and atresia.1 A striking association of grossly abnormal pinna, multiple defects and facial palsy has been reported in 9-15% of patients. The index case had bilateral anotia and right auditory canal atresia with right facial palsy. Aural atresia occurs in approximately one in 20,000 live births. Atresia and microtia are parts of several syndromes with inherited defects or acquired embryopathies owing to intrauterine infections (rubella,
CASE REPORT
Figure 1. Showing anotia of right side with skin tags. No external auditory meatus seen.
Figure 2. Showing anotia of left side and the external auditory meatus.
syphilis), ischemic injury (hemifacial microsomia) or toxin exposure (thalidomide, isotretinon). Embryonic insult, severe enough to cause aural atresia would also affect other organ systems. Aberration in the canalization process of external auditory canal can lead to stenosis, canal tortuosity or fibrosis/osseous obliteration. Since middle ear structure develops independently, the tympanic cavity and ossicles may be normal. Defects in the canalization process may also be associated with faulty formation of pinna.5 In the index case right side CFP was associated with anotia and right sided atresia. No other abnormalities were observed. Several surgical techniques are employed for treatment of CFP. The ideal time for the intervention is controversial. Some clinicians advocate early (preschool) surgery for the animation of children’s faces6,7 while others propose surgery not before adolescence.8 Muscle transplantation for facial paralysis has been shown to be effective.7 However, the possibilities of reconstructive surgery are limited. Traumatic facial palsy in neonates is associated with good prognosis. In contrast facial palsies, as in the index, case carry a poor functional outcome.9,10
Figure 3. Showing lower motor neuron type of facial palsy on the right side with bilateral anotia.
REFERENCES 1. Bergstrom L, Baker BB. Syndromes associated with congenital facial paralysis. Otolaryngol Head Neck Surg 1981;89(2):336-42. 2. Falco NA, Eriksson E. Facial nerve palsy in the newborn: incidence and outcome. Plast Reconstr Surg 1990;85(1):1-4. 3. Jemec B, Grobbelaar AO, Harrison DH. The abnormal nucleus as a cause of congenital facial palsy. Arch Dis Child 2000;83(3):256-8. 4. Smith JD, Crumley RL, Harker LA. Facial paralysis in the newborn. Otolaryngol Head Neck Surg 1981;89(6):1021-4. 5. Parisier SC, Fayad JN, Kimmelman CP. Microtia, canal atresia, and middle ear anomalies. In: Ballenger’s Otorhinolaryngology Head and Neck Surgery. 16th edition, Snow JB, Ballenger JJ (Eds.), Williams & Wilkins: Spain 2003:p.997-9. 6. Harrison DH. Treatment of infants with facial palsy. Arch Dis Child 1994;71(3):277-80. 7. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant. Plast Reconstr Surg 2000;106(1):1-8; discussion 9. 8. May M. Facial paralysis at birth: medicolegal and clinical implications. Am J Otol 1995;16(6):711-2. 9. Laing JH, Harrison DH, Jones BM, Laing GJ. Is permanent congenital facial palsy caused by birth trauma? Arch Dis Child 1996;74(1):56-8.
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EXPERT OPINION
What is the Role of Bioengineering Solutions for Hearing Loss? RAGHUNANDHAN
R
apid technological advancements in recent times have resulted in prospective cuttingedge bioengineering solutions for congenital/ acquired hearing loss, unresponsive to conventional amplification, advances in microelectronics, battery technology and mechanical packaging have resulted in development of effective auditory neural prosthesis for patients with severe to profound hearing impairment. These devices represent the first successful human attempt at restoring a lost special neurological sense by integrating an external circuit with neuronal circuitry. This is possible, owing to the low rejection property of the inner ear and nervous system. Thus, introduction of auditory neural prostheses have revolutionized the management of unaidable sensorineural deficits in the last few decades. Middle ear implants have been recommended for patients with moderate-to-severe hearing loss with normal middle ear function and good speech perception. They are partially implantable and deliver sound by driving the middle ear ossicles mechanically, rather than acoustically, through electromagnetic or piezoelectric transducers, while reducing acoustic feedback and sound distortion. Newer development in this technology has brought the introduction of Totally Implantable Hearing Aids (TIHA), which is soon to arrive into the commercial market. Cochlear implants restore hearing in patients with severe-profound cochlear hearing loss unresponsive to amplification by hearing aids, by bypassing damaged or undeveloped sensory structures in the cochlea and directly stimulating the auditory nerve. Today, new sound processing strategies are available as a result of which, the benefit from cochlear implantation has increased, including improved understanding of speech in noise and better sound quality. Development if new sound processing algorithms that mimic nonlinear processes inducing acoustic compression of the normal cochlea may improve the signal delivered to the auditory nerve. Frequency resolution and precise signal band filtering may be enhanced by steering current to discrete sites along the cochlea, thereby increasing the number of spectral channels that can be perceived. Future research also looks into the possibility of drug/
Consultant ENT Surgeon; Madras ENT Research Foundation, Chennai
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Asian Journal of Ear, Nose and Throat, April-June 2013
growth factor impregnation into the electrode array to induce neural growth towards the electrodes in order to preserve and promote electroneuronal integration. A recent innovation in Cochlear Implant technology is the introduction of the Totally Implantable Cochlear Implant (TIKI), which has undergone successful human trials. Recent research also focuses into the higher centers of hearing in the auditory pathway, progressing from the well-established Auditory Brainstem Implants onto the arrival of the Auditory Mid-brain Implants. Molecular basis of deafness has been investigated widely, with the well-known isolation of the Connexin gene, implicated in congenital deafness. Research has now shown that genetic mutations in a protein called â&#x20AC;&#x2DC;Espinâ&#x20AC;&#x2122; can cause floppiness in tiny bundles of protein filaments within the robust hair cells, impairing the passage of acoustic vibrations and resulting in congenital deafness. Genetic mapping of such mutations in Espinâ&#x20AC;&#x2122;s F-actin binding sites, provide a clue to the origin of deafness and gene therapy could be initiated to prevent or restore the mutation-induced damages within the organ of Corti. Stem cell research has developed by leaps and bounds in the field of neurology and organ transplantation, with standardization of procedures for harvesting umbilical cord-based cells used for processing neuronal/in vitro growth factors. A similar principle has been followed for the ongoing research for development of neural regeneration factors to stimulate hair cells and afferent neuronal fibers of the organ of Corti within the cochlea. Preliminary results have been promising in animal studies and the near future should see the advent of commercially producible neural regeneration factors for the restoration of hearing. SUGGESTED READING 1. Qun LX, et al. Neurotrophic factors in the auditory periphery. Ann NY Acad Sci 1999;884:292-304. 2. Peterson GE, et al. Revised CNC lists for auditory tests. J Speech Hear Disord 1962;27:62-70. 3. Wilson BS, et al. Cochlear implants: some likely steps. Annu Rev Biomed Eng 2003;5:207-49. 4. Koch DB, et al. Bioengineering solutions for hearing loss and related disorders. Otolaryngol Clin North Am 2005;38(2):255-72. 5. Kloeppel JE, et al. Molecular basis for congenital form of deafness. Am J Natl Instt Health Sci 2007;(S2):17-21.
ALGORITHM
Diagnosis and Management of Sore Throat
Does clinician accept that antibiotics offer a clinically significant benefit in acute Group A streptococcal (GAS) pharyngitis?
No
Yes
Features do not suggest acute GAS pharyngitis
Features suggest acute GAS pharyngitis:
Fever* Tonsillar or pharyngeal erythema or swelling* zz Tonsillar or pharyngeal exudate* zz Tender or enlarged anterior cervical lymph nodes* zz Absence or viral symptoms (cough, conjunctivitis, coryza)* † zz Age: 5-15 years † zz Season: winter/early spring † zz Headache † zz History of exposure to GAS zz zz
No investigations No antibiotics
Throat swab and culture‡ Phenoxymethyl penicillin 250 mg (500 mg in adults) twice daily§
Culture negative for GAS
Culture positive for GAS
Cease antibiotics
Continue oral antibiotic for 10 days
*These feature have been identified as indicating GAS pharyngitis in all or most studies and clinical algorithms. †These ‡Optical
features have been identified as indicating GAS pharyngitis in some but not all studies and clinical algorithms. immunoassay rapid streptococcal antigen test can be substituted for culture if available.
§A
single intramuscular injection of benzathine penicillin G may be used instead. Erythromycin is currently recommended if the patient in allergic to penicillin. Symptomatic treatment should be considered regardless of clinical pathway
Source: MJA 2002;177(9):512-5.
Asian Journal of Ear, Nose and Throat, April-June 2013
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Asian Journal of
Ear, Nose Throat Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Ear, Nose and Throat strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter – The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. – Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. – Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript. Manuscript – Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). –
–
The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.
All pages should be numbered consecutively beginning with the title page. Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.
Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used. – The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary. – A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included. – The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. – A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text. Summary – The summary of not more than 200 words. It must convey the essential features of the paper. – It should not contain abbreviations, footnotes or references. Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives. Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others. – Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected. – Method of selecting the sample (cases, subjects, etc. from the statistical universe). – Method of allocating the subjects into different groups. – Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques. – Confidence intervals for the measurements should be provided wherever appropriate.
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Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text. Discussion – This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost. References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111. Books Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985. Articles in Books Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470. Tables – These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table. Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.
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Asian Journal of Ear, Nose and Throat, April-June 2013
– The legend must include enough information to permit interpretation of the figure without reference to the text. Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. – All photomicrographs should indicate the magnification of the print. – Special features should be indicated by arrows or letters which contrast with the background. – The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. – Color illustrations will be accepted if they make a contribution to the understanding of the article. – Do not use clips/staples on photographs and artwork. – Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)____________________________ 2. Total number of pages ______________________ 3. Number of tables __________________________ 4. Number of figures _________________________ 5. Special requests __________________________ 6. Suggestions for reviewers (name and postal address) Indian 1._____________Foreign 1.______________ 2._____________ 2.______________ 3._____________ 3.______________ 4._____________ 4.______________ 7. All authors’ signatures______________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers _______________________________________ Issue Editor Dr Jasveer Singh Asian Journal of Ear, Nose and Throat
Online Submission Also e- Issue @ www.ijcpgroup.com For Editorial Correspondence
Dr KK Aggarwal
Group Editor-in-Chief Asian Journal of Ear, Nose and Throat E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com
Volume 22, Number 11 Peer Reviewed Journal
Drug Review
Review Article
Original Article
Case Report
Photo Quiz
Lighter Reading
April 2012, Pages 545-596