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Vol. 66, No. 1 2015
Northeast Florida Medicine
Otolaryngology
o Any AOM or OME in an at risk child
• Tympanostomy tubes should NOT be recommended if:
o Recurrent AOM without MEE on
Otolaryngology evaluation
• For uncomplicated acute tympanostomy tube otorrhea only
ototopical drops should be used without oral antibiotics.
• Routine water precautions are not recommended for
children with tympanostomy tubes.
The recommendation causing the most debate among
diverse specialties is the opinion against tube placement for
children who meet criteria for recurrent AOM, but who do
not have middle ear effusions at the time of consultation with
theirOtolaryngologist.The support for this recommendation
is based on the favorable natural history of recurrent AOM
and the low risk of delaying tubes.
11
Important exceptions to
this recommendation are children who have complications
from AOM, history of difficult to treat AOM or multiple
antibiotic allergies, or are otherwise at risk.
11
Another departure from common practice is to not recom-
mend use of ear plugs in children with tympanostomy tubes.
This is based primarily on one large randomized controlled
trial that found that the average child with tubes would have
to wear ear plugs for 2.8 years to prevent one episode of otor-
rhea.
12
Other prior studies support these findings. Exceptions
to this are children who have persistent or recurrent otorrhea,
those with risk factors such as immune dysfunction, and deep
diving or simply ear discomfort with swimming.
Sensorineural hearing loss:
Early diagnosis and treatment
According to theCenters forDiseaseControl andPrevention
(CDC), more than 97 percent of newborns in the US were
successfully screened for hearing loss in 2011 highlighting
the huge success of the newborn infant hearing screening
programs.
13
The current focus is timely diagnosis of those
children who are deaf and hard of hearing (D/HH) and
referral for early intervention (EI). Many children who are
D/HH can achieve communication skills on par with their
peers of similar age and cognitive ability with appropriate
interventionprior to sixmonths of age. Achieving these results
in the majority of children with hearing loss requires equal
access to the required services on a local and state level and
awareness among the primary care medical community.
The most comprehensive guideline is the 2007 position
statement by the Joint Committee on Infant Hearing which
was updated in 2013.
14,15
A brief summary is provided below:
• By one month of age: Physiologic hearing screen (ABR
or OAE).
o Rescreening of an initially failed screen can be done
prior to hospital discharge, but no later than one
month after discharge.
• By three months of age: Infants who fail the initial hear-
ing screen should receive a comprehensive audiologic, an
otolaryngologic evaluation along with fitting of ampli-
fication devices (when appropriate). Genetic evaluation
should be offered at this stage as well.
o These recommendations apply to both bilateral and
unilateral hearing loss.
• Within 48 hours of confirmed hearing loss: referral to
early intervention services.
• By six months of age: A child with confirmed hearing
loss should be enrolled in early intervention services.
• On-going hearing screening for all children based on
AAP well visit schedule.
• Cochlear implantation: Should be considered for all
children with sensorineural hearing loss who are not
benefiting from appropriate amplification.
• FDA guidelines for cochlear implantation:
o Older than 12 months of age
o Bilateral severe to profound sensorineural hearing loss
• Bone anchored hearing aids (BAHA): should be consid-
ered for children with permanent conductive and mixed
hearing loss.
• FDA guidelines for BAHA:
o Older than 5 years of age
o Less than 65 dB conductive hearing loss for a pure
tone average
Pediatric Rhinosinusitis
The treatment of acute rhinosinusitis in children remains
controversial. This has been discussed in the literature which
has been summarized in a clinical practice guideline by the
American Academy of Pediatrics.
16
The last decade has seen
very little in the way of new evidence that alters or supports
our current understanding of recurrent acute and chronic
sinusitis in children.
When facedwith the chronically “snotty” child, it is import-
ant to distinguish between recurrent viral upper respiratory
infections and bacterial sinusitis which can be accomplished
using the following definitions
16
:
• Acute bacterial sinusitis is defined as any URI (nasal
discharge or daytime cough) that: lasts longer than 10 to
14 days, worsens after initial improvement, or is severe
in onset with temp higher than 39°C and purulent rhi-
norrhea for at least three days.
