Presence Of Cerumen Research Articles

Teaching pediatric otoscopy skills to the medical student in the clinical setting: preceptor perspectives and practice

BackgroundAcute otitis media (AOM) is the most frequent indication for antibiotic treatment of children in the United States. Its diagnosis relies on visualization of the tympanic membrane, a clinical skill acquired through a deliberate approach. Instruction in pediatric otoscopy begins in medical school. Medical students receive their primary experience with pediatric otoscopy during the required pediatric clerkship, traditionally relying on an immersion, apprentice-type learning model. A better understanding of their preceptors’ clinical and teaching practices could lead to improved skill acquisition. This study investigates how pediatric preceptors (PP) and members of the Council on Medical Student Education in Pediatrics (COMSEP) perceive teaching otoscopy.MethodsA 30-item online survey was administered to a purposeful sample of PP at six institutions in 2017. A comparable 23-item survey was administered to members through the 2018 COMSEP Annual Survey. Only COMSEP members who identified themselves as teaching otoscopy to medical students were asked to complete the otoscopy-related questions on the survey.ResultsSurvey respondents included 58% of PP (180/310) and 44% (152/348) of COMSEP members. Forty-one percent (62/152) of COMSEP member respondents identified themselves as teaching otoscopy and completed the otoscopy-related questions. The majority agreed that standardized curricula are needed (PP 78%, COMSEP members 97%) and that all graduating medical students should be able to perform pediatric otoscopy (PP 95%, COMSEP members 79%). Most respondents reported usefulness of the American Academy of Pediatrics (AAP) AOM guidelines (PP 95%, COMSEP members 100%). More COMSEP members than PP adhered to the AAP’s diagnostic criteria (pediatric preceptors 42%, COMSEP members 93%). The most common barriers to teaching otoscopy were a lack of assistive technology (PP 77%, COMSEP members 56%), presence of cerumen (PP 58%, COMSEP members 60%), time to teach in direct patient care (PP 46%, COMSEP members 48%), and parent anxiety (PP 62%, COMSEP members 54%).ConclusionsOur study identified systemic and individual practice patterns and barriers to teaching pediatric otoscopy. These results can inform education leaders in supporting and enabling preceptors in their clinical teaching. This approach can be adapted to ensure graduating medical students obtain intended core clinical skills.

Prevalence and Clinical Aspects of Otodectes cynotis Infestation in Dogs and Cats in the Semi-arid Region of Paraíba, Brazil

Background: Infestation by Otodectes cynotis is one of the main causes of external otitis in small animals, causing great disconfort and predisposition to secondary bacterial or fungal infections, with relevant importance in the small animal medicine. In dogs, a small number of this parasite in the ears may cause inflammation, while in cats, otoacariasis accounts for half of the external otitis cases. Due to the insufficiency of data about the prevalence of this disease in the Northeast region of Brazil, the purpose of the present study was to evaluate the prevalence and clinical aspects of O. cynotis in dogs and cats from the Semi-arid region of Paraíba, Brazil.Material, Methods & Results: The research was conducted in the municipality of Sousa, Paraíba State, Brazil. A total of 102 dogs and 152 cats had their external ear canals examined by bilateral otoscopy, using an otoscope with a veterinary cone that allows inspection of the external ear canal. Parasitological swabs were also used to determine the prevalence of parasitism by O. cynotis. Samples collected in swabs were stored in a 70% alcohol preservative solution and sent to the Laboratory of Veterinary Parasitology, in wich were examinated on direct research, using microscopes in the 10x objective (magnification of 100x). In all animals, clinical examinations were performed and their owners answered an epidemiological questionnaire to collect information about food and sanitary management. During the clinical examination, characteristics such as otopodal reflex, and the presence of pruritus and/or cerumen were also evaluated. The prevalence of dogs and cats positive for O. cynotis was 33.3% (34/102) and 52.6% (80/152), respectively. Bilateral infestations occurred in 52.9% (18/34) of the positive dogs. Most of the positive animals showed evidence of the mite in both tests, Otoscopy + Swab (dogs: 58.8% - 20/34, cats: 66.2% - 53/80).Discussion: A high prevalence of O. cynotis infestation was observed in dogs (33.3%) and even higher prevalence in cats (52.6%), both are higher than it was expected. The diagnosis methods were effective for detecting infestation by this parasite, and the parasitological swab resulted in higher diagnosis rate than the otoscopy. The use of two diagnosis methods resulted in a greater number of positive diagnoses, explaining the high prevalence found in the present study. A higher prevalence was observed for animals that had contact with other animals. The direct form is the most accepted mode of transmission of Otodectes sp. and close confinement of animals was considered the main associated factor for frequent reinfestation by the mite. For dogs, the presence of cerumen and pruritus were seen as O. cynotis infestation factors. Considering dogs, in the clinical examination, the presence of pruritus was significantly associated with the occurrence of parasitism. This association can be explained because O. cynotis is very active within the ear canals of parasitized animals, causing great annoyance and pruritus. No statistically significant risk factors were found for cats, but it was observed that adults had higher levels of infestation when compared to young cats, wich was not expected, as the literature commonly reports that young cats have higher levels of infestation. This can be explained by the confinement and the usual direct contact by different cats, increasing the occurrence of the parasite. In cats, the clinical examinations showed that the presence of otopodal reflex was significantly associated (p<0.2) with the parasitism occurrence (55.4%; 66/119). The evaluation of this reflex has been considered as one of the symptoms of otocariosis.

Fever: Measuring and Managing

1. Henry M. Adam, MD 1. Editor, In Brief, Bronx, NY 1. 1. Sullivan JE, 2. Farrar HC Clinical Report—Fever & Antipyretic Use in Children. Sullivan JE, Farrar HC Section on Clinical Pharmacology & Therapeutics and Committee on Drugs. Pediatrics. 2011;127:580–587 [OpenUrl][1][Abstract/FREE Full Text][2] 2. 1. Schmitt BD Fever Phobia: Misconceptions of Parents about Fevers. Schmitt BD. Am J Dis Child. 1980;134:176–181 [OpenUrl][3][CrossRef][4][PubMed][5] 3. 1. May A, 2. Bauchner H Fever Phobia: The Pediatrician’s Contribution. May A, Bauchner H. Pediatrics. 1992;90:851–854 [OpenUrl][6][Abstract/FREE Full Text][7] 4. 1. Simon HB Hyperthermia. Simon HB. N Engl J Med. 1993;329:483–487 [OpenUrl][8][CrossRef][9][PubMed][10][Web of Science][11] 5. 1. Adam HM 1. McInerny TK, 2. Adam HM, 3. Campbell DE, 4. Kamat DM, 5. Kelleher KJ Physiology & Management of Fever. Adam HM. In: McInerny TK, Adam HM, Campbell DE, Kamat DM, Kelleher KJ, eds. American Academy of Pediatrics Textbook of Pediatric Care. Elk Grove Village, IL: American Academy of Pediatrics; 2009:418–422 At least in Western cultures we have a strong tradition of viewing fever not only as a response to illness but also as a disease itself. Although our science teaches us that fever, as part of the inflammatory response, is only a sign or symptom of the real pathologic process, our nomenclature (blackwater, cat scratch, dengue, hay, jungle, puerperal, rat bite, relapsing, rheumatic, Rocky Mountain spotted, scarlet, typhoid, and yellow fever) reinforces the temptation to treat fever as if it were the noxious culprit itself. Fever, as opposed to hyperthermia, rarely poses a threat to a child’s well-being; in fact, as an energy-expensive phenomenon, fever is not likely to have weathered evolution without conferring some survival benefit. Considering that fever is the most common signal of illness in children, serving as the cause of as many as a third of all pediatric office visits, we would do well to clarify our approach to its management that is distinct from the illnesses that cause it. Fever is a regulated elevation of body temperature, mediated by the anterior hypothalamus, which occurs in response to any insult that stimulates the body’s inflammatory defenses. Similar to a thermostat, the hypothalamic set point controls the temperature the body tries to maintain. Some provocation, in children most commonly a viral infection, induces macrophages to release cytokines that function as endogenous pyrogens. They circulate to the anterior hypothalamus, where they increase local levels of prostaglandin E2 and induce an increase in the set point. Several mechanisms then come into play to bring the core temperature (the temperature of blood within the pulmonary artery) up to the new set point. Because … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2010-3852%26rft_id%253Dinfo%253Apmid%252F21357332%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=127/3/580&atom=%2Fpedsinreview%2F34%2F8%2F368.atom [3]: {openurl}?query=rft.jtitle%253DArchives%2Bof%2BPediatrics%2Band%2BAdolescent%2BMedicine%26rft.stitle%253DArch%2BPediatr%2BAdolesc%2BMed%26rft.issn%253D0002-922X%26rft.aulast%253DSchmitt%26rft.auinit1%253DB.%2BD.%26rft.volume%253D134%26rft.issue%253D2%26rft.spage%253D176%26rft.epage%253D181%26rft.atitle%253DFever%2BPhobia%253A%2BMisconceptions%2Bof%2BParents%2BAbout%2BFevers%26rft_id%253Dinfo%253Adoi%252F10.1001%252Farchpedi.1980.02130140050015%26rft_id%253Dinfo%253Apmid%252F7352443%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [4]: /lookup/external-ref?access_num=10.1001/archpedi.1980.02130140050015&link_type=DOI [5]: /lookup/external-ref?access_num=7352443&link_type=MED&atom=%2Fpedsinreview%2F34%2F8%2F368.atom [6]: {openurl}?query=rft.jtitle%253DPediatrics%26rft.stitle%253DPediatrics%26rft.issn%253D0031-4005%26rft.aulast%253DMay%26rft.auinit1%253DA.%26rft.volume%253D90%26rft.issue%253D6%26rft.spage%253D851%26rft.epage%253D854%26rft.atitle%253DFever%2BPhobia%253A%2BThe%2BPediatrician%2527s%2BContribution%26rft_id%253Dinfo%253Apmid%252F1437424%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [7]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=90/6/851&atom=%2Fpedsinreview%2F34%2F8%2F368.atom [8]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DSimon%26rft.auinit1%253DH.%2BB.%26rft.volume%253D329%26rft.issue%253D7%26rft.spage%253D483%26rft.epage%253D487%26rft.atitle%253DHyperthermia%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJM199308123290708%26rft_id%253Dinfo%253Apmid%252F8332154%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [9]: /lookup/external-ref?access_num=10.1056/NEJM199308123290708&link_type=DOI [10]: /lookup/external-ref?access_num=8332154&link_type=MED&atom=%2Fpedsinreview%2F34%2F8%2F368.atom [11]: /lookup/external-ref?access_num=A1993LR44300008&link_type=ISI

SENSORY NEURAL HEARING LOSS IN β-THALASSEMIA MAJOR PATIENTS TREATED WITH DEFEROXAMINE

This study evaluated the incidence of sensory neural hearing loss (SNHL) in β-thalassemia major patients treated with deferoxamine in Mofid Children's Hospital. Based on the patients’ file review, this descriptive and cross-sectional study was performed in all thalassemia patients older than 5 years old who were treated with regular blood transfusion and deferoxamine pump injection during the year 2006. The first visit with the otolaryngologist was performed in all patients to demarcate the presence of cerumen, otitis, and congenital abnormalities of ears. Then pure tone audiometery in frequency ranges of 250–8000 Hz was performed. Data statistical analysis was done by Mann-Whitney, chi square, and Fisher tests. There were 67 patients over 5 years old in our study. Five patients (7.4%), including 2 boys and 3 girls, in the age range of 7–24 years (mean:17.8 ± 6.6 years) had SNHL. Their hearing loss was bilateral and in the frequency range of 2000–4000 Hz, with a mean of 3200 ± 836.66 Hz. There were no significant differences between SNHL and non-SNHL patients in age, sex, serum ferritin level, age of the first transfusion, starting age of deferoxamine infusion, or duration and dosage of deferoxamine therapy. It seems that SNHL is not directly related to the serum ferritin level or deferoxamine dosage and other factors, including genetic or constitutional characteristics, may be also related. On the other hand, this complication may occur with doses lower than 50 mg/kg/day of deferoxamine, so no dosage can be considered safe for this drug. Despite the results of this study, hearing evaluation of β-thalassemia major patients by audiometry is recommended because of the importance of this complication and the consequent disabilities.

Clinical qualitative evaluation of the diagnosis of acute otitis media in general practice

Assess the quality of the diagnosis of acute otitis media (AOM) given by general practitioners (GPs) on a daily basis and compare it with the diagnosis of ear, nose and throat specialist (ENTS) which is considered as the gold standard. Every GP had to include six children aged 1-4 years for whom he suspected or diagnosed that they were suffering from AOM. Parents had to accept to see the ENTS participating in the survey within 48 h. Twenty-four GPs took part in the survey and included at least one child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis's of AOM (30/137) were declared null by the ENTS. GPs diagnose AOM without any doubt only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ENTS. The combination of redness and bulge, and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness and bulge, the diagnosis was confirmed in 83% of all cases by the ENTS as opposed to 75% regarding the isolated redness. An AOM was suspected in 57.1% of the eardrums barely or not visible or without any sign of infection and not confirmed in 25% of all cases. The global over diagnosis is 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums are only inflammatory. Even though the over diagnosis is inferior to the one mentioned in published writings, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy could contribute to improving the quality of diagnosing AOM.

Évaluation de la pertinence du diagnostic d'otite moyenne aiguë porté par le médecin généraliste

Objectives To assess reliability of the diagnosis of Acute Otitis Media (AOM) given by General Practitioners (GPs) compared with the diagnosis of Otorhinolaryngologists (ORLs) considered as the reference diagnosis. Methodology Every GP had to include 6 children aged 1 to 4 years for whom he suspected or diagnosed AOM. Parents had to accept to consult the ORL participating in the survey within 48 h. Results 24 GPs took part in the survey and included at least 1 child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis of AOM (30/137) were declared null by the ORL. GPs diagnose AOM with certainty only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ORL. The combination of redness and bulge and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness plus bulge, the diagnosis was confirmed in 83% of all cases by the ORL as opposed to 75% regarding the isolated redness. AOM was suspected in 57.1% of the eardrums little or not visible with no sign of infection and was not confirmed in 25% of all cases. Conclusion The global overdiagnosis was 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums show inflammation alone. Even though the overdiagnosis was lower than the reported one in literature, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy should contribute to improve the quality of diagnosing AOM.

Ceruminolytic Effects of Docusate Sodium: A Randomized, Controlled Trial

Study Objective: Assessment of the tympanic membrane is often impeded by the presence of cerumen. We compared the ceruminolytic effects of triethanolamine polypeptide and docusate sodium in patients with cerumen. Methods: We conducted a prospective, randomized, controlled, double-blind trial on a convenience sample of cooperative adult and pediatric patients presenting to a university-based emergency department who required removal of cerumen to visualize the tympanic membrane. Structured data collection was performed, and the physician determined whether visualization of the tympanic membrane was partially or totally obscured by cerumen (interobserver agreement, ρ=0.79). Patients received intra-aural instillation of 1mL of either docusate sodium or triethanolamine polypeptide in a liquid form. If not completely cleared within 15 minutes, the external ear canal was irrigated with 50 or 100 mL of normal saline solution and additional attempts to visualize the tympanic membrane were made. The main outcome was the proportion of ears in which the tympanic membrane could be totally visualized after ceruminolytic instillation with or without irrigation. This study had 80% power to detect a 40% difference between groups in the proportion of totally visualized tympanic membranes (χ2 test, α=.05). Results: Of 50 enrolled patients, 23 received triethanolamine polypeptide and 27 received docusate sodium. Mean patient age was 40 years (range 1 to 81 years); 35% were female. Groups were similar in age, sex, and proportion of completely obscured tympanic membranes at presentation (78%). The ability to completely visualize the tympanic membrane was significantly greater after treatment with docusate sodium versus triethanolamine polypeptide (81% versus 35%; difference in proportions 47%; 95% confidence interval [CI], 22 to 71) particularly in children aged 5 or less (90% versus 0%; difference in proportions 89%; 95% CI 50 to 100). Conclusion: Docusate sodium solution is a more effective ceruminolytic than triethanolamine polypeptide, allowing complete or partial visualization of the tympanic membrane in most patients after a single application when followed with irrigation. Use of docusate sodium as a ceruminolytic should be encouraged, particularly in children. [Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. September 2000;36:228-232.]

The Neurohistology of the Proximal Portion of the Human Ear Canal

The Neurohistology of the Proximal Portion of the Human Ear Canal