Sandbox:Amira Albawri
- Acut otitis media.
In general,approximately 80% of children have spontaneous relief of AOM within 214 days who absence of suspected complications it follow initial treatment of symptomatic (analgesia and antipyretics) as fever and ear pain.If severe,recurrent infections or persistent give antibioticor if there is complication may offer tympanostomy tubes.
If we use analgisic.
Oral acetaminophen and ibuprofen are commonly used to treat pain in children.
If we use antibiotics.
Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines.
Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin.
If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin.
Tympanocentesis use for drainage (theraby) and culture in difficult cases.
- In general,approximately 80% of children have spontaneous relief of AOM within 214 days who absence of suspected complications it follow initial treatment of symptomatic (analgesia and antipyretics) as fever and ear pain.If severe,recurrent infections or persistent give antibioticor if there is complication may offer tympanostomy tubes.
- If we use analgisic.
Oral acetaminophen and ibuprofen are commonly used to treat pain in children.
- Oral acetaminophen and ibuprofen are commonly used to treat pain in children.
- If we use antibiotics.
Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines.
Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin.
If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin.
Tympanocentesis use for drainage (theraby) and culture in difficult cases.
- Amoxicillin (90 mg/kg per day) is the recommended first-line agent in the 2013 guidelines.
- Amoxicillin with beta-lactamase coverage the patient has concurrent purulent conjunctivitis or recurrent acut otitis media unresponsive to amoxicillin.
- If there is penicillin-sensitive patients we can use second- or third-generation cephalosporins, including intramuscular ceftriaxone or if penicillin-sensitive patients or amoxicillin failures we can use second- and third-generation cephalosporins and clindamycin.
- Tympanocentesis use for drainage (theraby) and culture in difficult cases.
- Acute otitis externa.
American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or witout topical corticosteroids.
Oral antibiotics use for infection has spread beyond the ear canal.
- American guidelines promote initial ototopical therapy without systemic antibiotics for uncomplicated acute otitis externa such as topical antibiotics with or witout topical corticosteroids.
- Oral antibiotics use for infection has spread beyond the ear canal.
- Otitis media with effusion.
Antibiotics, histamines or decongestants not effect at treatment.
In less sever case and without hearing problems the effusion can resolve spontaneously or with autoinflation.
In sever case or persistent symptomatic cases the treatment by tympanostomy with or without adenoidectomy.
- Antibiotics, histamines or decongestants not effect at treatment.
- In less sever case and without hearing problems the effusion can resolve spontaneously or with autoinflation.
- In sever case or persistent symptomatic cases the treatment by tympanostomy with or without adenoidectomy.
- Tonsilitis
Treatment depends on to cause.
IF the cause is viral it is go by alone.
Antibiotics.
If the cause is group A streptococcus the first-line therapy antibiotics are useing is penicillin or amoxicillin .If there is alergic to pinicillin  we can use a macrolide .If there is not response to penicillin therapy we can use clindamycin or amoxicillin-clavulanate .
Pain medication.
Paracetamol or ibuprofen.
Surgery.
Tonsillectomy . It is as a choice for treatment the chronic tonsillitis
- Treatment depends on to cause.
- IF the cause is viral it is go by alone.
- Antibiotics.
If the cause is group A streptococcus the first-line therapy antibiotics are useing is penicillin or amoxicillin .If there is alergic to pinicillin  we can use a macrolide .If there is not response to penicillin therapy we can use clindamycin or amoxicillin-clavulanate .
- If the cause is group A streptococcus the first-line therapy antibiotics are useing is penicillin or amoxicillin .If there is alergic to pinicillin  we can use a macrolide .If there is not response to penicillin therapy we can use clindamycin or amoxicillin-clavulanate .
- Pain medication.
Paracetamol or ibuprofen.
- Paracetamol or ibuprofen.
- Surgery.
Tonsillectomy . It is as a choice for treatment the chronic tonsillitis
- Tonsillectomy . It is as a choice for treatment the chronic tonsillitis
- Ear wax
First-line treatmen is softening ear drops (oil or water).  
Ear syringing.
- First-line treatmen is softening ear drops (oil or water).  
- Ear syringing.

# Table
Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)
Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.
aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (discomfort clearly referable to the ear that results in interference with or precludes normal activity or sleep).
bRecent: <48 hours.
cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.
dNonsevere illness defined as mild otalgia and fever <39C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to mild otalgia for less than 48 hours and temperature less than 39C.
eSevere signs or symptoms include moderate or severe otalgia or temperature 39C in 2004 guideline; the 2013 guideline also includes otalgia for 48 hours.
Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e96499; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):145165
- Temporomandibular joint disorder (TMJ) PMID: 25822556
common cold or upper respiratory tract infection..... PMID 21918146
Your otoscopic examination reveals that her left tympanic membrane looks redder and less reflective than her right one, but you do not see bulging, retraction, or fluid behind the eardrum. There is no perforation or discharge. Her face, mouth, and throat look normal. Your examination reveals no foreign body. There is no swelling in front of her ears; the mastoids, temporomandibular joints, and maxillary sinuses are not tender. Her cervical glands are normal in size and are not tender. Her teeth and mouth look normal, and you notice that during the examination Amy moves her neck freely.

# cause
anatomic disorders of the nasopharynx such as cleft palate4 and Down syndrome.PMID: 2976173     PMID: 21918146

# FIRE  of ear pain

## Ear pain
*primary otalgia)
*secondary otalgia
IF Diagnosis is not clear from the history and physical examination.

# FIRE of ear pain
*primary otalgia
*Otitis externa = A red and tender ear ,Hearing loss ,pruritus and oedema , discharge
*Otitis media= pain fever ,hearing loss,headache, anorexia, vomiting
*secondary otalgia

# Complete Diagnostic Approch
Characterize the pain:  PMID: 30572868
- Usually the parents use pain scales to detect pain in their young children .
- Ear-related symptoms: ear rubbing.
- Non-specific symptoms: fever, irritability, excessive crying, decreased activity, poor appetite and restless sleep .
- Respiratory symptoms: rhinitis, cough, hoarse voice, conjunctivitis, mucus vomiting and  nasal congestion.
- Gastrointestinal symptoms: vomiting, and diarrhea.
History
- Enter into group child care and amounts of time spent.
- Exposure of smoking.
- Peroid of breastfeeding.
- swimming
- recurrent ear pain.
- Skills developmental delay like (language delay) due to hearing loss.
Examination
- Face (  lymph node, mastoids, temporomandibular joints, and maxillary sinuses ), mouth, and throat .
- Skin especially aroud the ear (mastoiditis)
- Myringotomy
It dose not do for children who have been diagnosed on the basis of assessment in the clinic.PMID: 14962529 / PMID: 24453496
- Tympanic membrane.
If the tympanic membrane is abnormal the most cause of it by primary otalgia.The primary otalgia include
- Acut otitis media.
Cloudy, bulging PMID: 22459064 erythema  of the tympanic membrane. PMID: 24453496
Acute onset symptoms and signs fever, otalgia  also see irritability, otorrhea, anorexia, and vomiting.
Usually affects children aged under 2 years,
- Cloudy, bulging PMID: 22459064 erythema  of the tympanic membrane. PMID: 24453496
- Acute onset symptoms and signs fever, otalgia  also see irritability, otorrhea, anorexia, and vomiting.
- Usually affects children aged under 2 years,
- Otitis media with effusion.
Retracted/concave tympanic membrane with change colour of tympanic membrane (yellow,amber,blue) , and airfluid levels. PMID: 24453496
Absence of signs and symptoms (asymptomatic).
Hearing loss.This is lead to speech delays.It is detected on screening of asymptomatic children.  PMID: 27604644/ PMID: 24453496
Affects children between 3 and 7 years old
- Retracted/concave tympanic membrane with change colour of tympanic membrane (yellow,amber,blue) , and airfluid levels. PMID: 24453496
- Absence of signs and symptoms (asymptomatic).
- Hearing loss.This is lead to speech delays.It is detected on screening of asymptomatic children.  PMID: 27604644/ PMID: 24453496
- Affects children between 3 and 7 years old
Treatment
- Acut otitis media.
Approximately 80% of children have spontaneous relief of AOM within 214 days.PMID: 24453496
Symptomatic management ( analgesia and antipyretics) like fever and ear pain.If severe,recurrent infections or persistent give antibiotic.
- otitis media with effusion

# Table 2
Key differences in the 2004 and 2013 American Academy of Pediatrics guidelines for the diagnosis and management of acute otitis media (AOM)
Abbreviations: MEE, middle ear effusion; TM, tympanic membrane.
aSigns and symptoms of middle ear inflammation include distinct erythema of TM or distinct otalgia (discomfort clearly referable to the ear that results in interference with or precludes normal activity or sleep).
bRecent: <48 hours.
cEar pain may be indicated by holding, tugging, or rubbing of the ear in a nonverbal child.
dNonsevere illness defined as mild otalgia and fever <39C in the past 24 hours in the 2004 guideline; the 2013 guideline modifies this to mild otalgia for less than 48 hours and temperature less than 39C.
eSevere signs or symptoms include moderate or severe otalgia or temperature 39C in 2004 guideline; the 2013 guideline also includes otalgia for 48 hours.
Adapted from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e96499; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5):145165.

# table

## table

### table
cause
- Genetics
BACA
brca1
brca2
- BACA
brca1
brca2
- brca1
- brca2
- family
First related
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