Rosen & Barkin's 5-Minute Emergency Medicine Consult (498 page)

• Alendronate: 10 mg/d or 70 mg weekly, alternative is risedronate 5 mg/d, 35 mg weekly, or 150 mg monthly
  
• Zoledronic acid: 5 mg IV yearly
  
• Raloxifene (selective estrogen receptor modulator): 60 mg PO QD
  
• Calcium: 1,200 mg daily (total of diet + supplement)
  
• Vitamin D: 800 IU/d
  
• Calcitonin: Nasal spray 200 IU/d
  
• Denosumab (monoclonal antibody): 60 mg SC every 6 mo
  
• Parathyroid hormone 1–34: 20 μg SC daily
  
• Estrogen: 0.625 mg/d (with or without medroxyprogesterone)
  

Ensure adequate calcium in diet from early age.

FOLLOW-UP

• Per normal orthopedic protocols, with special considerations for age and social situation
  
• Compression fractures are generally stable, but possibility of burst fracture with cord compression must be ruled out.
  
• Any cervical fracture or fracture with neurologic symptoms requires admission with emergent consultation with neurosurgery or orthopedics
  
• Admission may be necessary for pain control and because of decreased ambulation
  

• Per normal orthopedic protocols with special considerations for age and social situation
  
• Patients with minimal injuries, able to care for themselves at home or with appropriate assistance, and adequate postoperative pain control may be discharged with orthopedic follow-up
  

Orthopedic referral is driven by the acute injury.

• Follow-up is generally driven by the acute injuries
  
• Follow-up with the primary physician should be instituted to encourage treatment and monitoring of the disease to prevent recurrent fractures
  

• A history of recurrent fractures, particularly with a low-energy mechanism, suggests the possibility of osteoporosis
  
• Reduced bone density on plain radiographs is highly suggestive and warrants referral back to the PCP for further workup and treatment
  
• Bisphosphonates are 1st-line therapy for treatment
  

• Robbins J, Aragaki AK, Kooperberg C, et al. Factors associated with 5-year risk of hip fracture in postmenopausal women.
  JAMA
  . 2007;298(20):2389–2398.
  
• Silverman S, Christiansen C. Individualizing osteoporosis therapy.
  Osteoporos Int
  . 2012;23:797–809.
  
• Solomon DH, Polinski JM, Stedman M, et al. Improving care of patients at-risk for osteoporosis: A randomized controlled trial.
  J Gen Intern Med
  . 2007;22:362–367.
  
• Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, et al. Cost-effective osteoporosis treatment thresholds: The United States perspective.
  Osteoporos Int
  . 2008;19:437–447.
  
• Unnanuntana A, Gladnick BP, Donnelly E, et al. The assessment of fracture risk.
  J Bone Joint Surg Am
  . 2010;92(3):743–753.
  

See Also (Topic, Algorithm, Electronic Media Element)

Specific Orthopedic Injuries.

CODES

• 733.00 Osteoporosis, unspecified
  
• 733.01 Senile osteoporosis
  
• 733.09 Other osteoporosis
  

BASICS

• Inflammation or infection of the auricle, auditory canal, or external surface of the tympanic membrane (TM):
  
  • Spares the middle ear
    
  • Affects 4/1,000 persons in US
    
• Also called “swimmer’s ear” due to the usual history of recent swimming:
  
  • Occasional cases after normal bathing
    
• Necrotizing (malignant) otitis externa:
  
  • Infection starts at the ear canal and progresses through periauricular tissue toward the base of the skull
    
  • Occurs in elderly, diabetic, or other immunocompromised patients
    
  • Caused by
    Pseudomonas aeruginosa
    
  • Can lead to cellulitis, chondritis, and osteomyelitis
    
  • Associated with 20% mortality
    

• Often precipitated by an abrasion of the ear canal or maceration of the skin from persisting water or excessive dryness
  
• Predisposing factors include:
  
  • History of ear surgery or TM perforation
    
  • Narrow or abnormal canal
    
  • Humidity
    
  • Allergy
    
  • Eczema
    
  • Trauma
    
  • Abnormal cerumen production
    
• P. aeruginosa, Staphylococcus aureus,
  streptococcal species, and rarely fungi
  

DIAGNOSIS

• Recent swimming or prolonged water exposure
  
• History of diabetes
  
• History of chemotherapy, prolonged steroid use, HIV/AIDS, or other processes that compromises immune system
  
• Itching of the external ear canal is usually the 1st symptom
  
• 1–2 day history of progressive pain
  
• Ear drainage
  
• Decreased auditory acuity
  
• Clogged sensation in ear
  

• Pain in ear or with motion of pinna/tragus
  
• Swollen, erythematous external ear canal
  
• Ear drainage
  
• Decreased auditory acuity
  
• Pain/swelling in preauricular area
  
• Necrotizing (malignant) otitis externa:
  
  • Pain, tenderness, swelling in periauricular area
    
  • Headache
    
  • Otorrhea
    
  • Cranial nerve palsy:
    
    • Facial nerve most affected
      

Clinical diagnosis with typical signs/symptoms:

• Pain in ear or with motion of pinna/tragus
  
• Otoscopic exam
  
• Swollen, erythematous external ear canal
  
• Ear drainage
  
• Cheesy white or gray-green exudate
  

• None usually indicated, except when possibility of necrotizing otitis externa:
  
  • Signs of systemic toxicity or local spread of infection should be checked
    
• WBC count
  
• ESR
  
• Glucose (check for diabetes)
  
• Cultures
  

CT/MRI to exclude mastoiditis if the patient has signs of toxicity or bone involvement

• Remove debris with a soft plastic curette or gentle irrigation with peroxide/water mix
  
• Wick placement may be needed to facilitate medication delivery
  

• Necrotizing otitis externa
  
• Otitis media
  
• Folliculitis from obstruction of sebaceous glands
  
• Otic foreign bodies
  
• Herpes zoster infection of the geniculate ganglion
  
• Parotitis
  
• Periauricular adenitis
  
• Mastoiditis
  
• Dental abscess
  
• Sinusitis
  
• Tonsillitis
  
• Pharyngitis
  
• Temporomandibular joint pain
  
• Viral exanthems
  

Consider ear canal foreign bodies in children with purulent drainage from edematous, painful ear canals

TREATMENT