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Acute otitis media

Author: Edžus UrtānsMentor: Dr.Uldis Urtāns

Acute inflammation in middle ear < 3 weeks (month) Often associated with a viral upper

respiratory infection Most common reason for medical therapy

for children younger than 5 years

Recurrent otitis media: At least 4 episodes/ year At least 3 episodes/ 6 months

(with adequate therapy)

Acute otitis media

Most children have at least one episode of AOM (by age 3, 50-85%)

Peak incidence age 6-15 months Increased incidence in the fall and winter Only 20% are adults >700 milion cases/year

Epidemiology

Eustachian tube is lined with respiratory mucosa

Responds together with nasopharynx mucosa

Edema > narrowed > negative middlelumen ear pressure

Influx of pathogens from nasopharynx is possible

Causes

Causes

Inflammatory response in middle ear worsens the obstruction

Trigger: Allergies Upper respiratory tract infections GER (especially children) Adenoid hypertrophy Other

Viral (30-70%) RSV Rhinovirus Coronavirus Influenza, parainfluenza

Bacterial (55%) Streptococcus pneumoniae (44%) Haemophilus influenzae (41%) Moraxella catarrhalis (14%) Gram negative enteric bacteria S. Aureus

• Combined (15%)

Causes

Age: <7 Their Eustachian tubes are short, floppy,

horizontal and poorly functioning

Risk factors

Handbook of Pediatric Otolaryngology : A Practical Guide for Evaluation and Management of Pediatric Ear, Nose, and Throat Disorders

Risk factors

Genetic predisposition Eustachian tube dysfunction Allergic tendencies

Bottle feeding (first 3 months)(breast milk contains lactoferrin, oligosaccharideand surface immunoglobulin A that inhibitbacterial colonization)(sucking generates negative pressure)

Incorrect posture while breastfeeding

Risk factors

Underlying pathology Unrepaired cleft palate

Parental smoking Large familys/attending daycare Immunocompromised states

Otalgia (not always) Fever Hearing loss

(speech delay for children) Headache Nausea Cough Rhinitis Conjunctivitis

Signs and symptoms

Pneumatic otoscopy/otoscopy: Red or opaque eardrum Retracted eardrum Immobile or hypo-mobile eardrum Presence of fluid behind eardrum

(purulent, serous, mucoid) Retraction pockets Bullous myringitis

Physical Examination

Otorrhea (in case of tympanostomy tube, perforation)

Mastoid tenderness Anteriorly rotated pinna Tympanometry Audiometry Inspection or pharynx and

nasal cavity

Physical Examination

Diagnosis

Acute onset of signs and syptoms The presence of middle ear effusion

(hypomobile eardrum, air-fluid level) Signs and symptoms of middle ear inflamation

(erythema, otalgia)

Acute mastoiditis Abscess formation Facial paralysis Otitis media with effusion Persistent AOM Recurrent AOM Hearing loss Perforation of eardrum

Complications

Complications (rare)

Lateral sinus thrombosis Otitic hydrocephalus Septic shock Meningitis Encephalitis Extradural abscess Labyrinthitis

Antibacterial therapy for: Children of age <6months 6 months to 2 years with severe illness Recurrent or billateral AOM Immunocompromised patients Patients with a perforated tympanic membrane

Pain management (Ibuprofen, Diclofenac, paracetamol)

Decongestants and/or antihistamines, nasal steroids

Treatment

After 24-48h (48-72h)

If no improvemants: No antibiotics > antibiotics Antibiotics > change to a different antibiotics

Antibacterial therapy

Amoxicilin 750-1500mg/day 50-100 mg/kg/day

(has not recived amoxicilin in past 30 days and has no allergy to penicilin)

Amoxicillin-clavulanate 875/125mg/day90/6.4 mg/kg/day(alternative for amoxicilin)

Ceftriaxone 1-2g/day 50mg/kg/day or Cefuroxim 500mg/day 30mg/kg/day

Azithromycin, clarithromycin, erythromycin in case of allergy to penicilin

5-7-10 days

Recurrent AOM treatment

+Tympanostomy

Non-drug Treatment

Myringotomy in case of sevare pain Tympanocentesis in case of severe pain and as

a diagnostic procedure if there is no improvement with2nd line of antibiotics(local anesthesia)(narcosis)

Avoiding risk factors if possible Vaccination: ?

S. Pneumonia (PCV-7) Influenza

• Adenoidectomy• Polipectomy

Preventive measures

Differential diagnosis

Otitis externa Impacted cerumen or foreign body in ear Tympanosclerosis Otitis media with effusion Injury of the ear

Quiz (1)

Two most common bacterial causes of AOM:A. Haemophilus influenzae, S. Aureus;B. Moraxella catarrhalis , E. Coli;C. S. Pneumonia, Haemophilus influenzae;D. S. Pneumonia, Moraxella catarrhalis

Quiz (2)

Recurrent AOM means:A. At least 5 episodes of AOM a year;B. At least 8 episodes of AOM till age of 5 years ;C. At least 3 episodes of AOM in 6 months;D. At least 2 episodes of AOM in a month

Quiz (3)

What can’t be seen in otoscopy of AOM patient:A. Retracted eardrum;B. Perforation of eardrum;C. Bubbles behind eardrum;D. Bullose myringitisE. All of above can be seen

Quiz (4)

What is always necessary to treat AOM:(more then one answer is possible)A. Antibiotics;B. Analgetics;C. Tympanostomy;D. Tea;E. None from above

Shapiro, Nina L. Handbook Of Pediatric Otolaryngology : A Practical Guide For Evaluation And Management Of Pediatric Ear, Nose, And Throat Disorders. Singapore: World Scientific Publishing Company, 2012. eBook Academic Collection (EBSCOhost). Web. 5 Mar. 2016.

https://www.clinicalkey.com.db.rsu.lv/#!/content/medical_topic/21-s2.0-1014193?scrollTo=%23heading0

http://web.a.ebscohost.com.db.rsu.lv/dynamed/detail?vid=2&sid=74b4fa24-4f97-43f1-a411-581c0fcc826e%40sessionmgr4003&hid=4204&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=116345&db=dme

https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-B9780323079327000247?scrollTo=%23hl0001072

https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-B9780323280471005540

http://www.aafp.org/afp/2007/1201/p1650.html http://

journals.plos.org/plosone/article?id=10.1371/journal.pone.0036226 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC153141/

Sources

Thank you for your attention!(and sorry for terrible english)