Otitis Media: Otitis Media: Clinical Practice Clinical Practice

Guidelines and Current Guidelines and Current ManagementManagement

Tamekia L. Wakefield, MDTamekia L. Wakefield, MD

Pediatric OtolaryngologistPediatric Otolaryngologist

ENT & Allergy Associates, LLPENT & Allergy Associates, LLP

Disclosures:Disclosures:

Tamekia Wakefield, MD is a member of Tamekia Wakefield, MD is a member of the speakers bureau for Alcon. The the speakers bureau for Alcon. The makers of Ciprodex otic.makers of Ciprodex otic.

►$4 billion in combined direct and $4 billion in combined direct and indirect cost annuallyindirect cost annually

►2.2 million episodes diagnosed annually2.2 million episodes diagnosed annually►Most common reason for visit to Most common reason for visit to

pediatricianpediatrician►Tympanostomy tube placement is 2nd Tympanostomy tube placement is 2nd

most common surgical procedure in most common surgical procedure in childrenchildren

►OME: the presence of fluid in the OME: the presence of fluid in the middle ear without acute signs or middle ear without acute signs or symptomssymptoms

►AOM: the presence of fluid in the AOM: the presence of fluid in the middle ear with the acute onset of middle ear with the acute onset of signs and symptoms of middle ear signs and symptoms of middle ear inflammation.inflammation.

► S. pneumoniaeS. pneumoniae - 30-35% - 30-35%►H. influenzaeH. influenzae - 20-25% - 20-25%►M. catarrhalisM. catarrhalis - 10-15% - 10-15%►Group A strep - 2-4%Group A strep - 2-4%► Infants with higher incidence of gram Infants with higher incidence of gram

negative bacillinegative bacilli► RSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates► RhinovirusRhinovirus► Parainfluenza virusParainfluenza virus► Influenza virusInfluenza virus

Microbiology/VirologyMicrobiology/Virology

►Risk factors:Risk factors: DaycareDaycare Tobacco smoke exposureTobacco smoke exposure Inverse relationship between length of Inverse relationship between length of

breastfeeding and number of AOM breastfeeding and number of AOM episodesepisodes

Acute otitis mediaAcute otitis media

►Clinical Indicators: Myringotomy and Clinical Indicators: Myringotomy and Tubes:Tubes:

Severe acute otitis media (myringotomy)Severe acute otitis media (myringotomy) Poor response (describe) to antibiotic for otitis media Poor response (describe) to antibiotic for otitis media

(myringotomy or tube)(myringotomy or tube) Impending mastoiditis or intra-cranial complication Impending mastoiditis or intra-cranial complication

due to otitis media (myringotomy)due to otitis media (myringotomy) Recurrent episodes of acute otitis media (more than 3 Recurrent episodes of acute otitis media (more than 3

episodes in 6 months or more than 4 episodes in 12 episodes in 6 months or more than 4 episodes in 12 months) (tympanostomy tube)months) (tympanostomy tube)

►Eustachian tube dysfunctionEustachian tube dysfunction►Post-AOMPost-AOM

►Most episodes resolve spontaneously Most episodes resolve spontaneously within 3 monthswithin 3 months

►30%-40% Recurrent OME30%-40% Recurrent OME►5%-10% Persistent OME > 1 year5%-10% Persistent OME > 1 year

►High prevalence of OMEHigh prevalence of OME►Difficulties in diagnosis and assessing Difficulties in diagnosis and assessing

durationduration► Increased risk of CHLIncreased risk of CHL►Potential impact on language and Potential impact on language and

cognitioncognition►Significant practice variations in Significant practice variations in

managementmanagement

► Clinicians should use pneumatic otoscopy as Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME. the primary diagnostic method for OME. OME should be distinguished from AOM. OME should be distinguished from AOM. Strong recommendationStrong recommendation Pneumatic otoscopy is gold standardPneumatic otoscopy is gold standard

►ColorColor►PositionPosition►MobilityMobility►Tympanic membrane appearanceTympanic membrane appearance

Sensitivity of 94% and specificity of 80% versus Sensitivity of 94% and specificity of 80% versus myringotomymyringotomy

Readily available, cost effective and accurate in Readily available, cost effective and accurate in experienced handsexperienced hands

►Tympanometry can be used to confirm Tympanometry can be used to confirm diagnosis. diagnosis. OptionOption

When diagnosis is uncertain, consider When diagnosis is uncertain, consider tympanometrytympanometry►Cost associated with equipmentCost associated with equipment►PainlessPainless►Reliable for ages 4 months or olderReliable for ages 4 months or older

► Population-based screening programs for OME are Population-based screening programs for OME are not recommended in healthy, asymptomatic not recommended in healthy, asymptomatic children. children. Recommendation AgainstRecommendation Against Highly prevalent in young children. 15%-40% Highly prevalent in young children. 15%-40%

point prevalence in healthy children under 5 yrpoint prevalence in healthy children under 5 yr No influence on short-term language outcomesNo influence on short-term language outcomes No benefit from treatment that exceeds the No benefit from treatment that exceeds the

favorable natural history of the diseasefavorable natural history of the disease Risk of inaccurate diagnoses, overtreatment, Risk of inaccurate diagnoses, overtreatment,

parental anxiety, and increased costparental anxiety, and increased cost

►Clinicians should document the Clinicians should document the laterality, duration of effusion, and laterality, duration of effusion, and presence and severity of associated presence and severity of associated symptoms at each assessment of the symptoms at each assessment of the child with OME. child with OME. RecommendationRecommendation Medical decision making depends on Medical decision making depends on

these featuresthese features 40%-50% of OME cases no symptoms40%-50% of OME cases no symptoms Preponderance of benefit over harmPreponderance of benefit over harm

► Clinicians should distinguish the child with OME who is at risk Clinicians should distinguish the child with OME who is at risk for speech, language, or learning problems from other for speech, language, or learning problems from other children with OME, and should more promptly evaluate children with OME, and should more promptly evaluate hearing, speech, language, and need for intervention. hearing, speech, language, and need for intervention. RecommendationRecommendation Permanent hearing lossPermanent hearing loss Speech and language delay or disorderSpeech and language delay or disorder Autism-spectrum disorder/PDDAutism-spectrum disorder/PDD Syndromes with cognitive, speech, and language delaysSyndromes with cognitive, speech, and language delays BlindnessBlindness Cleft PalateCleft Palate Developmental delayDevelopmental delay

► Clinicians should manage the child with OME who Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 months is not at risk with watchful waiting for 3 months from the date effusion onset (if known) or from from the date effusion onset (if known) or from the date of diagnosis (if onset is unknown). the date of diagnosis (if onset is unknown). RecommendationRecommendation OME is usually self-limited OME is usually self-limited 75%-90% of OME after AOM resolves 75%-90% of OME after AOM resolves

spontaneously by 3 monthsspontaneously by 3 months Waiting results in little harm to childWaiting results in little harm to child Optimize listening and learning environment Optimize listening and learning environment

until effusion resolvesuntil effusion resolves

►Antihistamines and decongestants are Antihistamines and decongestants are ineffective for OME and are not ineffective for OME and are not recommended for treatment. recommended for treatment. Antimicrobials and corticosteroids do no Antimicrobials and corticosteroids do no have long-term efficacy and are not have long-term efficacy and are not recommended for routine management. recommended for routine management. Recommendation AgainstRecommendation Against Short-term, small magnitude benefitsShort-term, small magnitude benefits Significant adverse effectsSignificant adverse effects

►Hearing testing is recommended when Hearing testing is recommended when OME persists for 3 months or longer, OME persists for 3 months or longer, or at any time that language delay, or at any time that language delay, learning problems, or a significant learning problems, or a significant hearing loss is suspected in a child hearing loss is suspected in a child with OME. Language testing should be with OME. Language testing should be conducted for children with hearing conducted for children with hearing loss. loss. RecommendationRecommendation

►HL may impair early language HL may impair early language acquisition acquisition

►Extended periods of CHL may result in Extended periods of CHL may result in developmental and academic sequelaedevelopmental and academic sequelae

►Early language delays are associated Early language delays are associated with later delays in reading and with later delays in reading and writing.writing.

► Children with persistent OME who are not at risk should Children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the TM or identified, or structural abnormalities of the TM or middle ear are suspected. middle ear are suspected. RecommendationRecommendation

Resolution rates decrease the longer the effusion has been Resolution rates decrease the longer the effusion has been present present

Risk factors for non-resolution:Risk factors for non-resolution:►Summer or fall onsetSummer or fall onset►HL>30dBHL>30dB►H/O prior tympanostomy tubesH/O prior tympanostomy tubes►Not having had an adenoidectomyNot having had an adenoidectomy

►When children with OME are referred by When children with OME are referred by the primary care clinician for evaluation by the primary care clinician for evaluation by an otolaryngologist, audiologist, or speech-an otolaryngologist, audiologist, or speech-language pathologist, the referring language pathologist, the referring clinician should document the effusion clinician should document the effusion duration and specific reason for referral duration and specific reason for referral (evaluation vs. surgery), and provide (evaluation vs. surgery), and provide additional relevant information such as additional relevant information such as history of AOM and developmental status history of AOM and developmental status of the child. of the child. OptionOption

►When a child becomes a surgical candidate, When a child becomes a surgical candidate, tympanostomy tube insertion is the tympanostomy tube insertion is the preferred initial procedure; adenoidectomy preferred initial procedure; adenoidectomy should not be performed unless a distinct should not be performed unless a distinct indication exists (nasal obstruction, chronic indication exists (nasal obstruction, chronic adenoiditis). Repeat surgery consists of adenoiditis). Repeat surgery consists of adenoidectomy plus myringotomy, with or adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone without tube insertion. Tonsillectomy alone or myringotomy alone should not be used or myringotomy alone should not be used to treat OME. to treat OME. RecommendationRecommendation

►OME > 4 months with persistent OME > 4 months with persistent hearing losshearing loss

►Recurrent or persistent OME in at risk Recurrent or persistent OME in at risk childchild

►OME with structural damage to TM or OME with structural damage to TM or MEME

► Alternative MedicineAlternative Medicine No recommendation: No recommendation:

►Limited evidence Limited evidence ►Few studiesFew studies►Medications are Medications are

unregulatedunregulated

► Allergy Allergy ManagementManagement No recommendation:No recommendation:

►Few studiesFew studies

ConsequencesConsequences

► Inappropriate antibiotic treatment of Inappropriate antibiotic treatment of OM OM Multidrug-resistant strains Multidrug-resistant strains Drug side effectsDrug side effects Parental/caregiver confusionParental/caregiver confusion

BiofilmsBiofilms

►Communities of sessile bacteria Communities of sessile bacteria embedded in a matrix of extracellular embedded in a matrix of extracellular polymeric substances of their own polymeric substances of their own synthesis that adhere to a foreign body synthesis that adhere to a foreign body or a mucosal surfaceor a mucosal surface

►Chronic ear infections or persistent Chronic ear infections or persistent effusion in the middle ear are biofilm effusion in the middle ear are biofilm relatedrelated

BiofilmsBiofilms

►Unable to culture with traditional methodsUnable to culture with traditional methods►Traditional antibiotics are relatively Traditional antibiotics are relatively

ineffective for eradicating biofilm infectionineffective for eradicating biofilm infection►Higher doses of antibiotics required to Higher doses of antibiotics required to

treattreat►Macrolides (clarithromycin/erythromycin)Macrolides (clarithromycin/erythromycin)►Physical disruption is beneficial Physical disruption is beneficial ►Non-antibiotic therapies may be more Non-antibiotic therapies may be more

successfulsuccessful

Acute otitis media with tubesAcute otitis media with tubes

► DiagnosisDiagnosis Acute purulent Acute purulent

otorrheaotorrhea11

►Commonly occurs after Commonly occurs after insertion of insertion of tympanostomy tubestympanostomy tubes

► Risk FactorRisk Factor Occurs more Occurs more

frequently in children frequently in children with upper respiratory with upper respiratory infectionsinfections2,32,3

AOMTAOMT

►Ototopical antibiotics are appropriate therapy Ototopical antibiotics are appropriate therapy in uncomplicated casesin uncomplicated cases FluoroquinolonesFluoroquinolones

► Adjunctive systemic antibiotics may be usedAdjunctive systemic antibiotics may be used When infection has spread beyond middle ear or When infection has spread beyond middle ear or

external ear canalexternal ear canal With lack of adherence to ototopical therapyWith lack of adherence to ototopical therapy When ototopical treatment fails (after 7-10 days)When ototopical treatment fails (after 7-10 days) In children with associated In children with associated streptococcalstreptococcal pharyngitis pharyngitis

► Special populations (e.g. immunocompromised Special populations (e.g. immunocompromised patients) require additional considerationpatients) require additional consideration

►High prevalenceHigh prevalence►Accurate diagnosis Accurate diagnosis ►At risk childrenAt risk children►Hearing lossHearing loss►Speech and language assessmentSpeech and language assessment►Antibiotic useAntibiotic use►Surgery Surgery ►ReferralReferral