Otitis Media

Gil C. Grimes, MDAssistant Professor Family Medicine

Texas A&M HSC COMScott and White Family Medicine Residency

May 31st 2005

Objectives Describe criteria for diagnosing Acute Otitis

Media Describe rationale for therapy for Acute

Otitis Media Describe Therapy for Serous Otitis Media Describe the role of Tympanostomy Tubes

My Bias I am a minimalist

If the evidence for intervention is not good I do nothing

Acute Otitis Media A diagnosis of AOM requires

a history of acute onset of signs and symptoms

the presence of middle ear effusion (MEE)

signs and symptoms of middle-ear inflammation.

Pediatrics 2004 May;113(5):1451-65 Level 1a

Acute Otitis Media The presence of MEE that is

indicated by any of the following: Bulging of the tympanic membrane Limited or absent mobility of the

tympanic membrane Air-fluid level behind the tympanic

membrane Otorrhea

Acute Otitis Media Signs or symptoms of middle-ear

inflammation as indicated by either Distinct erythema of the tympanic

membrane or Distinct otalgia

discomfort clearly referable to the ear(s) and

interference with or precludes normal activity or sleep

Acute Otitis Media Otitis Media?

Yes No

http://www.otol.uic.edu/research/microto/Microtoscopy/Case10origweb.jpg

Acute Otitis Media Otitis Media?

Yes No

www.orldoc.ch/index

Acute Otitis Media Prevalence Prevalence

10% US children diagnosed by 3 months 90% by 2 years (1)

Prospective cohort of children (2)

62% with AOM by 1 year 83% with AOM by 3 years

9th most common diagnosis during FM visits(3)

Coded 3.2% visits (3)

1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b2)J Infect Dis 1989 Jul;160(1):83 Level 2b3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c

Acute Otitis Media Etiology Viral pathogens found Tympanocentesis and

Nasal Aspirate in AOM RSV and coronavirus RNA in 75% children

5% dual viral infections

Bacterial pathogens detected 62%

Viral RNA detected in 57% bacteria-negative and 45% bacteria-positive samples

Pediatrics 1998 Aug;102(2):291 Level 1c

Acute Otitis Media Etiology Bacteria shifts

Streptococcus pneumoniae S. pneumoniae is the most common bacterial organism

identified non-typeable Haemophilus influenzae

H. flu identified primarily in children < 5, but reduced with routine immunization

Moraxella (Branhamella) catarrhalis

may be changing due to heptavalent pneumococcal vaccine

decrease in S. pneumoniae and increase in H. influenzae

Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b

Acute Otitis Media Risk Factors Formula feeding

incidence of otitis media is higher in formula-fed infants vs. breast-fed infants

incidence of prolonged ear infections was 5x higher among formula-fed infants

Duration OM episodes longer (8.8 vs. 5.9 days)

J Pediatric 1995 May;126(5 Pt 1):696 Level 2b

Acute Otitis Media Risk Factors Day Care Attendance

day care associated with increased risk of upper and lower respiratory tract illnesses in first year of life for children with familial history of atopy

prospective birth cohort study of 498 children with parental history of allergy or asthma followed prospectively for first year of life

Pediatrics 1999 Sep;104(3):495 Level 2b

Acute Otitis Media Risk Factors. Associated with 2 or more doctor-

diagnosed ear infections (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.7-3.6)

For children attending day care independent predictors of 2 or more doctor-diagnosed ear infections included exposure to pets in day care presence of rug or carpet in area where child

slept in day care nonresidential setting for day care

Pediatrics 1999 Sep;104(3):495 Level 2b

Acute Otitis Media Risk Factors Passive Smoking

625 Children Calgary first graders Middle ear disease

2 or more household smokers (crude odds ratio) [OR], 1.85; 95% confidence interval [CI], 1.15-2.97

10 or more cigarettes smoked by the mother per day (crude OR, 1.68; 95% CI, 1.12-2.52)

10 or more cigarettes smoked in total in the household per day (crude OR, 1.40; 95% CI, 0.98-2.00) during the first 3 years of life

Arch Pediatric Adolescent Med. 1998 Feb;152(2):127 Level 2c

Acute Otitis Media History

Poor predictive value Studies are not good

Statistics LR+ greater than 5 good LR- less than 0.5 good Specificity to rule in Sensitivity to rule out

Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

Acute Otitis Media

Symptom LR+ LR- Sensitivity Specificity

Ear rubbing 3.20 0.670 42% 87%

Ear pain 3.00 0.560 54% 82%

Excessive crying 1.80 0.650 55% 69%

Rhinitis 1.30 0.580 75% 43%

Restless sleeping 1.30 0.710 64% 51%

Poor appetite 1.10 0.970 36% 66%

Vomiting 1.00 1.000 11% 89%

Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

Acute Otitis Media Physical Findings

Based on prospective study of 8,859 ear-related visits among children 0.5-2.5 years with acute symptoms

myringotomy performed if middle ear effusion suspected on exam

51.5% had acute otitis media (i.e. middle ear effusion confirmed on myringotomy)

Color not particularly helpful but cloudy membrane predictive

red color was not highly predictive cloudy tympanic membrane had 80-96% positive predictive

value normal color dramatically reduces likelihood of AOM (2-5%

probability of middle ear effusion if normal color)

Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b

Acute Otitis Media Physical Continued

Position helpful if clearly bulging bulging tympanic membrane had 89-96%

positive predictive value retracted tympanic membrane had 47-

50% positive predictive value normal position had 22-32% probability of

AOM

Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b

Acute Otitis Media Mobility helpful if distinctly impaired

or clearly normal distinctly impaired mobility had 78-94%

positive predictive value slightly impaired mobility had 33-60%

positive predictive value normal mobility dramatically reduces

likelihood of AOM (2-5% probability of middle ear effusion if normal mobility)

Acute Otitis MediaTest Name

Positive Likelihood Ratio

TM position: bulging 51.00

TM color: cloudy 34.00

TM mobility: distinctly impaired

31.00

TM color: distinctly red 8.40

TM mobility: slightly impaired 4.00

TM position: retracted 3.50

TM color: slightly red 1.40

TM position: normal 0.50

TM color: normal 0.20

TM mobility: normal 0.20

Acute Otitis Media Type A pattern is

normal Type B pattern is

consistent with MEE

Type C is seen with retracted TM

Acute Otitis Media Prognosis Spontaneous resolution is the

norm 81% spontaneously resolve (1)

5000 children with otitis(2)

>90% resolved with supportive care 2.7% had a severe course (required

antibiotics or myringotomy at 5 days)

1) Pediatrics 5 May 2004 113:1452 Level 1a

2) Br Med J (Clin Res Ed). 1985 Apr 6; 290(6474):1033 Level 1b

Acute Otitis Media Prognosis Recurrent otitis media no long term

consequences usually spontaneous recovery study of 222 children with recurrent otitis

media who received no prophylaxis 4% developed chronic otitis media with effusion 12% continued having recurrent episodes most significant risk factor for continued

recurrence was age < 16 months (1)

1) Pediatrics 5 May 2004 113:1452 Level 1a

Acute Otitis Media Prognosis

Persistent effusion Watchful Waiting recommended in children

without the following: Permanent hearing loss independent of OME Suspected or diagnosed speech and language

delay or disorder Autism-spectrum disorder and other pervasive

developmental disorders syndromes (e.g., Down) Craniofacial disorders that include cognitive,

speech, and language delays Blindness or uncorrectable visual impairment Cleft palate with or without associated syndrome Developmental delay

Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a

Acute Otitis Media Prognosis

Persistent effusion Change from B to non-B tympanogram

favorable 25% of OME of unknown duration

resolves in 3 months Warn parents of decreased hearing while

effusion present Recheck every three months

Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a

Acute Otitis Media Treatment Treat Pain

Acetaminophen and ibuprofen (1)

219 children treated with cefaclor evaluated pain at 2 days

Ibuprofen 7% with pain NNT 5 Acetaminophen 10% with pain NNT 6 Placebo 25%

1) Fundam Clin Pharmacol. 1996;10(4):387 Level 1c

Acute Otitis Media Treatment Initial treatment options are observation or

antibiotics for children < 6 months old, antibiotics recommended for children 6 months to 2 years old observation

option recommended only if all of the following are present

otherwise healthy child uncertain diagnosis non-severe illness follow-up can be ensured so antibiotics can be started if

symptoms persist or worsen

antibiotics recommended if certain diagnosis of AOM, severe illness, or follow-up cannot be ensured

Acute Otitis Media Treatment

For children > 2 years old Observation option recommended only if the

following are present otherwise healthy child uncertain diagnosis OR non-severe illness follow-up can be ensured so antibiotics can be

started if symptoms persist or worsen

Antibiotics recommended if certain diagnosis of AOM and severe illness, or follow-up cannot be ensured

DynaMed Acute Otitis Media Accessed March 19 2005

Acute Otitis Media Treatment No improvement in 48-72 hours

Confirm the diagnosis If AOM certain then begin antibiotics if

not already started Change antibiotics if already started

Acute Otitis Media Treatment Antibiotics

CDC guidelines for management and surveillance of acute otitis media in era of pneumococcal resistance

You must know your community

1) Pediatrics 5 May 2004;113(5):1452 Level 1a

Acute Otitis Media Treatment

Amoxicillin 80-90 mg/kg/day divided TID for 10 days

Failure at 3 days switch to one of the following cefuroxime axetil (Ceftin) 15 mg/kg BID for 10

days amoxicillin-clavulanate (Augmentin)

Augmentin 45 mg/kg/day divided BID or 40 mg/kg/day divided TID, both for 10 days

ceftriaxone (Rocephin) IM 50mg/kg for 3 days

1) Pediatric Infect Dis J. 1999 Jan;18(1):1 Level 1a

Acute Otitis Media Treatment Penicillin Sensitive patients

Not Type I reaction (no urticaria or anaphylaxis) (1)

Cefdinir (Omnicef) 14 mg/kg divided once daily or BID for 5 days (BID dosing) or 10 days (once daily dosing) slightly better taste (2)

Cefpodoxime (Vantin) 10 mg/kg once daily for 10 days or divided BID for 5 days

Cefuroxime (Ceftin or Zinacef) 30 mg/kg divided BID for 10 days

Ceftriaxone (Rocephin) 50mg/kg IM once

1) Pediatrics 5 May 2004;113(5):1452 Level 1a 2) Pediatric Infect Dis J 2000 Dec;19(12 Suppl):S181 Level 3

Acute Otitis Media Treatment Penicillin Sensitive Patients

Type I reaction Azithromycin (Zithromax) 10 mg/kg day one then

5 mg/kg days 2-5 Clarithromycin (Biaxin) 15 mg/day divided BID for

10 days Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg

daily of erythromycin divided TID to QID for 10 days

Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10 mg/kg daily of trimethoprim divided BID for 10 days

Pediatrics 5 May 2004;113(5):1452 Level 1a

Acute Otitis Media Reality Shorter therapy 5 days is likely as

beneficial as longer therapy (1)

Early treatment with antibiotics may lead to increased resistance (2)

Side effects are as common as benefit NNT 15-17 at 1 week NNH 17 at one week

Delayed antibiotics result in decreased use and decreased likelihood of asking for antibiotics in the future (3)

1) JAMA. 1998 Jun 3;279(21):1736 Level 1a2) J Infect Dis. 2001 Mar 15;183(6):880 Level 43) BMJ 2001 Feb 10;322:336 Level 1c

Acute Otitis Media Guideline Review

Pediatrics 2004 May;113(5):1451 Summary can be found in Am Fam

Physician 2004 Jun 1;69(11):2713 editorial can be found in Am Fam

Physician 2004 Jun 1;69(11):2537 commentary can be found in Pediatrics

2004 Sep;114(3):898 commentary can be found in Pediatrics

2005 Feb;115(2):513

Serous Otitis Media

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Serous Otitis Media Causes Causes

Overgrowth of lymphoid tissue in the nasopharynx

Chronic sinus infection Allergies of nose and nasopharynx Gastric reflux implicated

Pepsin seen in MEE 45 of 54 children with SOM (1)

Pepsin seen in MEE 59 of 65 children with SOM (2)

1) Lancet 2002 Feb 9;359(9305):493 Level 42) Laryngoscope. 2002 Nov;112(11):1930 Level 4

Serous Otitis Media Complications Permanent hearing loss (?) (5)

Tympanosclerosis Fibrosis of middle ear space Balance problems (1)

Minor language deficits (+/-) (2)

No association with attention or behavior in first 6 years of life (3)

Possible behavior problems in teens (4)

1) Pediatrics. 1997 Mar;99(3):334 Level 42) Pediatrics. 2000 May;105(5):1119 Level 2c3) Pediatrics. 2001 May;107(5):1037 Level 1b

4) Arch Dis Child. 2001 Aug;85(2):91 Level 1b5) Pediatrics. 2000 Sep;106(3):E42 Level 1c

Serous Otitis Media Physical Physical examination

Pearly gray Minimal dullness Minimal retraction Presence of effusion

Serous Otitis Media Tests Key tests

Pneumo-otoscopy with limited movement (1)

Sensitivity of 94% (95% CI: 92%-96%) Specificity of 80% (95% CI: 75%-86%)

Tympanogram B-curve (2)

81% sensitivity 56% specificity

Audiometry Carhart Notch (2) 77% sensitivity 98% specificity

1) Pediatrics. 2003 Dec;112(6 Pt 1):1379 Level 1a2) Clin Otolaryngol. 2003 Jun;28(3):183 Leve 1c

Serous Otitis Media Prognosis High rate of spontaneous resolution (1)

Most resolve in 3 months Meta-analysis 11 trials (2)

No significant hearing loss No speech/language delay

Tubes have consequences (3)

140 children followed 8 years Sequela higher at 3-5 years

47% for retraction pocket 67% for tympanic membrane atrophy 40% for myringosclerosis 23% for hearing loss

1) Pediatrics 2004 May 5;113(5):1412 Level 1a2) Pediatrics 2004 March; 113(3): e238 Level 1a3) Arch Otolaryngol Head Neck Surg. 2003 May;129(5):517 level 1b

Serous Otitis Media Treatment Medications

Antibiotics not beneficial (1)

Most rigorous meta-analysis find no benefit long-term

Some short-term benefit may exist Steroids

Nasal steroids no evidence of benefit (2)

Systemic steroids no difference long term (3)

1) J Fam Pract. 2003 Apr;52(4):321 FPIN network answer2) Cochrane Library 2002 Issue 4:CD001935 Level 1a3) Pediatrics. 2002 Dec;110(6):1071 Level 2b

Serous Otitis Media Treatment Surgery no clear evidence of benefit

RCT of a birth cohort that developed MEE (1)

Randomized to early tube placement or delay of 6 months (unilateral MEE) to 9 months (bilateral MEE)

Delayed group had better outcomes cognition, language (not significant) at age 3

Reduced time with MEE but no change in language or hearing (2)

No change in quality of life1) N Engl J Med. 2001 Apr 19;344(16):1179 Level 1b2) Cochrane Library 2005 Issue 1:CD001801 Level 1a

Serous Otitis Media Treatment

Surgery no clear evidence of benefit Cohort 30,099 children born in the Netherlands

Routine hearing screening at age 9 months 1,081 who failed 3 successive hearing screens were

referred to ENT surgeon 386 found to have persistent bilateral otitis media with

effusion for 4-6 months 187 children (mean age 19.5 months) were

randomized to ventilation tubes vs. watchful waiting and followed for 1 year with language tests

Ventilation tubes reduced diagnoses of bilateral otitis media with effusion at all measurements (NNT 2-4),

No differences in language development Pediatrics 2000 Sep;106(3):e42 Level 1c

Serous Otitis Media Treatment Post-tube precautions

unrandomized trial in 533 children who underwent tympanostomy tube placement

parents self-selected into 1 of 3 "treatments" to prevent complications of swimming

no additional precautions antibiotic drops following swimming ear molds worn during swimming control group consisted of children who never went

swimming all were given precautions against deep water swimming

(> 180 cm), diving and soapy water in ears during bathing no benefit was noted from antibiotic ear drops or ear

plugs

Arch Otolaryngol Head Neck Surg. 1996 Mar;122(3):276 Level 2b

Questions?