10 Acute Otitis Media Steinberg

Question 1

What is Acute Otitis Media (AOM)?

Answer 1

Infection of the middle ear with acute onset and S/Sx, MEE, and acute S/Sx of middle ear inflammation

Question 2

What is Otitis Media with Effusion (OME)?

Answer 2

Presence of middle ear effusion (MEE) without signs and symptoms of infection

Question 3

What is Treatment-Failure AOM?

Answer 3

Lack of improvement in S/Sx within 48-72hrs after initiation of antibiotic therapy

Question 4

What is Recurrent AOM?

Answer 4

3 or more AOM episodes in the previous 6 months or four or more AOM episodes in the preceding 12 months

Question 5

What is Difficult-To-Treat AOM?

Answer 5

Includes both recurrent AOM and treatment-failure AOM (affects up to 20% of children who develop AOM in their first postnatal years)

Question 6

What is Chronic OME?

Answer 6

OME for 3 or more months duration (chronic serous otitis)

Question 7

What is Chronic Suppurative Otitis Media (CSOM)?

Answer 7

Is a perforated tympanic membrane with persistent purulent drainage from the middle ear

Question 8

What are the characteristics of a “Normal” Tympanic membrane in children?

Answer 8

Translucent/transparent. Gray or pink color. Neutral position. Fully mobile with pneumatic otoscopy. No effusion

Question 9

What are the characteristics of an AOM Tympanic membrane?

Answer 9

Opaque. Red, yellow, or cloudy. Bulging or full position. Reduced mobility with pneumatic otoscopy. Effusion present

Question 10

What is the Otoscopic diagnosis of otitis media like?

Answer 10

Purulent Otorrhea of < 24 hours. OR. 2 of 4 TM abnormalities (MEE): Impaired or absent mobility, Yellow/white discoloration, Opacification (other than from scarring), Air-fluid interfaces. WITH. 1 indicator of inflammation: New ear pain (+/- unaccustomed ear pulling), Marked TM redness, Bulging TM; loss of anatomic landmarks

Question 11

What is Tympanocentesis?

Answer 11

Trans-tympanic needle aspiration of ME contents; decreases ME pressure and very effective in relieving pain; culture and sensitivity is performed on the aspirate

Question 12

What virus is AOM strongly correlated with?

Answer 12

RSV, HMNV

Question 13

Which viruses are most commonly associated with otitis media?

Answer 13

Streptococcus pneumoniae. Haemophilus influenzae. Moraxella catarrhalis

Question 14

Which virus is most often associated with a Fever in AOM?

Answer 14

S. pneumoniae

Question 15

What is the primary antibiotic used in AOM?

Answer 15

Amoxicillin

Question 16

For ages 6mo to 2yo when can just just observe AOM?

Answer 16

Unilateral AOM without Otorrhea

Question 17

For ages > 2yo when can you just observe AOM?

Answer 17

Bilateral or Unilateral AOM without Otorrhea

Question 18

Why can observation of AOM be good?

Answer 18

Provides an opportunity for shared decision making with the child’s family. If observation is offered, a mechanism must be in place to ensure follow-up and begin antibiotics if the child worsens or fails to improve within 48-72 hrs of AOM onset

Question 19

Who are the Non-Qualifiers for delayed prescription for AOM (no observation allowed)?

Answer 19

Symptoms suggestive of AOM for more than 48 hrs. Antibiotic therapy w/in past 7 days for any reason. Infant 6 months of age or less. Toxic-appearing child. Hearing impairment. Another episode of AOM w/in the past 3 months. Co-existing bacterial infection

Question 20

What is the recommended first-line treatment for AOM?

Answer 20

Amoxicillin (80-90mg/kg/day in 2 divided doses). OR. Amoxicillin-Clavulanate (Augmentin; 90mg/kg/day, 14:1 ratio of amox:clav)

Question 21

What is the alternate first line treatment for AOM if patient has a Penicillin Allergy?

Answer 21

Cefdinir. Cefuroxime. Cefpodoxime. Ceftriaxone (IM/IV, might not be best choice of the CEPHs)

Question 22

What is the antibiotic of choice if the initial antibiotics failed after 48-72hrs of treatment?

Answer 22

Augmentin (if this was not used for initial therapy). OR. Ceftriaxone

Question 23

What is an alternate to first line therapy in failed initial therapy?

Answer 23

Ceftriaxone (if Augmentin was used). Clindamying w/ or w/o 3rd gen CEPH

Question 24

What are the choices if patient failed second antibiotic?

Answer 24

Clindamycin + 3rd gen CEPH. Tympanocentesis. Consult specialist

Question 25

What are Dr. Steinbergs problems with the AAP Guidelines?

Answer 25

Reliability of quoted spontaneous resolution rates (14-88%). Ignores other clinical factors influencing microbiology. Is clavulanate dose sufficient to reliably eradicate H. influenzae? Can PO CEPHs be used for more than just PCN allergy? Reliance/acceptability of 3-dose IM Ceftriaxone as the lead recommendation for treatment failure after Amox-Clav failure. Clindamycin never evaluated formally or comparatively in AOM

Question 26

What are some “Modifying Factors” that could make you change your treatment decision?

Answer 26

Daycare center attendance. Recent antibiotic use. Resistance suspected/documented. Bilateral disease. Conjunctivitis-Otitis syndrome. Recurrent AOM/Otitis prone. Past/central Amox failure. AOM in patient w/ chronic OME. TM perforation/tympanostomy tubes. Immunosuppression. Infants < 6 months old