2: Otitis Media Flashcards
increased risk of OM with?
-age
decreased risk of OM with?
breastfeeding - may be position of infant or the passive Ab’s from mom
incidence of OM?
- most common reason for abx therapy
- most common diagnosis in sick children in US
- highest incidence 6-18 mo/o
- by 1y, 60-80% affected
- by 3y, 90% affected
how does blockage of the eustachian tube cause middle ear infections?
-
describe respiratory epithelium - why is it important?
- pseudostratified ciliated columnar epithelium with goblet cells
- lines eustachian tube, mastoid air cells, and down into lungs
what three functions does the eustachian tube serve for the middle ear?
- protection
- drainage
- ventilation
pathogenesis of OM (factors associated)
- inflammation (URI, allergies)
- Eustachian tube obstruction (mass, anatomy, smoke)
- middle ear effusion (barotrauma)
- (nasopharyngeal contamination) -> AOM
- can go to OME or become complicated
- OME resolves or becomes complicated
can you catch OM?
no - it is not contagious, BUT the respiratory infection that caused it IS contagious
big 3 for OM
S. pneumoniae
H. influenzae (non-typable)
M. catarhallis
what are some other bugs that cause OM?
- GAS, S. aureus, anerobes (more common in patients w/ tubes and chronic drainage)
- mycoplasma, Chlamydia
- TB, diphtheria, tetanus, fungus
some viruses associated with OM
- HPIV
- RSV
- Human metapneumovirus
- Rhinovirus
- Adenovirus
- Coronavirus
how do you get a sample of purulent fluid in OM if necessary?
tympanocentesis - needle through tympanic membrane
AOM history -what will you see?
- PAIN
- URI
- fever (only in about 1/3 of patients)
- headache
- irritability, apathy
- anorexia/ decreased appetite
- vomiting
- diarrhea
OME history - what will you see?
- behavior changes
- communication problems (not hearing well due to fluid)
- plugged ears
- popping ears
- recent URI or allergy symptoms
ddx: other options for otalgia
- otitis externa
- Ramsay-Hunt (VZV)
- TMJ
- dental problems
- pharyngitis
ddx: other options for ottorhea
-otitis externa
ddx: other options for hearing loss
- EAC (external auditory canal) impaction (could be wax)
- sensorineural
ddx: other options for vertigo, nystagmus, tinnitus
- eustachian tube dysfunction
- labyrinthitis
ddx: other options for postauricular swelling
- mastoiditis
- lymphadenitis
ddx: other options for facial paralysis
Bell’s palsy
what to look for on physical exam:
- general appearance
- head
- eyes
- nose
- throat
- neck
- gen: sepsis
- head: craniofacial abnormalities
- eyes: drainage
- nose: polyps (allergies, chronic infection), septal deviation, congestion, drainage - purulent?
- throat**: LOOK AT LAST - bifid uvula (submucosal cleft palate), redness, drainage, masses
- neck: masses, lymph nodes, meningismus
what to look for on ear exam:
- external
- otoscopic
- AOM TM triad?
external: tenderness, swelling
otoscopic: tympanic membrane
- landmarks
- position
- color
- translucency
- mobility
triad: bulging, immobile, red***
tympanic membrane abnormalities
- bulging
- bubbles
- air fluid levels
- perforation
- ottorhea
- bullae (blisters/vesicles) - very painful
- tympanosclerosis
- atrophy
- retraction pockets
- cholesteatoma (keratin accumulation - can erode through ossicles and TM in chronic OM)
micro associations w/ fever and earache
suspect pneumococcal infection
micro associations w/ otitis conjunctivitis syndrome or bilateral otitis
suspect H. flu
micro associations w/ membrane perforation or mastoiditis
suspect GAS
landmarks in posterosuperior quadrant
- incudostapedial joint
- pars flaccida
landmarks in anterosuperior quadrant
- lateral process
- manubrium of malleus
landmarks in posteroinferior quadrant
- pars tensa
- umbo
landmarks in anteroinferior quadrant
- light reflex
treatment of AOE
-roll of cotton w/ a wick containing meds: hydrocortizone and antibiotics
don’t give drops if suspect perforation of TM
how predictive is redness of OM? what else can it indicate?
- redness along only predictive about 25%
- can also get redness w/ crying, cerumen removal, (baro)trauma
special studies: tympanometry
-measures impedance of TM - if there is fluid, there will be no TM movement
special studies: acoustic reflectometry
-sound stimulus to see if TM will move
special studies: audiometry
-use this to monitor hearing if 3 ear infections in a row
special studies: CT/MRI
-look for masses, including infectious abscesses
other special studies you can do
- tympanocentesis/myringotomy
- CBC
- blood culture
- sed rate
AAP guidelines for AOM diagnosis:
- acute history (recent URI, congestion)
- evidence of middle ear effusion (drainage, bulging TM, abnormal tympanometry)
- signs and/or symptoms (fever, pain)
AOM tx: symptomatic relief
- topical anesthetic
- analgesics
- local heat
AOM tx: antimicrobial therapy
- med options
- how long
- when you see response
- when to recheck
- amoxicillin!!
- amoxicillin clavulanate
- cephalosporins
- macrolides
- erythromycin sulfisoxazole
- TMX (when allergic to penicillins)
- 10d
- short course if > 2y/o and no risk factors
- response in 24-48h
- recheck in 10-14d
treatment for recurrent OM
- treat for AOM
- antibiotic prophylaxis (amoxicillin or sulfisoxasole at 1/2 dose) or ENT referral
- adults - image for masses
- surgery (myringotomy w/ tympanostomy tubes - young age or frequent infections)
- monitor hearing, speech, and language
AOM tx: observation
many of these cases resolve on their own - but can treat b/c there can be severe complications and it keeps patients happy
OME treatment
- observe unless infant
- trial of full course antibiotics if effusion > 3 mo
- surgery (tubes, adenoidectomy - remove lymphadenopathy next to eustachian tube) - due to concern for hearing loss affecting language
- effusion > 4-6 mo
- bilateral effusion
- > or = 21dB hearing loss
- high risk
- monitor hearing, speech, and language
speech and language at risk
-infant
timeline of OME resolution
- 70% still have effusion at 2 w
- most clears by 4-6 w
anything remaining in there creates risk of another infection
type and placement of tubes in TM
- grommet tubes (to help it stay in TM)
- placed inferiorly
AOM prognosis
- 20% resolve spontaneously
- effusion remains in 40% at 1 mo after AOM
- effusion remains in 10% at 3 mo after AOM
- 20% will have recurrent episodes
AOM complications (long list)
- hearing loss (most common)**
- mastoiditis
- perforation
- chronic supporative OM (could be due to chronic mastoid infection)
- cholesteatoma (keratin tumor, appears white on TM)
- facial paralysis
- supporative labyrinthitis and petrositis (Gradenigo syndrome - signs of increased ICP: papilledema, headache)
- meningitis
- extradural abscess
- subdural empyema
- lateral sinus and carotid artery thrombosis
- brain abscess
- otitic hydrocephalus
prevention of AOM
- parental education:
- NO smoking
- breastfeeding
- vaccines
- fewer children in care setting for higher risk children
- chemoprophylaxis
- surgery
developments
- observation instead of therapy
- decreased length of therapy
- vaccinations
- xylitol sugar dosed with a gum
- probiotics, other complementary medical therapies not proven
where is one susceptible to cholesteatomas?
at areas of retraction in the TM
how to differentiate tympanosclerosis from cholesteatoma
tympanosclerosis doesn’t change movement of TM, whereas cholesteatoma will cause a mass behind TM that prevents movement of TM
