Acute Otitis Media

Question 1

Etiology

Answer 1

S. Pneumoniae (32%)
H. Influenzae (non-typable) (>50%)
M. Catarrhalis
GAS (rare)

Question 2

Symptoms

Answer 2

Symptoms are non specific:
Otalgia 
\+/-fever 
Vomiting
Conductive hearing loss
Otorrhea (if tympanic membrane perforation)

Question 3

Symptoms in infants and toddlers

Answer 3

fever, fussiness, decreased activity, poor sleeping, vomiting, ear-tugging, non consolable

Question 4

Risk Factors

Answer 4

Males
White, First Nation, Inuit
Age: Most prevalent between 6 mo – 24 mo; Peak incidence 6 – 9 mo, 75% of children have an episode before age 2
PMHx: Enlarged tonsils + adenoids, anatomic abnormalities (ex. Cleft palate)
Family history
Prolonged bottle feeding and / or shorter duration of breast feeding
SoHx: Crowded conditions (ex/ day care, nursery school), Second hand smoke

Maternal smoking
Daycare
Pacifier use
Bottle feeding

Question 5

DDX

Answer 5

Myringitis
Otitis Media with Effusion (OME)
Chronic Suppurative Otitis Media
Teething, Migraine, Stasis

Question 6

RED FLAG DDX

Answer 6

Mastoiditis
Meningitis
Intracranial Abscess

Question 7

Findings on Otoscopy

Answer 7

Impaired mobility on pneumatic otoscopy
• most sensitive and specific (95% and 85%) for Middle Ear Effusion
Bulging on otoscopy
• Spe>97% Sen 51% for the presence of MEE; PLR 51.1
Erythema of the TM
• (PLR 8.4).1
Cloudy Opacification / Yellow / White TM on otoscopy
Loss of visualization of bony landmarks on otoscopy
Air Fluid Levels

Question 8

Diagnostic Criteria

Answer 8

1. Presence of middle ear effusion, and
2. Presence of middle ear inflammation, and
3. Acute onset (<48 hrs) of symptoms

Need all 3

Question 9

Investigations

Answer 9

NONE

Question 10

Management steps for >6 mo of age, healthy, no chronic medical issues:

Answer 10

• Perforated TM with purulent D/C -> antibiotics x 10 days
• MEE + Bulging TM, mild (<39 C w/out antipyretics, <48 h, mild pain, able to sleep, alert, responsive) -> observe 24-48 hrs w/ good medical follow up.
• MEE + Bulging TM, moderate (>/39 w/out antipyretics, >48 hrs, severe pain, difficulty sleeping, irritable) -> treat
• No MEE and no bulging TM -> observe 24-48 hrs w/ good medical follow up.

Question 11

Management steps if < 6 mo

Answer 11

Treat

Question 12

Pharmacologic treatment duration for < 2y vs. > 2 yr

Answer 12

• <2y/o txt for 10 d, >2y/o txt for 5 d

Question 13

Pharmacologic treatment for uncomplicated AOM, first line and 2nd line

Answer 13

First Line
• Amoxicillin – 75 mg/kg/day–90 mg/kg/day divided twice per day as capsules or suspension; OR
• Amoxicillin – 45 mg/kg/day–60 mg/kg/day divided three times per day as capsules or suspension
Second Line:
• Amoxicillin-Clavulanic Acid

Question 14

Pharmacologic treatment for uncomplicated AOM, with penicillin allergy: first line and 2nd line

Answer 14

First line: 
•	Cefuroxime
•	Cefprozodil
2nd line:
•	Azithromycin
•	Clarithromycin

Question 15

Pharmacologic treatment for AOM with purulent conjunctivitis

Answer 15

• Amoxicillin-Clavulanic Acid

* Cefuroxime

Question 16

Follow Up Instructions

Answer 16

• f/u in 48-72 hours if symptoms persist

* f/u in 3 mo post AOM to assess for persistent OME

Question 17

Indications to refer to ENT for tympanostomy tubes

Answer 17

ENT for Tympanostomy tubes
• OME for >3 mo with bilateral hearing loss > 20 db
• >3 episodes in 6 mo
• >4 episodes in 12 mo
• Retracted TM
• Cleft Palate / craniofacial abnormalities

Question 18

Prevention

Answer 18

• Hand washing
• Breastfeeding until at least 3 months of age
• Pacifiers INCREASE the risk
• Avoid tobacco smoke
• Avoid feeding in supine / flat position
• Flu shot
• Prevnar