Acute Otitis Media Flashcards
Definition acute otitis media
The presence of inflammation in the middle ear, associated with effusion and accompanied by the rapid onset of signs and symptoms of ear infection (i.e pain in ear and fever)
Classifications of acute otitis media
- persistent AOM- occurring when people return for medical advice with the same episode of AOM, either because the symptoms persist after initial management or because symptoms are worsening
- Recurrent AOM- defined as three or more well-documented and separate episodes of AOM in 6 months, or four or more in 12 months (with at least one episode in the past 6 months)
Why is AOM more common in childhood, what are the causative organisms
- Young eustachian tubes are short, horizontal and function poorly leading to middle ear infection (also more likely to develop viral infections)
- AOM can be caused by both bacteria and viruses and commonly these present at the same time. Most common causative organsims include:
1. H.influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes
2. RSV (respiratory syncytial virus), rhinovirus, adenovirus, influenza
Risk factors for AOM
Young age, male sex, smoking or passive smoking, formula feeding (breastfeeding has a protective effect), cleft palate, lack of pneumococcal vaccine, GORD, FHx, prematurity, immunodeficiency, recurrent URTIs
Prevalence of AOM and peak incidence by age
- Children from birth to 4 years of age are most likely to present with AOM > most frequently affects children between 6 and 24 moths old (incidence peaks at 9-15 months)
- There is seasonal incidence in cases (more common in winter and in children born in the Autumn)
- Incidence: 3.6 per 110/ annum (Europe), 43.4 West and Central Africa
Presentation of AOM
Acute onset of symptoms including
* Earache in older children and adults
* In younger children: holding, tugging or rubbing ear, or non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough or rhinorrhoea (do not differentiate from URTI)
What will be seen on otoscopy
- A distinctly red, yellow or cloudy tympanic membrane
- Moderate to severe bulging of the tympanic membrane with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicates middle ear effusion)
- Perforation of the tympanic membrane +/- discharge in the external auditory canal
What might complicate diagnosis in children younger than 6 months
(particularly less than 3 months)
- co-existent systemic illness (bronchiolitis, bacteraemia), non-specific symptoms and a tympanic membrane which is not visible (often lies in an oblique position + ear canal tends to be small and collapse)
- Symptoms which are NOT suggestive of AOM: tympanic membrane which is not bulging (regardless of presence of erythema or cloudiness) and air-fluid level without a bulging tympanic membrane
Differentials for AOM
- Otitis media with effusion (glue ear)- fluid in the middle ear without symptoms or signs of acute infection
- Chronic suppurative otitis media- persistent inflammation and perforation of the tympanic membrane with draining discharge for more than 2 weeks
- Myringitis- erythema and injection (red and popping) of the tympanic membrane, but no other features of otitis media
- Otitis externa
- Eustachian tube dysfunction, Mastoiditis
When should children be admitted with AOM
- Evidence of severe systemic infection
- Evidence of acute complications of AOM: meningitis, mastoiditis, intracranial abscess facial nerve palsy
- Children < 3 months with a temperature >38 degress
Consider admitting children < 3 months old and children 3-6 months with a temperature of 39 degrees or more
What isthe usual course of AOM
Around 3 days, but can be up to 1 week
How can AOM be actively managed
- Should take regular doses of paracetamol or ibuprofen for pain (no evidence to support the use of decongestants or antihistamines for the management of symptoms)
- For antibiotic prescription, consider:
1. No antibiotic prescription: acute complications such as mastoiditis are rare with or without antibiotics which have their own complications. Need to advise to seek help if symptoms worsen rapidly, do not improve after 3 days, or the person becomes systemically very unwell.
2. A back-up antibiotic prescription: advise that antibiotics are NOT NEEDED IMMEDIATELY but should be used if the symptoms have not improved after 3 days or they worsen significantly over time
3. Immediate antibiotic prescription: for people who are systemically very unwell, have symptoms and signs of more serious condition or high risk of complications (can also consider in those less than 2 years with bilateral infection). Need to seek medical help if symptoms worsen rapidly or they develop signs of systemic illness (if not already)
For children who are not prescribed antibiotics and who do not have ear drum perforation or otorrhea, prescribe ear drops containing an anaesthetic and an analgesic
Which antibiotics should be considered and how should children be followed up
- A 5- day course of amoxicillin
- OR clarithromycin/ erythromycin in the case of penicillin allergy
- Second choice Abx is 5-7 day course of co-amoxiclav (seek micro help if penicillin allergy)
- If there is perforation give oral amoxicillin for 5 days and review in 6 weeks to ensure healing
Review treatment if no improvement after 7 days or if symptoms worsen at any time consider alternative diagnosis, organism resistance
- Antibiotics marginally reduce the duration of the pain but have no effect on risk of hearing loss
How shoudl recurrent otitis media be managed
- Consider referral to an ENT specialist for all people with recurrent AOM, especially if:
1. The person has a craniofacial abnormality (Down’s syndrome or a cleft palate).
2. Recurrent episodes are unexplained, very distressing or associated with complications. - If referral is not necessary:
1. Manage acute episodes in the same way as for initial presentation
2. In people with grommets with acute discharge, consider swab for culture + sensitivity, consider ENT referral - Advise to avoid exposure to passive smoking, use of dummies and supine feeding. Ensure that they have had pneumococcal vaccines and GORD is managed appropriately
