Acute otitis Media

Question 1

What is the recommendation regarding treatment for children 6 months to 2 years presenting with symptoms of AOM?

Answer 1

The recommendation is:
AAP guideline’s recommendation of prompt antimicrobial
treatment for children younger than 2 years with AOM that is
bilateral and/or apparently severe should be extended to include also those children whose disease is unilateral and apparently nonsevere.

Question 2

What are the defining features of the tympanic membrane that has a high sensitivity for AOM upon examination?

Answer 2

A bulging tympanic membrane, especially if yellow or hemorrhagic, has a high sensitivity for AOM that is likely to be bacterial in origin
Perforation of the tympanic membrane with purulent discharge similarly indicates a bacterial cause.

Question 3

When is Immediate antibiotic treatment recommended?

Answer 3

1. Immediate antibiotic treatment is recommended for children who are highly febrile (≥39°C),
2. Moderately to severely systemically ill or
3. Who have very severe otalgia, or have already been significantly ill for 48 h.

For all other cases, parents can be provided with a prescription for antibiotics to fill if the child does not improve in 48 h or the child can be reassessed if this occurs. Amoxicillin remains the clear drug of choice.

Question 4

How long should therapy be for Acute Otitis Media for kids < 2 and >2?

Answer 4

Ten days of therapy is appropriate for children <2 years of age, whereas older children can be treated for five days.

Question 5

How does AOM develop?

Answer 5

Normally, mucocilliary clearance mechanisms in the eustachian tube (ET) ventilate and drain fluid away from the middle ear. ET dysfunction or obstruction due to a viral infection or other causes of mucosal inflammation can impair this normal mechanism.
The lack of middle ear drainage leads to fluid stasis and, if the fluid is colonized with bacterial and/or viral pathogens, can lead to AOM.

Question 6

Why are children more likely to get AOM than adults?

Answer 6

Children are predisposed to AOM because they acquire viral infections more often than adults, and their ETs are also shorter and more horizontal compared with adults

Question 7

What are risk factors for AOM?

Answer 7

Risk factors for AOM include
-young age and frequent contact with other children, which increases exposure to viral illnesses.
- orofacial abnormalities (such as cleft palate),
- -household crowding,
- -exposure to cigarette smoke,
- pacifier use,
- shorter duration of breastfeeding,
- prolonged bottle-feeding while lying down and a
- family history of otitis media.
- Children of First Nations or Inuit ethnicity are also at higher risk for AOM

Question 8

Which bacteria would be considered less virulent causes of AOM? Which are more?

Answer 8

Less: M. Catarrhalis, and some strains of H. Influenzae
More: S. Pneumoniae, and S. Pyogenes

Question 9

What bacteria are the most common cause of AOM?

Answer 9

S. Pneumoniae, (Non-typeable) H. influenzae, M. Catarrhalis and (less commonly) GAS.

The most common bacteria causing AOM are S pneumoniae, nontypeable H influenzae (NTHi; which means unencapsulated), M catarrhalis and (less commonly) group A strep.27 In 20-30% of cases no bacteria is found. In up to 44% of cases, the cause is a virus with or without concomitant bacteria. S. pneumoniae may be more common in first or early otitis media episodes, but this is also possible with H. influenzae and M. catarrhallis.29 S. pneumoniae is isolated with equal frequency in bilateral and unilateral AOM. NTHi is commonly isolated in bilateral than unilateral by NTHi is frequently associated with concurrent conjunctivitis and milder symptoms.

Question 10

What is the only way to consistently confirm AOM in terms of diagnostics?

Answer 10

Using an otoscope with a bright light source (ie, replacing otoscope bulbs yearly) and the largest ear speculum that fits into a child’s ear facilitates visualization and the application of validated criteria to diagnose AOM.

Question 11

What are the necessary diagnostic criteria for AOM?

Answer 11

• acute onset of symptoms (Otalgia, or suspected otalgia
• Middle ear fluid AND
• Significant inflammation of middle ear

Similarly, an acute perforation with purulent discharge (otorrhea) in the setting of AOM strongly supports a bacterial cause.

Question 12

When is an effusion present?

Answer 12

An effusion is present when there is little or no mobility of the tympanic membrane (TM) when both positive and negative pressure is applied using a pneumatic otoscope

As a distinct entity, AOM should be differentiated from OME, which is also characterized by the presence of MEE; however, in contrast to AOM, signs of acute inflammation of the middle ear are absent.

Question 13

Does ear drainage always mean AOM?

Answer 13

the drainage associated with acute symptoms of AOM and perforation should always be distinguished from otitis externa, chronic ear drainage from a previous perforation (with no middle ear inflammation) or drainage associated with a tympanostomy tube, because management for these conditions would be very different.

Question 14

Watch this video on Otoscopy technique and diagnosing AOM!

Answer 14

An excellent video describing otoscopy technique and diagnostic criteria for otitis media is available at http://www.nejm.org/doi/full/10.1056/NEJMvcm0904397.[34]

Question 15

What is the most common complication of AOM?

Answer 15

Acute mastoiditis!

Although AOM is usually accompanied by inflammation of the mastoid air cells (including radiographic changes on computerized tomography), clinical symptoms, such as pain or swelling over the mastoid bone (behind the ear), suggest mastoiditis.

Question 16

Which children can be given watchful waiting?

Answer 16

Children who have a:
-mild or moderately bulging TM, and
- who are mildly ill, alert, responding to antipyretics, have a low-grade fever (<39°C) and mild otalgia can be safely managed with an observation or ‘watchful waiting’ period of 24 h to 48 h.

• Planned reassessment, access to timely reassessment or “expectant” antimicrobial prescriptions may be acceptable approaches, depending on clinical and social circumstances

In all instances, their caregivers should be informed about and be attentive to any change or worsening of symptoms, and should have ready access to medical care. If symptoms worsen or do not improve within 24 h to 48 h, antimicrobials should be prescribed. Explanations regarding the management plan should be discussed with caregivers so decision-making can be shared. It is vital to provide appropriate advice about analgesics.

Question 17

Which children should be treated with antimicrobials?

Answer 17

Children with AOM (defined by a bulging TM) who are
- highly febrile (≥39°C) and
- moderately to severely systemically ill, or
- children who have severe otalgia or have been significantly ill for 48 h should be treated with antimicrobials (Figure 1).

In all instances, their caregivers should be informed about and be attentive to any change or worsening of symptoms, and should have ready access to medical care. If symptoms worsen or do not improve within 24 h to 48 h, antimicrobials should be prescribed. Explanations regarding the management plan should be discussed with caregivers so decision-making can be shared. It is vital to provide appropriate advice about analgesics.

Question 18

What is the the first drug of choice in AOM and why?

Answer 18

the penicillin susceptibility rate of S pneumoniae, which causes invasive disease, is >90% in most jurisdictions in Canada.[37]-[39] Because S pneumoniae is the predominant pathogen in AOM and because it also covers GAS, empirical amoxicillin remains the drug of first choice

Amoxicillin has excellent middle ear penetration (so may still be effective despite in vitro resistance), is inexpensive, well tolerated and has a relatively narrow antimicrobial spectrum.

M catarrhalis and some strains of H influenzae are more likely to be amoxicillin-resistant (ie, are more likely to produce beta-lactamases) but they are less common pathogens, and AOM caused by either bacteria is more likely to resolve spontaneously.

Question 19

How do we get clinical cure of AOM with amoxicillin?

Answer 19

For clinical cure of AOM, the levels of amoxicillin in the middle ear should be adequate for over 50% of the day.

Administering 45 mg/kg/day to 60 mg/kg/day of amoxicillin in three divided doses will achieve adequate middle ear levels,

whereas a twice per day dosing regimen requires higher total daily doses of 75 mg/kg/day to 90 mg/kg/day to maintain adequate levels for a comparable percentage of the day

Question 20

Which situations do we prefer perhaps an Amox/clav, or secongeneration cephalosporin (Eg. Cefuroxime) as first line?

Answer 20

In the setting of AOM with purulent conjunctivitis (otitis-conjunctivitis syndrome), H influenzae and M catarrhalis are common pathogens.

It may also be prudent to use amoxicillin-clavulanate if the child has had a recent treatment with amoxicillin – within the previous 30 days – or infection that suggests a relapse of a recent infection or nonresponse to amoxicillin.

If the child has a history of a hypersensitivity reaction to amoxicillin or penicillin, using the second-generation cephalosporins (cefprozil or cefuroxime-axetil) or a third-generation cephalosporin is acceptable, unless the previous reaction was life-threatening (ie, associated with angioedema, bronchospasm or hypotension)

Question 21

What is an alternative option for AOM in children with allergies to penicillin (severe allergy)?

Answer 21

Alternatively, using a macrolide/azalide (clarithromycin or azithromycin) or clindamycin is an option; however, these antibiotics generally have inferior bacterial killing capabilities, especially for S pneumoniae and H influenzae, compared with the beta-lactams (eg, penicillins or cephalosporins).

Question 22

When should symptoms improve for AOM in children starting antimicrobials?

Answer 22

Symptoms should improve within 24 h and resolve within two to three days of starting antimicrobials. If symptoms persist or worsen, the patient should be evaluated again to assess for either complications or persistent AOM

Question 23

What should the practitioner do if the AOM persists despite amoxicillin given in recommended doses with good compliance,

Answer 23

switch to amox clav

H influenzae and M catarrhalis may be causing the AOM. In this setting, treatment should be changed to amoxicillin-clavulanate, reserving intravenous or intramuscular ceftriaxone for cases where oral drugs are not tolerated or amoxicillin-clavulanate failed

Question 24

WHat dose of clav is linked to higher risk of diarhea for children?

Answer 24

> 10mg/kg per day

Amoxicillin-clavulanate

In Canada, the preferred suspension is the 7:1 formulation* because it has the most amoxicillin combined with the least amount of clavulanate. Each 5 mL of suspension contains 400 mg of amoxicillin and 57 mg of clavulanate. Therefore, a patient treated with 60 mg/kg/day would receive approximately 8.5 mg/kg/day of clavulanate. This dosage amount does not exceed the 10 mg/kg/day dose of clavulanate linked with higher risk for diarrhea

Question 25

Summarize the first line:
1. If no penicillin allergy
2. If penicillin allergyu
3. If initial therapy fails

Answer 25

Question 26

What is the most common cause of acute care visits and use of antibiotics in children?

Answer 26

AOM!

Question 27

Which children should never be treated as “watch and wait”

Answer 27

• Age <6 months
• Age > 6:
• In Children >6 If the ear drum has perforated and there is drainage treat X 10 days
• If they are moderately or severely ill or have other criteria you are going to treat with antimicrobials, 10 days (6 months to 2 years) and 5 days > 2 years of age.27 Moderately or severely ill means: irritable, difficulty sleeping, poor response to antipyretics, severe otalgia; OR ≥39°C in absence of antipyretics; OR >48 h of symptoms.

Question 28

Should we recommend any of the following therapies as adjunct to AOM?
Topical anesthetics- (definitely not benzocaine, more trials are needed for lidocaine); decongestants and antihistamines-; olive oil/herbal extracts into ear; heat or cold application-; distraction-

Answer 28

NO!!
IBUPROFEN AND ACETAMINOPHEN YES!!

Question 29

Describe the the symptoms to improve and completely resolve?

Answer 29

Signs and symptoms of infection (pain, fever, redness/bulging of tympanic membrane) should start to improve after 24 hours and resolve within 2-3 days of starting antibiotics.27 Complete resolution should occur within 7-14 days.

Question 30

Does persistance of middle ear effusion mean infection is still there after symptoms are gone?

Answer 30

Persistence of a middle ear effusion is common after resolution of symptoms and should not prompt antibiotic therapy. Prophylaxis is generally not considered as it may not be effective and increases the risk of resistance developing.

Question 31

What is the treatment for Otitis externa?

Answer 31

A very brief word on otitis externa (swimmer’s ear). This is probably the only place that topical antibiotics/anti-inflammatories are used and probably only in moderate to severe disease. In severe disease, oral antibiotics and even IV antibiotics (malignant otitis externa) are used.