B3.054 Otitis Media Flashcards
most common condition for which antimicrobial agents are prescribed in the US for children
otitis media
when do children usually get AOM?
coincident with or following a viral upper respiratory tract infection
what happens in 75% of kids with an URI
Eustachian tube dysfunction
discuss the breakdown of viral vs bacterial AOM cases
96% virus and/or bacteria
66% both
27% bacteria alone
4% viruses alone
4 most common bacterial pathogens of URIs
S. pneumoniae
H. influenzae
M. catarrhalis
S. pyogenes
what has caused certain serotypes of S. pneumo to decrease?
conjugate pneumococcal vaccine
pen resistant isolates also decreased
most likely cause of otitis-conjunctivitis
non typeable H. influenzae (NTHi)
best way to confirm AOM
tympanocentesis and bacterial culture of middle ear fluid
what factors increase the risk of AOM
daycare
non-Hispanic white
atopy (allergies, asthma)
siblings/ fam history of recurrent AOM
risk factors for RECURRENT AOM
male sex
day car
fam history
first episode within first 6 mo of life
what qualifies as recurrent AOM
> 3 episodes in 6 months or >4 in 1 year
protective against AOM
breastfeeding in first 6 months
strong recommendation
follow unless a clear and compelling rationale for an alternate approach is present
recommendation
prudent to follow but should remain alert to new info and sensitive to patient preferences
option
consider the option in their decision making and patient preference may have a substantial role
no recommendations
be alert to new published evidence that clarifies balance of benefit vs harm
symptoms of AOM
rapid onset of ear pain
preverbal: tugging/rubbing/holding of the war, crying, fever, changes in sleep/ behavior
most useful symptom in AOM diagnosis
ear pain
+ likelihood ratio 3-7.3
present in 50-60% of kids w AOM
physical signs of AOM
cloudy, bulging TM with impaired mobility
impaired mobility highest sensitivity
bulging highest specificity
bulging associated with bacterial pathogen
what is OME
otitis media w/ effusion
distinguish OME from AOM
can occur either as an aftermath of AOM or as a consequence of Eustachian tube dysfunction attributable to an URI
can also precede and predispose to development of AOM
segments of a disease continuum
does OME benefit from antibiotics? why or why not?
no
not an acute infectious process
AOM diagnostic criteria
moderate to severe bulging of the tympanic membrane or new onset of otorrhea not due to acute otitis externa
ORRR
mild bulging of the TM and recent onset of ear pain or intense erythema of the TM
when should you not diagnose AOM?
children who DO NOT have middle ear effusion based on pneumatic otoscopy and/or tympanometry
how can you detect the presence of MEE
bulging of the TM
limited or absent mobility of the TM
air-fluid level behind the TM
otorrhea
how does a retracted tympanic membrane in OME appear
short process points to 9 o clock instead of 8
tenants of AOM treatment
assessment of pain
treatment to reduce pain
what % of AOMs clear on their own?
19% of S. pneumo
48% of H.influenzae
75% M. catarrhalis
cleared 2-7 days after initial tympanocentesis
when is there a clinically significant benefit of immediate antimicrobial therapy?
bilateral AOM
S. pneumo
AOM with otorrhea
how is severe AOM classifies
moderate to severe otalgia
fever >39 C
when do you have an observational option?
> 2 yr old not severe uni or bilateral AOM
6 mo - 2 yr not severe unilateral AOM
no otorrhea
most common drug/dose prescribes to children
amoxicillin
80-90 mg/kg/day
when should you use additional beta lactamase coverage?
kids who have had amoxicillin in the past 30 days
purulent conjunctivitis
recurrent AOM unresponsive to amoxicillin
what do you do if a patient fails to respond to initial management option within 48-72 hours?
reassess, exclude other causes of illness
start antimicrobials if it wasn’t already
switch antimicrobials if they were started already
alternative treatment for people w penicillin allergies
cephalosporin
more broad spectrum, more expensive, and not necessarily better
define OME
present of fluid in the middle ear without signs or symptoms of acute ear infection
may occur during URI from poor Eustachian tube function or as an inflamm response following AOM
what % of people get OME
90% of kids before school age
>50% in first year of life
how long does OME usually last?
most resolve within 3 months
30-40% of kids can have repeat episodes
5-10% of episodes last >1 year
25% of OME episodes last >3 mo
what is a consequence of OME?
persistent OME results in decreased mobility of the TM and serves as a barrier to sound conduction
most common cause of hearing impairment in children in developing countries
perm hearing loss prevalence 2-35 per 100,000
when do you perform pneumatic otoscopy?
diagnosis of OME
child w otalgia, hearing loss, or both
when do you do tympanometry?
suspected OME when diagnosis is uncertain after performing/attempting pneumatic otoscopy
when do you do a hearing test?
OME persists >3 mo
OR
OME of any duration in an at risk child
what are factors accounted for in surgical candidacy for OME
hearing status
associated symptoms
developmental risk
anticipated chance of timely spontaneous resolution of effusion
