Ear Disorders 3 Flashcards
Acute Otitis Media
general
Acute inflammation of the middle ear cavity leading to eustachian tube obstruction
accumulation of fluid and mucus
Secondary bacterial infection may occur
More common in children
Viral or bacterial
Most commonly follows an acute upper respiratory tract infection
Usually unilateral in adults
Typically, children 6-24 months of age
Risk greatly decreases after age 5
Decreased rate over past 20 years
Likely due to introduction of Pneumococcal vaccine in 2000
Acute otitis media
RF
Allergies
Day Care
Crowded living conditions
Smoke exposure
Pacifier use
Prone sleeping
Absence of breastfeeding
Eustachian tube dysfunction
Eustachian tube obstruction
Immunosuppression
Prematurity
Young
Family History
Altered Immunity
Craniofacial Abnormalities
Acute otitis media
S/Sx
Adults and young children
Otalgia
+/- fever
1/3 to 2/3 of children
Ear pressure
Conductive hearing loss
Disequilibrium
young children
Irritability
Headache
Bulging fontanelle (infants)
Apathy
Restless sleep
Poor feeding/anorexia
Vomiting
Diarrhea
Tugging ears
Acute otitis media
Dx
Otoscopic exam
Pneumatic Otoscopy
Culture from fresh perforation
may be helpful for choice of antibiotic
Acute otitis media
Exam Findings and Dx
Bulging TM hallmark finding
Important sign of acute inflammation
Erythematous, chalky white, or pale-yellow TM
Reduced mobility of TM
Loss of identifiable landmarks such as the short process and handle of the malleus
Clinical diagnosis
requires middle ear effusion (MEE) and acute signs of middle ear inflammation
Tympanocentesis (aspiration of contents for diagnostic evaluation)
Neonates
more likely to have unusual or more invasive pathogen
Immunosuppressed
Antibiotic failure
Complication that requires a culture for appropriate therapy
Acute otitis media
Bacterial & viral etiology
Streptococcus pneumoniae
Haemophillus influenzae
Moraxella catarrhalis
Misc:
Group A Strep, S. Aureus, E. coli, pseudomonas aeruginosa, mycoplasma pneumonia, chlamydia trachomatis
*May also be parasitic or fungal
VIRAL
In children 25% viral
Limited data for adults on viral incidence
Adults and most children, standard of care is antibiotic therapy
Child with mild symptoms, observation is reasonable
RSV
Rhinovirus
Parainfluenza*
Adenovirus*
Coronavirus (including SARS-CoV-2)*
*Less common
Acute otitis media
Tx and indications
Observation without antimicrobial therapy is now the recommended option in the United States for:
Acute otitis media in children >2 years of age
Mild to moderate disease without middle-ear effusion in children 6 months to 2 years of age.
Treatment is typically indicated for:
patients < 6 months old
Children 6 months to 2 years old who have middle-ear effusion and signs/symptoms of middle-ear inflammation
All patients > 2 years old who have bilateral disease, TM perforation, immunocompromise, or emesis
Any patient who has severe symptoms, including a fever ≥39°C or moderate to severe otalgia
Analgesics
Acetaminophen
Antibiotics, usually 5-7 days (Peds dosing for age > 6 months)
Amoxicillin
Pediatrics: 90 mg/kg/day divided BID
Adults: 500mg PO TID
Augmentin (Amoxicillin-Clavulanate)
Use in children with recent antibiotic use or risk of beta lactam resistance
Pediatrics: Dose per amoxicillin above
Adults: 875mg PO BID
Penicillin allergy
Cephalosporins (multiple)
Ex: Cefdinir
Acute otitis media
Treatment Failure
Symptoms typically improve in 48-72 hours
Failure of first line antibiotic therapy
Reexamination
Failure on anything other than amoxicillin-clavulanate
Amoxicillin-clavulanate high dose for 10 days
efficacy against beta-lactamase-producing H. influenzae and M. catarrhalis
Failure on amoxicillin-clavulanate
Cephalosporin
Surgery
Tympanocentesis
Myringotomy
Myringotomy with ventilating tube
Chronic Otitis Media
S/Sx
Symptoms
Persistent or recurrent purulent otorrhea in the setting of TM perforation
Some degree of conductive hearing loss
Pain is uncommon except during acute exacerbations
Exam
Purulent drainage from TM perforation
Drainage may be continuous or intermittent, with increased severity during upper respiratory tract infection or following water exposure
Chronic Otitis Media
Dx and general
Offending agents
Diagnostic Studies
None needed
Consequence of recurrent acute otitis media, although it may follow other diseases and trauma
The bacteriology of chronic otitis media differs from that of acute otitis media. Common organisms includeP aeruginosa, Proteusspecies,Staphylococcus aureus,and mixed anaerobic infections
Chronic Otitis Media
Tx
Removal of infected debris, use of earplugs to protect against water exposure, and topical antibiotic drops for exacerbations.
OralCiprofloxacin
Active againstPseudomonas
Definitive management is surgical
Mastoidectomy, myringoplasty, and and/or tympanoplasty
Otitis Media
Complications
Mastoiditis
Labyrinthitis
Persistent perforation
Cholesteatoma
Hearing loss
Otitis meningitis
Facial paralysis
Epidural, subdural, or brain abscess
Otic Therapies
Hydrocortisone/Neomycin/Polymyxin B (Cortisporin, Cortomycin)Hydrocortisone/Neomycin/Polymyxin B (Cortisporin, Cortomycin)
Available as suspension or solution
Indications: Otitis Externa, mastoidectomy infections
Dosing
Adults: Instill 4 drops 3 to 4 times daily
Infants, Children, and Adolescents (Limited data in ages < 2 years):
Without a cotton wick: Instill 3 drops 3 to 4 times daily
With a cotton wick: Insert saturated wick of cotton; keep moist by adding drops every 4 hours
Replace wick every 24 hours
Use < 10 days
Ofloxacin (Floxin)/Ciprofloxacin (Cetraxal)
MOA indications
Inhibits bacterial synthesis (and thus growth) by inhibiting DNA gyrase. It has activity against pseudomonads, streptococci, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, and most gram-negative organisms but has no activity against anaerobes.
Indications: Otitis Externa, Acute Otitis Media with tympanostomy tubes, Chronic supportive otitis media with TM perforation
