Lecture 4 Otitis Media Flashcards
Predisposing factors to otitis media
Immune response: bacterial polysaccharides not fully developed in children <2 years
Eustachian tube: connects back of throat and middle year, maintain normal pressure, smaller and more horizontal in children
Predisposing factors for AOM
Common cold: swelling and thick secretions in Eustachian tube, swelling of adenoids, negative middle ear pressure , trapped bacteria may result in bacterial infection
Young age
Day care attendance
Environmental tobacco smoke
Male sex
Allergy
Frequent contact with other children
Prevention of AOM
Handwashing
Cleaning shared toys
Avoidance of second hand smoke
Avoidance of feeding in flat, supine position
Reduce pacifier use in children >6 months
Breast feeding
Influenza vaccine
Symptoms of Acute otitis media
Pain, earache
Fever up to 40.5 degrees Celsius
Irritability
Night restlessness
Poor feeding
Nausea
Vomiting
Acute otitis media 2 requirements
Inflammation of the middle ear
Fluid in the middle ear
Bacterial otitis media includes….
Bulging, “cloudy, inflamed ear drum”
Purulent fluid behind ear drum or purulent otorrhea if tympanic membrane has been ruptured
Decreased mobility on pneumatoscopy
Complications of AOM
Perforated ear drum
Otitis media with effusion
Hearing loss, delayed speech development
Rare:
facial paralysis
meningitis
mastoiditis
Chronic suppurative otitis media - persistent inflammatory process associated with perforated tympanic membrane and draining exudate for > 6 weeks
What is otitis media with effusion or serous otitis media
Fluid in middle ear without symptoms of acute inflammation
Most frequently occurs following an episode of acute otitis media, but may be unrelated
Up to 5-% of children have an effusion 1 month post AOM
Up to 10% of children have an effusion 3 months post AOM
What is myringitis
Inflammation of the tympanic membrane alone or in associated with otitis external
May be due to crying, fever, viral infection, or URI
Is not indicated of otitis media
What is the impact of PCV vaccines on AOM
Decrease incidence AOM 13%-19% due to 7 valent pneumococcal conjugate vaccine in Canada
Spontaneous resolution of AOM, each pathogen with incidence and resolution rate
S. Pneumonia, incidence 40%, resolution rate 20%
H. Influenzae, incidence 50%, resolution 50%
M. Catarrhalis, Incidence 1-9%, resolution 75%
S. Aureus, S.pyogenes are rare 2% incidence
Treatment of AOM
Spontaneous recovereery is 81%
Antibacterial therapy enhanced acute symptom relief by 13.7%
Watchful waiting recommended for 48-72hours before intimating antibiotic therapy if
- > 6 months of age
- symptoms can be managed with analgesics
- follow up can be assured
Watchful waiting treatment decision ( treating with antibacterial)
Children < 6 months, or >6 months with perforated ear drum, unresponsive to analgesic, unlikely to return for follow up
Antibiotic treatment for AOM for s. Pneumonia
Amoxicillin 40mg/kg/day (give TID)
Cefuroxime 30mg/kg/day (give BID)
Treatment of acute otitis media with purulent conjunctivitis
Amoxicillin/Calvulanate 7:1
45mg/kg/day divided BID for 5 days
Treatment of acute otitis media with no purulent conjunctivitis
2 different treatments
If recent antibacterial use (within 3 months), <2 years of age, and/or in daycare than treat with amoxicillin 90mg/kg/day divided bid-tid for 5 days
If no recent antibacterial use, >2 yrs old, and isn’t in daycare than amoxicillin 40mg/kg/day divided tid for 5 days
* 10 day RX if <2yrs of age, perforated ear drum or recurrent otitis**
If Initial treatment fails with each treatment what is the next step
Amoxi 40mg/kg/day (failed rx)—> amoxi 45mg/kg/day plus amox/clav 7:1 ( clavulin 200 or 400) 45mg/kg/day each div bid or tid for 10 days
Amoxi 90mg/kg/day (Rx fail) —> amoxi clav 7:1 45mg/kg/day div bid for 10 days
Otitis media - complications, pathogens
Mastoiditis, vertigo, facial paralysis
Pathogens : S.pneumoniae, M.Catarhalis, H. Influenzae
Best duration of treatment for AOM
5 day treatment appears to have equivalent efficacy to 10days in uncomplicated AOM
10 days if :
Children <2 yrs
Perforated ear drum
Recurrent AOM
Non-responders
High risk
What are some advantages of reduced duration of therapy
Reduced potential to promote bacterial resistance
Reduced adverse effects
Increased compliance
Reduced cost
Follow up for AOM
Follow up visit at 3 months to assess for OME, Which may lead to hearing loss
Routine follow up before 3 months not required
otitis media with effusion (OME)
Should resolve in 72 hours
60-70% of children have middle ear effusion two weeks
In 40-50% of patients, may persist up to 1 month
In 10-25% of patients, middle ear effusion may persist up to 3 months
Fluid in the middle ear without symtpoms of acute inflammation of the year
Most frequently occurs following an episode of acute otitis media, but may be unrelated
Otitis media role of the pharmacist
Correct antibacterial and dosing
5 day therapy when appropriate
Adequate analgesic
Handwashing
Education about prevention
Education about antibacterial
Referral to ENT specialist
OME > 3 months with bilateral hearing loss
> 3 episodes in 6 months
> 4 episodes in 12 months
Retracted tympanic membrane
Cleft palate of craniofacial malformations
Advice to patients
My patient has a fever, what should I do ??
Fevers are sign that ur child’s body is fighting an infection and the best way to treat your child is to keep them hydrated and comfortable
Fluids
Acetaminophen, ibuprofen
Bathing
Clothing
Most children will get better on their own in 3-5 days
Treatment of acute otitis media (Beta lactam allergy) If initial treatment failure
Allergy not severe
Severe allergy
Allergy not severe : Clindamycin + cefixime or Ceftriaxone
Severe allergy: Levofloxacin
Treatment of AOM (beta lactam allergy)
Severe type 1 allergy
Non severe type 1 allergy
Severe:
if >8yrs, doxycycline
If <8yrs, calrithromycin or azithromycin
Non severe:
If <8 yrs, clindamycin
If >8 yrs, cefixime or cefuorxime
** if S.pneumoniae >20% local resistant, Levofloxacin
