Otitis Media 1.0 Flashcards
A father and his 2 year old son, TS, present to your pharmacy. TS’s father states that TS has been very fussy, has been frequently rubbing his left ear, and has a temperature of 37.9°C. He just came from their
family physician who said that TS has a mild case of otitis media and recommended watchful waiting. TS’s father was wanting to get your opinion on this, as he was expecting that TS would get antibiotics.
What is your approach?
???
Incidence of AOM
- a disease of infancy and childhood
- most frequently diagnosed bacterial infection in pediatric patients
• peak incidence between 6 & 9 months
▫ > 60% of children have 1 episode by 1 yr of age
▫ 17% have 3 episodes by 1yr
- If first episode by 6 months, 60% have 2 or more recurrences by 2 years
- 75% of children have at least 1 episode of AOM before starting school
- after 6 yrs of age <40% develop AOM
Predisposing Factors
Immune response:
• to bacterial polysaccharides not fully developed in children <2 years
Eustachian Tube:
• Connects back of throat and middle ear
• Maintains normal air pressure
• Mucocilliary clearance normally ventilate and drain fluid away from the middle ear
• Is smaller and more horizontal in children
Anatomy of the Ear
see slide 6, 7
Predisposing Factors
Most cases follow a viral respiratory illness - one study 22% children 6 months - 3 years old developed otitis media in 1 st week of URI
Common cold
Common cold:
▫ Swelling & thick secretions in eustachian tube
▫ Swelling of adenoid
▫ Obstruction or dysfunction of eustachian tube
▫ Negative middle ear pressure
▫ Fluid stasis and collection in middle ear
▫ Increased colonization of nasopharynx with otitis pathogens
▫ Increased bacterial adherence to mucous promotes bacterial overgrowth
▫ Trapped bacteria may result in bacterial infection
Predisposing Factors
Other factors besides following a viral respiratory illness
• Young age
• Frequent contact with other children and viral illnesses
• Daycare attendance
- Increased viral respiratory illnesses
- Increased exposure to resistant organisms
• Shorter duration breastfeeding
• Bottle feeding, particularly supine
• Environmental tobacco smoke
• Male sex
• Indigenous populations – First Nations, Inuit
• Allergy
• Seasonal peaks in fall and winter
• Orofacial deformities – e.g., cleft palate
Prevention
- Handwashing
- Cleaning of shared toys
- Breast Feeding (even 3 months)
(AAP now encourages exclusive breast feeding for 6 months of life, and to continue for at least the 1 st year and beyond if desired) - Avoidance of second hand smoke
- Avoidance of feeding in flat, supine position
- Reduce pacifier use in children > 6 months
- Influenza vaccine
- Routine pneumococcal conjugate PCV-13 vaccine
Symptoms
- Pain, earache (rubbing, tugging at ear)
- Fever up to 40.5 o C
- Irritability
- Night restlessness
- Poor feeding
- Nausea
- Vomiting
• Often associated with cough and rhinitis
Acute Otitis Media
What are the 2 Requirements?
- Inflammation of the middle ear
2. Fluid in the middle ear
What is Bacterial Otitis Media?
- Bulging, “cloudy, inflamed ear drum”
- Purulent fluid behind the ear drum or purulent otorrhea if tympanic membrane has been ruptured
- Decreased mobility on pneumatoscopy
- Early otitis may appear as inflammation along handle of malleus and in superior pole of tympanic membrane - need to be followed closely
Normal ear drum (picture)
see slide 13
Acute Otitis Media ear drum (picture)
see slide 14
Complications of AOM
common?
rarely?
Common:
• Perforated ear drum
• Otitis Media with Effusion (OME)
• Hearing loss, delayed speech development
Rarely
• Facial paralysis
• Meningitis
• Mastoiditis
• Chronic Suppurative Otitis Media - persistent inflammatory process associated with perforated tympanic membrane and draining exudate for > 6 weeks
Perforated Ear Drum (picture)
see slide 16
Chronic Suppurative Otitis Media (picture)
see slide 17
Facial Nerve (picture)
Proximity can lead to facial paralysis
to middle ear
Mastoiditis (picture)
see slide 19
Inflammation of mastoid air cells
Otitis Media With Effusion (OME)
Serous Otitis Media
- Fluid in the middle ear without symptoms of acute inflammation of the ear
- Most frequently occurs following an episode of acute otitis media, but may be unrelated
- Up to 50% of children have an effusion 1 month post AOM
• Up to 10% of children have an effusion 3 months post AOM
- may interfere with hearing
Myringitis
- Inflammation of the tympanic membrane alone or in association with otitis externa
- May be due to crying or fever or viral infection or URI
- Is not indicative of otitis media
Changing Etiology of Acute Bacterial Otitis Media
see slide 22
more being caused by H influ now
Impact of PCV Vaccines
- Estimated decreased incidence AOM 13% - 19% due to 7 valent Pneumococcal Conjugate Vaccine (PCV7) in Canada
- More severe cases caused by S. pneumoniae decreased since introduction PCV13 in 2011, especially in children < 2yrs of age
- A study from Israel reported 85% decline in AOM due to PCV13 serotypes and overall 77% decline in pneumococcal AOM since PCV7 to PCV13 era
Spontaneous Resolution
see slide 24
- S. pneumoniae has lowest spontaneous resolution rate
- S. pneumoniae is associated with more serious complications
- It is essential to ensure optimal coverage for S. pneumoniae
- H. influenzae more associated with conjunctivitis – use agent with good activity against H. influenzae when this finding present
Percentage of Penicillin Non-Susceptible
S. pneumoniae in Canada: 1988-2009
see slide 25
Macrolide-Resistant Pneumococci:
Canadian Bacterial Surveillance Network, 1993-2009
see slide 26
