Otitis Media Flashcards
What is otitis media?
inflammation in the middle ear
-may be caused by infection
can be acute or chronic
What is the most common pediatric disease for which attention is sought?
otitis media
-kids make up at least 80% of cases
-2/3 children have an episode by age 3
-75% experience at least one ear infection before school
-1/3 children have 3+ cases
When is the peak incidence of otitis media seen in kids? When is otitis media rare in kids?
peak is 6-36 months
rare after age of 8
What are the three functions of the eustachian tube?
equalizing pressure on both sides of the tympanic membrane
protecting the middle ear from nasopharyngeal secretions
draining middle ear secretions into nasopharynx
What does eustachian tube dysfunction lead to?
impaired middle ear ventilation
Describe the process of how otitis media occurs.
- viral URTI (causes vasodilation and edema of
nose+nasopharynx) - occlusion of Eustachian tube (causes edema of ET mucosa)
- impaired middle ear ventilation
- accumulation of fluid (effusion)
- normal flora from nasopharynx enter ET and middle ear
- effusion becomes colonized and infected
- symptoms
What are the non-modifiable risk factors for otitis media?
age<5 (shorter, wide ET that is more horizontal)
gender (slightly more common in males)
First Nation and Inuit
family history
anatomic differences (Downs syndrome, cleft palate)
URTI (recurrent or concurrent)
allergies
reduced immunity (from drugs or conditions)
What are the modifiable risk factors for otitis media?
daycare (close contact with sick kids)
exposure to tobacco smoke (inflammation)
lower socioeconomic status
True or false: there may be more drug resistant drug organisms within daycare groups
true
What are the preventable risk factors for otitis media?
lack/short period of breast-feeding (Ig’s boost immunity)
extended pacifier use
What are you some tips you can give a mom about bottle-feeding and pacifier use to try prevent otitis media?
avoid bottle feeding while baby is laying down (reflux in ear)
prolonged pacifier use can increase mucus production which may cause reflux of flora into ear
What is the definition of recurrent otitis media infections?
3 episodes within 6 months
OR
at least 4 episodes within 12 months
What can recurrent otitis media infections lead to?
alterations in middle ear mucosa
damage to tympanic membrane and ossicles
adhesions (may immobilize ossicles)
conductive hearing loss
What are the 4 types of otitis media?
acute otitis media (AOM)
otitis media with effusion (OME)
persistent otitis media
recurrent otitis media
What is the diagnosis of acute otitis media?
middle ear effusion
acute onset of symptoms
significant inflammation of middle ear (bulging TM)
True or false: you can diagnose AOM based off the presence of middle ear effusion
false
all three elements must be present
What are the symptoms of inflammation/infection in AOM?
pain (tugging at ear, crying, irritability, altered sleep)
may see fever
may see N/V/D
What does spontaneous rupture of the tympanic membrane result in?
pain relief and purulent discharge
What is a HCP looking for in the ear to diagnose AOM?
redness
loss of anatomical markers (tympanic membrane)
bulging eardrum
What are the intracranial and extracranial complications of AOM?
intracranial:
-meningitis
-subdural or brain abscess
extracranial:
-hearing loss
-TM perforation
-chronic OM
-mastoiditis
-facial paralysis
-tympanosclerosis
-labyrinthitis
True or false: complications from AOM are common, and only 20% of cases resolve spontaneously without treatment
false
complications are uncommon
80% resolve spontaneously
Which organisms cause AOM?
streptococcus pneumoniae (25-30%) *
non-typable strains of Haemophilus influenza (20-30%) *
moraxella catarrhalis (10-20%) *
group A streptococcus (~10%)
viral (up to 40%)
Which organisms would you expect to cause AOM in an infant less than 6 weeks old?
E.coli
group B strep
What is our antibiotic selection for AOM based on?
spectrum of activity
adverse effects
ability to penetrate middle ear
cost
convenience
What are the goals of therapy for AOM?
reduction in signs and symptoms
eradicate infection
prevent complications
avoid unnecessary antibiotic prescribing
When is it indicated to use antibiotics in children 6 months and older for otitis media?
acute onset
middle ear effusion
bulging TM
moderately or severely ill (irritable, difficulty sleeping, poor response to antipyretics, severe otalgia OR >39 C in absence of antipyretics OR >48h of symptoms)
If a child is mildly ill and there has been discussion with the caregiver, what is the recommended action?
observe for 24-48hr (watchful waiting) and ensure follow up
recommend analgesia
if things get worse–>fill antibiotic
What is the criteria for watchful waiting?
> 6 months of age
not bilateral
no cranofacial abnormalities, immune deficiency, tympanostomy tubes, or recurrent AOM
access to timely reassessment or antibiotic Rx
reliable caregiver
Which causative organism of AOM is least likely to resolve on its own?
S.pneumoniae
Which organism are we targeting AOM therapy towards?
S.pneumoniae
but keep the others in mind
What is first line therapy for AOM?
amoxicillin
What is the max daily dose of amoxicillin for AOM?
3g/day
What is the high dose of amoxicillin for AOM?
75-90mg/kg/d BID
-when activity against penicillin non-susceptible S.pneumoniae
is desired
What is the standard dose of amoxicillin for AOM?
45mg/kg/d TID
When is secondary line therapy initiated for AOM?
initial therapy fails (no symptomatic improvement in 2-3D)
OR
AOM with purulent conjunctivitis
OR
recent amoxicillin treatment
OR
relapse of recent infection
What is second line therapy for AOM?
amoxicillin/clavulanate 40-80mg/kg/d BID
What is the preferred suspension of AmoxiClav?
7:1
has the most amount of amoxicillin with the least amount of clavulanate
What is the most common side effect of clavulanate?
diarrhea
What are the treatments for AOM in a penicillin allergic patient?
cefprozil 30mg/kg/day BID
cefuroxime axetil 30-40mg/kg/day BID
clarithromycin 15mg/kg/day BID
azithromycin 10mg/kg/d day 1, then 5mg/kg/d x 4d OR 10mg/kg/d OD x 3d OR 30mg/kg single dose
Which antibiotic class is discouraged for AOM?
macrolides (not as effective)
What is the duration of treatment for AOM?
traditionally-10 days
5 days may be enough for some:
-uncomplicated AOM
->24 months old
-no perforation of the eardrum
When should patients expect to see improvement with their AOM from antibiotic treatment?
2-3 days
When should a patient with AOM on antibiotic treatment go see their doctor?
symptoms persist, worsen, or reappear
What will 50% of patients experience after antibiotic treatment for AOM?
remaining effusion which may persist for weeks
What are non-pharmacologic treatments for AOM?
glycerin or vegetable oil (soothing)
-CI with ruptured TM
heating pad or warm wash cloth (soothing)
Aside from antibiotics, what are some pharmacologic treatments for AOM?
auralgan (antipyrene 5.4%/benzocaine 1.4%)
-anesthetic cant penetrate middle ear=warm oil
pain relief: acetaminophen, ibuprofen, NOT ASA
True or false: decongestants and antihistamines have proven benefit in AOM
false
What is otitis media with effusion?
presence of middle ear effusion without any signs of infection
-asymptomatic (may be a bit of hearing loss)
What may be mistaken for AOM?
otitis media with effusion
What are the causes of otitis media with effusion?
recent AOM (40-50% of cases)
allergic rhinitis
anatomic problems
OFTEN FOLLOWS AOM AND RESOLVES IN 6-12 WKS
What are the issues that can arisen for a child with otitis media with effusion?
decreased hearing can impair language development
scarring of tympanic membrane
What is the treatment process for otitis media with effusion?
- wait and see (may resolve spontaneously after 2-3mo)
- second trial of antibiotics (not recommended)
- antihistamines/decongestants (not helpful)
- corticosteroids (PO not drops, some studies show benefit)
- surgical procedures (myringotomy, tympanostomy tubes)
When are surgical procedures performed for otitis media with effusion?
reserved for recurrent cases
What is the treatment of recurrent AOM?
antibiotics x 10 days (retreat each time)
prophylaxis:
-sulfisoxazole: 75mg/kg/d HS
-amoxicillin: 20mg/kg/d HS
-cotrimoxazole: 0.5mg/kg/d of TMP
surgery
pneumococcal vaccine
