Otitis Media

Question 1

Peak age in which Otitis Media infections are most frequent?

Answer 1

6-36 months

Question 2

Otitis Media infections become rare after what age?

Answer 2

8yrs

Question 3

In what location do most middle ear infections take place?

Answer 3

Tympanic Membrane Space

Question 4

Three functions of the Eustachian Tube?

Answer 4

1) Equalize pressure on both sides of Tympanic Membrane

2) Protect middle ear from Nasopharyngeal secretions

3) Drain middle ear secretions into Nasopharynx

Question 5

Progression of Otitis Media infection?

Answer 5

-Viral URTI causes vasodilation & edema of nose / nasopharynx.

-Eustachian Tubes become occluded & middle ear ventilation impaired… Leads to fluid accumulation (Effusion).

-Nasopharynx flora enter ET / Middle Ear, leading to further Effusion, Bacterial Colonization & Infection.

Question 6

Some non-modifiable risk factors that increase Otitis Media susceptibility?

Answer 6

• <5yrs
  -Male
  -FN’s / Inuit populations
  -Genetic Factor
  -Medical conditions (Down Syndrome & Cleft Palate)
  -Recurrent URTI’s
  -Allergies
  -Decreased Immunity

Question 7

Modifiable risk factors that increase Otitis Media susceptibility?

Answer 7

-Daycare
-Tobacco Smoke Exposure
-SES

Question 8

Preventable risk factors increasing Otitis Media susceptibility?

Answer 8

-Lack of (or short period) breastfeeding
-Extended Pacifier use

Question 9

What would be described as a “Recurrent Otitis Media Infection”?

Answer 9

At least 3 episodes within 6mths

OR

At least 4 episodes within 12mths

Question 10

What might Recurrent Otitis Infections lead to?

Answer 10

-Alteration to Middle Ear Mucosa
-Damage to Tympanic Membrane / Ossicles
-Adhesions
-Conductive Hearing Loss

Question 11

Acute Otitis Media diagnosing parameters?

Answer 11

1) Middle Ear Effusion
2) Acute Symptom Onset
3) Significant Middle Ear Inflammation

Question 12

Acute Otitis Media symptoms that are more commonly seen in kids?

Answer 12

-NVD
-Ear Tugging / Pain
-Crying / Irritability
-Altered Sleep

Question 13

What sorts of complications may arise from Acute Otitis Media infections?

Answer 13

-Hearing Loss / TM Perforation
-Mastoiditis
-Labyrinthitis
-Meningitis
-Brain Abscess

Question 14

What % of AOM cases resolve spontaneously w/o treatment?

Answer 14

80%

Question 15

Top three most prevalent bacterial strains responsible for AOM?

Answer 15

1) S. pneumoniae (25-30%)
2) H. influenzae (20-30%)
3) M. catarrhalis (10-20%)

Question 16

If a patient comes in with AOM & is <6wks of age, what two bacterial species should be suspected?

Answer 16

E. coli & Group B Strep

Question 17

What parameters would make AB prescribing an appropriate choice for AOM?

Answer 17

1) Acute onset of symptoms (ie. irritable, sleep disrupted, poor antipyretic response, severe otalgia, >39 degree fever, >48hrs symptoms)

2) Middle Ear Effusion present

3) Bulging TM

Question 18

What is the directed course of treatment that should be taken if the patient presents as mildly ill with AOM parameters?

Answer 18

24-48hr observation (Watchful Waiting)

Question 19

What criteria should be followed if “Watchful Waiting” is the treatment course that is chosen?

Answer 19

-Pt. > 6mths of age
-Unilateral Infection
-No anatomical abnormalities or immunocompromised
-Access to AB’s or a timely reassessment

Question 20

What species should we direct AB therapies towards treating if we suspect AOM?

Answer 20

S. pneumoniae
But be wary of Beta Lactamase resistance to certain AB’s!

Question 21

Why might high dose Amoxicillin be given?

Answer 21

Overcome S. pneumoniae resistance

Question 22

Dosing regimen for high dose Amox? Standard?

Answer 22

HD: Amoxicillin 75-90mg / kg / day (divided BID dosing)

SD: Amox 45mg / kg / day (BID division)

Question 23

2nd line AOM treatment?

Answer 23

Amox/Clavulanate 40-80mg / kg / day (divided into BID dosing)

Question 24

What parameters would cause one to resort to a 2nd line therapy?

Answer 24

-Purulent Conjunctivitis
-Amox treatment last 30d
-Relapse of recent infection

Question 25

If Penicillin allergy, what can be used as an AOM therapy?

Answer 25

i) Cefprozil 30mg / kg / day (divided into BID dosing)

ii) Cefuroxime Axetil 30-40mg / kg / day (divided into BID dosing)

iii) Clarithromycin 15mg / kg / day (divided into BID dosing)

Question 26

Why are 2nd gen CS’s used instead of 1st gen CS’s as a 3rd line therapy?

Answer 26

-1st gen CS’s poor middle ear penetrance & Beta Lactamase resistance… 2nd gens have better penetrance & get around Beta Lactamase resistance.

Question 27

Azithromycin dosing regimens for AOM?

Answer 27

Day 1: 10mg / kg / day
Days 2-5: 5mg / kg / day

OR

10mg / kg / day OD x 3d

OR

30mg / kg (single dose)

Question 28

What % of patients will have remaining effusion after treatment?

Answer 28

50%

Question 29

Are decongestants or antihistamines good to use for effusion?

Answer 29

Not overly… Don’t decrease symptoms or speed up effusion clearance.

Question 30

What distinguishes Otitis Media w Effusion from AOM?

Answer 30

Presence of Effusion w/o other signs of infection (asymptomatic & up to 50% cases mistaken for AOM)

Question 31

Acute OME? Sub-Acute? Chronic?

Answer 31

Acute: <3wks
Sub-Acute: 3wks-3mths
Chronic: >3mths

Question 32

What non-specific signs & symptoms may present themselves with OME?

Answer 32

-Rhinitis
-Cough
-Diarrhea

Question 33

Primary course of treatment to take with OME cases?

Answer 33

Wait and see (!!!)
-Normally resolves spontaneously after 2-3mths.

Question 34

Treatment of recurrent AOM?

Answer 34

AB’s x 10d

Question 35

Treatment of Recurrent AOM (Prophylaxis)?

Answer 35

1) Sulfisoxazole 75mg / kg / day HS

2) Amox 20mg / kg / day HS

3) Cotrimoxazole 0.5mg / kg / day of TMP

Question 36

Ultimate goal of treating recurrent AOM?

Answer 36

Decrease frequency of AOM by at least 1 episode / yr.