Otitis Media Flashcards
What is Otitis Media
- Inflammation in the middle ear (may be caused by infection)
- Most common pediatric disease which attention is sought
Can be acute or chronic
- Most common pediatric disease which attention is sought
Where does otitis media occur
- Middle ear
- In the tympanic membrane which is connected to the eustachian tube
What are the functions of the eustachian tube
- Equalizing pressure on both sides of tympanic membrane
- Protects the middle ear from nasopharyngeal secretions
- Draining middle ear secretions into nasopharynx
How does Otitis media occur
- Viral URTI - (vasodilation and edema of nose and nasopharynx)> occlusion of eustachian tubes (ET) - (edema of ET mucosa)> impaired middle ear ventilation -> accumulation of fluid (effusion)-> normal flora from nasopharynx enter the ET and middle ear-> effusion becomes colonized and infected
What are non-modifiable risk factors of otitis media
- Age <5 (this is because it is shorter, wider eustachian that is more horizontal
- Gender: a bit more common in males
- More likely in first nations/ inuit
- Family history: possible genetic factor
- Medical conditions :anatomic differences (down syndrome/ cleft palate)
- Recurrent URTI
- Allergies
- Reduced immunity: from either drugs or conditions
Why is age a risk factor of otitis media
- The eustachian tube is shorter, wider and more horizontal
- By age 8 eustachian tube is more adult like so less chance of getting infection
What are modifiable risk factors of otitis media
a) Daycare
- Leads to close contact with other sick kids
- There is more drug resistant organisms within daycare
b) Exposure to tobacco smoke
- Can increase inflammation of mucosal surfaces of nose, throat and ears which increases chance of infection
- Tobacco smoke can also impair mucociliary clearance
c) Lower socio-economic status
- This is from crowded living condition, less access to care
What are preventable risk factors of otitis media
a) Lack/short period of breast feeding
- Immunoglobins in breast milk are believed to boost immune system of infant (can last 4-12 months after stopping)
- Should avoid bottle feeding while baby is laying down (prevents and reflux into middle ear
b) Extended pacifier use
- Increased mucus production with prolonged use may cause reflux of flora into middle ear
What is a recurrent infection of otitis media defined by
- At least 3 episodes of otitis media within 6 months or at least 4 within 12 months
What are the types of otitis media
- Acute otitis media (AOM): main one
- Otitis media with effusion (OME)
- Persistent otitis media (treatment resistant)
- Recurrent otitis media
What does an diagnosis of otitis media need
- Middle ear effusion
- Acute onset of symptoms
- Significant inflammation of middle ear (bulging tympanic membrane)
What are symptoms of acute otitis media
- Symptoms of inflammation/ infection
- Pain: the child may cry, tug at ear, be irritable, altered sleep
- High fever
- May see nausea, vomiting, diarrhea
What does the spontaneous rupture of the tympanic membrane do
- Relieves pain and purulent discharge
What are complications with acute otitis media
a) Intracranial
- Meningitis
- Subdural/ brain abscess
b) Extracranial
- Hearing loss
- TM perforation
- Chronic Otitis media
- Mastoiditis (bone behind ear infected)
- Facial paralysis
- Tympanosclerosis
- Labyrinthitis
What is the etiology of acute otitis media
- Streptococcus pneumoniae: 25-30%
- Non typable stains of Haemophilus influenzae: 20-30%
- Moraxella catarrhalis: 10-20%
- Group A streptococcus: 10%
- Staphylococcus aureas: 5%
- Could be viral: up to 40%
- If less then 6 weeks old expect E.coli and group B strep
If a child <6 weeks has otitis media what would we expect and why
- Expect E.coli and group B strep
- This is as these bacteria colonize the upper respiratory from mothers vaginal cannel
What are the goals of treatment with acute otitis media
- Reduce signs and symptoms
- Eradicate infection
- Prevention of complications
- Avoid unnecessary antibiotic prescribing
What % of cases resolve with antibiotics and without of acute otitis media
- 95% with antibiotics
- 80% without antibiotics
- This means that for every 12 kids that use antibiotics 1 additional would be cured
When to use antibiotics in children 6 months and older for AOM
- Acute onset, Middle ear effusion and bulging Tympanic membrane if moderately or severely ill
- Moderately/ severely ill: irritable, difficulty sleeping, poor response to antipyretics, severe otalgia or fever >39C in absence of antipyretics/ >48 hours of symptoms
When to not use antibiotics in children 6 months and older for AOM
- Mildly ill, talked with caregiver: observe for 24-48 hours and ensure follow up
Recommend analgesia
What is the observational option (watchful waiting)
- Antibiotic treatment is waited for 48-72 hours of symptom onset
- Caregiver watches for signs of worsening (if don’t trust caregiver would most likely offer and antibiotic)
- If things get worse or don’t improve then fill the antibiotic prescription
- Analgesics are important
What is the criteria for watchful waiting
- Age > 6 months
- Not bilateral
- No craniofacial abnormalities, immune deficiency, tympanostomy tubes or recurrent AOM
- Access to timely reassessment or antibiotic Rx
- Reliable caregiver
When using antibiotics what organism are we likely to target and why
- Strep pneunomiae: this is as it is the least likely to resolve on its own
- Keep the other causative organisms in mind
What is the first line therapy for AOM
Ø Amoxicillin
- American guidelines: 80mg/kg/day BID or TID (max 3g a day)
- Standard dose: 45/mg/kg/day
- High dose: 75-90mg/kg/day BID or 45-60mg/kg/day TID
