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
When to use second line therapy for AOM
- Use if no symptomatic improvement in 2-3 days
- AOM with purulent conjunctivitis
- Recent treatment with amoxicillin (last 30 days)
- Relapse of recent infection
What is the second line therapy for AOM
- Amoxicillin/ clavulanate 40-80mg/kg/day
Explain what Amox/Clav is
- Amoxicillin- clavulanate
- 7-1 suspension (5ml has 400mg amoxicillin and 57mg of clavulanate
- Does not exceed 10mg/kg/day dose of clavulanate as it links with risk for diarrhea
How to treat a patient with AOM if they have a penicillin allergy
- Cefuroxime axetil 30-40mg/kg/day BID *
- Cefprozil: 30mg/ kg/ day BID
- Clarithromycin 15mg/kg/day
- Azithromycin 10mg/kg/day x1 day/ 5mg/kg/day x4 days/// or 10 mg/kg/day OD for 3 days//or 30mg/kg single dose
- Use of macrolides is discouraged as not as effective
When you receive an antibiotic prescription for AOM what should you always check
- Dosing
- Common side effects
- Drug interactions
- What should you tell parents/ caregivers
What is the duration of antibiotic treatment for AOM
- Traditionally 10 days
Ø 5 days may be enough for those that:- > 24 months old
- No perforation of eardrum
- Uncomplicated AOM
What is uncomplicated AOM
- Not recurrent or chronic and no underlying disease, not tx failure
When should improvements be seen with antibiotic treatment of AOM (what to do if they don’t)
- With 2-3 days
- If symptoms persist, worsen, or reappear should see doctor
- 50% of cases will have effusion for up to 1 month
What is nonpharmacologic treatment of AOM
a) Glycerin/ vegetable oil (probably not)
- If see drainage don’t
- Heat to body temp
- Soothing
- CI with ruptured tympanic membrane
b) Heating pad or warm wash cloth
- Soothing
What is the pharmacological treatment for AOM (other then antibiotics)
Ø Auralgan (no)
- Antipyrene 5.4%/ benzocaine 1.4%
- Same effect as warm oil as anesthetic cant get into the middle ear
Ø Pain relief *(yes)
- Acetaminophen
- Ibuprofen
- Not ASA (associated with reyes syndrome in kids
Ø Decongestants/ antihistamines (no)
- Most see no benefits
- Can be used for other symptoms depending on age of child
What is otitis media with effusion
- Prescence of middle ear effusion without signs of infection
- Asymptomatic (may have hearing loss)
Different classes of otitis media with effusion
- Acute: <3 weeks
- Subacute: 3 weeks to 3 months
- Chronic: >3 months
What are the causes of otitis media with effusion
- Recent AOM
- Allergic rhinitis
- Anatomic problems
How long does it take for otitis media with effusion to resolve
- Usually in 6-12 weeks
- 70% will have fluid at 2 weeks, 50% at one month, 10% at 3 months
What is the treatment of otitis media with effusion
- Wait and see (yes)
- It may resolve on its own after 2-3 months
2. Second trial of antibiotics (no) - Bacteria could be present in 50% of cases
- Not recommended
3. Decongestants/ antihistamines (no) - Not usually useful
4. Corticosteroids (maybe) - PO, not drops
- Some benefit
- Should use shortest course
5. Surgical procedures (yes if does not resolve or reoccurs) - Myringotomy
- Tympanostomy tubes
- Reserved for recurrent cases
- It may resolve on its own after 2-3 months
What is the treatment of recurrent AOM
Ø Antibiotics of 10 days
Ø Prophylaxis
- Sulfisoxazole: 75mg/kg/day HS
- Amoxicillin: 20mg/kg/day HS
- Cotrimoxazole: 0.5mg/kg/day of TMP
Ø Surgery
Ø Vaccines (pneumococcal vaccine)
What is the goal of therapy for treatment of recurrent AOM
- Decrease frequency of AOM by at least 1 episode a year
