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152 > Otitis Media > Flashcards

Otitis Media Flashcards

1
Q

What is Otitis Media

A
  • Inflammation in the middle ear (may be caused by infection)
    • Most common pediatric disease which attention is sought
      Can be acute or chronic
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2
Q

Where does otitis media occur

A
  • Middle ear
    • In the tympanic membrane which is connected to the eustachian tube
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3
Q

What are the functions of the eustachian tube

A
  • Equalizing pressure on both sides of tympanic membrane
    • Protects the middle ear from nasopharyngeal secretions
    • Draining middle ear secretions into nasopharynx
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4
Q

How does Otitis media occur

A
  • 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
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5
Q

What are non-modifiable risk factors of otitis media

A
  • 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
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6
Q

Why is age a risk factor of otitis media

A
  • The eustachian tube is shorter, wider and more horizontal
    • By age 8 eustachian tube is more adult like so less chance of getting infection
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7
Q

What are modifiable risk factors of otitis media

A

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

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8
Q

What are preventable risk factors of otitis media

A

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

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9
Q

What is a recurrent infection of otitis media defined by

A
  • At least 3 episodes of otitis media within 6 months or at least 4 within 12 months
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10
Q

What are the types of otitis media

A
  • Acute otitis media (AOM): main one
    • Otitis media with effusion (OME)
    • Persistent otitis media (treatment resistant)
    • Recurrent otitis media
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11
Q

What does an diagnosis of otitis media need

A
  • Middle ear effusion
  • Acute onset of symptoms
  • Significant inflammation of middle ear (bulging tympanic membrane)
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12
Q

What are symptoms of acute otitis media

A
  • Symptoms of inflammation/ infection
    • Pain: the child may cry, tug at ear, be irritable, altered sleep
    • High fever
    • May see nausea, vomiting, diarrhea
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13
Q

What does the spontaneous rupture of the tympanic membrane do

A
  • Relieves pain and purulent discharge
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14
Q

What are complications with acute otitis media

A

a) Intracranial
- Meningitis
- Subdural/ brain abscess
b) Extracranial
- Hearing loss
- TM perforation
- Chronic Otitis media
- Mastoiditis (bone behind ear infected)
- Facial paralysis
- Tympanosclerosis
- Labyrinthitis

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15
Q

What is the etiology of acute otitis media

A
  • 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
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16
Q

If a child <6 weeks has otitis media what would we expect and why

A
  • Expect E.coli and group B strep
    • This is as these bacteria colonize the upper respiratory from mothers vaginal cannel
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17
Q

What are the goals of treatment with acute otitis media

A
  • Reduce signs and symptoms
    • Eradicate infection
    • Prevention of complications
    • Avoid unnecessary antibiotic prescribing
18
Q

What % of cases resolve with antibiotics and without of acute otitis media

A
  • 95% with antibiotics
    • 80% without antibiotics
    • This means that for every 12 kids that use antibiotics 1 additional would be cured
19
Q

When to use antibiotics in children 6 months and older for AOM

A
  • 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
20
Q

When to not use antibiotics in children 6 months and older for AOM

A
  • Mildly ill, talked with caregiver: observe for 24-48 hours and ensure follow up
    Recommend analgesia
21
Q

What is the observational option (watchful waiting)

A
  • 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
22
Q

What is the criteria for watchful waiting

A
  • Age > 6 months
    • Not bilateral
    • No craniofacial abnormalities, immune deficiency, tympanostomy tubes or recurrent AOM
    • Access to timely reassessment or antibiotic Rx
    • Reliable caregiver
23
Q

When using antibiotics what organism are we likely to target and why

A
  • Strep pneunomiae: this is as it is the least likely to resolve on its own
    • Keep the other causative organisms in mind
24
Q

What is the first line therapy for AOM

A

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

25
Q

When to use second line therapy for AOM

A
  • Use if no symptomatic improvement in 2-3 days
    • AOM with purulent conjunctivitis
    • Recent treatment with amoxicillin (last 30 days)
    • Relapse of recent infection
26
Q

What is the second line therapy for AOM

A
  • Amoxicillin/ clavulanate 40-80mg/kg/day
27
Q

Explain what Amox/Clav is

A
  • 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
28
Q

How to treat a patient with AOM if they have a penicillin allergy

A
  • 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
29
Q

When you receive an antibiotic prescription for AOM what should you always check

A
  • Dosing
    • Common side effects
    • Drug interactions
    • What should you tell parents/ caregivers
30
Q

What is the duration of antibiotic treatment for AOM

A
  • Traditionally 10 days
    Ø 5 days may be enough for those that:
    • > 24 months old
    • No perforation of eardrum
    • Uncomplicated AOM
31
Q

What is uncomplicated AOM

A
  • Not recurrent or chronic and no underlying disease, not tx failure
32
Q

When should improvements be seen with antibiotic treatment of AOM (what to do if they don’t)

A
  • With 2-3 days
    • If symptoms persist, worsen, or reappear should see doctor
    • 50% of cases will have effusion for up to 1 month
33
Q

What is nonpharmacologic treatment of AOM

A

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

34
Q

What is the pharmacological treatment for AOM (other then antibiotics)

A

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

35
Q

What is otitis media with effusion

A
  • Prescence of middle ear effusion without signs of infection
    • Asymptomatic (may have hearing loss)
36
Q

Different classes of otitis media with effusion

A
  • Acute: <3 weeks
    • Subacute: 3 weeks to 3 months
    • Chronic: >3 months
37
Q

What are the causes of otitis media with effusion

A
  • Recent AOM
    • Allergic rhinitis
    • Anatomic problems
38
Q

How long does it take for otitis media with effusion to resolve

A
  • Usually in 6-12 weeks
    • 70% will have fluid at 2 weeks, 50% at one month, 10% at 3 months
39
Q

What is the treatment of otitis media with effusion

A
  1. 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
40
Q

What is the treatment of recurrent AOM

A

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)

41
Q

What is the goal of therapy for treatment of recurrent AOM

A
  • Decrease frequency of AOM by at least 1 episode a year

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