Otitis media Flashcards
Define acute otitis media
Inflammation in the middle ear that is accompanied by the rapid onset of symptoms and signs of an ear infection, associated with effusion
Define persistent otitis media
Symptoms persist after initial management or because symptoms are worsening
Define recurrent otitis media
3 or more well-documented and separate AOM episodes in the preceding 6 months, or 4 or more episodes in the preceding 12 months
What are the causes of acute otitis media
Bacterial:
* Haemophilus influenzae
* Streptococcus pneumoniae
* Moraxella catarrhalis
* Streptococcus pyogenes
Viral:
* RSV
* Rhinovirus
* Adenovirus
* Influenza virus
* Parainfluenza virus
What are the risk factors for acute otitis media
- 6-24 months of age
- Winter season
- Lack of pneumococcus vaccination
- Male sex
- Smoking and/or passive smoking
- Frequent contact with other children e.g. daycare, nursery, siblings
- Formula feeding (breastfeeding is protective)
- Craniofacial abnormalities e.g. cleft palate
- Dummy usage
- Prolonged bottle feeding in supine position
- FHx otitis media
- Gastro-oeseophageal reflux
- Recurrent URTI
- Immunodeficiency
Infants have a shorter, wider, more horizontal, and floppy Eustachian tube than adults, which increases the likelihood of middle ear infection
What are the symptoms of acute otitis media
Older children/adults: earache
Younger children:
* Holding, tugging, rubbing of the ear
* Fever
* Crying
* Poor feeding
* Restlessness
* Behavioural change
* Cough
* Rhinorrhoea
What are the signs of otitis media on examination
Otoscopic ear examination
* Red, yellow, or cloudy tympanic membrane
* Bulging of the tympanic membrane
* Loss of normal landmarks
* Air-fluid level behind the tympanic membrane (indicates a middle ear effusion)
* Perforation of the tympanic membrane and/or discharge in the external auditory canal
Features that suggest that it’s NOT otitis media:
- Tympanic membrane not bulging ± erythema/cloudiness
- Air-fluid level without bulging tympanic membrane
What are the differentials for otitis media
URTI
Glue ear (OM with effusion)
Chronic suppurative otitis media
Otitis externa
Eustachian tube dysfunction
Mastoiditis
Malignancy
What investigations should be done for otitis media
Basic observations
Otoscopic examination
Pneumatic otoscopy: impaired ear drum mobility
What features necessitate admission for otitis media
Severe systemic infection
Less than 3 months old with temp. >38oc
Immunocompromised
Suspected acute complications:
- Meningitis
- Mastoiditis
- Intracranial abscess
- Sinus thrombosis
- Facial nerve paralysis
Consider IV ABx
What is the a management for otitis media in a child who is systemically well
Supportive:
* Advise on the course of disease (3-7 days)
* Will resolve spontaneously, seek help if symptoms do not improve
* Paracetamol or ibuprofen for pain
* Back-up Abx prescription
* Ear drops with anaesthetic/analgesic:
*```
Contraindicated: ear drum perforation, otorrhoea
* For children <18yo who are not prescribed antibiotics
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What is the management for a child with otitis media who is systemically unwell
First line: amoxicillin for 5-7 days
Second line: co-amoxiclav
+supportive
What is the management for acute otitis media with perforation
Oral amoxicillin, 5 days
Review in 6 weeks to ensure healing
What are the compliclations of acute otitis media
Persistent otitis media with effusion
Recurrence of infection
Hearing loss (usually conductive and temporary)
Tympanic membrane perforation
Labyrinthitis
Mastoiditis, meningitis, intracranial abscess, sinus thrombosis, facial nerve paralysis
What is the prognosis for acute otitis media
Excellent prognosis
Without antibiotic treatment: symptoms improve within 24 hours in 60% of children, most recover within 3 days
Recurrent episodes are not common, but if they are present they usually resolves as the child gets older
Long term complications are rare
Define chronic suppurative otitis media
A chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation
Persistent (>2 weeks) drainage through an eardrum perforation
What are the causes of chronic suppurative otitis media
CSOM can be caused by bacterial and/or fungal infection (often polymicrobial), including:
* Pseudomonas aeruginosa (most common).
* Staphylococcus aureus.
* Proteus species.
* Aspergillus species.
* Candida albicans.
What are the risk factors for Chronic suppurative otitis media
Younger age — children under 5 years old are most commonly affected.
Allergy/atopy.
Upper respiratory tract infection.
Acute or recurrent otitis media.
Exposure to second-hand smoke.
Social deprivation.
Snoring.
What are the symptoms of chronic suppurative otitis media
Ear discharge persisting for more than 2 weeks, without ear pain or fever.
Hearing loss in the affected ear.
A history of acute otitis media (AOM), ear trauma, or glue ear and grommet insertion
A history of allergy, atopy, and/or upper respiratory tract infection.
Tinnitus and/or a sensation of pressure in the ear may also be present.
Examination of the ear may reveal tympanic membrane perforation and/or middle ear inflammation.
What is the management for chronic suppurative otitis media
keep dry + refer to ENT
What is otitis media with effusion
Condition characterised by a collection of fluid within the middle ear space without signs of acute infection
What is the epidemiology of otitis media with effusion
Common in children between 6 months and 4 years old
Most common cause of hearing impairment in childhood
>50% of children will experience OME in the first year of life
Prevalence of OME in children with Down syndrome or cleft palate is 60–85%.
OME is most common in the winter months.
What are the symptoms of otitis media with effusion
Hearing loss
- May have been picked up on the newborn hearing screening test (OAE)
- Mishearing
- Difficulty communicating in a group
- Asking for things to be repeated
- Listening to the media at excessively high sound levels
Mild intermittent ear pain with fullness or ‘popping’
Aural discharge (Persistent, foul smelling)
Recurrent ear infections, URTI, or nasal obstruction
What are the signs of otitis media with effusion on examination
Otoscope
Effusion: Serous, mucoid, or purulent
Abnormal colour of the drum e.g. yellow, amber, blue
Loss of light reflex or a more diffuse light reflex
Opacification of the drum
Air bubbles or an air/fluid level
A retracted, concave, indrawn drum, fullness or bulging
Usually no signs of inflammation or discharge on examination
What investigations should be done for otitis media with effusion
Pneumatic otoscopy
Typanometry
Audiometry
What features necessitate referral for ENT assessment for otitis media with effusion
Persistent foul smelling discharge (choleastoma)
Hearing loss, impact on development/education
Severe hearing loss or significant on two occasions
Structural abnormality of the tympanic membrane
Down’s syndrome or cleft palate
What is the management for otitis media with effusion
- Watchful waiting for 3 months (spon. resolves
- 2 hearing tests at least 3 months apart (pure tone audiometry) + tympanometry
- Consider autoinflation or valsalva manouevre in older children (blowing a bloon via the nostril 2-3x a day)
Consider need for hearing aids
No resolve -> refer to ENT specialist
Surgery: myringotomy and grommet insertion
