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Infectious Diseases > Otitis Media > Flashcards

Otitis Media Flashcards

1
Q

Diagnosis of acute OM include ALL 3 of these criteria:

A
  1. Middle ear effusion
  2. Acute onset of symptoms
  3. Significant inflammation of middle ear

Middle ear inflammation = bulging tympanic membrane

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2
Q

Overdiagnosis of AOM contributes to…

A

Inappropriate antibiotic use and bacterial resistance

…And potential development of asthma

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3
Q

Symptoms of AOM may include:

A

Pain
Fever
N/V/D

Pain is caused by pus + fluid under pressure

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4
Q

If pain relief and purulent discharge from the ear occur, what has happened?

A

Spotaneous rupture of TM

TM will usually heal without issues

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5
Q

Should we be concerned about complications from OM?

A

No, they are rare, and 80% of AOM also resolve spontaneously without tx.

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6
Q

What is the most common bacterial pathogen with OM?

A

Streptococcus pneumoniae (25-30%)

G+ cocci

Group A strep and staph aureus also occur, but more rare (other G+ cocci)

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7
Q

Besides strep and other G+ cocci pathogens, what are the other two pathogens that may cause OM?

A

H. Flu (20-30%) and Moraxella catarrhalis (10-20%)

H.Flu = G- cocci
Moraxella = G-

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8
Q

What pathogens may be present if the patient is <6 weeks old?

A

E.Coli and Group B strep

Vaginal flora

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9
Q

Besides bacterial pathogens, OM may also be caused by…

A

Viral infection (40%), from viral URTI or influenzae

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10
Q

Goals of treatment for AOM include:

A

Reduction in signs and symptoms
Eradication of infection
Prevention of complications

Also avoiding unnecessary abx prescribing

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11
Q

Antibiotic treatment selection is based on:

A

Ability to penetrate middle ear
Spectrum of activity
Adverse effects, convenience, cost

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12
Q

Are antibiotics effective for AOM symptoms? Do we need antibiotics for treatment?

A

Abx resolved symptoms in ~95% of patients, but 80% without abx also had resolution of symptoms

…Therefore many cases do not require antibiotics

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13
Q

Good criteria for antibiotic usage in AOM cases include:

3 cases of criteria (diagnosis criteria, fever, duration of symptoms)

A

6 months older and:
Acute onset, MEE present, bulging TM, and moderately/severely ill (both ears)
OR
Fever of 39C without antipyretics
OR
>48h of symptoms

MEE = middle ear effusion

Moderately/severely ill = irritability, difficulty sleeping, poor response to antipyretics, severe otalgia

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14
Q

If a patient is mildly ill with AOM, what should be done?

A

Discuss with caregiver - watchful waiting, and ensure follow-up.
Analgesia recommended

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15
Q

What is watchful waiting?

A

Caregiver watches child for signs of worsening. If worsening or no improvement in 24-48 hours, then fill Abx Rx.

Analgesics would continue to be given

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16
Q

What is optimal criteria for watchful waiting?

A

6+ months, not bilateral
No anatomical abnormalities or immune deficiency, or recurrent AOM

Also consider timely reassessment access as well as reliable caregiver

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17
Q

Which pathogen is least likely to resolve on its own in AOM?

A

S. Pneumoniae

Therefore, we should aim therapy at S. Pneumoniae

H.Flu and Moraxella usually spontaneously resolve

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18
Q

What is first-line therapy for AOM?

A

Amoxicillin

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19
Q

Why is amoxicillin considered first-line therapy for AOM?

A

Excellent activity against S. Pneumoniae + excellent penetration to middle ear

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20
Q

What is standard dosing for amoxicillin treatment?

A

40-50 mg/kd/day, divided TID

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21
Q

What is an issue for using amoxicillin standard dosing?

A

Potential for resistance

Resistance rates are still low… (0-1.3%)

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22
Q

What classifies high dose amoxicillin for AOM?

A

80-90 mg/kg/day divided BID or TID

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23
Q

When should high dose amoxicillin be used?

A

Daycare
Under/unimmunized
<2 years
Recent antibiotics within 3 months

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24
Q

What is second line therapy?

A

Amoxicillin/Clavulanate 40-80 mg/kg/day divided BID

Beta-lactamase inhibitor helps target other organisms (H.Flu, moraxella)

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25
Q

When should second-line therapy be considered for AOM?

A

Initial therapy failure
Purulent conjunctivitis present
Recent tx with amoxi (previous 30 days)
Relapse of recent infection

Initial tx failure = no improvement in 2-3 days
Conjunctivitis = H.Flu

26
Q

How long should antibiotic treatment be?

A

Traditionally 10 days, but 5 days may be enough for some

26
Q

If a patient has a penicillin allergy or experiences treatment failure, what alternative drugs could be given instead for AOM?

A

Cephalosporins - cefprozil (15-30 mg/kg/day) or cefuroxime (20-30 mg/kg/day) divided BID/TID

Broader spectrum vs. amoxicillin

ARE THEY ACTUALLY ALLERGIC?

26
Q

Why should macrolide usage be discouraged for AOM?

A

Resistance to S. Pneumoniae (21-38%)

For severe penicillin allergy and concern for cross-reactivity

Clarithromycin preferred over azith - potentially less resistance + major DI uncommon

27
Q

Which patients may be sufficient to treat with antibiotics for 5 days?

A

Uncomplicated AOM
>24 months old
No perforation of eardrum

Uncomplicated AOM = not recurrent, chronic, tx failure, or conditions

27
Q

When should we see improvements with antibiotics?

A

Within 2-3 days

27
Q

If AOM symptoms persist, worsen, or reappear, what should be done?

A

Return to physician for reassessment

28
Q

What may remain after AOM treatment, and for how long?

A

Effusion may remain after treatment (50% of patients) and may persist for weeks

Acute signs of inflammation likely gone

29
Q

What are some non-pharmacological treatments for AOM?

A

Glycerin/vegetable oil heated to body temp
Heating pads

Soothing sensations

30
Q

When is glycerin/vegetable oil CI?

A

Ruptured tympanic membrane
Microwaved/too hot

31
Q

Are anesthetics effective for AOM?

A

No - anesthetic cannot penetrate into middle ear

Essentially a warm oil

32
Q

What analgesics can be given for pain relief?

A

Acetaminophen (10-15 mg/kg Q4-6H) or Ibuprofen (5-10 mg/kg Q6-8H)

IMPORTANT

ASA = Reye’s

33
Q

Are decongestants/antihistamines effective for AOM?

A

Most studies = no benefit - do not decrease sx’s or speed clearance of effusion

Can be used for other s/sx’s depending on age

34
Q

What is otitis media with effusion (OME)?

A

Presence of middle ear effusion without signs of infection

Asymptomatic - but may be a bit of hearing loss

Often mistaken for AOM

35
Q

What are the different classifications of OME?

A

Acute (<3 weeks), subacute (3 weeks - 3 months), chronic (>3 months)

36
Q

What are some causes of OME?

A

Recent AOM
Allergic rhinitis
Anatomic problems

After AOM, usually resolves in 6-12 weeks

37
Q

What can recurrent OME cause?

A

Decreased hearing
Scarring of TM

Decreased hearing can impair language development

38
Q

When may OME spontaneously resolve?

A

2-3 months

39
Q

Is a second trial of abx recommended for OME?

A

NOT recommended

Bacteria may be present in 1/2 of cases, but may not be active infection

40
Q

Are decongestants or antihistamines useful for OME?

A

No, not really useful

41
Q

Are corticosteroids used for OME?

A

Some studies show benefit - consider risk vs. benefit, and shortest course should be used

PO, not drops

42
Q

For recurrent cases of OME, what can be done?

A

Surgical procedures

Myringotomy, tympanostomy

43
Q

How should recurrent AOM be treated?

A

Antibiotics for 10 days, retreating each time.

High dose amoxi or amoxi/clav

44
Q

What are some options for prevention of recurrent AOM?

A

Prophylaxis, surgery, vaccines

Abx prophylaxis = Sulfisoxazole, amoxicillin, cotrimoxazole

45
Q

What is the goal when aiming to decrease frequency of AOM?

A

Reduction of at least 1 episode per year

Ignoring rate of effusion

Important to note for kids <2 years, to prevent long term complications

46
Q

What classifies otitis media?

A

Middle ear inflammation

47
Q

What population is otitis media most common in?

A

Children (80%) - pediatric infection

48
Q

What are the THREE important anatomical structures in the middle ear?

A

Tympanic membrane (eardrum), eustachian tube, and auditory bones

49
Q

What are the 3 functions of the eustachian tube?

A
  1. Equalizing pressure on both sides of tympanic membrane
  2. Protect middle ear from nasopharyngeal secretions
  3. Draining middle ear secretions into nasopharynx
50
Q

What does eustachian tube dysfunction lead to?

A

Impaired middle ear ventilation

Plugged ear feeling

51
Q

What often starts the cascade leading to otitis media?

A

Viral URTI

Vasodilation + edema of nose, and nasopharynx

52
Q

Briefly describe the cascade leading to development of otitis media.

A

ET becomes occluded.
Edema of ET causes impairment of middle ear ventilation, resulting in effusion

ET = eustachian tubes

53
Q

How does fluid effusion in the middle ear result in infection?

A

Normal flora from nasopharynx enters ET + middle ear:
Resulting in colonization and infection

54
Q

Non-modifiable risk factors for OM include:

(5 factors)

A

Age <5
Medical conditions involving anatomical differences
Recurrent URTI’s
Allergies
Reduced immunity

55
Q

Modifiable risk factors for OM include:

(5 factors)

A

Close contact
Exposure to tobacco smoke
Lower socio-economic status
Lack of breastfeeding
Extended pacifier use

Close contact = daycare
Tobacco smoke may increase inflammation, increasing infection chance
Breastfeeding increases immune system

56
Q

Recurrent OM infection is classified as ____ episodes of acute OM within ____ months.

There are 2 critieria for recurrent infection.

A

3/4 episodes, 6/12 months

57
Q

What may recurrent OM infections lead to?

A

Damage to middle ear anatomy - alterations in mucosa, adhesions, or conductive hearing loss

Crucial in times of important language development

Infectious Diseases (7 decks)

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