shevchuk- otitis media Flashcards
1
Q
what is it
A
inflammation of the middle ear that may be caused by infection
2
Q
how common is it in kids (%), when is peak incidence, when is it rare
A
most common pediatric disease for which attention is sought
- at least 80% of cases
- 2/3 of children have an episode by age 3
- up to 90% have an episode by age 6
- peak incidence is 6-36 months
- rare after age 8
3
Q
why can kids grow out of it
A
growth/lengthening/change/maturation of eustachian tubes- protects middle ear space from infection
4
Q
what is the middle ear close to, what does the middle ear connect to
A
auditory bones
eustachian tubes
5
Q
when will we say a child is or will be otitis prone
A
-first episode before 6 months
OR
-more than 3 episodes in previous 6 months
6
Q
3 functions of the eustachian tube
A
- equalize pressure on both sides of the tympanic membrane
- protect the middle ear from nasopharyngeal secretions
- draining middle ear secretions into nasopharynx
7
Q
what is usually the first thing that happens before otitis media
A
viral upper respiratory tract infection
8
Q
steps to development on otitis media
A
- usually viral URTI causing vasodilation and edema of nose and nasopharynx
- occlusion of eustachian tubes causing edema of eustachian mucosa
- impaired middle ear ventilation (no drainage) leading to effusion (accumulation of fluid)
- bacteria invade the warm fluid (connected to mouth) (ie normal flora from nasopharynx enter ETs and middle ear
- effusion becomes colonized and infected
9
Q
what causes the pain in OM
A
pus under pressure in a closed space (pressure on tympanic membrane)
10
Q
non preventable risk factors
A
- age- younger kids have shorter, wider ET (more horizontal)
- gender (more in males)
- race (more in first nations/inuit)
- family history- possible genetic factor
- low socioeconomic status (crowded living situations and less access to care)
- other medical conditions causing anatomic differences (down’s syndome, cleft palate)
- recurrent (or concurrent) URTI
- allergies
- reduced immunity (from drugs or conditions)
11
Q
preventable risk factors
A
- daycare (close contact, and increased resistance within)
- exposure to tobacco smoke (increase inflammation of mucosal surfaces, and can impair mucociliary clearance which increases chance of infection)
- lack of breastfeeding (immunoglobulins in breast milk are believed to boost immune system of infant and may last 4-12 months after stopping). Also, avoiding bottle feeding while baby is laying down prevents reflux into middle ear)
- extended pacifier use (increases mucus production with prolonged use may cause reflux of flora into middle ear)- controversial
12
Q
what is a recurrent infection
A
-at least 3 episodes of AOM within 6 months, or 4 within 12 months
13
Q
what can recurrent infections lead to
A
- alterations in middle ear mucosa
- damage to tympanic membrane and ossicles (hammer, anvil, stirrup)
- adhesions (may immobilize ossicles)
- conductive hearing loss
14
Q
what is the biggest concern with middle ear infections in kids
A
-could lead to hearing loss and as a consequence have trouble with speech and language development, causing potential slower learning
15
Q
4 types of otitis media
A
- acute otitis media
- otitis media with effusion
- persistent otitis media (usually happens when kids have tubes)
- recurrent otitis media
16
Q
elements needed to diagnose acute otitis media
A
- red, painful, moderate-severe bulging TM/eardrum, loss of anatomical landmarks (opaque TM)
- can have discharge from ear (otorrhea) not due to otitis externa- this would be severe AOM and tympanic membrane has ruptured
17
Q
when are AOM sx seen
A
within 24-48 hours of pain
18
Q
sx of AOM
A
- pain (tugging ear, crying, irritable, altered sleep). Spontaneous rupture of tympanic membrane results in purulent discharge and pain relief
- sometimes fever (high can indicate a more severe infection)
- N/V/D
19
Q
what is a pneumatic otoscope exam
A
another way to check for AOM- checks mobilty of TM
-poorly done by Drs
20
Q
intracranial complication of AOM, how common?
A
- not very common, rare
- meningitis
- subdural or brain absess
21
Q
what % of AOM resolve spontaneously without tx
A
80%
22
Q
extracranial complication of AOM
A
- hearing loss, TM perforation, chronic OM, mastoiditis (infection spreading from mastoid process ie portion of skull behind ear)- more common but still not very common
- very rare= facial paralysis, tympanosclerosis, labyrinthitis
23
Q
top three causes of AOM
A
- streptococcus pneumoniae
- haemophilus influenzae
- moraxella catarrhalis
24
Q
if less than six weeks old, what likely causes AOM
A
E-Coli or group B strep
25
can AOM be viral?
yes, with or without concomitant bacteria- do culture, often see both and cannot be sure which is causing pain/sx
26
goals of treating AOM
- reduction in signs/sx
- eradication of infection
- prevention of complications
- avoid unnecessary AB prescribing (esp in light of problem of Strep pneumoniae resistance)
27
what is antibiotic treatment selection based on
- spectrum of activity
- AEs
- ability to penetrate middle ear
- convenience
- cost
28
in a child 6 months or older with severe signs or symptoms (moderate to severe otalgia, or otalgia for at least 48 hours, or temperature of 39)- what to do
ABs
29
unilateral AOM in children 6-23 months without severe signs and sx
ABs
OR
observation
30
AOM in children 24 months or older without severe signs/sx
ABs
OR
observation
31
what is observation (aka _________)
- watchful waiting
- AB tx is deferred for 48-72 hours
- caregiver watches child for signs of worsening; if worsen of don't improve at all then fill rx
32
what % of AOM resolves without ABs? Which is least likely to go away?
80%, but strep pneumoniae is least likely to resolve on its own
33
first line therapy for AOM, dose (what not to exceed), what it covers
amoxicillin: 80mg/kg/day BID or TID max 3g/day
- child: some references say use high dose ie 80mg/kg/day in everyone regardless of age, some references say 40mg/kg/day. Just don't exceed 1.5g/dose
- covers strep pneumoniae and most of haemophilis (only 25% will produce beta lactamases and be resistant to it)
34
why can we use such a high dose of amoxicillin?
-hard to get ABs to site of action in middle ear in adequate concentrations
35
mechanism of resistance of strep pneum to amox ie penicillins
penicillins work by binding to penicillin binding proteins on cell so the mechanism of resistance is decreased binding affinity, but not lack of binding
36
how do you overcome resistance to penicillin for AOM
giving more drug and flooding the organism with amoxicillin
| -amox is still the most active against strep pneumoniae even with resistance
37
why is amoxicillin first line?
- good activity against strep pneumoniae, even resistant strains
- has a fairly narrow spectrum
- safe unless allergic to it
- very cheap
38
what is second line therapy for AOM? What is it? Dose?
amoxicillin/clavulanate: 40mg/kg/day divided BID
| -has a beta lactamase inhibitor added on it; handles haemophilis (25% that is amox resistant) and moraxilla
39
why is morexilla not cured by amox? Is this a problem?
resistant to it because almost all of it produces beta lactamases- but it is most likely to go away on its own
40
why wouldn't be just give everyone amox/clav?
- more expensive
- SEs= stomach upset, **diarrhea (clav causes a lot of this), GI distress, etc
- if on amox and not responding, this can be a good second line
41
in penicillin allergic patients, what is next therapy?
- cefprozil 30mg/kg/day BID
- Cefuroxime 30-40mg/kg/day BID
- Clarithromycin 15mg/kg/day BID
- azithromycin 10mg/kg/day for day one, then 5mg/kg/day for 4 days OR 10mg/kg/day for 3 days, OR 30mg/kg single dose
42
why wouldn't you want to use cephalosporins potentially in people who can't take penicillin?
- don't have as good of activity against strep pneumoniae
- more expensive
- if it was a severe reaction or allergy, would be worried about cross allergy and wouldn't take this either
43
which tastes better- cefprozil or cefuroxime?
-cefPROzil tastes good, cefuroxime tastes bad
44
why would you maybe not consider a macrolide AB for AOM?
- resistance rates are much higher
- major common side effect is GI upset (throw up common)
- cannot up doses to overcome resistance because of SEs, and they don't bind to penicillin binding proteins
- they change mRNA binding and increased SEs
- clarithromycin and erythromycin cover haemophilis, but clarity only does because of its metabolite
45
which AB is not longer recommended due to resistance to all 3 organisms?
- trimethoprim/sulfamethoxazole
| - only recommended in some very specific patients
46
why is it important to ask if kids have had AB in the past month before new treatment?
if had same class in the past month, more likely to have resistance to that organism
47
when would you use clarithromycin and why
- it only has activity against gram positive aerobes and some anaerobes- the only gram positive organism in AOM is strep pneu, so it will only be active against this
- use if sure you are only dealing with strep pneu (has a very narrow spectrum)
- good for pen allergic children
48
how long should AB tx last
- generally 10 days
- 5 days may be enough for some (uncompicated AOM- not recurrent/chronic and no underlying disease, over 24 months, no perforation of eardrum)
49
how long should under six months always be treated
10 days
50
treating otitis externa vs AOM
- externa needs drips
| - AOM needs to get to site of infection so much be oral
51
sx resolution with AB treatment within
- 2-3 days improvement seen
| - if persist or worsen, see Dr
52
what will half of patients have remaining after treatment
effusion (fluid)- may persist for weeks (up to one month). This is normal and does not mean treatment failure, just takes body time to get rid of the effusion.
-fluid in ears is not a reason to put child on ABs
53
non pharm tx for AOM
- glycerin or vegetable oil (heat to body temp in pocket or with hands and drop in, soothing, DON'T DO IF RUPTURED TM (guidelines, prob still okay)
- heating pad or warm wash cloth (soothing)
54
pharm tx for AOM
- don't use Auralgan- it has an anesthetic but it can't actually penetrate the middle ear, and quite a few people are allergic to it
- pain relief (ibu, acet, NOT ASA- associated with Reyes syndrome
- decongestants and antihistamines- thought to prevent occlusion and help clear it p, but most studies show no benefit. Can be used for other signs/sx. Stimulant effect can be more pronounced in kids
55
what is reye's syndrome
causes fatty liver and severe encephalopathy (brain swelling)
56
what is otitis media with effusion
presence of middle ear effusion without any sign of infection- may be asymptomatic except a bit of hearing loss
57
how can otitis media with effusion be further subdivided
- acute (less than 3 weeks)
- subacute (3 weeks to 3 months)
- chronic (over 3 months)
58
causes of otitis media with effusion
- recent AOM (40-50% of cases) (often follows AOM and resolves in 6-12 weeks-should employ watchful waiting in the meantime)
- allergic rhinitis
- anatomic problems
59
what might happen with recurrent OM with effusion
- may decrease hearing which can impair language development over time
- cause scarring of tympanic membrane
60
how to treat otitis media with effusion
- wait and see (may resolve spontaneously in 2-3 months)
- 2nd trial of ABs- not really recommended, bacteria may be present in half of cases
- decongestants and AHs not usually useful
- corticosteroids orally- some studies show benefit, short courses should be used if used
- surgical procedures- myringotomy (drain middle ear space), tympany tubes : these tend to be reserved for recurrent cases
61
how to treat recurrent AOM
- ABs for 10 days
- prophylaxis no longer recommended
- surgery
- vaccines (pneumococcal vaccine-could prevent, but can't guarantee because 70-80 strains of it and can only contain/target most prominent ones. Influenza vaccine can reduce AOM in children
62
treatment outcomes for recurrent AOM
- decrease frequency of AOM by at least one episode per year
- does not affect the rate of effusion
- good idea for kids under 2 to prevent long term complications, but this is not a generally acceptable statement for all people
- must worry about resistance and compliance
63
non pharm tx for recurrent ear infections
-insertion on tympanostomy tubes (T tubes)
64
pharmacists role- what to recommend, what to avoid
- recommend something for pain
- avoid AHs/decongestant and drops
- instruct on proper AB use and follow up
