W31 Otitis media management Flashcards
Aetiopathogenesis, presentation, diagnosis and management
What is Acute Otitis Media (AOM)?
What are the causes?
- AOM is the presence of inflammation in the middle ear, associated with an effusion, and accompanied by the rapid onset of symptoms and signs of an ear infection
Cause:
* Bacteria: Haemophilus influenzae,
Streptococcus pneumoniae, Moraxella
catarrhalis, and Streptococcus pyogenes
* Virus: respiratory syncytial virus (RSV),
rhinovirus, adenovirus, influenza virus, and
parainfluenza virus
(same as URT infections)
Aetiology of AOM
- AOM occurs frequently in children
-Less common in adults - Children are more likely to develop AOM because
-They acquire viral infections more often than adults
-They have shorter and more horizontal eustachian tubes (anatomical structure of the eustachian tube) - AOM occurring most commonly in the winter, and in children born in the autumn
Risk factors for developing AOM?
- Young age
- Male sex (lifestyle, anatomical, behaviour)
- Smoking and/or passive smoking
- Frequent contact with other children such as day care or nursery
attendance or having siblings (increases exposure to viral illnesses) - Formula feeding — breastfeeding has a protective effect
- Craniofacial abnormalities (such as cleft palate)
- Use of a dummy
- Prolonged bottle feeding in the supine position
- Family history of otitis media
- Lack of pneumococcal vaccination
- Gastro-oesophageal reflux
- Prematurity
- Recurrent upper respiratory tract infection
- Immunodeficiency
Presenting symptoms & diagnosis of AOM:
- Rapid onset
- Earache
- Children with AOM may present with systemic symptoms such as difficulty
sleeping, fever and irritability - It is important to consider these symptoms are non-specific and may be due
to a simple URTI - Signs and symptoms of middle ear inflammation, which is characterised by
redness of the tympanic membrane (eardrum). - Middle ear effusion characterised by any of the following:
-Bulging, perforation, or limited or absent movement of the tympanic membrane
(eardrum)
Other considerations of AOM:
- It can be difficult in infants to visualise the tympanic membrane to confirm a diagnosis of AOM
- Mild inflammation of the middle ear due to a viral URTI can complicate a diagnosis of AOM
- Pain alone is not sufficient for a diagnosis and is a poor indicator of whether antibiotics will provide effective treatment
- Middle ear effusion alone is insufficient to diagnose AOM (as middle ear effusion can persist for several weeks following the resolution of AOM)
What is the Differential diagnosis of AOM? (4)
- Otitis media with effusion (glue ear) — fluid in the middle ear without symptoms or signs of acute infection
- Chronic suppurative otitis media — persistent inflammation and perforation of the tympanic membrane with draining discharge for more than 2 weeks
- Myringitis — erythema and injection of the tympanic membrane are visible on otoscopy but there are no other features of otitis media.
- Earache is a common problem – causes of ear pain also include eustachian tube dysfunction, mastoiditis, malignancy, and referred pain.
Management of AOM
- Advise- AOM lasts about 3 days but can last up to 1 week
- Ottorhea (discharge) ? Under 2 with infection in both ears?
No= No abx, give paracetamol/ibuprofen (analgesics)
Yes= Regular dose of analgesics, no abx
Child/young person systemically unwell:
= Immediate abx rx, or ref to hosp if severe
Which patients are at high risk of complication?
- Otogenic complication
- Immunodeficiency
- Severe underlying diseases
- Down syndrome
- Cleft lip and palate
- Presence of cochlear implant
Management of AOM
Advise?
Explain?
- ADVISE: Self-limiting condition – usual course of AOM is about 3 days to 1 week
- ADVISE: Regular doses of paracetamol or ibuprofen for pain, using a dosing schedule appropriate for the age and weight of a child
- Consider ear drops containing an anaesthetic and an analgesic for pain if an immediate antibiotic is not given and there is no ear drum perforation or otorrhoea – Phenazone with lidocaine ear drop up to 7 days (Otigo®)
- EXPLAIN: There is no evidence to support the use of decongestants or antihistamines for the management of symptoms
Antibiotics choice for the treatment of AOM?
1st line?
2nd line?
First line:
* Amoxicillin – 1st choice
* Clarithromycin – if patient is allergic to penicillin
* Erythromycin – if pregnant and allergic to penicillin
( 5-to-7-day course, then review or review when there is no improvement)
Second line:
* Co-amoxiclav – where there are worsening symptoms on the 1st choice antibiotic taken for at least 2-3 days
* Where a person has a penicillin allergy or is intolerant contact local specialist advice from a microbiologist
Other treatment considerations for AOM?
- Rest
- Drink lots of fluid and eat normally
- Maintain good hygiene
- Take paracetamol or ibuprofen to treat fever and pain
- Most ear infections get better without any treatment. Recovery usually takes place within three days but can take up to a week
Prognosis (for info)
- Without antibiotic treatment – symptoms will improve within 24 hours in 60% of children with AOM, and most people will recover within 3 days
- Recurrent episodes of AOM are not common – recurrent AOM will resolve as the child gets older, often at 3–4 years of age
- Long term complications are rare
Complications of AOM?
- Persistent otitis media with effusion
- Recurrence of infection
- Hearing loss (usually conductive and temporary)
- Tympanic membrane perforation
- Labyrinthitis
- Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis
Preventive strategies – advice to patients/parents/carers
- Upper respiratory tract infections, such as colds and flus can lead to ear
infections. You can minimise the number of your child getting infections by:
-Ensuring your child is vaccinated against the pneumococcal disease
-Washing hands regularly, wiping down shared toys etc
-Treating allergies because inflammation in the airways can make it easier to get respiratory
and ear infections - Smoking: Minimising the exposure to second-hand smoke
- If your child is still bottle-fed, this should be in an upright position rather than
lying down – breastfeeding has protective effect - Use of dummies after 6 months is associated with more ear infections and is
therefore recommended to start reducing/stopping pacifier use if your child still
uses a dummy - Chewing gum for older children and adults
Applied shared decision making into
practice (for info)
What are the benefits of shared decision making? (3)
Do I need an antibiotic?
Target website – Discussing antibiotics with patients section
Shared decision making
* Improve adherence
* Improve antibiotic prescribing
* Increase patient satisfaction and understanding of the prescribing decision
