Download Acute Otitis Media and Otitis Media with Effusion

ACUTE OTITISE MEDIA
&OTITIS MEDIA WITH
EFFUSION
DIAGNOSIS
AOM

rapid inflammation + middle
ear effusion (MEE)
OME:
MEE without acute
inflammation
inflamation
Signs:
bulging or fullness or erythema or perforation of the TM with otorrhea
Symptoms:
otalgia , irritability, and fever
EPIDEMIOLOGY
(AOM) is the most frequent diagnosis in sick children in US
approximately $5 billion in US
otitis media 39% of children by 9 months and 62% of children by 2 years of age
occurs in older children, adolescents,and adults.
peak incidence of AOM was during the first 6 to 12 months of life
OME is asymptomatic. approximately 65% of OME episodes in children 2 to 7 years of age resolve
within 1 month.
difficult to determine the “true” incidence of OME
PHYSICAL EXAMINATION
Ears
Head and neck
Craniofacial anomalies ( Down and Treacher Collins )
Oropharynx( bifid uvula or cleft palate)
Hypernasality ( velopharyngeal insufficiency)
Hyponasality (obstructing adenoids or nasal obstruction due to
nasal polyposis or deviated septum)
PNEUMATIC OTOSCOPY
Middle ear
TM and its mobility.
normal TM :
translucent
concave
moves with positive and negative pressure.
landmark: handle (manubrium) of the malleus
.
umbo: in the center of the TM.
Note: position, color, degree of translucency, mobility
POSITION
position of the tympanic membrane is the most critical
characteristic in distinguishing AOM from OME
 normal position is neutral
 negative pressure: retracted TM
 fullness (infection)
bulging:large amount of infected fluid (posterosuperior area)
when bulging: the malleus is obscured

TRANSLUCENCY

normal TM is translucent
with fluid: cloudy or opaque
Air fluid levels are more suggestive of OME than AOM
COLOR
“red” TM that is full or bulging often is a sign of AOM
A pink, gray, yellow, or blue retracted TM with reduced or no
mobility usually is seen with OME.
red but translucent TM is a typical finding in a crying or sneezing
infant,
TYMPANOMETRY
inconclusive otoscopy
difficult otoscopy
children older than 6 months
TYMPANOMETRY
−400 to +200 daPa(decapascals).
flat or round pattern(TW>350 daPa)with a small ear canal volume:MEE
flat pattern with a large ear canal volume : perforation or a patent
tympanostomy tube.
 normal middle ear: peak pressure 0 daPa
 no OME : TW<150 daPa
OME: TW> 350 daPa
 TW=150-350 daPa presence or absence of OME is determined by
otoscopy

AUDIOMETRY
 MEE
usually results in a mild to moderate conductive
hearing loss and causes delay in speech and language
development
OAE
 cochlear
function (outer hair cells)
-newborn hearing screening :fast and easy
MEE may confound the results.
 ABR
PATHOPHYSIOLOGY AND
PATHOGENESIS
multifactorial with various overlapping factors
1.infection(bacteria,viral)
2.Host factors(Allergy,immunology,gender,race,age,gentic)
3.anatomic/physiologic(eustachian tube,cleft palat)
4.Enviroment factor(daycar,tobacco smoke exposure seasonality
breast/bottle feeding,pacifier,obisity
EUSTACHIAN TUBE FUNCTION

The eustachian tube in the infant is shorter, wider, and more horizontal
By the age of 7 years prevalence of otitis media is low.
INFECTION
in AOM Streptococcus pneumoniae most common
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pyogenes
other miscellaneous bacteria
in chronic OME, H. influenzae most common pathogen
S. pneumoniae
M. catarrhalis
other bacteria
VIRUSES
respiratory syncytial virus (RSV)
influenzavirus
adenoviruse
parainfluenza virus
rhinoviruses
ALLERGY AND IMMUNOLOGY
mechanism is not understood,it may be:
(1) the middle ear is a “shock organ” (target)
(2) induce inflammatory swelling of the eustachian tube mucosa
(3) inflammatory obstruction of the nose
(4) bacteria-laden allergic nasopharyngeal secretions may be aspirated into the midle
ear
RISK FACTORES
HOST-RELATED FACTORS
Age. highest incidence 6 -11 months of age, first episode < 6 or 12 months a
powerful predictor of recurrence.
first episode of MEE < 2 months is higher risk for persistent fluid during their first
year of life
Sex. no difference between male & female
Prematurity controversy
Allergy. controversy .
Immunocompetence. HIV demonstrate a significantly higher recurrence
Cleft Palate/Craniofacial Abnormality.
Infants < 2 year with unrepaired cleft palate
Surgical repair reduces otitis media
 Anatomic or functional eustachian tube abnormalities
 Down syndrome:
low resistance of the tube
poor active eustachian tube
reflux of nasal secretions into the middle ear.

ENVIRONMENTAL FACTORS
 Upper

Respiratory Infection/Seasonality
Rhinovirus, RSV,adenovirus, and coronavirus
 Day
Care/Home care
day-care centers
more tympanostomy tubes inserted
than home care
 Tobacco Smoke Exposure
 passive exposure to smoking
 Breastfeeding/Bottle
 Pacifier
unclear.
Use
 Obesity
Feeding
SYMPTOMATIC THERAPY

ibuprofen 10 mg/kg
Auralgan® (combination of antipyrine, benzocaine , and glycerin )
 topical aqueous lidocaine (lignocaine) ear drops
 topical herbal extract Otikon Otic solution
Decongestants and antihistamines:
no benefit
potential for delayed resolution of middle ear fluid
increased medication side effects

ANTIBIOTIC THERAPY VERSUS OBSERVATION


< six months
antibacerial therapy regardless of degree of diagnostic certainly
six months to two years,
antibacterial therapy is when:
certain diagnosis of AOM
uncertain diagnosis but the illness is severe
(moderate to severe otalgia or fever ≥39ºC in the previous 24 hours).
Observation when diagnosis is not certain and illness is not severe.
>
two years,
antibacterial therapy when:
certain diagnosis and illness is severe
Observation when:
certain diagnosis but illness is not severe
uncertain diagnosis.
ANTIMICROBIAL THERAPY
Seventeen antimicrobial drugs (16 oral and 1 parenteral preparation)
 two otic preparations (eg, ofloxacin otic and ciprofloxacindexamethasone otic) for treatment of AOM with otorrhea in children
with tympanostomy tubes in place or tympanic membrane perforation

Antimicrobial agents available for treatment of acute otitis media
Most used drugs
Others
Amoxicillin
Cephalexin
Amoxicillin-clavulanate*
Cefaclor
Cefuroxime axetil*
Loracarbef
Ceftriaxone IM or IV*
Cefixime
Erythromycin + sulfisoxazole •
Ceftibuten
Azithromycin •
Cefprozil
Clarithromycin •
Cefpodoxime
Trimethoprim-sulfamethoxazole •Δ
Cefdinir
Ofloxacin otic ◊
Trimethoprim
Ciprofloxacin-dexamethasone otic ◊
 First-line
therapy
amoxicillin of 80 to 90 mg/kg per day maximum dose of 3 g/day
 Amoxicillin-clavulunate AOM by an amoxicillin-resistant
otopathogen:
 antibiotictherapy in the previous 30 days, particularly beta-lactam
antibiotics
 concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome
usually is caused by nontypeable H. influenzae , which is
frequently resistant to beta-lactam antibiotics)
 receiving amoxicillin for chemoprophylaxis of recurrent AOM (or
urinary tract infection)

PENICILLIN ALLERGY
Non-type 1 reactions :
Cefdinir 14 mg/kg per day
Cefpodoxime 10 mg/kg per day once daily
Cefuroxime – cefuroxime axetil suspension:
A single intramuscular dose of ceftriaxone 50 mg/kg If clinical signs
persist, a second dose is administered and, if necessary, a third dose.
 Type 1 reactions :
azithromycin , and clarithromycin . Trimethoprimsulfamethoxazole

DURATION OF THERAPY
< 2 years old :
10 days
 >2 years old:
5-7 days
single dose of azithromycin has been approved by the FDA

TREATMENT FAILURE





Lack of improvement by 48 to 72 hours :
another disease is present
the initial therapy was not adequate.
Inadequate therapy :
organism resistant to beta-lactam antibiotics
Persistent MEE after the resolution of acute symptoms is not an
indication of treatment failure or an indication for additional antibiotic
therapy
high-dose amoxicillin-clavulanate 90 mg/kg per day amoxicillin and 6.4
mg/kg per day of clavulanate


Tympanocentesis for patients with persistently refractory AOM, to
define the etiology
Alternatively, use of levofloxacin and/or tympanostomy tube placement
may be appropriate .
RECURRENT AOM






signs and symptoms of AOM (fever, pain, bulging tympanic membrane)
soon after completion of successful treatment.(within 30 days)
bulging of the tympanic membrane and signs of inflammation.
persistent MEE in a child with a febrile upper respiratory infection may
be misinterpreted as a recurrent episode.
Parenteral ceftriaxone
50 mg/kg per day for 3 days or possibly every 36 hour
levofloxacin
10 mg/kg every 12 hrs
recurrence more than 30 days is most often due to a different
pathogene: high dose amoxicillin-clavulanate
Tympanostomy tube insertion may be warranted for children with
recurrent AOM
TYMPANIC MEMBRANE PERFORATION


acute otorrhea, 10 days of oral therapy
topical therapy for the well-appearing, immunocompetent > 2 years
oral therapy is preferred.
Topical therapy ( quinolone) = oral therapy in otorrhea +VT or chronic
suppurative otitis media
but not in AOM + acute perforation




TM perforation with pain is due to:
mastoiditis
otitis externa
Auralgan, lidocain or olive oil, should not be used in perforation of TM
FOLLOW-UP
Persistent symptoms ( after 48 to 72 hours)
 Resolved symptoms : for MEE ( may affect speech, language, and
cognitive abnormality) 8-12 weeks after AOM:
 All children < 2 years two years
 Children > 2 years and have language or learning problems

Surgical Treatment:
Myringotomy/Tympanocentesis.
relief of pain
samples for culture
no advantage in duration of effusion or recurrence of episodes of AOM.
MYRINGOTOMY WITH TYMPANOSTOMY TUBE INSERTION.
three or more episodes of AOM in 6 months
or four or more episodes in 12 months
ADENOIDECTOMY WITH AND WITHOUT TONSILLECTOMY
Is not recommended as a firstline procedure unless indicated for airway
obstruction.
Tonsillectomy, in conjunction with adenoidectomy,has no significant
advantage over adenoidectomy alone
OTITIS MEDIA WITH
EFFUSION
 Watchful
disabilities
waiting if not at risk for speech and language or learning
Hearing testings
if MEE persists for 3 months or longer
 language delay, learning difficulties, or significant hearing loss is
suspected
average hearing level:
< 20 dB watchful waiting
>
40 dB in the better ear, surgery
21 -39 dB, in better ear
if not at risk, examination at 3- 6-month intervals
until the fluid has resolved; hearing loss or language or learning delays are
identified; or structural abnormalities of the eardrum are suspected

MEDICAL TREATMENT
:Decongestant/Antihistamine.
no efficacy
 Antibiotics.
 are not recommend
 Steroids.

systemic steroids have demonstrated an advantage over placebo
but are not recommended for long-term management.

SURGICAL TREATMENT
Myringotomy.
 Myringotomy alone is ineffective

Myringotomy with Tympanostomy Tube Insertion.
 based on the child’s hearing status and risk for developmental
problems.
for chronic OME

ADENOIDECTOMY
adenoidectomy or adenotonsillectomy at the time of first or subsequent
tube insertion is associated with reduced risk of further tube insertion.
SURGICAL ISSUES
anterior-superior or anterior-inferior quadrant of the parstensa
 The anterosuperior quadrant is associated with a longer clinical tube
life; but a persistent perforation in that area is more difficult to repair

SELECTION OF TYMPANOSTOMY TUBES AND INDICATIONS
In a young child with a history of recurrent or persistent otitis media, a
tympanostomy tube that remains in place for at least a year is preferable.
 If the child has recurrent otitis media after the tubes have become
nonfunctional or extruded, a similar type of tube should be recommended
 Grommets in older children
 T-tubes for older children with persistent problems due to poor eustachian
tube function

..
PERIOPERATIVE AND POSTOPERATIVE OTOTOPICAL DROPS

to reduce early postoperative otorrhea and tube blockage
FDA-approved ototopical agents such as ofloxacin (Floxin) and
ciprofloxacin plus dexamethasone (Ciprodex)
POSTSURGICAL FOLLOW-UP

follow-up visit after few weeks to assess the status of the
tympanostomy tube.
with a hearing loss, repeat hearing evaluation postoperatively.
if preoperative hearing test was not done should be examined
postoperatively to document that the hearing is normal.
evaluation 6 to 12 months after the insertion of the tubes and
every 6 months thereafter,
or when problems occur, to assess the status of the tubes and the
TM.
COMPLICATIONS AND SEQUELAE
OTORRHEA

50%
transient otorrhea : 16%
later in: 26%
recurrent otorrhea :7.4%
chronic otorrhea :3.4%











under 6 years of age same pathogens of typical AOM
6 years of age or older: P.aerpginosa
(1) ototopical agents : ofloxacin otic or ciprofloxacin-dexamethasone otic are effective
(2) in severe systemic symptoms, a systemic antibiotic
(3). If drainage does not resolve in 7 to 10 days, suctioning and culture
(4) yeast : topical antifungal drop
(5) Repeated aural toilet is a very important
(6) Intravenous antibiotics if :aural toilet and topical fails,or the organisms are not
sensitive to oral antibiotics
(7) removal of the tube
(8)rarely a simple mastoidectomy should be considered.
CT scan of the temporal bones should be obtained before possible mastoidectomy,
(8) In older children with recurrent episodes of otorrhea, removal of the tubes is the
treatment because of refluxing into the middle ear & tube act as a foreign body,
TYMPANOSCLEROSIS, ATROPHY, AND RETRACTION POCKETS
tympanosclerosis occurred in 32%
 focal atrophy in 25%
 retraction pockets in3.1%
 The type of tube (short-term vs. long-term) had no significant
impact on these rates.

PERSISTENT PERFORATION
4.8%
 small
 hearing loss is very mild
 managed with a simple fat graft or surgical gel , paper patch, or
Steri-strip myringoplasty.

CHOLESTEATOMA

For all types of tubes 0.7%
RETAINED TYMPANOSTOMY TUBES
usually is not removed surgically( most tubes extrude
spontaneously)
 Indications for removing
(1) Retention of one tube after extrusion of the other tube if the
middle
ear has been free of disease for 1 year or longer in a child 5
to 6 years old or older
(2) Bilateral retained tubes in an older child with good eustachian
tube function
(3) Chronic or recurrent otorrhea that are not managed medically
(4) Blockage of a tympanostomy tube that has become embedded in
granulation tissue

WATER PRECAUTIONS
no increase of otorrhea in patients with tympanostomy tubes
water precautions
(1)recurrent otorrhea,specially with Pseudomonas or S. aureus
(2)risk factors for infections and complications.
(3)heavily contaminated water (lakes)
(4)deep diving
(5)dunking the head in the bathtub with soapy water
(6)ear discomfort during swimming.er precautions.


EARLY EXTRUSION
3.9%
 infection in the middle ear
 not have been properly inserted, especially if the TM is thickened
owing to an infection at the time of tube insertion.
 An atrophic TM

TUBE BLOCKAGE

6.9%
clot, mucus, granulation tissue ,polyp
 unpluging : pick, suction, a Rosen needle, or ototopical drops for 10
to 14 days.
 If effusion-free with normal middle ear pressure: the tube can be
left in place and watched until extrusion.
 If infection or fluid : replacement

TUBE DISPLACEMENT INTO THE MIDDLE EAR
0.5%
 at the time of surgery (commonly)
 later due to infection or trauma (rare)
 displacement during surgery: retrieve the tube at the time of
surgery
visualized behind an intact TM, risks versus benefits must be
asses.is whit rarely problems.
