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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.