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‫بنام خداوند جان وخرد‬
‫‪Otitis‬‬
‫‪Media‬‬
Otitis Media - Definition
Inflammation of the middle ear •
May also involve inflammation of mastoid, •
petrous apex, and perilabyrinthine air cells
Eustachian Tube
Lumen shaped like two cones with apex •
directed toward middle
Mucosa has mucous producing cells and •
ciliated cells
Connects middle ear and nasopharynx •
Eustachian tube
Adults •
ant 2/3- cartilaginous
post 1/3- bony
45 degree angle
isthmus 1-2 mm
nasopharyngeal orifice
8-9 mm
–
–
–
–
–
Children •
longer bony portion
10 degree angle
isthmus larger
nasopharyngeal orifice
4-5 mm in infants
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–
–
–
Eustachian tube
Usually closed
Opens during swallowing, yawning, and
sneezing
Opening involves cartilaginous portion
Tensor veli palatini responsible for active
tubal opening
No constrictor function
•
•
•
•
•
Eustachian tube
Protection from nasopharyngeal sound •
and secretions
clearance of middle ear secretions •
ventilation (pressure regulation) of middle •
ear
Pathology
Edema, capillary engorgement, and PMN
infiltration
Epithelial ulceration and granulation tissue
Fibrosis, influx of chronic inflammatory cells
Increased columnar and goblet cells
Osteitis
•
•
•
•
•
Edema and polypoid changes •
Pathology
Eustachian tube abnormalities •
Impaired opening –
open in DS and American Indians –
shorter tube –
Impaired immunity •
children have poorer immune response –
less cytokines in nasopharynx in children with OM –
Inflammatory mediators •
Bacterial products induce inflam response with IL-1, –
IL-6, and TNF
Allergy •
Microbiology
S. pneumoniae - 30-35%
H. influenzae - 20-25%
M. catarrhalis - 10-15%
Group A strep - 2-4%
Infants with higher incidence of gram
negative bacilli
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•
•
•
•
Bacteriology
Virology
RSV - 74% of middle ear isolates
Rhinovirus
Parainfluenza virus
Influenza virus
•
•
•
•
otitis media can be subclassified
into
Acute otitis media •
(AOM)
otitis media with •
effusion (OME)
. AOM generally is characterized
by rapid onset of signs and symptoms of •
inflammation in the middle ear
accompanied by middle ear effusion
(MEE).
Signs and Symptoms
bulging or fullness of the tympanic
membrane (TM)
erythema of the TM
and acute perforation of the TM with
Otorrhea
otalgia
irritability
fever
•
•
•
•
•
•
•
Physical Examination
proper head and neck examination is invaluable •
Facial features( Down syndrome and Treacher
Collins syndrome )
Examination of the oropharynx may show a bifid
uvula or a cleft palate
. . Hypernasality indicates velopharyngeal
insufficiency
, whereas hyponasality may be caused by
obstructing adenoids or nasal obstruction due to
nasal polyposis or deviated septum.
Pneumatic otoscopy
Reduced or no mobility of the TM
•
increased stiffness due to scarring or increased thickness of the TM
•
. Total absence of mobility of the TM may also be due to an •
opening in the TM either as a perforation or a patent tympanostomy
tube
fluid levels or bubbles
•
The position of the TM ranges from severely retracted to •
bulging. Mild to moderate retraction indicates negative
pressure
Immittance Testing
(Tympanometry)
can be very useful in evaluating ear •
disease in children older than 6 months of
age
Audiometry
Behavioral audiometry requires cooperation of the child •
with the examination and the test is adapted to the age
of the child
Auditory brainstem audiometry (ABR) and transitory •
otoacoustic emissions (TOAE) are excellent methods for
testing children who do not cooperate with behavioral
hearing evaluation because of very young age or
developmental delay
Otoacoustic emissions (OAE) testing measures cochlear •
function (outer hair cells) and is a means of objective
assessment of auditory function
Pathophysiology and Pathogenesis
The eustachian tube
The eustachian tube in the infant is shorter, wider, and more •
horizontal than in the adult, which accounts for the high rate of otitis
media in infants and children
. By the age of 7 years, when the tube has a more adult
•
configuration, the prevalence of otitis media is low
The three physiologic functions of the eustachian tube are •
(1) pressure regulation (ventilation), •
(2) protection, and •
(3) clearance (drainage).
•
Allergy and Immunology
, the causal mechanism is not understoodSeveral mechanisms by
•
which allergy may cause otitis media
: (1) the middle ear is a “shock organ” (target); •
(2) allergy may induce inflammatory swelling of the eustachian tube
mucosa;
(3) allergies produce inflammatory obstruction of the nose •
(4) bacteria-laden allergic nasopharyngeal secretions may be •
aspirated into the middle ear
•
Gastroesophageal Reflux
reflux may be a causative factor in otitis •
media, with a potential role for antireflux
therapy in the treatment of otitis media in
some children,
but adequate controlled trials have not •
been done with a potential role for
antireflux therapy in the treatment of otitis
media in some children, but adequate
controlled trials have not been done.
Viruses
Using PCR techniques, however, •
it has been possible to identify
respiratory syncytial virus (RSV)
, influenzavirus, •
adenovirus, •
parainfluenza virus, and •
rhinoviruses in MEE
Acute Otitis Media
In a majority of these studies, the peak •
incidence of AOM was during the first 6 to
12 months of life
The incidence decreases with age, and by •
the age of 7 years, few children
Recurrent episodes of AOM are common •
in young childrenexperience episodes of
AOM
Otitis Media with Effusion
It may be difficult to determine the “true” •
incidence of OME because, by
definitionOME is asymptomatic
approximately 65% of OME episodes in •
children 2 to 7 years of age resolve within
1 month
Risk Factors
(age, •
gender •
, race, •
prematurity, •
allergy •
, immunocompetence •
, cleft palate and craniofacial abnormalities
, genetic predisposition) •
as well as environmental •
(upper respiratory infections •
, seasonality •
, day care •
, siblings •
, tobacco smoke exposure •
, breastfeeding •
, socioeconomic status •
, pacifier use, and obesity •
•
Otitis media also is common in children with other craniofacial
abnormalities or Down syndrome, also due to anatomic or functional
eustachian tube abnormalities
highest incidence of AOM is between 6 and 11 months of age,[39] •
and onset of the first episode of AOM before 6 months[39] or 12
months of age is a powerful predictor of recurrence.
.[54] Some studies have found a significantly higher incidence of •
AOM in males as well as more recurrent episodes than in females,
but others have not found this.[
studies have suggested a lower incidence of otitis media in African- •
American children than in white children46]
Some studies have shown a possible association between low birth •
Otitis media is considered “universal” in infants younger than 2 years
of age with unrepaired cleft palate.[65] After surgical repair of the
palate, the occurrence of otitis media is reduced, probably because
of improvement in eustachian tube function.
weight and prematurity and otitis media, but others have not. •
A study was conducted to assess the variation in environmental risk •
factors for otitis media across Western countries, including
European countries, the United States, Canada, and Australia.[74]
The main risk factors for otitis media were day care atendance,
number of siblings, tobacco smoke exposure, breastfeeding, birth
weight, socioeconomic status, and air pollution. However, the results
indicated large variations in rates across the various countries: day
care at ages 1 to 3 years: Sweden 75% versus Italy 6%; breastfed at
6 months: Norway 80% versus Poland 6%; and women smoking:
Germany, France, and Norway 30% to 40% versus Portugal less
than 10%.
Both epidemiologic evidence and clinical •
experience strongly suggest that otitis
media frequently is a complication of an
upper respiratory infection (URI). The
incidence of AOM is highest during the fall
and winter months and lowest during
spring and summer months, which
parallels the incidence of URI
Tobacco Smoke Exposure
a metabolite of nicotine, in blood, urine, or
saliva of the child and have been able to
more accurately determine the association
, between otitis media and smoke
exposure
tympanostomy
, myringosclerosis
•
•
•
•
Bacterial
Vaccines
•
Treatment
Medical •
Surgical•
Medical Treatment
Amoxicillin is still the first-line antibiotic for non-severe •
episodes of AOM and, at 90 mg/kg per day in two
divided doses
For severe episodes of AOM, amoxicillin–clavulanic acid •
(amoxicillin 90 mg/kg per day and clavulanic acid
6.4 mg/kg per day in two divided doses)
Cephalosporins should be considered as accepted first- •
line treatment only for patients with penicillin allergy
Macrolides should be prescribed for patients with •
penicillin and cephalosporin allergies
Antibiotics
First line •
Amoxil - 60-90 mg/kg divided tid –
Ceftin - B lactam stable –
Augmentin - B lactam stable –
Bactrim, Pediazole –
Second line •
Augmentin –
Ceftin –
Rocephin –
Macrolides - Zithromax, Biaxin –
‫دو نکته مهم‬
Treatment failure is defined as persistence or recurrence
of symptoms and signs 48 to 72 hours after institution of
initial treatment. In such cases, the diagnosis should
then be reassessed and antibiotics started if not given
previously or changed to a broader-spectrum agent if
antibiotics were previously prescribed (amoxicillin–
clavulanic acid if amoxicillin failed to produce
improvement and ceftriaxone for 3 days if amoxicillin–
clavulanic acid was not effective)
Tympanocentesis should always be considered if the •
child does not respond to the antibiotic treatment, in
order to identify the bacteria in the MEE and to select an
appropriate antibiotic.
•
Duration of Treatment
Ten days of antibiotic treatment has been the •
standard
Longer courses of antibiotics have also been •
proposed. In a randomized, double-blind trial of
10 days of amoxicillin versus 20 days of
amoxicillin or 10 days of amoxicillin with an
additional 10 days of amoxicillin-clavulanate, no
advantage in treatment failure or duration of
MEE was found with the longer courses.[123]
Decongestants/Antihistamines
A meta-analysis of studies of •
decongestant-antihistamine preparations
for AOM found no benefit of these agents
for early cure, symptom resolution, or
prevention of surgery or complications
Recurrent Acute Otitis Media
. Many antibiotics have been studied, •
particularly amoxicillin and sulfisoxazole,
used at one-half of their recommended
daily dose and given once per day for
months
Surgical Treatment
• myringotomy or tympanocentesis is
helpful for relief of pain and allows
samples to be obtained for culture to
identify the pathogen and to guide in
the selection of antibiotics, but
provides no advantage in duration of
effusion or recurrence of episodes of
AOM
When preventive and medical •
treatments for recurrent AOM
have failed, tympanostomy tube
insertion is recommended.
Adenoidectomy with and without •
Tonsillectomy
Tympanostomy tube insertion
Unresponsive OME >3 mos bil, or >6 mos •
uni, sooner if assoc hearing problems
Recurrent MEE with excessive cumulative •
duration
Recurrent AOM - >3/6 mos or >4/12 mos •
Eustachian tube dysfunction •
Suppurative complication •
Complications
Intratemporal •
hearing loss
TM perforation
CSOM
retraction pockets
cholesteatoma
mastoiditis
petrositis
labyrinthitis
adhesive OM
tympanosclerosis
ossicular dyscontinuity and
fixation
facial paralysis
cholesterol granuloma
necrotizing OE
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Intracranial •
meningitis
extradural abscess
subdural empyema
focal encephalitis
brain abscess
lateral sinus thrombosis
otitic hydrocephalus
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Treatment - Recurrent AOM
Chemoprophylaxis •
Sulfisoxazole, amoxicillin, ampicillin, pcn –
less efficacy for intermittent propylaxis –
Myringotomy and tube insertion •
decreased # and severity of AOM –
otorrhea and other complications –
may require prophylaxis if severe –
Adenoidectomy •
28% and 35% fewer episodes of AOM at first and –
second years
Otitis Media with Effusion
Hearing testing should be done if MEE persists •
for 3 months or longer or at any time that
language delay, learning difficulties or significant
hearing loss is suspected.
If the average hearing level is below 20 dB, •
watchful waiting is suggested, but if it is greater
than 40 dB in the better ear, surgery is
recommended.
Medical Treatment
Decongestant/Antihistamine •
Antibiotics((1) amoxicillin (40 mg/kg/day) for 14 days plus a •
decongestant/antihistamine combination for 28 days
Steroids •
•
Surgical Treatment
Myringotomy •
Myringotomy with Tympanostomy Tube •
Insertion
Adenoidectomy •
Tonsillectomy •