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Acute Otitis Media Dr. Hamid Rahimi Pediatric Infectious Disease Specialist Acute Otitis Media The most common infection for which antibacterial agents are prescribed for children in the US 1/3 of office visits to pediatricians Peak incidence 6 – 12 months old ≈ 2/3 of children experience at least one episode by 1 year old Acute Otitis Media - Definitions AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea) Recurrent otitis >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodes Most children with recurrent acute otitis media are otherwise healthy Otitis prone Six or more acute otitis media episodes in the first 6 years of life 12% of children in the general population Persistent Middle-Ear Effusion When an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobile More common in white children & < 2 yo AOM vs. COM Chronic otitis media Called chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months. Some sort of eustachian tube dysfunction is the principal predisposing factor. Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection. Acute otitis media is commonly defined as… 1. Presence of a middle ear effusion (MEE) 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or earache Diagnosis Etiologic diagnosis Clinical diagnosis Case one History One year old boy brought with cough, runny nose, and fever. He is also tugging at his ear and appears to be very fussy. Physical Exam T= 38 0C Ax. Upper respiratory tract sign & symptom Normal TM Gray Pink Describe TM appearance What’s your advice? 1. Tell mother that he has a viral upper respiratory infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection. 2. Tell mother that he has an ear infection that requires treatment with antibiotics. 3. Explain to mother that he has a red ear drum. The redness is probably caused by his cold but may also be the beginning of an ear infection. You will need to examine him again in 2 days to determine if he has an ear infection and needs antibiotics. 4. Explain to mother that you aren't sure whether Robert is developing an ear infection. Since he has a fever you would prefer to treat him with antibiotics. Something might be brewing. Clinical diagnosis A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded. Presence of a middle ear effusion & acute signs of middle ear inflammation in presence of acute onset of signs & symptoms History Children with AOM usually present with … History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, and/or fever Except otorrhea other findings are nonspecific i.e. Fever, earache, and excessive crying present in children … 90% 72% with AOM without AOM Laboratory tests Routine laboratory studies, including complete blood count and ESR, are not useful in the evaluation of otitis media. Otoscopy The key to distinguishing AOM from OME is the performance of pneumatic otoscopy using appropriate tools and an adequate light source Use of visual otoscopy alone is discouraged Pneumatic otoscope - equipment Technique Systematic assessment of the TM by the use of the COMPLETES mnemonic Color Other conditions Mobility Position Lighting Entire surface Translucency External auditory canal and auricle Seal Normal tympanic membrane Middle-Ear Effusion MEE is commonly confirmed … Directly by… Tympanocentesis Presence of fluid in the external auditory canal Indirectly by… Pneumatic otoscopy Tympanometry Acoustic reflectometry Signs of presence of MEE Signs of presence of MEE Fluid level Bobbles Signs of presence of MEE Perforation Cobble stoning Normal TM Translucent Signs of presence of MEE Semi-opaque Opaque Normal TM Gray Pink Signs of presence of MEE Pale yellow White Signs of presence of MEE Pneumatic otoscopy Reduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle ear Tympanometry or acoustic reflectometry Can be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determine Tympanometry OME vs. AOM Major challenge Otitis Media with Effusion Vs. Acute Otitis Media Signs & symptoms of middle-ear inflammation Signs or symptoms of middle-ear inflammation indicated by … a. Non – otoscopic findings a. Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep) b. However, these symptoms must be accompanied by abnormal otoscopic findings b. Otoscopic findings Acute inflammation – otoscopic findings Signs of acute inflammation are necessary to differentiate AOM from OME. Distinct fullness or bulging The best and most reproducible sign of acute inflammation Marked redness of the tympanic membrane Marked redness of the tympanic membrane without bulging is an unusual finding in AOM. Normal TM Neutral Signs of presence of MEE Distinct fullness Bulging Normal TM Gray Pink Signs of middle-ear inflammation Injection Marked redness Usefulness of findings Adjusted LR 95% CI Bulging tympanic membrane 51 36-73 Cloudy tympanic membrane 34 28-42 Distinctly impaired tympanic membrane mobility 31 26-37 Distinctly red tympanic membrane (hemorrhagic, strongly, or moderately red) 8.4 6.7-1 Findings Predictive value of combinations of otoscopic findings in children with acute ear symptoms Normal TM Neutral Signs of presence of MEE Distinct fullness Bulging Established acute otitis media Differential diagnosis - 2 Other conditions Redness of tympanic membrane AOM Crying Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tract Trauma and/or cerumen removal Decreased or absent mobility of tympanic membrane AOM and OME Tympanosclerosis A high negative pressure within the middle ear cavity Ear pain Otitis externa Ear trauma Throat infections Foreign body Temporomandibular joint syndrome Uncertainty in diagnosis of AOM The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty. Common factors … Inability to sufficiently clear the external auditory canal of cerumen Narrow ear canal Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE. Management Case two A 1.5 year old boy, is brought into your office because of cough, runny nose, and fever. Physical Exam T= 39 0C Ax. Upper respiratory tract sign & symptom The finding of pneumatic otoscopy are shown in next slide… Describe TM appearance & mobility How would you manage this illness episode? 1. Tell mother that his son has a viral upper respiratory infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection. 2. Tell mother that his son has an ear infection that requires treatment with antibiotics. 3. Tell mother that his son has an ear infection but doesn't need treatment with antibiotics. Clinical Course The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated. However, middle ear effusion persisted for weeks to months after the onset of AOM … Among children who were successfully treated… 70% resolution of effusion within two weeks 90% up to 3 months Symptomatic therapy - 1 Pain remedies PO analgesics Ibuprofen and acetaminophen The efficacy of a topical agent Auralgan (combination of antipyrine, benzocaine, and glycerin) The topical herbal extract Otikon Otic solution Remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly address the effectiveness of these remedies Symptomatic therapy - 2 Decongestants and antihistamines Alone or in combination were associated with… Increased medication side effects Did not improve healing or prevent surgery or other complications in AOM Not approved by AAP for < 2 year old In addition, treatment with antihistamines may prolong the duration of middle ear effusion Comparative AOM Outcomes for Observation vs Antibacterial Agent AOM Outcome Antibacteral Rx Observation P Value Relief at 24 hours 60% 59% NS Relief at 2-3 days 91% 87% NS Relief at 4-7 days 79% 71% NS Clinical Resolution 82% 72% NS Mastoiditis/Complication 0.59% 0.17% NS Persistent MEE 4-6 wks 45% 48% NS Persistent MEE 3 mo. 21% 26% NS Diarrhea/Vomiting 16% - - Skin Rash/Allergy 2% - - Number Need to Treat (NNT) NNT for antibiotic therapy in AOM 7 to 8 children with AOM would have to be treated with antibiotics to prevent one case of clinical failure by 1 week. One review estimated the need to treat 17 children in order for 1 child to have improved pain at 2 days. In addition, antibiotics were associated with almost twice the rate of vomiting, diarrhea, and rashes. Watch & See protocol Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children In this protocol … Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief Observation option is based on … Diagnostic certainty Age Illness severity Assurance of follow-up Criteria for initial antibacterial-agent treatment or observation in children with AOM Age <6 mo Certain Diagnosis Antibacterial therapy 6mo – 2 yr Antibacterial therapy >2 yr Antibacterial therapy if severe illness Observation option if non-severe illness Uncertain Diagnosis Antibacterial therapy Antibacterial therapy if severe illness Observation option if non-severe illness Observation option Definitions Non-severe illness is … Mild otalgia & fever <39°C in the past 24 hours Severe illness is Moderate to severe otalgia OR fever 39°C A certain diagnosis of AOM meets all 3 criteria … 1) Rapid onset 2) Signs of MEE 3) Signs and symptoms of middle-ear inflammation. Criteria for initial antibacterial-agent treatment or observation in children with AOM Age <6 mo 6 mo – 2 yr >2 yr Certain Diagnosis Uncertain Diagnosis Antibacterial therapy Antibacterial therapy Antibacterial therapy Antibacterial therapy if severe illness Observation option if non-severe illness Antibacterial therapy if severe illness Observation option if non-severe illness Observation option Observation Observation is only appropriate when … Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsen Specific follow-up system i.e. Reliable parent / caregiver Convenient obtaining medications if necessary Observation Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hours Adequate follow-up may include … 1 - A parent-initiated visit or phone contact if symptoms worsen or do not improve at 48 -72 hrs 2 - A scheduled follow-up appointment in 48 -72 hrs 3 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame. Which antibiotic ??? Amoxicillin Ammoxicillin + Clavulanate Azithromycin Cefixime Cefuroxime Ceftriaxone Clarithromycin Clindamycin Erythromycin Cotrimoxazole Erythromycin + Cotrimoxazole Penicillin V / G Penicillin Procain 800.000 / 400.000 Penicillin 6:3:3 / 1.200.000 Gentamicin / Amikacin Cephalexin Cloxacillin Metronidazole Microbiology of AOM Frequency Major Mechanism of Resistance What we can do? S. pneumoniae +++ penicillin-resistant (PBP2a) High Dose PCN H. influenzae ++ beta-lactamase 35-50% M. catarrhalis ++ Bacterial Species beta-lactamase 55-100% beta-lactamase Inhibitors (clavulanate) Antibacterial therapy If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. When amoxicillin is used, the dose should be 80 - 90 mg/kg/day Predicted treatment failure rates based on PD breakpoints for expected pathogens in low- or high-risk AOM AOM high risk for amoxicillin-resistant organism In patients who have severe illness & AOM high risk for amoxicillin-resistant organism Children who were received antibiotics in the previous 30 days Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) High-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate ) In allergy to amoxicillin If allergic reaction was not a type I hypersensitivity reaction (urticaria or anaphylaxis) Cefuroxime (30 mg/kg per day in 2 divided doses) If type I reactions Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose) Clarithromycin (15 mg/kg per day in 2 divided doses) Other possibilities include Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim). In daily clinical practice… Month of year ( mehr vs. farvardin) Previous antibacterial treatment When return In daily clinical practice… q8h Amoxicillin (2/3) 125 250 Co-Amoxiclav. (1/3) 156(125+31) 312(250+62) Bid Faramox (1/2) 200 400 Farmentin (1/2) 228(200+28) 456(400+56) In daily clinical practice… Previous antibacterial treatment Amoxicillin 45 mg/kg Amoxicillin - Clavul. 90mg/kg Azithromycin Cefixime Cotri-Erythro Cefuroxime Azithromycin Cefixime Cotri-Erythro Cefuroxime Amoxicillin - Clavul. 30mg/kg Amoxicillin - Clavul. 90mg/kg Amoxicillin 90mg/kg Duration of therapy For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate For younger children and for children with severe disease, a standard 10-day course is recommended Acute Otitis Media Management - Tympanocentesis Indications for a tympanocentesis or myringotomy are… 1. AOM in an infant <6 wks with a past NICUadmission 2. AOM in a patient with compromised host resistance 3. Unresponsive AOM despite courses of 2-4 different antibiotics 4. Acute mastoiditis or suppurative labyrinthitis 5. Severe pain Algorithm to distinguish AOM from OME Malpractice Administering PCN 6:3:3 in treatment Decongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics Antihistamines may prolong the duration of middle ear effusion Prevention Continue exclusive breastfeeding as long as possible NO "bottle-propping" or taking a bottle to bed Smoke-free environment IF high-risk for recurrent acute otitis media Prolonged courses of antimicrobial prophylaxis Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer Pneumococcal vaccine & influenza vaccine marginally benefit Pneumococcal vaccine reduce all otitis media by 6%. Case 3 You are seeing a 18 month old infant at your office. His mother is concerned about his frequent ear infections. You note in his chart that he has had 4 ear infections; 3 of which occurred in the past 6 months. Two of the 4 infections were unresponsive and required multiple antibiotic courses. According to mother, the baby is now asymptomatic; eating and sleeping well. Which risk factor you consider?? 1. Altered eustacian tube function 2. Frequent colds 3. Immune system 4. Smoking 5. Hay fever and allergies Management of Recurrent Acute Otitis Media A child has recurrent acute otitis media (RAOM) when 3 new episodes of AOM have occurred in 6 months or 4 episodes within 12 months. Approximately 20% of children younger than two years of age have RAOM. Follow patients with RAOM monthly with pneumatic otoscopy, as AOM episodes are often asymptomatic. Consider obtaining audiologic and speech evaluations in these cases when there are concerns about language development, and when appropriate begin a home language intervention program. Antibiotic prophylaxis Studies suggest that the benefits, if any, are quite marginal. While antibiotic prophylaxis reduced the AOM rate by 44%, the mean rate difference was only about one and a third less episodes per patient year for patients receiving antibiotics compared to controls. Consider antibiotic prophylaxis for certain time limited situations such as the time period between deciding to place ventilating tubes and the day surgery will be performed, or when surgery is being considered in late winter or spring and 1 or 2 months of prophylaxis may get the child out of the high risk season and avoid the surgery. Therapeutic options include either continuous antibiotic prophylaxis or intermittent prophylaxis for colds especially during winter respiratory viral infection months. Antibiotics used for prophylaxis include amoxicillin and sulfisoxazole (Gantrisin). Amoxicillin appears to be more effective in the current environment.The efficacy of these antibiotics is best documented with dosing twice/day, but daily doses may be effective. Consider referring patients for ventilating tubes after a first breakthrough episode of AOM on prophylaxis. Immunoprophylaxis Another approach to preventing recurrent AOM episodes is active immunization. Use of the conjugate pneumococcal vaccine, Prevenar, appears to reduce the overall frequency of AOM by 6-7% . However, immunized children with RAOM experience more benefit; such as a 23% reduction in AOM episodes after the 12 month dose and a 20 % reduction in the need for ventilating tubes . Immunize children older than 2 years who experience RAOM with 23 valent polysaccaride pneumococcal vaccine (Pneumovax) . Immunize children older than 6 months who have had an AOM episode in the first 6 months of life or have RAOM with influenza vaccine when supplies are available. Clinically significant reductions in AOM episodes have been well documented . Ventilating Tubes with or without Adenoidectomy Ventilating tubes are indicated when a child has experienced 5 or more new AOM episodes within 12 months. The decision to insert ventilating tubes for recurrent AOM should not be based on parental recall. In selected patients, especially those with associated otitis media with effusion, performing an adenoidectomy as well as inserting tubes may reduce the likelihood of ventilating tube reinsertions and additional otitis media related hospitalizations.