Acute Otitis Media Dr. Hamid Rahimi Pediatric Infectious Disease Specialist.

Acute Otitis MediaAcute Otitis Media

Dr. Hamid RahimiDr. Hamid Rahimi

Pediatric Infectious Disease SpecialistPediatric Infectious Disease Specialist


The most common infection for which antibacterial agents The most common infection for which antibacterial agents

are prescribed for children in the USare prescribed for children in the US

1/3 1/3 of office visits to pediatriciansof office visits to pediatricians

Peak incidence 6 – 12 months old Peak incidence 6 – 12 months old

≈ ≈ 2/3 of children experience at least one episode by 1 year old2/3 of children experience at least one episode by 1 year old

Acute Otitis Media - DefinitionsAcute Otitis Media - DefinitionsAOM is an inflammation of the middle ear associated with a collection AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea)of fluid in the middle ear space (effusion) or a discharge (otorrhea)

Recurrent otitis Recurrent otitis >3 episodes of AOM within 6 months that middle ear is normal, without >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodeseffusions, between episodesMost children with recurrent acute otitis media are otherwise healthyMost children with recurrent acute otitis media are otherwise healthy

Otitis proneOtitis proneSix or more acute otitis media episodes in the first 6 years of lifeSix or more acute otitis media episodes in the first 6 years of life12% of children in the general population 12% of children in the general population

Persistent Middle-Ear EffusionPersistent Middle-Ear EffusionWhen an episode of otitis media results in persistence of middle-ear fluid When an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobilefor 3 months, & TM remains immobileMore common in white children & < 2 yoMore common in white children & < 2 yo

AOM vs. COMAOM vs. COM

Chronic otitis mediaChronic otitis mediaCalled chronic serous otitis in the past, this pattern is usually defined as 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.a middle-ear effusion that has been present for at least 3 months.

Some sort of eustachian tube dysfunction is the principal predisposing Some sort of eustachian tube dysfunction is the principal predisposing factor.factor.

Persistent structural changes, such as a persistent eardrum perforation, Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection. imply past otitis but not necessarily chronic infection.

Acute otitis media is commonly defined as…Acute otitis media is commonly defined as…1. Presence of a middle ear effusion (MEE) 1. Presence of a middle ear effusion (MEE) 2. TM inflammation 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or 3. Presenting with a rapid onset of symptoms such as fever, irritability, or

earache earache

Diagnosis Diagnosis

Etiologic diagnosisEtiologic diagnosis

Clinical diagnosisClinical diagnosis

Case one

History History One year old boy brought with cough, runny nose, and One year old boy brought with cough, runny nose, and

fever. fever.

He is also tugging at his ear and appears to be very fussy. He is also tugging at his ear and appears to be very fussy.

Physical ExamPhysical Exam T= 38 T= 38 00C C Ax.Ax.

Upper respiratory tract sign & symptomUpper respiratory tract sign & symptom

Normal TMNormal TM

Gray Gray Pink Pink

Describe TM appearance Describe TM appearance

What’s your advice?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 Clinical diagnosis

A diagnosis of AOM can be established if acute purulent A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.otorrhea is present and otitis externa has been excluded.

Presence of a middle ear effusion Presence of a middle ear effusion & & acute signs of middle acute signs of middle ear inflammation ear inflammation in presence of in presence of acute onset of signs & acute onset of signs & symptomssymptoms

History History

Children with AOM usually present with …Children with AOM usually present with …History of rapid onset of otalgia (or pulling of the ear in an History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, infant), irritability, poor feeding in an infant or toddler, otorrhea, and/orand/or fever fever

Except otorrhea other findings are nonspecific i.e. Except otorrhea other findings are nonspecific i.e.

Fever, earache, and excessive crying present in Fever, earache, and excessive crying present in children …children …

90% 90% with AOM with AOM

72% 72% without AOMwithout AOM

Laboratory testsLaboratory tests

Routine laboratory studies, including complete Routine laboratory studies, including complete blood count and ESR, are not useful in the blood count and ESR, are not useful in the evaluation of otitis media. evaluation of otitis media.

Otoscopy Otoscopy

The key to distinguishing AOM from OME is the The key to distinguishing AOM from OME is the performance of performance of pneumatic otoscopy pneumatic otoscopy using using appropriate tools and an adequate light sourceappropriate tools and an adequate light source

Use of visual otoscopy alone is discouragedUse of visual otoscopy alone is discouraged

Pneumatic otoscope - equipment Pneumatic otoscope - equipment

Technique Technique

Systematic assessment Systematic assessment of the TM by the use of the of the TM by the use of the COMPLETES mnemonicCOMPLETES mnemonic

Color Color

Other conditions Other conditions

Mobility Position Mobility Position

Lighting Lighting

Entire surface Entire surface

Translucency Translucency

External auditory canal and auricle External auditory canal and auricle

Seal Seal

Normal tympanic membraneNormal tympanic membrane

Middle-Ear EffusionMiddle-Ear Effusion

MEE is commonly confirmed …MEE is commonly confirmed …

Directly by…Directly by…Tympanocentesis Tympanocentesis

Presence of fluid in the external auditory canalPresence of fluid in the external auditory canal

Indirectly by… Indirectly by… Pneumatic otoscopy Pneumatic otoscopy

Tympanometry Tympanometry

Acoustic reflectometryAcoustic reflectometry

Signs of presence of MEESigns of presence of MEE


Fluid levelFluid level BobblesBobbles


Perforation Perforation Cobble stoningCobble stoning

Normal TMNormal TM

TranslucentTranslucent


OpaqueOpaqueSemi-opaqueSemi-opaque

Normal TMNormal TM

Pink Pink Gray Gray


White White Pale yellowPale yellow


Pneumatic otoscopyPneumatic otoscopyReduced or absent mobility of the tympanic membrane is Reduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle earadditional evidence of fluid in the middle ear

Tympanometry or acoustic reflectometryTympanometry or acoustic reflectometryCan be helpful in establishing a diagnosis when the presence of Can be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determinemiddle-ear fluid is difficult to determine

Tympanometry Tympanometry

OME vs. AOMOME vs. AOM

Major challenge Major challenge

Otitis Media with Effusion Otitis Media with Effusion

Vs.Vs.


Signs & symptoms of middle-ear inflammationSigns & symptoms of middle-ear inflammation

Signs or symptoms of middle-ear inflammation indicated Signs or symptoms of middle-ear inflammation indicated by …by …

a.a. Non – otoscopic findingsNon – otoscopic findings

a.a. Distinct otalgia (discomfort clearly referable to the ear[s] that Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or results in interference with or precludes normal activity or sleep) sleep)

b.b. However, these symptoms must be accompanied by abnormal However, these symptoms must be accompanied by abnormal otoscopic findings otoscopic findings

b.b. Otoscopic findingsOtoscopic findings

Acute inflammation – otoscopic findings Acute inflammation – otoscopic findings

Signs of acute inflammation are necessary to differentiate AOM from Signs of acute inflammation are necessary to differentiate AOM from OME. OME.

Distinct fullness or bulgingDistinct fullness or bulgingThe best and most reproducible sign of acute inflammationThe best and most reproducible sign of acute inflammation

Marked redness of the tympanic membraneMarked redness of the tympanic membraneMarked redness of the tympanic membrane without bulging is an unusual finding Marked redness of the tympanic membrane without bulging is an unusual finding in AOM. in AOM.

Normal TMNormal TM

Neutral Neutral


BulgingBulgingDistinct fullnessDistinct fullness

Normal TMNormal TM

Pink Pink Gray Gray

Signs of middle-ear inflammationSigns of middle-ear inflammation

Marked rednessMarked rednessInjectionInjection

Usefulness of findingsUsefulness of findings

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

Predictive value of combinations of otoscopic findings Predictive value of combinations of otoscopic findings in children with acute ear symptomsin children with acute ear symptoms

Normal TMNormal TM

Neutral Neutral


BulgingBulgingDistinct fullnessDistinct fullness

Established acute otitis mediaEstablished acute otitis media

Differential diagnosis - 2Differential diagnosis - 2

Other conditions Other conditions Redness of tympanic membrane Redness of tympanic membrane

AOMAOM

CryingCrying

Upper respiratory infection with congestion and inflammation of the mucosa lining the Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tractentire respiratory tract

Trauma and/or cerumen removalTrauma and/or cerumen removal

Decreased or absent mobility of tympanic membrane Decreased or absent mobility of tympanic membrane AOM and OMEAOM and OME

Tympanosclerosis Tympanosclerosis

A high negative pressure within the middle ear cavityA high negative pressure within the middle ear cavity

Ear pain Ear pain Otitis externa Otitis externa

Ear traumaEar trauma

Throat infectionsThroat infections

Foreign bodyForeign body

Temporomandibular joint syndromeTemporomandibular joint syndrome

Uncertainty in diagnosis of AOMUncertainty in diagnosis of AOM

The diagnosis of AOM, particularly in infants and The diagnosis of AOM, particularly in infants and young children, is often made with a degree of young children, is often made with a degree of uncertainty. uncertainty.

Common factors …Common factors …Inability to sufficiently clear the external auditory canal of Inability to sufficiently clear the external auditory canal of cerumencerumen

Narrow ear canalNarrow ear canal

Inability to maintain an adequate seal for successful Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometrypneumatic otoscopy or tympanometry

An uncertain diagnosis of AOM is caused most often An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE. by inability to confirm the presence of MEE.

Management Management

Case twoCase two

A 1.5 year old boy, is brought into your office A 1.5 year old boy, is brought into your office because of cough, runny nose, and fever. because of cough, runny nose, and fever.

Physical ExamPhysical Exam T= 39 T= 39 00C C Ax.Ax.

Upper respiratory tract sign & symptomUpper respiratory tract sign & symptom The finding of pneumatic otoscopy are shown in next The finding of pneumatic otoscopy are shown in next

slide… slide…

Describe TM appearance & Describe TM appearance & mobilitymobility

How would you manage this How would you manage this illness episode? illness episode?

1. Tell mother that his son has a viral upper respiratory 1. Tell mother that his son has a viral upper respiratory infection or cold that will not benefit from treatment with infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection.antibiotics at this time as he does not have an ear infection.

2. Tell mother that his son has an ear infection that requires 2. Tell mother that his son has an ear infection that requires treatment with antibiotics. treatment with antibiotics.

3. Tell mother that his son has an ear infection but doesn't need 3. Tell mother that his son has an ear infection but doesn't need treatment with antibiotics. treatment with antibiotics.

Clinical CourseClinical Course

The systemic and local signs and symptoms of AOM usually resolve in 24 The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated. slowly in children who are not treated.

However, middle ear effusion persisted for weeks to months after the However, middle ear effusion persisted for weeks to months after the onset of AOM …onset of AOM …

Among children who were successfully treated…Among children who were successfully treated…70% resolution of effusion within two weeks 70% resolution of effusion within two weeks

90% up to 3 months90% up to 3 months

Symptomatic therapy - 1Symptomatic therapy - 1

Pain remedies Pain remedies PO analgesicsPO analgesics

Ibuprofen and acetaminophen Ibuprofen and acetaminophen

The efficacy of a topical agentThe efficacy of a topical agent Auralgan (combination of antipyrine, benzocaine, and Auralgan (combination of antipyrine, benzocaine, and glycerin) glycerin)

The topical herbal extract Otikon Otic solutionThe topical herbal extract Otikon Otic solution

Remedies such as distraction, external application of heat or Remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been cold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly address proposed, but there are no controlled trials that directly address the effectiveness of these remediesthe effectiveness of these remedies

Symptomatic therapy - 2Symptomatic therapy - 2

Decongestants and antihistamines Decongestants and antihistamines Alone or in combination were associated with…Alone or in combination were associated with…

Increased medication side effects Increased medication side effects

Did not Did not improve healing or prevent surgery or other improve healing or prevent surgery or other complications in AOM complications in AOM

Not approved by AAP for < 2 year oldNot approved by AAP for < 2 year old

In addition, treatment with antihistamines may In addition, treatment with antihistamines may prolong the prolong the duration of middle ear effusionduration of middle ear effusion

Comparative AOM Outcomes for Comparative AOM Outcomes for Observation Observation vs vs Antibacterial AgentAntibacterial 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% NSMastoiditis/

Complication0.59% 0.17% NS

Persistent MEE 4-6 wks 45% 48% NSPersistent MEE 3 mo. 21% 26% NS

Diarrhea/Vomiting 16% - -

Skin Rash/Allergy 2% - -

Number Need to Treat (NNT)Number Need to Treat (NNT)

NNT for antibiotic therapy in AOMNNT for antibiotic therapy in AOM7 to 8 children with AOM would have to be treated with 7 to 8 children with AOM would have to be treated with antibiotics to prevent one case of clinical failure by 1 week. antibiotics to prevent one case of clinical failure by 1 week.

One review estimated the need to treat 17 children in order for 1 One review estimated the need to treat 17 children in order for 1 child to have improved pain at 2 days. child to have improved pain at 2 days.

In addition, antibiotics were associated with almost twice the rate In addition, antibiotics were associated with almost twice the rate of vomiting, diarrhea, and rashes. of vomiting, diarrhea, and rashes.

Watch & See protocol Watch & See protocol

Observation without use of antibacterial agents in Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for a child with uncomplicated AOM is an option for selected children selected children

In this protocol … In this protocol … Deferring antibacterial treatment of selected children for Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief48 -72 hrs & limiting management to symptomatic relief

Observation option is based on …Observation option is based on …Diagnostic certaintyDiagnostic certainty

AgeAge

Illness severityIllness severity

Assurance of follow-upAssurance of follow-up

Age Age Certain DiagnosisCertain Diagnosis Uncertain DiagnosisUncertain Diagnosis

<6 mo<6 mo Antibacterial therapyAntibacterial therapy Antibacterial therapyAntibacterial therapy

6mo – 2 yr6mo – 2 yr Antibacterial therapyAntibacterial therapy

Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illness non-severe illness

>2 yr>2 yr

Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illnessnon-severe illness

Observation optionObservation option

Criteria for initial antibacterial-agent treatment or Criteria for initial antibacterial-agent treatment or observation in children with AOMobservation in children with AOM

Definitions Definitions

Non-severe illness is …Non-severe illness is …Mild otalgia Mild otalgia & & fever <39°C in the past 24 hoursfever <39°C in the past 24 hours

Severe illness isSevere illness isModerate to severe otalgia Moderate to severe otalgia OROR fever fever 39°C 39°C

A certain diagnosis of AOM meets all 3 criteria …A certain diagnosis of AOM meets all 3 criteria …1) Rapid onset1) Rapid onset

2) Signs of MEE2) Signs of MEE

3) Signs and symptoms of middle-ear inflammation. 3) Signs and symptoms of middle-ear inflammation.

Age Age Certain DiagnosisCertain Diagnosis Uncertain DiagnosisUncertain Diagnosis

<6 mo<6 mo Antibacterial therapyAntibacterial therapy Antibacterial therapyAntibacterial therapy

6 mo – 2 yr6 mo – 2 yr Antibacterial therapyAntibacterial therapy

Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illness non-severe illness

>2 yr>2 yr

Antibacterial therapy if Antibacterial therapy if severe illnesssevere illnessObservation option if Observation option if non-severe illnessnon-severe illness

Observation optionObservation option

Criteria for initial antibacterial-agent treatment or Criteria for initial antibacterial-agent treatment or observation in children with AOMobservation in children with AOM

ObservationObservation

Observation is only appropriate when …Observation is only appropriate when …

Follow-up can be ensured and antibiotic therapy initiated Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsenif symptoms persist or worsen

Specific follow-up system i.e. Specific follow-up system i.e. Reliable parent / caregiver Reliable parent / caregiver

Convenient obtaining medications if necessaryConvenient obtaining medications if necessary

ObservationObservation

Antibiotics should be prescribed when the patient does not Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hoursimprove with observation for 48 to 72 hours

Adequate follow-up may include …Adequate follow-up may include …1 - A parent-initiated visit or phone contact if symptoms worsen or do 1 - A parent-initiated visit or phone contact if symptoms worsen or do

not improve at 48 -72 hrsnot improve at 48 -72 hrs

2 - A scheduled follow-up appointment in 48 -72 hrs2 - A scheduled follow-up appointment in 48 -72 hrs

3 - Giving parents an antibiotic prescription that can be filled if 3 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame. illness does not improve in this time frame.

Which antibiotic ???Which antibiotic ???

AmoxicillinAmoxicillin Ammoxicillin + ClavulanateAmmoxicillin + Clavulanate AzithromycinAzithromycin CefiximeCefixime CefuroximeCefuroxime CeftriaxoneCeftriaxone ClarithromycinClarithromycin ClindamycinClindamycin Erythromycin Erythromycin CotrimoxazoleCotrimoxazole Erythromycin + CotrimoxazoleErythromycin + Cotrimoxazole Penicillin V / GPenicillin V / G Penicillin Procain 800.000 / 400.000Penicillin Procain 800.000 / 400.000 Penicillin 6:3:3 / 1.200.000Penicillin 6:3:3 / 1.200.000 Gentamicin / Amikacin Gentamicin / Amikacin CephalexinCephalexin CloxacillinCloxacillin MetronidazoleMetronidazole

Microbiology of Microbiology of AOMAOM

Bacterial Species Frequency Major Mechanism of

Resistance What we can do?

S. pneumoniae +++ penicillin-resistant (PBP2a) High Dose PCN

H. influenzae ++beta-lactamase

35-50% beta-lactamase Inhibitors (clavulanate)M. catarrhalis ++

beta-lactamase55-100%

Antibacterial therapyAntibacterial therapy

If a decision is made to treat with an antibacterial agent, If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most the clinician should prescribe amoxicillin for most children. children.

When amoxicillin is used, the dose should be When amoxicillin is used, the dose should be 80 - 90 mg/kg/day 80 - 90 mg/kg/day

Predicted treatment failure rates Predicted treatment failure rates based on PD breakpoints for for expected pathogens in low- or high-risk AOMexpected pathogens in low- or high-risk AOM

AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organism

In patients who have severe illness In patients who have severe illness

&&

AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organismChildren who were received antibiotics in the previous 30 days Children who were received antibiotics in the previous 30 days

Children with concurrent purulent conjunctivitis (otitis-conjunctivitis Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) syndrome)

Children receiving amoxicillin for chemoprophylaxis of recurrent AOM Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) (or urinary tract infection)

High-dose amoxicillin-clavulanate High-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )

In allergy to amoxicillin In allergy to amoxicillin

If allergic reaction was not a type I hypersensitivity reaction (urticaria If allergic reaction was not a type I hypersensitivity reaction (urticaria or anaphylaxis)or anaphylaxis)

Cefuroxime (30 mg/kg per day in 2 divided doses)Cefuroxime (30 mg/kg per day in 2 divided doses)

If type I reactionsIf type I reactionsAzithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose) days as a single daily dose)

Clarithromycin (15 mg/kg per day in 2 divided doses) Clarithromycin (15 mg/kg per day in 2 divided doses)

Other possibilities include Other possibilities include Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim). sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).

In daily clinical practice…In daily clinical practice…

Month of year ( mehr vs. farvardin)Month of year ( mehr vs. farvardin)

Previous antibacterial treatmentPrevious antibacterial treatment

When returnWhen return


q8hq8hAmoxicillin Amoxicillin (2/3)(2/3) Co-Amoxiclav. Co-Amoxiclav. (1/3)(1/3)

125 125 156(125+31)156(125+31)

250250 312(250+62)312(250+62)

BidBidFaramox Faramox (1/2)(1/2) Farmentin Farmentin (1/2)(1/2)

200200 228(200+28)228(200+28)

400400 456(400+56)456(400+56)


Previous antibacterial treatmentPrevious antibacterial treatment

Amoxicillin 45 mg/kgAmoxicillin - Clavul.

90mg/kg

AzithromycinCefixime

Cotri-ErythroCefuroxime

AzithromycinCefixime

Cotri-ErythroCefuroxime

Amoxicillin - Clavul. 30mg/kg

Amoxicillin - Clavul. 90mg/kg

Amoxicillin 90mg/kg

Duration of therapyDuration of therapy

For children ≥ 6 years of age with mild to For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate moderate disease 5 -7 days is appropriate

For younger children and for children with severe For younger children and for children with severe disease, a standard 10-day course is recommendeddisease, a standard 10-day course is recommended

Acute Otitis MediaAcute Otitis Media Management - Tympanocentesis Management - Tympanocentesis

Indications for a tympanocentesis or myringotomy are…Indications for a tympanocentesis or myringotomy are…

1. AOM in an infant <61. AOM in an infant <6 wks with a past NICUadmissionwks with a past NICUadmission

2. AOM in a patient with compromised host resistance2. AOM in a patient with compromised host resistance

3. Unresponsive AOM despite courses of 2-4 different antibiotics3. Unresponsive AOM despite courses of 2-4 different antibiotics

4. Acute mastoiditis or suppurative labyrinthitis4. Acute mastoiditis or suppurative labyrinthitis

5. Severe pain5. Severe pain

Algorithm to distinguish AOM from OMEAlgorithm to distinguish AOM from OME

Malpractice Malpractice

Administering PCN 6:3:3 in treatmentAdministering PCN 6:3:3 in treatment

Decongestants may decreased blood flow to the respiratory Decongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics mucosa, which may impair delivery of antibiotics

Antihistamines may Antihistamines may prolong the duration of middle ear prolong the duration of middle ear effusioneffusion

Prevention Prevention

Continue exclusive breastfeeding as long as Continue exclusive breastfeeding as long as possiblepossible

NO "bottle-propping" or taking a bottle to bed NO "bottle-propping" or taking a bottle to bed

Smoke-free environmentSmoke-free environment

IF high-risk for recurrent acute otitis media IF high-risk for recurrent acute otitis media Prolonged courses of antimicrobial prophylaxisProlonged courses of antimicrobial prophylaxis

Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) 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 given once daily at bedtime for 3 to 6 months or longer

Pneumococcal vaccine & influenza vaccine Pneumococcal vaccine & influenza vaccine marginally benefitmarginally benefit

Pneumococcal vaccine reduce all otitis media by 6%. Pneumococcal vaccine reduce all otitis media by 6%.

Case 3Case 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 Which risk factor you consider??consider??1. Altered eustacian tube function1. Altered eustacian tube function

2. Frequent colds2. Frequent colds

3. Immune system3. Immune system

4. Smoking 4. Smoking

5. Hay fever and allergies 5. Hay fever and allergies

Management of Management of Recurrent Acute Otitis Media 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 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 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 Ventilating Tubes with or without Adenoidectomy 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.

Acute Otitis Media Dr. Hamid Rahimi Pediatric Infectious Disease Specialist.

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Transcript of Acute Otitis Media Dr. Hamid Rahimi Pediatric Infectious Disease Specialist.