Ear Infections

in Children

Gavin Morrison Guy’s & St Thomas’ & Evelina Hospitals

www.gavinmorrison.com

Expert Opinion in Otorhinolaryngology Head & Neck Surgery

Inst Physics January 2009 LONDON

2

Everything you ever wanted to

know about paediatric ear

infections! But….. • Biofilms

• Discharging Ears – Recurrent Otitis Media

– Discharging grommets

– CSOM

– Otitis Externa

– Important rarites

• Surgery for ear infections

• Immunity & Antibiotic resistance in recurrent ear infections

• Acute Mastoiditis – Contentious Issues

3

Sources

• Extensive Literature searches

– Some level I b, also II, III

• Level IV – My ideas !

4

Biofilms

• Community of bacteria embedded in slime

of extracellular polymeric substances

(polysaccharides, nucleic acids & proteins)

• Complex multicellular microenvironment of

mushroom shaped structures.

• Very low metabolic/reproductive rate

• 1000 more resistant to antibiotic agents.

• Develop on mucosal or on inert surfaces

5

Biofilms in ENT

• Cholesteatoma

• CSOM

• OME (ref 17)

• Implants – grommets, cochlear implants.

• Chronic tonsillitis

• Adenoids (ref 15)

• chronic sinusitis

6

Scanning electron micrograph – discharging grommet (ref 5)

7

• Demonstration of biofilms • OME

• Recurrent AOM

• Pseudomonas aeruginosa - biofilm

isolated from cholesteatoma

8

Drugs against Biofilms

• Nontypeable Haemophilus influenzae (NTHi) biofilm study (ref 13)

– Fluoroquinolones: levofloxacin and gatifloxacin significantly inhibited biofilm formation

– Fluoroquinolones potentially have a role in therapy

against diseases caused by biofilms.

• Subinhibitory concentrations of Azithromycin inhibited biofilms. (ref 14)

9

Systemic Fluroquinolone

Concerns • Licensed by the US FDA in <18 years for pyelonephritis

& inhalation anthrax only

• Used off licence in CF patients in U.K.

• Fluoroquinolones - arthrotoxicity in juvenile animals

• CNS disorders, photosensitivity, disorders of glucose homeostasis, prolongation of QT interval

• Fluoroquinolone use should be restricted to situations in which there is no safe and effective alternative (ref 40)

10

Ear Discharge - Organisms

Viruses

30 %

Respiratory

syncytial

virus (RSV)

human

rhinovirus

(HRV)

human

coronavirus

(HCV)

influenza

(IV) type A

(9.3%),

adenovirus

70%

Bacterial

Strep.

Pneum 40 – 50 %

Haemoph

infl. 20 – 30 %

Moxarella

catarrhalis 10 – 15 %

Pseudomonas

aeruginosa

Staph. aureus

Proteus sp.

Other Staph.

sp.

E. Coli

Klebsiella sp.

Pseudomonas

aeruginosa

Staph. Aureus

Other Staph.

Sp.

Enterococcus

faecalis

Enterobacter

cloacae

Fungal

Infections

Otitis Externa Rec AOM CSOM

Strep.

Pneumonae

Pseudomonas

Sp.

Haemophilus

Infl.

Moxarella Cat.

Grommet-

Otorrhoea

11

OME & Microrganisms

• Streptococcus pneumonia(ref 9)

• Staphylococcus aureus

• H. Influenzae

• Pseudomonas aeruginosa

• Fungal organisms (ref 43)

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Grommet Concerns

13

14

15

16

Discharging Grommets -

associations

• Frequency of infections not related to swimming !

• Titanium Grommets – higher incidence of infection & granulation tissue (ref 2)

• Antibiotic Coated Tubes – no difference in complications using phosphorylcholine (PC) antibacterial coating fluoroplastic Armstrong tubes (ref 4)

• Ionized processed silicone tubes superior to other silicon ventilation tubes in regard biofilm growth & "otorrhea" rate (ref 18)

17

Discharging Grommets -

Managements

• Quinolone Ear Drops = Otosporin drops

• Consensus View – ENT UK: Ototoxic Drops with

steroid for up to 2 weeks max.

• Systemic Antibiotics and ear drops – Use for fever or severe otalgia

– Doesn’t clear otorrhoea quicker

• Systemic Ciprofloxacin – occasionally needed

18

Grommet Concerns – Frequency of

Complications & Late Sequelae

• Otorrhoea 2 % up to 14 %

• Tube Blockage – 8.6%. Thick Glue, use of drops (ref7)

• Persistent perforation 4.6 %

• Retraction 5.2 %

• Atelectesis 6 %

• Increased prevalence of long-term changes

- myringosclerosis and late atrophy. (ref 1)

19

Grommet problems ctd.

• purulent otorrhoea 10-26% p.a.

• Myringosclerosis 39-65%

• atrophic scars 28%

• tympanic membrane perforations 3%

• granulation tissue 5-40%

• complications associated with tympanostomy

tube insertion - 80% of operated ears (ref16)

20

Montelukast ?

Pneumoccal Vaccination ?

21

Acute Otitis Media

22

Management of Recurrent Acute

Otitis Media

• Low dose prolonged antibiotics ?

• Insertion of Grommets: frequency of otitis

media / discharge significantly decreased

(t test, p<0.0001) (ref12)

• Data are not enough to support anti-reflux

treatment in children with refractory middle

ear infections (ref45)

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O.M. PRONE CHILDREN

• Parental smoking

– nasopharynx of healthy children of smokers

– nasopharynx of parents

– number of pathogens c.f non-smokers (ref30)

• Streptococcus pneumoniae

• Haemophilus influenzae

• Moraxella catarrhalis (ref 39)

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What else in AOM ?

• AOM - 70% of cases bacteria.

- 30% viral

• Redness and bulging of the tympanic membrane are characteristic findings in bacterial AOM (ref 38)

• Streptococci pneumoniae with partial penicillin resistance associated with recurrent AOM.

• treatment duration - 10 days

25

Pneumococcal vaccination ?

• After vaccination, get increase incidence of colonisation and infections by other bacteria (Haemophilus) and see non-vaccine serotype shift

• Finnish study - Reduced incid AOM by 7 %

• Vaccine efficacy in OME – 2-5 years

39 % reduction in grommet insertions

Overall frequency of AOM in the ambulatory setting declined by 20% (ref 33)

26

Pneumococcal vaccination

• Standard UK Immunisation Schedule: • At 2 and 4 months of age

• Prevenar = 7 valent vaccine (7 capsular subtypes)

• At risk children • Incl. Cochlear implants

• Pneumovax II – 23 valent

• Not recommended under 2 years of age

27

CSOM – Medical treatments

• Otic drops of either ciprofloxacin 0.2% or polymyxin B, neomycin, and hydrocortisone - 6 to 12 days (ref 29)

• Bacteriologic eradication was seen in 89% on Cipro. and 85% of Otosporin cases

• Oral Antibiotics also reduce discharge in short term (ref 37)

28

CSOM

• Cholesteatoma Surgery - Open vs Closed

• Paediatric Tympanoplasty

– Surgical Technique

– Age

29

30

31

History of Tympanoplasty

• Howard House (1930s) - latex from

condoms with a Toynbee silver wire (ref 53)

32

Graft Material ?

Temporalis fascia

Cartilage Palisades

Periosteum

33

Technique

• On-lay / Over-lay

• Underlay

• Reverse Through-lay

34

EAM

ME

Anterior

35

What Age to perform

myringoplasty ?

• Smyth any age, as soon as possible

• Plester 5 years

• Dawes 10 years

• Strong over 7 years (tubal cartilage and tensor palati mass after 7)

• Mawson over 12 years

• Many authors success rate not influenced by age (eg House Ear Institute, Chandrasekhar et al. Arch Oto H&N Surg

1995; 121:873-878, and Denoyelle, Garabedien group, Paris Laryngoscope)

36

Myringoplasty Age

• Mean age of most paediatric published series

= 10 – 11 years (range 4 – 17)

• Younger age acceptable if post-grommet cases – Other ear predicts outcome

• General Advice (G.Morrison) – 8 yrs or over if infections controllable and one good

hearing ear

– Much earlier if bilat. Subtotal perfs. with disabling hearing loss & infections

37

Mastoid Surgery for tubotympanic

CSOM

• 34 ears - mastoid surgery for chronic

otorrhea - 97% cure (ref 47)

• tympanoplasty without mastoidectomy (31

ears) 91% cure.

38

Otitis Externa

• Unusual in Children

– Check attic

– Consider Immunity

• Use of Cotton buds causes it (ref 20)

• Instrumenting the ear canal

• Swimming

39

Fungal Otitis Externa

• Candida albicans - 43% of cultures. – Candida parapsilosis 24%

– Aspergillus fumigatus in 13%. (ref 41)

• Median of 3.8 weeks for symptom

resolution.

40

Keratosis Obturans / Chronic

Otitis Externa

• Keratosis obturans - regular aural toilet, (ref

19)

• bilateral obstructive cerumen plugs leading to

circumferential canal distention, irritation, pain, and

hypoacusis (ref 51)

• DIPROSALIC SCALP LOTION – Betamethasone,

2% salicylic acid, alcohol solvent

41

Ear Infections – Differential

Diagnosis: LCH

42

Differential Diagnosis –

Rhabdomyosarcoma

43

Ear Infections - Influence of

Immunity

• Surface polysaccharides of encapsulated

bacteria of these bacteria poorly

immunogenic

• the polysaccharides are thymus-

independent (TI)-2 antigens which induce

an inadequate immune response in

neonates and infants. (ref 31)

44

Immune Investigations

• IgG, IgA, IgM, IgE and IgG subclasses.

• HIV-serology

• Lymphocyte populations

• In vitro lymphocyte responses to mitogens and alloantigens

• Immunodeficiency maybe limited to defective antibody responses to polysaccharide antigens.

45

Drug Resistance • 1930s - Sulfonamides - resistance of Pneumococci

gp A Streptococci

• 1950s - beta-lactamase-producing Staphylococci

• 1960s - highly resistant gram-negative enteric bacteria

• 1970s beta-lactamase-producing Haemophilus influenzae &

Moraxella catarrhalis

• 1980s - multidrug-resistant Pneumococci.

• Currently – In USA 25% of pneumococci are resistant to penicillin

– 25% of H influenzae and 90% of M catarrhalis produce beta-lactamase (ref 22)

– Multresistant Pseudomonas

– MRSA

MANAGEMENT STRATEGY:

• Topical rather than systemic antimicrobial drugs

• Avoid unnecessary use of antibiotics

46

Acute Mastoiditis

47

Acute Mastoiditis

• Post auricular Swelling

• Fever

• Masked Mastoiditis

– Acute OM signs settled on antibiotics

– Insidious course

– Presents with a complication of mastoiditis.

• Organisms (refs 11 & 49):

– Strep. Pneumoniae

(58%)

– Strep pyogenes

– H. Influenzae

– Staph. Aure

– Klebsiella

pneumonia

– Pseudomonas

aeruginosa

48

Changing Incidence of Acute

Mastoiditis?

• 1990-2002 - A significant increase in the incidence of AM in infants recorded (p= 0.01).Tel-aviv, (ref 11)

• 1996 -2005 Melbourne: The yearly number of cases of AM treated remained stable (ref 36)

– % mastoiditis patients given prior antibiotics for AOM decreased over time to 2005

49

Acute Mastoiditis - Management

• 50 - 60 % Require surgery • Mastoidectomy in > 25%.(ref 8)

• Grommet +/- post-aural abscess (ref 6)

• complications in under 2 year olds (ref 8)

• 45% of patients had received oral

antibiotics prior to presentation.

50

Whether to Scan ?

• CT diagnosis

- coalescent left

mastoiditis

51

Complications – Spread of infection

• 30 % Subperiostial Abscess (ref 11)

• 12% Lateral Sinus Thrombosis

• Extradural Abscess

• Brain Abscess

• Meningitis

• Hydrocephalus

52

53

54

Lateral Sinus Thrombosis • Clinical: headache, spiking fever, vomiting, torticollis,

tender IJV, papilloedema

• Diagnosis:

– Contrast CT / MRI

• isointense on T1 and hypointense on T2-weighted images. Magnetic resonance venography

– Neck U/S of upper IJV

• Fusobacterium necrophorum, inducer of hemagglutinin-mediated platelet aggregation (ref 54)

• Thrombophilic tendency in some patients (ref 56)

• Anticoagulation ? (ref 55)

– Pros – recanalisation (ref 57)

– Cons – bleeding, release of septic emboli - Lemierre syndrome.

55

56

Bibliography - 57 Refs.

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• Tos, Myringotomy Versus Ventilation Tubes in Secretory Otitis Media:

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• Treatment Otology & Neurotology. 29(5):649-657, August 2008

• 2) Shone G.R. Griffith I.P. Titanium grommets: A trial to assess function and

• extrusion rates. Journal of Laryngology and Otology. 104(3)(pp 197-199), 1990

• 3) PRENDERGAST, P. J. *; KELLY, D. J. *; RAFFERTY, M. +; BLAYNEY, A. W. + The effect of ventilation tubes on stresses and vibration motion in the tympanic

membrane: a finite element analysis. Clinical Otolaryngology & Allied Sciences. 24(6):542-548, December 1999 4) Licameli G. Johnston P. Luz J. Daley J. Kenna M.

Phosphorylcholine-coated antibiotic tympanostomy tubes: Are post-tube placement complications reduced?. International Journal of Pediatric Otorhinolaryngology.

72(9)(pp 1323-1328), 2008.

• 5) Barakate M. Beckenham E. Curotta J. Da Cruz M.D. Bacterial biofilm adherence to middle-ear ventilation tubes: Scanning electron micrograph images and literature

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57

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Embryonal rhabdomyosarcoma of tympanomastoid region with intracranial extension. Indian Journal of Otology. 11(MAR.)(pp 36-37), 2005(28) Durve D.V. Kanegaonkar R.G. Albert D. Levitt G. Paediatric rhabdomyosarcoma of the ear and temporal bone. Clinical Otolaryngology and Allied Sciences. 29(1)(pp 32-37), 2004(29) MIRO, NURIA MD Controlled multicenter study on chronic suppurative otitis media treated with topical applications of ciprofloxacin 0.2% solution in single- dose containers or combination of polymyxin B, neomycin, and hydrocortisone suspension Otolaryngology - Head & Neck Surgery. 123(5):617-623, 2000.(30) Brook I. Gober A.E Recovery of potential pathogens in the nasopharynx of healthy and otitis media-prone children and their smoking and non-smoking parents. Annals of Otology, Rhinology and Laryngology. 117(10)(pp 727-730), 2008(31) Klein Klouwenberg P. Bont L Neonatal and infantile immune responses to encapsulated bacteria and conjugate vaccines. 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Laryngoscope. 93(8)(pp 1034-1037), 1983(51) Dubach, Patrick; Häusler, Rudolf External Auditory Canal Cholesteatoma: Reassessment of and Amendments to Its Categorization Otology & Neurotology Volume 29(7), October 2008, pp 941-948 (52) McDonald, Jay A. M.D.*; Saulsbury, Frank T. M.D. Chronic candida albicans otitis media in children with immunodeficiency The Pediatric Infections Diseases JournalVolume 16(5), May 1997, pp 529- 531(53) Rizer, Franklin M. MD Overlay Versus Underlay Tympanoplasty. Part I: Historical Review of the Literature LaryngoscopeVolume 107(12) Supplement 84, December 1997, pp 1-25(54) Le Monnier, Alban PharmD, Jamet, Anne Carbonnelle, Etienne Barthod, Gwladys Moumile, Kaoutar Lesage, Fabrice Zahar, Jean-Ralph Mannach, Yves Berche, Patrick; Couloigner, Vincent Fusobacterium necrophorum Middle Ear Infections in Children and Related Complications: Report of 25 Cases and Literature ReviewPediatric Infectious Disease Journal. 27(7):613-617, July 2008(55) Bradley, Dewayne T. MD; Hashisaki, George T. MD; Mason, John C Otogenic Sigmoid Sinus Thrombosis: What Is the Role of Anticoagulation Laryngoscope. 112(10):1726-1729, October 2002(56) Oestreicher-Kedem, Yael MD; Raveh, Eyal MD; Kornreich, Liora MD; Yaniv, Isaac Tamary, Hannah MDProthrombotic Factors in Children with Otitis Media andSinus Thrombosis Laryngoscope. 114(1):90-95, January 2004.(57) Redaelli de Zinis, Luca Oscar *; Gasparotti, Roberto +; Campovecchi, ChiaraAnnibale, Giacomo *; Barezzani, Maria Grazia Internal Jugular Vein Thrombosis Associated with Acute Mastoiditis in a Pediatric Age Otology & Neurotology. 27(7):937-944, October 2006.

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