Prevention of middle ear infections in Prevention of middle ear infections in childrenchildren

Dr Graeme CopleyDepartment of Paediatric Otorhinolaryngology

Red Cross Children’s Hospital

Acute middle ear infectionsAcute middle ear infections

• Seen mostly by primary care givers

• Rarely by ENT specialist• Rarely by ENT specialist

– We see the chronic end point

• Intervention on history provided

– If you suggest grommets that’s what will happen

Are acute middle ear infections Are acute middle ear infections in children an issue?in children an issue?

• Most common reason for prescribing antibiotics

• 1995= US$ 2 billion• 1995= US$ 2 billion

• School and work

• Incidence increasing• Despite research

• improved healthcare?

SideSide--effects of treatmenteffects of treatment

• Antibiotic resistance

• Side-effects– Diarrhoea and vomiting

– Nappy rash– Nappy rash

– Immune suppression

• Cost

Why are children susceptible?Why are children susceptible?

• Immune maturity / impairment

• Short narrow Eustachian tube

• Small nasopharynx

Adenoidal tissue• Adenoidal tissue

Children at risk for AOMChildren at risk for AOM

• Genetic factors • Male sex

• Low socio-economic status– Immune function

– Nutrition

– Hand washing

– Over crowding

– Access to health care

• Breast vs bottle feeding– Immune function

– Nutrition

• Household smokers

• Creche

Risk factorsRisk factors

• Syndromic children• Cleft palate

• Down’s syndrome

• Pacifier use?• Pacifier use?

• Sleeping position?

PathophysiologyPathophysiology

Viral URTI

ET

Mucosal Injury

AOM OME

AOM natural historyAOM natural history

Chronic middle ear infections Chronic middle ear infections

Prevention of AOMPrevention of AOM

• Less middle ear damage

• Less meningitis

• Less antibiotic resistance

Less burden on healthcare• Less burden on healthcare

Treatment of Acute Otitis Media in Children under 2 Years of Age

Alejandro Hoberman NEJM Nov 2011

Antibiotic use and the Antibiotic use and the incidence of resistanceincidence of resistance

Antimicrobial Drug Use and Resistance in Europe van de Sande-Bruinsma Emerg Infect Dis. 2008

November; 14(11): 1722–1730.

Bacteria resistance is nothing Bacteria resistance is nothing personalpersonal

Bacteria resistance is nothing Bacteria resistance is nothing personalpersonal

What about grommets for What about grommets for acute infections?acute infections?

A good indication for A good indication for ventilation tubesventilation tubes

• Persistent middle ear effusion

• Hearing loss

Complications of grommetsComplications of grommets

• ? complication of the grommet?

• Or due to chronic disease?

• Persistent infection• Persistent infection

• Granulation tissue

• Persistent perforation

• Hearing loss

Key to middle ear health is the Key to middle ear health is the health of the nose and health of the nose and

postnasal spacepostnasal space

Lateral wall of nasal cavityLateral wall of nasal cavity

AdenoidalsAdenoidals

Protection of upper airway and Protection of upper airway and postnasal spacepostnasal space

• Mechanical

• Chemical

• Immunological

RespirationRespiration

• Heat exchange

• Humidification

• Filtration

Fluids and ciliary action• Fluids and ciliary action

Removing particlesRemoving particles

• Mechanical barrier

• Vibrissae

Filtration• Filtration

– Laminar

– Turbulent

• Physical characteristics mucus

• Mucociliary blanket

Blood supply turbinateBlood supply turbinate

Respiratory mucosaRespiratory mucosa

Respiratory Respiratory epithiliumepithilium

Mucus blanketMucus blanket

SinonasalSinonasal epithelial blanket epithelial blanket flowflow

MucusMucus

• Goblet cells

• Glandular mucus cells

• Glycoproteins

Quantity and quality• Quantity and quality

• Neurovascular control

Chemical protection of mucus Chemical protection of mucus layerlayer

• Water

• Phospholipids

• Enzymes

Complement• Complement

Immunological protectionImmunological protection

– Ig A & Ig E on surface

– Ig M & Ig G in tissues

– Primed macrophages

– Lymphocytes– Lymphocytes

– Adenoids

Surface cellsSurface cells

• Mucus contains immunologically active cells

– Macrophages

– Mast cells– Mast cells

– Leukocytes

– Eosinophil

• Cytology of secretions assist diagnosis

Factors affecting Factors affecting ciliaryciliaryfunctionfunction

• Temperature

• Drying

• URTI= epithelial damage

– Sloughing off of cells– Sloughing off of cells

The health of The health of nasopharynxnasopharynx and and nasal cavitynasal cavity

• Avoid viral infections

• Avoid allergens

• Immune function

Quality of the mucus• Quality of the mucus

• Action of the cilia

Avoid viral infectionsAvoid viral infections

• Hand washing

• Nasal saline douches

• Quarantine

Temperature and humidity control• Temperature and humidity control

• Smokers in the house

• Smoking

Avoid allergens

• Skin prick tests

• Cigarette smoke

• Pollution

Pollen• Pollen

• House dust mite

• Nasal saline douche

Immune function boostImmune function boost

• Avoid infections

• Nutrition• Raw food

• Avoid preservatives/ additives• Avoid preservatives/ additives

• Immunizations

• MALT & GALT• Natural probiotic= Kefir

Quality of the mucusQuality of the mucus

• Nasal saline douches

• Alkalinisation of secretions

– Raw food diet

– Vegetables– Vegetables

– Fruit

Maintain Maintain ciliaryciliary actionaction

• Avoid viral infections!

• Temperature control

• Humidity control

Nasal douches• Nasal douches

• Smoking

Take home messageTake home message

Tailor intervention to the particular patient

Reduce risk factors

Boost the immune system

Clean the nose

Avoid viral URTIAvoid viral URTI

Stop smoking

Wait till summer

• Avoid antibiotics and grommets

• A healthy body and mind doesn’t get sick

• AOM is a public health disease