Otitis MediaOtitis Media

Otitis MediaOtitis Media

Most common reason for visit to Most common reason for visit to pediatricianpediatrician

Tympanostomy tube placement is Tympanostomy tube placement is 2nd most common surgical 2nd most common surgical procedure in childrenprocedure in children

Development of multidrug-Development of multidrug-resistant bacteria resistant bacteria

Otitis Media - DefinitionOtitis Media - Definition

Inflammation of the middle Inflammation of the middle earear

May also involve inflammation May also involve inflammation of mastoid, petrous apex, and of mastoid, petrous apex, and

perilabyrinthine air cellsperilabyrinthine air cells

Otitis Media - Otitis Media - ClassificationClassification

Acute OM - rapid onset of signs & Acute OM - rapid onset of signs & sx, < 3 wk coursesx, < 3 wk course

Subacute OM - 3 wks to 3 mosSubacute OM - 3 wks to 3 mos Chronic OM - 3 mos or longer Chronic OM - 3 mos or longer

OM - EpidemiologyOM - Epidemiology

AgeAge SexSex RaceRace Day careDay care SeasonsSeasons

GeneticsGenetics Breast-feedingBreast-feeding Smoke exposureSmoke exposure Medical Medical

conditions conditions

OM - EpidemiologyOM - Epidemiology

Increasing incidenceIncreasing incidence Increases after newborn periodIncreases after newborn period 2/3 with AOM by one year of age2/3 with AOM by one year of age 1/2 with >3 episodes by three 1/2 with >3 episodes by three

yearsyears most common in 6 - 11 mos most common in 6 - 11 mos

OM - persistent middle ear OM - persistent middle ear effusion (MEE)effusion (MEE)

High incidence of MEE, avg of 40 High incidence of MEE, avg of 40 daysdays

Children less that 2 years much Children less that 2 years much more likely to have persistent MEEmore likely to have persistent MEE

White children with higher White children with higher incidence of MEEincidence of MEE

OM - Day Care OM - Day Care

Greater risk of AOM in children < 3 Greater risk of AOM in children < 3 yearsyears

Home care best, large group day care Home care best, large group day care worstworst– more exposures with wider range of floramore exposures with wider range of flora– increased URI’sincreased URI’s– more frequent visits to MD to decrease more frequent visits to MD to decrease

parental leave time from workparental leave time from work

OM - Breast-feedingOM - Breast-feeding

Decreases incidence of URI and GI Decreases incidence of URI and GI diseasedisease

Inverse relationship between Inverse relationship between incidence of OM and duration of incidence of OM and duration of breast-feedingbreast-feeding

Protective factor in breast-milk?Protective factor in breast-milk?

OM - smoke exposureOM - smoke exposure

Induces changes in respiratory Induces changes in respiratory tracttract

Increased AOM and persistent Increased AOM and persistent effusioneffusion

Increased otorrhea, chronic and Increased otorrhea, chronic and recurrent AOM in children with recurrent AOM in children with parental smokingparental smoking

OM - Medical ConditionsOM - Medical Conditions

Cleft palateCleft palate– decreases after decreases after

repairrepair Craniofacial Craniofacial

disordersdisorders– Treacher-CollinsTreacher-Collins

Down’s syndromeDown’s syndrome Ciliary Ciliary

dysfunctiondysfunction

Immune Immune dysfunctiondysfunction– AIDSAIDS– steroids, chemosteroids, chemo– IgG deficiencyIgG deficiency

ObstructionObstruction– NG tubesNG tubes– NT intubationNT intubation– adenoidsadenoids– malignancymalignancy

Eustachian TubeEustachian Tube

Connects middle ear and Connects middle ear and nasopharynxnasopharynx

Lumen shaped like two cones with Lumen shaped like two cones with apex directed toward middleapex directed toward middle

Mucosa has mucous producing Mucosa has mucous producing cells and ciliated cellscells and ciliated cells

Eustachian tubeEustachian tube

AdultsAdults– ant 2/3- ant 2/3-

cartilaginouscartilaginous– post 1/3- bonypost 1/3- bony– 45 degree angle45 degree angle– isthmus 1-2 mmisthmus 1-2 mm– nasopharyngeal nasopharyngeal

orifice 8-9 mmorifice 8-9 mm

ChildrenChildren– longer bony longer bony

portionportion– 10 degree angle10 degree angle– isthmus largeristhmus larger– nasopharyngeal nasopharyngeal

orifice 4-5 mm in orifice 4-5 mm in infantsinfants

Eustachian tubeEustachian tube

Usually closedUsually closed Opens during swallowing, yawning, Opens during swallowing, yawning,

and sneezing and sneezing Opening involves cartilaginous Opening involves cartilaginous

portionportion Tensor veli palatini responsible for Tensor veli palatini responsible for

active tubal openingactive tubal opening No constrictor functionNo constrictor function

Eustachian tubeEustachian tube

Protection from nasopharyngeal Protection from nasopharyngeal sound and secretionssound and secretions

clearance of middle ear secretionsclearance of middle ear secretions ventilation (pressure regulation) of ventilation (pressure regulation) of

middle earmiddle ear

PathologyPathology

Eustachian tube abnormalitiesEustachian tube abnormalities– Impaired openingImpaired opening– open in DS and American Indiansopen in DS and American Indians– shorter tubeshorter tube

Impaired immunityImpaired immunity– children have poorer immune responsechildren have poorer immune response– less cytokines in nasopharynx in children with OMless cytokines in nasopharynx in children with OM

Inflammatory mediatorsInflammatory mediators– Bacterial products induce inflam response with IL-1, Bacterial products induce inflam response with IL-1,

IL-6, and TNFIL-6, and TNF AllergyAllergy

MicrobiologyMicrobiology

S. pneumoniaeS. pneumoniae - 30-35% - 30-35% H. influenzaeH. influenzae - 20-25% - 20-25% M. catarrhalisM. catarrhalis - 10-15% - 10-15% Group A strep - 2-4%Group A strep - 2-4% Infants with higher incidence of Infants with higher incidence of

gram negative bacilligram negative bacilli

VirologyVirology

RSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates RhinovirusRhinovirus Parainfluenza virusParainfluenza virus Influenza virusInfluenza virus

MicrobiologyMicrobiology

PCN-resistant PCN-resistant StrepStrep– 1979 - 1.8%1979 - 1.8%– 1992 - 41%1992 - 41%– Altered PCN-Altered PCN-

binding proteinsbinding proteins– Lysis defectiveLysis defective– Age, day-cares, Age, day-cares,

and previous txand previous tx

H. flu and M. H. flu and M. catarrhaliscatarrhalis– beta-lactamase beta-lactamase

productionproduction– All All M. catarrhalisM. catarrhalis

++– 45-50% 45-50% H. fluH. flu

Chronic MEE Chronic MEE

Previously thought sterilePreviously thought sterile 30-50% grow in culture30-50% grow in culture over 75% PCR +over 75% PCR + Usual organismsUsual organisms

DiagnosisDiagnosis

Acute OMAcute OM– preceding URIpreceding URI– fever, otalgia, fever, otalgia,

hearing loss, hearing loss, otorrheaotorrhea

Chronic MEEChronic MEE– asymptomaticasymptomatic– hearing losshearing loss– ““plugged” earplugged” ear

DiagnosisDiagnosis

Pneumatic otoscopy is gold standardPneumatic otoscopy is gold standard– Color - opaque, yellow, blue, red, pinkColor - opaque, yellow, blue, red, pink– Position - bulging, retractedPosition - bulging, retracted– Mobility - normal, hypomobile, neg Mobility - normal, hypomobile, neg

pressurepressure– Assoc pathology - perfs, cholesteatoma, Assoc pathology - perfs, cholesteatoma,

retraction pocketsretraction pockets Head & neck examHead & neck exam

DiagnosisDiagnosis

AudiogramAudiogram– document CHL, SNHL, baseline, preopdocument CHL, SNHL, baseline, preop– sooner if high risksooner if high risk

ImpedanceImpedance Acoustic reflexesAcoustic reflexes

Treatment - AOMTreatment - AOM

Adults and older children - Adults and older children - observation?observation?

Antibiotics - consider drug Antibiotics - consider drug resistance patternsresistance patterns– Amoxicilin ,Coamoxiclave,Azitramycin Amoxicilin ,Coamoxiclave,Azitramycin – Need high middle ear concentrationsNeed high middle ear concentrations

AntibioticsAntibiotics

First lineFirst line– Amoxil - 60-90 mg/kg divided tidAmoxil - 60-90 mg/kg divided tid– CoamoxiclaveCoamoxiclave

Second lineSecond line– CoamoxiclaveCoamoxiclave– AzithramycinAzithramycin

Treatment - Recurrent Treatment - Recurrent AOMAOM

ChemoprophylaxisChemoprophylaxis– Sulfisoxazole, amoxicillin, ampicillin, pcnSulfisoxazole, amoxicillin, ampicillin, pcn– less efficacy for intermittent propylaxisless efficacy for intermittent propylaxis

Myringotomy and tube insertionMyringotomy and tube insertion– decreased # and severity of AOMdecreased # and severity of AOM– otorrhea and other complicationsotorrhea and other complications– may require prophylaxis if severemay require prophylaxis if severe

AdenoidectomyAdenoidectomy– 28% and 35% fewer episodes of AOM at first and 28% and 35% fewer episodes of AOM at first and

second yearssecond years

Treatment - OMETreatment - OME

MEE > 3 mos or assoc hearing loss, vertigo, MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, discomfortfrequency, ME pathology, discomfort

AntibioticsAntibiotics– shown to be of benefit, 75% PCR + bacterial DNAshown to be of benefit, 75% PCR + bacterial DNA

Antibiotics + steroidAntibiotics + steroid– 21% improvement compared to abx alone21% improvement compared to abx alone– prednisone 1 mg/kg day x 7 daysprednisone 1 mg/kg day x 7 days– varicella?varicella?

Myringotomy & tympanostomy +/- Myringotomy & tympanostomy +/- adenoidectomyadenoidectomy

Tympanostomy tube Tympanostomy tube insertioninsertion

Unresponsive OME >3 mos bil, or >6 Unresponsive OME >3 mos bil, or >6 mos uni, sooner if assoc hearing mos uni, sooner if assoc hearing problemsproblems

Recurrent MEE with excessive Recurrent MEE with excessive cumulative durationcumulative duration

Recurrent AOM - >3/6 mos or >4/12 Recurrent AOM - >3/6 mos or >4/12 mosmos

Eustachian tube dysfunctionEustachian tube dysfunction Suppurative complicationSuppurative complication

ComplicationsComplications IntratemporalIntratemporal

– hearing losshearing loss– TM perforationTM perforation– CSOMCSOM– retraction pocketsretraction pockets– cholesteatomacholesteatoma– mastoiditismastoiditis– petrositispetrositis– labyrinthitislabyrinthitis– adhesive OMadhesive OM– tympanosclerosistympanosclerosis– ossicular dyscontinuity and ossicular dyscontinuity and

fixation fixation – facial paralysisfacial paralysis– cholesterol granulomacholesterol granuloma– necrotizing OEnecrotizing OE

IntracranialIntracranial– meningitismeningitis– extradural abscessextradural abscess– subdural empyemasubdural empyema– focal encephalitisfocal encephalitis– brain abscessbrain abscess– lateral sinus lateral sinus

thrombosisthrombosis– otitic hydrocephalusotitic hydrocephalus