Pediatrics in Review 1993 Howie 320 3

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DOI: 10.1542/pir.14-8-3201993;14;320Pediatrics in Review

Virgil M. HowieOtitis Media

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FOCUS Q UEST iO NS

1 . H ow can a fi rm diagnos is o f o t i t i s

m edia w ith e ffu sion b e m ad e?

2 . H ow w ell d o techn ica l procedures

su pp ort the d ia gno sis o f t i t i s

media?

3 . W hat fac tors pred i spose to fre -

qu en t or recurren t o titis m ed ia in

ch i ldren?

4. Ho w is th e occurrence o f o titis

medi a re la ted to v ira l in fec tion s?

5 Ho w Is therap y o f ot i t i s med ia

ta ilored b y Id en tifica tion o f th e

resp onsib le pa thogen?

#{149}Pr Jf t ! o r o f Pediatr i cs , D epor tm en t o f

Pediatr i cs , Th e Un ive rs ity o f Te xas M ed ica l

B ran ch at G a lv es ton , G a lv es ton , 7X .

32 0 P ed ia tr ic s i n R ev ie w VoL 14 N o. 8 Augus t 1993

ART iCLE

O titis M ed ia

V irg il M . H ow ie , M D *

Def in i t ions

W hen th e d iag no s is o f o titis m ed ia

h as b een m ade on the b as is o f sk illed

c lin ic al o bse rva tio n and the tym pan ic

m em brane is in tac t, it is p rac tic al to

a ssum e tha t an e ffus io n is p resen t.

H ow eve r, th is can be con firm ed on ly

by recov ery o f flu id from the m idd le

ea r o n tym panocen te s is on m y ringo-

tom y . S eve ral m e thods w ill con firm

the d iagnos is o f e ffus io n w ith the in -

d icated accu racy , as g en e ra lly re -

p o rted in the lite ratu re (T ab le 1 ).

A cu te O titis M ed ia

A com m on erro r in th e d iagno sis o fo tit is m ed ia w ith e ffus io n (OM E ) is

eq ua tin g an “in jected ” on “red” ear-

d rum w ith OM E . A cu te o titis m ed ia

m ay p resen t w ith an in jected drum ,

bu t th e c ritic a l fac to r is no t d rum

co lo r b u t th e p re sen ce of flu id in th e

m idd le ea r cav ity . T he drum fre-

qu en tly is su ffused and red w hen an

in fan t o r to dd ler is cry ing from e ith er

fea r o r pa in du ring th e o to sco p ic ex -

am in atio n . A bu lg ing ea rd rum , o n

the o th er h and , usu ally is rega rded as

de fin ing acu te o titis m ed ia (a lso

ca lled suppuna tiv e o r p uru len t o titism ed ia) w ith o r w ith ou t sym ptom s

(p ain , sleep le ssne ss, fev er, irritab il-

i ty ) o f sys tem ic illn ess .

E xp e rien ced c lin ic ians try to avo id

the “red ea r” erro r w ith e ith er tym -

panom e try o r acou s tic refle ct iv ity

(T ab le 1 ) on by care fu l rem ova l o f a ll

ex te rna l ea r con ten ts to v isua liz e

fu lly th e lan dm arks (eg , bo th end s of

th e m a lleo lu s) and th eir m ob ili ty w ith

th e pneum a tic o tosco pe . T h e prac tic-

in g clin ic ian w an ts to k now w heth e r

an upp er re sp ira to ry in fection , o n ig i-

n ally v ira l in m o st cases , h as b ecom e

com p licated by a b acte ria l in fec tion

w arran ting an tib io tic th e rap y .

F acto rs p ned isp os in g to OM E in-

dude prio r OM E , pro pp ed bo ttle

feed in gs , exposure to in fec tio us

g roups (eg , in day ca re sett ing s), pa -

ren ta l sm ok in g , w in te r sea son , pnes-

en ce o f sib lin gs , and fam ily h is to ry

of freq uen t OM E . C le ft p ala te and

re sp ira to ry a lle rgy a lso a re b eliev ed

to p red ispo se to m idd le ear d isea se .

Ch ro n ic O titis M ed ia

O titis m ed ia w ith pe rs is ten t pe rfo na -

tion a lw ay s has occurred m o re o ften

in m ed ica lly unde rserv ed popu la tio ns

than in popu lations h av in g good ac-

ce ss to ca re , b u t it a lso o ccurs in ra re

ins tances a s a com plica tion of ven ti-

la t ion tu be in se rtio n . R are com p lica-

tio ns o f ch ro n ic o ti tis m ed ia in clu de

m asto id itis, lab yn in th itis , an d cho le s-

te atom a . C ho le s te atom a is m an ifes ted

by chro n ic d ischa rg e th rough a p er-

s is ten t p e rfo rat ion . M asto id itis m aypre sen t a s edem a and tende rne ss o ve r

the m asto id b on e o r occu lt feve r in a

pa tien t w ho h as OM E resistan t to

the rapy . L abyn in th itis is ex trem ely

rare and is m an ifes ted by v ertigo . If

no physical signs of th ese th ree con-

d it ion s are fo und in a ca refu lly ex am -

m ed pa tien t w ho has chro n ic

pe rfo ra tio n and dra inage , add itio na l

in fo rm a tio n m ay b e ob ta ined by con -

su lting w ith an o to la ryngo log is t o r

rad io log is t. T he rad io lo g is t m ay be

ab le to iden tify an o th e rw ise h idden

cho les te a tom a or o ccu lt m asto id itis .

M asto id itis u sua lly re spond s to p ro -

lon ged the rap y w ith an appro pria te

an tib io tic , bu t m ay requ ire su rg ery .

C ho les te a tom a requ ire s su rge ry . T h e

pe rs is ten t p erfo ration of ch ron ic o ti tis

m ed ia req u ire s tym panop las ty a fte r

the ch ild ha s m atu red su ffic ien tly to

have adequ ate re s is tance to recu rren t

OME .

If th erapy w ith th e firs t an tib io tic

ag en t chosen does no t stop dra inage

in 3 to 4 days , d ra in ing flu id sh ou ld

b e cu ltu red from any p erfo ra tio n or

from the lum en o f any p aten t, d ra in -

in g tym panostom y tub es . As eudo-

m ona s in fec tio n often com plica te s

ch ro n ic OM E w ith a v en tila tio n tu be

on o the r pe rfo ra tion . T h is o rgan ism is

e rad icated m o st effec tive ly b y d aily

c lean s ing of the ex tern al and m idd le

ea r w ith suc tio n or by irriga tio n w ith

Bu row so lu tion and the ins tillatio n of

oph th alm ic g rad e an tib io tic so lu tio ns

tha t are e ffec tiv e ag ains t th e p art icu -

Ian s tra in of Pseudomonas isolated.

M ost of th ese lo ca lly in stilled an ti-

b io tic s shou ld b e d isco n tin ued a fte r 3

days h av e p assed w ith ou t m id d le ear

d ra inage becau se they w ould be tox ic

to the coch lea if in s til led in th e ab-

sen ce of m idd le ea r in flam m ation .

T ym pano cen te s is fo r cu ltu re o f th e

m idd le ear flu id in p atien ts w ho have

OM E and are se rio usly ill o r imm u-

no com p rom ised on w ho have an un-

satisfa c to ry re sponse to an tib io tic

the rap y y ie lds in fo rm a tion h e lp fu l to

th e ch o ice o f specific th e rap y . W hen

OME is sym ptom atic (ie , p ain , sleep-

lessn ess , h igh fev er) a fter 2 to 3 d ay s

o f an tib io tic th erapy , tym pano cen -

te s is o f th e in tac t d rum fo r cu ltu re

and aera tio n of the m idd le ear shou ld

be pe rfo rm ed . T h is p rocedu re w ill

iden tify the o ffend ing org an ism and

its sens itiv ity pa tte rn , so the rapy can

b e ind iv id ua liz ed . In sk illed h and s,

tym panocen te sis essen tia lly is com -

p lica tio n -free , w ith n o p ers is ten t pen-

fo ra tio ns o r m idd le ea r dam age .

F Tab i I A ccu racy o f Tests

I To C on firm E ffus ion

T ym panocen tesis y ie ld in g flu idm idd le ea r con ten ts: 10 0%

A coustic re flec tiv ity >5 in ch ild

5 m o- 12y : 96%

F la t o r Jen gen typ e B tym panog ram :

90%

Skilled pneum atic o tosco py : 60%

90 %

N onpn eum a tic o to scop y , aud i og r ams , th e

rep o r t o f o ta lg ia , an d other metho Lc p rov ide

usefu l i n format ion but a re no t diagnos t i c of

otit is m ed ia w ith effus io n (OM E).








Tympanocentesis o f t h e in t a c t d r u m fo r cu lt u r e a n d a er a t io n o f

t h e m id d le ear sh ou ld b e performed when symptomati c O M E (ie ,

p a in , s leep le ssn ess , h igh fever ) con t in u e s a ft e r 2 t o 3 d a ys o fa nt ib io t ic t h er ap y.

M a n a g e m e n t

M anagement of either acute OM E on

Pediatrics in Review VoL 14 N o. 8 August 1993 3 2 1

r IN F E C T IO U S D IS E A S E

OU tis M ed ia

In c id e n c e a n d P re v a le n c e

The axiom that you find what you

look for applies to OM E. The mci-

dence of otitis media appears to in-

crease with the intensity with which

the problem is studied and the num-

ben of observations made. A study of

the incidence of OM E in 173 infantsincluded monitoring by tympanome-

try on acoustic reflectometry by

trained technicians, who made an av-

erage of 45 house calls during these

infants’ first 3 years of life. Only in

1 child of the 173 followed was no

evidence of middle ear effusion

found during this period. The per-

centage of the first 3 years of life

spent with OM E among these chil-

dren varied from 0 to 83%, despite

the ready availability of physicians,

antibiotics, and continued free moni-

toning of middle ear status at homevisits.

M ost other reported series in this

and other countries have estimated

the incidence and prevalence of OM E

primarily from observations in medi-

cal settings. In the Scandinavian

countries, selected populations were

invited for special testing (usually

tympanometry) at different consecu-

tive ages so that a cross-section of

the same populations at different ages

and in different seasons could be

viewed. Since the percentage of the

surveyed populations responding to

these invitations was very high, these

estimates of the cross-sectional mci-

dence and prevalence of OM E most

likely are reasonably accurate for the

countries studied. H owever, the mci-

dence and prevalence of OM E cannot

be generalized from one society to

another because of differences in

childrearing practices (eg, breastfeed-

ing, day cane, exposure to crowds,

parental smoking). In this article, I

w ill address primarily the manage-

ment and clinical aspects of OM E as

it occurs in the North American com-

munities with which I am familiar.

P a t h o g e n e s i s

Recent refinements in the detection

of viral infections by antigen detec-

tion, antibody response, and viral

isolation, in combination with new

epidemiologic studies, have led to

the recognition that viruses are in-

volved in about 40% of cases of

acute otitis media. A number of ani-

mal models of otitis media have been

developed, and studies involving

both viruses and bacteria are helping

to elucidate the transmission and

pathogenesis of acute and recurrent

OM E. I t is widely accepted that any

factors in the infant’ s or child’s he-

nedity, early environment, on laterenvironment that increase the chance

of contracting entenic or respiratory

viral infections also increases his on

hen risk for all types of OM E.

One prospective study in a nursery

school for A frican-American children

in N orth Carolina has shown a clear

association between viral respiratory

and entenic infections and subsequent

episodes of otitis media. The investi-

gators recorded in detail how the in-

cidence of OM E surged with

increases in the prevalence of viral

infection each year. Another group of

investigators followed in a medical

setting a fairly large cohort of white

children through the second grade in

school in the Boston area. These in-

vestigators estimated the number ofdays spent with OM E in these chil-

dren during the first 3 years of life

based on the number of episodes ob-

served during medical office visits.

W hen children with less than 30 days

of OM E were compared with those

having more than 1 10 days, a signifi-

cant difference in IQ scores, as ob-

tamed by the W ISC-R test adminis-

tered at the second-grade level, was

found. A nother investigator followed

a group of infants prospectively

through the first 2 years of life in

Cleveland and reported that the “oti-tis-pnone” infant was very likely to

have had bilateral OM E at the second

month check-up. This association be-

tween early onset and more frequent

disease has been reported by other

investigators. The peak prevalence of

OM E is from 6 to 18 months of age.

recently discovered “silent” OM E

(50% of cases are asymptom ati c)

usually involves the systemic admin-

istration of an antibiotic. Therapy

with antihistamines and deconges-

tants has been shown to be ineffec-

tive and sometimes harmful in the

management of acute OM E. The pre-dominant bacterial pathogens causing

O M E in t h is c ou n t r y co n t in u e t o b e

Streptococcus pneum o niae (30% to

40% ), nontypable H aem ophilus in/lu-

enzae (25% to 45% ) , M oraxella

catarrhalis (5% to 20%), and S py-

ogenes (2% to 3% ); less frequently,

Staphylococcus aureus and gram -neg-

ative entenic pathogens are involved.

Recent studies of acute otitis me-

dia have shown that about 40% of

subjects have an acute viral illness at

the same time as the acute OM E is

discovered. The respiratory syncytial

virus is most common, although

other respiratory and entenic viruses

also are found.

Nearly 100% of the M oraxella and

about 20% of theH aem ophilus on-ganisms isolated by tympanocentesis

are beta-lactamase producers and,

therefore, resistant to beta-lactam-

containing amoxicillin and ampicil-

lin. In 1992 and 1993, investigators

in V irginia, W ashington, DC, K en-

tucky, and Texas reported isolation

of pneumococci from ears with acute

otitis media that exhibited moderate-

to-marked penicillin resistance. Some

of these practitioner-investigators nec-

ommended new combinations of anti-

biotics to address this new develop-

ment. T he am inopenicil lins(ampicill in and amoxicillin) always

have been associated with early and-

frequent relapses, and I do not nec-

ommend them as first-line therapy in

the first 24 months of life. Sulfon-

amides given along with erythromy-

cm or penicillin G or V are less

“nelapsogenic” and, thus, are prefer-

able. Scandinavian experience has

never favored the aminopenicill ins.

In comparing the frequency of otitis

proneness (eg, 5 or more attacks) in










Y EARS NUMBER

ANTIB IOTIC* STUD IED T R EAT ED

Amox icillin** 1985 -1987 18 1 8(+ ) 5(+ ) 12(+) 3(+ ) 18%

13 (-) 0Amox icillin! 1988 -1989 15 1 15 0 S t 0 3%

clavulanate 1989 -1991 27 1 28 10 l8 2t 18 %

Ce f i x i me 1 9 8 5 - 1 9 8 7 4 5 1 2 6 1 4 2 8 3 1 4 %

Ce f p od ox i me 1 9 8 8 - 1 9 9 1 2 4 4 2 2 1 1 5 6 1 5 %

Cefpnoz il 1987 -1988 13 1 14 8 4 1 32%

Ce f u r o x i me 1 9 8 7 - 1 9 8 8 1 1 0 5 1 3 0 5%

Clanithromycin 1990-1991 12 0 15 12 5 1 41%

Ceftniaxone 1991 -1993 24 0 30 0 20 3 4%

* Ant ib io t i cs w ere adm inistered p.o. for 10 d ays,xce pt c eftr iaxone , w h ich wa s g iv en IM S O m g/kg o n day 0 on ly.1 On- the r apy cu l tu res usua l l y were ta ken a t 2 to 4 d ays o r nolater than 9 days a fte r s tar t o f th e ra p y.

( +) ind ica tes he to -kc tam ase positive (-) in d ica tes he to -kc tam ase nega tiv e

** O n ly am o xiciilin h ad in vivo g ro w th (failures)e la ted to h e ta -la c tam a se p rod uc tion .

322 P ed ia tr ics in Rev iew V oL 14 N o. 8 A ugu st 1993

IN FEC T IO US D ISEASE

Otitis Med i a

patients treated w ith ampic illin co rn-

pared w ith those treated w ith m ix-

tunes , w e found a 30% inc idence in

the former and 6% incidence in the

latter.

Table 2 contains a list o f antibio t-

ic s recently marketed for OME in the

USA , w ith the ir re lative e ffectivenessagainst the three most common path-

og ens. These culture results came

from tympanocentese s at 2 to 4 days

on-therapy during antibio tic trials

ov er the past 6 years . In 1985 , w e

reported sim ilar studie s on antibio tic s

currently used, but marketed earlier.

W e be lieve that the only w ay to es-

tablish antibio tic efficacy is through

the use o f on-therapy cultures of

samples from the diseased site . It is

apparent from Table 2 that most o f

the failures o f indiv idual antim icro -

bial drug s on therapy are assoc iatedw ith only one of the princ ipal patho -

gens .

Each antibio tic has its ow n pro file

o f efficacy . Remembering that 50%

o f H influenzae strains w ill disappear

after tympanocente sis alone , it is ap-

parent that ce fpro zil, c lanithromyc in,

and amoxicil lin (against be ta lac ta-

mase-positiv e strains) lack efficacy

against this o rganism in children w ho

have o titis m edia. In addition, ce fix -

ime failed to eradicate pneumoco cc i

in 12 o f 45 patients . My recommen-

dation is that antibio tic therapy thatmisse s less than 10% of the know n

princ ipal pathogens is most des irable .

Any antibio tic that misse s 30% or

more o f the principal pathogens

should be used only w hen the partic -

ular pathog en invo lved in the ear at

the tim e is know n to be sensitiv e to

that antibio tic , as demonstrated by

tympanocente s is , culture , and sensi-

tiv ity te sting . Most frequently , w e

w ill have available antibio tic s thatare only 80% effectiv e , and the anti-

bio tics that meet this requirement

change through tim e .

In a paper demonstrating the “Po l-

lyanna” effect, one investig ato r has

show n that le ss v igo rous evaluation

methods than on-therapy culture (eg ,

clinical re sponse ) are unable to show

significant differences betw een most

antibio tic s w ithout huge numbers of

subjec ts . A ntibio tic s are evaluated

best by the ir in v ivo effectiveness in

elim inating o rganism s judged to be

pathogenic in causing o titis m edia. Itw ould appear that even co rrec tion of

the failure o f am inopenic ill ins against

beta-lactamase producers (by addition

o f clavulanic ac id) w as fo llow ed by

the dev elopment of another fo rm of

res is tance , w hich appeared in the

influenzae organisms w e iso lated be-

tween 1 9 8 9 and 1991 .

Ma n a g e m e n t a n d P r e v e n t io n

o f t h e O t it is -p r o n e C o n d it io n

D espite symptomatic contro l o f acute

infections and produc tion of sterilityin middle ear fluid, a s ignificant

number of children, espec ially in-

fants, remain otitis -prone. Care ful

fo llow -up of antibio tic -treated OME

w ill show that 20% to 40% of infants

and toddlers have pers is tent middle

ear fluid for periods vary ing from 6

to 12 w eeks . Patients should be fo l-

low ed until the m iddle ear is normal

and contains air. OME is accom-

panied by up to a 40- to 50-dBdecrease in hearing acuity (av erag ing

25 dB) .

The medical community varies as

to how aggress iv ely and w ith w hat

therapy this condition should be

treated. It is fairly w ell e stablished

that breast feeding of infants de-

crease s and that attendance at nursery

schoo ls increase s the occurrence of

the otitis -pnone condition. How ever,

some authorities believ e that no pen-

manent disability comes from months

or y ears o f OME and that aggressive

therapy (such as co rtico stero idadm inistration on placement o f venti-

latory tubes) should be reserved fo r

the w orst case s. O thers , inc luding

myse lf, believ e that diminished hear-

ing and pers is tent OME should not

be to lerated at any ag e; w e advocate

the placement of pressure equaliza-

tion (PE) tubes w hen OME has per-

s is ted fo r 6 to 12 w eeks despite tw o

courses o f appropriate antibio tic then-

apy . The occurrence of three epi-

sodes of OME in 6 months on four

episodes in 12 months also should

lead to the placement o f PE tubes ,pre ferably under lo cal anesthesia w ith

appropriate sedation in the outpatient

se tting . Hearing te sts in the presence

S T R E P T O C O C C U S

P N E U M O N IA E

NUMBER

CUL TURE -

POS IT IVE t

H A E M O P H IL U S

IN F L U E N Z A E

NUMBER

NUMB E R C ULTUR E -

TR E ATE D P O S IT IVE t

M O R4Y.ELLA

CATARRHAL IS

NUMBER

NUMB E R C ULTUR E -

TREATED POS ITIVEt

K N OWN

P A T h O G E N

P E R C E N T

FA ILURES








Pediatrics in Review VoL 14 No. 8 August 1993 3 2 3

IN F E C T IO U S D IS E A S E

O titis M e d i a

of fluid are expected to show a m od-

enate hearing loss. PE tubes im prove

hearing im m ediately, and the im -

provem ent lasts until the tube is ex-

tnuded on until the next ear infection

occurs. M anagem ent is designed to

keep the m iddle ear air-filled w ith

norm al hearing. In 90% of patientsreceiving tubes, ear infections occur

m uch less frequently follow ing tube

placem ent than before. F unctioning

PE tubes bypass the eustachian tube

to provide m iddle ear ventilation, but

do not change the susceptibility to in-

fectious agents. W hen infection oc-

curs, the etiology is easy to ascertain

by culturing the fluid draining from

the tubes.

S u rg ic a l M an ag em en t

P rior to the advent of antibiotics,

m yningotom y frequently w as used to

alleviate pain and drain the m iddle

ear cavity w hen it w as filled w ith

purulent m aterial. Effective antibiotic

therapy can sterilize the m iddle ear

cavity, but m iddle ear effusion m ay

persist in the absence of a m iddle ear

pathogen. In the 1950s, one investi-

gaton reintroduced the insertion of

ventilation tubes through the tym -

panic m em brane to reestablish the

eardrum as a drum (m em brane w ith

air on both sides). W hen antibiotics

have not been successful in elim inat-

ing the effusion in O M E, the persist-

ent ventilation of the m iddle ear w ith

the various types of A rm strong tubes

has been practiced w idely. Their in-

sertion can be perform ed as an outpa-

tient procedure w ith local ionto-

phonesis anesthesia by using

xylocaine and epinephnine after ap-

propriate sedation. W e favor this

m o de of treatm ent in conjunction

w ith the adm inistration of prophylac-

tic doses of sulfonam ide in patients

younger than 2 years of age on 20

m g /kg of erythnom y cin or am o xicillin

in patients w ho are 2 years on olden

or w ho are allergic to one of the

other drugs.

T raditionally, adenoidectom y has

been advocated to help prevent recur-

rent acute otitis m edia; this has been

show n to be effective in olden age

groups, but not in the 6- to 18-

m onth-old infants and toddlers inw hom the incidence of O M E is high-

est. W ith general anesthesia and hos-

pitalization, this procedure entails

greaten risk and expense. T onsillec-

tom y has not been show n to be of

any benefit in controlling O M E . For

procedures that are beyond his on her

skills (eg, PE tube insertion, tym pa-

noplasty, on adenoidectom y w hen ap-

pnopniate), the prim ary care physician

can refer the patient to an otolaryn-

gologist. D iagnostic tympanocentesis

for identification of resistent patho-

gens on relief of severe pain shouldbe am o ng the pediatrician’s skills.

P r o g n o s i s

W ith persistent, conscientious pni-

m ary m edical cane, the outlook for

infants and children w ho have O M E

is generally very good. There are

very few persistent perforations, and

the incidences of m astoiditis and cho-

lesteatom a are m uch low er than prior

to the m odern era. It is hoped that

w ith the advent of effective vaccines

against respiratory syncytial virus and

som e of the other respiratory and en-

tenic viral pathogens, the precursor

viral infections that com m only lead

to O M E w ill be elim inated. W ith

better conjugated vaccines against the

com m on bacterial invaders, these

also m ay be controlled, and the

scourge of recurrent O M E m ay be

relegated to history, along w ith po-

liom y elitis, m easles, m um p s, rubella,

diphtheria, and pertussis.

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DOI: 10.1542/pir.14-8-3201993;14;320Pediatrics in Review

Virgil M. HowieOtitis Media

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