Acute otitise media &OTITIS MEDIA WITH EFFUSION - PowerPoint Presentation

Slide1

Acute otitise media

&OTITIS MEDIA WITH EFFUSIONSlide2

DIAGNOSISrapid inflammation + middle ear effusion (MEE)

MEE

without

acute inflammation

AOM

OME:

inflamation

Signs:

bulging

or

fullness

or

erythema

or

perforation of the TM with

otorrhea

Symptoms:

otalgia

, irritability, and fever Slide3

EPIDEMIOLOGY (

AOM) is the most frequent diagnosis in sick children

in US

approximately $5 billion in US

otitis

media

39

%

of children

by

9 months

and

62%

of children

by 2

years

of age

occurs

in older children,

adolescents,and

adults

.

peak

incidence

of

AOM was during

the first 6 to 12 months

of

life

OME

is asymptomatic. approximately 65% of OME episodes in children 2 to 7 years of age resolve within 1 month

.

difficult to determine the “true” incidence of OME Slide4

PHYSICAL EXAMINATION Ears Head and

neck

C

raniofacial

anomalies

(

Down and

Treacher

Collins

)

O

ropharynx

(

bifid uvula or

cleft

palate)

Hypernasality

(

velopharyngeal

insufficiency)

H

yponasality

(

obstructing

adenoids or nasal obstruction due to

nasal polyposis

or deviated

septum)Slide5

Pneumatic otoscopy

M

iddle ear

TM and its mobility.

normal TM : translucent

concave

moves

with

positive and negative pressure

.

landmark:

handle (manubrium) of the

malleus

. umbo:

in the center of the TM.

Note:

position, color, degree of translucency

,

mobilitySlide6
Slide7

position position of the tympanic membrane is the most critical characteristic in distinguishing AOM from OME normal position is neutral negative

pressure: retracted TM

fullness (infection)

bulging:large

amount of infected fluid (

posterosuperior

area) when bulging: the malleus is obscured Slide8

Translucency normal TM is translucent with fluid: cloudy or opaque Air

fluid levels are more suggestive of OME than

AOMSlide9

color “red” TM that is full or bulging often is a sign of

AOM

A

pink

,

gray, yellow

, or

blue

retracted TM with reduced or no

mobility

usually is seen with

OME

.

red but translucent

TM is a typical finding in a

crying or sneezing

infant

, Slide10
Slide11
Slide12
Slide13

TYMPANOMETRY inconclusive otoscopy difficult

otoscopy

children older than 6 months Slide14

tympanometry −400 to +200 daPa(decapascals

).

flat

or round pattern(TW>350

daPa

)with a small ear canal volume:

MEE

flat pattern with a large ear canal volume :

perforation

or

a patent

tympanostomy

tube.

normal middle ear: peak pressure 0

daPa

no OME : TW<150

daPa

OME: TW> 350

daPa

TW=150-350

daPa

presence or absence of OME is determined by

otoscop

ySlide15

AUDIOMETRYMEE usually results in a mild to moderate conductive hearing loss and causes delay in speech and language development

Slide16

OAEcochlear function (outer hair cells) -newborn hearing screening :fast and easy

MEE

may confound the results

.

ABRSlide17

PATHOPHYSIOLOGY ANDPATHOGENESIS

multifactorial

with various overlapping factors

1.infection(bacteria,viral

)2.Host factors(Allergy,immunology,gender,race,age,gentic

)

3.anatomic/physiologic(

eustachian

tube,cleft

palat

)

4.Enviroment factor(

daycar,tobacco

smoke exposure seasonality breast/bottle

feeding,pacifier,obisitySlide18

EUSTACHIAN TUBE FUNCTIONThe eustachian tube in the infant is shorter, wider, and more horizontal By the age of 7

years prevalence of

otitis media is low

.

Slide19

INFECTION in AOM

Streptococcus

pneumoniae

most common

Haemophilus

influenzae

Moraxella

catarrhalis

Streptococcus

pyogenes

other miscellaneous bacteria

in chronic OME

,

H.

influenzae

most common pathogen

S.

pneumoniae

M.

catarrhalis

other bacteria Slide20

Viruses respiratory syncytial

virus (RSV

)

influenzavirus

adenoviruse

parainfluenza

virus rhinoviruses Slide21

ALLERGY AND IMMUNOLOGY mechanism is not

understood,it

may be:

(1)

the middle ear is a “shock organ

” (

target

)

(2

)

induce inflammatory swelling of

the

eustachian

tube

mucosa

(3

) inflammatory

obstruction

of the

nose

(4)

bacteria-laden allergic

nasopharyngeal secretions

may be aspirated into the

midle

earSlide22

RISK FACTORESSlide23

Host-Related Factors

Age

.

highest incidence

6 -

11 months

of

age,

first episode <

6

or 12 months

a

powerful

predictor

of recurrence.

first episode of MEE <

2 months

is higher

risk for persistent fluid during their

first year

of

life

Sex

.

no difference between male & female

Prematurity

controversy

Allergy

.

controversy .

Immunocompetence

.

HIV

demonstrate a significantly higher recurrence

Slide24

Cleft Palate/Craniofacial Abnormality. Infants < 2 year

with

unrepaired cleft

palate Surgical

repair reduces otitis

media Anatomic

or functional eustachian tube abnormalities

Down

syndrome:

low resistance of the

tube

poor active

eustachian

tube

reflux of nasal secretions into the middle

ear.Slide25

Environmental FactorsUpper Respiratory Infection/Seasonality Rhinovirus, RSV,adenovirus

, and coronavirus

Day Care/Home

care

day-care centers more

tympanostomy tubes inserted than home care

Tobacco

Smoke Exposure

passive exposure to smoking

Breastfeeding/Bottle Feeding

Pacifier

Use

unclear.

ObesitySlide26

SYMPTOMATIC THERAPY ibuprofen 10 mg/kg

Auralgan

® (combination of

antipyrine

,

benzocaine , and glycerin

)

topical aqueous

lidocaine

(lignocaine) ear drops

topical herbal extract

Otikon

Otic

solution

Decongestants and antihistamines:

no

benefit

potential for

delayed resolution of middle ear

fluid

increased medication

side effectsSlide27

ANTIBIOTIC THERAPY VERSUS OBSERVATION < six

months

antibacerial

therapy regardless of degree of diagnostic certainly

six months to two years

,

antibacterial therapy

is

when: certain diagnosis of AOM uncertain diagnosis

but the illness is severe

(moderate

to severe

otalgia

or fever ≥39ºC in the previous 24 hours

).

Observation

when

diagnosis is not certain

and

illness is not severe.

>

two years

,

antibacterial therapy

when: certain diagnosis

and

illness is

severe

Observation

when:

certain diagnosis

but

illness is not

severe

uncertain diagnosis. Slide28

ANTIMICROBIAL THERAPY Seventeen antimicrobial drugs (16 oral and 1 parenteral preparation) two otic preparations (eg

,

ofloxacin

otic

and ciprofloxacin-dexamethasone otic)

for treatment of AOM with otorrhea in children with

tympanostomy

tubes in place or tympanic membrane perforation Slide29

Antimicrobial agents available for treatment of acute otitis media

Most used drugs

Others

Amoxicillin

Cephalexin

Amoxicillin-

clavulanate

*

Cefaclor

Cefuroxime

axetil

*

Loracarbef

Ceftriaxone IM or IV*

Cefixime

Erythromycin +

sulfisoxazole

•

Ceftibuten

Azithromycin

•

Cefprozil

Clarithromycin

•

Cefpodoxime

Trimethoprim-

sulfamethoxazole

•

Δ

Cefdinir

Ofloxacin

otic

◊

Trimethoprim

Ciprofloxacin-dexamethasone

otic

◊ Slide30

First-line therapy   amoxicillin of 80 to 90 mg/kg per day maximum dose of 3 g/day Amoxicillin-clavulunate

AOM by

an amoxicillin-resistant

otopathogen:

antibiotictherapy

in the previous 30 days, particularly beta-lactam antibiotics concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome usually is caused by

nontypeable

H.

influenzae

, which is frequently resistant to beta-lactam antibiotics)

receiving

amoxicillin

for chemoprophylaxis of recurrent AOM (or urinary tract infection) Slide31

Penicillin allergy   Non-type 1 reactions : Cefdinir 14 mg/kg per day

Cefpodoxime

10 mg/kg per day once

daily

Cefuroxime – cefuroxime axetil suspension:

A

single intramuscular dose of

ceftriaxone

50 mg/kg

If clinical signs persist, a second dose is administered and, if necessary, a third dose

.

Type 1 reactions

:

azithromycin

, and

clarithromycin

.

Trimethoprim-

sulfamethoxazoleSlide32

Duration of therapy   < 2 years old : 10 days >2 years old:

5-7 days single

dose of

azithromycin

has been approved by the FDA Slide33

Treatment failure Lack of improvement by 48 to 72 hours : another disease is present

the initial therapy was not adequate

.

Inadequate therapy :

organism resistant to beta-lactam antibiotics

Persistent

MEE

after the resolution of acute symptoms

is not an indication of treatment failure

or an indication for additional antibiotic

therapy

high-dose

amoxicillin-

clavulanate

90 mg/kg per day amoxicillin and 6.4 mg/kg per day of

clavulanate

Tympanocentesis

for

patients with persistently refractory AOM,

to define the

etiology Alternatively

,

use of

levofloxacin

and/or

tympanostomy

tube placement may be appropriate

. Slide34

Recurrent AOM  signs and symptoms of AOM (fever, pain, bulging tympanic membrane) soon after completion of successful treatment.(within 30 days)

bulging of the tympanic membrane

and signs of inflammation.

p

ersistent

MEE in a child with a febrile upper respiratory infection may be misinterpreted as a recurrent episode.

Parenteral

ceftriaxone

50 mg/kg per day for 3 days or possibly every 36

hour

levofloxacin

10

mg/kg every 12

hrs

recurrence

more than 30 days

is most often due to a different

pathogene

: high

dose

amoxicillin-

clavulanate

Tympanostomy

tube insertion may be warranted for

children with recurrent AOMSlide35

Tympanic membrane perforation   acute otorrhea, 10 days of oral therapy

topical

therapy

for the well-appearing, immunocompetent

> 2 years oral therapy is preferred

.

Topical

therapy (

quinolone) = oral

therapy

in

otorrhea

+VT

or

chronic

suppurative

otitis

media

but

not in

AOM +

acute perforation

TM perforation with pain is due to:

mastoiditis

otitis

externa

Auralgan

,

lidocain

or olive oil,

should not be used

in

perforation of TM Slide36

FOLLOW-Up

Persistent symptoms  (

after 48 to 72

hours)

Resolved symptoms : for MEE ( may affect speech, language, and cognitive abnormality) 8-12 weeks after AOM:

All children < 2 years two

years

Children

> 2

years and have language or learning

problemsSlide37

Surgical Treatment:Myringotomy/

Tympanocentesis

.

relief of pain

samples for

culture

no

advantage in duration of effusion or recurrence of

episodes of

AOM.Slide38

Myringotomy with Tympanostomy

Tube Insertion.

three or more episodes of AOM in 6 months

or

four or more episodes in 12

months Slide39

Adenoidectomy with and without Tonsillectomy

I

s

not recommended

as a

firstline

procedure unless indicated for airway obstruction

.

Tonsillectomy, in conjunction with

adenoidectomy,has

no

significant advantage over adenoidectomy

aloneSlide40

OTITIS MEDIA WITH EFFUSIONSlide41

Watchful waiting if not

at risk for speech and language or learning

disabilities

Hearing

testings

if MEE persists

for 3 months or

longer

language delay, learning difficulties, or significant hearing loss is

suspected

average hearing

level:

<

20

dB watchful waiting

>

40

dB in the better ear,

surgery

21 -39

dB

, in better ear if

not

at risk

, examination at

3-

6-month

intervals

until the fluid has resolved; hearing loss or language or learning delays are identified; or structural abnormalities of the eardrum are suspectedSlide42
Slide43
Slide44

Medical Treatment:Decongestant/Antihistamine

.

no

efficacy

Antibiotics

.

are not

recommend

Steroids.

systemic steroids have demonstrated an advantage over placebo

but are

not recommended for long-term management.Slide45

Surgical Treatment

Myringotomy

.

Myringotomy

alone is

ineffective

Myringotomy

with

Tympanostomy

Tube Insertion

.

based on the child’s hearing status and risk for developmental problems

.

for chronic

OMESlide46

Adenoidectomy adenoidectomy or

adenotonsillectomy

at the time of first or subsequent tube insertion

is

associated with reduced risk of further tube insertion.Slide47

SURGICAL ISSUES

anterior-superior or anterior-inferior quadrant of the

parstensa

The

anterosuperior

quadrant is associated with a longer clinical tube life;

but a

persistent perforation in that area is

more

difficult to repairSlide48

Selection of Tympanostomy Tubes and Indications

In a young child with a history of recurrent or persistent otitis media, a

tympanostomy

tube that remains in place for at least a year is preferable

.

If the child has recurrent otitis media after the tubes have become nonfunctional or

extruded

, a similar type of tube should be

recommended

Grommets in older children

T-tubes for older children with persistent problems due to poor

eustachian

tube function

..Slide49

Perioperative and Postoperative Ototopical Drops

to reduce early postoperative

otorrhea

and tube

blockage

FDA-approved

ototopical

agents such as

ofloxacin

(

Floxin

) and ciprofloxacin plus dexamethasone (

Ciprodex

) Slide50
Slide51
Slide52
Slide53
Slide54

Postsurgical Follow-up follow-up visit after few

weeks

to assess the status of the

tympanostomy

tube.

with a hearing loss,

repeat hearing evaluation postoperatively. if preoperative hearing

test was not done

should be examined postoperatively to document that the hearing is normal

. evaluation

6 to 12 months

after the insertion of the tubes and

every 6 months

thereafter,

or

when problems

occur, to assess the status of the tubes and the TM.Slide55

Complications and SequelaeSlide56

Otorrhea 50% transient

otorrhea

:

16%

later in: 26%

recurrent otorrhea

:7.4% chronic

otorrhea

:

3.4% Slide57

under 6 years of age same pathogens of typical AOM 6 years of age or older: P.aerpginosa

(1)

ototopical

agents :

ofloxacin otic

or ciprofloxacin-dexamethasone otic

are effective

(2)

in

severe systemic symptoms, a systemic

antibiotic

(3)

. If

drainage does not resolve in 7 to 10 days, suctioning

and

culture

(4)

yeast :

topical antifungal drop

(5)

Repeated aural toilet is a very

important

(6)

Intravenous antibiotics if :aural

toilet and topical

fails,or

the

organisms are not sensitive to oral

antibiotics

(7)

removal of the

tube

(8)

rarely

a simple

mastoidectomy

should be considered.

CT

scan of the temporal bones should be obtained before possible

mastoidectomy

,

(8)

In older children with recurrent episodes of

otorrhea

, removal of the tubes is the

treatment because of

refluxing into the middle

ear

&

tube

act as a foreign body

,Slide58

Tympanosclerosis, Atrophy, and Retraction Pockets

tympanosclerosis

occurred in 32%

focal atrophy in 25%

retraction pockets in3.1%

The type of tube (short-term vs. long-term) had no significant

impact

on these rates.

Slide59

Persistent Perforation 4.8% small hearing loss is very

mild

managed with a simple fat graft or surgical gel

,

paper patch, or Steri-strip

myringoplasty. Slide60

Cholesteatoma For all types of tubes 0.7%Slide61

Retained Tympanostomy Tubes

usually is not removed

surgically

(

most tubes extrude

spontaneously) Indications for removing

(1)

Retention of one tube after extrusion of the other tube if the middle

ear

has been free of disease for 1 year or longer in a child 5 to 6 years old or older

(2)

Bilateral retained tubes in an older child with good

eustachian

tube

function

(3)

Chronic or

recurrent

otorrhea

that are

not

managed

medically

(4)

Blockage of a

tympanostomy

tube that has become embedded in granulation tissue Slide62

Water Precautions no

increase

of

otorrhea

in patients with

tympanostomy

tubes

water

precautions

(1)

recurrent

otorrhea,specially

with

Pseudomonas

or

S.

aureus

(2)

risk

factors for infections and complications.

(3)

heavily

contaminated water (

lakes)

(4)

deep diving

(5)

dunking

the head in the bathtub with soapy

water

(6)

ear

discomfort during swimming.

er

precautions

. Slide63

Early Extrusion 3.9% infection in the middle ear not have been properly inserted, especially if the TM is thickened owing to an infection at the time of tube insertion

.

An atrophic TM

Slide64

Tube Blockage

6.9%

clot,

mucus, granulation tissue

,polyp

unpluging

:

pick, suction, a Rosen needle, or

ototopical

drops for 10 to 14 days

.

If

effusion-free with normal middle ear

pressure:

the tube can be left in place and watched until extrusion.

If infection or

fluid

: replacement Slide65

Tube Displacement into the Middle Ear 0.5% at the time of surgery (commonly)

later due to infection or

trauma (rare

)

displacement

during surgery: retrieve the tube at the time of surgery

visualized behind an intact TM, risks versus benefits must be asses.is whit

rarely

problems. Slide66
Slide67