Otitis Media - PowerPoint Presentation

Slide1

Otitis Media

Mary Bennett, Amanda Buisman & Roline CampbellSlide2

Pertinent Anatomy

Ossicles

(malleus, incus, stapes)

OR

Tympanic Membrane

External Ear Canal

OR

AuricleSlide3

Pertinent Anatomy

(Cone of light)Slide4

Physiology of the Ear

External EarConsists of the pinna (auricle) and the auditory ear

canal

The pinna functions to both protect the tympanic membrane, and to collect sound waves.

The auditory ear canal distributes sounds in the form of pressure waves to the tympanic membrane.Slide5

Physiology of the Ear

Middle EarConsists of the tympanic membrane, auditory ossicles

(malleus, incus, stapes) and the eustachian tube.

The tympanic membrane receives sound waves (in the form of pressure waves) from the auditory ear canal and converts the waves into mechanical vibrations by way of the auditory ossicles. The mechanical vibrations are then transmitted to the inner ear.

The eustachian tube links the pharynx to the middle ear and while it is normally closed, it can let a small amount of air though to equalize the pressure between the middle ear and the atmosphere. It also drains mucous from the middle ear.Slide6

Physiology of the Ear

Inner EarConsists of the semicircular canals, vestibule, acoustic nerve, and the cochlea.Mechanical vibrations are received from the TM and are transformed into fluid vibrations, which are then converted into nerve impulses by nerve endings located in the cochlea. These impulses are conducted via the auditory nerve to higher levels and interpreted as sound by the brain.

The semicircular canals and vestibule function to maintain balance and equilibrium. Slide7

Pathophysiology of Otitis Media (OM)

OM is defined as inflammation in the middle ear without reference to etiology. OM is one of the most common reasons for a child to visit the pediatrician. OM can be classified into four categories;

Acute Otitis Media (AOM)

Otitis Media with Effusion (OME)

Recurrent AOM

Chronic OMESlide8

Pathophysiology of Acute Otitis

Media (AOM) The most important factor in the pathogenesis of AOM is

abnormal function of the eustachian tube

.

Reflux, aspiration, or insufflation of nasopharyngeal bacteria into the middle ear via the dysfunctional eustachian tube may lead to infection.

Eustachian tube dysfunction occurs due to either abnormal patency, or obstruction (either functional or mechanical). Slide9

Pathophysiology of Acute Otitis

Media (AOM) Common causative microorganisms for AOM are:

Streptococcus pnumoniae

(30-50% of cases)

Haemophilus influenzae

(20-30% of cases)

Moraxella catarrhalis (7-25% of cases)Slide10

Acute Otitis Media (AOM)With and Without Perforation

When AOM is present and the TM is intact, it is referred to as “AOM without perforation”. When AOM is present and the TM is NOT intact, it is referred to as “AOM with perforation”.Slide11

AOM with Perforation

AOM with perforation has two categories;AOM complicated by perforation of the tympanic membrane presenting as otorrhea. (Left)AOM in a patient with tympanostomy tubes. (Right)Slide12

OM with Effusion (OME)

OME occurs when thick fluid accumulates behind the TM. OME typically occurs immediately following treatment of AOM due to the resolution of acute inflammation, allowing visualization of the middle ear fluid behind the TM. Slide13

Epidemiology

The overall prevalence of AOM is 15-20%, with the highest peak at 6-36 months of age. An additional smaller peak occurs at 4-6 years of age. Between 60-80% of infants have had at least one episode of AOM by one year of age.AOM is uncommon in older children and adolescents.Slide14

Epidemiology

AOM is more common in boys, and the prevalence is greatest in Alaskan natives and Native Americans (Caucasian race is also considered a risk factor however).AOM is most common in the winter months and in early spring, coinciding with peaks in the incidence of URI’s. Slide15

Epidemiology

Risk factors for developing OM;Male genderAbsence of breastfeedingWhite racePassive exposure to tobacco smokeDaycare attendance

Low socioeconomic status

Presence of siblings in the household

Altered host defenses/underlying conditionsSlide16

Patient Evaluation-History

Clinical presentation- children with AOM often have a history of rapid onset of fever and ear pain (usually within 48 hours). The patient may also have hearing loss, otorrhea, and irritability. Nonverbal children present with “ear pulling” and generalized fussiness. Associated symptoms include URI, cough, diarrhea, and nonspecific complaints such as decreased appetite, waking at night, or irritability in infants.Slide17

Patient Evaluation- History

It is important in the history to differentiate nonspecific symptoms of OM from those indicating a more serious condition such as meningitis.For infants or children with a history of persistent or recurrent OM, it is important to find out when they had their last documented infection and what treatment they received.Slide18

Patient Evaluation- History

Helpful questions to ask when obtaining the patient’s history;Does the infant have fever, ear pain, hearing loss, or otorrhea?Is the infant/child inconsolable or lethargic?Has the infant/child had a previous ear infection? If so, when?Did the child complete the course of prescribed antibiotics?Slide19

Helpful Questions

How many ear infections has the child had in the past year?Is the child taking any medication to prevent recurrent OM?Does the child attend daycare?Is the child exposed to passive smoke?Is the infant breast-fed?Does the child appear to hear?

Is the child’s speech development normal?Slide20

Physical Exam Findings

To diagnose OM, the TM must be visualized. The position, color, degree of translucency, and mobility of the TM must be evaluated. Classically, in AOM the TM is full or bulging, opaque, and has limited or no mobility, or is retracted. The light reflex is usually absent or distorted. Slide21

Physical Exam Findings

Associated physical exam findings may include;posterior auricular and/or cervical adenopathypain on movement of the pinnaanterior ear displacement

*The presence of these symptoms may also suggest a more serious condition such as mastoiditis therefore thorough history taking and visualization of the TM is essential. Slide22

Normal (no AOM present) Exam Findings

Position- process of the malleus should be visible but not prominent through the membrane.Color- pearly gray.Translucency

- middle ear or bony landmarks should be visible through the TM.

Mobility

- normal ear will move with pneumatic otoscopy.Slide23

Physical Exam Findings

Here is a normal TMSlide24

Physical Exam Findings

Here is a picture of a typical TM with AOM. The TM is noted to appear erythematous or injected in color, the light reflex is absent, landmarks are poorly visualized, and

there is a poor degree of

translucency. Slide25

Physical Exam Findings

Here is an example of AOM with a bulging TM. Note the color, position, transparency, lack of visible landmarks,

and distorted light reflexSlide26

Physical Exam Findings

Here is a retracted TM Slide27

Diagnosis of AOM

Accuracy in diagnosis of utmost importanceEnsures appropriate treatment for AOMAvoids unnecessary use of antibiotics in OMEPrevents overuse of antibiotics – considered a major factor in increased drug-resistanceSlide28

AOM in Infants & Children

Challenges in establishing a diagnosis:UncooperativeTM obscured by cerumenSymptoms of AOM may overlap with other conditions (URI)Symptoms may be subtle or even absentSuccessful diagnosis facilitated by:

Systematic assessment

Stringent diagnostic criteria

Training and experienceSlide29

AAP & AAFP Diagnostic Criteria

Three diagnostic criteria 1. Recent, abrupt onset of ME inflammation & effusion (ear pain, irritability, otorrhea, and/or fever)

2. MEE confirmed by:

bulging TM,

limited or absent mobility (pneumatic otoscopy),

air-fluid level behind TM, or

Otorrhea (with TM not intact) 3. Evidence of ME inflammation - confirmed by:

distinct erythema of TM, or distinct

otalgia interfering with normal sleep or activitySlide30

Diagnostic Techniques

Pneumatic otoscopyAssess inflammationAssess effusionAssess perforation & character of otorrheaTympanometry and/or acoustic reflectometry

Assess/confirm effusion

Tympanocentesis (by otolaryngologist)

Identify infectious organism

Use in special populationsSlide31

Tympanometry

Acoustic Reflectometry

Analyzes sound reflected off the TM to detect MEE

No pressure seal required

Small quantity of cerumen does not affect this test

Increased use in primary care

Accurate & objective assessment of effusion

Requires an air-tight seal & pressurization of the ear canal

Painful & uncomfortable for children

Limited use & costlySlide32

Pneumatic Otoscopy

Allows direct visualization of TM & ear structures to confirm presence of inflammation, effusion and assess for perforation. Important to:Remove cerumen obscuring TMEnsure adequate lightingAppropriately restrain the child to allow examination & prevent injury

For pneumatic otoscopy – adequate airtight seal by choosing correct size and shape speculum. Slide33

Assessment of the TM

Locate border between external ear canal & TMAssess:Surface OpacityColorMobilityOther findingsSlide34

The Surface of the TM

Are the landmarks visible? Are the landmarks obscured or unusually prominent?Where is the cone of light?Is the TM intact? Slide35

Retracted & Bulging TMAbnormally retracted TM

Bulging TMSlide36

Opacity of the TM

Normal Tympanic Membrane

- Usually translucent

Scarred Tympanic Membrane

note loss of translucency

at area of scarSlide37

Color of the TM

Expected FindingsNormal TM = Pearly greyCrying infant = Pink TM

Classic AOM = red or infused TM

Atypical AOM = white or yellow TM (from purulent middle ear fluid)

AOM with infused erythemaSlide38

Mobility of the TM

Successful pneumatic otoscopy requires airtight seal of external ear canalWith normal mobility the TM willmove inward when positive pressure is appliedmove outward when negative pressure is applied

A retracted TM will show

decreased or absent inward deflection

but normal outward deflection with negative pressure

Crying children have increased middle ear pressures during exhalation which fleetingly normalize during inspiration

Severely diminished or absent mobility is indicative of effusionSlide39

Normal TM MovementSlide40

Decreased TM MovementSlide41

Other Findings

Air-fluid level behind the TM

- Indicative of Middle Ear Effusion (MEE

)

Cholesteatoma – grey or white mass behind the TM

Blebs / blisters on the surface of the TM – Bullous Myringitis

Cholesteatoma →

↖ Bleb / blisterSlide42

Clinical Diagnosis of AOM

Requires: Acute onset of symptoms AND Middle Ear Effusion AND

Middle Ear Inflammation

OR

Acute purulent otorrhea

via perforated TM or tympanostomy tube

AND otitis externa has been excluded Slide43

Differential Diagnoses

Viral

Myringitis

OME

AOM

Otalgia

Present

Usually absent -

some reports "fullness“

Acute pain

Inflammation

Present

Absent

Present

Bulging TM

No bulging

Normal position

or retracted

Bulging

TM Mobility

Normal

Decreased

Decreased

Diff.

Dx

S & SSlide44

AOM or OME?

Two year old Ron’s mom reports him rubbing and slapping at his left ear since early this morning. He refused breakfast and has been irritable all day. Pneumatic otoscopy reveals a bulging, yellow tympanic membrane with marked decrease in mobility.Is this AOM or OME?Slide45

Summary: MEEMEE (Middle Ear Effusion) = fluid in middle ear

Occurs in both AOM and OMEOME often precedes development of AOMOME mostly also follows resolution of AOMSlide46

OM with ruptured TM

AOM with TM intact Acute onset otalgia

Inflamed TM

Middle Ear Effusion present (Bulging and decreased mobility)

AOM with ruptured TM

(or with Tympanostomy tube)

History of acute onset otalgia which improved when ear started draining (relief of pressure when TM ruptured)

Inflamed TM

TM ruptured & draining purulent fluid into external ear canalSlide47

Treatment of AOMClinical course of 24 – 72 hours with appropriate antimicrobial Rx

Slightly slower resolve of acute symptoms when not treatedMEE may persist for weeks or monthsSlide48

Clinical Practice Guideline

AAP and AAFP Clinical Practice Guidelines (2004) state that the following aspects of management should be considered:1. Symptomatic therapy2. Observation (“Watchful waiting”)3. Appropriate antimicrobial therapySlide49

1. Symptomatic Therapy - Pain

Acetaminophen10 -15mg/kg PO/PR every 4 – 6 hours as needednot to exceed 90mg/kg/day

Ibuprofen

5 - 10mg/kg PO/PR every 6 – 8 hours as needed

not to exceed 40mg/kg/day

Topical agents

Antipyrine-benzocaine otic drops

4 – 5 drops into affected ear(s) every 2 hours as needednot to be given in case of TM perforationAqueous

lidocaine ear drops (30 minute efficacy – needs further evaluation – not currently a recommendation)Slide50

Treatment of pain (cont.)

Complementary treatmentsHerbal extracts:Otikon Otic solutionCompared well to topical anestheticHome remedies

Distraction

External application of heat or cold

Instillation of oil into external auditory canal

Clinical evidence still lackingSlide51

Symptomatic Therapy - Congestion

Decongestants and antihistaminesStill commonly used in some populationsNo proof of efficacy in treatment of AOM

Demonstrated:

Increased medication side-effects

Did not improve healing or reduce complications/surgery

Prolonged duration of MEE

AAP recommends OTC cough and cold medications NOT used in infants & children < 2 years (danger of life-threatening side effects!)Slide52

2. “Watchful waiting”

Objective is to reduce the unnecessary use of antibioticsLimit development of drug-resistance Option only for selected children Certain criteria must be met to ensure safety

“Watchful waiting” is NOT appropriate for any infant < 6 months

Infants < 6 months should be treated with antibiotics REGARDLESS of the degree of diagnostic certainty. Slide53

Considerations for “Watchful Waiting”

Age of infant/childCertainty of diagnosisSeverity of illnessCan follow-up be ensured?Ability to acquire prescription medications if neededParents must understand risks and benefits of “watchful waiting”

vs

immediate treatmentSlide54
Slide55

3. Antimicrobial treatment

Selection of drugs should be based on:Clinical & microbiologic efficacyAcceptability of the oral preparation (taste & texture)

Absence of side effects and toxicity

Convenience of dosing schedule

CostSlide56

First-line antimicrobial therapy

AmoxicillinControversy but still recommended as drug of choice (safe, effective, affordable, narrow spectrum)Doubled dose increase concentration in ME

Then active against most intermediate strains of S.

pneumoniae

(including many resistant strains)

80 – 90 mg/kg per day (divided in 2 doses)

Heavier children – max of 3g/daySlide57

When is Amoxicillin contra-indicated?

High risk for AOM caused by an amoxicillin-resistant otopathogenTreated with antibiotics in previous 30 days (especially beta-lactam antibiotics)

Concurrent purulent conjunctivitis (non-

typable

H.

influenzae)

Receiving amoxicillin chemoprophylaxis for recurrent AOM or UTIAllergySlide58

Alternative 1st Choice treatment

Amoxicillin-clavulanate

Active against beta-

lactamase

-producing non-

typeable

H. influenzaeAlso active against S. pneumoniae

Dosing:< 3 months: 30mg/kg/day PO divided in 2 daily doses≥ 3 months & < 40 kg: 90mg/kg/day PO divided in 2 daily doses x 10 days

Children weighing > 40 kg – 250-500mg every 8 hoursSlide59

Secondary treatment options

Choice of alternatives depend on type of previous hypersensitivity reactionHISTORY OF NON-TYPE 1 REACTIONS

Cefdinir

14 mg/kg/day in 1 or 2 doses (limit total 600mg/day)

Cefpodoxime

10 mg/kg /day once daily (limit 800 mg/day)

Cefuroxime (cefuroxime

axetil suspension)30 mg/kg/day in 2 divided doses (limit total 1 g/day)

Cefuroxime

tablets

250 mg every 12 hoursSlide60

Treating AOM due to Penicillin-resistant S. pneumoniae

Oral Cephalosporins are not effective against penicillin-resistant S. pneumonia Consider :

Ceftriaxone

50mg/kg in single IM dose

If clinical signs do not improve after 48 hours, a second dose may be given. In some cases even a third dose may be necessary.

Be mindful of the physical discomfort and psychological distress caused in a young child when following this approach.Slide61

Secondary treatment options

HISTORY OF TYPE 1 REACTIONSErythromycin plus sulfisoxazole

50-150 mg/kg/day in 4 divided doses

Limit total erythromycin to 2g/day

Often rejected due to taste and high frequency of dosing

Azithromycin

Single dose Rx: Give 30mg/kg in one single dose x1 day3-day Rx: Give 20mg/kg/day – one dose daily x3 days5-day Rx: Give 10mg/kg on day 1 & 5mg/kg/day on days 2 – 5 Slide62

Secondary options cont.

HISTORY OF TYPE 1 REACTIONSClarithromycin 15mg/kg/day divided in 2 doses (limit to 1g/day) OR

30-40mg/kg/day divided in 4 doses (limit to 1g/day)

Clindamycin

30-40 mg/kg/day divided in 3 – 4 dosesSlide63

Treatment of AOM in children with Tympanostomy Tubes

For some children, topical antibiotic therapy may be an alternative to oral therapy.Requirements:Mild to moderate illness

No immune compromise

Must be older than 2 years

Options:

Quinolone

otic drops (Ofloxacin

/ Ciprofloxacin)Efficacy has not been studied in children with AOM & acute perforationOral therapy is always preferredSlide64

Complications of Otitis Media

Risks for complications associated with otitis media:Increase if an acute episode of otitis media persists longer

than 2

weeks.

Increase if symptoms recur

within a 2-3 week

period.Decrease with early diagnosis and effective antibiotic treatment.Slide65

Complications of Otitis Media

Intracranial complications are uncommon in developed counties but are a concern where access to medical care is limited. They develop and spread: Through vascular channels.

By direct extension.

Through

preformed pathways such as the round

window.

Extracranial complications are direct sequelae of:Localized acute inflammation, or Chronic inflammation. Slide66

Complications of Otitis Media

Hearing loss: Temporary: hearing loss of 25 to 30dB for several months due to OME; risk of impaired language development, vestibular, balance, and motor dysfunctions.

Permanent

:

damage to the tympanic membrane or other middle ear structures, resulting in vertigo or facial weakness

.Slide67

Complications of Otitis Media

Adhesive otitis media: abnormal healing in inflamed middle ear. Irreversible thickening of the mucus membranes causing impaired movement of the ossicles and possible conductive hearing loss (e.g., tympanosclerosis).Chronic suppurative otitis media: chronic otorrhea through a perforated TM; the cycle of inflammation, ulceration, infection, and granulation tissue formation may destroy surrounding bony margins and ultimately lead to various complications. Slide68

Complications of Otitis Media

Postauricular abscess: the most common extracranial complication.Tympanic membrane perforation due to increased middle ear pressure.Meningitis: AOM is the most common cause of this intracranial complication. Cholesteatoma: cystlike lesions of the middle ear that may erode the ossicles, labyrinth, adjacent mastoid bone, and surrounding soft tissues.

Mastoiditis: inflammation as an extension of acute or chronic OM, causing necrosis of the mastoid process and destruction of the bony intercellular matrix

.Slide69

Complications of Otitis Media

Facial nerve paresisLabyrinthitis: intratemporal complicationLabyrinthine fistulaTemporal abscessPetrositis: intratemporal complicationIntracranial abscess

Otitic hydrocephalus

Sigmoid sinus thrombosis or thrombophlebitis

Encephalocele

CSF leakSlide70

Signs of possible impending complication:

Sagging of the posterior canal wallPuckering of the attic or epitympanic recessSwelling of the postauricular areas with loss of the skin creasePersistent headache and/or fever

Tinnitus

Stiff neck

Visual or other neurologic symptoms

Severe otalgia

VertigoLethargyNausea and vomitingFetid otorrheaSlide71

Signs or Symptoms of complication: Intracranial

Fever associated with a chronic perforationLethargyFocal neurologic signs (e.g., ataxia, oculomotor deficits, seizure)

Papilledema

Meningismus

Altered mental status

Severe HeadachesSlide72

Signs or Symptoms of complication:Extracranial

Fever associated with a chronic perforation.Postauricular edema or erythema.Slide73

Patient Education

Explain the natural history of acute otitis media.Explain the benefits of using analgesics to treat ear pain. Do not use longer than 3 days for pain without consulting healthcare professional.Explain to parents topical analgesics must not be used if the tympanic membrane ruptures. Explain the use of antibiotics in the management of otitis media and implications of antibiotic-resistant bacteria in AOM. Slide74

Patient Education

Provide parent with extensive information about antibiotic overuse. Explain signs and symptoms of allergic reaction to antibiotics and to report to healthcare provider immediately. Explain that symptoms should decrease in 24-72 hours with the use of analgesics and/or antibiotics.Explain that persistent otalgia, fever, and other systemic symptoms past 72 hours should be reevaluated by healthcare provider. Slide75

Patient Education

Educate regarding the signs and symptoms of clinical deterioration.Educate on preventable risk factors.Educate parents and patients regarding the problem of drug-resistant bacteria and the need to avoid the use of antibiotics unless absolutely necessary.Explain the entire course of the prescription of antibiotics must be completed.Slide76

Patient Education

Measure body temperature via oral, rectal, or axillary methods. Transtympanic measurements of temperature in children with middle ear effusions may be inconsistent.Heat packs to affected ear may help relieve discomfort.Saltwater nasal spray or rinses may decrease congestion.

Elevating head of crib may facilitate drainage.Slide77

Patient Education

Do not use Q-tips in ears. Keep follow-up appointments until the tympanic membrane is normal. Middle ear effusion may persist for several weeks, affecting speech and language development. AOM treatment failure requires referral to otolaryngologist. Slide78

Prevention Measures

Identify and treat underlying conditions that predispose the child to AOM. This includes: 1. Immune deficiencies: e.g., IgG subclass deficiency, hypogammaglobulinemia, granulocyte defects. 2. Anatomic abnormalities: e.g., craniofacial

abnormalities, such as micrognathia, or palatal clefts.Slide79

Prevention Measures

Breast feed infants: breastfeeding provides for the transfer of protective maternal antibodies to the infant; bottle-fed infants have a higher incidence of AOM than breast-fed infants, probably due to feeding position during bottle-feeding, which facilitates the reflux of milk into the middle ear.Reduce or eliminate pacifier use, especially after 6 months of age. Slide80

Prevention Measures

Minimal exposure to group settings or daycare setting with few children.Avoid or eliminate bottle-propping.Avoid feeding infants in supine position.Infection can spread more easily through the eustachian canal of infants who spend most of the day in the supine position.Avoid exposure to passive tobacco smoke. Slide81

Prevention Measures

Chewing at least 3-5 sticks a day of Xylitol chewing gum may reduce recurrence rate (if age appropriate). Xylitol is a sugar found in fruits and the bark of birch trees that has bacteriostatic effects against S. pneumonia and interferes with bacterial adhesion to mucous membranes. Side effects include excessive gas and diarrhea. Slide82

Prevention Measures

Annual influenza vaccine, especially in high-risk children who attend day care.Early treatment of influenza with the antiviral oseltamivir may reduce OM.Immunization with heptavalent pneumococcal conjugate vaccine (PCV7 or Prevnar) may reduce the incidence of AOM caused by S. pneumoniae.Consider tympanostomy tube placement for prevention of recurrent AOM. Slide83

References

American Academy of Pediatrics and American Academy of Family Physicians (2004). Diagnosis and management of acute otitis media. Clinical practice guideline. Retrieved from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;113/5/1451.pdfBurns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B. & Blosser

, C.G. (2009).

Pediatric primary care .

(4

th

ed.). St. Louis, MO: Saunders/ElsevierSlide84

References

Donaldson, J. (2010). Middle ear, acute otitis media, medical treatment. Retrieved from http://emedicine.medscape.com/article/859316-overviewEaton, D. (2009). Complications of otitis media. Retrieved from http://emedicine.medscape.com/article/859316-overviewGreydanus, D., Feinberg, A., Patel, D., & Homnick, D. (2008).

The pediatric diagnostic examination

. NY: McGraw-Hill.Slide85

References

Klein, J. & Pelton, S. (2011). Acute otitis media in children: Treatment. Retrieved from http://0-www.uptodate.com.topekalibraries.info/contents/acute-otitis-media-in-children-treatment?source=search_result&selectedTitle=1%7E150Klein, J. & Pelton, S. (2011). Acute otitis media in children: Prevention of recurrence. Retrieved from http://0-www.uptodate.com.topekalibraries.info/contents/acute-otitis-media-in-children-prevention-of-recurrence?source=search_result&selectedTitle=1%7E150Slide86

References

Leskinen, K. (2005). Complications of acute otitis media in children. Current Allergy and Asthma Reports, 4, 308-312. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15967073Porth, C. & Matfin

, G. (2009).

Pathophysiology

: Concepts of altered health states.

(8

th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.