Acute otitis media
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Acute Otitis Media. Dr. Hamid Rahimi Pediatric Infectious Disease Specialist. Acute Otitis Media. The most common infection for which antibacterial agents are prescribed for children in the US 1/3 of office visits to pediatricians Peak incidence 6 – 12 months old

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Acute otitis media

Acute Otitis Media

Dr. Hamid Rahimi

Pediatric Infectious Disease Specialist


Acute otitis media1

Acute Otitis Media

  • The most common infection for which antibacterial agents are prescribed for children in the US

  • 1/3 of office visits to pediatricians

  • Peak incidence 6 – 12 months old

    • ≈ 2/3 of children experience at least one episode by 1 year old


Acute otitis media definitions

Acute Otitis Media - Definitions

  • AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea)

  • Recurrent otitis

    • >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodes

    • Most children with recurrent acute otitis media are otherwise healthy

  • Otitis prone

    • Six or more acute otitis media episodes in the first 6 years of life

    • 12% of children in the general population

  • Persistent Middle-Ear Effusion

    • When an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobile

    • More common in white children & < 2 yo


Aom vs com

AOM vs. COM

  • Chronic otitis media

    • Called chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.

    • Some sort of eustachian tube dysfunction is the principal predisposing factor.

    • Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection.

  • Acute otitis media is commonly defined as…

    1. Presence of a middle ear effusion (MEE)

    2. TM inflammation

    3. Presenting with a rapid onset of symptoms such as fever, irritability, or earache


Diagnosis

Diagnosis

Etiologic diagnosis

Clinical diagnosis


Case one

Case one

  • History

    • One year old boy brought with cough, runny nose, and fever.

    • He is also tugging at his ear and appears to be very fussy.

  • Physical Exam

    • T= 38 0C Ax.

    • Upper respiratory tract sign & symptom


Normal tm

Normal TM

Gray

Pink


Describe tm appearance

Describe TM appearance


What s your advice

What’s your advice?

1. Tell mother that he has a viral upper respiratory infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection.

2. Tell mother that he has an ear infection that requires treatment with antibiotics.

3. Explain to mother that he has a red ear drum. The redness is probably caused by his cold but may also be the beginning of an ear infection. You will need to examine him again in 2 days to determine if he has an ear infection and needs antibiotics.

4. Explain to mother that you aren't sure whether Robert is developing an ear infection. Since he has a fever you would prefer to treat him with antibiotics. Something might be brewing.


Clinical diagnosis

Clinical diagnosis 

A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.

Presence of a middle ear effusion & acute signs of middle ear inflammation in presence of acute onset of signs & symptoms


History

History

  • Children with AOM usually present with …

    • History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, and/or fever

    • Except otorrhea other findings are nonspecific i.e.

      Fever, earache, and excessive crying present in children …

      90% with AOM

      72% without AOM


Laboratory tests

Laboratory tests

Routine laboratory studies, including complete blood count and ESR, are not useful in the evaluation of otitis media.


Otoscopy

Otoscopy

The key to distinguishing AOM from OME is the performance of pneumatic otoscopyusing appropriate tools and an adequate light source

Use of visual otoscopy alone is discouraged


Pneumatic otoscope equipment

Pneumatic otoscope - equipment


Technique

Technique


Acute otitis media

  • Systematic assessment of the TM by the use of the COMPLETES mnemonic

    • Color

    • Other conditions

    • Mobility Position

    • Lighting

    • Entire surface

    • Translucency

    • External auditory canal and auricle

    • Seal


Normal tympanic membrane

Normal tympanic membrane


Middle ear effusion

Middle-Ear Effusion

  • MEE is commonly confirmed …

    • Directly by…

      • Tympanocentesis

      • Presence of fluid in the external auditory canal

    • Indirectly by…

      • Pneumatic otoscopy

      • Tympanometry

      • Acoustic reflectometry


Signs of presence of mee

Signs of presence of MEE


Signs of presence of mee1

Signs of presence of MEE

Fluid level

Bobbles


Signs of presence of mee2

Signs of presence of MEE

Perforation

Cobble stoning


Normal tm1

Normal TM

Translucent


Signs of presence of mee3

Signs of presence of MEE

Opaque

Semi-opaque


Normal tm2

Normal TM

Gray

Pink


Signs of presence of mee4

Signs of presence of MEE

Pale yellow

White


Signs of presence of mee5

Signs of presence of MEE

  • Pneumatic otoscopy

    • Reduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle ear

  • Tympanometry or acoustic reflectometry

    • Can be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determine


Tympanometry

Tympanometry


Ome vs aom

OME vs. AOM

  • Major challenge

    Otitis Media with Effusion

    Vs.

    Acute Otitis Media


Signs symptoms of middle ear inflammation

Signs & symptoms of middle-ear inflammation

  • Signs or symptoms of middle-ear inflammation indicated by …

    • Non – otoscopic findings

      • Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep)

      • However, these symptoms must be accompanied by abnormal otoscopic findings

    • Otoscopic findings


Acute inflammation otoscopic findings

Acute inflammation – otoscopic findings

  •  Signs of acute inflammation are necessary to differentiate AOM from OME.

  • Distinct fullness or bulging

    • The best and most reproducible sign of acute inflammation

  •  Marked redness of the tympanic membrane

    • Marked redness of the tympanic membrane without bulging is an unusual finding in AOM.


Normal tm3

Normal TM

Neutral


Signs of presence of mee6

Signs of presence of MEE

Distinct fullness

Bulging


Normal tm4

Normal TM

Gray

Pink


Signs of middle ear inflammation

Signs of middle-ear inflammation

Marked redness

Injection


Usefulness of findings

Usefulness of findings


Predictive value of combinations of otoscopic findings in children with acute ear symptoms

Predictive value of combinations of otoscopic findings in children with acute ear symptoms


Normal tm5

Normal TM

Neutral


Signs of presence of mee7

Signs of presence of MEE

Distinct fullness

Bulging


Established acute otitis media

Established acute otitis media


Differential diagnosis 2

Differential diagnosis - 2

  • Other conditions 

    • Redness of tympanic membrane

      • AOM

      • Crying

      • Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tract

      • Trauma and/or cerumen removal

    • Decreased or absent mobility of tympanic membrane

      • AOM and OME

      • Tympanosclerosis

      • A high negative pressure within the middle ear cavity

    • Ear pain

      • Otitis externa

      • Ear trauma

      • Throat infections

      • Foreign body

      • Temporomandibular joint syndrome


Uncertainty in diagnosis of aom

Uncertainty in diagnosis of AOM

  • The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty.

  • Common factors …

    • Inability to sufficiently clear the external auditory canal of cerumen

    • Narrow ear canal

    • Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry

  • An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE.


Management

Management


Case two

Case two

  • A 1.5 year old boy, is brought into your office because of cough, runny nose, and fever.

  • Physical Exam

    • T= 39 0C Ax.

    • Upper respiratory tract sign & symptom

    • The finding of pneumatic otoscopy are shown in next slide…


Describe tm appearance mobility

Describe TM appearance & mobility


How would you manage this illness episode

How would you manage this illness episode?

1. Tell mother that his son has a viral upper respiratory infection or cold that will not benefit from treatment with antibiotics at this time as he does not have an ear infection.

2. Tell mother that his son has an ear infection that requires treatment with antibiotics.

3. Tell mother that his son has an ear infection but doesn't need treatment with antibiotics.


Clinical course

Clinical Course

  • The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated.

  • However, middle ear effusion persisted for weeks to months after the onset of AOM …

    • Among children who were successfully treated…

      • 70% resolution of effusion within two weeks

      • 90% up to 3 months


Symptomatic therapy 1

Symptomatic therapy - 1

Pain remedies 

  • PO analgesics

    • Ibuprofen and acetaminophen

  • The efficacy of a topical agent

    • Auralgan (combination of antipyrine, benzocaine, and glycerin)

    • The topical herbal extract OtikonOtic solution

  • Remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly address the effectiveness of these remedies


Symptomatic therapy 2

Symptomatic therapy - 2

Decongestants and antihistamines 

  • Alone or in combination were associated with…

    • Increased medication side effects

    • Did not improve healing or prevent surgery or other complications in AOM

    • Not approved by AAP for < 2 year old

  • In addition, treatment with antihistamines may prolong the duration of middle ear effusion


Comparative aom outcomes for observation vs antibacterial agent

Comparative AOM Outcomes for Observation vsAntibacterial Agent


Number need to treat nnt

Number Need to Treat (NNT)

  • NNT for antibiotic therapy in AOM

    • 7 to 8 children with AOM would have to be treated with antibiotics to prevent one case of clinical failure by 1 week.

    • One review estimated the need to treat 17 children in order for 1 child to have improved pain at 2 days.

    • In addition, antibiotics were associated with almost twice the rate of vomiting, diarrhea, and rashes.


Watch see protocol

Watch & See protocol

  • Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children

    In this protocol …

  • Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief


Acute otitis media

  • Observation option is based on …

    • Diagnostic certainty

    • Age

    • Illness severity

    • Assurance of follow-up


Criteria for initial antibacterial agent treatment or observation in children with aom

Criteria for initial antibacterial-agent treatment or observation in children with AOM


Definitions

Definitions

  • Non-severe illness is …

    • Mild otalgia & fever <39°C in the past 24 hours

  • Severe illness is

    • Moderate to severe otalgia OR fever  39°C

  • A certain diagnosis of AOM meets all 3 criteria …

    1) Rapid onset

    2) Signs of MEE

    3) Signs and symptoms of middle-ear inflammation.


Criteria for initial antibacterial agent treatment or observation in children with aom1

Criteria for initial antibacterial-agent treatment or observation in children with AOM


Observation

Observation

  • Observation is only appropriate when …

    Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsen

  • Specific follow-up system i.e.

    • Reliable parent / caregiver

    • Convenient obtaining medications if necessary


Observation1

Observation

  • Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hours

  • Adequate follow-up may include …

    1 - A parent-initiated visit or phone contact if symptoms worsen or do not improve at 48 -72 hrs

    2 - A scheduled follow-up appointment in 48 -72 hrs

    3 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame.


Which antibiotic

Which antibiotic ???

  • Amoxicillin

  • Ammoxicillin + Clavulanate

  • Azithromycin

  • Cefixime

  • Cefuroxime

  • Ceftriaxone

  • Clarithromycin

  • Clindamycin

  • Erythromycin

  • Cotrimoxazole

  • Erythromycin + Cotrimoxazole

  • Penicillin V / G

  • Penicillin Procain 800.000 / 400.000

  • Penicillin 6:3:3 / 1.200.000

  • Gentamicin / Amikacin

  • Cephalexin

  • Cloxacillin

  • Metronidazole


Microbiology of aom

Microbiology of AOM


Antibacterial therapy

Antibacterial therapy

If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children.

When amoxicillin is used, the dose should be 80 - 90 mg/kg/day


Acute otitis media

Predicted treatment failure rates based on PD breakpoints for expected pathogens in low- or high-risk AOM


Aom high risk for amoxicillin resistant organism

AOM high risk for amoxicillin-resistant organism

  • In patients who have severe illness

    &

  • AOM high risk for amoxicillin-resistant organism

    • Children who were received antibiotics in the previous 30 days

    • Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome)

    • Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection)

  • High-dose amoxicillin-clavulanate(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate)


In allergy to amoxicillin

In allergy to amoxicillin

  • If allergic reaction was not a type I hypersensitivity reaction (urticaria or anaphylaxis)

    • Cefuroxime (30 mg/kg per day in 2 divided doses)

  • If type I reactions

    • Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose)

    • Clarithromycin (15 mg/kg per day in 2 divided doses)

  • Other possibilities include

    • Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).


In daily clinical practice

In daily clinical practice…

Month of year ( mehr vs. farvardin)

Previous antibacterial treatment

When return


In daily clinical practice1

In daily clinical practice…

q8hAmoxicillin (2/3)Co-Amoxiclav. (1/3)

125 156(125+31)

250312(250+62)

BidFaramox(1/2)Farmentin(1/2)

200228(200+28)

400456(400+56)


In daily clinical practice2

In daily clinical practice…

Amoxicillin - Clavul. 90mg/kg

Amoxicillin 45 mg/kg

Azithromycin

Cefixime

Cotri-Erythro

Cefuroxime

Azithromycin

Cefixime

Cotri-Erythro

Cefuroxime

Amoxicillin - Clavul. 30mg/kg

Amoxicillin - Clavul. 90mg/kg

Amoxicillin 90mg/kg

Previous antibacterial treatment


Duration of therapy

Duration of therapy

For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate

For younger children and for children with severe disease, a standard 10-day course is recommended


Acute otitis media management tympanocentesis

Acute Otitis Media Management - Tympanocentesis

Indications for a tympanocentesis or myringotomy are…

1. AOM in an infant <6wks with a past NICUadmission

2. AOM in a patient with compromised host resistance

3. Unresponsive AOM despite courses of 2-4 different antibiotics

4. Acute mastoiditis or suppurative labyrinthitis

5. Severe pain


Algorithm to distinguish aom from ome

Algorithm to distinguish AOM from OME


Malpractice

Malpractice

Administering PCN 6:3:3 in treatment

Decongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics

Antihistamines may prolong the duration of middle ear effusion


Prevention

Prevention

  • Continue exclusive breastfeeding as long as possible

    • NO "bottle-propping" or taking a bottle to bed

  • Smoke-free environment

  • IF high-risk for recurrent acute otitis media

    • Prolonged courses of antimicrobial prophylaxis

      • Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer

  • Pneumococcal vaccine & influenza vaccine marginally benefit

    • Pneumococcal vaccine reduce all otitis media by 6%.


Case 3

Case 3

  • You are seeing a 18 month old infant at your office. His mother is concerned about his frequent ear infections.

  • You note in his chart that he has had 4 ear infections; 3 of which occurred in the past 6 months. Two of the 4 infections were unresponsive and required multiple antibiotic courses. According to mother, the baby is now asymptomatic; eating and sleeping well.


Which risk factor you consider

Which risk factor you consider??

1. Altered eustacian tube function

2. Frequent colds

3. Immune system

4. Smoking

5. Hay fever and allergies


Management of recurrent acute otitis media

 Management of Recurrent Acute Otitis Media

  • A child has recurrent acute otitis media (RAOM) when 3 new episodes of AOM have occurred in 6 months or 4 episodes within 12 months. Approximately 20% of children younger than two years of age have RAOM.

  • Follow patients with RAOM monthly with pneumatic otoscopy, as AOM episodes are often asymptomatic.

  • Consider obtaining audiologic and speech evaluations in these cases when there are concerns about language development, and when appropriate begin a home language intervention program.


Antibiotic prophylaxis

Antibiotic prophylaxis

  • Studies suggest that the benefits, if any, are quite marginal.

    • While antibiotic prophylaxis reduced the AOM rate by 44%, the mean rate difference was only about one and a third less episodes per patient year for patients receiving antibiotics compared to controls.

  • Consider antibiotic prophylaxis for certain time limited situations such as the time period between deciding to place ventilating tubes and the day surgery will be performed, or when surgery is being considered in late winter or spring and 1 or 2 months of prophylaxis may get the child out of the high risk season and avoid the surgery.

  • Therapeutic options include either continuous antibiotic prophylaxis or intermittent prophylaxis for colds especially during winter respiratory viral infection months.

    • Antibiotics used for prophylaxis include amoxicillin and sulfisoxazole (Gantrisin). Amoxicillin appears to be more effective in the current environment.The efficacy of these antibiotics is best documented with dosing twice/day, but daily doses may be effective. Consider referring patients for ventilating tubes after a first breakthrough episode of AOM on prophylaxis.


Immunoprophylaxis

Immunoprophylaxis

  • Another approach to preventing recurrent AOM episodes is active immunization. Use of the conjugate pneumococcal vaccine, Prevenar, appears to reduce the overall frequency of AOM by 6-7% .

    • However, immunized children with RAOM experience more benefit; such as a 23% reduction in AOM episodes after the 12 month dose and a 20 % reduction in the need for ventilating tubes .

  • Immunize children older than 2 years who experience RAOM with 23 valent polysaccaride pneumococcal vaccine (Pneumovax) .

  • Immunize children older than 6 months who have had an AOM episode in the first 6 months of life or have RAOM with influenza vaccine when supplies are available. Clinically significant reductions in AOM episodes have been well documented .


Ventilating tubes with or without adenoidectomy

Ventilating Tubes with or without Adenoidectomy

  • Ventilating tubes are indicated when a child has experienced 5 or more new AOM episodes within 12 months.

    • The decision to insert ventilating tubes for recurrent AOM should not be based on parental recall.

  • In selected patients, especially those with associated otitis media with effusion, performing an adenoidectomy as well as inserting tubes may reduce the likelihood of ventilating tube reinsertions and additional otitis media related hospitalizations.


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