Acute Otitis Media

1. Acute Otitis Media Dr. Hamid Rahimi Pediatric Infectious Disease Specialist

2. 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

3. 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

4. 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

5. Diagnosis Etiologic diagnosis Clinical diagnosis

6. 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

7. Normal TM Gray Pink

8. Describe TM appearance

9. 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.

10. 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

11. 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

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

13. 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

14. Pneumatic otoscope - equipment

15. Technique

17. 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

18. Normal tympanic membrane

19. 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

20. Signs of presence of MEE

21. Signs of presence of MEE Fluid level Bobbles

22. Signs of presence of MEE Perforation Cobble stoning

23. Normal TM Translucent

24. Signs of presence of MEE Opaque Semi-opaque

25. Normal TM Gray Pink

26. Signs of presence of MEE Pale yellow White

27. 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

28. Tympanometry

29. OME vs. AOM • Major challenge Otitis Media with Effusion Vs. Acute Otitis Media

30. 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

31. 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.

32. Normal TM Neutral

33. Signs of presence of MEE Distinct fullness Bulging

34. Normal TM Gray Pink

35. Signs of middle-ear inflammation Marked redness Injection

36. Usefulness of findings

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

38. Normal TM Neutral

39. Signs of presence of MEE Distinct fullness Bulging

40. Established acute otitis media

41. 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

42. 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.

43. Management

44. 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…

45. Describe TM appearance & mobility

46. 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.

47. 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

48. 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

49. 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

50. Comparative AOM Outcomes for Observation vsAntibacterial Agent