Acute Otitis Media and Otitis Media with Effusion

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 https://upload.wikimedia.org/wikipedia/commons/5/58/Otitis_media_entdiff...


Helpful Resources:
                        NEJM Video - covers diagnosis, exam techniques and findings.

                       Otitis Media Guide - images of all stages of AOM


AOM

Acute otitis media (AOM) is defined as an inflammatory process of the middle ear associated with an effusion.  It is the most common childhood infection for which antibiotics are prescribed, representing one of the most frequent reasons for visits to the pediatrician with an estimated expenditure of $350 per child with AOM, totaling approximately $2.8 billion/year in the U.S.  Almost all children will have one episode of AOM by 7 years of age; however, it is an unusual finding in older children and adults. The highest incidence is between 6-13 months of age during the winter season.  In the past 20 years, there has been three times the number of visits to pediatrician's offices for ear infections. The placement of ventilating tubes into the middle ear is the second most frequently performed surgical procedure in the United States behind circumcision.  The management guidelines below are based on AAP/AAFP joint clinical guidelines from May 2004, although new AOM management guidelines are currently in preparation by the AAP.

 

Risk factors

  1. First episode before 6 months of age may be related to anatomical abnormalities or minor immunologic deficiency.
  2. Family history of frequent ear infections.
  3. Formula feeding. Breast feeding allows for passive transmission of antibodies, typically with breastfeeding > 3mos.
  4. Anatomical variations- cleft palate, Eustachian tube abnormalities, nasopharyngeal tumors, Down Syndrome
  5. Altered immune system: HIV, immune suppression secondary to drugs, IgA deficiency, Kartagener's syndrome 
  6. Exposure to smoke, allergens.  Increased exposure in daycare centers.
  7. Native Americans and Eskimos, Whites > African-Americans
  8. Males 
  9. Allergic rhinitis
  10. Bottle propping

 

Pathogenesis

  1. Normal Eustachian tube function
    1. Equalizes pressure between the middle ear and atmosphere-middle ear pressure slightly negative normally
    2. Protects the middle ear from nasopharyngeal secretions and sounds
    3. Drains secretions from the middle ear into the nasopharynx
  2. Eustachian tube in infants is shorter and at a greater angle than in older children
  3. Eustachian tube obstruction leads to negative pressure within the middle ear and transudation of capillary fluid into the space. 
  4. Functional obstruction: supporting structures of the Eustachian tube in infants are not well developed.
  5. Extrinsic obstruction may be due to tumors or enlarged lymphoid tissue.
  6. Inflammatory obstruction: viral infections, especially RSV and Influenza, may increase the vulnerability to AOM due to obstruction secondary to inflammatory changes.

 

Microbiology

  1. Streptococcus pneumoniae (35-40%): The least likely to resolve spontaneously. The highest incidence of antibiotic resistance is in daycare attendees and those with prior exposure to antibiotics within the last 1-3 months. The introduction of Prevnar has resulted in a decrease incidence of AOM by 34% for culture-confirmed pneumococcal episodes, and by 57% for serotypes contained in the vaccine, with a shift towards predominantly non-typable H. influenzae.  However, there may be a new shift back towards S. pneumo with non-vaccine serotypes.  Further surveillance with the introduction of PCV13 is needed.
  2. Non-typable Hemophilus influenzae (20-25%): may be associated with conjunctivitis. Frequently will resolve without antibiotic treatment.
  3. Moraxella catarrhalis (5-20%): Often cures spontaneously. Usually beta-lactamase resistant.
  4. Group A beta hemolytic strep/Streptococcus pyogenes (2-3%)
  5. Staphylococcus aureus and Mycoplasma are unusual pathogens. 
  6. Viral causes <10%. The incidence may be higher if PCR were done on all specimens.  Often associated with bacterial infections. The presence of viruses may promote bacterial suprainfection, impair Eustachian tube function, and destroy normal epithelial cell barriers. 
  7. Sterile middle ear fluid may result from prior antibiotic treatment, Mycoplasma or Chlamydia infections, anaerobes and improper collection of specimens.
  8. Nasopharyngeal cultures are not indicated. They are and not specific for middle ear pathogens.
  9. Newborns have an increased incidence of Group B strep and gram-negative organisms.

 

Symptoms

  1. Often there is a history of a preceding URI.  There may be fever, irritability, ear pulling,, vomiting, diarrhea, and pain on swallowing. 
  2. The older child will complain of ear pain and the younger child may awake at night with some discomfort.
  3. Otorrhea: spontaneous rupture of the tympanic membrane
  4. Decreased hearing
  5. Vertigo, nystagmus, tinnitus, and facial paralysis are unusual presenting symptoms.
  6. Eye drainage: infections secondary to non-typable H. influenza are often associated with conjunctivitis

 

Diagnosis

A symptomatic child with a red, bulging, tympanic membrane that doesn't move with insufflation.

  1. A clinical diagnosis based on 3 main criteria: signs of acute infection, evidence of middle ear inflammation, evidence of middle ear effusion (MEE)
  2. AOM diagnosis is NOT associated with occurrence, duration, or severity of parent-reported symptoms (ear pain, ear rubbing, fever). Over-diagnosis is commonly secondary to relying on redness, not using pneumatic otoscope, relying on past history, parental pressure, and rechecking too soon after treatment.
  3. Pneumatic otoscopic examination is the most reliable tool to diagnose AOM. It is 95% sensitive and 80% specific. Must establish a tight seal and remove cerumen. Signs of middle ear inflammation (redness) and signs of middle ear effusion (cloudy, immobile, bulging) are suggestive of AOM but the accuracy/precision of these findings have not been determined.
  4. Assessment may be hindered by the presence of cerumen, a poor light source, failure to establish a tight seal, mistaking the canal wall for the drum, and narrow canals
  5. Redness of the tympanic membrane may be associated with URIs, crying, sneezing, and following cerumen removal.
  6. Tympanometry- tests the condition of the middle ear and mobility of the eardrum using variations of air pressure in the ear canal.  Useful for teaching and confirming presence of fluid that you diagnose with pneumatic otoscope. Better negative predicative value. 50% of abnormal tympanograms will have normal ears. Majority of normal tympanograms will have normal ears.
  7. Tympanocentesis- drainage of fluid from the middle ear using a small gauge needle.
    1. useful to relieve pain 
    2. in infants, immunodeficient children, and treatment failures a means to obtain organism for culture and sensitivity.

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AOM with suppuration

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AOM prior to perforation

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AOM with perforation

 

Antibiotic Therapy

  1. Greater than 60% will resolve spontaneously within 10 days but there is no clinical means to distinguish those that need to be treated. In patients older than 6 months without severe symptoms, current studies are controversial regarding immediate antibiotic treatment vs. observation for 48-72 hours with possible delayed antibiotic treatment if symptoms persist.  Immediate treatment appears to have a modest benefit over delayed treatment and placebo, but with a higher incidence of side effects (diarrhea and rash).
  2. Amoxicillin is the first drug of choice for uncomplicated AOM, and there is no evidence of initial use of higher-cost antibiotics for uncomplicated cases.  The initial dosage amoxicillin should be 80 to 90 mg/kg/day.  Amoxicillin has excellent middle ear penetration and despite penicillin resistance, levels may be high enough to kill many bacteria. It is 85-94% effective, tastes good, is inexpensive, has a narrow spectrum of activity, and has a good safety record.   Ampicillin can also be used and has been studied extensively as well as a first line drug of choice for treatment of AOM. 
  3. If the child is not clinically improved on antibiotics within 48 to 72, re-evaluation of the child is warranted, as there may be a poor response to Amoxicillin.  This occurs in 10% of cases and more frequently when viruses are present.  Alternative treatment should be effective against drug resistant Streptococcal pneumoniae and beta-lactamase producing organisms. This would include amoxicillin-clavulanate (Augmentin), PO cefuroxime (Ceftin) Cefpodoxime (Vantin), Cefuxime (Supra), PO Cefaclor, or IM ceftriaxone.  PO Azithromycin has been found to have equal efficacy to PO Cefaclor, although 10 days amoxicillin-clavulanate was more efficacious than 5 days of Azithromycin.
  4. If there is no response after initiating second-line antibiotics, 3 daily IM injections of Ceftriaxone or Clindamycin PO have been tried.  It is important to remember that Clindamycin is not effective against beta-lactamase producing organisms. Tympanocentesis should be considered to obtain cultures.
  5. There is an increased incidence of drug resistance in daycare attendees, recent users of antibiotics, and patients on prophylactic antibiotics. Often penicillin-resistant pneumococci will also be resistant to trimethoprim/sulfisoxazole, erythromycin, and cephalosporins.
  6. Antibiotic choice must take in consideration cost, compliance and convenience of dosing schedule, taste, and bacterial resistance in the community or region. 
  7. Symptomatic otitis media greater than 2 weeks after completion of therapy should be considered to be a new pathogen and Amoxicillin may be started. 
  8. Current evidence suggests that there is no benefit of long-term course of antibiotics (over 7 days) vs short-term course of antibiotics (less than 7 days).  Current studies also suggest limitation of antibiotic use to prevent further development of antibiotic resistance.

 

Management

  1. Active monitoring for recurrence of symptoms, persistent infection, OME.  MEE may still be present in 60% at 2 weeks, 50% at 4 weeks, 20% at 8 weeks and 15% at 90 days. Children who are asymptomatic should be checked in 3-6 weeks. 
  2. Adjuvant therapy: Pain relief, including local drops, analgesics, heating pad, warm oil. Most studies have shown that antihistamines and decongestants do not facilitate cure nor decrease the incidence of developing OME. 
  3. Instructions to parents
    1. When to follow-up
    2. Directions on how to give the medicine including the importance to complete the entire prescription
    3. Tell parents that the medicine will not help URI symptoms
    4. Symptoms/signs that the medicine is not working and any complications that they should notify you about. 
    5. Tell the family that pain may persist for up to 24 hours after starting treatment.
  4. Influenza vaccine- if infant had many bouts the previous year, may consider vaccine to decrease the incidence of viral illness.
  5. Xylitol, a sugar substitute, has been shown to inhibit the growth of pneumococcus. Study of 5 year olds who chewed gum containing xylitol, had a decreased incidence of AOM.
  6. Prophylaxis- use of prophylactic antibiotics may decrease the frequency of AOM. Data for appropriate dosage and timing is not available. Studies have demonstrated that prophylaxis is a good as ventilating tubes in preventing AOM. May induce increase of resistant organisms and some studies have shown no benefit. Amoxicillin and sulfasoxazole recommended if you choose to use prophylaxis.
  7. If the child presents with otorrhea, treatment is the same as AOM without perforation, but need to reassure parents that resolution doesn't differ and there are no long-term complications. 

 

Complications

  1. Hearing Loss: usually conductive and temporary. There have been rare cases of sensorineural hearing loss. If there are adhesions of the drum, tympanosclerosis, or ossicle changes, may have permanent loss of hearing. 
  2. Perforation: May be associated with AOM. Use same antibiotics as without perforation. Some recommend antibiotic/corticosteroid drops to prevent external otitis. Perforations usually heal by themselves. If there is a chronic perforation, may need surgical repair but this is uncommon.
  3. Cholesteotoma: presence of keratinized material in the middle ear. There is an odorous chronic drainage. There may be bony destruction and invasion of the cranium.
  4. Mastoiditis: infection of the mastoid process, now quite rare with antibiotic therapy.  Due to inflammation of the mastoid air cell.  Treatment includes placement of tympanostomy tube and IV antibiotics usually necessary.  If an abscess develops in the subperiostal tissue, surgery may be required. 
  5. Otitic hydrocephalus: a rare complication of AOM.  Characterized by increased intracranial pressure with normal CSF analysis.
  6. Intracranial abscesses
  7. Sinus thrombosis
  8. Facial nerve paralysis 

 

Otitis Media with Effusion (OME)

  1. Definition- A common condition of childhood characterized by the presence of fluid in the middle ear without signs or symptoms of infection. In some instances, aspiration may yield the presence of bacteria. 
  2. Because of association with hearing loss and concern of this relationship to learning, speech, and other developmental abnormalities, physicians are anxious to treat OME. 
  3. Risk Factors- Same as AOM (cleft palate, Down’s syndrome, etc)
  4. Diagnosis-
    1. May be incidental finding 
    2. Seen following treatment of AOM
    3. Present with decreased hearing, "discomfort", or behavioral changes. 
    4. Pneumatic otoscope is recommended for assessing the middle ear. Examination will have decreased mobility of TM, yellow-orange fluid, may have air fluid level, and drum may appear thickened. Hearing evaluation may be used in diagnostic evaluation.
    5. Tympanometry
  5. Natural history
    1. Most of the cases of OME will resolve spontaneously 
    2. Fluctuating clinical symptoms that vary with time and age
    3. Some children will experience transient hearing loss
    4. Intervention is needed due to the effects of prolonged hearing loss
  6. Complications
    1. High frequency hearing loss
    2. Difficulty discriminating sounds
    3. Decreased expressive language skills (indistinct speech, language development delay)
    4. Decreased attention span
    5. Poor educational progress
    6. Balance difficulties
    7. Recurrent infections (AOM, URIs)
  7. Therapeutic Interventions 1-3 year olds -US Agency on Health Care Policy and Research
    1. Once OME is diagnosed, guidelines suggest active observation for 3 months with interval rechecks of the status of the effusion.
    2. Treatment with antibiotics. Studies have shown a slight advantage in resolution of the fluid with antibiotic treatment.
    3. Environmental risk factor control counseling
    4. After 6 weeks, hearing evaluation can be considered.  Also consider other etiologies for hearing loss (sensorineural, permanent conductive, non-organic causes).
    5. After 3 months of effusion, evaluate hearing loss, speech and language development. If there is significant (>20 decibel) bilateral hearing loss, consider antibiotic treatment or bilateral tympanostomy tubes and environmental control counseling (smoking, daycare attendance). Interventions such as bilateral tympanostomy tubes should be withheld until persistence of bilateral OME and hearing loss is confirmed for at least 3 months.
    6. Tympanostomy tubes have been shown to have a 7-9 dB improvement in hearing loss when placed unilaterally, and 4-10 dB when placed bilaterally.  Children with tubes placed should have regular hearing checks to ensure that hearing remains normal.
    7. However, placement of tympanostomy tubes remains controversial, as no benefits in developmental outcomes has been shown for children with previous tube placement between 3-6 y/o and 9-11 y/o.
    8. There is no role in the treatment of OME for Antihistamines/decongestants, topical or systemic steroids, adenoidectomy, or tonsillectomy. Current guidelines do not recommend adjuvant adenoidectomy with bilateral tympanostomy tube placement without signs/symptoms of persistent/frequent URIs.

 

References

  1. Acute otitis media: management and surveillance in an era of pneumococcal resistance- a report from the Drug resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatric Infectious Disease Journal. January 1999.
  2. Berman, Stephen. Otitis Media in Children. NEJM June 8, 1995.
  3. Bluestone CD and Klein JO. Consultation with the Specialist: Chronic Suppurative Otitis Media. Pediatrics in Review. 1999; 20:277-279.
  4. Daly KA, Hunter LL and Giebink GS. Chronic Otitis Media with Effusion. Pediatrics in Review. 1999; 20:85-94.
  5. Dowell SF et al. Otitis Media - Principles of Judicious Use of Antimicrobial Agents. Pediatrics. 1998; 101(1 Suppl.):165-171.
  6. Hendley J. Owen. Otitis Media NEJM Vol 347, No. 15 pg1169 October 10,2002
  7. The Treatment and Prevention of Recurrent Otitis Media Journal of Clinical Prevention May 2003
  8. American Academy of Pediatrics Diagnosis and Management of Acute Otitis Media. Pediatrics May 2004
  9. Paradise J. et al. Otitis Media and Tympanostomy Tube Inseition during the first 3 Years of Life: Developmental outcomes at 4 years of Age. Pediatrics 112(2) 265-277 2003
  10. American Academy of Pediatrics Clinical Practice Guidelines. Otitis Media with Effusion.  Pediatrics May 2004
  11. Paradise J. et al. Developmental Outcomes after Early or Delayed Insertion of Tympanostomy Tubes.  NEJM 353;6 August 11, 2005
  12. Paradise J. and Bluestone C. Tympanostomy Tubes: A Contemporary Guide to Judicious Use. Pediatrics in Review February 2005
  13. Stenstrom R et al. Hearing Thresholds and Tympanic Membrane Sequelae in Children Managed Medically or Surgically for Otitis Media With Effusiion. Arch Pediatr Adolesc Med Dec 2005
  14. BermanS. Long-term Sequelae of Ventilating Tubes Arch Pediatr Adolesc Med Dec 2005
  15. Paradise J. et al.  Tympanosotomy Tubes and Developmental Outcome 9-11 Years Later.  NEJM Jan 18, 2007
  16. Roberts J. etal. Otitis Media in Early Childhood and Its Relationship to Later Verbal and Academic Performance.  Pediatarics Sept 1986
  17. Rover M. et al. Antibiotics for Acute Otitis Media: Meta-analysis .  Lancet October 2006
  18. Feldman H. and Paradise J.  OME and Child Development. Rethinking Management.  Contemporary Pediatrics.  May 2009
  19. http://content.nejm.org/cgi/video/362/20/e62/http://content.nejm.org/cgi/video/362/20/e62/ Video of examining ears
  20. Eskola J, et al. Efficacy of pneumococcal conjugate vaccine against acute otitis media. NEJM; 344(6): 403-409. Feb 2001.
  21. Coker TR, et al. Diagnosis, medical epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA; 304(19): 2161-2169. Nov 2010.
  22. Khanna R, Lakhanpaul M, Bull PD. Surgical management of otitis media with effusion in children: summary of NICE guidelines. Clin Otolaryng; 33(6): 600-605. Dec 2008.
  23. Paradise J, et al.  Tympanosotomy Tubes and Developmental Outcome 9-11 Years Later.  NEJM Jan 18, 2007.
  24. Kozyrskyj A, et al. Short-course antibiotics for acute otitis media: an update of Cochrane Database Systematic Review (2000). Cochrane database syst rev; 9: Sep 2010.
  25. Viswanatha B, et al. Otitic hydrocephalus: a report of 2 cases. Ear nose throat; 89(7): E34-7. Jul 2010.
  26. Hoberman et al. Treatment of Acute Otitis Media in Children less than 2 years old. NEJM Jan 13, 2011
  27. Tantinen,P.  A Placebo Controlled Trial of AntiMmicrobial Treatment of Acute Otitis Media.  NEJM Jan 13, 2011
  28. Klein,J. Is Acute Otitis Media a Treatable Disease? NEJM Jan 13, 2011
  29. American Academy of Pediatrics.  The Diagnosis and Management of Acute Otitis Media.  Pediatrics March 2013

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