OTITIS MEDIA
Treatment OM most causes?
There has been a strong push for OBSERVATION of treating the uncomplicated otitis media -most viral Based upon the understanding that spontaneous resolution of otitis media would occur in the majority.
Preventative medicine
Immunization is changing the presentation of otitis media in the general community Immunization is changing the complexity or virulence of otitis media as to presents to the otolaryngologist Immunization is changing the bacteriology of the disease
New frontier immunizations
11 Valent polysaccharide conjugated to in Haemophilus influenza proteins D is showing promise in protecting individuals again streptococcal pneumonia + non-typeable H. influenzae
Bacteriologic profile actively changing incidence currently increase in what bacteria vs other?
Incidence of acute otitis media decreasing in developed world In one practices suburban Rochester 25% decrease reported in persistent acute otitis media and treatment failures Fewer streptococcal pneumonia organisms identified with increase in Haemophilus influenza
Surgical management Myringotomy and tympanostomy tube placement -time frame for indication -condition for indication -complications for indications?
Indicated for recurrent AOM disease in light of medical management with greater than 3 infections in 6 months or 4 infections in 12 Indicated for OME When middle ear effusions have been present for over 4 months When there is a significant hearing loss associated with speech and language delay When there are structural changes to the middle ear suggesting changes to chronic middle ear disease
Intratemporal but extra cranial
Mastoiditis acute and chronic Petrositis Labyrinthitis Facial nerve paralysis -treat via tubing -NOT bells palsy
Otitis media with effusion def how is it often diag what is the key factor for long term effects
Middle ear effusion without signs or symptoms of inflammation Very difficult to assess. -Mostly asymptomatic with no signs of illness Incidence studies vary on the nature of the instrument used to diagnose effusion -often via school hearing studies 1 study in Pittsburgh daycare revealed 50% incidence in children between 2 and 7 years of age Duration of disease is key factor regarding long-term consequences including hearing loss
Quality of life assessment after placement of ventilation tubes
Rosenfeld et al significant improvement in short-term quality-of-life Dutch study revealed in retrospective fashion that parents had underestimated the effects of otitis media until the surgery. The noted a dramatic improvement in hearing and did not realize the extent of presurgical hearing loss
Risk Factors Environmental factors
Seasonality supporting the hypothesis that the upper respiratory tract infection plays a significant role in predisposing individual to otitis media Daycare setting Tobacco smoke exposure Breast versus bottle feeding Increased risk for 3 or more otitis media in children who are breast-fed less than 6 months Pacifier use studies inconclusive
Microbiology otitis media 3 most common causes?
Streptococcal pneumonia -main Haemophilus influenza Moraxella catarrhalis
Risk Factors Genetic predisposition
Suggestion that there are genetic factors Heritability: 0.5-0.79 Linkage studies: chromosomes 19q and 10q Candidates: mannose binding proteins surfactant protein mucin expression associated with mucosal immunity
Other options for treatment role antihistamines or steroids?
Decongestants and antihistamines CANNOT be recommended as data does not show any improvement and as of 2008 are contraindicated in children as per FDA recommendations Steroids have no role in the management of otitis media
Complications of otitis media
Degenerative changes to the middle ear, tympanic membrane and ossicular chain -Tympanic membrane perforation -Chronic otorrhea -Chronic otomastoiditis -Cholesteatoma -Hearing loss Divided into 2 categories -Intratemporal but extra cranial -intracranial
Cholesteatomas def organism implicated
EXPANDING GROWTH OF CELLS consisting of epithelial cells that begin to develop in the middle ear or sometimes in the mastoid air cell Bacteroides are the most common organisms associated with cholesteatoma
Sign that otitis media is no longer simply a difficult ear infection...........
-Persistent low intensity pain greater than one weeks duration -Foul smelling persistant otorrhea -Retroorbital pain -Facial nerve paralysis -Vertigo
acute otitis media Epidemiology -peak ages? - prevalence in developing world vs developed world
40% of children are diagnosed with otitis media by 9 months of age 60% of children are diagnosed with otitis media by 2 years of age. Peak age for recurrent otitis media is between 6 and 12 months of life with incremental decreased per year until 7 years of age Incidence of otitis media is noted to be decreasing in the developing world Heavy burden of disease still present within the developing countries
Acute otitis media is divided into 2 separate diagnoses
AOM= acute otitis media Acute inflammatory disease of the middle ear and tympanic membrane with or without purulent middle ear fluid OME= otitis media effusion Presence of middle-ear effusion without any local or systemic signs of inflammation
Treatment OM Absolute contraindications to observation 4
Age less than 6 months Immune deficiency or disorder Severe illness or previous treatment failure Inability to ensure follow-up
Acute otitis media Risk Factors 6
Age: Race: Inconclusive but well established increase of chronic middle ear disease in Native American and Eskimo population. Allergy: Inconclusive data. There are some studies to suggest that there is a higher incidence of atopy in population susceptible to OME. Immunocompetence Children with immunosuppression -Children with atypical courses of otitis media should have immune workup looking for common variance of immunosuppression such as IgG subclasses deficiencies. Craniofacial disorder Down syndrome craniosynostosis cleft palate genetic predisposition
Allergy linked to OM link btw treatment of allergies and preventing OM?
Allergies thought to be considered in the pathogenesis of otitis media but studies to date have not shown any efficacy in anti-allergic medication in the treating of otitis media
Treatment OM Chemotherapy Treatment Antibiotic choice: -first line -second line duration of treatments when to not use first line treatment 2
Antibiotic choice: 1.First-line therapy is amoxicillin at 90 mg/kg per day divided into 2 doses -First-line therapy not considered option when recurrence is within 30 days or failure 2. Amoxicillin and clavulanic acid at 90 mg/kg per day of amoxicillin is recommended for severe otitis media -First-line therapy not considered option when recurrence is within 30 days or failure 3. Cephalosporin is considered first-line therapy with penicillin allergy 4. Macrolides considered first-line therapy with penicillin and cephalosporin allergy Ten-day course recommended for younger children and for increased severity Shorter course of 5-7 days is acceptable for children older than 6 years of age with mild to moderate disease
Limits of immunization
Bacteriology of current immunizations gain reveals increase in nontypeable Haemophilus influenza and non-13 valent pneumococcal strains Nontypeable Haemophilus influenza immunization still in its infancy No success in immunization against Moraxella catarrhalis
Link btw influenza and OM
Children infected with influenza have a high incidence of otitis media during infection or immediately afterwards Immunization against influenza has decreased the rate of otitis media in this population.
Immunization for OM and s. pneumo 2 cat benefit of this immunization
Conjugated 7 valent available since 2000 13 valent available since 2013 Polysaccharide 23 Available but not for use in children under 2 because of the lack of antibody response Current data regarding implications of the vaccination includes large California study 10% reduction in otitis media episodes 20% reduction in placement of ventilation tubes 80% reduction in invasive pneumococcal disease
Intracranial spread of infection
Extradural granulation tissue an abscess Sigmoid sinus thrombophlebitis Brain abscess Otitic hydrocephalus Meningitis Subdural abscess
Gastroesophageal disease linked to OM
Higher incidence of otitis media noted in incidence with severe gastroesophageal reflux. Pepsin and pepsinogen identified within the middle ear fluid of individuals undergoing placement of myringotomy for OME Prospective study of children with acute otitis media and esophageal reflux disease show significant decrease in middle ear disease with reflux therapy
Risk Factors Cleft palate
Otitis media is considered universal in children less than 2 years of age with unrepaired cleft palate. Incidence improved post repair. Incidence remains high over 50%.
Serous Otitis Media
Preceding viral illness Assumption that most episodes of otitis media are viral (see rational for "watchful waiting") Immature immune status Eustachian tube dysfunction
Eustachian Tube Dysfunction
Pt presents with stuffy ears that look normal (aural fullness) , fluctuating hearing, and sensitivity to pressure changes (generally hear popping in their ears).
acute otitis media pt presentation signs? symptoms
Rapid onset of signs and symptoms of inflammation in the middle ear Signs include bulging or fullness of tympanic membrane; redness of tympanic membrane; perforation of membranes with drainage Symptoms include ear pain; irritability and fever
Treatment OM Relative contraindications to observation 4
Relapse within the last 30 days Otorrhea Bilateral otitis media if less than 2 years of age Syndrome such as craniofacial malformation
Mastoiditis causes 2
inflammation of the mastoid bone complication of s. pneumo Anaerobic organisms are associated with mastoiditis with abscess and not seen within acute otitis media.