Otitis Media
Gil C. Grimes, MDAssistant Professor Family Medicine
Texas A&M HSC COMScott and White Family Medicine Residency
May 31st 2005
Objectives Describe criteria for diagnosing Acute Otitis
Media Describe rationale for therapy for Acute
Otitis Media Describe Therapy for Serous Otitis Media Describe the role of Tympanostomy Tubes
My Bias I am a minimalist
If the evidence for intervention is not good I do nothing
Acute Otitis Media A diagnosis of AOM requires
a history of acute onset of signs and symptoms
the presence of middle ear effusion (MEE)
signs and symptoms of middle-ear inflammation.
Pediatrics 2004 May;113(5):1451-65 Level 1a
Acute Otitis Media The presence of MEE that is
indicated by any of the following: Bulging of the tympanic membrane Limited or absent mobility of the
tympanic membrane Air-fluid level behind the tympanic
membrane Otorrhea
Acute Otitis Media Signs or symptoms of middle-ear
inflammation as indicated by either Distinct erythema of the tympanic
membrane or Distinct otalgia
discomfort clearly referable to the ear(s) and
interference with or precludes normal activity or sleep
Acute Otitis Media Otitis Media?
Yes No
http://www.otol.uic.edu/research/microto/Microtoscopy/Case10origweb.jpg
Acute Otitis Media Otitis Media?
Yes No
www.orldoc.ch/index
Acute Otitis Media Prevalence Prevalence
10% US children diagnosed by 3 months 90% by 2 years (1)
Prospective cohort of children (2)
62% with AOM by 1 year 83% with AOM by 3 years
9th most common diagnosis during FM visits(3)
Coded 3.2% visits (3)
1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b2)J Infect Dis 1989 Jul;160(1):83 Level 2b3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c
Acute Otitis Media Etiology Viral pathogens found Tympanocentesis and
Nasal Aspirate in AOM RSV and coronavirus RNA in 75% children
5% dual viral infections
Bacterial pathogens detected 62%
Viral RNA detected in 57% bacteria-negative and 45% bacteria-positive samples
Pediatrics 1998 Aug;102(2):291 Level 1c
Acute Otitis Media Etiology Bacteria shifts
Streptococcus pneumoniae S. pneumoniae is the most common bacterial organism
identified non-typeable Haemophilus influenzae
H. flu identified primarily in children < 5, but reduced with routine immunization
Moraxella (Branhamella) catarrhalis
may be changing due to heptavalent pneumococcal vaccine
decrease in S. pneumoniae and increase in H. influenzae
Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b
Acute Otitis Media Risk Factors Formula feeding
incidence of otitis media is higher in formula-fed infants vs. breast-fed infants
incidence of prolonged ear infections was 5x higher among formula-fed infants
Duration OM episodes longer (8.8 vs. 5.9 days)
J Pediatric 1995 May;126(5 Pt 1):696 Level 2b
Acute Otitis Media Risk Factors Day Care Attendance
day care associated with increased risk of upper and lower respiratory tract illnesses in first year of life for children with familial history of atopy
prospective birth cohort study of 498 children with parental history of allergy or asthma followed prospectively for first year of life
Pediatrics 1999 Sep;104(3):495 Level 2b
Acute Otitis Media Risk Factors. Associated with 2 or more doctor-
diagnosed ear infections (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.7-3.6)
For children attending day care independent predictors of 2 or more doctor-diagnosed ear infections included exposure to pets in day care presence of rug or carpet in area where child
slept in day care nonresidential setting for day care
Pediatrics 1999 Sep;104(3):495 Level 2b
Acute Otitis Media Risk Factors Passive Smoking
625 Children Calgary first graders Middle ear disease
2 or more household smokers (crude odds ratio) [OR], 1.85; 95% confidence interval [CI], 1.15-2.97
10 or more cigarettes smoked by the mother per day (crude OR, 1.68; 95% CI, 1.12-2.52)
10 or more cigarettes smoked in total in the household per day (crude OR, 1.40; 95% CI, 0.98-2.00) during the first 3 years of life
Arch Pediatric Adolescent Med. 1998 Feb;152(2):127 Level 2c
Acute Otitis Media History
Poor predictive value Studies are not good
Statistics LR+ greater than 5 good LR- less than 0.5 good Specificity to rule in Sensitivity to rule out
Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
Acute Otitis Media
Symptom LR+ LR- Sensitivity Specificity
Ear rubbing 3.20 0.670 42% 87%
Ear pain 3.00 0.560 54% 82%
Excessive crying 1.80 0.650 55% 69%
Rhinitis 1.30 0.580 75% 43%
Restless sleeping 1.30 0.710 64% 51%
Poor appetite 1.10 0.970 36% 66%
Vomiting 1.00 1.000 11% 89%
Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
Acute Otitis Media Physical Findings
Based on prospective study of 8,859 ear-related visits among children 0.5-2.5 years with acute symptoms
myringotomy performed if middle ear effusion suspected on exam
51.5% had acute otitis media (i.e. middle ear effusion confirmed on myringotomy)
Color not particularly helpful but cloudy membrane predictive
red color was not highly predictive cloudy tympanic membrane had 80-96% positive predictive
value normal color dramatically reduces likelihood of AOM (2-5%
probability of middle ear effusion if normal color)
Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b
Acute Otitis Media Physical Continued
Position helpful if clearly bulging bulging tympanic membrane had 89-96%
positive predictive value retracted tympanic membrane had 47-
50% positive predictive value normal position had 22-32% probability of
AOM
Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b
Acute Otitis Media Mobility helpful if distinctly impaired
or clearly normal distinctly impaired mobility had 78-94%
positive predictive value slightly impaired mobility had 33-60%
positive predictive value normal mobility dramatically reduces
likelihood of AOM (2-5% probability of middle ear effusion if normal mobility)
Acute Otitis MediaTest Name
Positive Likelihood Ratio
TM position: bulging 51.00
TM color: cloudy 34.00
TM mobility: distinctly impaired
31.00
TM color: distinctly red 8.40
TM mobility: slightly impaired 4.00
TM position: retracted 3.50
TM color: slightly red 1.40
TM position: normal 0.50
TM color: normal 0.20
TM mobility: normal 0.20
Acute Otitis Media Type A pattern is
normal Type B pattern is
consistent with MEE
Type C is seen with retracted TM
Acute Otitis Media Prognosis Spontaneous resolution is the
norm 81% spontaneously resolve (1)
5000 children with otitis(2)
>90% resolved with supportive care 2.7% had a severe course (required
antibiotics or myringotomy at 5 days)
1) Pediatrics 5 May 2004 113:1452 Level 1a
2) Br Med J (Clin Res Ed). 1985 Apr 6; 290(6474):1033 Level 1b
Acute Otitis Media Prognosis Recurrent otitis media no long term
consequences usually spontaneous recovery study of 222 children with recurrent otitis
media who received no prophylaxis 4% developed chronic otitis media with effusion 12% continued having recurrent episodes most significant risk factor for continued
recurrence was age < 16 months (1)
1) Pediatrics 5 May 2004 113:1452 Level 1a
Acute Otitis Media Prognosis
Persistent effusion Watchful Waiting recommended in children
without the following: Permanent hearing loss independent of OME Suspected or diagnosed speech and language
delay or disorder Autism-spectrum disorder and other pervasive
developmental disorders syndromes (e.g., Down) Craniofacial disorders that include cognitive,
speech, and language delays Blindness or uncorrectable visual impairment Cleft palate with or without associated syndrome Developmental delay
Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a
Acute Otitis Media Prognosis
Persistent effusion Change from B to non-B tympanogram
favorable 25% of OME of unknown duration
resolves in 3 months Warn parents of decreased hearing while
effusion present Recheck every three months
Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a
Acute Otitis Media Treatment Treat Pain
Acetaminophen and ibuprofen (1)
219 children treated with cefaclor evaluated pain at 2 days
Ibuprofen 7% with pain NNT 5 Acetaminophen 10% with pain NNT 6 Placebo 25%
1) Fundam Clin Pharmacol. 1996;10(4):387 Level 1c
Acute Otitis Media Treatment Initial treatment options are observation or
antibiotics for children < 6 months old, antibiotics recommended for children 6 months to 2 years old observation
option recommended only if all of the following are present
otherwise healthy child uncertain diagnosis non-severe illness follow-up can be ensured so antibiotics can be started if
symptoms persist or worsen
antibiotics recommended if certain diagnosis of AOM, severe illness, or follow-up cannot be ensured
Acute Otitis Media Treatment
For children > 2 years old Observation option recommended only if the
following are present otherwise healthy child uncertain diagnosis OR non-severe illness follow-up can be ensured so antibiotics can be
started if symptoms persist or worsen
Antibiotics recommended if certain diagnosis of AOM and severe illness, or follow-up cannot be ensured
DynaMed Acute Otitis Media Accessed March 19 2005
Acute Otitis Media Treatment No improvement in 48-72 hours
Confirm the diagnosis If AOM certain then begin antibiotics if
not already started Change antibiotics if already started
Acute Otitis Media Treatment Antibiotics
CDC guidelines for management and surveillance of acute otitis media in era of pneumococcal resistance
You must know your community
1) Pediatrics 5 May 2004;113(5):1452 Level 1a
Acute Otitis Media Treatment
Amoxicillin 80-90 mg/kg/day divided TID for 10 days
Failure at 3 days switch to one of the following cefuroxime axetil (Ceftin) 15 mg/kg BID for 10
days amoxicillin-clavulanate (Augmentin)
Augmentin 45 mg/kg/day divided BID or 40 mg/kg/day divided TID, both for 10 days
ceftriaxone (Rocephin) IM 50mg/kg for 3 days
1) Pediatric Infect Dis J. 1999 Jan;18(1):1 Level 1a
Acute Otitis Media Treatment Penicillin Sensitive patients
Not Type I reaction (no urticaria or anaphylaxis) (1)
Cefdinir (Omnicef) 14 mg/kg divided once daily or BID for 5 days (BID dosing) or 10 days (once daily dosing) slightly better taste (2)
Cefpodoxime (Vantin) 10 mg/kg once daily for 10 days or divided BID for 5 days
Cefuroxime (Ceftin or Zinacef) 30 mg/kg divided BID for 10 days
Ceftriaxone (Rocephin) 50mg/kg IM once
1) Pediatrics 5 May 2004;113(5):1452 Level 1a 2) Pediatric Infect Dis J 2000 Dec;19(12 Suppl):S181 Level 3
Acute Otitis Media Treatment Penicillin Sensitive Patients
Type I reaction Azithromycin (Zithromax) 10 mg/kg day one then
5 mg/kg days 2-5 Clarithromycin (Biaxin) 15 mg/day divided BID for
10 days Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg
daily of erythromycin divided TID to QID for 10 days
Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10 mg/kg daily of trimethoprim divided BID for 10 days
Pediatrics 5 May 2004;113(5):1452 Level 1a
Acute Otitis Media Reality Shorter therapy 5 days is likely as
beneficial as longer therapy (1)
Early treatment with antibiotics may lead to increased resistance (2)
Side effects are as common as benefit NNT 15-17 at 1 week NNH 17 at one week
Delayed antibiotics result in decreased use and decreased likelihood of asking for antibiotics in the future (3)
1) JAMA. 1998 Jun 3;279(21):1736 Level 1a2) J Infect Dis. 2001 Mar 15;183(6):880 Level 43) BMJ 2001 Feb 10;322:336 Level 1c
Acute Otitis Media Guideline Review
Pediatrics 2004 May;113(5):1451 Summary can be found in Am Fam
Physician 2004 Jun 1;69(11):2713 editorial can be found in Am Fam
Physician 2004 Jun 1;69(11):2537 commentary can be found in Pediatrics
2004 Sep;114(3):898 commentary can be found in Pediatrics
2005 Feb;115(2):513
Serous Otitis Media
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Serous Otitis Media Causes Causes
Overgrowth of lymphoid tissue in the nasopharynx
Chronic sinus infection Allergies of nose and nasopharynx Gastric reflux implicated
Pepsin seen in MEE 45 of 54 children with SOM (1)
Pepsin seen in MEE 59 of 65 children with SOM (2)
1) Lancet 2002 Feb 9;359(9305):493 Level 42) Laryngoscope. 2002 Nov;112(11):1930 Level 4
Serous Otitis Media Complications Permanent hearing loss (?) (5)
Tympanosclerosis Fibrosis of middle ear space Balance problems (1)
Minor language deficits (+/-) (2)
No association with attention or behavior in first 6 years of life (3)
Possible behavior problems in teens (4)
1) Pediatrics. 1997 Mar;99(3):334 Level 42) Pediatrics. 2000 May;105(5):1119 Level 2c3) Pediatrics. 2001 May;107(5):1037 Level 1b
4) Arch Dis Child. 2001 Aug;85(2):91 Level 1b5) Pediatrics. 2000 Sep;106(3):E42 Level 1c
Serous Otitis Media Physical Physical examination
Pearly gray Minimal dullness Minimal retraction Presence of effusion
Serous Otitis Media Tests Key tests
Pneumo-otoscopy with limited movement (1)
Sensitivity of 94% (95% CI: 92%-96%) Specificity of 80% (95% CI: 75%-86%)
Tympanogram B-curve (2)
81% sensitivity 56% specificity
Audiometry Carhart Notch (2) 77% sensitivity 98% specificity
1) Pediatrics. 2003 Dec;112(6 Pt 1):1379 Level 1a2) Clin Otolaryngol. 2003 Jun;28(3):183 Leve 1c
Serous Otitis Media Prognosis High rate of spontaneous resolution (1)
Most resolve in 3 months Meta-analysis 11 trials (2)
No significant hearing loss No speech/language delay
Tubes have consequences (3)
140 children followed 8 years Sequela higher at 3-5 years
47% for retraction pocket 67% for tympanic membrane atrophy 40% for myringosclerosis 23% for hearing loss
1) Pediatrics 2004 May 5;113(5):1412 Level 1a2) Pediatrics 2004 March; 113(3): e238 Level 1a3) Arch Otolaryngol Head Neck Surg. 2003 May;129(5):517 level 1b
Serous Otitis Media Treatment Medications
Antibiotics not beneficial (1)
Most rigorous meta-analysis find no benefit long-term
Some short-term benefit may exist Steroids
Nasal steroids no evidence of benefit (2)
Systemic steroids no difference long term (3)
1) J Fam Pract. 2003 Apr;52(4):321 FPIN network answer2) Cochrane Library 2002 Issue 4:CD001935 Level 1a3) Pediatrics. 2002 Dec;110(6):1071 Level 2b
Serous Otitis Media Treatment Surgery no clear evidence of benefit
RCT of a birth cohort that developed MEE (1)
Randomized to early tube placement or delay of 6 months (unilateral MEE) to 9 months (bilateral MEE)
Delayed group had better outcomes cognition, language (not significant) at age 3
Reduced time with MEE but no change in language or hearing (2)
No change in quality of life1) N Engl J Med. 2001 Apr 19;344(16):1179 Level 1b2) Cochrane Library 2005 Issue 1:CD001801 Level 1a
Serous Otitis Media Treatment
Surgery no clear evidence of benefit Cohort 30,099 children born in the Netherlands
Routine hearing screening at age 9 months 1,081 who failed 3 successive hearing screens were
referred to ENT surgeon 386 found to have persistent bilateral otitis media with
effusion for 4-6 months 187 children (mean age 19.5 months) were
randomized to ventilation tubes vs. watchful waiting and followed for 1 year with language tests
Ventilation tubes reduced diagnoses of bilateral otitis media with effusion at all measurements (NNT 2-4),
No differences in language development Pediatrics 2000 Sep;106(3):e42 Level 1c
Serous Otitis Media Treatment Post-tube precautions
unrandomized trial in 533 children who underwent tympanostomy tube placement
parents self-selected into 1 of 3 "treatments" to prevent complications of swimming
no additional precautions antibiotic drops following swimming ear molds worn during swimming control group consisted of children who never went
swimming all were given precautions against deep water swimming
(> 180 cm), diving and soapy water in ears during bathing no benefit was noted from antibiotic ear drops or ear
plugs
Arch Otolaryngol Head Neck Surg. 1996 Mar;122(3):276 Level 2b
Questions?