Otitis MediaOtitis Media

Lawrence PikeLawrence Pike

DefinitionDefinition

• Inflammation of the middle ear Inflammation of the middle ear nearly always preceded by an URTI. nearly always preceded by an URTI.

CausesCauses

• Organisms in children include viruses (min. Organisms in children include viruses (min. 25%), Haemophilus influenzae (25%), 25%), Haemophilus influenzae (25%), Moraxella catarrhalis(15%), Streptococcus Moraxella catarrhalis(15%), Streptococcus pneumoniae (25%) and Staphlococcus pneumoniae (25%) and Staphlococcus aureus (2%). aureus (2%).

• Organisms in adults include viruses most Organisms in adults include viruses most commonly. commonly.

• The term recurrent is defined as 3 or more The term recurrent is defined as 3 or more episodes in 6 months, or 4 or more in a year. episodes in 6 months, or 4 or more in a year.

IncidenceIncidence

• Approximately 40% of children suffer Approximately 40% of children suffer one or more episodes before the age one or more episodes before the age of 10 years. More cases are seen in of 10 years. More cases are seen in the winter months. the winter months.

• Uncommon in adults. Uncommon in adults.

SymptomsSymptoms

• Pain Pain – Usual onset at night and severe for 12 hrs, then settles Usual onset at night and severe for 12 hrs, then settles

and niggles for 3-5 daysand niggles for 3-5 days

• Discharge can occur (and often relieves pain)Discharge can occur (and often relieves pain)• Fever, vomiting and loss of appetite may occur, Fever, vomiting and loss of appetite may occur,

especially in young children. especially in young children. • Occasionally tinnitus, voice resonance, giddiness Occasionally tinnitus, voice resonance, giddiness

and sickness occur. and sickness occur. • Irritability may be the only indication in infants. Irritability may be the only indication in infants. • Hearing loss occurs if accumulation of fluid has Hearing loss occurs if accumulation of fluid has

taken place. taken place.

SignsSigns

• change of colour of the tympanic change of colour of the tympanic membrane to pink/red membrane to pink/red

• bulging drumbulging drum• loss of outline of drum and landmarksloss of outline of drum and landmarks• discharge in meatus discharge in meatus • perforation. perforation. • there may be tenderness over the there may be tenderness over the

mastoid.mastoid.

Risk FactorsRisk Factors

• Passive smokerPassive smoker

• MaleMale

• Family history of otitis media. Family history of otitis media.

• In day careIn day care

• On formula feedOn formula feed

Differential DiagnosisDifferential Diagnosis

• Furuncle or diffuse otitis externa Furuncle or diffuse otitis externa

• Post auricular adenitis Post auricular adenitis

• Referred otalgia (eg from teeth) Referred otalgia (eg from teeth)

• Herpetic lesion of earHerpetic lesion of ear

What can go wrong?What can go wrong?

• Progression to glue ear or perforation. Progression to glue ear or perforation. Rarely to mastoiditis, labyrinthitis, Rarely to mastoiditis, labyrinthitis, meningitis, intracranial sepsis or facial meningitis, intracranial sepsis or facial nerve palsy. nerve palsy.

• Recurrent episodes may lead to atrophy Recurrent episodes may lead to atrophy and scarring of the eardrum, chronic and scarring of the eardrum, chronic perforation and otorrhoea, cholesteatoma, perforation and otorrhoea, cholesteatoma, permanent hearing loss, chronic permanent hearing loss, chronic mastoiditis and intracranial sepsis. mastoiditis and intracranial sepsis.

TreatmentTreatment

• 80% will resolve within 3 days without treatment, 80% will resolve within 3 days without treatment, 95% in 5 days 95% in 5 days

• Antibiotics may improve short term symptoms, Antibiotics may improve short term symptoms, although evidence for any gain in medium to long although evidence for any gain in medium to long term outcome is lackingterm outcome is lacking

• Countries with lower rates of antibiotic Countries with lower rates of antibiotic prescribing for acute otitis media do not have an prescribing for acute otitis media do not have an increase in the number of complicationsincrease in the number of complications

• The Standing Medical Advisory Committee The Standing Medical Advisory Committee concluded that 'antibiotics are probably concluded that 'antibiotics are probably unnecessary in acute otitis media. Reassurance, unnecessary in acute otitis media. Reassurance, time and adequate pain relief are required.' time and adequate pain relief are required.'

TreatmentTreatment

• Simple analgesiaSimple analgesia– ParacetamolParacetamol– Ibuprofen (some evidence superior) Ibuprofen (some evidence superior)

• There are no published controlled There are no published controlled trials to support the use of trials to support the use of antihistamine and decongestant antihistamine and decongestant preparations. preparations.

Antibiotic Treatment (if Antibiotic Treatment (if chosen)chosen)• ChildrenChildren and Adultsand Adults

– Amoxycillin limited to three days [SMAC Amoxycillin limited to three days [SMAC 1998] 1998]

• In patients with penicillin allergyIn patients with penicillin allergy– Clarithromycin or azithromycin are both Clarithromycin or azithromycin are both

effective and are active against the effective and are active against the common pathogen H influenzae. common pathogen H influenzae.

– Erythromycin may be useful, although it Erythromycin may be useful, although it lacks activity against H. influenzae lacks activity against H. influenzae