Otitis Media Jahangir Ghorbani MD.

Division of Rhinology

Department of Otorhinolaryngology, Head & Neck Surgery

Massih Daneshvari Hospital

SBMU

ACUTE OTITIS MEDIA (AOM),

OTITIS MEDIA WITH EFFUSION

(OME) & MIDDLE EAR EFFUSION

(MEE)

Generally a childhood disease

In most children it resolves with anatomic

and physiologic changes with growth.

Until the condition has resolved, it may

affect balance, hearing, and speech and

language development and cause poor

school performance.

COSTS

It is more than the cost for medicine or

visits to the doctors.

Enduring sleepless nights due to a crying

child, having to take off from work to stay

home with the child, and taking the child

to the doctors can be very stressful for the

family.

DIAGNOSIS

Rapid onset of signs and symptoms of

inflammation in the middle ear

accompanied by middle ear effusion

(MEE).

Signs of inflammation include bulging or

fullness of the tympanic membrane

Erythema of the TM

Acute perforation of the TM with otorrhea.

SYMPTOMS

Otalgia

Irritability

Fever

OME

MEE without signs and symptoms of acute

inflammation as found in AOM.

PHYSICAL EXAMINATION

Complete examination of head & neck

Facial features should be assessed for

craniofacial anomalies: Down syndrome

and Treacher Collins syndrome.

Examination of the oropharynx may show

a bifid uvula or a cleft palate.

PHYSICAL EXAMINATION

Pneumatic otoscopy is the primary diagnostic tool to evaluate the status of the middle ear, because it allows assessment of the TM and its mobility.

The normal TM is translucent and concave and moves briskly with application of positive and negative pressure.

Reduced or no mobility of the TM

indicates loss of compliance of the TM,

either as a result of effusion in the middle

ear or from increased stiffness due to

scarring or increased thickness.

OTOSCOPY Fluid levels or bubbles

The position of the TM ranges from severely retracted to bulging.

Mild to moderate retraction indicates negative pressure, MEE, or both, whereas a severely retracted TM usually is associated with effusion.

Fullness and bulging of the TM are caused by increased pressure or fluid, or both, in the middle ear.

Opacification of the TM may be caused by thickening or scarring or presence of MEE.

A red but translucent TM is a typical finding in a crying or sneezing infant, secondary to engorgement of blood vessels in the TM. On the other hand, a ―red‖ TM that is full or bulging often is a sign of AOM.

A pink, gray, yellow, or blue retracted TM with reduced or no mobility usually is seen with OME.

Myringitis is inflammation of the TM without fluid in the middle ear. Use of an operating microscope may clarify features seen on otoscopy.

TYMPANOMETERY

When otoscopic evaluation is

inconclusive or difficult to perform,

tympanometry can be very useful in

evaluating ear disease in children older

than 6 months of age.

TYMPANOMETERY

TW < = 150 daPa no OME

TW > = 350 daPa OME

TW 150 to 350 daPa: presence or absence

of OME is determined by otoscopy.

AUDIOMETERY

MEE usually results in a mild to moderate

conductive hearing loss.

The assessment of hearing is essential to

management, because hearing

impairment can predispose the affected

child to delays in speech and language

development and may later affect school

performance.

AUDIOMETERY

Behavioral audiometery

Auditory brain stem response(ABR)

Otoacoustic emission(OAE)

Pure tone audiometery(PTA)

PATHOLOGY & PATHOGENESIS

The pathophysiology of otitis media is

multifactorial, with various overlapping

factors

EUSTACHIAN TUBE

Functions of the eustachian tube

(ET)–middle ear (ME)— mastoid (Mast) gas cell system. A, Pressure regulation function is related to active dilation of the tube by contraction of the tensor veli palatini muscle (TVP). B, Protective function is dependent in part on an

intact middle ear and mastoid gas cells to maintain a gas cushion. C, Clearance function is enhanced by mucociliary activity and muscular activity during tubal closing. EC, external canal; NP, nasopharynx; TM, tympanic membrane.

The otitis-prone children had

significantly poorer active tubal

function than the normal control

subjects, suggesting that recurrent AOM

is the result of functional obstruction of

the eustachian tube.

BACTERIOLOGY (Before the year 2000)

AOM

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis;

Chronic OME

H. influenzae

S. Pneumoniae

M. catarrhalis

VACCINE

Data from vaccine trials conducted in

California and Finland revealed only a

7.8% and a 6% relative risk reduction,

respectively, in AOM.

VACCINE A decrease in recovery of S. pneumoniae

Increase in H. influenzae

S. pneumoniae vaccine serotypes were not found in middle ear fluid of vaccinated children;

H. influenzae remained a major pathogen of AOM

Nonvaccine serotypes were more frequent in those who received more than one dose of vaccine.

BIOFILMS Biofilms have been known to exist on hard

surfaces such as metal pipes or teeth. However, recent animal and human studies have suggested that biofilms can also be isolated from the middle ear.

Biofilms also have been identified in the nasopharynx of children with otitis media, and it was suggested that the biofilm may act as a reservoir for bacterial pathogens resistant to antibiotics.

VIRUSES Using PCR techniques, however, it has been

possible to identify respiratory syncytial virus (RSV), influenzavirus, adenovirus, parainfluenza virus, and rhinoviruses in MEE.

In a majority of children, viral infection of the upper respiratory tract mucosa initiates the whole cascade of events that finally leads to the development of AOM, and AOM may be regarded as a complication of a preceding or concomitant viral infection.

ALLERGY & IMMUNOLOGY

Even though allergy is considered to

play a role in the pathogenesis of otitis

media, the causal mechanism is not

understood, and well-controlled studies

to prove the efficacy of antiallergic

medication in the treatment of OM

are lacking.

Children with major immune

deficiencies may have recurrent otitis

media as part of their overall clinical

picture, but most otitis-prone children

may have only a subtle immunologic

abnormality that predisposes them to

recurrent infections.

GASTROESOPHAGEAL REFLUX

Pepsin/ pepsinogen was found in 90.8%

of MEE samples obtained at the time

of myringotomy in children.

EPIDEMYOLOGY

Although the highest incidence of

otitis media is in young children, it also

occurs in older children, adolescents,

and adults.

Multivariate analysis showed that those

living below the poverty level were at

increased risk of recurrent OM.

In a majority of studies, the peak

incidence of AOM was during the first 6

to 12 months of life. The incidence

decreases with age.

Otitis Media with Effusion

It may be difficult to determine the

―true‖ incidence of OME because, by

definition, OME is asymptomatic.

PREVENTION

Environmental factors

Vaccine

PCV13 is recommended for all children

2 to 59 months of age, as well as for

children 60 to 71 months of age with

increased susceptibility to

pneumococcal disease.

Immunocompromised adults 19 years of

age and older as well as those with

cerebrospinal fluid (CSF) leaks or

cochlear implants.

TREATMENT

Observation

Medical treatment

Surgery

OBSERVATION in AOM

With close follow-up is an option for young children (6 to 23 months of age) with nonsevere unilateral AOM and for children 24 months and older with nonsevere unilateral or bilateral AOM.

―Nonsevere‖ :―without severe signs or symptoms, i.e., mild otalgia for less than 48 hours, temperature less than 39°C (102.2°F),‖ and follow-up in case the child worsens or fails to improve within 48 to 72 hours of the onset of symptoms is stressed. The new guidelines also strongly recommend pain management

MEDICAL TREATMENT for AOM

Antibiotics

ANTIBIOTICS in AOM

Amoxicillin: is still the first-line antibiotic for AOM.

80 to 90 mg/kg/day in two divided doses.

Amoxicillin–clavulanic acid:(amoxicillin 90 mg/kg/day and clavulanic acid 6.4 mg/ kg/day in two divided doses). For children who have been treated with amoxicillin in the previous 30 days, for those with concurrent purulent conjunctivitis, or for those with a history of recurrent AOM unresponsive to amoxicillin.

Cephalosporins: cefdinir, cefuroxime, cefpodoxime, and ceftriaxone should be considered as acceptable first-line treatment only for patients with penicillin allergy.

INITIAL TREATMENT FAILURE The diagnosis should be reassessed and

antibiotics started if not given previously.

If initial treatment failure occurs after antibiotics were previously prescribed, the antibiotic should be changed to a broader-spectrum agent (amoxicillin–clavulanic acid if amoxicillin failed to produce improvement, and ceftriaxone, 50 mg intramuscularly or intra- venously for 3 days if amoxicillin–clavulanic acid was not effective).

TYMPANOCENTESIS

Considered if the child does not respond

to the antibiotic treatment, in order to

identify the bacteria.

DURATION of TREATMENT Ten days of antibiotic treatment has been

the standard.

The recent U.S. Guidelines: the standard 10-day course of therapy for younger children and for children with severe disease.

A 7-day course appears to be effective in children 2 to 5 years of age with mild to moderate AOM.

For those 6 years of age and older with mild to moderate disease, a 5 to 7 day course may be used.

APPROVED SHORT COURSES

Cefpodoxime proxetil and cefdinir

have each been approved for a 5-day

course.

Azithromycin for 1-, 3-, and 5-day

courses.

One dose of IM ceftriaxone may be

given, although results for penicillin-

resistant S. pneumoniae are better with a

3-day course.

DECONGESTANT/ANTIHISTAMIN

ES

In AOM no benefit of these agents for

early cure, symptom resolution, or

prevention of surgery or complications.

STEROIDS

RECURRENT ACUTE OTITIS

MEDIA

ANTIBIOTIC PROPHYLAXIS Antimicrobials are effective in preventing

disease.

This method is not recommended, however, because of the potential for increasing resistant organisms and potential complications.

Rather than daily medicine given for months at a time, treating intermittently at the time of upper respiratory tract symptoms has been tried, but efficacy is less than with continuous medication

SURGERY

Myringotomy/Tympanocentesis.

Myringotomy with Tympanostomy Tube

Insertion

Adenoidectomy with and without

Tonsillectomy.

OTITIS MEDIA WITH EFFUSION

OBSERVATION For children not at risk for speech and language or

learning disabilities.

Hearing testing should be done if MEE persists for 3 months or longer or at any time that language delay, learning difficulties, or significant hearing loss is suspected. If the average hearing level is below 20 dB, watchful waiting is suggested, but if it is greater than 40 dB in the better ear, surgery is recommended. For children with hearing levels in the better ear between 21 and 39 dB, management is based on the duration of effusion and severity of symptoms. For children not at risk, examination at 3- to 6-month intervals is recommended until the fluid has resolved; hearing loss or language or learning delays are identified; or structural abnormalities of the eardrum are suspected.

MEDICAL TREATMENT

Decongestant/Antihistamine

Antibiotics: Despite short-term efficacy,

antibiotics are not recommended for

routine treatment of OME, due to lack

of long-term efficacy, the high

spontaneous cure rate, and concern

about overuse of antibiotics.

STEROIDS

In clinical trials, systemic steroids have

demonstrated an advantage over

placebo in resolving MEE, but owing to

the high recurrence rate after treatment,

steroids are not recommended for long-

term management.

SURGERY

M&T provided more disease-free time

and better hearing than myringotomy

only or no surgery.

ADENOIDECTOMY

Chronic OME showed that

adenoidectomy alone and M&T alone

provided better results than no surgery,

but the combination of the two

surgical procedures provided better

results than either alone.

GUIDELINES for SURGERY

Surgical candidates are children with (1)

OME lasting 4 months or longer with

persistent hearing loss or other signs or

symptoms; (2) recurrent or persistent

OME associated with increased risk of

developmental problems regardless of

hearing status; and (3) OME and

structural damage to the TM or middle

ear

COMPLICATIONS

ACUTE MASTOIDITIS In the early stage, there are no specific signs and symptoms of

mastoid infection. With later progression to:

erythema

tenderness over the mastoid area

edema

subperiosteal abscess

displacement of the pinna inferiorly and anteriorly and obliteration of the postauricular crease.

The CT scan in the early stage most frequently shows a cloudy mastoid; the inflammatory process may progress and develop into osteitis, with destruction of the mastoid bone. Mastoiditis with and without periosteitis often responds to medical treatment and tympanocentesis or tympanostomy tube insertion, whereas mastoiditis with osteitis and bone destruction usually requires cortical mastoidectomy and tympanostomy tube placement.

INTRACRANIAL

COMPLICATIONS

Suppurative intracranial complications due to AOM include:

meningitis

epidural abscess

subdural empyema

focal otitic encephalitis

brain abscess

sigmoid sinus thrombosis

lateral sinus thrombosis

otic hydrocephalus.

symptoms

persistent headache

lethargy

malaise

irritability

severe otalgia

fever, and nausea

vomiting

signs

stiff neck

focal seizures, ataxia

blurred vision

papilledema,

Diplopia

hemiple- gia

aphasia

intention tremor

cranial nerve deficits other than of the facial nerve

dysmetria

hemianopia. Any child with an intracranial infection such as meningitis or brain abscess should be evaluated for middle ear disease.

Antibiotics for clinically diagnosed acute rhinosinusitis in

adults.

Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.:

CD006089. DOI: 10.1002/14651858.CD006089.pub4.

Copyright © 2012 The Cochrane Collaboration. Published by

JohnWiley & Sons, Ltd.

The potential benefit of antibiotics in the treatment of clinically diagnosed acute rhinosinusitis needs to be seen in the context of a high

prevalence of adverse events. Taking into account antibiotic resistance and the very low incidence of serious complications, we conclude

that there is no place for antibiotics for the patient with clinically diagnosed, uncomplicated acute rhinosinusitis. This review cannot

make recommendations for children, patients with a suppressed immune system and patients with severe disease, as these populations

were not included in the available trials.