otitis media - xinhui

8/14/2019 Otitis Media - XinHui

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OTITIS MEDIA

LOH XIN HUI

21/10/09


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THE STRUCTURE OF THEHUMAN EAR

Is a sense organ for hearing and balance. Can be divided into 3 portions:

The outer ear, containing air The middle ear, containing air The inner ear, containing fluid

Otitis media is an infection or inflammation

of the middle ear. (the cavity between the

eardrum and the inner ear).


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WHAT IS OTITIS MEDIA?

Otitis media(OM) is an infection or inflammation of themiddle ear.

This inflammation often begins when infections that causesore throats, colds, or other respiratory problems spreadto the middle ear.

OM is primarily a disease of infants and young children, butit can also affect adults. Highest incidence occurs between 6-24months of age. Slightly more common in boys than girls. Incidence declines after the second year of life.


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DESCRIPTION OF OTITIS MEDIA

The eustachian tubes equalize the pressure between themiddle ear cavity and the outside atmosphere and allowfluid and mucus to drain out of the middle ear cavity.

Bacteria from the back of the nose can travel through

the lining or passageway of eustachian tube directly intothe middle ear cavity and get trapped. These germs canbreed in the trapped fluid.

If the eustachian tube gets infected/inflammed, thefluid cannot drain through the tube, causing obstruction

of the eustachian tube, results in an ear infection.


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RISK FACTORS OF OTITISMEDIA

Kids develop ear infections more frequently in the first 2 to 4 years oflife for several reasons: Their eustachian tubes are shorter and more horizontal than those

of adults, which allows bacteria and viruses to find their way into themiddle ear more easily. Their tubes are also narrower and less stiff,

which makes them more prone to blockage. Daycare attendance More opportunity for spread of bacterial and

viral pathogens among children in daycare. Bottle-feeding Breastfeeding for at least 3 months diminishes

colonization of the nasopharynx by bacterial pathogens and isassociated with fewer episodes of OM. The reasons for the lower

incidence of OM in breastfeeding children are uncertain, but may bedue to immunologic or non-immune protective factors in breastmilk. Exposure to cigarette smoke Mechanism is not entirely clear, but

may be associated with increased nasopharyngeal and oropharyngealcarriage of Streptococcus pneumonia.

Family history of OM


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COMMON PATHOGENS IN OTITISMEDIAOtitis media can be viral or bacterial infection.

BACTERIA INFECTION Streptococcus pneumonia, Haemophilus influenzae, and

Moraxellacatarrhalis are the bacteria most commonlyinvolved in otitis media. Less common causes are Mycoplasmaspecies,

staphylococcus aureus and anaerobic bacteria.

VIRAL INFECTION Most frequently isolated viruses are respiratory syncytial

virus, rhinoviruses, influenza viruses, and adenoviruses.


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TYPES OF OTITIS MEDIA

(1) Acute Otitis Media (AOM) due to a bacterial (85%) or viral (15%) infection usually rapid onset and short duration

SIGNS & SYMPTOMS irritability, pain, fever, wakefulness occasional balance problems(vertigo) conjunctivitis (inflammation of the eye)

bulging and reddened ear drum. Drum may perforate(10-20%) causing a bloody, purulent discharge/pus(otorrhea)


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SIGNS AND SYMPTOMS ofAOM

For Children < 3 years old more often present with non-specific symptoms (eg.

fever, headache, anorexia, vomiting and diarrhea) Frequently, infants and toddlers with AOM have

associated upper respiratory infection symptoms. Infants may be asymptomatic - may tug at the ear

or simply act irritable and cry more than usual. Ear pulling without associated symptoms is usually not

a symptom of AOM.

For Children Ages Three and Older Symptoms include earache, drainage from ears,

hearing loss, vertigo, or dizziness.


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DIAGNOSIS

Diagnosis confirmed by the examination ofthe ear drum.

Normal Ear Drum

Ear Drum in Acute Otits Media

Diagnosis is considered certain if:

History of acute onset +

Demonstrable middle ear effusion +

Signs and symptoms of middle ear inflammation


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(2) RECURRENT ACUTE OTITIS MEDIA

more than 3 episodes of AOM in 6 months or >4episodes in 12 months.

is a major risk factor for OM with effusion andchronic suppurative OM.

Onset of OM before 6 months of age is strongpredictor for recurrent OM.


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(3) OTITIS MEDIA WITH EFFUSION(GLUE EAR)

is a build up of fluid in the middle ear for >3 months

follows AOM or viral URTI. Whenever fluid fills the midle ear, there is

conductive hearing impairment. NO signs and symptoms of acute infection (pain, redness

of the eardrum, pus, and fever). No perforation of the eardrum. Does not usually cause pain and tends to resolve

spontaneously. Associated with increased risk of permanent damage to

middle ear and impaired language development in children.


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(4) CHRONIC OTITIS MEDIA (SUPPURATIVE)

persistent inflammation of the middle ear for longer than 3months characterised by perforated eardrum andmucopurulent discharge.

often starts painlessly without fever. involves a perforation in the eardrum and active bacterial

infection within the middle ear. Following an acute infection, fluid (an effusion) may remain

behind the ear drum for up to 3 months before resolving. may be enough pus that it drains to the outside of the ear

(otorrhea) can cause ongoing damage to the middle ear and eardrum

May be accompanied with a subtle loss of hearing.


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TREATMENT

Management of pain

Pain is a common feature of AOM. Over-the-counter (OTC) remedies and medications can

alleviate the pain and symptoms of an ear infection, but

there are no OTC measures that kill the bacteria in themiddle ear space that actually cause the infection. The "feel better" measures that work the best are oral

pain medications like paracetamol or oral NSAIDs, suchas ibuprofen.

Since the infection is caused by bacteria in the middleear space on the other side of the eardrum, nothingapplied externally can help kill the bacteria through theintact eardrum.


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TREATMENT

An oral decongestant may relieve nasal congestion, andantihistamines may help patients with known orsuspected nasal allergy. However, the efficacy ofantihistamines and decongestants in treating AOM hasnot been proven.

A systematic review found that decongestants andantihistamines alone or in combination did notimprove healing or other complications in AOM .

Otic solution is administered when inflammation is inmucosa of the middle ear locally. In case thatinflammation spreads to around eardrum, oral antibioticshould be considered along with otic administration.


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CRITERIA FOR INITIAL ANTIBACTERIALAGENT TREATMENT OR OBSERVATION INCHILDREN WITH OM

If patient is only mildly unwell, ~80% will resolve spontaneously otherwise, symptomatic treatment with paracetamol or NSAID

(ibuprofen) may be adequate.

Children with AOM who are younger than the age of 6 months should betreated with antibiotics, regardless of the degree of diagnostic certainty.

For children ages 6 months to 2 years, antibacterial therapy is recommendedwhen the diagnosis of AOM is certain, or if the diagnosis is uncertain butillness is severe (moderate to severe otalgia or fever >39C in the previous24hours).

Children older than 2 years, antibacterial therapy is recommended if thediagnosis is certain and illness is severe.

UpToDate


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ANTIBIOTIC TREATMENT

Controlled studies of effective antibiotics in the United States havedemonstrated 90-95% efficacy.

Although antibiotics are not effective against viral infections, it is oftendifficult to distinguish between a viral and a bacterial infection of the middleear. So, doctor may prescribe an antibiotic as a precautionary measure.

FIRST LINE THERAPY Amoxicillin

10-25 mg/kg 8H IV, IM or oral; or 20mg/kg 12H oral Severe infection: IV 50mg/kg 12H(1st wk of life), 6H (2-4wk), 4-6H or

constant infusion (4+ wk) Amoxicillin-clavulanate

Dose as amoxycillin is advantageous and more efficacious against beta-lactamase producing H.

influenzae and M. catarrhalis, but has the same efficacy as amoxicillin forS. pneumoniae.


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ANTIBIOTIC TREATMENT

IF ALLERGIC TO PENICILLIN,

Cephalosporins Cefuroxime

Oral: 10-15mg/kg 12H IV : 25mg/kg 8H

Severe infection: IV 50mg/kg(max. 2g) 12H (1st

wk life), 8H(2nd

wk), 6Hor constant infusion (>2wk).

Macrolides Erythromycin

Oral: 10mg/kg 6H (or 20mg/kg BD) Severe infection: 15-25mg/kg 6H

Clarithromycin Oral 7.5-15 mg/kg 12H

Azithromycin Oral: 15mg/kg on day 1, then 7.5mg/kg on day 2-5, or 15mg/kg daily for

3 days.

Co-trimoxazole (trimethoprim + sulfamethoxazole) TMP: 1.5-3mg/kg 12H IV over 1hr or oral.


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FOLLOW UP

Most cases of OM are self-limited. Once antibiotic treatment is initiated, patient should demonstrate

symptomatic benefit within 72 hours. Failure to show improvement indicates need for re-

evaluation. Although fever and discomfort may continue in a patient taking

antibiotics, they should improve daily. If the patients condition fails to improve within 48-72 hours,

compliance must be emphazized. If the patient has been adherent to the therapy, then the

antibiotic should be changed. Patients who do not respond to multiple antibiotic courses, or those

with persistent effusion, should be referred to ENT specialist forfurther evaluation and treatment.


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References

Australia Medicines Handbook 2007. Helms RA et al. Textbook of therapeutics: drug and disease

management. Lippincott Williams & Wilkins. 8th Edition. 2006.p312-318.

http://en.wikipedia.org/wiki/Otitis_media http://www.medicinenet.com/otitis_media/article.htm http://www.nidcd.nih.gov/health/hearing/otitism.asp UpToDate

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