Otitis Media

Definitions

Clinical picture

• Children: URI followed by otalgia, fever, hearing loss, tinnitis, vertigo.
• Infants: Irritability, diarrhea, vomiting, malaise

Predisposing conditions

URI, eustachian tube dysfunctio, prematurity, cleft palate, hypertrophied adenoids, immune disorder, respiratory allergies, recurrence of otitis, smoke exposure, absence of breast feeding, sinusitis

Exam

• Hyperemic, opaque, bulging TM with poor mobility (pneumatic otoscopy)
• purulent otorrhea
• retracted TMs
• serous (thin), mucoid (thick), or purulent effusion
• air/fluid level or bubbles behind TM
• rough, cobblestoned surface of the TM; bullae on TM
• tympanosclerosis (focal thickening of the TM)
• flat tympanogram
• cholesteotoma (keratinizing squamous epithelium in the middle ear or mastoid space): locally invasive, can destroy the ossicles, cochlea, or semicircular canals.
• ispelateral conjunctivitis suggests H. influenza (treat with Augmentin, Ceftin, Biaxin, etc.)

Pathogens

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• (less common: Staphylococcus aureus, Group A Alpha Streptococcus, Pseudomonas aeruginosa)
• In neonates: Gram negative bacteria, Staphylococcus aureus, Group B Streptococcus.

Treatment

• 80% clear spontaneously ("favorable natural history of untreated otitis")
• 10 to 15% cured due to antibiotics
• Begin with amoxacillin 40 mg/kg/day divided TID x 10 days
• Use higher dose amoxacillin is recommend for:
• children under 2 years of age
• children in a day care setting
• children with history of Recurrent AOM
• Alternatives
• erythromycin/sulfamethoxazole
• amoxacillin/clavulinic acid
• trimethoprim/sulfamethoxazole
• cefuroxime
• cefixime
• cefpodoxime
• Consider the rist of accelerating bacterial resistance with antibiotic overuse
• Antipyretics/analgesics/pain relief
• Heat
• Auralgen drops (antipyrene, benzocaine, glycerin) if TM intact
• No proven efficacy of antihistimines or decongestants in OM
• Myringotomies

Problems with overdiagnosis and treatment

• Development of resistent organisms (especially in daycare settings)
• Missed diagnoses (eg, UTI) when misdiagnosed as otitis

Follow Up

• Usually defervesce and have no more otalgia by day 3 of treatment
• Reexamine in 3 weeks for decreased erythema and improved mobility
• Consider retreatment with same or alternative antibiotic.  Avoid overtreatment.
• Consider hearing testing (repeated if effusion persists)

Recurrent AOM

• Consider prophylaxis (discouraged)
• Myringotomies with ventilation tubes
• If hearing loss despite antibiotic treatment
• If effusion persists 4-6 months with bilateral hearing loss
• Consider polyvalent pneumococcal vaccine (for children over 2 years)
• Role of immunotherapy is children with upper airway allergy is unclear
• Consider adenoidectomy
• Consider flu vaccine
• Counsel about predisposing factors, eg smoke exposure

Complications

• Hearing loss (effusions or negative pressure in middle ear)
• Audiogram shows conductive hearing loss; may have sensorineural too
• May be temporary or permanent
• May have associated speech/language problems
• Perforations (treat as AOM, but add cortisporin otic suspension QID to ear canals).
• Mastoiditis (CT scan)
• Cholesteotoma: sac of desquamated epithelium cells
• Meningitis/brain abcess

OME (Otitis media with effusion)

• Occurs in 50% of children after AOM (90% clear by 3 months)
• Be patient, recheck, may last for months
• Check hearing if OME persists more than 3 months
• Consider steroid/antibiotic therapy for patients older than 3 years
• Myringotomy tubes if:
• Hearing loss with otalgia, recurrent AOM, retraction pockets, speech delay, antibiotic intolerance
• OME for 4 to 6 months with hearing loss
• Adenoidectomy for older children (over 3 years old)
• Monitor with otoscopy and audiometry every 3 to 4 months

Recommended Reference

Acknowlegment