Transcript Update: Otitis Media

ACUTE OTITIS MEDIA
OTITIS MEDIA
Huyønh Khaéc Cöôøng , M.D.
Senior Lecturer – Otolaryngology Department
University UMP at HoChiMinh City
Otitis Media

Otitis media is one of the most common
diagnoses among children

Nat’l Ambulatory Medical Care Surveys data
indicate that the number of office visits for OM
increased by more than 2-fold from 1975-1990

This survey estimated over 5.18 million
episodes of AOM in 1995 at a cost of $2.98
billion
Acute Otitis Media

OTITIS MEDIA = inflammation of the middle ear, is
defined by the presence of fluid in the middle ear
accompanied by signs or symptoms of acute illness.

The peak incidence occurs in the first 3 years of life.
The disease is less common in the school-aged child,
adolescents, and adults.

Nevertheless, infection of the middle ear may be the
cause of fever, significant pain, and impaired hearing in
these age groups.
Definitions
Acute Otitis Media with
Effusion (AOME):
 suppurative
 sudden
 short
 the
infection of the middle ear
onset
duration
inflamed tympanic membrane is bulging
and/or opacified
Definitions
Chronic Otitis Media
(COM)

COM with Effusion or nonsuppurative
OM :

Middle ear effusion behind an intact
eardrum

Persist for more than 2-3 months

Asymptomatic except for hearing loss

No acute symptoms
Definitions
Chronic Suppurative Otitis
Media
(CSOM):




chronic perforation of the TM
purulent discharge for >6 weeks
insidious onset
may follow AOM
Otitis Media Epidemiology
Most common bacterial infection in
children and most commonly diagnosed
 Half of all children will have an episode
before the first birthday, and 80% before
the third birthday
 The most frequent reason for
prescribing antibiotics

Otitis Media Epidemiology

It accounts for more than 1/3 of office
visits to pediatricians each year

The number of office visits continues to
rise, in 1997 it reached 25.9 billion

4-5 billion dollars spent each year in
direct care costs
Pathogenesis
The vast majority of children have no obvious defect responsible for severe and
recurrent otitis media, but a small number have anatomic changes (cleft palate, cleft
uvula, submucous cleft), alteration of normal physiologic defenses (patulous
eustachian tube), or congenital or acquired immunologic deficiencies.
Pathophysiology and Risk
Factors for Infection

The introduction of infants into large day care
groups increases the incidence of respiratory
infections, including otitis media.

Almost one episode of respiratory tract
infections a month occurs during the first year
of life, and AOM is a complication of about one
third to one half of the respiratory tract
infections.
Pathophysiology and Risk
Factors for Infection

Passive smoking increased the incidence of new
episodes of otitis media with effusion and the
duration of effusion.

The age at the time of the first episode of AOM
appears to be among the most powerful
predictors of recurrent middle ear infections.

Breast-feeding for 3 or more months is
associated with a decreased risk of AOM in the
first year of life.
Caùc Yeáu Toá Beänh Caên Hoïc
cuûa VIEÂM TAI GIÖÕA CAÁP
TÍNH
Otitis Media Risk Factors
 Host
factors
 Environmental
factors
Otitis Media Host Factors
Age < 2 years
 Gender ( Males > Females)
 Race (Native Americans, Alaskan>AA
and Caucasian)
 Genetic predisposition
 Sibling with history of recurrent disease
 Down’s syndrome, cleft palate, tumors,
immunodeficiency states

Otitis Media Environmental Factors

Allergies

Second hand smoke + wood burning stoves

Not breastfeeding

Seasonal

Large group day care

Low socioeconomic group

Use of pacifiers
Otitis Media Natural History

Upper respiratory tract mucosal congestion
spreads to eustachian tube obstruction
leading to stasis, effusion and multiplication
of bacteria

Spontaneous resolution with drainage via the
eustachian tubes or with perforation of the
tympanic membrane

Effusion may remain if tube still obstructed
Etiology
Virologic and epidemiologic data suggest that viral infection is
frequently associated with AOM.
Recent studies identify respiratory viruses or viral antigens in
approximately one quarter of middle ear fluids of children with AOM.
Respiratory syncytial virus, influenza virus, enteroviruses, and
rhinoviruses = most common viruses found in middle ear fluids. Many
patients with virus in middle ear fluid have a mixed viral-bacterial
infection.
Etiology

The bacteriology of otitis media has been
documented by appropriate cultures of middle
ear effusions obtained by needle aspiration.

S. pneumoniae is the most important bacterial
cause of otitis media . Relatively few types are
responsible for most disease ; the most
common types in order of decreasing
frequencies are 19, 23, 6, 14, 3, and 18. All are
included in the currently available 23-type
PNEUMOCOCCAL POLYSACCHARIDE
Etiology
 Otitis
media due to H. influenzae is
associated with nontypable strains in the
vast majority of patients.
 In
12 reports from the United States,
Finland, and Canada, M. catarrhalis was
isolated from a mean of 10% of children
with AOM (range 2 to 15%).
Signs and Symptoms

AOM is defined by the presence of fluid in the
middle ear along with signs or symptoms of
acute illness.

Signs and symptoms may be specific, such as
ear pain, ear drainage, or hearing loss, or may
be nonspecific, such as fever, lethargy, or
irritability. Vertigo, nystagmus, and tinnitus may
occur.
Signs and Symptoms

Redness of the tympanic membrane is an early
sign of otitis media, but erythema alone is not
diagnostic of middle ear infection since it may be
caused by inflammation of the mucosa
throughout the upper respiratory tract (the socalled “red reflex”).

The presence of fluid in the middle ear is
determined by the use of pneumatic otoscopy, a
technique that permits an assessment of the
mobility of the tympanic membrane.
Otitis Media Signs & Symptoms
Specific signs
otalgia
 otorrhea
 hearing loss
 vertigo

Nonspecific
signs
fever
 irritability
 lethargy
 anorexia
 vomiting
 diarrhea

Otitis Media : Pneumatic Otoscopy
Used to assess the landmarks, mobility,
color, transparency, vascularity and
position of the tympanic membrane
 Fluid levels or bubbles can be seen if
membrane is translucent
 Confirms middle ear effusion by
assessing mobility when + or –
pressure is applied
 Needs an adequate seal with ear canal

Acute Otitis Media Diagnosis
 Identification
of middle ear effusion
 pneumatic
otoscopy
 tympanometry
 acoustic reflectometry
 Signs
or symptoms of acute local
or systemic illness
OM : Short Term Complications
Intratemporal :
Intracranial :

mastoiditis

meningitis

labrynthitis


facial nerve
paralysis
lateral sinus
thrombosis

brain abscesses

petrositis


hearing loss

subperiosteal
abscess
sigmoid sinus
thrombophlebiti
s
OM Long Term Complications
Speech and Language delay
 Tympanic membrane perforation
 Cholesteatoma
 Tympanic membrane retraction
pockets
 Hearing loss
 Chronic otorrhea
 Cognitive impairment

Otitis Media Etiology
S. Pneumoniae
 H. Influenzae
 M. Catarrhalis
 Group A Strep
 Staph Aureus
 Negative culture/


non pathogens
32%
22%
16%
5%
2%
25%
Otitis Media : Antimicrobial Resistance
S. pneumoniae 30-40% penicillin
resistant
 H. influenzae 30-40% -lactamase
positive
 M. catarrhalis 80-90% -lactamase (+)
 Levels of resistance vary with different
geographic areas

Resistance Patterns in the
Common Bacterial Pathogens

Pneumococcus: variable resistance to
penicillin is found including both high
level and intermediate level resistance.

H. influenzae: increasing beta-lactamase
production , up to 80% in some areas

M. catarrhalis: nearly universal betalactamase production
Guidelines for the use of
Antibiotics in AOM
Rationale for the continued use of amoxicillin :

S. pneumoniae is responsible for about 40% of cases of
AOM. Concentrations of amoxicillin can be achieved in the
middle ear fluid sufficient to sterilize all but highly
resistant strains.

Less than 10% of pneumococci isolated from the
nasopharynx of Boston children are high level resistant
(MIC’s>2 mug/ml) and treatment in about 4% of all children
with acute otitis might fail if they are treated with regular
doses of amoxicillin (40 mg/kg/day).
Guidelines for the use of
Antibiotics in AOM
The recent recommendation of doubling
the dose of amoxicillin to 80 mg/kg/day will
achieve higher concentrations in middle
ear fluid and further reduce the number of
children in whom amoxicillin therapy will
fail because of resistant pneumococci.
Guidelines for the use of
Antibiotics in AOM

H. influenzae and M. catarrhalis are responsible for
about 30 and 10% of AOM cases, respectively. If 30% of
H Flu and 75% of M. cat are b-lactamase +, then 16% of
AOM cases are caused by beta-lactamase-producing
organisms.

If 50% improve spontaneously or despite beta-lactamase
activity, then less than 10% of the failures could be
anticipated to be due to failure of amoxicillin to be active
against beta-lactamase-producing organisms.
Second Line Therapy
CHOICES:
–Augmentin® (adds coverage for
beta-lactamase producing
organisms)
–Cefuroxime axetil; cefpodoxime;
azithromycin; ceftriaxone IM
injection
To treat or not to treat ?

Previous studies have shown that the majority
of cases of AOM will resolve without specific
therapy

Antibiotic usage varies from 31% in the
Netherlands to 98% in the US and Australia

Cockrane Abstract : review of evidence-based
literature to assess the effects of
antibiotherapy in AOM
Cockrane Abstract : review of evidenced based literature to
assess the effects of antibiotics in children with AOM

10 randomized trials comparing antimicrobial agents to
placebo in children with AOM

Total of 2,202 children

Pain:
– No reduction in pain at 24 hours with antibx
– 28% relative reduction in pain at 2-7 days
– Since ~ 80% of cases will have resolved in this time,
this represents an absolute reduction of about 5%
Cockrane Abstract : review of evidenced based
literature to assess the effects of antibiotics in children
with AOM
 Other
Effects:
–No effect on hearing problems (as measured
by tympanometry and audiometry in two
studies only)
–No influence on other complications or
recurrences
 Complications:
–One case of mastoiditis occurred (in PCN
treated group)
What can we do ?
1.
Increase the accuracy of AOM diagnosis
2.
Understand societal pressures for
antibiotic prescriptions and educate
parents about appropriate use of
antibiotics
3.
Evaluate non-antimicrobial treatments or
preventives (e.g. vaccines)