Otitis Media

Definition Otitis media (OM): second most common disease of childhood (after upper respiratory infection) most common cause for childhood visits to a physician's office Roughly 16 million office visits annually Infection or inflammation of the middle ear cavity Classified into many variants on the basis of etiology, duration, symptomatology, and physical findings. this does not include visits to the emergency department.

Epidemiology 90% of children have at least one documented middle ear effusion by age of 2 years OM is frequently recurrent 1/3 of children experience more than 6 episodes of acute OM by the age of 7 years

Classification

Signs and Symptoms Acute Otitis Media (AOM) cause rapid onset of ≥ 1 of the following symptoms: Otalgia Otorrhea Irritability Fever Loss of appetite Young children may also tug on their ear(s) Otitis Media with Effusion (OME) often follows an episode of AOM. Symptoms include : Hearing loss Tinnitus Vertigo

Acute OM (AOM) Otoscopic Appearance: Purulent effusion behind bulging tympanic membrane (TM) Severely inflamed osseous canal Increased vascularity R3 http://img.medscapestatic.com/pi/meds/ckb/15/44915tn.jpg

OM with Effusion (OME) Otoscopic Appearance: Erythema Effusion (partial or complete) Opacification Bulging of TM outward http://www.utmb.edu/pedi_ed/aom-otitis/grading.htm

Adhesive OM Otoscopic Appearance: Chief sign is tympanic membrane immobility Appearance may vary from minimal scarring to TM thickening and opacity. Severe retraction of the TM http://ts1.mm.bing.net/th?id=OIP.M465c1cff0859f5dc62202b04fae5bfd9o0&pid=15.1

Chronic Suppurative OM Otoscopic Appearance: Perforated TM with persistent drainage from the middle ear Granulation tissue in the medial ear cavity Edematous and pale middle ear mucosa http://www.assignmentpoint.com/wp-content/uploads/2013/05/chronic-suppurative-otitis-media.jpg

Diagnosis Pneumatic otoscopy is the gold standard examination Examination should include description of the following four TM characteristics: Color –Yellow or blue coloration of the TM is consistent with effusion Position – In AOM: the TM is usually bulging whereas in OME, the TM is typically retracted or in the neutral position Mobility – decreased TM mobility Perforation – Single perforations are most common Pneumatic Otoscopy Exam: https://emedicine.medscape.com/article/1348950-overview#a7

Diagnosis Lab testing Usually unnecessary Sepsis workup is recommended in infants with <12 week with fever and AOM  Appropriate laboratory studies to confirm the etiology for OM when suspecting systemic diseases or congenital syndromes as OM is commonly associated.

Diagnosis Imaging Imaging usually not indicated (Exception include: Suspected intra-temporal or intracranial complications) Contrast-enhanced CT Diagnose complications such as mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, brain abscess, and subdural abscess. MRI is usually performed if CT is unrevealing

Treatment Pain management with acetaminophen or ibuprofen either in the presence or absence of antibiotic treatments AAFP Recommendations for prescribing antibiotics include the following: Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms and for nonsevere, bilateral AOM in children aged 6 to 23 months On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6-23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding antibiotics unless the child worsens or does not improve within 48-72 hours of symptom onset Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should prescribe an antibiotic with additional beta-lactamase coverage https://www.aafp.org/patient-care/clinical-recommendations/all/otitis-media.html