Chronic Sinusitis and Chronic Otitis Media The Biofilm Theory Gary Kroukamp ENT Specialist Kingsbury Hospital

What is a biofilm? Any group of micro-organisms where cells stick to each other on a surface Embedded within a self-produced matrix of extracellular polymeric substance Slime! Cause – binding sites present exposure of cells to sub-inhibitory concentrations of antibiotics Phenotypic shift in behavior

Where are they? Dental plaque 80% of Chronic Sinusitis Chronic otitis media Recurrent tonsillitis Cystic Fibrosis

Macrolides Disrupt biofilms – staph, strep, psedomonas Disrupt quorum sensing (cell to cell signalling) Anti-inflammatory effect – by inhibiting expression of pro-inflammatory cytokines Decrease mucous viscosity – improves clearance

Chronic Dosage 500 mg 3 times per week

Acute Otitis Media To treat or not to treat

Introduction Concern about antibiotic resistance Overuse of antibiotics, over diagnosis of AOM Most will improve spontaneously without antibiotics Normal part of childhood? 95% of kids by age 7 Part of viral URTI Netherlands vs Australia

Controversies To treat or not to treat AOM with antibiotics To treat or not to treat MEE that persists after treatment of AOM with antibiotics To treat or not to treat OME with antibiotics Which management options are safe and effective for prevention of recurrent AOM

Microbiology Bacterial pathogens found in 70% of AOM and 30% of OME S. Pneumoniae – 40% H. Influenzae – 25% M. Catarrhalis – 12% Beta-haemolytic strep and Staph. Aureus Beta lactamase production in 25% of Haemophilus and all Moraxella Drug resistance in S.Pneumoniae is increasing

Against antibiotics Australia 98% vs. Netherlands 31% (vs Africa?) – no difference in complications European literature suggests non-antibiotic treatment has low complication rate and may be intercepted

Evidence for Antibiotics (vs Placebo) Sterilises the effusion – Howie et al 1972 Earlier resolution of symptoms – Rosenfeld et al (metanalysis 5400 children) 81% vs 95% resolution Shortens time of MEE – Kaleida et al, 2 weeks of antibiotics 47% vs 63% Decreases suppurative complications – mastoiditis and meningitis almost exclusively in placebo treated kids S. Pneumonia tends not to resolve spontaneously (20%)

Conclusion Treatment justified in SA If part of viral URTI may be watched if close follow-up is guaranteed Medico-legal implications of not treating?

To treat or not to treat persistent MEE with antibiotics MEE in 50% after treatment of AOM 90% resolve in 3 months Antibiotics not indicated Treat as for OME

Recurrent AOM 3 in 6 months or 4 in 12 months Prevention Smoking Crèche Vaccination – pneumococcal and flu Antibiotic prophylaxis Grommets Adenoidectomy

When parents ask for antibiotics to treat viral infections: Explain that unnecessary antibiotics can be harmful. Tell parents that based on the latest evidence, unnecessary antibiotics CAN be harmful, by promoting resistant organisms in their child and the community. Share the facts Explain that bacterial infections can be cured by antibiotics, but viral infections never are. Explain that treating viral infections with antibiotics to prevent bacterial infections does not work. Build cooperation and trust. Convey a sense of partnership and don’t dismiss the illness as only a viral infection

Encourage active management of the illness. Explicitly plan treatment of symptoms with parents. Describe the expected normal time course of the illness and tell parents to come back if the symptoms persist or worsen. Be confident with the recommendation to use alternative treatments. Prescribe analgesics and decongestants, if appropriate. Emphasize the importance of adequate nutrition and hydration. Consider providing “care packages” with non-antibiotic therapies

Antibiotic Strategy Patients or parents concerns and expectations should be addressed when agreeing on one of the three antibiotic prescribing strategies no prescribing delayed prescribing immediate prescribing.

acute viral otitis media A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute viral otitis media acute sore throat/acute pharyngitis/acute tonsillitis common cold acute rhinosinusitis

bilateral acute otitis media in children younger than 2 years Patients in the following subgroups can be considered for an immediate antibiotic prescribing strategy bilateral acute otitis media in children younger than 2 years acute otitis media in children with otorrhoea acute sore throat/acute pharyngitis/acute tonsillitis with three or more Centor criteria

Centor Criteria The patients are judged on four criteria, with one point added for each positive criterion History of fever Tonsillar exudates Tender anterior cervical adenopathy Absence of cough

Natural History Average duration of the disease acute otitis media: 4 days acute sore throat/acute pharyngitis/acute tonsillitis : 1week common cold : 1½ weeks acute rhinosinusitis: 2½weeks

Immediate Antibiotics patient systemically very unwell symptoms and signs of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) high risk of serious complications pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis premature babies if the patient is older than 65 years with acute cough one or more of the following criteria: hospitalisation in previous year type 1 or type 2 diabetes history of congestive heart failure on steroids

Strep Pneumonia

Antibiotic Choice Tonsillopharyngitis – amoxycillin/penicillin (90mg/kg/day) AOM – co-amoxyclav Rhinosinusitis – co-amoxyclav 2nd line – 3rd gen cephalosporin, fluoroquinolone or telithromycin Chronic sinusitis – co-amoxyclav + macrolides (anti-inflammatory/immune modulating)

The Middle Ear The Good, The Bad and The Ugly

ACUTE OTITIS MEDIA Easily diagnosed URT pathogens High dose Augmentin (resistant pneumococcus) Analgesia

CHRONIC SUPPURATIVE OTITIS MEDIA CLUES TO CHOLESTEATOMA: Squamous epithelium Really bad anaerobe smell Attic perforation diagnostic; BUT “central” doesn’t exclude Relentless otorrhoea (no response to Rx )

CHRONIC SUPPURATIVE OTITIS MEDIA WITHOUT CHOLESTEATOMA Local treatment!!! Toilet -syringing -mopping Antibiotic/Steroid drops or cream Pus swab & repeat Refer ? Cholesteatoma?

MIDDLE EAR EFFUSION / OME / GLUE EAR Children>adults History not always obvious: asymptomatic Clinical signs difficult to see (child&subtle) TM movement useful: pneumatise tympanometry

TYMPANOSCLEROSIS This is NOT cholesteatoma/ disease Usually clinically insignificant Very low incidence hearing Loss

Otitis Externa Painful Swimming Earbuds Rx – drops or Quadriderm

HOW TO DISTINGUISH MASTOIDITIS FROM POSTAURICULAR LYMPHADENITIS 2° TO OTITIS EXTERNA / IMPETIGO Signs of inflammation over mastoid ANTRUM? Inflammation of drum?

WHEN TO DO NOTHING! Traumatic perforation due to “dry” trauma 90% will heal

TB Middle Ear TB elsewhere Multiple perforations Painless Facial Nerve Palsy in children Pus swab unresponsive CSOM