Acute Otitis Media in the 21st Century: What Now. Richard C Acute Otitis Media in the 21st Century: What Now? Richard C. Wasserman, MD, MPH Jeffrey S. Gerber, MD, PhD Prepared by: Jana May Marie B. Cruz, MD Photo of typical AOM

Objectives

Define Acute Otitis Media (AOM) Determine risk factors, signs and symptoms of AOM This study aims to further discuss the epidemiology of Acute Otitis Media, its current bacteriology, the use of antibiotics and pneumococcal conjugate vaccine.

Introduction

According to a study done by Caro, R. et al According to a study done by Caro, R. et al. the total prevalence of clinically diagnosed acute otitis media in the Philippines is 9.6%. There is no gender predilection noted, with ages 0-2 having the most occurrence of AOM in the sample. Also a projection from the National Statistics Office in 2010, predicted that 83% will have at least one episode of acute otitis media in the first three years of life, those in the pediatric age group are more commonly affected. The world health organization included the Philippines among the countries having the highest incidence of chronic otitis media.

Acute Otitis Media (AOM) by standard definition is the process in which the middle ear shows the signs and symptoms of acute inflammation occurring in the first three weeks. AOM is a general term for inflammatory diseases of the middle ear with particular involvement of the tympanic cavity. It is also the most common indication for prescription of antibiotics in children. The peak incidence in children is between ages 3-18 months, highest in the first 2 years of life and decreases by 2% by the age of 8 years. Infants experiencing their first attack shortly after birth are more likely to be otitis-prone. In most cases, AOM is preceded by viral infections of the upper respiratory tract.

Common symptoms of otitis media are earache, discharge from the ear, hearing loss, ear popping, ear fullness, dizziness and fever. Examination of tympanic membrane by otomicroscopy or otoscopy is the keystone for correct diagnosis. New guidelines of the American Academy of Pediatrics for diagnosis recommend the following criteria be met: Moderate to severe bulging of tympanic membrane or newly occurring otorrhea not caused by acute otitis externa Mild bulging of the tympanic membrane with occurrence of earache or pronounced reddening of the tympanic membrane in the previous 48h. AOM is usually a self-limiting condition, with 80%-90% of children recovering within 3 days and full recovery within 7 days. Absence of fluid accumulation in the tympanic cavity is considered to exclude the presence of AOM.

Discussion

Acute Otitis Media as previously defined is an inflammatory process involving the middle ear specifically in the tympanic cavity. It is usually a complication of a eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. AOM has to be distinguished from myringitis associated with an inflammation of the external auditory meatus and from acute exacerbation of chronic otitis media as well as from serous/mucous tympanic effusion. An understanding of its epidemiology is fundamental to optimize clinical outcomes and promote cautious antibiotic use. A more stringent diagnostic criteria for AOM and evidence-based AAP guidelines are used for diagnosis and treatment.

Diagnostic action statements from the AAP guidelines include the following: AOM should be diagnosed when there is moderate to severe tympanic membrane bulging or new-onset otorrhea not caused by acute otitis externa AOM may be diagnosed from mild tympanic membrane bulging and ear pain for less than 48 hours or from intense tympanic membrane erythema; in a nonverbal child, ear holding, tugging, or rubbing suggests ear pain AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show middle ear effusion

Risk Factors: Attending day care centers Changes in altitude and changes in climate; cold climate Exposure to smoke Genetic factors Not being breastfed Recent or past ear infection Recent illness of any type that reduces immunity level Studies have shown that children who attend daycare centers have a higher incidence of ear infections than kids who do not attend such centers. However, other studies have also shown that such infections acquired from a daycare may help children build their immune system Both firsthand and secondhand smoke can increase the incidence of Acute Ear Infection Breast milk has high quality proteins that boost the immune system of the child

Common microoorganisms that cause Acute Otitis Media: Bacteria: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Streptococcus pyogenes Virus: Respiratory syncytial virus

Acute Otitis Media prevalence appears to be decreasing concurrent with the usage and development of pneumococcal vaccine coverage. Tympanocentesis is considered as a valuable strategy in managing AOM, it is regarded to be safe, diagnostic and therapeutic. This procedure involves puncturing of the tympanic membrane with a small gauged-needle syringe allowing the aspiration of fluid from the middle ear cavity. The best choice for antibiotic therapy is still uncertain. However, according to AAP-guidelines the recommended antibiotic for most children is amoxicillin. In another study done, amoxicillin-clavulanate was used based on the bacteriology of middle ear cultures. Although head-to-head clinical trials comparing the different antibiotics and duration are still urged providing the best evidence for managing AOM. In a randomized controlled trial, 5 days of antibiotic therapy (amoxicillin-clavulanate) revealed that it was inferior to a 10-day therapy.

First-line antibiotics in acute otitis media Antibiotic of choice Amoxicillin 50 (–60) mg/kg BW/day, divided into two or three doses Exceptions Treatment with amoxicillin in the previous 30 days, presence of accompanying purulent conjunctivitis, history of recurring episodes of acute otitis media that have not responded to amoxicillin, or suspected infection with a β-lactamase–positive pathogen: amoxicillin + clavulanic acid (50 mg/kg BW/day amoxicillin + 12.5 mg/kg BW/day clavulanic acid, divided into two or three doses) Alternative substances Cefuroxime (30 mg/kg BW/day divided into two doses) Cefpodoxime (5–12 mg/kg BW/day divided into two doses) Ceftriaxone i.v. or i.m. (50 mg/kg BW/day in one dose for 1 or 3 days) In the case of definite previous anaphylactic reaction to penicillin Erythromycin (30–50 mg/kg BW/day divided into three doses) Clarithromycin (15 mg/kg BW/day divided into two doses) Azithromycin (10 mg/kg BW on day 1, 5 mg/kg for next 4 days, one dose per day)

Second-line antibiotics in acute otitis media: The second-line antibiotic of choice is amoxicillin + clavulanic acid (unless used as first-line antibiotic) (dosage 50 mg/kg BW/day amoxicillin + 12.5 mg/kg BW/day clavulanic acid) Ceftriaxone i.v. or i.m. (50 mg/kg BW/day in one dose for 3 days) Clindamycin (30–40 mg/kg BW/day divided into three doses) + group-3 cephalosporin

Algorithm for treatment of AOM

Conclusion

Acute Otitis Media is an intricate disease with a number of different factors involved in its epidemiology taking risk factors into consideration. It is best to be certain with the diagnosis, especially since the AOM diagnostic criteria have become more rigorous over time. This resulted in decrease in number of AOM incidence as well as number of otitis-prone children. In addition, the introduction of PCV formulations and increase in its use has been noted to be a key factor. It can be concluded that epidemiology rather than risk factors of AOM had more extensive and notable alterations since introduction of the pneumococcal conjugate vaccines. The importance and compliance of antibiotic therapy is also vital to prevent resistance in treating AOM. Further clinical trials directly evaluating variety of antibiotics and duration of therapy is absolutely of great value to working clinicians in managing AOM in the 21st century.

Sources: Thomas JP, Berner R, Zahnert T, Dazert S: Acute otitis media: a structured approach. Dtsch Arztebl Int 2014; 111(9): 151–60. DOI: 10.3238/arztebl.2014.0151 Worall, Graham. Acute otitis media. Canadian family physician 2007. Vol. 53. Kaur R, Morris M, Pichichero ME. Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era. Pediatrics. 2017;140(3):e20170181 Wasserman RC and Gerber JS. Acute Otitis Media in the 21st Century: What Now?. Pediatrics. 2017;140(3):e20171966 https://www.dovemed.com/diseases-conditions/acute-otitis-media/ Harmes, K.M. et. al. Otitis media; diagnosis and treatment. American family physician. 2013:Vol. 88 no. 7. University of michigan medical school. https://www.cdc.gov/vaccines/vpd/pneumo/index.html