Otitis Media

n Most common reason for visit to pediatrician n Tympanostomy tube placement is 2nd most common surgical procedure in children n Development of multidrug-resistant bacteria

Otitis Media - Definition Inflammation of the middle ear May also involve inflammation of mastoid, petrous apex, and perilabyrinthine air cells

Otitis Media - Classification n Acute OM - rapid onset of signs & sx, < 3 wk course n Subacute OM - 3 wks to 3 mos n Chronic OM - 3 mos or longer

OM - Epidemiology n Age n Sex n Race n Day care n Seasons n Genetics n Breast-feeding n Smoke exposure n Medical conditions

OM - Epidemiology n Increasing incidence n Increases after newborn period n 2/3 with AOM by one year of age n 1/2 with >3 episodes by three years n most common in mos

OM - persistent middle ear effusion (MEE) n High incidence of MEE, avg of 40 days n Children less that 2 years much more likely to have persistent MEE n White children with higher incidence of MEE

OM - Day Care n Greater risk of AOM in children < 3 years n Home care best, large group day care worst –more exposures with wider range of flora –increased URI’s –more frequent visits to MD to decrease parental leave time from work

OM - Breast-feeding n Decreases incidence of URI and GI disease n Inverse relationship between incidence of OM and duration of breast-feeding n Protective factor in breast-milk?

OM - smoke exposure n Induces changes in respiratory tract n Increased AOM and persistent effusion n Increased otorrhea, chronic and recurrent AOM in children with parental smoking

OM - Medical Conditions n Cleft palate –decreases after repair n Craniofacial disorders –Treacher-Collins n Down’s syndrome n Ciliary dysfunction n Immune dysfunction –AIDS –steroids, chemo –IgG deficiency n Obstruction –NG tubes –NT intubation –adenoids –malignancy

Eustachian Tube n Connects middle ear and nasopharynx n Lumen shaped like two cones with apex directed toward middle n Mucosa has mucous producing cells and ciliated cells

Eustachian tube n Adults –ant 2/3- cartilaginous –post 1/3- bony –45 degree angle –isthmus 1-2 mm –nasopharyngeal orifice 8-9 mm n Children –longer bony portion –10 degree angle –isthmus larger –nasopharyngeal orifice 4-5 mm in infants

Eustachian tube n Usually closed n Opens during swallowing, yawning, and sneezing n Opening involves cartilaginous portion n Tensor veli palatini responsible for active tubal opening n No constrictor function

Eustachian tube n Protection from nasopharyngeal sound and secretions n clearance of middle ear secretions n ventilation (pressure regulation) of middle ear

Pathology n Eustachian tube abnormalities –Impaired opening –open in DS and American Indians –shorter tube n Impaired immunity –children have poorer immune response –less cytokines in nasopharynx in children with OM n Inflammatory mediators –Bacterial products induce inflam response with IL- 1, IL-6, and TNF n Allergy

Microbiology n S. pneumoniae % n H. influenzae % n M. catarrhalis % n Group A strep - 2-4% n Infants with higher incidence of gram negative bacilli

Virology n RSV - 74% of middle ear isolates n Rhinovirus n Parainfluenza virus n Influenza virus

Microbiology n PCN-resistant Strep – % – % –Altered PCN-binding proteins –Lysis defective –Age, day-cares, and previous tx n H. flu and M. catarrhalis –beta-lactamase production –All M. catarrhalis + –45-50% H. flu

Chronic MEE n Previously thought sterile n 30-50% grow in culture n over 75% PCR + n Usual organisms

Diagnosis n Acute OM –preceding URI –fever, otalgia, hearing loss, otorrhea n Chronic MEE –asymptomatic –hearing loss –“plugged” ear

Diagnosis n Pneumatic otoscopy is gold standard –Color - opaque, yellow, blue, red, pink –Position - bulging, retracted –Mobility - normal, hypomobile, neg pressure –Assoc pathology - perfs, cholesteatoma, retraction pockets n Head & neck exam

Diagnosis n Audiogram –document CHL, SNHL, baseline, preop –sooner if high risk n Impedance n Acoustic reflexes

Treatment - AOM n Adults and older children - observation? n Antibiotics - consider drug resistance patterns –Amoxicilin,Coamoxiclave,Azitramycin –Need high middle ear concentrations

Antibiotics n First line –Amoxil mg/kg divided tid –Coamoxiclave n Second line –Coamoxiclave –Azithramycin

Treatment - Recurrent AOM n Chemoprophylaxis –Sulfisoxazole, amoxicillin, ampicillin, pcn –less efficacy for intermittent propylaxis n Myringotomy and tube insertion –decreased # and severity of AOM –otorrhea and other complications –may require prophylaxis if severe n Adenoidectomy –28% and 35% fewer episodes of AOM at first and second years

Treatment - OME n MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, discomfort n Antibiotics –shown to be of benefit, 75% PCR + bacterial DNA n Antibiotics + steroid –21% improvement compared to abx alone –prednisone 1 mg/kg day x 7 days –varicella? n Myringotomy & tympanostomy +/- adenoidectomy

Tympanostomy tube insertion n Unresponsive OME >3 mos bil, or >6 mos uni, sooner if assoc hearing problems n Recurrent MEE with excessive cumulative duration n Recurrent AOM - >3/6 mos or >4/12 mos n Eustachian tube dysfunction n Suppurative complication

Complications n Intratemporal –hearing loss –TM perforation –CSOM –retraction pockets –cholesteatoma –mastoiditis –petrositis –labyrinthitis –adhesive OM –tympanosclerosis –ossicular dyscontinuity and fixation –facial paralysis –cholesterol granuloma –necrotizing OE n Intracranial –meningitis –extradural abscess –subdural empyema –focal encephalitis –brain abscess –lateral sinus thrombosis –otitic hydrocephalus