MIDDLE EAR INFECTIONS

Otitis Media inflammation of the middle ear In the US, second most common disease of childhood, after URTI, accounting for approximately 20 million physician visits every year. Caused by eustachian tube (ET) dysfunction  In ET dysfunction (ETD), the mucosa at the pharyngeal end of the ET is part of the mucociliary system of the middle ear. Interference with this mucosa by edema, tumor, or negative intratympanic pressure facilitates direct extension of infectious processes from the nasopharynx to the middle ear, causing OM. Esophageal contents regurgitated into the nasopharynx and middle ear through the ET can create a direct mechanical disturbance of the middle ear mucosa and cause middle ear inflammation. In children, developmental alterations of the ET, an immature immune system, and frequent infections of the upper respiratory mucosa all play major roles in AOM development. Studies have demonstrated how viral infection of the upper respiratory epithelium leads to increased ETD and increased bacterial colonization and adherence in the nasopharynx.1 Certain viral infections cause abnormal host immune and inflammatory responses in the ET mucosa and subsequent microbial invasion of the middle ear. The host immune and inflammatory response to bacterial invasion of the middle ear produces fluid in the middle ear and the signs and symptoms of AOM. Although interactions between the common pathogenic bacteria in AOM and certain viruses are not fully understood, strong evidence indicates that these interactions often lead to more severe disease, lowered response to antimicrobial therapy, and OME development following AOM.

Risk factors Frequent and prolonged URTI Craniofacial abnormality Smoking by parents Bottle feeding

Anorexia, nausea, vomiting, diarrhea Irritability Signs of URTi Symptoms Signs Otalgia Fever Headache Otorrhea Anorexia, nausea, vomiting, diarrhea Irritability Signs of URTi Otoscopy findings: - Opacity - Bulging - Erythema - Middle ear effusion - Decreased mobility with pneumatic otoscopy Suspect acute otitis media (AOM), with or without effusion, in children with a history of the following symptoms: Head and neck Otalgia: Young children may exhibit signs of otalgia by pulling on the affected ear or ears or pulling on the hair. Otalgia apparently occurs more often when the child is lying down (eg, during the night, during nap time), which may be due to increased ETD when the child is in a recumbent position. Otorrhea: Discharge may come from the middle ear through a recently perforated TM, through a preexisting TT, or through another perforation. For trauma patients, excluding a basilar skull fracture with associated cerebrospinal fluid (CSF) otorrhea is important. Headache Concurrent or recent URI symptoms (eg, cough, rhinorrhea, sinus congestion) General Two thirds of children with AOM have a history of fever, although fevers greater than 40°C are uncommon and may represent bacteremia or other complications. Irritability may be the sole early symptom in a young infant or toddler. A history of lethargy, although nonspecific, is a sensitive marker for sick children and should not be dismissed. GI tract: Symptoms include anorexia, nausea, vomiting, and diarrhea. OME often follows an episode of AOM. Consider OME in patients with recent AOM in whom the history includes any of the following symptoms: Hearing loss: Most young children cannot provide an accurate history. Parents, caregivers, or teachers may suspect a hearing loss or describe the child as inattentive. Tinnitus: This is possible, although it is an unusual complaint from a child. Vertigo: Although true vertigo (ie, room-spinning dizziness) is a rare complaint in uncomplicated AOM or OME, parents may report some unsteadiness or clumsiness in a young child with AOM. Otalgia: Intermittent otalgia tends to worsen at night. OM treatment widely varies based on the duration of symptoms, past therapeutic failures, and severity of current symptoms. Exposure to environmental risk factors is another important aspect of the history and includes the following: Passive exposure (ie, secondhand) to tobacco smoke Group daycare attendance Seasonality: AOM prevalence is much higher in winter and early spring than in summer and early fall. Supine bottle feeding (ie, bottle propping) Physical Pneumatic otoscopy remains the standard examination technique for patients with suspected OM. When performed correctly, this technique is 90% sensitive and 80% specific for diagnosis of AOM, and findings are more accurate than with myringotomy. Proper pneumatic otoscopy technique is crucial to distinguish AOM from OME because recommended therapies for these entities are significantly different. Studies show that most practitioners improperly perform otoscopic examinations. Almost one half of physicians never use pneumatic compression of the TM during routine otoscopic examination, and almost 30% use otoscopes with inadequate light sources. Tympanometry, acoustic reflectometry, and audiometry are important adjunctive techniques with which to evaluate patients with MEE. In addition to a carefully documented examination of the external ear and TM, examining the entire head and neck region of patients with suspected OM is important. Several congenital syndromes, craniofacial anomalies, and systemic diseases have increased incidence associated with OM, including cleft palate, Down syndrome, Treacher Collins syndrome (ie, mandibulofacial dysotosis), hemifacial microsomia, diabetes mellitus, human immunodeficiency virus (HIV) infection, and many types of mucopolysaccharidosis.

OM with effusion/Serous OM usually follows an episode of AOM d/t the accumulation of fluid from a block ET Hearing loss, intermittent otalgia Gray or brown fluid/bubbles behind an intact eardrum Hearing loss: Most young children cannot provide an accurate history. Parents, caregivers, or teachers may suspect a hearing loss or describe the child as inattentive. Tinnitus: This is possible, although it is an unusual complaint from a child. Vertigo: Although true vertigo (ie, room-spinning dizziness) is a rare complaint in uncomplicated AOM or OME, parents may report some unsteadiness or clumsiness in a young child with AOM. Otalgia: Intermittent otalgia tends to worsen at night.

Chronic OM chronic inflammation of the middle ear that persists at least 6 weeks associated with otorrhea through a perforated TM, conductive hearing loss

Intratemporal complications Intracranial complications Hearing loss  TM perforation Chronic suppurative OM Cholesteatoma Tympanosclerosis Mastoiditis Petrositis Labyrinthitis Facial paralysis Meningitis Subdural empyema Brain abscess Extradural abscess Lateral sinus thrombosis Otitic hydrocephalus Some studies show bimodal prevalence peaks; a second, lower peak occurs at age 4-5 years and corresponds with school entry. Although OM can occur at any age, 80-90% of cases occur in children younger than 6 years. Children who are diagnosed with AOM during the first year of life are much more likely to develop recurrent OM and chronic OME than children in whom the first middle ear infection occurs after age 1 year.

Diagnosis Diagnostic certainty is based on all 3 of the following criteria: acute onset middle ear effusion (MEE) middle ear inflammation

Antibacterial therapy Treatment Age Certain Diagnosis Uncertain Diagnosis <6 mo Antibacterial therapy 6 mo–2 y Antibacterial therapy if severe illness; observation option* if nonsevere illness >2 y Observation option*

Treatment Observation: Antibiotic therapy Observe for 48-72 hours, with symptomatic treatment Antibiotic therapy DOC: Amoxicillin 80-90 mg/kg/d 10 days : <6y/o; with severe illness 5-7 days : >6 y/o Alternatives: cefdinir, cefpodoxime, or cefuroxime persistent symptoms or recurrent acute otitis media (AOM) should be referred to an otorhinolaryngologist for evaluation and possible tympanocentesis

Prevention breastfeed infants for at least 6 months to help to prevent the development of early episodes of ear infections. If a child is bottle-fed, hold the infant at an angle rather than allowing the child to lie down with the bottle. prevent exposure to secondhand smoke reduce exposure, if possible, to large groups of other kids, such as in child-care centers. good hand washing keep children's immunizations up-to-date, because certain vaccines can help prevent ear infection