OTITIS MEDIA Dr.Isazadehfar

OTITIS MEDIA Definition: Presence of a middle ear infection Acute Otitis Media: occurrence of bacterial infection within the middle ear cavity Otitis Media with Effusion: presence of nonpurulent fluid within the middle ear cavity OM is the second most common clinical problem in childhood after upper respiratory infection

EPIDEMIOLOGY Peak incidence in the first two years of life (esp. 6-12 months) Boys more affected girls 50% of children 1 yr of age will have at least 1 episode. 1/3 of children will have 3 or more infections by age 3 90% of children will have at least one infection by age 6 Occurs more frequently in the winter months

MICROBES AT FAULT!!! Streptococcus pneumonia Homophiles influenza(non-typeable) Moraxella catarrhalis Group A Streptococcus Staph aureus Pseudomonas aeruginosa RSV assoc. with Acute Otitis Media

Classification of Otitis Media Acute Otitis Media: presents with fever, otalgia, and hearing loss Otitis Media with Effusion: evidence of middle ear effusion on pneumatic otoscopy Recurrent Otitis Media: inability to clear middle ear effusions Chronic Serous Otitis Media: presents as ‘fullness in the ear’, tinnitus, or another acute disease

RISK FACTORS Upper Respiratory Infections Allergies Craniofacial abnormalities (cleft palate) Down’s Syndrome Passive smoking

PATHOGENESIS This problem mainly deals with Eustachian tube dysfunction Otitis Media usually follows an URI in which there is edema of the eustacian tube, leading to blockage. Stasis of these middle ear secretions lead to infection and irritation Other factors: allergic rhinitis, nasal polyps, adenoidal hypertrophy

SIGNS & SYMPTOMS Neonates/Infants: change in behavior, irritability, decreased appetite, vomiting Children(2-4): otalgia, fever, noises in ears, cannot hear properly, changes in personality Children (>4): complain of ear pain, changes in personality

On Physical exam… The classic description → erythematic, opaque, bulging tympanic membrane with loss of anatomic landmarks including a dull/absent light reflex Pneumatic Otoscopy → decreased tympanic membrane mobility

DIAGNOSIS Pneumatic Otoscopy→ standard tool Impedance Tympanometry Spectral Gradient Acoustic Reflectometry Diagnostic tympanocentesis & myringotomy: involves puncturing the tympanic membrane and aspirating middle ear fluid to relieve pressure.(Only used if the primary and secondary line treatment fail) Measures the resonance of the ear canal for a fixed sound as the air pressure is varied (MEE) :Impedance Tympanometry Spectral Gradient Acoustic Reflectometry: measures the condition of the middle ear by assessing the response of the TM to a sound stimulus. Equivalent to tympanometry for dx of middle ear effusions(MEE)

INDICATIONS FOR TYMPANOCENTESIS Toxic appearing child Failed treatment regimen with antibiotics Suppurative complications Immunosuppressed pt Newborn infant in which the usual pathogens may not be the case

DIFFERENTIAL DIAGNOSIS Otitis externa Bullous myringitis Cerumen impaction Dental abscess Foreign body in ear canal Referred pain (parotid/tooth/lymphadenitis) Tonsilitis

TREATMENT Amoxicillin: 20-40 mg/kg/day tid for 10-14 days or, Augmentin: 45 mg/kg/day po bid for 10-14 days (amoxicillin and clavulanate potassium) Auralgan: analgesic/adjunct for ear pain 2-4 drops tid (antipyrine, benzocaine, and dehydrated glycerin)

2nd Line Treatment Regimen Cefzil Pediazole ( erythromycin/sulfisoxazole) Bactrim (trimethoprim/sulfamethoxazole These medications are used as secondary agents if the primary antibiotic has failed after 10 days and the symptoms persists.

COMPLICATIONS Hearing loss: conductive, sensoneural, mixed) Acute mastoiditis: before the advent of antibiotics Chronic perforation of the TM Tympanosclerosis Cholesteatoma(keratin cyst) Chronic suppurative OM Cholesterol granuloma: ‘Blue drum syndrome’ Facial nerve paralysis

Complications cont… Intracranial complications Bacterial meningitis Epidural abscess Subdural empyema Brain abscess Otitic hydrocephalus Lateral sinus thrombosis

What Is Chronic otitis media? Inflammation of the middle ear that lasts for more than 6 weeks Usually preceded by Acute otitis media, or viral URTI Common in the age 3-6

Causes and predisposing factors: Late onset or inappropriate antibiotic treatment of acute otitis media. URTI, Allergic rhinitis Lowered Resistance in malnutrition and anemia In early onset type: Short period breastfeeding and long time group child care Eustachian tube deformity, adenoid hypertrophy Septal deviation, cleft palate, sinusitis unusual growth ("hypertrophy") of the adenoid tonsil.

Symptoms: Conductive deafness Vertigo Tinnitus Ear discharge

Etiologies Pseudomonas aerugenosa Proteus E.coli H. influenza

1. Serous ( Otitis media with effusion OME ) Stages: 1. URTI or acute otitis media –> Fluid collection in middle ear and obstruction of Eustachian tube  tympanic membrane retraction 2. Fluid become pus and glue like  conductive hearing impairment and pain  necrosis  tympanic membrane perforation 3. Could end up with mastoiditis ( if not stopped ) Enlarged adenoid is most common cause in children

Management of serous Chronic otitis media Systemic decongestants Nasal drops Surgery ( myringotomy ) , if the above 2 failed Myringotomy is tiny incision done in the ear drum to relief pressure and drain pus

CHOLESTEATOM