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

2. 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

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

5. 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

6. Chronic Dosage
500 mg 3 times per week

7. Acute Otitis Media To treat or not to treat

8. 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

9. 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

10. 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

11. 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

12. 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%)

13. 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?

14. 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

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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. Strep Pneumonia

25. 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)

26. The Middle Ear The Good, The Bad and The Ugly

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

32. 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 )

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

34. 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

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

36. Otitis Externa
Painful
Swimming
Earbuds
Rx – drops or
Quadriderm

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

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

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