1. Childhood Otitis MediaBy
Rahul Gladwin, MS3
University of Health Sciences Antigua
School of Medicine
rahul[AT]rahulgladwin.com

2. Otitis Media definition
Otitis Media is defined as an inflammation of the middle ear i.e., the area between the tympanic membrane and the inner ear.

3. Pathogenesis
Infection mostly occurs in infants and children because of the shorter and more horizontal orientation of the Eustachian tube which allows reflux from the pharynx.

4. Bacterial Etiology S. pneumonia. 1. Incidence: 38%
2. Beta Lactamase producing: 15-25%
3. Causes more severe cases with Otalgia and fever.
Nontypeable H. influenzae.
1. Incidence: 27%
2. Beta Lactamase producing: 35%
3. More often associated with eye redness and discharge.
Moraxella catarrhalis.
1. Incidence: 10%
2. Beta Lactamase producing: %

5. Viral Etiology 57% of RSV, 35% of influenza A,
33% of parainfluenza type 3,
30% of adenovirus,
28% of parainfluenza type 1,
18% of influenza B and
10% of parainfluenza type 2 virus infections.

6. Fungal Etiology
Aspergillus or Candida

7. Correlation factors

8. Signs
Crying,
Irritability,
Tugging or pulling on the ear.

9. Symptoms
Ear pain,
Rhinitis,
Cough,
Ear drainage,
Hearing loss,
Fever.

10. Complications Acute mastoiditis – infection of the mastoid process.
Cholesteatoma – cystic lesion within the middle ear.
Meningitis.
Hearling loss.
Tympanic membrane perforation.
Brain abscess.

11. Ear Anatomy

12. Ear Anatomy

13. Types of Otitis Media Acute Otitis Media
Most common type seen in children
Occurs when there is fluid in the middle ear
Occurs with inflammation of the TM
May be bacterial or viral

14. Phases of Acute Otitis Media
1st phase - exudative inflammation lasting 1–2 days, fever, rigors, meningism (occasionally in children), severe pain (worse at night), muffled noise in ear, deafness, sensitive mastoid process, ringing in ears (tinnitus)
2nd phase - resistance and demarcation lasting 3–8 days. Pus and middle ear exudate discharge spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical therapy.
3rd phase - healing phase lasting 2–4 weeks. Aural discharge dries up and hearing becomes normal.

15. Types of Acute Otitis Media
Otitis Media without effusion
Inflammation of the TM with fluid in the middle ear
May cause myringitis (cyst on TM)
Present during the beginning stages of otitis media
Formation of painful blisters on the eardrum (tympanum).

16. Types of Acute Otitis Media
Serous Otitis Media or Otitis Media with effusion
Inflammation of the TM with fluid in the middle ear
Caused by vacuum created by malfunction of the Eustachian tube
Can cause hearing impairment and delayed speech in children
Since infants cannot hear they cannot learn how to talk

17. Chronic Otitis Media
Occurs when the middle ear infection perists and causes significant hearing loss and damage to the middle ear
May involve a perforation of the TM
Pus may drain through the ear canal – a concept called otorrhea

18. Chronic Otitis Media - Types
Tubotympanic disease – called safe disease. The infection is limited to the mucosa and the antero inferior part of the middle ear cleft, hence the name. This disease does not have any risk of bone erosion.
Atticoantral disease – called unsafe disease. Fatal intra-cranial and extra-cranial complications can occur. Disease spreads by erosion of the bony wall of the attic. Cholesteatoma may occur. Commonly seen in sclerosed mastoid cavities.

19. Recommended Otitis Media Workup
Laboratory Studies – sepsis workup
Imaging - study of choice is a contrast-enhanced CT scan of the temporal bones
MRI is more helpful in depicting fluid collections
Tympanometry may help with diagnosis in patients with OM with effusion

20. Diagnostic criteria for OM
Bulging TM
Retracted TM
Impaired mobility of the TM
Loss of light reflex
Erythematous TM
Purulent otorrhea
Opacification of the TM

21. Normal TM Appears as:
Glistening, translucent (scarring often may be evident in adults).
Light reflex extending anteriorly/inferiorly from the umbo (most depressed part of the tympanic membrane).
Pearly gray to pale pink membrane with cone of light well visualized.
Mobile (to the air pulses).
Non-erythematous.
Handle (manubrium) and short process of malleus well identified.

22. Normal Right TM

23. Acute Otitis Media-TM

24. Acute Otitis Media

25. Serous Otitis Media

26. Serous Otitis Media

27. Ruptured TM

28. Ruptured TM

29. Otorrhea

30. Myringitis - blisters on TM

31. Myringitis - blisters on TM

32. Cholesteatoma

33. Cholesteatoma

34. Brain Abscess

35. Mastoiditis

36. Mastoiditis

37. Otitis Media Pathology Video

38. Quick Statistics More common in Caucasian children.
70% of all children have at least 3 infections before the age of 6.
Children given antibiotics were 2-6 more likely to get re-infected.
About 2 to 3 out of every 1,000 children in the United States are born deaf or hard-of-hearing. Nine out of every 10 children who are born deaf are born to parents who can hear.
Approximately 188,000 people worldwide have received cochlear implants. In the United States, roughly 41,500 adults and 25,500 children have received them.

39. Trends on newborn screening

40. Office visits for OM

41. Treatment with penicillin
1. Antibiotic duration
1. Age under 6 years
2. First Line
1. Amoxicillin mg/kg/day PO divided twice daily for 10 days (7 days if age>6)
2. If Penicillin Allergy, use Macrolide (e.g. Azithromycin)
3. Second Line (10 day course)
1. Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice daily for 10 days
2. Cefuroxime (Zinacef, Ceftin) 30 mg/kg/day divided twice daily for 10 days
3. Cefprozil (Cefzil) 30 mg/kg/day divided twice daily for 10 days
4. Cefdinir (Omnicef) 14 mg/kg/day divided one to two times daily fo 10 days
5. Cefpodoxime (Vantin) 30 mg/kg once daily for 10 days
4. Third Line
1. Strongly consider Tympanocentesis for bacterial culture
2. Ceftriaxone (Rocephin) 50 mg/kg IM daily for 3 days
3. Clindamycin mg/kg/day divided four times daily for 10 days.

42. Treatment if allergic to penicillin
1. Consider Tympanocentesis
2. Clindamycin (Cleocin) mg/kg/day (max 1800 mg) divided four times daily for 10 days
3. Macrolide antibiotics (High bacterial resistance rate)
1. Erythromycin
2. Clarithromycin (Biaxin) 15 mg/kg/day divided twice daily for 10 days
3. Azithromycin (Zithromax)
1. One dose of Azithromycin XR (Zmax) at 30 mg/kg (up to 1500 mg) or
2. Three days of Azithromycin at 20 mg/kg/day once daily (up to 500 mg/day) or
1. This high dose approached Augmentin efficacy in one study
2. Arrieta (2003) Antimicrob Agents Chemother 47:3179
3. Azithromycin 10 mg/kg (max: 500 mg) day 1, then 5 mg/kg/day (max 250 mg) for 5 days
4. Fluoroquinolones (avoid under age 16 years)
1. Gatifloxacin (Tequin)
2. Levofloxacin (Levaquin)
3. Moxifloxacin (Avelox)

43. Resources Robbins Pathology Kaplan CK Lecture notes www.fpnotebook.com
emedicine.medscape.com
kidshealth.org
cme.med.umich.edu