Childhood Otitis Media by EZe40i5

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									Childhood Otitis Media

  By
  Rahul Gladwin, MS3
  University of Health Sciences Antigua
  School of Medicine

  Email: rahul[AT]rahulgladwin.com
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.
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.
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: 85-100%
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.
Fungal Etiology
Aspergillus or Candida
Correlation factors
Signs
 Crying,
 Irritability,
 Tugging or pulling on the ear.
Symptoms
   Ear pain,
   Rhinitis,
   Cough,
   Ear drainage,
   Hearing loss,
   Fever.
Complications
 Acute mastoiditis – infection of the mastoid
  process.
 Cholesteatoma – cystic lesion within the
  middle ear.
 Meningitis.
 Hearling loss.
 Tympanic membrane perforation.
 Brain abscess.
Ear Anatomy
Ear Anatomy
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
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.
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).
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
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
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.
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
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
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.
Normal Right TM
Acute Otitis Media-TM
Acute Otitis Media
Serous Otitis Media
Serous Otitis Media
Ruptured TM
Ruptured TM
Otorrhea
Myringitis - blisters on TM
Myringitis - blisters on TM
Cholesteatoma
Cholesteatoma
Brain Abscess
Mastoiditis
Mastoiditis
Otitis Media Pathology Video
http://www.youtube.com/watch?v=1km
   sPEd2Efk&feature=related
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.
Trends on newborn screening
Office visits for OM
Treatment with penicillin
1. Antibiotic duration
      1. Age under 6 years
 2. First Line
      1. Amoxicillin 80-90 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 30-40 mg/kg/day divided four times daily for 10 days.
Treatment if allergic to penicillin
1. Consider Tympanocentesis
  2. Clindamycin (Cleocin) 30-40 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)
Resources
   Robbins Pathology
   Kaplan CK Lecture notes
   www.fpnotebook.com
   www.ncbi.nlm.nih.gov
   www.nidcd.nih.gov
   www.medicinenet.com
   emedicine.medscape.com
   www.webmd.com
   kidshealth.org
   cme.med.umich.edu
   www.audiologynet.com

								
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