Pediatric ENT in 40 Minutes

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					Otitis Media

              Gil C. Grimes, MD
       Assistant Professor Family Medicine
              Texas A&M HSC COM
    Scott and White Family Medicine Residency
                  May 31st 2005
Objectives
   Describe criteria for diagnosing Acute Otitis
    Media
   Describe rationale for therapy for Acute Otitis
    Media
   Describe Therapy for Serous Otitis Media
   Describe the role of Tympanostomy Tubes
My Bias
   I am a minimalist



   If the evidence for
    intervention is not
    good I do nothing
    Acute Otitis Media
        A diagnosis of AOM requires
              a history of acute onset of signs and
               symptoms
              the presence of middle ear effusion (MEE)
              signs and symptoms of middle-ear
               inflammation.



Pediatrics 2004 May;113(5):1451-65   Level 1a
Acute Otitis Media
   The presence of MEE that is indicated
    by any of the following:
       Bulging of the tympanic membrane
       Limited or absent mobility of the tympanic
        membrane
       Air-fluid level behind the tympanic
        membrane
       Otorrhea
Acute Otitis Media
   Signs or symptoms of middle-ear
    inflammation as indicated by either
     Distinct erythema of the tympanic
      membrane
    or
     Distinct otalgia

           discomfort clearly referable to the ear(s) and
           interference with or precludes normal activity
            or sleep
     Acute Otitis Media
         Otitis Media?
               Yes
               No




http://www.otol.uic.edu/research/microto/Microtoscopy/Case10origweb.jpg
Acute Otitis Media
   Otitis Media?
       Yes
       No




                    www.orldoc.ch/index
Acute Otitis Media Prevalence
   Prevalence
       10% US children diagnosed by 3 months
       90% by 2 years (1)
       Prospective cohort of children (2)
           62% with AOM by 1 year
           83% with AOM by 3 years
       9th most common diagnosis during FM
        visits(3)
       Coded 3.2% visits (3)
               1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b
               2)J Infect Dis 1989 Jul;160(1):83 Level 2b
               3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c
    Acute Otitis Media Etiology
        Viral pathogens found Tympanocentesis and Nasal
         Aspirate in AOM
           RSV and coronavirus RNA in 75% children

                    5% dual viral infections


              Bacterial pathogens detected 62%

              Viral RNA detected in 57% bacteria-negative and
               45% bacteria-positive samples


Pediatrics 1998 Aug;102(2):291 Level 1c
      Acute Otitis Media Etiology
           Bacteria shifts
                 Streptococcus pneumoniae
                       S. pneumoniae is the most common bacterial organism
                        identified
                 non-typeable Haemophilus influenzae
                       H. flu identified primarily in children < 5, but reduced with
                        routine immunization
                 Moraxella (Branhamella) catarrhalis

           may be changing due to heptavalent pneumococcal
            vaccine
                 decrease in S. pneumoniae and increase in H. influenzae


Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b
Acute Otitis Media Risk Factors
   Formula feeding
         incidence of otitis media is higher in
          formula-fed infants vs. breast-fed infants

         incidence of prolonged ear infections was
          5x higher among formula-fed infants

         Duration OM episodes longer (8.8 vs. 5.9
          days)
J Pediatric 1995 May;126(5 Pt 1):696 Level 2b
Acute Otitis Media Risk Factors
   Day Care Attendance
         day care associated with increased risk of upper
          and lower respiratory tract illnesses in first year of
          life for children with familial history of atopy

         prospective birth cohort study of 498 children with
          parental history of allergy or asthma followed
          prospectively for first year of life



Pediatrics 1999 Sep;104(3):495 Level 2b
  Acute Otitis Media Risk Factors.
     Associated with 2 or more doctor-diagnosed
      ear infections (odds ratio [OR] 2.4, 95%
      confidence interval [CI] 1.7-3.6)

     For children attending day care independent
      predictors of 2 or more doctor-diagnosed ear
      infections included
          exposure to pets in day care
          presence of rug or carpet in area where child slept
           in day care
          nonresidential setting for day care

Pediatrics 1999 Sep;104(3):495 Level 2b
 Acute Otitis Media Risk Factors
     Passive Smoking
           625 Children Calgary first graders
           Middle ear disease
                 2 or more household smokers (crude odds ratio) [OR],
                  1.85; 95% confidence interval [CI], 1.15-2.97
                 10 or more cigarettes smoked by the mother per day
                  (crude OR, 1.68; 95% CI, 1.12-2.52)
                 10 or more cigarettes smoked in total in the household
                  per day (crude OR, 1.40; 95% CI, 0.98-2.00) during the
                  first 3 years of life



Arch Pediatric Adolescent Med. 1998 Feb;152(2):127 Level 2c
Acute Otitis Media
   History
        Poor predictive value
        Studies are not good


   Statistics
        LR+ greater than 5 good
        LR- less than 0.5 good
        Specificity to rule in
        Sensitivity to rule out

        Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
                Acute Otitis Media
               Symptom                         LR+        LR-       Sensitivity Specificity
               Ear rubbing                    3.20 0.670                 42%              87%
               Ear pain                       3.00 0.560                 54%              82%
               Excessive crying 1.80 0.650                               55%              69%
               Rhinitis                       1.30 0.580                 75%              43%
               Restless sleeping 1.30 0.710                              64%              51%
               Poor appetite                  1.10 0.970                 36%              66%
               Vomiting                       1.00 1.000                 11%              89%



Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
             Acute Otitis Media
   Physical Findings
       Based on prospective study of 8,859 ear-related visits
        among children 0.5-2.5 years with acute symptoms
            myringotomy performed if middle ear effusion suspected on exam
            51.5% had acute otitis media (i.e. middle ear effusion confirmed on
             myringotomy)
       Color not particularly helpful but cloudy membrane
        predictive
            red color was not highly predictive
            cloudy tympanic membrane had 80-96% positive predictive value
            normal color dramatically reduces likelihood of AOM (2-5%
             probability of middle ear effusion if normal color)


              Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b
  Acute Otitis Media
       Physical Continued
             Position helpful if clearly bulging
                   bulging tympanic membrane had 89-96%
                    positive predictive value
                   retracted tympanic membrane had 47-50%
                    positive predictive value
                   normal position had 22-32% probability of AOM



Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1b
Acute Otitis Media
    Mobility helpful if distinctly impaired or
     clearly normal
         distinctly impaired mobility had 78-94%
          positive predictive value
         slightly impaired mobility had 33-60% positive
          predictive value
         normal mobility dramatically reduces likelihood
          of AOM (2-5% probability of middle ear
          effusion if normal mobility)
Acute Otitis Media
                                 Positive Likelihood
Test Name
                                   Ratio
TM position: bulging                      51.00
TM color: cloudy                          34.00
TM mobility: distinctly
                                          31.00
  impaired
TM color: distinctly red                   8.40
TM mobility: slightly impaired             4.00
TM position: retracted                     3.50
TM color: slightly red                     1.40
TM position: normal                        0.50
TM color: normal                           0.20
TM mobility: normal                        0.20
Acute Otitis Media
   Type A pattern is
    normal
   Type B pattern is
    consistent with MEE
   Type C is seen with
    retracted TM
         Acute Otitis Media Prognosis
             Spontaneous resolution is the norm
             81% spontaneously resolve (1)
             5000 children with otitis(2)
                   >90% resolved with supportive care
                   2.7% had a severe course (required
                    antibiotics or myringotomy at 5 days)


1)   Pediatrics 5 May 2004 113:1452 Level 1a
2)   Br Med J (Clin Res Ed). 1985 Apr 6; 290(6474):1033 Level 1b
       Acute Otitis Media Prognosis
          Recurrent otitis media no long term
           consequences
              usually spontaneous recovery
              study of 222 children with recurrent otitis media
               who received no prophylaxis
                   4% developed chronic otitis media with effusion
                   12% continued having recurrent episodes
                   most significant risk factor for continued recurrence was
                    age < 16 months (1)


1) Pediatrics 5 May 2004 113:1452 Level 1a
      Acute Otitis Media Prognosis
                Persistent effusion
                       Watchful Waiting recommended in children
                        without the following:
                             Permanent hearing loss independent of OME
                             Suspected or diagnosed speech and language delay
                              or disorder
                             Autism-spectrum disorder and other pervasive
                              developmental disorders syndromes (e.g., Down)
                             Craniofacial disorders that include cognitive, speech,
                              and language delays
                             Blindness or uncorrectable visual impairment
                             Cleft palate with or without associated syndrome
                             Developmental delay
Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a
         Acute Otitis Media Prognosis
                   Persistent effusion
                          Change from B to non-B tympanogram
                           favorable
                          25% of OME of unknown duration resolves in 3
                           months
                          Warn parents of decreased hearing while
                           effusion present
                          Recheck every three months



Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a
    Acute Otitis Media Treatment
        Treat Pain
            Acetaminophen and ibuprofen (1)
            219 children treated with cefaclor
             evaluated pain at 2 days
                 Ibuprofen 7% with pain NNT 5
                 Acetaminophen 10% with pain NNT 6
                 Placebo 25%



1) Fundam Clin Pharmacol. 1996;10(4):387 Level 1c
Acute Otitis Media Treatment
   Initial treatment options are observation or antibiotics
       for children < 6 months old, antibiotics recommended
       for children 6 months to 2 years old observation option
        recommended only if all of the following are present
            otherwise healthy child
            uncertain diagnosis
            non-severe illness
            follow-up can be ensured so antibiotics can be started if
             symptoms persist or worsen

       antibiotics recommended if certain diagnosis of AOM, severe
        illness, or follow-up cannot be ensured
         Acute Otitis Media Treatment
   For children > 2 years old
         Observation option recommended only if the following
          are present
               otherwise healthy child
               uncertain diagnosis OR non-severe illness
               follow-up can be ensured so antibiotics can be started if
                symptoms persist or worsen


         Antibiotics recommended if certain diagnosis of AOM
          and severe illness, or follow-up cannot be ensured

        DynaMed Acute Otitis Media Accessed March 19 2005
Acute Otitis Media Treatment
   No improvement in 48-72 hours
       Confirm the diagnosis
       If AOM certain then begin antibiotics if not
        already started
       Change antibiotics if already started
   Acute Otitis Media Treatment
      Antibiotics
          CDC guidelines for management and
           surveillance of acute otitis media in era of
           pneumococcal resistance
               You must know your community




1) Pediatrics 5 May 2004;113(5):1452 Level 1a
        Acute Otitis Media Treatment
                Amoxicillin 80-90 mg/kg/day divided TID
                 for 10 days
                     Failure at 3 days switch to one of the following
                     cefuroxime axetil (Ceftin) 15 mg/kg BID for 10
                      days
                     amoxicillin-clavulanate (Augmentin) Augmentin
                      45 mg/kg/day divided BID or 40 mg/kg/day
                      divided TID, both for 10 days
                     ceftriaxone (Rocephin) IM 50mg/kg for 3 days


1) Pediatric Infect Dis J. 1999 Jan;18(1):1 Level 1a
 Acute Otitis Media Treatment
     Penicillin Sensitive patients
          Not Type I reaction (no urticaria or
           anaphylaxis) (1)
                Cefdinir (Omnicef) 14 mg/kg divided once daily
                 or BID for 5 days (BID dosing) or 10 days
                 (once daily dosing) slightly better taste (2)
                Cefpodoxime (Vantin) 10 mg/kg once daily for
                 10 days or divided BID for 5 days
                Cefuroxime (Ceftin or Zinacef) 30 mg/kg
                 divided BID for 10 days
                Ceftriaxone (Rocephin) 50mg/kg IM once
1)   Pediatrics 5 May 2004;113(5):1452 Level 1a
2)   Pediatric Infect Dis J 2000 Dec;19(12 Suppl):S181 Level 3
   Acute Otitis Media Treatment
       Penicillin Sensitive Patients
            Type I reaction
                  Azithromycin (Zithromax) 10 mg/kg day one then 5
                   mg/kg days 2-5
                  Clarithromycin (Biaxin) 15 mg/day divided BID for 10
                   days
                  Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg daily of
                   erythromycin divided TID to QID for 10 days
                  Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10
                   mg/kg daily of trimethoprim divided BID for 10 days



Pediatrics 5 May 2004;113(5):1452 Level 1a
     Acute Otitis Media Reality
        Shorter therapy 5 days is likely as beneficial
         as longer therapy (1)
        Early treatment with antibiotics may lead to
         increased resistance (2)
        Side effects are as common as benefit
            NNT 15-17 at 1 week
            NNH 17 at one week
        Delayed antibiotics result in decreased use
         and decreased likelihood of asking for
         antibiotics in the future (3)
1)   JAMA. 1998 Jun 3;279(21):1736 Level 1a
2)   J Infect Dis. 2001 Mar 15;183(6):880 Level 4
3)   BMJ 2001 Feb 10;322:336 Level 1c
Acute Otitis Media
   Guideline Review
       Pediatrics 2004 May;113(5):1451
       Summary can be found in Am Fam
        Physician 2004 Jun 1;69(11):2713
       editorial can be found in Am Fam Physician
        2004 Jun 1;69(11):2537
       commentary can be found in Pediatrics
        2004 Sep;114(3):898
       commentary can be found in Pediatrics
        2005 Feb;115(2):513
 Serous Otitis Media




www.pedisurg.com/ PtEducENT/Default.htm
     Serous Otitis Media Causes
         Causes
               Overgrowth of lymphoid tissue in the
                nasopharynx
               Chronic sinus infection
               Allergies of nose and nasopharynx
               Gastric reflux implicated
                     Pepsin seen in MEE 45 of 54 children with SOM
                      (1)

                     Pepsin seen in MEE 59 of 65 children with SOM
                      (2)
1)   Lancet 2002 Feb 9;359(9305):493 Level 4
2)   Laryngoscope. 2002 Nov;112(11):1930 Level 4
                Serous Otitis Media Complications
                    Permanent hearing loss (?) (5)
                    Tympanosclerosis
                    Fibrosis of middle ear space
                    Balance problems (1)
                    Minor language deficits (+/-) (2)
                    No association with attention or behavior in
                     first 6 years of life (3)
                    Possible behavior problems in teens (4)
1)   Pediatrics. 1997 Mar;99(3):334 Level 4
2)   Pediatrics. 2000 May;105(5):1119 Level 2c   4) Arch Dis Child. 2001 Aug;85(2):91 Level 1b
3)   Pediatrics. 2001 May;107(5):1037 Level 1b   5) Pediatrics. 2000 Sep;106(3):E42 Level 1c
Serous Otitis Media Physical
   Physical examination
       Pearly gray
       Minimal dullness
       Minimal retraction
       Presence of effusion
     Serous Otitis Media Tests
        Key tests
            Pneumo-otoscopy with limited movement                (1)

                   Sensitivity of 94% (95% CI: 92%-96%)
                   Specificity of 80% (95% CI: 75%-86%)
            Tympanogram B-curve                      (2)

                   81% sensitivity
                   56% specificity
            Audiometry Carhart Notch                       (2)

                   77% sensitivity
                   98% specificity

1)   Pediatrics. 2003 Dec;112(6 Pt 1):1379 Level 1a
2)   Clin Otolaryngol. 2003 Jun;28(3):183 Leve 1c
      Serous Otitis Media Prognosis
           High rate of spontaneous resolution                      (1)

                Most resolve in 3 months
           Meta-analysis 11 trials                    (2)

                No significant hearing loss
                No speech/language delay
           Tubes have consequences                           (3)

                140 children followed 8 years
                Sequela higher at 3-5 years
                       47%   for   retraction pocket
                       67%   for   tympanic membrane atrophy
                       40%   for   myringosclerosis
                       23%   for   hearing loss
1)   Pediatrics 2004 May 5;113(5):1412 Level 1a
2)   Pediatrics 2004 March; 113(3): e238 Level 1a
3)   Arch Otolaryngol Head Neck Surg. 2003 May;129(5):517 level 1b
        Serous Otitis Media Treatment
            Medications
                  Antibiotics not beneficial              (1)

                        Most rigorous meta-analysis find no benefit
                         long-term
                        Some short-term benefit may exist
            Steroids
                  Nasal steroids no evidence of benefit         (2)

            Systemic steroids no difference long
             term (3)
1)   J Fam Pract. 2003 Apr;52(4):321 FPIN network answer
2)   Cochrane Library 2002 Issue 4:CD001935 Level 1a
3)   Pediatrics. 2002 Dec;110(6):1071 Level 2b
     Serous Otitis Media Treatment
        Surgery no clear evidence of benefit
            RCT of a birth cohort that developed MEE (1)
                  Randomized to early tube placement or delay of 6
                   months (unilateral MEE) to 9 months (bilateral MEE)
                  Delayed group had better outcomes cognition, language
                   (not significant) at age 3
            Reduced time with MEE but no change in
             language or hearing (2)
            No change in quality of life


1)   N Engl J Med. 2001 Apr 19;344(16):1179 Level 1b
2)   Cochrane Library 2005 Issue 1:CD001801 Level 1a
        Serous Otitis Media Treatment
   Surgery no clear evidence of benefit
       Cohort 30,099 children born in the Netherlands
             Routine hearing screening at age 9 months
             1,081 who failed 3 successive hearing screens were referred to
              ENT surgeon
             386 found to have persistent bilateral otitis media with effusion
              for 4-6 months
       187 children (mean age 19.5 months) were randomized
        to ventilation tubes vs. watchful waiting and followed for
        1 year with language tests
       Ventilation tubes reduced diagnoses of bilateral otitis
        media with effusion at all measurements (NNT 2-4),
       No differences in language development
Pediatrics 2000 Sep;106(3):e42 Level 1c
   Serous Otitis Media Treatment
       Post-tube precautions
             unrandomized trial in 533 children who underwent
              tympanostomy tube placement
             parents self-selected into 1 of 3 "treatments" to prevent
              complications of swimming
                   no additional precautions
                   antibiotic drops following swimming
                   ear molds worn during swimming
                   control group consisted of children who never went swimming
                   all were given precautions against deep water swimming (>
                    180 cm), diving and soapy water in ears during bathing
             no benefit was noted from antibiotic ear drops or ear plugs


Arch Otolaryngol Head Neck Surg. 1996 Mar;122(3):276 Level 2b
Questions?

				
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