Otitis Media with effusion_ Clinical Practice guidelines by pptfiles


									        Otitis Media:
Clinical Practice Guidelines
and Current Management

     Tamekia L. Wakefield, MD
     Pediatric Otolaryngologist
     ENT & Allergy Associates, LLP

Tamekia Wakefield, MD is a member of the
speakers bureau for Alcon. The makers of
Ciprodex otic.
► $4 billion in combined direct and indirect
  cost annually
► 2.2 million episodes diagnosed annually
► Most common reason for visit to pediatrician
► Tympanostomy tube placement is 2nd most
  common surgical procedure in children
► OME:  the presence of fluid in the middle
 ear without acute signs or symptoms

► AOM:  the presence of fluid in the middle
 ear with the acute onset of signs and
 symptoms of middle ear inflammation.
► S. pneumoniae - 30-35%
► H. influenzae - 20-25%
► M. catarrhalis - 10-15%
► Group A strep - 2-4%
► Infants   with higher incidence of gram negative
► RSV - 74% of middle ear isolates
► Rhinovirus
► Parainfluenza virus
► Influenza virus
► Risk   factors:
  § Daycare
  § Tobacco smoke exposure
  § Inverse relationship between length of
    breastfeeding and number of AOM episodes
              Acute otitis media
► Clinical   Indicators: Myringotomy and Tubes:

  § Severe acute otitis media (myringotomy)
  § Poor response (describe) to antibiotic for otitis media
    (myringotomy or tube)
  § Impending mastoiditis or intra-cranial complication due
    to otitis media (myringotomy)
  § Recurrent episodes of acute otitis media (more than 3
    episodes in 6 months or more than 4 episodes in 12
    months) (tympanostomy tube)
► Eustachian   tube dysfunction
► Post-AOM
► Mostepisodes resolve spontaneously within
  3 months
► 30%-40% Recurrent OME
► 5%-10% Persistent OME > 1 year
► High  prevalence of OME
► Difficulties in diagnosis and assessing
► Increased risk of CHL
► Potential impact on language and cognition
► Significant practice variations in
► Cliniciansshould use pneumatic otoscopy as the
  primary diagnostic method for OME. OME should
  be distinguished from AOM. Strong
   § Pneumatic otoscopy is gold standard
      ► Color
      ► Position
      ► Mobility
      ► Tympanic   membrane appearance
   § Sensitivity of 94% and specificity of 80% versus
   § Readily available, cost effective and accurate in
     experienced hands
► Tympanometry      can be used to confirm
 diagnosis. Option

  § When diagnosis is uncertain, consider
    ►Cost associated with equipment
    ►Reliable for ages 4 months or older
►   Population-based screening programs for OME are not
    recommended in healthy, asymptomatic children.
    Recommendation Against
    § Highly prevalent in young children. 15%-40% point
      prevalence in healthy children under 5 yr
    § No influence on short-term language outcomes
    § No benefit from treatment that exceeds the favorable
      natural history of the disease
    § Risk of inaccurate diagnoses, overtreatment, parental
      anxiety, and increased cost
► Cliniciansshould document the laterality,
  duration of effusion, and presence and
  severity of associated symptoms at each
  assessment of the child with OME.
  § Medical decision making depends on these
  § 40%-50% of OME cases no symptoms
  § Preponderance of benefit over harm
►   Clinicians should distinguish the child with OME who is at risk for
    speech, language, or learning problems from other children with OME,
    and should more promptly evaluate hearing, speech, language, and
    need for intervention. Recommendation
     § Permanent hearing loss
     § Speech and language delay or disorder
     § Autism-spectrum disorder/PDD
     § Syndromes with cognitive, speech, and language delays
     § Blindness
     § Cleft Palate
     § Developmental delay
► Clinicians should manage the child with OME who
  is not at risk with watchful waiting for 3 months
  from the date effusion onset (if known) or from
  the date of diagnosis (if onset is unknown).
   § OME is usually self-limited
   § 75%-90% of OME after AOM resolves
     spontaneously by 3 months
   § Waiting results in little harm to child
   § Optimize listening and learning environment
     until effusion resolves
► Antihistamines and decongestants are
 ineffective for OME and are not
 recommended for treatment. Antimicrobials
 and corticosteroids do no have long-term
 efficacy and are not recommended for
 routine management. Recommendation
  § Short-term, small magnitude benefits
  § Significant adverse effects
► Hearing testing is recommended when OME
 persists for 3 months or longer, or at any
 time that language delay, learning
 problems, or a significant hearing loss is
 suspected in a child with OME. Language
 testing should be conducted for children
 with hearing loss. Recommendation
► HL  may impair early language acquisition
► Extended periods of CHL may result in
  developmental and academic sequelae
► Early language delays are associated with
  later delays in reading and writing.
►   Children with persistent OME who are not at risk should be
    reexamined at 3- to 6-month intervals until the effusion is
    no longer present, significant hearing loss is identified, or
    structural abnormalities of the TM or middle ear are
    suspected. Recommendation

    § Resolution rates decrease the longer the effusion has been present
    § Risk factors for non-resolution:
       ► Summer or fall onset
       ► HL>30dB
       ► H/O prior tympanostomy tubes
       ► Not having had an adenoidectomy
► When  children with OME are referred by the
 primary care clinician for evaluation by an
 otolaryngologist, audiologist, or speech-
 language pathologist, the referring clinician
 should document the effusion duration and
 specific reason for referral (evaluation vs.
 surgery), and provide additional relevant
 information such as history of AOM and
 developmental status of the child. Option
► When  a child becomes a surgical candidate,
 tympanostomy tube insertion is the
 preferred initial procedure; adenoidectomy
 should not be performed unless a distinct
 indication exists (nasal obstruction, chronic
 adenoiditis). Repeat surgery consists of
 adenoidectomy plus myringotomy, with or
 without tube insertion. Tonsillectomy alone
 or myringotomy alone should not be used to
 treat OME. Recommendation
► OME   > 4 months with persistent hearing
► Recurrent or persistent OME in at risk child
► OME with structural damage to TM or ME
► Alternative    Medicine   ► Allergy   Management
  § No recommendation:        § No recommendation:
     ► Limited evidence          ► Few   studies
     ► Few studies
     ► Medications are
► Inappropriate   antibiotic treatment of OM
  § Multidrug-resistant strains
  § Drug side effects
  § Parental/caregiver confusion
► Communities  of sessile bacteria embedded
 in a matrix of extracellular polymeric
 substances of their own synthesis that
 adhere to a foreign body or a mucosal

► Chronicear infections or persistent effusion
 in the middle ear are biofilm related
► Unable  to culture with traditional methods
► Traditional antibiotics are relatively
  ineffective for eradicating biofilm infection
► Higher doses of antibiotics required to treat
► Macrolides (clarithromycin/erythromycin)
► Physical disruption is beneficial
► Non-antibiotic therapies may be more
   Acute otitis media with tubes
► Diagnosis
  § Acute purulent
     ► Commonly       occurs after
         insertion of
         tympanostomy tubes
► Risk   Factor
  § Occurs more frequently
    in children with upper
    respiratory infections2,3
► Ototopicalantibiotics are appropriate therapy
  in uncomplicated cases
  § Fluoroquinolones
► Adjunctive   systemic antibiotics may be used
  § When infection has spread beyond middle ear or
    external ear canal
  § With lack of adherence to ototopical therapy
  § When ototopical treatment fails (after 7-10 days)
  § In children with associated streptococcal pharyngitis
► Special populations (e.g. immunocompromised
  patients) require additional consideration
► High  prevalence
► Accurate diagnosis
► At risk children
► Hearing loss
► Speech and language assessment
► Antibiotic use
► Surgery
► Referral

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