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Acute Otitis Media

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					             Acute Otitis Media




Continuity Clinic
                    Objectives
  • Define otitis media (OM), acute otitis
    media (AOM) and otitis media with
    effusion (OME)

  • Be familiar with the epidemiology of AOM

  • List causative pathogens in children with
    AOM and current bacteriologic resistance
    patterns
Continuity Clinic
                                        1999 7th International Symposium on Recent Advances in Otitis Media


                                    Terms and Definitions
 Otitis Media (OM)                  Inflammation of the middle ear without reference to cause or pathogenesis.1

 Middle Ear Effusion (MEE)          Liquid in the middle ear but not the etiology, pathogenesis, or duration (recent onset,
                                    acute, subacute or chronic).1
                                     Serous: thin, watery liquid
                                     Mucoid: a thick, viscid mucus-like liquid
                                     Purulent: a pus-like liquid
                                     A combination of these

 Otitis Media with Effusion (OME)   Inflammation of the middle ear with a collection of liquid in the middle ear space.
                                    Signs and symptoms of acute infection absent.1
                                    Serous, secretory or non-suppurative otitis media are terms that are no longer
                                    recommended.

 Acute Otitis Media (AOM)           Inflammation of the middle ear that is of rapid and short onset in association with
                                    signs and symptoms indicating acute infection. The tympanic membrane is full or
                                    bulging, opaque, and has limited mobility. Erythema is an inconsistent finding.1
                                    One or more local or systemic signs are present: otalgia, otorrhea, fever, irritability,
                                    anorexia, vomiting or diarrhea.


 Otorrhea                           Discharge from:1
                                     external auditory canal
                                     middle ear
                                     mastoid
                                     inner ear or intracranial cavity


Continuity ClinicMiddle ear disorder that can have symptoms similarusually absent. such as hearing
 Eustachian Tube Dysfunction
                             loss, otalgia, and tinnitus, but middle ear effusion is
                                                                                     to otitis media,
                                                                                                              1
                    Distinguishing AOM from OME
       At least two of :
       1. Abnormal color: white, yellow,
                                                           Bubbles or air-fluid interfaces               Acute purulent otorrhea
                             amber, blue           Or
                                                                  behind the TM                          not due to otitis externa
       2. Opacification not due to scarring
       3. Decreased or absent mobility


                                    Yes                        Yes


                                   Middle Ear Effusion
                                         (MEE)


                               No Acute                        Acute
                             Inflammation                  Inflammation



                                                        1. Distinct fullness or bulging of the TM
                                                        2. Substantial ear pain, including
                                                           unaccustomed tugging or rubbing of
                                                           the ear
                                                        3. Distinct erythema of the TM

                                                                                Yes

        Otitis Media with Effusion                                 Acute Otitis Media
                                                                                                           Yes
                  (OME)                                                 (AOM)

                              Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission)




Continuity Clinic
       Prevalence of Otitis Media
   • 1993 - 1995 (NCHS),2 OM accounted for
       18% ambulatory visits (1-4 yr)
       14% visits during the 1st yr of life

   • AOM episodes diagnosed2
       81% in pediatric practices
       13% in hospital ED
       6% in hospital outpatient departments


Continuity Clinic
         Prevalence of Otitis Media
    • Peak incidence of OM occurs during the first 2
      years

    • 60%-70% of children have >1 AOM before 1st
      birthday4,5

    • Early onset (<6 mo) associated with recurrent
      AOM and chronic OME

    • Recurrent AOM, >3 episodes/6 mo or >4
      episodes/yr, ~ 20% of children

Continuity Clinic
          Prevalence of Otitis Media
    AOM and OME, segments of a disease
     continuum7

    Mean cumulative time with MEE (AOM or
     OME)5
         20.4% in 1st yr
         16.6% in 2nd yr


Continuity Clinic
            Risk Factors for OM
    • Host factors
          Age/Gender
          Genetic predisposition
          Cleft palate/Down syndrome
          Allergy/Immunity
    • Environmental factors
          Daycare/Siblings
          Bottle (versus breast) feeding
          Pacifier use
          Smoking
          Low socioeconomic status
          Season/Upper respiratory infections
Continuity Clinic
       Host-Related Risk Factors

     Age/Gender
         AOM most prevalent between 6 and 11 mo

         Shorter, horizontal lying eustachian tube

         Males, higher cumulative time with OME




Continuity Clinic
        Environmental Risk Factors

 Day Care Attendance
     Most important risk factor
     50-70% children 6-18 mo attending day care have
      bilaterally persistent OME
     Number of children in day care, hours spent, age
      at entry and siblings in daycare influence risk
     Day care increases risk of infection, use of
      antibiotics, thus increasing selection of resistant
      organisms
Continuity Clinic
          Environmental Risk
                Factors
 Exposure to Household Cigarette Smoke
     Positive relationship between smokers in
      household and OM during 1st but not 2nd year5
     Increased levels of cotinine in saliva correlated
      with abnormal tympanograms and number of
      smokers
     Association between early AOM onset and
      cotinine in urine not found

Continuity Clinic
           Pathophysiology of AOM
                                                                                                               Otitis Media
                                                             Infection




    Host Factors
                                                                                                           Anatomic/Physiologic
     • Immature/impaired                                                                                   Dysfunction
        immunology
                                                                                                           • Eustachian tube
     • Familial predisposition
                                                                                                             dysfunction
     • Type of milk (breast                                                                                • Cleft Palate
        or formula)
      • Gender
      • Race



                                  Allergy                                           Environmental
                                                                                    Factors

                         Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission)




Continuity Clinic
         Pathophysiology of AOM
  • Eustachian tube (ET) functions include ventilation,
    protection and clearance of secretions
  • Impairment ET function MEE
  • URI  inflammation of nasopharynyx (NP) and ET
  • Inflammation  ET dysfunctionnegative middle
    ear pressure
  • Organisms colonizing NP aspirated into middle ear
    resulting in AOM



Continuity Clinic
                  Microbiology: Antimicrobial
                          Resistance
                                     Resistant (MICs 2 µg/mL)

                                     Intermediate (MICs 0.12-1 µg/mL)
                      35

                      30
     Resistance (%)




                      25

                      20

                      15

                      10

                       5

                       0
   Year       1988-891 1990-911 1992-931 1994-952 1997-982 1999-002 2001-023
   # Isolates   476      524      799      1527     1601     1531     1925
                           1.   Doern GV. Am J Med. 1995; 99:3S-7S
                           2.   Doern GV. ACC. 2001;45:1721
                           3.   Doern GV. Unpublished data



Continuity Clinic
Bacterial Resistance Against β-Lactam Abx


  β-lactamase                                                                     Peptidoglycan cell wall
  enzymes inactivate
  β-lactam antibiotics                                                                Plasma membrane



                                                      Altered PBPs


                                           Cytoplasm
                                                                                           Resistance increases
                                                                                           as altered PBPs
Clavulanic acid                                                                            accumulate
irreversibly binds to
β-lactamase protecting
                                     Antibiotic                        Normal PBP
β-lactam antibiotics from            β-lactamase                       Altered PBP
enzymatic cleavage                   Clavulanic acid
                         Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661   .
      Bacterial Resistance Against
               Macrolides
  Bacteria alter macrolide binding site                               Bacterial efflux pumps
    (ermAM gene, MLSB phenotype)                                    (mefE gene, M phenotype)
                                                                                
Macrolide unable to block protein synthesis                         Macrolide excreted from cell




                                Ribosomes
                               50       50       50
                               30       30       30

                                                      Cytoplasm
                                                                                  Macrolide




                        Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661
               Antibiotic Options
  • 1st Line
     – Amoxicillin : low versus high dose
     – Augmentin
     – PC allergy  Zithromax
  • 2nd Line
     – Cephalosporins
     – Zithromax



Continuity Clinic
         The Observation Option
         Limited to healthy kids over the age of 6mos

         May observe age group 6 months to 2 years if
         AOM is uncertain and pt has nonsevere illness.

             What defines a severe illness?

                    fever ≥ 39 C or 102.2 F, severe otalgia

         Older than 2 years if nonsevere illness

         Family has access to doctor, and family
         member to close eye on patient

Continuity Clinic
            A picture is worth a
           thousand words…….




Continuity Clinic
            Acute Otitis Media?




Continuity Clinic
            Acute Otitis Media?




Continuity Clinic
         What is your diagnosis?




Continuity Clinic
         What is your diagnosis?




Continuity Clinic
   Bonus Question -What is this?




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