In the Name of God

1. In the Name of God ACUTE OTITIS MEDIA

2. Acute Otitis Media • The most common infection for which antibacterial agents are prescribed for children in the US • 1/3 of office visits to pediatricians • Peak incidence 6 – 12 months old • ≈ 2/3 of children experience at least one episode by 1 year old

3. Acute Otitis Media - Definitions • AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea) • Recurrent otitis • >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodes • Most children with recurrent acute otitis media are otherwise healthy • Otitis prone • Six or more acute otitis media episodes in the first 6 years of life • 12% of children in the general population • Persistent Middle-Ear Effusion • When an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobile • More common in white children & < 2 yo

4. AOM vs. CSOM • Chronic Serous otitismedia • This pattern is usually defined as a middle-ear effusion that has been present for at least 3 months. • Some sort of eustachian tube dysfunction is the principal predisposing factor. • Acute otitis media is commonly defined as… 1. Presence of a middle ear effusion (MEE) 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or earache

5. Clinical diagnosis  A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded. Presence of a middle ear effusion & acute signs of middle ear inflammation in presence of acute onset of signs & symptoms

6. History • Children with AOM usually present with … • History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, and/or fever • Except otorrhea other findings are nonspecific i.e. Fever, earache, and excessive crying present in children … 90% with AOM 72% without AOM

7. Laboratory tests • Routine laboratory studies, including complete blood count and ESR, are not useful in the evaluation of otitis media.

8. Otoscopy • The key to distinguishing AOM from OME is the performance of otoscopyusing appropriate tools such as pnematicotoscopy.

9. Pneumatic otoscope - equipment

10. Technique

12. Middle-Ear Effusion • MEE is commonly confirmed … • Directly by… • Tympanocentesis • Presence of fluid in the external auditory canal • Indirectly by… • Pneumatic otoscopy • Tympanometry

13. Signs of presence of MEE • Pneumatic otoscopy • Reduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle ear • Tympanometry or acoustic reflectometry • Can be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determine

14. Signs of presence of MEE

15. Systematic assessment of the • Color • Mobility Position • Translucency • External auditory canal and auricle

16. Normal tympanic membrane

17. Normal TM Translucent

18. Signs of presence of MEE Fluid level Bobbles

19. Signs of presence of MEE Perforation Cobble stoning

20. Signs of presence of MEE Opaque Semi-opaque

21. Normal TM Gray Pink

22. Signs of presence of MEE Pale yellow White

23. Tympanometry

24. OME vs. AOM • Major challenge Otitis Media with Effusion Vs. Acute Otitis Media

25. Signs & symptoms of middle-ear inflammation • Signs or symptoms of middle-ear inflammation indicated by … • Non – otoscopic findings • Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep) • However, these symptoms must be accompanied by abnormal otoscopic findings • Otoscopic findings

26. Acute inflammation – otoscopic findings • Signs of acute inflammation are necessary to differentiate AOM from OME. • Distinct fullness or bulging • The best and most reproducible sign of acute inflammation •  Marked redness of the tympanic membrane • Marked redness of the tympanic membrane without bulging is an unusual finding in AOM.

27. Normal TM Neutral

28. Signs of presence of MEE Distinct fullness Bulging

29. Signs of middle-ear inflammation Injection Marked redness

30. Established acute otitis media

31. Differential diagnosis • Other conditions  • Redness of tympanic membrane • AOM • Crying • Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tract • Trauma and/or cerumen removal • Decreased or absent mobility of tympanic membrane • AOM and OME • Tympanosclerosis • A high negative pressure within the middle ear cavity • Ear pain • Otitisexterna • Ear trauma • Throat infections • Foreign body • Temporomandibular joint syndrome

32. Uncertainty in diagnosis of AOM • The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty. • Common factors … • Inability to sufficiently clear the external auditory canal of cerumen • Narrow ear canal • Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry • An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE.

33. Management

34. Clinical Course • The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated. • However, middle ear effusion persisted for weeks to months after the onset of AOM … • Among children who were successfully treated… • 70% resolution of effusion within two weeks • 90% up to 3 months

35. Symptomatic therapy - 1 Pain remedies  • PO analgesics • Ibuprofen and acetaminophen • Remedies such as external application of heat or cold have been proposed, but there are no controlled trials that directly address the effectiveness of these remedies

36. Symptomatic therapy - 2 Oral Decongestants and antihistamines  • Alone or in combination were associated with… • Increased medication side effects • Did not improve healing or prevent surgery or other complications in AOM • Not approved for < 2 year old • In addition, treatment with antihistamines may prolong the duration of middle ear effusion • Topical decojestant & steroids

37. Comparative AOM Outcomes for Observation vsAntibacterial Agent

38. Watch & See protocol • Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children In this protocol … • Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief

39. Observation option is based on … • Diagnostic certainty • Age • Illness severity • Assurance of follow-up

40. Criteria for initial antibacterial-agent treatment or observation in children with AOM

41. Definitions • Non-severe illness is … • Mild otalgia& fever <39°C in the past 24 hours • Severe illness is • Moderate to severe otalgiaOR fever  39°C • A certain diagnosis of AOM meets all 3 criteria … 1) Rapid onset 2) Signs of MEE 3) Signs and symptoms of middle-ear inflammation.

42. Criteria for initial antibacterial-agent treatment or observation in children with AOM

43. Observation • Observation is only appropriate when … Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsen • Specific follow-up system i.e. • Reliable parent / caregiver • Convenient obtaining medications if necessary

44. Observation • Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hours • Adequate follow-up may include … 1 - A parent-initiated visit if symptoms worsen or do not improve at 48 -72 hrs 2 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame.

45. Which antibiotic ??? • Amoxicillin • Ammoxicillin + Clavulanate • Azithromycin • Cefixime • Cefuroxime • Ceftriaxone • Clarithromycin • Clindamycin • Erythromycin • Cotrimoxazole • Erythromycin + Cotrimoxazole • Penicillin V / G • Penicillin Procain 800.000 / 400.000 • Penicillin 6:3:3 / 1.200.000 • Gentamicin / Amikacin • Cephalexin • Cloxacillin • Metronidazole

46. Microbiology of AOM

47. Antibacterial therapy • If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. • When amoxicillin is used, the dose should be 80 - 90 mg/kg/day

48. Predicted treatment failure rates based on PD breakpoints for expected pathogens in low- or high-risk AOM

49. AOM high risk for amoxicillin-resistant organism • In patients who have severe illness & • AOM high risk for amoxicillin-resistant organism • Children who were received antibiotics in the previous 30 days • Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) • Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) • High-dose amoxicillin-clavulanate(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate)

50. In allergy to amoxicillin • Cefuroxime (30 mg/kg per day in 2 divided doses) • Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose) • Clarithromycin (15 mg/kg per day in 2 divided doses) • Other possibilities include • Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).