Otitis Media Otitis Media
Otitis MediaOtitis Media
Otitis MediaOtitis Media $3.5 billion in expenditures$3.5 billion in expenditures Most common reason for visit to Most common reason for visit to
pediatricianpediatrician Tympanostomy tube placement is Tympanostomy tube placement is
2nd most common surgical 2nd most common surgical procedure in childrenprocedure in children
Development of multidrug-resistant Development of multidrug-resistant bacteria bacteria
Otitis Media - HistoryOtitis Media - History Egyptian mummies have Egyptian mummies have
perforations of TM and mastoid perforations of TM and mastoid destructiondestruction
Prehistoric Iranian population has Prehistoric Iranian population has evidence of middle ear diseaseevidence of middle ear disease
OM accounted for 27% of admissions OM accounted for 27% of admissions to Bellevue Hospital in 1932 to Bellevue Hospital in 1932
Otitis Media - Otitis Media - DefinitionDefinition
Inflammation of the middle Inflammation of the middle earear
May also involve May also involve inflammation of mastoid, inflammation of mastoid,
petrous apex, and petrous apex, and perilabyrinthine air cellsperilabyrinthine air cells
Otitis Media - Otitis Media - ClassificationClassification
Acute OM - rapid onset of signs & Acute OM - rapid onset of signs & sx, < 3 wk coursesx, < 3 wk course
Subacute OM - 3 wks to 3 mosSubacute OM - 3 wks to 3 mos Chronic OM - 3 mos or longer Chronic OM - 3 mos or longer
OM - EpidemiologyOM - Epidemiology AgeAge SexSex RaceRace Day careDay care SeasonsSeasons
GeneticsGenetics Breast-feedingBreast-feeding Smoke exposureSmoke exposure Medical conditions Medical conditions
OM - EpidemiologyOM - Epidemiology Increasing incidence?Increasing incidence? Increases after newborn periodIncreases after newborn period 2/3 with AOM by one year of age2/3 with AOM by one year of age 1/2 with >3 episodes by three years1/2 with >3 episodes by three years most common in 6 - 11 mos most common in 6 - 11 mos
OM - persistent middle OM - persistent middle ear effusion (MEE)ear effusion (MEE)
High incidence of MEE, avg of 40 High incidence of MEE, avg of 40 daysdays
Children less that 2 years much Children less that 2 years much more likely to have persistent MEEmore likely to have persistent MEE
White children with higher incidence White children with higher incidence of MEEof MEE
Otitis Media - RaceOtitis Media - Race Higher incidence in:Higher incidence in:
EskimosEskimos Native AmericansNative Americans Australian and African aboriginesAustralian and African aborigines
OM - Day Care OM - Day Care Greater risk of AOM in children < 3 Greater risk of AOM in children < 3
yearsyears Home care best, large group day Home care best, large group day
care worstcare worst more exposures with wider range of more exposures with wider range of
floraflora increased URI’sincreased URI’s more frequent visits to MD to decrease more frequent visits to MD to decrease
parental leave time from workparental leave time from work
OM - Breast-feedingOM - Breast-feeding Decreases incidence of URI and GI Decreases incidence of URI and GI
diseasedisease Inverse relationship between Inverse relationship between
incidence of OM and duration of incidence of OM and duration of breast-feedingbreast-feeding
Protective factor in breast-milk?Protective factor in breast-milk?
OM - smoke exposureOM - smoke exposure Induces changes in respiratory tractInduces changes in respiratory tract Cotinine marker associated with Cotinine marker associated with
increased AOM and persistent increased AOM and persistent effusioneffusion
Increased PET, otorrhea, chronic Increased PET, otorrhea, chronic and recurrent AOM in children with and recurrent AOM in children with hx of parental smokinghx of parental smoking
OM - Medical ConditionsOM - Medical Conditions Cleft palateCleft palate
decreases after decreases after repairrepair
Craniofacial Craniofacial disordersdisorders Treacher-CollinsTreacher-Collins
Down’s syndromeDown’s syndrome Ciliary dysfunctionCiliary dysfunction
Immune Immune dysfunctiondysfunction AIDSAIDS steroids, chemosteroids, chemo IgG deficiencyIgG deficiency
ObstructionObstruction NG tubesNG tubes NT intubationNT intubation adenoidsadenoids malignancymalignancy
Eustachian TubeEustachian Tube Connects middle ear and Connects middle ear and
nasopharynxnasopharynx Lumen shaped like two cones with Lumen shaped like two cones with
apex directed toward middleapex directed toward middle Mucosa has mucous producing cells Mucosa has mucous producing cells
and ciliated cellsand ciliated cells
Eustachian tubeEustachian tube AdultsAdults
ant 2/3- ant 2/3- cartilaginouscartilaginous
post 1/3- bonypost 1/3- bony 45 degree angle45 degree angle isthmus 1-2 mmisthmus 1-2 mm nasopharyngeal nasopharyngeal
orifice 8-9 mmorifice 8-9 mm
ChildrenChildren longer bony portionlonger bony portion 10 degree angle10 degree angle isthmus largeristhmus larger nasopharyngeal nasopharyngeal
orifice 4-5 mm in orifice 4-5 mm in infantsinfants
Eustachian tubeEustachian tube Usually closedUsually closed Opens during swallowing, yawning, Opens during swallowing, yawning,
and sneezing and sneezing Opening involves cartilaginous Opening involves cartilaginous
portionportion Tensor veli palatini responsible for Tensor veli palatini responsible for
active tubal openingactive tubal opening No constrictor functionNo constrictor function
Eustachian tubeEustachian tube Protection from nasopharyngeal Protection from nasopharyngeal
sound and secretionssound and secretions clearance of middle ear secretionsclearance of middle ear secretions ventilation (pressure regulation) of ventilation (pressure regulation) of
middle earmiddle ear
PathologyPathology
Edema, capillary engorgement, and PMN Edema, capillary engorgement, and PMN infiltrationinfiltration
Epithelial ulceration and granulation tissueEpithelial ulceration and granulation tissue Fibrosis, influx of chronic inflammatory Fibrosis, influx of chronic inflammatory
cellscells Increased columnar and goblet cellsIncreased columnar and goblet cells OsteitisOsteitis Edema and polypoid changesEdema and polypoid changes
PathologyPathology Eustachian tube abnormalitiesEustachian tube abnormalities
Impaired openingImpaired opening open in DS and American Indiansopen in DS and American Indians shorter tubeshorter tube
Impaired immunityImpaired immunity children have poorer immune responsechildren have poorer immune response less cytokines in nasopharynx in children with OMless cytokines in nasopharynx in children with OM
Inflammatory mediatorsInflammatory mediators Bacterial products induce inflam response with IL-1, Bacterial products induce inflam response with IL-1,
IL-6, and TNFIL-6, and TNF AllergyAllergy
MicrobiologyMicrobiology S. pneumoniaeS. pneumoniae - 30-35% - 30-35% H. influenzaeH. influenzae - 20-25% - 20-25% M. catarrhalisM. catarrhalis - 10-15% - 10-15% Group A strep - 2-4%Group A strep - 2-4% Infants with higher incidence of Infants with higher incidence of
gram negative bacilligram negative bacilli
VirologyVirology RSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates RhinovirusRhinovirus Parainfluenza virusParainfluenza virus Influenza virusInfluenza virus
MicrobiologyMicrobiology PCN-resistant PCN-resistant
StrepStrep 1979 - 1.8%1979 - 1.8% 1992 - 41%1992 - 41% Altered PCN-Altered PCN-
binding proteinsbinding proteins Lysis defectiveLysis defective Age, day-cares, and Age, day-cares, and
previous txprevious tx
H. flu and M. H. flu and M. catarrhaliscatarrhalis beta-lactamase beta-lactamase
productionproduction All All M. catarrhalisM. catarrhalis + + 45-50% 45-50% H. fluH. flu
Chronic MEE Chronic MEE Previously thought sterilePreviously thought sterile 30-50% grow in culture30-50% grow in culture over 75% PCR +over 75% PCR + Usual organismsUsual organisms
DiagnosisDiagnosis Acute OMAcute OM
preceding URIpreceding URI fever, otalgia, fever, otalgia,
hearing loss, hearing loss, otorrheaotorrhea
may have assoc may have assoc constitutional sxconstitutional sx
Chronic MEEChronic MEE poss asymptomaticposs asymptomatic hearing losshearing loss ““plugged”plugged” ““popping”popping”
DiagnosisDiagnosis Pneumatic otoscopy is gold standardPneumatic otoscopy is gold standard
Color - opaque, yellow, blue, red, pinkColor - opaque, yellow, blue, red, pink Position - bulging, retractedPosition - bulging, retracted Mobility - normal, hypomobile, neg Mobility - normal, hypomobile, neg
pressurepressure Assoc pathology - perfs, cholesteatoma, Assoc pathology - perfs, cholesteatoma,
retraction pocketsretraction pockets Head & neck examHead & neck exam
DiagnosisDiagnosis AudiogramAudiogram
document CHL, SNHL, baseline, preopdocument CHL, SNHL, baseline, preop sooner if high risksooner if high risk
ImpedanceImpedance Acoustic reflexesAcoustic reflexes
Treatment - AOMTreatment - AOM Adults and older children - Adults and older children -
observation?observation? Antibiotics - consider drug Antibiotics - consider drug
resistance patternsresistance patterns Amoxil - not for Amoxil - not for BB lactamase + lactamase + TMP-SMT - not for group A strepTMP-SMT - not for group A strep Need high middle ear concentrationsNeed high middle ear concentrations
AntibioticsAntibiotics First lineFirst line
Amoxil - 60-90 mg/kg divided tidAmoxil - 60-90 mg/kg divided tid Ceftin - B lactam stableCeftin - B lactam stable Augmentin - B lactam stableAugmentin - B lactam stable Bactrim, PediazoleBactrim, Pediazole
Second lineSecond line AugmentinAugmentin CeftinCeftin RocephinRocephin Macrolides - Zithromax, BiaxinMacrolides - Zithromax, Biaxin
Treatment - Recurrent Treatment - Recurrent AOMAOM
ChemoprophylaxisChemoprophylaxis Sulfisoxazole, amoxicillin, ampicillin, pcnSulfisoxazole, amoxicillin, ampicillin, pcn less efficacy for intermittent propylaxisless efficacy for intermittent propylaxis
Myringotomy and tube insertionMyringotomy and tube insertion decreased # and severity of AOMdecreased # and severity of AOM otorrhea and other complicationsotorrhea and other complications may require prophylaxis if severemay require prophylaxis if severe
AdenoidectomyAdenoidectomy 28% and 35% fewer episodes of AOM at first and 28% and 35% fewer episodes of AOM at first and
second yearssecond years
Treatment - OMETreatment - OME MEE > 3 mos or assoc hearing loss, vertigo, MEE > 3 mos or assoc hearing loss, vertigo,
frequency, ME pathology, discomfortfrequency, ME pathology, discomfort AntibioticsAntibiotics
shown to be of benefit, 75% PCR + bacterial DNAshown to be of benefit, 75% PCR + bacterial DNA Antibiotics + steroidAntibiotics + steroid
21% improvement compared to abx alone21% improvement compared to abx alone prednisone 1 mg/kg day x 7 daysprednisone 1 mg/kg day x 7 days varicella?varicella?
Myringotomy & tympanostomy +/- Myringotomy & tympanostomy +/- adenoidectomyadenoidectomy
Tympanostomy tube Tympanostomy tube insertioninsertion
Unresponsive OME >3 mos bil, or >6 Unresponsive OME >3 mos bil, or >6 mos uni, sooner if assoc hearing mos uni, sooner if assoc hearing problemsproblems
Recurrent MEE with excessive Recurrent MEE with excessive cumulative durationcumulative duration
Recurrent AOM - >3/6 mos or >4/12 Recurrent AOM - >3/6 mos or >4/12 mosmos
Eustachian tube dysfunctionEustachian tube dysfunction Suppurative complicationSuppurative complication
ComplicationsComplications IntratemporalIntratemporal
hearing losshearing loss TM perforationTM perforation CSOMCSOM retraction pocketsretraction pockets cholesteatomacholesteatoma mastoiditismastoiditis petrositispetrositis labyrinthitislabyrinthitis adhesive OMadhesive OM tympanosclerosistympanosclerosis ossicular dyscontinuity and ossicular dyscontinuity and
fixation fixation facial paralysisfacial paralysis cholesterol granulomacholesterol granuloma necrotizing OEnecrotizing OE
IntracranialIntracranial meningitismeningitis extradural abscessextradural abscess subdural empyemasubdural empyema focal encephalitisfocal encephalitis brain abscessbrain abscess lateral sinus lateral sinus
thrombosisthrombosis otitic hydrocephalusotitic hydrocephalus
Case historyCase history
1 1/2 year old wm presents to ENT clinic 1 1/2 year old wm presents to ENT clinic with 2nd episode of “ear infections” in with 2nd episode of “ear infections” in last monthlast month
Normal history with no medical problems Normal history with no medical problems and no prior surgical proceduresand no prior surgical procedures
Mother describes a “cold” for the last few Mother describes a “cold” for the last few days and then started running a fever days and then started running a fever and pulling at ears. Describes the child and pulling at ears. Describes the child as very irritable as very irritable
Physical ExamPhysical Exam Temp 100 F, VS wnlTemp 100 F, VS wnl Irritable childIrritable child Ears - eac clear, tms erythematous, Ears - eac clear, tms erythematous,
bulging with yellowish MEE AUbulging with yellowish MEE AU Nose - clear rhinorrheaNose - clear rhinorrhea otherwise wnlotherwise wnl
Case historyCase history Returns to clinic one month later Returns to clinic one month later
with same complaints againwith same complaints again Dx as AOMDx as AOM 3rd episode in last 2 mos and 5th in 3rd episode in last 2 mos and 5th in
last yearlast year
Case historyCase history Placed on sulfisoxizol prophylaxisPlaced on sulfisoxizol prophylaxis 3 wks later presents with recurrent 3 wks later presents with recurrent
AOM AOM
Case historyCase history BM&T performed, doing well at 3 BM&T performed, doing well at 3
wkswks Mother calls at 3 mos and says has Mother calls at 3 mos and says has
had to be tx with po abx and ear gtts had to be tx with po abx and ear gtts 3 times by pcp for bilateral otorrhea 3 times by pcp for bilateral otorrhea
New FrontiersNew Frontiers Prevention more cost effective than Prevention more cost effective than
treatmenttreatment Even slight decrease would have Even slight decrease would have
profound economic impactprofound economic impact VaccinesVaccines XylitolXylitol
VaccinesVaccines Pneumococcal vaccinePneumococcal vaccine
poorly immunogenic in childrenpoorly immunogenic in children did exhibit antibody response did exhibit antibody response
H. influenzaeH. influenzae no polysaccharide capsuleno polysaccharide capsule serum bactericidal antibodyserum bactericidal antibody
M. catarrhalisM. catarrhalis human pathogen human pathogen
VaccinesVaccines 150 viral immunotypes150 viral immunotypes 100 rhinoviruses with poor 100 rhinoviruses with poor
prognosis for vaccine developmentprognosis for vaccine development RSV most common - developing RSV most common - developing
intranasal delivery systemintranasal delivery system
XylitolXylitol Sweetening substituteSweetening substitute Inhibits growth of pneumococcus Inhibits growth of pneumococcus
and inhibits adhesion of and inhibits adhesion of pneumococcus and H. flu in pneumococcus and H. flu in nasopharynxnasopharynx
Gum and syrup reduced incidence of Gum and syrup reduced incidence of AOM 40% and 30% AOM 40% and 30%
Otitis Otitis MediaMedia