What is acute otitis media?

1
What is acute otitis media?

• sudden onset, short duration
• tympanic membrane has abnormal appearance AND
• fluid in middle ear OR
• purulent otorrhoea
• at least one symptom or finding indicative of
  generalised infection

2
Risk factors of otitis media

• age lt2 years (A)
• respiratory tract infection (A)
• day-care (A)
• family history (A)
• siblings (A)
• cigarette smoke (B)
• dummy (C)
• short duration of breastfeeding or none at all
  (B)

3
Aetiology of otitis media

• bacteria isolated in 70 of cases,
• virus isolated in about 20 of cases
• Main bacteria
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

4
Diagnosis of otitis media

• history and symptoms
• tympanic membrane finding
• with pneumatic otoscope and
• tympanometry or acoustic reflectometry (if
  available)

5
Tympanic membrane findings

• tympanic membrane is red, translucent or
  yellowish AND
• has decreased mobility
• tympanic membrane either smooth or bulging
• often unilateral findings

6
Myringotomy

• There is no evidence in primary care that
  paracentesis would enhance recovery from the
  illness (B)
• may be indicated to establish aetiology if
• the child has generalised illness (i.e.
  mastoiditis, meningitis)
• the child is immunocompromised
• the child is generally unwell and admitted to
  hospital
• the child has very severe earache
• may be indicated in children lt2 years with
  frequent episodes of otitis media when exudate
  impairs hearing for a prolonged time

7
Antimicrobial therapy

• First choice
• amoxicillin 40mg/kg/day in 2 divided doses or
• penicillin V 100,000 IU/kg/day in 2 divided
  doses, for 5 days.
• Second choice
• co-amoxiclav or
• sulphatrimethoprim (for patients with penicillin
  allergy)
• Reserve
• azithromycin/clarithromycin, cefaclor, cefuroxime
  axetil, ceftriaxone (single dose injection)

8
Other treatments of otitis media

• pain relief (C)
• paracetamol 15-20mg/kg 4 times a day
• ibuprofen 10mg/kg 3 times a day
• naproxen 5mg/kg twice a day
• ear drops with local anaesthetic (C)
• decongestants
• postural treatment

9
Follow-up

• Follow-up appointment in about 1 month
• in addition to physical examination, tympanometry
  and acoustic reflectometry recommended
• if asymptomatic, normal hearing, normal tympanic
  membrane
• no further follow-up
• if asymptomatic, but fluid in middle ear
• new appointment in 1 month, and if needed
  further appointment in another month
• if symptoms of OM and fluid in middle ear
• start another course of antibiotics with other
  than the first choice drug. Follow-up as above.

10
Prevention of otitis media

• Evidence exists for
• breastfeeding (B)
• Antibiotics (B)
• Xylitol (B)
• ventilation tubes (B)
• immunisation
• pneumococci ?
• Influenza (A)
• immunoglobulins (-B)

• No evidence or no data
• day-care?
• cigarette smoke?
• dummy?
• Adenoidectomy (-C)
• decongestants/antihistamines (-C)

positive effect - no effect
11
When ENT referral?

• suspicion of complications (e.g. mastoiditis,
  facial paralysis)
• purulent otorrhoea of over one weeks duration
  despite appropriate antibiotic treatment
• pseudomonas isolated in exudate
• symptomatic illness continues despite second
  choice antibiotics
• fluid in middle ear persists for over 3 months
• frequent episodes of otitis media (gt3 / 6 months
  or
• gt4 / 1 year)
• child has underlying hearing impairment