Title: Otitis Media To Treat or Not to Treat
1Otitis MediaTo Treat or Not to Treat
- Cheryl Pollock PGY2
- 21 January 2003
2Outline
- Introduction
- Definition
- Pathophysiology
- Symptoms and Signs
- Diagnosis
- Treatment
- Prevention
- Pneumococcal vaccination
- Tympanostomy tubes
3Introduction
- Otitis media (AOM) is a middle ear infection
- Most commonly occurs in children
- Symptoms are neither sensitive nor specific
- Acute otitis media is overdiagnosed
4Definition
- Acute otitis media (AOM)
- Presence of symptoms of acute illness and signs
of TM under positive pressure (full or bulging) - Otitis media with effusion (OME)
- Effusion persists for several weeks post-AOM
- No acute infection, maybe reduced hearing
- Signs of TM under negative or no pressure
(retracted or neutral position) and fluid in
middle ear space
5Definition
- Recurrent otitis media (ROM)
- Three episodes of AOM within six months or four
or more episodes in a year - Chronic supparative otitis media (CSOM)
- a.k.a. chronic OME
- Continuing inflammation in the middle ear causing
otorrhea and a perforated TM
6Epidemiology
- Very common
- Canada
- 1.8 million MD visits epr year for AOM
- USA
- 50-60 of children have one episode of AOM by age
1 year - 25 MD visits in first three years of life
- WHO
- 51 000 children lt5 years die from OM annually in
developing nations
7Pathophysiology
- Complication of preceding viral URTI
- Secretions and inflammation cause relative
occlusion of eustachian tube - Generates negative pressure and leads to serous
effusion - Effusion provides media for microbial growth
- With URTI, introduction of the upper airway
viruses and/or bacteria into the middle ear
8Etiology of AOM
- Anatomic and immunologic factors in the presence
of acute infectious states - Lower angle of the eustachian tube in relation to
nasopharynx - Lack of pneumococcal antibodies
- Most common agents
- Streptococcus pneumoniae (30-55)
- Haemophilus influenzae (12-30)
- Moraxella catarrhalis (4-15)
- Less common
- Mycoplasma, viruses
9Risk Factors
- Age
- Daycare
- Bottle-feeding
- Second-hand smoke
- Race
- Sex
- Family history of middle ear disease
- Patient history of allergies or asthma
- Immunosupression
10Symptoms of AOM
- Ear-related
- Earache, tugging, sensation of fullness
- Fever
- Current or preceding URTI symptoms
- Cough, rhinorrhea
- Decreased hearing
- Fever, earache, crying, and irritability present
in 90 with AOM, and 72 without AOM. - No difference in duration
11Symptoms
- AOM in infants
- May be asymptomatic
- May present only with irritability
- Otitis media with effusion
- Usually asymptomatic
- Decreased hearing (can be demonstrated on
audiometry)
12Signs of AOM
- Problems
- Uncooperative patient
- Cerumen blockage of the auditory canal
- Hallmarks of AOM
- Bulging, opaque, immobile TM 99 PV
- Red TM with normal position and mobility 7
- AOM with perforation
- Suspicious history and auditory canal full of
purulent exudate
13Other Factors to Consider
- Coexistent conjunctivitis
- Acute hearing loss
- Tympanosclerosis
- Erythema caused by crying
- Referred pain from teeth or jaw
- Parotitis (e.g. mumps)
14Differential Diagnosis
- Otitis externa
- Sinusitis
- Peritonsillar abscess
- Mastoiditis
- Ear foreign bodies
- Labyrinthitis
- Herpes zoster
- Brain abscess
15Improving Diagnostic Accuracy
- Otoscopy
- Tympanometry
- Tympanocentesis
16Otoscopy
- Four characteristics of TM
- Position, mobility, colour, translucency
- Normal neutral position, pearly gray,
translucent, and briskly responding to positive
and negative pressure - Pneumatic otoscopy
- Cuffed ear speculums for insufflation
- Pitfalls
- Light source
- Cerumen
- cooperation
17Tympanometry
- Information about actual pressure in middle ear
space - Portable models
- In a difficult examination, normal tympanometry
can support absence of AOM - Overall, not commonly used in family medicine
setting
18Tympanocentesis
- The gold standard for the diagnosis of AOM in
clinical trials - Determines the presence of middle ear fluid, with
subsequent culture for identification of
causative pathogens - Pitfalls
- Cost, effort, availability- ENT consult
- No consensus guidelines for routine use in AOM
- In refractory or recurrent middle ear disease, it
can improve accuracy of diagnosis and guide
treatment
19Other Diagnostic Aides
- Lab studies
- No role for routine CBC or blood cultures
- Imaging studies
- No role in diagnosis of AOM
20Treatment
- Parental Education
- Role of antibiotics
- Need for compliance and follow-up
- No resolution of symptoms in 48 hours requires
reevaluation - Analgesia
- NSAIDs and acetaminophen equally effective
- Antibiotics
21Impact of Antibiotics on Outcome
- AOM has a favourable natural history regardless
of antibiotic use - Three systematic reviews
- Spontaneous resolution in 81 cases AOM
- Antibiotics reduce both the proportion of kids in
pain at 2-7 days and risk of contralateral AOM - Antibiotics have no effect on pain within 24h,
and no effect on incidence of AOM or deafness at
one month
22Impact of Antibiotics on Outcome
- No evidence that antibiotics improve outcomes in
children aged under 2 years with uncomplicated
AOM - One systematic review and one subsequent RCT
23Impact of Antibiotics on Outcome
- Proposed non-treatment of AOM
- Two day delay in treatment to see if symptoms
resolve spontaneously - However, these approaches may be flawed because
the data on which they are based does not reflect
the current era of bacterial resistance
24Impact of Antibiotics
- Canadian Paediatrics Society states that because
it is not possible to predict which cases of AOM
will result in supparative complications (e.g.
mastoiditis), all cases of AOM should be
considered for antimicrobial therapy
25Principles of Antibiotic Use
- Empiric coverage for common pathogens
- S. pneumoniae, H. influenzae, M. catarrhalis
- Amoxicillin still drug of choice
- Antibiotic resistance
- Geographic factors
- Patient factors
- Patient compliance
- Less frequent dosing
- Shorter courses (5 days vs. 10 days) with higher
doses (amoxicillin 80 mg/kg/day) now endorsed by
CDC
26Antibiotic Resistance
- Geographic factors
- Not yet an issue in NF
- In Toronto, 17 of S. pneumoniae isolates from
daycare were penicillin resistant - In USA 30-60 of S. pneumoniae strains have
reduced susceptibility to amoxicillin - Patient factors
- Recent antibiotic treatment of AOM
- Daycare
- Wintertime infections
- AOM in children lt2 years of age
27Empiric Antibiotic SelectionWithout
Tympanocentesis
- Drug efficacy
- Safety
- All antibiotics indicated for AOM generally very
safe - Compliance potential
- Palatability
- Less frequent dosing, shorter course
- Cost
28Antibiotic Selection for AOM
- First-line
- Amoxicillin 40 mg/kg/day divided t.i.d. x 10 d
(recommended by the Can. Paediatric Society) - Amoxicillin 80 mg/kg/day divided t.i.d. x 5 d
29Antibiotic Selection for AOM
- Second-line
- If penicillin allergy
- TMP/SMX 8 mg/kg/day of TMP div b.i.d. x 10 d
- erythromycin/sulfisoxazole 40mg/kg/day div qid 10
d - Clarithromycin 15 mg/kg/day div b.i.d. x 10 d
- Azithromycin 10 mg/kg once daily x 5 d
- Amoxicillin/clavulanate 40 mg/kg/day of
amoxicillin divided t.i.d. x 10 d - Ceftriaxone
30Complications
- OM with effusion
- Most common complication
- Mild discomfort
- if bilateral, significant hearing loss and speech
delay - Mastoiditis
- Very rare due to antibiotic treatment
- Mastoid tenderness plus edema plus AOM treat
aggressively in consult with ENT
31Complications
- TM perforation
- Frequent, not usually serious
- Most heal in a few weeks
- Follow-up essential
- Intracranial complications
- e.g. epidural abscess, cavernous sinus thrombosis
exceedingly rare - Usually present primarily rather than as a late
complication of a treated AOM
32Prevention of AOM
- Long term antibiotic prophylaxis
- Xylitol syrup or gum
- Pneumococcal conjugate vaccine
33Long Term Antibiotic Prophylaxis
- One systematic review found that it does have an
effect in preventing recurrence of AOM - 1993, 33 RCTs
- ARR 11, 95 CI 3-19
- No significant difference between antibiotics
- One RCT (1997) found no significant difference
between antibiotic prophylaxis and placebo
34Xylitol Syrup or Gum
- Limited evidence from one RCT (1998) that xylitol
syrup or gum taken five times per day may reduce
incidence of AOM - No evidence for optimum duration
- Abdominal discomfort
- No information on long term effects of xylitol
35Pneumococcal Vaccine
- S. pneumoniae causes a wide spectrum of disease
- URTI to invasive diseases such as meningitis and
bacteremia - 30-55 of AOM caused by S. pneumoniae
- Role of vaccination in preventing AOM and more
invasive disease
36Pneumococcal Vaccine
- PCV7 Heptavalent pneumococcal polysaccharide-prot
ein conjugate vaccine - Licensed in Canada and USA for use in children lt2
years - The 7 valances account for 87 of S. pneumoniae
isolates identified in Canadian children aged
6-23 months who had invasive disease, and 65 of
isolates in children lt6 months
37Pneumococcal Vaccine
- In Canada, the National Advisory Committee on
Immunization has recommended that the new vaccine
be administered to all children younger than two
years, and to high-risk children aged 24-59
months for prevention of invasive pneumococcal
disease - Canadian Communicable Disease Report 200228ACS-2
38Pneumococcal Vaccine
- The Finnish Otitis Media Vaccine Trial
- Eskola et al. Efficacy of a pneumococcal
conjugate vaccine against acute otitis media. - New England Journal of Medicine 2001 344403-9
39Finnish Otitis Media Vaccine Trial
- Prospective randomized, double-blind trial of the
efficacyof the heptavalent conjugated
pneumococcal vaccine (PCV7) - Lasted three years
- 1662 infants randomized at two months to receive
either the pneumococcal vaccine or the hepatitis
B vaccine at 2, 4, 6, and 12 months
40Finnish Otitis Media Vaccine Trial Conclusions
- Administration of heptavalent pneumococcal
vaccine did not significantly reduce the overall
risk of AOM by all causes - It did reduce pneumococcal episodes by 34
- the number of episodes caused by the serotypes
contained in the vaccine were reduced by 57 - The number of episodes due to all other serotypes
increased by 33 - Vaccine appears to be safe
- Relatively low incidence of local side effects
41Finnish Otitis Media Vaccine Trial Conclusions
- About 1800 children need to be vaccinated per
year to prevent one case of invasive disease - Cost 400 for a series of four vaccinations
42Cochrane Review
- 2002
- Assess the effect of pneumococcal vaccination in
preventing AOM in children up to 12 years of age - Two arms PPV and PCV
- Ten RCTs fit inclusion criteria
- Only two relate to the heptavalent pneumococcal
conjugate vaccine (PCV7)
43Cochrane Review Conclusions
- Effects of PPV and PCV on prevention of AOM are
minimal - PPV only prevents 10 AOM episodes, irrespective
of age - PCV effective against pneumococcal serotypes
included in PCV - AOM episodes due to non-vaccine pneumococcal
serotypes increased in vaccinated children - Potential pneumococcal shift
44At the End of the Day
- AOM is over-diagnosed
- Crying, cerumen removal, and fever can all cause
TM redness in the absence of disease - The colour of the TM is of lesser importance than
its position and mobility - A red TM alone does not indicate a diagnosis of
AOM
45At the End of the Day
- Amoxicillin is the initial drug of choice
- Canadian Paediatric Society recommends a 10 day
course dosed by weight - All cases of AOM should be considered for
antimicrobial therapy - Tympanocentesis, culture and sensitivity may be
indicated in cases not responding to empiric
treatment
46Ventilation Tubes
- Myringotomy with insertion of tympanostomy tubes
(TT) - Most common surgical procedure in children that
requires GA - Potential treatment for
- Chronic otitis media with effusion
- And recurrent acute otitis media
47Indications for TT Placement
- Resolution of hearing loss secondary to
persisting effusions - Otitis media with effusion gt3 months
- Recurrent AOM
- Chronic retraction of TM
- Barotitis syndrome
48Early Complications of TT
- Persistent otorrhea
- TT blockage
- Early extrusion
- Hearing loss
- Ossicular disruption
- Bleeding
49Late Complications of TT
- Persistent perforation after tube extrusion
- Scarring of the TM
- Granuloma
- Tympanosclerosis
- Cholesteatoma
- Migration of TT into middle ear canal
50Water Precautions in Children with TT
- Debatable
- No universal guidelines exist
- No evidence that unprotected swimming with TT
increases the risk of otorrhea
51Water Precautions Suggestions
- Surface swimming (above 180cm depth) in fresh
water and pools is okay without earplugs - Earplugs when washing hair and bathing
- If soapy water enters ear canal, apply antibiotic
drops - Recommend custom made or premanufactured earplugs
/- bathing cap