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Otitis Media To Treat or Not to Treat

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Title: Otitis Media To Treat or Not to Treat


1
Otitis MediaTo Treat or Not to Treat
  • Cheryl Pollock PGY2
  • 21 January 2003

2
Outline
  • Introduction
  • Definition
  • Pathophysiology
  • Symptoms and Signs
  • Diagnosis
  • Treatment
  • Prevention
  • Pneumococcal vaccination
  • Tympanostomy tubes

3
Introduction
  • Otitis media (AOM) is a middle ear infection
  • Most commonly occurs in children
  • Symptoms are neither sensitive nor specific
  • Acute otitis media is overdiagnosed

4
Definition
  • 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

5
Definition
  • 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

6
Epidemiology
  • 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

7
Pathophysiology
  • 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

8
Etiology 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

9
Risk Factors
  • Age
  • Daycare
  • Bottle-feeding
  • Second-hand smoke
  • Race
  • Sex
  • Family history of middle ear disease
  • Patient history of allergies or asthma
  • Immunosupression

10
Symptoms 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

11
Symptoms
  • AOM in infants
  • May be asymptomatic
  • May present only with irritability
  • Otitis media with effusion
  • Usually asymptomatic
  • Decreased hearing (can be demonstrated on
    audiometry)

12
Signs 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

13
Other Factors to Consider
  • Coexistent conjunctivitis
  • Acute hearing loss
  • Tympanosclerosis
  • Erythema caused by crying
  • Referred pain from teeth or jaw
  • Parotitis (e.g. mumps)

14
Differential Diagnosis
  • Otitis externa
  • Sinusitis
  • Peritonsillar abscess
  • Mastoiditis
  • Ear foreign bodies
  • Labyrinthitis
  • Herpes zoster
  • Brain abscess

15
Improving Diagnostic Accuracy
  • Otoscopy
  • Tympanometry
  • Tympanocentesis

16
Otoscopy
  • 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

17
Tympanometry
  • 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

18
Tympanocentesis
  • 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

19
Other Diagnostic Aides
  • Lab studies
  • No role for routine CBC or blood cultures
  • Imaging studies
  • No role in diagnosis of AOM

20
Treatment
  • 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

21
Impact 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

22
Impact 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

23
Impact 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

24
Impact 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

25
Principles 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

26
Antibiotic 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

27
Empiric Antibiotic SelectionWithout
Tympanocentesis
  • Drug efficacy
  • Safety
  • All antibiotics indicated for AOM generally very
    safe
  • Compliance potential
  • Palatability
  • Less frequent dosing, shorter course
  • Cost

28
Antibiotic 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

29
Antibiotic 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

30
Complications
  • 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

31
Complications
  • 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

32
Prevention of AOM
  • Long term antibiotic prophylaxis
  • Xylitol syrup or gum
  • Pneumococcal conjugate vaccine

33
Long 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

34
Xylitol 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

35
Pneumococcal 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

36
Pneumococcal 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

37
Pneumococcal 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

38
Pneumococcal 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

39
Finnish 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

40
Finnish 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

41
Finnish 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

42
Cochrane 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)

43
Cochrane 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

44
At 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

45
At 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

46
Ventilation 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

47
Indications 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

48
Early Complications of TT
  • Persistent otorrhea
  • TT blockage
  • Early extrusion
  • Hearing loss
  • Ossicular disruption
  • Bleeding

49
Late Complications of TT
  • Persistent perforation after tube extrusion
  • Scarring of the TM
  • Granuloma
  • Tympanosclerosis
  • Cholesteatoma
  • Migration of TT into middle ear canal

50
Water Precautions in Children with TT
  • Debatable
  • No universal guidelines exist
  • No evidence that unprotected swimming with TT
    increases the risk of otorrhea

51
Water 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
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