Otitis

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Otitis

• Sandra Rolston, MD
• Baystate Medical Center

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(No Transcript)
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• Otitis externa
• Inflammation of external auditory canal or
  auricle
• Otitis Media
• middle ear inflammation
• Acute Otitis Media
• fluid in the middle ear
• presence of signs or symptoms of infection
• Otitis Media with Effusion
• fluid in the middle ear
• absence of signs or symptoms of infection

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Impact of Otitis Media

• most commonly diagnosed illness in children
• 30 million annual cases in the US
• 20-40 of office visits in the first 5 years
• 5 billion a year in US on treatment of middle
  ear infections in children less than 5 years of
  age
• peak age 6-18 months
• by age 1 yr 75 of children have had one episode

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Case 1

• Ivan Leshko, a two year old, is brought into your
  office because of cough, runny nose, and fever.
  The finding of pneumatic otoscopy are shown.

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Case 2

• You see David 2 days after you have treated him
  for AOM with amoxicillin. He does not seem
  better. He still has fever intermittently and
  cries throughout the night. He continues to eat
  poorly and is fussy during the day. His
  temperature is 38.7 c. There are no signs that
  suggest bacteremia or meningitis. He is not
  allergic to any antibiotics.

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Case 3

• You see Arron Buskey, a two year old, in your
  office 6 weeks after diagnosing bilateral AOM and
  initiating antibiotic treatment with amoxicillin.
  This is Arron's second AOM episode. He has
  remained asymptomatic from the second day of
  treatment.

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Otitis Externa

• Inflammation of external auditory canal or auricle

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Pathogenesis

• Breakdown of skin cerumen barrier
• Inflammation edema of skin
• Obstruction of adnexal structures pruritus
• Itch, scratch, further injury
• Alters cerumen, epithelial migration, and ear
  canal pH
• Warm, alkaline, moist canal ideal breeding ground

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Risk factors

• Excessive cleaning
• Swimming
• Devices that occlude ear canal

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Presentation

• Unilateral ear pain
• Tenderness on manipulation of tragus or pinna
• Normal tympanic membrane
• Erythematous external auditory canal

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Microbiology

• Pseudomonas aeruginosa
• S aureus
• Other skin flora
• S epidermis
• Diptheroids
• Polymicrobial

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Staging

• Mild
• minor discomfort and pruritus
• minimal canal edema
• Moderate
• intermediate degree of pain and pruritus
• canal partially occluded

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Staging

• Advanced
• intense pain
• complete canal occlusion
• /- auricular erythema
• Severe
• severe pain fever
• canal completely occluded
• auricular periauricular erythema

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Treatment

• Thoroughly clean ear canal
• Treat inflammation and infection
• Control pain
• Culture severe or recalcitrant disease
• Avoid promoting factors

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Topical agents

• Acidifying solution
• Acetic acid, hcl, salicylic acid, boric acid
• Topical corticosteroids
• Topical antibiotics
• Polymyxin, neosporin
• gentamicin, tobramycin
• ciprofloxacin, ofloxacin

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Acute Otitis Media

• fluid in the middle ear
• presence of signs or symptoms of infection

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Pathogenesis of Acute Otitis Media

• Viral upper respiratory tract infection
• Eustachian tube dysfunction
• Impaired efficacy of mucociliary system
• Alteration of bacterial colonization

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Risk Factors

• Viral respiratory illness/ winter season
• Nasopharyngeal colonization with middle ear
  pathogens
• Day care
• Siblings in household
• Familial predisposition
• Formula fed
• Lower socioeconoimic status

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Risk factors (cont)

• Tobacco smoke exposure
• Pacifier use
• Immunodeficiency
• Native American/ Eskimo
• Male gender
• Allergy
• Down syndrome
• Craniofacial abnormalities

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Tympanic Membrane in Acute Otitis Media

• 1. Contour/ Position
• 2. Color
• 3. Translucency
• 4. Mobility

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Visualization of tympanic membrane landmarks

• This diagram of a left tympanic membrane is
  divided into four quadrants by a line drawn
  through the long process of the malleus and its
  perpendicular line through the center of the umbo.

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The cone light reflex

• Located in the anterior inferior quadrant of the
  tympanic membrane. The broad base of the light
  reflex points anteriorly while the narrower
  section of the cone points to the end of the
  malleus named the umbo.

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• The color of the tympanic membrane can be
  considered red, amber, yellow, or colorless in
  the absence of inflammation. This tympanic
  membrane is both a yellow and red color.

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Increased vascularity

• Can produce injection
• Most prominent on the malleus
• May result from crying
• Associated with cerumen removal
• Common reason for overdiagnosing acute otitis
  media

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Bulging TM

• When the middle ear space contains a large amount
  of fluid, the membrane is forced outward. Note
  that the membrane seems to bulge around the umbo
  creating a donut like appearance. The bulging
  often impairs the visibility of the bony
  landmarks.

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Retracted TM

• The key to recognizing retraction of the tympanic
  membrane is the position of the lateral process
  of the malleus and foreshortening of the long
  process of the malleus.

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Normal mobility
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Decreased mobility
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Increased Mobility
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Microbial Pathogens

• Streptococcus pneumoniae (35-40)
• Haemophilus influenzae ( 25-30)
• Moraxella catarrhalis (10-20)
• Group A strep (3)
• Staphylococcal aureus (2)
• Gram negative (1-2)
• Viral

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Treatment of Acute Otitis Media

• First line
• amoxicillin
• standard dose 40 mg/kg/day
• high dose 80-90 mg/kg/day
• Treatment failure
• amoxicillin-clavulanate
• cefuroxime
• ceftriaxone (IM)

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Treatment of Acute Otitis Media

• PCN Allergy
• oral cephalosporin
• azithromycin
• trimethoprim/ sulfamethoxazole
• clindamycin

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Clinical course

• Symptoms improve in 2-3 days
• Asymptomatic in 7 days
• Eardrum gradually returns to normal position,
  color, and thickness

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Clinical course (cont)

• Pus replaced by serous fluid
• 60 present after 2 weeks
• 40 present after 1 month
• 20 present after 2 months
• 10 present after 3 months

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Clinical course- other outcomes

• Tympanic membrane perforation
• Resistant bacterial otitis media
• persistence of symptoms after 3 or more days of
  antibiotic therapy
• Recurrent acute otitis media
• 3 or more episodes in 6 months
• 4 or more episodes in 12 months

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Otitis Media with Effusion

• fluid in the middle ear
• absence of signs or symptoms of infection

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Etiology

• Post acute otitis media
• Eustachian tube dysfunction
• Allergy

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Signs and symptoms

• May be symptom free
• Sensation of blocked ear
• Hearing loss
• Behavioral change
• Speech delay
• Recurrent otitis media

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Assessment of Otitis media with effusion

• Pneumatic otoscopy
• Confirm presence of middle ear effusion
• Contour
• Color
• Translucency
• Mobility
• Tympanometry
• Hearing evaluation

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Treatment

• Consider one course of antibiotics
• Follow at one month intervals
• If present gt3 months with bilateral hearing loss
  or 4-6 months with unilateral hearing loss
• Myringotomy tubes

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Complications
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Intratemporal Complications

• Hearing loss
• Tympanic membrane perforation
• Mastoiditis
• Petrositis
• Facial paralysis
• Labyrinthitis
• Cholesteatoma
• Tympanosclerosis

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Intracranial complications

• Meningitis
• Extradural abscess
• Subdural empyema
• Brain abscess
• Dural sinus thrombosis
• Otic hydrocephalus
• Focal otitic encephalitis

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Indication for surgery

• Recurrent acute otitis media
• 3-4 episodes in 6 months
• 4-6 episodes in one year
• Persistent middle ear effusion
• 3 months if bilateral
• 6 months if unilateral
• Impending complications
• Symptomatic eustachian tube dysfunction

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Surgical Options

• Tympanocentesis
• Myringotomy
• traditional
• laser assisted
• Tympanostomy tubes
• Disease directed treatment

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Cases
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Case 1

• Ivan Leshko, a two year old, is brought into your
  office because of cough, runny nose, and fever.
  The finding of pneumatic otoscopy are shown.

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Case 2

• You see David 2 days after you have treated him
  for AOM with amoxicillin. He does not seem
  better. He still has fever intermittently and
  cries throughout the night. He continues to eat
  poorly and is fussy during the day. His
  temperature is 38.7 c. There are no signs that
  suggest bacteremia or meningitis. He is not
  allergic to any antibiotics.

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The findings of pneumatic otoscopy are shown
below.
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Case 3

• You see Arron Buskey, a two year old, in your
  office 6 weeks after diagnosing bilateral AOM and
  initiating antibiotic treatment with amoxicillin.
  This is Arron's second AOM episode. He has
  remained asymptomatic from the second day of
  treatment.

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The findings of pneumatic otoscopy are shown
below.