2015./2016.akad.gada LOR pulciņa 9.sēdes prezentācija "Acute otitis media". Autors Edžus Urtāns (RSU MF III kursa students).

1. 1
Acute otitis media
Author: Edžus Urtāns
Mentor: Dr.Uldis Urtāns

2.  Acute inflammation in middle ear
 < 3 weeks (month)
 Often associated with a viral upper
respiratory infection
 Most common reason for medical therapy
for children younger than 5 years
 Recurrent otitis media:
 At least 4 episodes/ year
 At least 3 episodes/ 6 months
(with adequate therapy)
Acute otitis media

3.  Most children have at least one episode of
AOM (by age 3, 50-85%)
 Peak incidence age 6-15 months
 Increased incidence in the fall and winter
 Only 20% are adults
 >700 milion cases/year
Epidemiology

4.  Eustachian tube is lined with respiratory
mucosa
 Responds together with nasopharynx
mucosa
 Edema > narrowed > negative middle
lumen ear pressure
 Influx of pathogens from nasopharynx is
possible
Causes

5. Causes
 Inflammatory response in middle ear worsens
the obstruction
 Trigger:
 Allergies
 Upper respiratory tract infections
 GER (especially children)
 Adenoid hypertrophy
 Other

6.  Viral (30-70%)
 RSV
 Rhinovirus
 Coronavirus
 Influenza, parainfluenza
 Bacterial (55%)
 Streptococcus pneumoniae (44%)
 Haemophilus influenzae (41%)
 Moraxella catarrhalis (14%)
 Gram negative enteric bacteria
 S. Aureus
• Combined (15%)
Causes

7.  Age: <7
 Their Eustachian tubes are short, floppy,
horizontal and poorly functioning
Risk factors

8. Handbook of Pediatric Otolaryngology : A Practical Guide for Evaluation and Management
of Pediatric Ear, Nose, and Throat Disorders

9. Risk factors
 Genetic predisposition
 Eustachian tube dysfunction
 Allergic tendencies
 Bottle feeding (first 3 months)
(breast milk contains lactoferrin, oligosaccharide
and surface immunoglobulin A that inhibit
bacterial colonization)
(sucking generates negative pressure)
 Incorrect posture while breastfeeding

10. Risk factors
 Underlying pathology
 Unrepaired cleft palate
 Parental smoking
 Large familys/attending daycare
 Immunocompromised states

11.  Otalgia (not always)
 Fever
 Hearing loss
(speech delay for children)
 Headache
 Nausea
 Cough
 Rhinitis
 Conjunctivitis
Signs and symptoms

12.  Pneumatic otoscopy/otoscopy:
 Red or opaque eardrum
 Retracted eardrum
 Immobile or hypo-mobile eardrum
 Presence of fluid behind eardrum
(purulent, serous, mucoid)
 Retraction pockets
 Bullous myringitis
Physical Examination

15.  Otorrhea (in case of
tympanostomy tube, perforation)
 Mastoid tenderness
 Anteriorly rotated pinna
 Tympanometry
 Audiometry
 Inspection or pharynx and
nasal cavity
Physical Examination

16. Diagnosis
 Acute onset of signs and syptoms
 The presence of middle ear effusion
(hypomobile eardrum, air-fluid level)
 Signs and symptoms of middle ear inflamation
(erythema, otalgia)

17.  Acute mastoiditis
 Abscess formation
 Facial paralysis
 Otitis media with effusion
 Persistent AOM
 Recurrent AOM
 Hearing loss
 Perforation of eardrum
Complications

18. Complications (rare)
 Lateral sinus thrombosis
 Otitic hydrocephalus
 Septic shock
 Meningitis
 Encephalitis
 Extradural abscess
 Labyrinthitis

19.  Antibacterial therapy for:
 Children of age <6months
 6 months to 2 years with severe illness
 Recurrent or billateral AOM
 Immunocompromised patients
 Patients with a perforated tympanic membrane
 Pain management (Ibuprofen, Diclofenac,
paracetamol)
 Decongestants and/or antihistamines,
nasal steroids
Treatment

20. After 24-48h (48-72h)
 If no improvemants:
 No antibiotics > antibiotics
 Antibiotics > change to a different antibiotics

21. Antibacterial therapy
 Amoxicilin 750-1500mg/day 50-100 mg/kg/day
(has not recived amoxicilin in past 30 days and has no
allergy to penicilin)
 Amoxicillin-clavulanate 875/125mg/day
90/6.4 mg/kg/day
(alternative for amoxicilin)
 Ceftriaxone 1-2g/day 50mg/kg/day or
Cefuroxim 500mg/day 30mg/kg/day
 Azithromycin, clarithromycin, erythromycin in
case of allergy to penicilin
 5-7-10 days

22. Recurrent AOM treatment
 +Tympanostomy

23. Non-drug Treatment
 Myringotomy in case of sevare pain
 Tympanocentesis in case of severe pain and as
a diagnostic procedure if there is no
improvement with
2nd line of antibiotics
(local anesthesia)
(narcosis)

24.  Avoiding risk factors if possible
 Vaccination: ?
 S. Pneumonia (PCV-7)
 Influenza
• Adenoidectomy
• Polipectomy
Preventive measures

25. Differential diagnosis
 Otitis externa
 Impacted cerumen or foreign body in ear
 Tympanosclerosis
 Otitis media with effusion
 Injury of the ear

26. Quiz (1)
Two most common bacterial causes of AOM:
A. Haemophilus influenzae, S. Aureus;
B. Moraxella catarrhalis , E. Coli;
C. S. Pneumonia, Haemophilus influenzae;
D. S. Pneumonia, Moraxella catarrhalis

27. Quiz (2)
Recurrent AOM means:
A. At least 5 episodes of AOM a year;
B. At least 8 episodes of AOM till age of 5 years ;
C. At least 3 episodes of AOM in 6 months;
D. At least 2 episodes of AOM in a month

28. Quiz (3)
What can’t be seen in otoscopy of AOM patient:
A. Retracted eardrum;
B. Perforation of eardrum;
C. Bubbles behind eardrum;
D. Bullose myringitis
E. All of above can be seen

29. Quiz (4)
What is always necessary to treat AOM:
(more then one answer is possible)
A. Antibiotics;
B. Analgetics;
C. Tympanostomy;
D. Tea;
E. None from above

30.  Shapiro, Nina L. Handbook Of Pediatric Otolaryngology : A Practical
Guide For Evaluation And Management Of Pediatric Ear, Nose, And
Throat Disorders. Singapore: World Scientific Publishing Company,
2012. eBook Academic Collection (EBSCOhost). Web. 5 Mar. 2016.
 https://www.clinicalkey.com.db.rsu.lv/#!/content/medical_topic/21-s2.0-
1014193?scrollTo=%23heading0
 http://web.a.ebscohost.com.db.rsu.lv/dynamed/detail?vid=2&sid=74b4f
a24-4f97-43f1-a411-
581c0fcc826e%40sessionmgr4003&hid=4204&bdata=JnNpdGU9ZHlu
YW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=116345&db=dme
 https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-
B9780323079327000247?scrollTo=%23hl0001072
 https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-
B9780323280471005540
 http://www.aafp.org/afp/2007/1201/p1650.html
 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.00362
26
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC153141/
Sources

31. Thank you for your attention!
(and sorry for terrible english)