1. Otitis Media J. MacCormick, MD, FRCSC Associate Professor U of Ottawa
Division Otolaryngology
Children’s Hospital Eastern Ontario
Images used in this lecture were obtained from the presenter’s collection, various textbooks and internet websites., particulaly Abraham Jacob MD, The Ohio State University. Their use is for educational purposes only.

2. Objectives Define the middle ear cavity
Compare and contrast acute otitis media and serous otitis media with respect to natural history, etiology, prevalence, symptoms and signs
List the complications of acute otitis media
Describe the contemporary management of acute otitis media

3. The Eustachian Tube

4. The Eustachian Tube
Connection between middle ear (ME) & nasopharynx (NP)
Medial 2/3 fibro-cartilage; lateral 1/3 bony
Equalizes ME pressure with atmospheric pressure
Lined with respiratory epithelium
Mucociliary clearance towards the NP – drains fluid from ME
Usually closed to prevent reflux of NP contents into ME
13 birth; 36 mm in adulthood
More horizontal at birth; elongates and descends over time

5. Eustachian Tube Embryology
ET and middle ear develop from the first pharyngeal pouch (endoderm)
The external ear canal develops from the first branchial cleft (ectoderm)
The ossicles develop from the 1st and 2nd branchial arches
The interface between the first pharyngeal pouch and the first branchial cleft forms the tympanic membrane

6. Eustachian Tube Dysfunction
Abnormal cranial base anatomy
Bony anatomy
Abnormal musculature
Tensor veli palatini and/or levator veli palatini, e.g. cleft palate
Inflammation/edema
Physical obstruction (e.g. adenoids)
Usually “too closed” but can also be “too open” (patulous Eustachian tube)

7. Eustachian Tube Musculature

9. EUSTACHIAN TUBE (ET) DYSFUNCTION
Active Opening equalizes pressure in middle ear
If dysfunctional, air in middle ear space is gradually absorbed
Negative middle-ear pressure
Retraction
With enough vacuum effect, fluid is sucked from the surrounding tissue (effusion)
Increasing angulation of tube improves ET function
95% children normal ET function by age 7

10. ACUTE OTITIS MEDIA antecedent event (URI)
congestion mucosa Eustachian tube
negative middle ear pressure
aspiration of potential pathogens
accumulation of effusion
microbial pathogens proliferate
suppurative & symptomatic O.M.

12. Acute Otitis Media (AOM)

13. Acute Otitis Media

14. Severe AOME, pre Rupture

15. ACUTE OTITIS MEDIA
Treatment
Antibiotics +/-
anti-inflammatories

16. CASE #1 Lisa HPI: 3 yo healthy girl
4 day hx Upper Respiratory Infection
fever last pm, crying, pulling at ears
mom using Tylenol

17. Rel Hx: O/E: daycare no previous AOME’s T 38oC cranky
red TM’s, slight bulge

19. Management….

20. TO TREAT OR NOT TO TREAT 80% AOM resolve without antibiotics
no diff in fever, otorrhea, or middle ear effusions at 3 mos,
between treatment vs nontreatment groups
only benefit: pain by day 2 is less in treated group
therefore do not need to treat everyone….but who??

21. NEED TO TREAT DUE TO HIGHER FAILURE RATE:
age <2 ( risk meningitis)
perforated ear
temp >38.5oC

22. RECOMMENDATIONS if Watch & Wait
carefully choose subjects
recheck 48 hrs, or if reliable parent, return if , or persistent symptoms
Advil/Motrin
treat if toxic, temp >38.5o
F/U 4 weeks

23. Lisa’s Management?

24. Lisa’s Management
Age>2, not too toxic, reliable parents, not perforated
Conservative watch and wait
Reassess in office 48 hrs

25. CASE #2 Tom HPI: 18 month boy
Upper Respiratory Tract Infection x2 days
fever & crying last pm
pulling at ears

26. O/E:
38.5oC
red bulging TM’s
No previous AOME’s

28. Immediate management
to treat or not?
with what?
how long?

29. Tom’s Management
Age<2
High fever
Will treat

30. Etiology of AOM: Bacteria
H. influenzae
M. catarrhalis
22%
14%
GAS 3%
S. pneumoniae No
36%
growth
25%

31. Antibiotic Choice
First Line antibiotics if no previous antibiotics in last 3 months
Amoxicillin
For Penicillin allergic patient:
Clarithromycin
Azithromycin
(TMP/SMX- but significant resistance)

32. DURATION OF THERAPY 5-7 day treatment (3 days for azithromycin)
equal efficacy to 10 days
fewer side effects better compliance
10 days needed for:
age <2
perforation & otorrhea (drainage)

33. Tom’s Follow Up
In 4 wks
No symptoms
Fluid present

36. Case #3 David 2 days after given amoxicillin for AOM
He still has fever intermittently and cries throughout the night.
He continues to eat poorly and is fussy during the day
His temperature is 38.7o C
The otoscopy findings follow:

38. Trends in Resistance to S. pneumoniae in Canada
Amoxicillin %
High Dose Amoxil <1%
Cefuroxime %
Cefprozil 10%
Erythromycin* 10%
TMP/SMX % 0%
10%
20%
30%
*Cross-resistance with other macrolides e.g., azithromycin, clarithromycin
Low DE et al. Antimicrob Agent Chemother 2002;46: , Kellner JD et al. 42nd ICAAC, San Diego, September 2002

39. S. PNEUMONIAE RESISTANCE
S. pneumoniae is often cause of persistent otitis
is cause of majority of complications
increases with antibiotic use in the 3 months prior
Best oral agent is high dose amoxicillin ( mg/kg/day)

40. Trends in Resistance to H.influenzae in Canada
Amoxicillin %
Cefuroxime 1%
Cefprozil 10%
Azithromycin <1%
Clarithromycin 2%
TMP/SMX % 0%
10%
20%
30%
Zhanel G et al. JAC 2000;45:655-62, Hoban DJ et al. Clin Infect Dis 2001;32(Suppl 2):S81-93

41. David’s Management Failed Treatment of Amoxil
May be S pneumonia, H influenza
Consider 2nd line antibiotic:
Clavulin (amoxil + clavulinic acid, neutralizes Beta Lactamase)
2nd generation cephalosporin
macrolide for penicillin allergic
If quite ill, more likely S pneumonia
High dose amoxicillin
If very ill or not sure of bug:
amoxicillin (40mg/kg/d)+ Clav/amox (40 mg/kg/d)
to provide high dose amox for pen resistant pneumococcus, as well as the clavulinic acid for Beta Lactamase positive H influenza

42. PROPHYLAXIS
works 73% of time BUT OUT OF FAVOR because it causes resistance
amoxicillin prophylaxis study*
Showed an increase in Beta Lactamase Positive(BLP) organisms in nasopharynx from baseline 20%- 100%
Showed an increase in penicillin resistant s. pneumoniae (PRSP) from 0% to 25%
Use for patients too ill to go to OR for tubes, or waiting for OR
* Brook 1995

43. Indications for Ventilation Tubes for Recurrent AOM
4 episodes AOM in 6 months, 6 in 12 months
Most ENT’s require also evidence of significant quality of life interference
e.g. miserable, febrile, screaming with each AOM; needing 2 courses of antibiotics to clear; developing allergies to Ab
Reduced number needed if febrile seizures occurring, language delay with recurrent transient hearing loss

44. CASE #4- Ahmed 4 year old boy with speech delay
seems to understand well but does not speak clearly
only 2 known ear infections, but has a lot of colds
Doc notes fluid always present
parents are concerned that he is not joining in at kindergarten and other children do not understand what he says
kindergarten teacher suggests he is not ready to start school next year, even though he will be 5 in October

47. Otitis Media with Effusion (Chronic non-suppurative Otitis Media)
Middle ear filled with serous or mucoid fluid, no purulence
Often present after acute otitis media is treated appropriately with antibiotics
Most will clear within 3 months
Chronic after 3 months (COME)

48. Etiology of OME
50% sterile to culture
Eustachian tube dysfunction 48

49. Mucoid OM (Glue)

51. Mucoid OM

52. Serous OM

53. Serous OM

54. MIDDLE EAR EFFUSION CLEARANCE RATE AFTER AOM
2 weeks - 30%
4 weeks - 60%
8 weeks - 80%
12 weeks- 90%

55. Management COME After 3 Months
rarely consider trial antibiotics
boost short-term resolution by only 15% (benefit to one in seven treated)
fix modifiable factors
consider nasal steroid if congested
control allergies
do hearing test
If fluid and hearing loss persist, esp if speech/language delay consider tubes

56. Modifiable Risks for COME
Going to sleep with a bottle or drinking from a bottle while lying on his/her back
Smoking in the house
A wood burning stove, Cat
Day care with > 6 kids
Pacifier

57. VENTILATION TUBES FOR COME
Insert if:
Fluid present bilaterally for more than 3 months
Hearing level worse than 30dB threshold hearing level
Be more aggressive if language delay is present
Unilateral- if present, worse than 30dB for > 6 months

58. Tympanostomy Tubes Not just there to “drain fluid”
Bypass Eustachian tube to ventilate middle ear 58

60. Complications of otitis media
Intratemporal
Mastoiditis
Petrositis
Labyrinthitis
Facial paralysis
Perforation
Intracranial
Extradural abscess
Subdural abscess
Brain abscess
Meninigitis
Sinus thrombophlibitis
Extracranial
Retropharyngeal abscess
Parapharyngeal abscess
Lymphadentitis

61. Intra-Temporal complications

62. PERFORATIONS Can reduce hearing Risk of water entry
Risk of cholesteatoma invasion

65. Acute Mastoiditis AOM: 88% fever: 83%
History/Px
AOM: 88%
fever: 83%
narrowed external auditory canal: 80%
Sagging of posterosuperior meatal wall
postauricular edema: 76%
Microbiology:
S. pneumoniae > P. aeruginosa > other species

66. Treatment Hospitalization for IV antibiotics +/- Myringotomy and tube
+/- I&D subperiosteal abscess if present
+/- CT
+/- Cortical Mastoidectomy

67. Surgery Conditions for surgical treatment:
failure to respond to antibiotics
significant abscess
intracranial complications
coalescence (Bony trabeculae broken down)= surgery
non-coalescence medical management +\- myringotomy

68. Facial nerve paralysis
-Acute otitis media
Treatment :
-ventilation tube
-rarely need mastoidectomy
-consider steroids
-most get complete recovery

69. Intracranial complications

70. Intra-cranial Complications
Meningitis
the most common intracranial complication of otitis media.
Tube, +/- mastoidectomy, IV Ab

71. Intra-cranial complications
Extradural abscess:
Diagnosis
– CT scans reveal the abscess as well as the middle
ear pathology.
Treatment:
– Mastoidectomy and drainage of the abscess

72. Intra-cranial complications
It is most lethal complication of suppurative otitis media

73. Intra-cranial complications
Venous Sinus Thrombosis Clinical picture: – Signs of blood invasion: • (spiking) fever with rigors and chills • persistent fever (septicemia). – Signs of increased intracranial pressure: headache, vomiting, and papilledema.

74. Otitic Hydrocephalus
increased intracranial pressure without effect or signs of hydrocephalus
no evidence of ventricular dilatation and focal neurologic signs are absent
Headache, drowsiness, vomiting, blurring of vision, and diplopia are typical symptoms.
Papilledema and sixth cranial nerve palsy are usually evident.

75. Otitis Hydrocephalus Optic atrophy can eventually develop
A normal CSF cytology and biochemistry along with an opening pressure greater than 24 mm H2O
very commonly associated with sigmoid sinus thrombophlebitis
not all patients with sigmoid sinus thrombophlebitis develop otitic hydrocephalus

76. Complications of Otitis Media
Due to antibiotics, the incidence of complications has greatly declined.
Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma.
Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures.

77. Complications of Otitis Media
Patients appear more ill than expected
fever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic ear
lethargy and mental status changes
CT +/- MRI are indicated

78. Cholesteatoma

79. Cholesteatoma
Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining
Contain keratin and desquamated epithelium
Misnomer because the cysts don’t contain cholesterol
Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation

80. Acquired Cholesteatoma From Perforation
As the edges of the Tympanic Membrane try to heal, the squamous epithelium migrates into the middle ear

81. Eustachian Tube Dysfunction: Progression of Cholesteatoma
Pars Flacida

83. Mastoidectomy
30% recurrence/persistence in pediatrics

84. Conclusion
Not all cases of acute otitis media need to be treated with antibiotics
Amoxicillin/TMP-SMX remains first line for non recurrent AOM
Recurrent AOM within 3 months, or recent antibiotic use, choose second line antibiotics
High dose amoxicillin for resistant cases

85. Refer to ENT and Audiology if fluid is present for 3 months
In meantime, assess environmental issues, nasal congestion, immunization
If you see something white coming through the tympanic mambrane, or behind it, refer to ENT in case it is a cholesteatoma

86. Questions?