Presentation on theme: "Otitis Media J. MacCormick, MD, FRCSC Associate Professor U of Ottawa"— Presentation transcript:
1 Otitis Media J. MacCormick, MD, FRCSC Associate Professor U of Ottawa Division OtolaryngologyChildren’s Hospital Eastern OntarioImages 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 signsList the complications of acute otitis mediaDescribe the contemporary management of acute otitis media
4 The Eustachian TubeConnection between middle ear (ME) & nasopharynx (NP)Medial 2/3 fibro-cartilage; lateral 1/3 bonyEqualizes ME pressure with atmospheric pressureLined with respiratory epitheliumMucociliary clearance towards the NP – drains fluid from MEUsually closed to prevent reflux of NP contents into ME13 birth; 36 mm in adulthoodMore 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 archesThe interface between the first pharyngeal pouch and the first branchial cleft forms the tympanic membrane
6 Eustachian Tube Dysfunction Abnormal cranial base anatomyBony anatomyAbnormal musculatureTensor veli palatini and/or levator veli palatini, e.g. cleft palateInflammation/edemaPhysical obstruction (e.g. adenoids)Usually “too closed” but can also be “too open” (patulous Eustachian tube)
9 EUSTACHIAN TUBE (ET) DYSFUNCTION Active Opening equalizes pressure in middle earIf dysfunctional, air in middle ear space is gradually absorbedNegative middle-ear pressureRetractionWith enough vacuum effect, fluid is sucked from the surrounding tissue (effusion)Increasing angulation of tube improves ET function95% children normal ET function by age 7
10 ACUTE OTITIS MEDIA antecedent event (URI) congestion mucosa Eustachian tubenegative middle ear pressureaspiration of potential pathogensaccumulation of effusionmicrobial pathogens proliferatesuppurative & symptomatic O.M.
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 groupsonly benefit: pain by day 2 is less in treated grouptherefore do not need to treat everyone….but who??
21 NEED TO TREAT DUE TO HIGHER FAILURE RATE: age <2 ( risk meningitis)perforated eartemp >38.5oC
22 RECOMMENDATIONS if Watch & Wait carefully choose subjectsrecheck 48 hrs, or if reliable parent, return if , or persistent symptomsAdvil/Motrintreat if toxic, temp >38.5oF/U 4 weeks
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 dayHis temperature is 38.7o CThe 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, clarithromycinLow 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 otitisis cause of majority of complicationsincreases with antibiotic use in the 3 months priorBest 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 influenzaConsider 2nd line antibiotic:Clavulin (amoxil + clavulinic acid, neutralizes Beta Lactamase)2nd generation cephalosporinmacrolide for penicillin allergicIf quite ill, more likely S pneumoniaHigh dose amoxicillinIf 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 PROPHYLAXISworks 73% of time BUT OUT OF FAVOR because it causes resistanceamoxicillin 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 monthsMost ENT’s require also evidence of significant quality of life interferencee.g. miserable, febrile, screaming with each AOM; needing 2 courses of antibiotics to clear; developing allergies to AbReduced 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 clearlyonly 2 known ear infections, but has a lot of coldsDoc notes fluid always presentparents are concerned that he is not joining in at kindergarten and other children do not understand what he sayskindergarten 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 purulenceOften present after acute otitis media is treated appropriately with antibioticsMost will clear within 3 monthsChronic after 3 months (COME)
48 Etiology of OME50% sterile to cultureEustachian tube dysfunction48
55 Management COME After 3 Months rarely consider trial antibioticsboost short-term resolution by only 15% (benefit to one in seven treated)fix modifiable factorsconsider nasal steroid if congestedcontrol allergiesdo hearing testIf 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 backSmoking in the houseA wood burning stove, CatDay care with > 6 kidsPacifier
57 VENTILATION TUBES FOR COME Insert if:Fluid present bilaterally for more than 3 monthsHearing level worse than 30dB threshold hearing levelBe more aggressive if language delay is presentUnilateral- if present, worse than 30dB for > 6 months
58 Tympanostomy Tubes Not just there to “drain fluid” Bypass Eustachian tube to ventilate middle ear58
65 Acute Mastoiditis AOM: 88% fever: 83% History/PxAOM: 88%fever: 83%narrowed external auditory canal: 80%Sagging of posterosuperior meatal wallpostauricular 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 antibioticssignificant abscessintracranial complicationscoalescence (Bony trabeculae broken down)= surgerynon-coalescence medical management +\- myringotomy
68 Facial nerve paralysis -Acute otitis mediaTreatment :-ventilation tube-rarely need mastoidectomy-consider steroids-most get complete recovery
70 Intra-cranial Complications Meningitisthe 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 middleear 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 Hydrocephalusincreased intracranial pressure without effect or signs of hydrocephalusno evidence of ventricular dilatation and focal neurologic signs are absentHeadache, 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 H2Overy commonly associated with sigmoid sinus thrombophlebitisnot 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 expectedfever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic earlethargy and mental status changesCT +/- MRI are indicated
79 CholesteatomaCholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial liningContain keratin and desquamated epitheliumMisnomer because the cysts don’t contain cholesterolNatural 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 Mastoidectomy30% recurrence/persistence in pediatrics
84 ConclusionNot all cases of acute otitis media need to be treated with antibioticsAmoxicillin/TMP-SMX remains first line for non recurrent AOMRecurrent AOM within 3 months, or recent antibiotic use, choose second line antibioticsHigh 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, immunizationIf you see something white coming through the tympanic mambrane, or behind it, refer to ENT in case it is a cholesteatoma