1. Otitis Media

2. n Most common reason for visit to pediatrician n Tympanostomy tube placement is 2nd most common surgical procedure in children n Development of multidrug-resistant bacteria

3. Otitis Media - Definition Inflammation of the middle ear May also involve inflammation of mastoid, petrous apex, and perilabyrinthine air cells

4. Otitis Media - Classification n Acute OM - rapid onset of signs & sx, < 3 wk course n Subacute OM - 3 wks to 3 mos n Chronic OM - 3 mos or longer

5. OM - Epidemiology n Age n Sex n Race n Day care n Seasons n Genetics n Breast-feeding n Smoke exposure n Medical conditions

6. OM - Epidemiology n Increasing incidence n Increases after newborn period n 2/3 with AOM by one year of age n 1/2 with >3 episodes by three years n most common in 6 - 11 mos

7. OM - persistent middle ear effusion (MEE) n High incidence of MEE, avg of 40 days n Children less that 2 years much more likely to have persistent MEE n White children with higher incidence of MEE

8. OM - Day Care n Greater risk of AOM in children < 3 years n Home care best, large group day care worst –more exposures with wider range of flora –increased URI’s –more frequent visits to MD to decrease parental leave time from work

9. OM - Breast-feeding n Decreases incidence of URI and GI disease n Inverse relationship between incidence of OM and duration of breast-feeding n Protective factor in breast-milk?

10. OM - smoke exposure n Induces changes in respiratory tract n Increased AOM and persistent effusion n Increased otorrhea, chronic and recurrent AOM in children with parental smoking

11. OM - Medical Conditions n Cleft palate –decreases after repair n Craniofacial disorders –Treacher-Collins n Down’s syndrome n Ciliary dysfunction n Immune dysfunction –AIDS –steroids, chemo –IgG deficiency n Obstruction –NG tubes –NT intubation –adenoids –malignancy

12. Eustachian Tube n Connects middle ear and nasopharynx n Lumen shaped like two cones with apex directed toward middle n Mucosa has mucous producing cells and ciliated cells

13. Eustachian tube n Adults –ant 2/3- cartilaginous –post 1/3- bony –45 degree angle –isthmus 1-2 mm –nasopharyngeal orifice 8-9 mm n Children –longer bony portion –10 degree angle –isthmus larger –nasopharyngeal orifice 4-5 mm in infants

14. Eustachian tube n Usually closed n Opens during swallowing, yawning, and sneezing n Opening involves cartilaginous portion n Tensor veli palatini responsible for active tubal opening n No constrictor function

15. Eustachian tube n Protection from nasopharyngeal sound and secretions n clearance of middle ear secretions n ventilation (pressure regulation) of middle ear

16. Pathology n Eustachian tube abnormalities –Impaired opening –open in DS and American Indians –shorter tube n Impaired immunity –children have poorer immune response –less cytokines in nasopharynx in children with OM n Inflammatory mediators –Bacterial products induce inflam response with IL- 1, IL-6, and TNF n Allergy

17. Microbiology n S. pneumoniae - 30-35% n H. influenzae - 20-25% n M. catarrhalis - 10-15% n Group A strep - 2-4% n Infants with higher incidence of gram negative bacilli

18. Virology n RSV - 74% of middle ear isolates n Rhinovirus n Parainfluenza virus n Influenza virus

19. Microbiology n PCN-resistant Strep –1979 - 1.8% –1992 - 41% –Altered PCN-binding proteins –Lysis defective –Age, day-cares, and previous tx n H. flu and M. catarrhalis –beta-lactamase production –All M. catarrhalis + –45-50% H. flu

20. Chronic MEE n Previously thought sterile n 30-50% grow in culture n over 75% PCR + n Usual organisms

21. Diagnosis n Acute OM –preceding URI –fever, otalgia, hearing loss, otorrhea n Chronic MEE –asymptomatic –hearing loss –“plugged” ear

22. Diagnosis n Pneumatic otoscopy is gold standard –Color - opaque, yellow, blue, red, pink –Position - bulging, retracted –Mobility - normal, hypomobile, neg pressure –Assoc pathology - perfs, cholesteatoma, retraction pockets n Head & neck exam

23. Diagnosis n Audiogram –document CHL, SNHL, baseline, preop –sooner if high risk n Impedance n Acoustic reflexes

24. Treatment - AOM n Adults and older children - observation? n Antibiotics - consider drug resistance patterns –Amoxicilin,Coamoxiclave,Azitramycin –Need high middle ear concentrations

25. Antibiotics n First line –Amoxil - 60-90 mg/kg divided tid –Coamoxiclave n Second line –Coamoxiclave –Azithramycin

26. Treatment - Recurrent AOM n Chemoprophylaxis –Sulfisoxazole, amoxicillin, ampicillin, pcn –less efficacy for intermittent propylaxis n Myringotomy and tube insertion –decreased # and severity of AOM –otorrhea and other complications –may require prophylaxis if severe n Adenoidectomy –28% and 35% fewer episodes of AOM at first and second years

27. Treatment - OME n MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, discomfort n Antibiotics –shown to be of benefit, 75% PCR + bacterial DNA n Antibiotics + steroid –21% improvement compared to abx alone –prednisone 1 mg/kg day x 7 days –varicella? n Myringotomy & tympanostomy +/- adenoidectomy

28. Tympanostomy tube insertion n Unresponsive OME >3 mos bil, or >6 mos uni, sooner if assoc hearing problems n Recurrent MEE with excessive cumulative duration n Recurrent AOM - >3/6 mos or >4/12 mos n Eustachian tube dysfunction n Suppurative complication

29. Complications n Intratemporal –hearing loss –TM perforation –CSOM –retraction pockets –cholesteatoma –mastoiditis –petrositis –labyrinthitis –adhesive OM –tympanosclerosis –ossicular dyscontinuity and fixation –facial paralysis –cholesterol granuloma –necrotizing OE n Intracranial –meningitis –extradural abscess –subdural empyema –focal encephalitis –brain abscess –lateral sinus thrombosis –otitic hydrocephalus