Otitis Media Dr. Yasir Hakim, MD Pathology& Microbiology. By د. ياسر عبدالله – دكتوراة علم الأحياء الدقيقة الطبية والطفيليات. رئيس قسم الأحياء الدقيقة الطبية والطفيليات. Dr. Yasir Hakim, MD Pathology& Microbiology. Head Department of Microbiology. School of Medicine Dar Uloom –University – KSA اسم ورقم المقرر – Course Name and No. 5/25/2019

Objectives Define and know the classification of middle ear infection (Otitis media (OM))  Know the epidemiology of OM  Explain the pathogenesis and recognize the risk factors and clinical presentation of OM  Define the microbiology of OM and list examples of common bacterial causes of different types of OM  Identify the diagnostic approaches and emphasize on microbiological aspect of diagnosis  Know the management of OM  Recall common complications of OM. اسم ورقم المقرر – Course Name and No. 5/25/2019

Anatomy & Physiology

Definition Otitis Media is defined as an inflammation of the middle ear i.e., the area between the tympanic membrane and the inner ear. The following behaviors in children often mean they have AOM: Intense crying. Clutching the ear while wincing in pain. Complaining about a pain in the ear

CONT: Otitis media (OM) is the second most common disease of childhood, after upper respiratory infection (URI). AOM is a recurrent disease. More than one third of children experience six or more episodes of AOM by age 7 years. OM is also the most common cause for childhood visits to a physician's office.

Classification Acute OM (AOM) OM with effusion (OME) Chronic suppurative OM Adhesive OM

Continuous AOM: the first 3 weeks of a process in which the middle ear shows the signs and symptoms of acute inflammation. Chronic suppurative OM is a chronic inflammation of the middle ear that persists for at least 6 weeks and is associated with otorrhea through a perforated TM. Adhesive otitis media is a form of chronic otitis media where there is a adhesion of medial ear structures as a result of chronic inflammation . Characterized by occlusion of the Eustachian tube and formation of adhesions in the tympanum OM with effusion (OME) is thick fluid behind the eardrum in the middle ear for more than three months .

Symptoms Otalgia (ear pain). Headache Otorrhea (ear discharge). Sleeplessness Deafness. Neck pain Irritability Rhinitis Rhinitis. Fever Vomiting Diarrhea Anorexia

Signs Crying. Irritability. Tugging or pulling on the ear.

Pathophysiology The most important factor in middle ear disease is Eustachian tube (ET) dysfunction (ETD), in which the mucosa at the pharyngeal end of the ET is part of the mucociliary system of the middle ear. Direct extension of infectious processes from the nasopharynx to the middle ear, causing OM. Esophageal contents regurgitated into the nasopharynx and middle ear through the ET can create a direct mechanical disturbance of the middle ear mucosa and cause middle ear inflammation.

Pathophysiology 4) In children, developmental alterations of the ET, an immature immune system, and frequent infections of the upper respiratory mucosa all play major roles in AOM development. 5) Studies have demonstrated how viral infection of the upper respiratory epithelium leads to increased ETD , increased bacterial colonization and adherence in the nasopharynx.

Complications Mastoiditis . Cholesteatoma . Meningitis. Hearing loss. Tympanic membrane perforation. Brain abscess

Etiology-Bacterial Infections Streptococcus pneumoniae is the most common bacterial cause of acute otitis media, causing about 40 - 80% of cases. Haemophilus influenzae, the next most common, is responsible for 20 - 30% of acute infections. Moraxella catarrhalis is responsible for 10 - 20% of infections. Other bacteria include Streptococcus pyogenes and Staphylococcus aureus. .

Etiology- Viral infections Viruses: Rhinovirus is a common virus that causes a cold and plays a leading role in the development of ear infections. Other viruses, such as respiratory syncytial virus (RSV, a virus responsible for childhood respiratory infections). And influenza (flu), can be the actual causes of some ear infections. Nearly a third of infants and toddlers with upper respiratory infections go on to develop acute otitis media. The eustachian tube can become swollen or blocked: a cold , a sinus infection, infected or enlarged adenoids and cigarette smoke.

Etiology - Anatomic Abnormalities Children with shorter than normal and relatively horizontal Eustachian tubes are at particular risk for initial and recurrent infections. Inborn structural abnormalities, such as cleft palate, increase risk. Genetic conditions, such as Kartagener's syndrome in which the cilia (hair-like structures) in the ear are immobile and cause fluid build up, also increase the risk. Children with Down syndrome or Fetal Alcohol Syndrome may also be at increased risk due to anatomical abnormalities.

Percentage of Organisms 57% of RSV, 35% of influenza A, 33% of parainfluenza type 3, 30% of adenovirus, 28% of parainfluenza type 1, 18% of influenza B 10% of parainfluenza type 2 virus infections Aspergillus or Candida as fungal infections.

Risk factors Being between 6 and 36 months old Using a pacifier Attending daycare Being bottle fed instead of breastfed (in infants) Being exposed to cigarette smoke Being exposed to high levels of air pollution Experiencing changes in climate Genetics also plays a role of AOM.

Recommended Otitis Media Workup Laboratory Studies – workup Otoscope Tuning fork Audiometry. Imaging - CT scan and MRI

Otoscopic findings of the tympanic membrane (TM), which may include the following: Bulging TM Retracted TM Impaired mobility of the TM Erythematous TM Purulent otorrhea Opacification of the TM Middle ear effusion (MEE)

Normal TM Appears as Glistening, translucent (scarring often may be evident in adults). Pearly gray to pale pink membrane . Mobile (to the air pulses). Non-erythematous.

Treatment 1. Antibiotic duration 1. Age under 6 years 2. First Line antimicrobial agent: 1. Amoxicillin 80-90 mg/kg/day PO divided twice daily or 8 hourly for 10 days (7 days if age>6) 2. If Penicillin Allergy, use Macrolide (e.g. Azithromycin) 3. Second Line (10 day course) 1. Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice daily for 10 days 2. Cefuroxime (Zinacef, Ceftin) 30 mg/kg/day divided twice daily for 10 days 3. Cefprozil (Cefzil) 30 mg/kg/day divided twice daily for 10 days 4. Cefdinir (Omnicef) 14 mg/kg/day divided one to two times daily for 10 days 5. Cefpodoxime (Vantin) 30 mg/kg once daily for 10 days 4. Third Line 1. Strongly consider Tympanocentesis for bacterial culture 2. Ceftriaxone (Rocephin) 50 mg/kg IM daily for 3 days 3. Clindamycin 30-40 mg/kg/day divided four times daily for 10 days 2. Myringotomy (FLUID – BUILD UP). 2. Surgery (tympanoplasty).

Mastoiditis

Acute Otitis Media-TM

Myringitis - blisters on TM

مع امنياتى لكم بالتوفيق د. ياسر اسم ورقم المقرر – Course Name and No. 5/25/2019