1. ACUTE OTITIS MEDIA

2.  The most common infection for which antibacterial agents are prescribed for children in the US  1/3 of office visits to pediatricians  Peak incidence 6 – 12 months old ◦ ≈ 2/3 of children experience at least one episode by 1 year old

3.  AOM is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea)  Recurrent otitis ◦ >3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodes ◦ Most children with recurrent acute otitis media are otherwise healthy  Otitis prone ◦ Six or more acute otitis media episodes in the first 6 years of life ◦ 12% of children in the general population  Persistent Middle-Ear Effusion ◦ When an episode of otitis media results in persistence of middle- ear fluid for 3 months, & TM remains immobile ◦ More common in white children & < 2 yo

4.  Chronic Serous otitis media ◦ This pattern is usually defined as a middle-ear effusion that has been present for at least 3 months. ◦ Some sort of eustachian tube dysfunction is the principal predisposing factor.  Acute otitis media is commonly defined as… 1. Presence of a middle ear effusion (MEE) 2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or earache

5.  A diagnosis of AOM requires 1) History of acute onset of signs and symptoms 2) Presence of MEE 3) Signs and symptoms of middle-ear inflammation

6.  A diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.  Presence of a middle ear effusion & acute signs of middle ear inflammation in presence of acute onset of signs & symptoms

7.  Children with AOM usually present with … ◦ History of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea, and/or fever ◦ Except otorrhea other findings are nonspecific i.e. Fever, earache, and excessive crying present in children … 90% with AOM 72% without AOM

8.  Routine laboratory studies, including complete blood count and ESR, are not useful in the evaluation of otitis media.

9.  The key to distinguishing AOM from OME is the performance of otoscopy using appropriate tools such as pnematic otoscopy.

13.  MEE is commonly confirmed … ◦ Directly by…  Tympanocentesis  Presence of fluid in the external auditory canal ◦ Indirectly by…  Pneumatic otoscopy  Tympanometry

14.  Pneumatic otoscopy ◦ Reduced or absent mobility of the tympanic membrane is additional evidence of fluid in the middle ear  Tympanometry or acoustic reflectometry ◦ Can be helpful in establishing a diagnosis when the presence of middle-ear fluid is difficult to determine

17.  Systematic assessment of the ◦ Color ◦ Mobility Position ◦ Translucency ◦ External auditory canal and auricle

19. Translucent

20. Fluid level Bobbles

21. Perforation Cobble stoning

22. OpaqueSemi-opaque

23. Gray Pink

24. Pale yellow White

28.  Major challenge Otitis Media with Effusion Vs. Acute Otitis Media

29.  Signs or symptoms of middle-ear inflammation indicated by … a.Non – otoscopic findings a.Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep) b.However, these symptoms must be accompanied by abnormal otoscopic findings b.Otoscopic findings

30.  Signs of acute inflammation are necessary to differentiate AOM from OME.  Distinct fullness or bulging ◦ The best and most reproducible sign of acute inflammation  Marked redness of the tympanic membrane ◦ Marked redness of the tympanic membrane without bulging is an unusual finding in AOM.

31.  The main consideration … Otitis media with effusion TM Changes AOMOME ColorRedyellow PositionBulgingRetracted or Neutral OtherPus behind TM, Perforated TM with purulent otorrhea, Bullae on TM Fluid level or Bubbles

32. Neutral

33. Distinct fullness Bulging

34. Marked redness Injection

36.  Other conditions ◦ Redness of tympanic membrane  AOM  Crying  Upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tract  Trauma and/or cerumen removal ◦ Decreased or absent mobility of tympanic membrane  AOM and OME  Tympanosclerosis  A high negative pressure within the middle ear cavity ◦ Ear pain  Otitis externa  Ear trauma  Throat infections  Foreign body  Temporomandibular joint syndrome

37.  The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty.  Common factors … ◦ Inability to sufficiently clear the external auditory canal of cerumen ◦ Narrow ear canal ◦ Inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry  An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE.

39.  The systemic and local signs and symptoms of AOM usually resolve in 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated.  However, middle ear effusion persisted for weeks to months after the onset of AOM … ◦ Among children who were successfully treated…  70% resolution of effusion within two weeks  90% up to 3 months

40. Pain remedies ◦ PO analgesics  Ibuprofen and acetaminophen ◦ Remedies such as external application of heat or cold have been proposed, but there are no controlled trials that directly address the effectiveness of these remedies

41. Oral Decongestants and antihistamines  Alone or in combination were associated with… ◦ Increased medication side effects ◦ Did not improve healing or prevent surgery or other complications in AOM ◦ Not approved for < 2 year old  In addition, treatment with antihistamines may prolong the duration of middle ear effusion  Topical decojestant & steroids

42. AOM OutcomeAntibacteral RxObservationP Value Relief at 24 hours60%59%NS Relief at 2-3 days91%87%NS Relief at 4-7 days79%71%NS Clinical Resolution82%72%NS Mastoiditis/Complication 0.09%0.17%NS Persistent MEE 4-6 wks 45%48%NS Persistent MEE 3 mo. 21%26%NS Diarrhea/Vomiting16%-- Skin Rash/Allergy2%--

43.  Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children In this protocol …  Deferring antibacterial treatment of selected children for 48 -72 hrs & limiting management to symptomatic relief

44.  Observation option is based on … ◦ Diagnostic certainty ◦ Age ◦ Illness severity ◦ Assurance of follow-up

45. Age Certain Diagnosis Uncertain Diagnosis <6 mo Antibacterial therapy 6mo – 2 yr Antibacterial therapy Antibacterial therapy if severe illness Observation option if non-severe illness >2 yr Antibacterial therapy if severe illness Observation option if non-severe illness Observation option

46.  Non-severe illness is … ◦ Mild otalgia & fever <39°C in the past 24 hours  Severe illness is ◦ Moderate to severe otalgia OR fever  39°C  A certain diagnosis of AOM meets all 3 criteria … 1) Rapid onset 2) Signs of MEE 3) Signs and symptoms of middle-ear inflammation.

47. Age Certain Diagnosis Uncertain Diagnosis <6 mo Antibacterial therapy 6 mo – 2 yr Antibacterial therapy Antibacterial therapy if severe illness Observation option if non-severe illness >2 yr Antibacterial therapy if severe illness Observation option if non-severe illness Observation option

48.  Observation is only appropriate when … Follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsen  Specific follow-up system i.e. ◦ Reliable parent / caregiver ◦ Convenient obtaining medications if necessary

49.  Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hours  Adequate follow-up may include … 1 - A parent-initiated visit if symptoms worsen or do not improve at 48 -72 hrs 2 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame.

50.  Amoxicillin  Ammoxicillin + Clavulanate  Azithromycin  Cefixime  Cefuroxime  Ceftriaxone  Clarithromycin  Clindamycin  Erythromycin  Cotrimoxazole  Erythromycin + Cotrimoxazole  Penicillin V / G  Penicillin Procain 800.000 / 400.000  Penicillin 6:3:3 / 1.200.000  Gentamicin / Amikacin  Cephalexin  Cloxacillin  Metronidazole

51. Bacterial Species Frequency Major Mechanism of Resistance What we can do? S. pneumoniae+++ penicillin-resistant (PBP2a) High Dose PCN H. influenzae++ beta-lactamase 35-50% beta- lactamase Inhibitors ( clavulanate ) M. catarrhalis++ beta-lactamase 55-100%

52.  If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children.  When amoxicillin is used, the dose should be 80 - 90 mg/kg/day

54.  In patients who have severe illness &  AOM high risk for amoxicillin-resistant organism ◦ Children who were received antibiotics in the previous 30 days ◦ Children with concurrent purulent conjunctivitis (otitis- conjunctivitis syndrome) ◦ Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection)  High-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )

55. ◦ Cefuroxime (30 mg/kg per day in 2 divided doses) ◦ Azithromycin (10 mg/kg / day on day 1 followed by 5 mg/kg / day for 4 days as a single daily dose) ◦ Clarithromycin (15 mg/kg per day in 2 divided doses)  Other possibilities include ◦ Erythromycin-sulfisoxazole (50 mg/kg per day of erythromycin) or sulfamethoxazole-trimethoprim (6 - 10 mg/kg per day of trimethoprim).

56.  Alternative therapy in the penicillin-allergic patient is clindamycin at 30 to 40 mg/kg per day in 3 divided doses.  In the patient who is vomiting or cannot otherwise tolerate oral medication, a single dose of parenteral ceftriaxone (50 mg/kg) has been shown to be effective for the initial treatment of AOM.

57. 

58.  Co-Amoxiclave + Amoxicillin 156/325 125/250 1/32/3  Farmentin BD + Faramox 228/456 200/400 1/2 1/2

59.  q8h Amoxicillin (2/3)Co-Amoxiclav. (1/3) 125 156(125+31) 250312(250+62)  Bid Faramox (1/2)Farmentin (1/2) 200228(200+28) 400456(400+56)

60.  For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate  For younger children and for children with severe disease, a standard 10-day course is recommended

61.  Indications for a tympanocentesis or myringotomy are… 1. AOM in an infant <6 wks with a past NICU admission 2. AOM in a patient with compromised host resistance 3. Unresponsive AOM despite courses of 2-4 different antibiotics 4. Acute mastoiditis or suppurative labyrinthitis 5. Severe pain

63.  Administering PCN 6:3:3 in treatment  Decongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibiotics  Antihistamines may prolong the duration of middle ear effusion

64.  Continue exclusive breastfeeding as long as possible ◦ NO taking a bottle to bed  Smoke-free environment  IF high-risk for recurrent acute otitis media ◦ Prolonged courses of antimicrobial prophylaxis  Amoxicillin (20 to 30 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer  Pneumococcal vaccine & influenza vaccine marginally benefit ◦ Pneumococcal vaccine reduce all otitis media by 6%.

65.  A child has recurrent acute otitis media (RAOM) when 3 new episodes of AOM have occurred in 6 months or 4 episodes within 12 months. Approximately 20% of children younger than two years of age have RAOM.   Follow patients with RAOM monthly with otoscopy, as AOM episodes are often asymptomatic.  Consider obtaining audiologic and speech evaluations in these cases

66.  Ventilating tubes are indicated when a child has experienced 5 or more new AOM episodes within 12 months.  In selected patients, especially those with associated otitis media with effusion, performing an adenoidectomy as well as inserting tubes may reduce the likelihood of ventilating tube reinsertions and additional otitis media related hospitalizations.