1. Department of Otorhinolaryngology

2. Terminology Otitis Media (OM):
It is an inflammation of the mucosa of the middle ear cleft.
Acute VS Chronic OM:
If it is less than 6 weeks it is called (acute otitis media), more than 12 weeks it is chronic.
Recurrent acute otitis media (AOM):
is defined as 3 episodes within 6 months or 4 or more episodes within 1 year (with complete resolution between the attacks).

3. AOM Epidemiology
AOM is the most frequent diagnosis made by pediatricians, second to the common cold.
Two thirds of all children have had at least one episode of AOM prior to 1 year of age, and 80% have had one by 3 years of age.
AOM is the most common indication for antimicrobial therapy in children.
Pediatricians often over-diagnose acute otitis media.

4. AOM Etiology
Its an acute (short lived) inflammation of the mucosa of the middle ear cleft, that most commonly follows an acute upper respiratory tract infection.
Common among children at age between 6 months and 6 years.
Mostly bacterial and may be viral.

5. AOM Predisposing Factors
Age; incompletely developed immunity, ET more horizontal.
ET dysfunction.
Congenital anomalies (cleft palate).
Smoking at house.
More in winter (frequent upper respiratory catarrh).
Pre-existing allergy.

6. AOM Microbiology Viral infection : Less than 10%
Streptococcus pneumoniae (gram + cocci): 40-50%
Haemophilus influenzae (gram – cocco-bacilli): 30–35%
Moraxella catarrhalis (gram - cocci):10-15%
Group A streptococcus (gram + cocci): rare
Staphylococcus aureus (gram + cocci): rare
Anaerobes: rare
Viral infection : Less than 10%

7. Bacterial Etiology S. pneumonia. 1. Incidence: 40-50%
2. Beta Lactamase producing: 15-25%
3. Causes more severe cases with Otalgia and fever.
Non-typeable H. influenzae.
1. Incidence: 30-35%
2. Beta Lactamase producing: 35% of it.
3. More often associated with eye redness and discharge.
Moraxella catarrhalis.
1. Incidence: 10%
2. Beta Lactamase producing: %

8. Viral Etiology 57% of RSV, 35% of influenza A,
33% of parainfluenza type 3,
30% of adenovirus,
28% of parainfluenza type 1,
18% of influenza B and
10% of parainfluenza type 2 virus infections.

9. AOM Microbiology
Penicillin-resistant Streptococcus
pneumoniae is the most common cause of Recurrent/Persistent AOM.

10. AOM Clinical Picture Symptoms Otalgia: usually throbbing and severe.
Hearing loss: older children may notice that they hear less with the affected ear.
Otorrhea: mucoid ear discharge (may be sanginous)
May be vomiting and diarrhea, irritability and poor feeding (infants).
Crying, irritability, tugging and pulling the ear may be the only symptoms in Infants.

11. Normal TM Appears as: Glistening, translucent
Light reflex extending antro-inferiorly (cone of light) from the umbo (most depressed part of the tympanic membrane).
Mobile (to the air pulses).
Handle (manubrium) and short process of malleus well identified.

12. AOM Clinical Picture Signs: - Pyrexia (temp. may rise up to 40).
- Tympanic membrane changes: becomes red, full, injected, bulging outward & with break up of its light reflex
- Ear discharge, possibly sanginous (indicates perforated tympanic membrane).

13. AOM (Bulging TM)

14. AOM Perforated Drum Membrane
Dry
Discharging

15. AOM Diagnosis IS MAINLY CLINICAL depending on: -Acute onset of symptom
-Signs of Middle ear inflammation: congested bulging TM, decreased mobility of TM, air-fluid level or mucopurelent ear discharge
-Systemic manifestations: Fever , disturbed sleep ,anorexia---

16. AOM & OME
- Otitis media with effusion (OME) can occur during the resolution AOM once the acute inflammation has resolved.
- 45% of children who have an episode of AOM have persistent effusion after one month,
- This number decreases to 10% after 3 months.

17. AOM Differential Diagnosis
Differential Diagnosis of otalgia Referred pain from pharyngitis Teething Wax in the ear canal Foreign body in ear canal Otitis externa

18. AOM Differential Diagnosis
Differential Diagnos is of abnormal tympanic membrane:
Bullous Myringitis : red TM
Otitis media with effusion (OME)
Absence of clinical manifestations of acute inflammation (fever, pain ---) , duration
Chronic otitis media (suppurative or non-suppurative) persistent or recurrent otorrhea through perforated TM

19. Bullous Myringitis

20. ACUTE MASTOIDITIS

21. ACUTE MASTOIDITIS

22. AOM Differential Diagnosis
AOM (Perforated TM)
Otitis Media with Effusion

23. AOM Treatment (Generally)
The general lines of treatment are
Pain management
Watchful waiting
Antibiotics
Follow-up

24. AOM Treatment
% of children will have spontaneous remission within 7-14 days. NOTE Oral decongestants or antihistamines are not useful in decreasing the symptoms or duration of illness of AOM

25. Watchful Waiting Vs. Antibiotics
1 – 2 years old with uncertain diagnosis
Children older than 2 years old with mild symptoms or uncertain diagnosis.
Note
Parents must be able to evaluate child’s symptoms and return to the treating physician if no improvements in 48 hours.

26. AOM Treatment Pain management: - Ibuprofen (10 mg/kg q 6 hours).
Local analgesic ear drops.
Watchful Waiting
Observation for hours.
If persistent or worsening symptoms, start antibiotic therapy.

27. Watchful waiting vs. antibiotics
Antibiotic is absolutely given to:
Less than 6 months old (even if doubtful).
6 months–2 years old with certain AOM.
Older than 2 years with moderate to severe manifestations (moderate to severe otalgia or temperature greater than 39 C).

28. AOM - Antibiotics FIRST LINE (Oral)
High dose amoxicillin-clavulanate (90 mg/kg/day)
Second line Antibiotics:
Cephalosporines ( third generations- Ceftriaxon 50 mg/kg/day )
Macrolides (Klacid or Zithromycin)
Cautions:
Antibiotic therapy within the past month
Amoxicillin chemoprophylaxis
Penicillin allergy

29. VOMITING/NON-COMPLIANCE Ceftriaxone 50mg/kg IV/IM in a single dose
AOM - Antibiotics
PENICILLIN ALLERGY
Urticaria/anaphylaxis: Macrolide
No urticaria/anaphylaxis: Cephalosporin
VOMITING/NON-COMPLIANCE
Ceftriaxone 50mg/kg IV/IM in a single dose
(Second dose may be needed on the third day)

30. AOM - Antibiotics PERSISTENT AOM
No improvement of symptoms within 48-72hrs.
Must return to be reassessed.
Confirmed diagnosis.
Start antibiotic if not started already. If on amoxicillin, change to a second line or injectable forms.

31. PERSISTENT AOM
If the tympanic membrane is bulging with no response to the antibiotic therapy or complications are suspected Myringotomy under general anesthesia is highly indicated to drain the pus & send a sample for sensitivity testing.

32. AOM Prevention Influenza vaccination Pneumococcal vaccination
Avoid exposure to cigarette smoking
Avoid feeding in supine position
Breast feeding for at least 3 months
Detection and treatment of predisposing factors (ET Dysfunction)
A= randomized control trial
C: Observational trials

33. AOM Complications Meningitis
Facial weakness / Paralysis (dehisent fallopian canal).
Acute Mastoiditis
OME (Otitis Media with Effusion)
Persistent tympanic membrane perforation.
Intra-cranial complications (rare)

34. Acute Mastoiditis