1. Otitis Media: Clinical Practice Guidelines and Current Management
Tamekia L. Wakefield, MD
Pediatric Otolaryngologist
ENT & Allergy Associates, LLP

2. Disclosures:
Tamekia Wakefield, MD is a member of the speakers bureau for Alcon. The makers of Ciprodex otic.

3. Otitis Media $4 billion in combined direct and indirect cost annually
2.2 million episodes diagnosed annually
Most common reason for visit to pediatrician
Tympanostomy tube placement is 2nd most common surgical procedure in children

4. Definitions:
OME: the presence of fluid in the middle ear without acute signs or symptoms
AOM: the presence of fluid in the middle ear with the acute onset of signs and symptoms of middle ear inflammation.

5. Microbiology/Virology
S. pneumoniae %
H. influenzae %
M. catarrhalis %
Group A strep - 2-4%
Infants with higher incidence of gram negative bacilli
RSV - 74% of middle ear isolates
Rhinovirus
Parainfluenza virus
Influenza virus

6. aom Risk factors: Daycare Tobacco smoke exposure
Inverse relationship between length of breastfeeding and number of AOM episodes

7. Acute otitis media Clinical Indicators: Myringotomy and Tubes:
Severe acute otitis media (myringotomy)
Poor response (describe) to antibiotic for otitis media (myringotomy or tube)
Impending mastoiditis or intra-cranial complication due to otitis media (myringotomy)
Recurrent episodes of acute otitis media (more than 3 episodes in 6 months or more than 4 episodes in 12 months) (tympanostomy tube)

8. OME Etiology
Eustachian tube dysfunction
Post-AOM

9. Natural history Most episodes resolve spontaneously within 3 months
30%-40% Recurrent OME
5%-10% Persistent OME > 1 year

10. Why do we need CPG? High prevalence of OME
Difficulties in diagnosis and assessing duration
Increased risk of CHL
Potential impact on language and cognition
Significant practice variations in management

11. Diagnosis
Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME. OME should be distinguished from AOM. Strong recommendation
Pneumatic otoscopy is gold standard
Color
Position
Mobility
Tympanic membrane appearance
Sensitivity of 94% and specificity of 80% versus myringotomy
Readily available, cost effective and accurate in experienced hands

12. diagnosis Tympanometry can be used to confirm diagnosis. Option
When diagnosis is uncertain, consider tympanometry
Cost associated with equipment
Painless
Reliable for ages 4 months or older

13. Screening
Population-based screening programs for OME are not recommended in healthy, asymptomatic children. Recommendation Against
Highly prevalent in young children. 15%-40% point prevalence in healthy children under 5 yr
No influence on short-term language outcomes
No benefit from treatment that exceeds the favorable natural history of the disease
Risk of inaccurate diagnoses, overtreatment, parental anxiety, and increased cost

14. Documentation
Clinicians should document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME. Recommendation
Medical decision making depends on these features
40%-50% of OME cases no symptoms
Preponderance of benefit over harm

15. At risk child
Clinicians should distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME, and should more promptly evaluate hearing, speech, language, and need for intervention. Recommendation
Permanent hearing loss
Speech and language delay or disorder
Autism-spectrum disorder/PDD
Syndromes with cognitive, speech, and language delays
Blindness
Cleft Palate
Developmental delay

16. Watchful waiting
Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 months from the date effusion onset (if known) or from the date of diagnosis (if onset is unknown). Recommendation
OME is usually self-limited
75%-90% of OME after AOM resolves spontaneously by 3 months
Waiting results in little harm to child
Optimize listening and learning environment until effusion resolves

17. Medication
Antihistamines and decongestants are ineffective for OME and are not recommended for treatment. Antimicrobials and corticosteroids do no have long-term efficacy and are not recommended for routine management. Recommendation Against
Short-term, small magnitude benefits
Significant adverse effects

18. Hearing and language
Hearing testing is recommended when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME. Language testing should be conducted for children with hearing loss. Recommendation

19. Hearing and language HL may impair early language acquisition
Extended periods of CHL may result in developmental and academic sequelae
Early language delays are associated with later delays in reading and writing.

20. Surveillance
Children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the TM or middle ear are suspected. Recommendation
Resolution rates decrease the longer the effusion has been present
Risk factors for non-resolution:
Summer or fall onset
HL>30dB
H/O prior tympanostomy tubes
Not having had an adenoidectomy

21. referral
When children with OME are referred by the primary care clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation vs. surgery), and provide additional relevant information such as history of AOM and developmental status of the child. Option

22. Surgery
When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis). Repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. Recommendation

23. surgery OME > 4 months with persistent hearing loss
Recurrent or persistent OME in at risk child
OME with structural damage to TM or ME

24. Alternative Medicine Allergy Management No recommendation:
Limited evidence
Few studies
Medications are unregulated
Allergy Management
No recommendation:
Few studies

25. Consequences Inappropriate antibiotic treatment of OM
Multidrug-resistant strains
Drug side effects
Parental/caregiver confusion

26. Biofilms
Communities of sessile bacteria embedded in a matrix of extracellular polymeric substances of their own synthesis that adhere to a foreign body or a mucosal surface
Chronic ear infections or persistent effusion in the middle ear are biofilm related

27. Biofilms Unable to culture with traditional methods
Traditional antibiotics are relatively ineffective for eradicating biofilm infection
Higher doses of antibiotics required to treat
Macrolides (clarithromycin/erythromycin)
Physical disruption is beneficial
Non-antibiotic therapies may be more successful

28. Acute otitis media with tubes
Diagnosis
Acute purulent otorrhea1
Commonly occurs after insertion of tympanostomy tubes
Risk Factor
Occurs more frequently in children with upper respiratory infections2,3

29. AOMT
Ototopical antibiotics are appropriate therapy in uncomplicated cases
Fluoroquinolones
Adjunctive systemic antibiotics may be used
When infection has spread beyond middle ear or external ear canal
With lack of adherence to ototopical therapy
When ototopical treatment fails (after 7-10 days)
In children with associated streptococcal pharyngitis
Special populations (e.g. immunocompromised patients) require additional consideration

30. Conclusion High prevalence Accurate diagnosis At risk children
Hearing loss
Speech and language assessment
Antibiotic use
Surgery
Referral