1. OTITIS MEDIA
Dr.Isazadehfar

2. OTITIS MEDIA Definition: Presence of a middle ear infection
Acute Otitis Media: occurrence of bacterial infection within the middle ear cavity
Otitis Media with Effusion: presence of nonpurulent fluid within the middle ear cavity
OM is the second most common clinical problem in childhood after upper respiratory infection

3. EPIDEMIOLOGY
Peak incidence in the first two years of life (esp months)
Boys more affected girls
50% of children 1 yr of age will have at least 1 episode.
1/3 of children will have 3 or more infections by age 3
90% of children will have at least one infection by age 6
Occurs more frequently in the winter months

4. MICROBES AT FAULT!!! Streptococcus pneumonia
Homophiles influenza(non-typeable)
Moraxella catarrhalis
Group A Streptococcus
Staph aureus
Pseudomonas aeruginosa
RSV assoc. with Acute Otitis Media

5. Classification of Otitis Media
Acute Otitis Media: presents with fever, otalgia, and hearing loss
Otitis Media with Effusion: evidence of middle ear effusion on pneumatic otoscopy
Recurrent Otitis Media: inability to clear middle ear effusions
Chronic Serous Otitis Media: presents as ‘fullness in the ear’, tinnitus, or another acute disease

6. RISK FACTORS Upper Respiratory Infections Allergies
Craniofacial abnormalities (cleft palate)
Down’s Syndrome
Passive smoking

7. PATHOGENESIS
This problem mainly deals with Eustachian tube dysfunction
Otitis Media usually follows an URI in which there is edema of the eustacian tube, leading to blockage. Stasis of these middle ear secretions lead to infection and irritation
Other factors: allergic rhinitis, nasal polyps, adenoidal hypertrophy

8. SIGNS & SYMPTOMS
Neonates/Infants: change in behavior, irritability, decreased appetite, vomiting
Children(2-4): otalgia, fever, noises in ears, cannot hear properly, changes in personality
Children (>4): complain of ear pain, changes in personality

9. On Physical exam…
The classic description → erythematic, opaque, bulging tympanic membrane with loss of anatomic landmarks including a dull/absent light reflex
Pneumatic Otoscopy → decreased tympanic membrane mobility

10. DIAGNOSIS Pneumatic Otoscopy→ standard tool Impedance Tympanometry
Spectral Gradient Acoustic Reflectometry
Diagnostic tympanocentesis & myringotomy: involves puncturing the tympanic membrane and aspirating middle ear fluid to relieve pressure.(Only used if the primary and secondary line treatment fail)
Measures the resonance of the ear canal for a fixed sound as the air pressure is varied (MEE) :Impedance Tympanometry
Spectral Gradient Acoustic Reflectometry: measures the condition of the middle ear by assessing the response of the TM to a sound stimulus. Equivalent to tympanometry for dx of middle ear effusions(MEE)

11. INDICATIONS FOR TYMPANOCENTESIS
Toxic appearing child
Failed treatment regimen with antibiotics
Suppurative complications
Immunosuppressed pt
Newborn infant in which the usual pathogens may not be the case

12. DIFFERENTIAL DIAGNOSIS
Otitis externa
Bullous myringitis
Cerumen impaction
Dental abscess
Foreign body in ear canal
Referred pain (parotid/tooth/lymphadenitis)
Tonsilitis

13. TREATMENT Amoxicillin: 20-40 mg/kg/day tid for 10-14 days or,
Augmentin: 45 mg/kg/day po bid for days (amoxicillin and clavulanate potassium)
Auralgan: analgesic/adjunct for ear pain 2-4 drops tid (antipyrine, benzocaine, and dehydrated glycerin)

14. 2nd Line Treatment Regimen
Cefzil
Pediazole ( erythromycin/sulfisoxazole)
Bactrim (trimethoprim/sulfamethoxazole
These medications are used as secondary agents if the primary antibiotic has failed after 10 days and the symptoms persists.

15. COMPLICATIONS Hearing loss: conductive, sensoneural, mixed)
Acute mastoiditis: before the advent of antibiotics
Chronic perforation of the TM
Tympanosclerosis
Cholesteatoma(keratin cyst)
Chronic suppurative OM
Cholesterol granuloma: ‘Blue drum syndrome’
Facial nerve paralysis

16. Complications cont… Intracranial complications Bacterial meningitis
Epidural abscess
Subdural empyema
Brain abscess
Otitic hydrocephalus
Lateral sinus thrombosis

17. What Is Chronic otitis media?
Inflammation of the middle ear that lasts for more than 6 weeks
Usually preceded by Acute otitis media, or viral URTI
Common in the age 3-6

18. Causes and predisposing factors:
Late onset or inappropriate antibiotic treatment of acute otitis media.
URTI, Allergic rhinitis
Lowered Resistance in malnutrition and anemia
In early onset type: Short period breastfeeding and long time group child care
Eustachian tube deformity, adenoid hypertrophy
Septal deviation, cleft palate, sinusitis
unusual growth ("hypertrophy") of the adenoid tonsil.

19. Symptoms:
Conductive deafness
Vertigo
Tinnitus
Ear discharge

20. Etiologies
Pseudomonas aerugenosa
Proteus
E.coli
H. influenza

21. 1. Serous ( Otitis media with effusion OME )
Stages:
1. URTI or acute otitis media –> Fluid collection in middle ear and obstruction of Eustachian tube  tympanic membrane retraction
2. Fluid become pus and glue like  conductive hearing impairment and pain  necrosis  tympanic membrane perforation
3. Could end up with mastoiditis ( if not stopped )
Enlarged adenoid is most common cause in children

22. Management of serous Chronic otitis media
Systemic decongestants
Nasal drops
Surgery ( myringotomy ) , if the above 2 failed
Myringotomy is tiny incision done in the ear drum to relief pressure and drain pus

23. CHOLESTEATOM