ACUTE OTITISE MEDIA OTITIS MEDIA WITH EFFUSION DIAGNOSIS

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ACUTE OTITISE MEDIA &OTITIS MEDIA WITH EFFUSION

ACUTE OTITISE MEDIA &OTITIS MEDIA WITH EFFUSION

DIAGNOSIS AOM rapid inflammation + middle ear effusion (MEE) OME: MEE without acute inflammation

DIAGNOSIS AOM rapid inflammation + middle ear effusion (MEE) OME: MEE without acute inflammation inflamation Signs: bulging or fullness or erythema or perforation of the TM with otorrhea Symptoms: otalgia , irritability, and fever

EPIDEMIOLOGY (AOM) is the most frequent diagnosis in sick children in US approximately $5

EPIDEMIOLOGY (AOM) is the most frequent diagnosis in sick children in US approximately $5 billion in US otitis media 39% of children by 9 months and 62% of children by 2 years of age occurs in older children, adolescents, and adults. peak incidence of AOM was during the first 6 to 12 months of life OME is asymptomatic. approximately 65% of OME episodes in children 2 to 7 years of age resolve within 1 month. difficult to determine the “true” incidence of OME

PHYSICAL EXAMINATION Ears Head and neck Craniofacial anomalies ( Down and Treacher Collins )

PHYSICAL EXAMINATION Ears Head and neck Craniofacial anomalies ( Down and Treacher Collins ) Oropharynx( bifid uvula or cleft palate) Hypernasality ( velopharyngeal insufficiency) Hyponasality (obstructing adenoids or nasal obstruction due to nasal polyposis or deviated septum)

PNEUMATIC OTOSCOPY Middle ear TM and its mobility. normal TM : translucent concave moves

PNEUMATIC OTOSCOPY Middle ear TM and its mobility. normal TM : translucent concave moves with positive and negative pressure. landmark: handle (manubrium) of the malleus umbo: in the center of the TM. Note: position, color, degree of translucency, mobility

POSITION position of the tympanic membrane is the most critical characteristic in distinguishing AOM

POSITION position of the tympanic membrane is the most critical characteristic in distinguishing AOM from OME normal position is neutral negative pressure: retracted TM q fullness (infection) bulging: large amount of infected fluid (posterosuperior area) when bulging: the malleus is obscured

TRANSLUCENCY normal TM is translucent with fluid: cloudy or opaque Air fluid levels are

TRANSLUCENCY normal TM is translucent with fluid: cloudy or opaque Air fluid levels are more suggestive of OME than AOM

COLOR “red” TM that is full or bulging often is a sign of AOM

COLOR “red” TM that is full or bulging often is a sign of AOM A pink, gray, yellow, or blue retracted TM with reduced or no mobility usually is seen with OME. red but translucent TM is a typical finding in a crying or sneezing infant,

 TYMPANOMETRY inconclusive otoscopy difficult otoscopy children older than 6 months

TYMPANOMETRY inconclusive otoscopy difficult otoscopy children older than 6 months

 TYMPANOMETRY − 400 to +200 da. Pa(decapascals). flat or round pattern(TW>350 da. Pa)with

TYMPANOMETRY − 400 to +200 da. Pa(decapascals). flat or round pattern(TW>350 da. Pa)with a small ear canal volume: MEE flat pattern with a large ear canal volume : perforation or a patent tympanostomy tube. normal middle ear: peak pressure 0 da. Pa no OME : TW<150 da. Pa OME: TW> 350 da. Pa TW=150 -350 da. Pa presence or absence of OME is determined by otoscopy

AUDIOMETRY MEE usually results in a mild to moderate conductive hearing loss and causes

AUDIOMETRY MEE usually results in a mild to moderate conductive hearing loss and causes delay in speech and language development

OAE v cochlear function (outer hair cells) -newborn hearing screening : fast and easy

OAE v cochlear function (outer hair cells) -newborn hearing screening : fast and easy MEE may confound the results. v ABR

PATHOPHYSIOLOGY AND PATHOGENESIS multifactorial with various overlapping factors 1. infection(bacteria, viral) 2. Host factors(Allergy,

PATHOPHYSIOLOGY AND PATHOGENESIS multifactorial with various overlapping factors 1. infection(bacteria, viral) 2. Host factors(Allergy, immunology, gender, race, age, gentic) 3. anatomic/physiologic(eustachian tube, cleft palat) 4. Enviroment factor(daycar, tobacco smoke exposure seasonality breast/bottle feeding, pacifier, obisity

EUSTACHIAN TUBE FUNCTION The eustachian tube in the infant is shorter, wider, and more

EUSTACHIAN TUBE FUNCTION The eustachian tube in the infant is shorter, wider, and more horizontal By the age of 7 years prevalence of otitis media is low.

INFECTION in AOM Streptococcus pneumoniae most common influenzae catarrhalis Streptococcus pyogenes other miscellaneous bacteria

INFECTION in AOM Streptococcus pneumoniae most common influenzae catarrhalis Streptococcus pyogenes other miscellaneous bacteria in chronic OME, H. influenzae most common pathogen S. pneumoniae M. catarrhalis other bacteria Haemophilus Moraxella

VIRUSES respiratory syncytial virus (RSV) influenzavirus adenoviruse parainfluenza virus rhinoviruses

VIRUSES respiratory syncytial virus (RSV) influenzavirus adenoviruse parainfluenza virus rhinoviruses

ALLERGY AND IMMUNOLOGY mechanism is not understood, it may be: (1) (2) (3) (4)

ALLERGY AND IMMUNOLOGY mechanism is not understood, it may be: (1) (2) (3) (4) the middle ear is a “shock organ” (target) induce inflammatory swelling of the eustachian tube mucosa inflammatory obstruction of the nose bacteria-laden allergic nasopharyngeal secretions may be aspirated into the midle ear

RISK FACTORES

RISK FACTORES

HOST-RELATED FACTORS Age. highest incidence 6 -11 months of age, first episode < 6

HOST-RELATED FACTORS Age. highest incidence 6 -11 months of age, first episode < 6 or 12 months a powerful predictor of recurrence. first episode of MEE < 2 months is higher risk for persistent fluid during their first year of life Sex. no difference between male & female Prematurity controversy Allergy. controversy. Immunocompetence. HIV demonstrate a significantly higher recurrence

Cleft Palate/Craniofacial Abnormality. Infants < 2 year with unrepaired cleft palate Surgical repair reduces

Cleft Palate/Craniofacial Abnormality. Infants < 2 year with unrepaired cleft palate Surgical repair reduces otitis media Anatomic or functional eustachian tube abnormalities Down syndrome: low resistance of the tube poor active eustachian tube reflux of nasal secretions into the middle ear.

ENVIRONMENTAL FACTORS Upper Respiratory Infection/Seasonality Rhinovirus, RSV, adenovirus, and coronavirus Day Care/Home care day-care

ENVIRONMENTAL FACTORS Upper Respiratory Infection/Seasonality Rhinovirus, RSV, adenovirus, and coronavirus Day Care/Home care day-care centers more tympanostomy tubes inserted than home care Tobacco Smoke Exposure passive exposure to smoking Breastfeeding/Bottle Pacifier unclear. Use Obesity Feeding

SYMPTOMATIC THERAPY ibuprofen 10 mg/kg Auralgan® (combination of antipyrine, benzocaine , and glycerin )

SYMPTOMATIC THERAPY ibuprofen 10 mg/kg Auralgan® (combination of antipyrine, benzocaine , and glycerin ) topical aqueous lidocaine (lignocaine) ear drops topical herbal extract Otikon Otic solution Decongestants and antihistamines: no benefit potential for delayed resolution of middle ear fluid increased medication side effects

ANTIBIOTIC THERAPY VERSUS OBSERVATION < six months antibacerial therapy regardless of degree of diagnostic

ANTIBIOTIC THERAPY VERSUS OBSERVATION < six months antibacerial therapy regardless of degree of diagnostic certainly six months to two years, antibacterial therapy is when: certain diagnosis of AOM uncertain diagnosis but the illness is severe (moderate to severe otalgia or fever ≥ 39ºC in the previous 24 hours). Observation when diagnosis is not certain and illness is not severe. > two years, antibacterial therapy when: certain diagnosis and illness is severe Observation when: certain diagnosis but illness is not severe uncertain diagnosis.

ANTIMICROBIAL THERAPY Seventeen antimicrobial drugs (16 oral and 1 parenteral preparation) two otic preparations

ANTIMICROBIAL THERAPY Seventeen antimicrobial drugs (16 oral and 1 parenteral preparation) two otic preparations (eg, ofloxacin otic and ciprofloxacin-dexamethasone otic) for treatment of AOM with otorrhea in children with tympanostomy tubes in place or tympanic membrane perforation

Antimicrobial agents available for treatment of acute otitis media Most used drugs Others Amoxicillin

Antimicrobial agents available for treatment of acute otitis media Most used drugs Others Amoxicillin Cephalexin Amoxicillin-clavulanate* Cefaclor Cefuroxime axetil* Loracarbef Ceftriaxone IM or IV* Cefixime Erythromycin + sulfisoxazole • Ceftibuten Azithromycin • Cefprozil Clarithromycin • Cefpodoxime Trimethoprim-sulfamethoxazole • Δ Cefdinir Ofloxacin otic ◊ Trimethoprim Ciprofloxacin-dexamethasone otic ◊

 First-line therapy amoxicillin of 80 to 90 mg/kg per day maximum dose of

First-line therapy amoxicillin of 80 to 90 mg/kg per day maximum dose of 3 g/day Amoxicillin-clavulunate AOM by an amoxicillin-resistant otopathogen: antibiotictherapy in the previous 30 days, particularly beta-lactam antibiotics concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome usually is caused by nontypeable H. influenzae , which is frequently resistant to beta-lactam antibiotics) receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection)

PENICILLIN ALLERGY Non-type 1 reactions : Cefdinir 14 mg/kg per day Cefpodoxime 10 mg/kg

PENICILLIN ALLERGY Non-type 1 reactions : Cefdinir 14 mg/kg per day Cefpodoxime 10 mg/kg per day once daily Cefuroxime – cefuroxime axetil suspension: A single intramuscular dose of ceftriaxone 50 mg/kg If clinical signs persist, a second dose is administered and, if necessary, a third dose. Type 1 reactions : azithromycin , and clarithromycin. Trimethoprim-sulfamethoxazole

DURATION OF THERAPY < 2 years old : 10 days >2 years old: 5

DURATION OF THERAPY < 2 years old : 10 days >2 years old: 5 -7 days single dose of azithromycin has been approved by the FDA

TREATMENT FAILURE Lack of improvement by 48 to 72 hours : another disease is

TREATMENT FAILURE Lack of improvement by 48 to 72 hours : another disease is present the initial therapy was not adequate. Inadequate therapy : organism resistant to beta-lactam antibiotics Persistent MEE after the resolution of acute symptoms is not an indication of treatment failure or an indication for additional antibiotic therapy high-dose amoxicillin-clavulanate 90 mg/kg per day amoxicillin and 6. 4 mg/kg per day of clavulanate Tympanocentesis for patients with persistently refractory AOM, to define the etiology Alternatively, use of levofloxacin and/or tympanostomy tube placement may be appropriate.

RECURRENT AOM signs and symptoms of AOM (fever, pain, bulging tympanic membrane) soon after

RECURRENT AOM signs and symptoms of AOM (fever, pain, bulging tympanic membrane) soon after completion of successful treatment. (within 30 days) bulging of the tympanic membrane and signs of inflammation. persistent MEE in a child with a febrile upper respiratory infection may be misinterpreted as a recurrent episode. Parenteral ceftriaxone 50 mg/kg per day for 3 days or possibly every 36 hour levofloxacin 10 mg/kg every 12 hrs recurrence more than 30 days is most often due to a different pathogene: high dose amoxicillin-clavulanate Tympanostomy tube insertion may be warranted for children with recurrent AOM

TYMPANIC MEMBRANE PERFORATION acute otorrhea, 10 days of oral therapy topical therapy for the

TYMPANIC MEMBRANE PERFORATION acute otorrhea, 10 days of oral therapy topical therapy for the well-appearing, immunocompetent > 2 years oral therapy is preferred. Topical therapy ( quinolone) = oral therapy in otorrhea +VT or chronic suppurative otitis media but not in AOM + acute perforation TM perforation with pain is due to: mastoiditis otitis externa Auralgan, lidocain or olive oil, should not be used in perforation of TM

FOLLOW-UP Persistent symptoms ( after 48 to 72 hours) Resolved symptoms : for MEE

FOLLOW-UP Persistent symptoms ( after 48 to 72 hours) Resolved symptoms : for MEE ( may affect speech, language, and cognitive abnormality) 8 -12 weeks after AOM: All children < 2 years two years Children > 2 years and have language or learning problems

Surgical Treatment: Myringotomy/Tympanocentesis. relief of pain samples for culture no advantage in duration of

Surgical Treatment: Myringotomy/Tympanocentesis. relief of pain samples for culture no advantage in duration of effusion or recurrence of episodes of AOM.

MYRINGOTOMY WITH TYMPANOSTOMY TUBE INSERTION. three or more episodes of AOM in 6 months

MYRINGOTOMY WITH TYMPANOSTOMY TUBE INSERTION. three or more episodes of AOM in 6 months or four or more episodes in 12 months

ADENOIDECTOMY WITH AND WITHOUTTONSILLECTOMY Is not recommended as a firstline procedure unless indicated for

ADENOIDECTOMY WITH AND WITHOUTTONSILLECTOMY Is not recommended as a firstline procedure unless indicated for airway obstruction. Tonsillectomy, in conjunction with adenoidectomy, has no significant advantage over adenoidectomy alone

OTITIS MEDIA WITH EFFUSION

OTITIS MEDIA WITH EFFUSION

v Watchful waiting if not at risk for speech and language or learning disabilities

v Watchful waiting if not at risk for speech and language or learning disabilities Hearing testings if MEE persists for 3 months or longer v language delay, learning difficulties, or significant hearing loss is suspected average hearing level: < 20 d. B watchful waiting > 40 d. B in the better ear, surgery 21 -39 d. B, in better ear if not at risk, examination at 3 - 6 -month intervals until the fluid has resolved; hearing loss or language or learning delays are identified; or structural abnormalities of the eardrum are suspected v

MEDICAL TREATMENT : Decongestant/Antihistamine. no efficacy Antibiotics. are not recommend Steroids. systemic steroids have

MEDICAL TREATMENT : Decongestant/Antihistamine. no efficacy Antibiotics. are not recommend Steroids. systemic steroids have demonstrated an advantage over placebo but are not recommended for long-term management.

SURGICAL TREATMENT Myringotomy alone is ineffective Myringotomy with Tympanostomy Tube Insertion. based on the

SURGICAL TREATMENT Myringotomy alone is ineffective Myringotomy with Tympanostomy Tube Insertion. based on the child’s hearing status and risk for developmental problems. for chronic OME

ADENOIDECTOMY adenoidectomy or adenotonsillectomy at the time of first or subsequent tube insertion is

ADENOIDECTOMY adenoidectomy or adenotonsillectomy at the time of first or subsequent tube insertion is associated with reduced risk of further tube insertion.

SURGICAL ISSUES anterior-superior or anterior-inferior quadrant of the parstensa The anterosuperior quadrant is associated

SURGICAL ISSUES anterior-superior or anterior-inferior quadrant of the parstensa The anterosuperior quadrant is associated with a longer clinical tube life; but a persistent perforation in that area is more difficult to repair

SELECTION OF TYMPANOSTOMY TUBES AND INDICATIONS In a young child with a history of

SELECTION OF TYMPANOSTOMY TUBES AND INDICATIONS In a young child with a history of recurrent or persistent otitis media, a tympanostomy tube that remains in place for at least a year is preferable. If the child has recurrent otitis media after the tubes have become nonfunctional or extruded, a similar type of tube should be recommended Grommets in older children T-tubes for older children with persistent problems due to poor eustachian tube function . .

PERIOPERATIVE AND POSTOPERATIVE OTOTOPICAL DROPS to reduce early postoperative otorrhea and tube blockage FDA-approved

PERIOPERATIVE AND POSTOPERATIVE OTOTOPICAL DROPS to reduce early postoperative otorrhea and tube blockage FDA-approved ototopical agents such as ofloxacin (Floxin) and ciprofloxacin plus dexamethasone (Ciprodex)

POSTSURGICAL FOLLOW-UP follow-up visit after few weeks to assess the status of the tympanostomy

POSTSURGICAL FOLLOW-UP follow-up visit after few weeks to assess the status of the tympanostomy tube. with a hearing loss, repeat hearing evaluation postoperatively. if preoperative hearing test was not done should be examined postoperatively to document that the hearing is normal. evaluation 6 to 12 months after the insertion of the tubes and every 6 months thereafter, or when problems occur, to assess the status of the tubes and the TM.

COMPLICATIONS AND SEQUELAE

COMPLICATIONS AND SEQUELAE

OTORRHEA 50% transient otorrhea : 16% later in: 26% recurrent otorrhea : 7. 4%

OTORRHEA 50% transient otorrhea : 16% later in: 26% recurrent otorrhea : 7. 4% chronic otorrhea : 3. 4%

 under 6 years of age same pathogens of typical AOM 6 years of

under 6 years of age same pathogens of typical AOM 6 years of age or older: P. aerpginosa (1) ototopical agents : ofloxacin otic or ciprofloxacin-dexamethasone otic are effective (2) in severe systemic symptoms, a systemic antibiotic (3). If drainage does not resolve in 7 to 10 days, suctioning and culture (4) yeast : topical antifungal drop (5) Repeated aural toilet is a very important (6) Intravenous antibiotics if : aural toilet and topical fails, or the organisms are not sensitive to oral antibiotics (7) removal of the tube (8)rarely a simple mastoidectomy should be considered. CT scan of the temporal bones should be obtained before possible mastoidectomy, (8) In older children with recurrent episodes of otorrhea, removal of the tubes is the treatment because of refluxing into the middle ear & tube act as a foreign body,

TYMPANOSCLEROSIS, ATROPHY, AND RETRACTION POCKETS tympanosclerosis occurred in 32% focal atrophy in 25% retraction

TYMPANOSCLEROSIS, ATROPHY, AND RETRACTION POCKETS tympanosclerosis occurred in 32% focal atrophy in 25% retraction pockets in 3. 1% The type of tube (short-term vs. long-term) had no significant impact on these rates.

PERSISTENT PERFORATION 4. 8% small hearing loss is very mild managed with a simple

PERSISTENT PERFORATION 4. 8% small hearing loss is very mild managed with a simple fat graft or surgical gel , paper patch, or Steri-strip myringoplasty.

CHOLESTEATOMA For all types of tubes 0. 7%

CHOLESTEATOMA For all types of tubes 0. 7%

RETAINED TYMPANOSTOMY TUBES usually is not removed surgically( most tubes extrude spontaneously) Indications for

RETAINED TYMPANOSTOMY TUBES usually is not removed surgically( most tubes extrude spontaneously) Indications for removing (1) Retention of one tube after extrusion of the other tube if the middle ear has been free of disease for 1 year or longer in a child 5 to 6 years old or older (2) Bilateral retained tubes in an older child with good eustachian tube function (3) Chronic or recurrent otorrhea that are not managed medically (4) Blockage of a tympanostomy tube that has become embedded in granulation tissue

WATER PRECAUTIONS no increase of otorrhea in patients with tympanostomy tubes recurrent otorrhea, specially

WATER PRECAUTIONS no increase of otorrhea in patients with tympanostomy tubes recurrent otorrhea, specially with Pseudomonas or S. aureus ctions and complications. akes) head in the bathtub with soapy water (6)ear discomfort during swimming. er precautions.

EARLY EXTRUSION 3. 9% infection in the middle ear not have been properly inserted,

EARLY EXTRUSION 3. 9% infection in the middle ear not have been properly inserted, especially if the TM is thickened owing to an infection at the time of tube insertion. An atrophic TM

TUBE BLOCKAGE 6. 9% clot, mucus, granulation tissue , polyp unpluging : pick, suction,

TUBE BLOCKAGE 6. 9% clot, mucus, granulation tissue , polyp unpluging : pick, suction, a Rosen needle, or ototopical drops for 10 to 14 days. If effusion-free with normal middle ear pressure: the tube can be left in place and watched until extrusion. If infection or fluid : replacement

TUBE DISPLACEMENT INTO THE MIDDLE EAR 0. 5% at the time of surgery (commonly)

TUBE DISPLACEMENT INTO THE MIDDLE EAR 0. 5% at the time of surgery (commonly) later due to infection or trauma (rare) displacement during surgery: retrieve the tube at the time of surgery visualized behind an intact TM, risks versus benefits must be asses. is whit rarely problems.