Otitis Media and Externa Definitions Middle ear effusion

Otitis Media and Externa

Definitions �Middle ear effusion: liquid in the middle ear cavity �Acute otitis media (AOM): rapid onset of signs and symptoms of middle ear inflammation �Recurrent AOM: 3 or more separate episodes of AOM in 6 months OR 4 episodes in 12 months, with at least 1 in the past 6 months �Otitis media with effusion (OME): middle ear fluid that is not infected �External otitis: inflammation of the external auditory canal

Acute Otitis Media �Background: �Most common condition for which antibiotics are prescribed for the pediatric population �Number of visits for AOM have been decreasing �Proportional decrease in antibiotic prescriptions

AOM Risk Factors � Age � Peak between 6 -18 months of age � Race �Native American, Alaskan/Canadian Eskimos, Indigenous Australian � Family History � Gender �Boys > Girls

AOM- Pathogens �Bacteria � Streptococcus pneumoniae (50%) � Nontypeable Haemophilus influenzae (45%) �Bilateral AOM � Moraxella catarrhalis (10%) � Group A streptococcus (2 -10%) �Older children �Local complications �Viruses �Respiratory syncytial virus (RSV) �Rhinovirus �Influenza virus �Metapneumovirus �Adenovirus

AOM- Signs and Symptoms �Can be non-specific, especially in infants �Fever �Poor appetite �Poor sleep �Vomiting/diarrhea �Irritability �Ear Pain � Most common complaint, even among preverbal children �Ear tugging has low sensitivity and specificity

AOM- Diagnosis �Diagnostic Criteria: 1) Middle ear effusion (opacity, decreased mobility, air-fluid levels) 2) Bulging of TM, as a sign of inflammation Moderate to severe bulging of the TM OR otorrhea Mild bulging + recent onset of ear pain (48 hours) OR intense TM erythema

AOM- Diagnosis Isn’t usually this obvious Normal Mild Bulging Moderate Bulging Lieberthal, Allen S. et al. “The Diagnosis and Management of Acute Otitis Media. ” Pediatrics. 131 (2013): 623 -628 Severe Bulging

AOM- Diagnosis Classification of severity of symptoms Severe AOM Otalgia Fever moderate to severe >39 °C (102. 2 °F) Non-severe AOM mild <39 °C (102. 2 °F)

AOM – Treatment Considerations �Antibiotics �Increasing or Observation? bacterial resistance �Studies show that 70% of children treated with initial observation did not require subsequent antibiotics �Observation should only be an option if followup can be ensured in 48 -72 hours from the onset of symptoms

AOM- Treatment 2013 Guidelines Based on age, severity of symptoms, laterality, and otorrhea AAP 2013

AOM- Treatment �To summarize � Treat the patient with antibiotics if: � The patient has otorrhea � The symptoms are severe � It’s bilateral, or the patient is <2 years old (per the text) � Always if under 6 months � Option to observe if non-severe and: � It’s unilateral, and the patient is < 2 years old (see above) � it’s bilateral/unilateral, and the patient is ≥ 2 years old � If you choose to observe, follow-up within 48 -72 hours of symptom onset must be ensured!

AOM- Treatment �First Line Antibiotics �High 13 dose Amoxicillin PO � 80 -90 mg/kg/day in 2 divided doses �If Penicillin Allergic �Nonanaphylactic: Cefdinir, cefuroxime, cefpodoxime PO, Ceftriaxone IM/IV x 1 -3 days �Anaphylactic: Azithromycin, clindamycin, levofloxacin (off label) �Note: Azithromycin has limited activity against resistant S. pneumoniae and H. influenzae

AOM- Treatment �Second-Line �High Antibiotics dose Amoxicillin-Clavulanate PO or 2 nd generation cephalosporins (see previous slide) � 90 mg/kd/day amoxicillin with 6. 4 mg/kg/day clavulanate in 2 divided doses �For treatment failure �If patient received amoxicillin in the last 30 days �If patient has Hx of AOM unresponsive to amoxicillin

AOM- Treatment �Duration of Treatment �<2 years old or severe symptoms: Standard 10 days � 2 -5 years old: 7 days �> 6 years old: 5 -7 days �Treat Pain �Acetaminophen or Ibuprofen �Topical benzocaine & antipyrine drops �Follow-up �Reassess if very young, severe symptoms, or recurrent AOM

AOM – Treatment - OMM � OMM- Galbreath Technique J Am Osteopath Assoc. 2000 Oct; 100(10): 635 -9 Patient is sitting or supine � Affected ear facing away � Apply downward, transverse force on mandible that crosses face � Hold for 3 -5 seconds. Continue for 30 -60 seconds �

AOM- Prevention �Risk Factors �Encourage exclusive breast feeding for at least 6 months �Avoid exposure to tobacco smoke �Provide pneumococcal vaccine (PCV 13) �Provide annual influenza vaccine �Xylitol gum or lozenges can be helpful in older children with low choking risk 17

AOM- Complications �TM perforation and tympanosclerosis �Hearing loss- from middle ear fluid �Balance problems �Cholesteatoma �White mass behind the TM, chronic drainage �Mastoiditis �Intracranial US) complications rare (Rare in the

OME Otitis Media with Effusion Remember…. this is NOT infected

OME- Signs and Symptoms �Often asymptomatic �No signs of acute infection �Hearing loss-mild �Conductive �Approximately 25 d. B (plugging ears) �School hearing screening �Ear pain/fullness �Tinnitus

OME- Diagnosis and Treatment �Diagnosis �Otoscopy Decreased mobility of TM-insufflator bulb �Treatment �Commonly resolves spontaneously, but can take weeks to months �Watchful waiting �No medications

OME- Treatment �Hearing evaluation and referral to otolaryngologist for tympanostomy tubes and if: �Persists for >3 months (chronic OME) �At-risk for speech/language or learning problems �Neurodevelopmental disorders �Craniofacial abnormalities �Persistent hearing loss >40 d. B

Otitis Externa

Otitis Externa � AKA “Swimmer’s Ear” � Inflammation of the external auditory canal, most commonly from infection

Otitis Externa- Pathophysiology 1 2 • Inflammation of skin • Edema and pruritis 3 • Increased p. H of ear canal • Alkaline, warm environment Bacterial or Fungal Growth 25 • Breakdown of skin-cerumen barrier

Otitis Externa- Risk Factors �Excess moisture (ie. swimming) �Trauma �Skin 26 conditions

Otitis Externa- Pathogens �Pseudomonas aeurginosa (38%) �Staph epidermidis (9%) �Staph aureus (8%) �Fungal (2 -10%) �Candida �Aspergillus 27

Otitis Externa- Diagnosis �Signs and Symptoms �Ear pain �Pruritus �Discharge �Hearing loss �Physical Exam �Tenderness �Swelling of pinna/periauricular skin �Edema and erythema of ear canal �Otorrhea- thick, clumpy, white 28

Otitis Externa- Treatment �Topical Otic Antibiotics x 7 days �Fluoroquinolone (ofloxacin, ciprofloxacin) �Polymyxin B-neomycin-hydrocortisone (Cortisporin) �Aminoglycosides �Treat Pain �Ibuprofen 29

Otitis Externa- Prevention �Leave your ears alone! �Keep ears dry �Acetic acid �Diluted isopropyl alcohol (rubbing alcohol) �Blow drying 30

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