Acute
Otitis Media
l Otitis media is
one of the most common diagnosis made by pediatricians
l
30-60%
of children have had at least one putative episode of AOM by age one.
l 10-20% have had three or more.
l 80% have had at least one episode by age 3
years.
Approximately 80-90% will have had aat least one episode of either AOM or asymptomatic middle ear
effusion in the first year of life.
Eustachian Tube
Eustachian Tube
l Connects middle
ear and nasopharynx
l Lumen shaped like
two cones with apex directed toward middle
l Mucosa has mucous
producing cells and ciliated cells
l Eustachian
tube
Adults
Adults
l ant 2/3-
cartilaginous
post 1/3- bony
l 45
degree angle
l isthmus 1-2 mm
l nasopharyngeal
orifice 8-9 mm
l Children
l longer bony
portion
l 10
degree angle
l isthmus larger
l nasopharyngeal
orifice 4-5 mm in infants
Eustachian tube
l Usually closed
l Opens during
swallowing, yawning, and sneezing
l Opening involves
cartilaginous portion
l Tensor veli
palatini responsible for active tubal opening
l No constrictor
function
l Eustachian
tube function
Protection from nasopharyngeal sound and secretions
Protection from nasopharyngeal sound and secretions
l clearance of
middle ear secretions
l ventilation
(pressure regulation) of middle ear
Bacteria can migrate along the eustachian tube from the upper respiratory tract, and a buildup of mucus and fluids can cause inflammation and effusion.
Bacteria can migrate along the eustachian tube from the upper respiratory tract, and a buildup of mucus and fluids can cause inflammation and effusion.
l Risk factors
for AOM
l
l Age
l Male gender
l Exposure to group
day care
l Exposure to
environmental smoke or other respiratory irritants and allergens that interfere
with Eustachian tube function.
l Lack of breast
feeding.
l Supine feeding
position.
l Winter season
l Siblings in
household
Immunodeficiency
l Allergies
l Craniofacial
abnormalities
l Down syndrome
l Pacifierl Large
tonsils can obstruct the Eustachian tubes
Otalgia usually is associated with inflammation of the external or middle ear, but it may represent pain referred from involvement of the teeth, temporomandibular joint, or pharynx.
In young infants,
- pulling or rubbing the ear along with
- general irritability or poor sleep,
especially
-when associated with fever, may be the
only signs of ear pain.
Ear pulling alone is not diagnostic of
ear pathology.
Three important keys to improving diagnostic accuracy for AOM centre around the following:
l
diligent cleaning of ear cerumen for better
visualisation of the tympanic membrane.
l use of nickel–cadmium or lithium rechargeable batteries.
l and the use of original equipment
full-length speculums.
Diagnostic Criteria: OME and AOM
At least two of:
- Abnormal
color of tympanic membrane (TM): white, yellow, amber, blue
- Opacification
not due to scarring
- Decreased
or absent motility
- Bubbles
or air-fluid interfaces
Clinical Practice Guideline on AOM: Conclusions
- To
diagnose acute otitis media the clinician should confirm a history of
acute onset, identify signs of middle–ear effusion, and evaluate for the
presence of signs and symptoms of middle-ear inflammation (Recommendation).
2. The
management of AOM should include an assessment of pain. If pain is present, the
clinician should recommend treatment to reduce pain (Strong Recommendation).
3A. Observation without use of antibacterial agents in a child
with uncomplicated AOM is an option for selected children based on diagnostic
certainty, age, illness severity, and assurance of follow-up (Option).
3B. If a decision is made to treat with an antibacterial agent,
the clinician should prescribe amoxicillin for most children. (Recommendation).
When amoxicillin is used, the dose should be 80–90 mg/kg/day (Option).
- If
the patient fails to respond to the initial management option within 48–72
hours, the clinician must reassess the patient to confirm AOM and exclude
other causes of illness. If AOM is confirmed in the patient initially
managed with observation, the clinician should begin antibacterial
therapy. If the patient was initially managed with an antibacterial
agent(s), the clinician should change the antibacterial agent(s) (Recommendation).
- Clinicians
should encourage the prevention of AOM through reduction of risk factors (Recommendation).
- There
is insufficient evidence to make a recommendation regarding the use of
Complementary and Alternative Medicine (CAM) for AOM (No
Recommendation).
The recommendations in this guideline
do not indicate an exclusive course of treatment or serve as a standard of
medical care. Variations, taking into account individual circumstances, may be
appropriate.
l Amoxicillin: first line therapy for AOM
Recommended as the first line drug of choice by:
Recommended as the first line drug of choice by:
l CDC DRSP
Working Group Pediatr Infect Dis J 1999;18:1-9
l AAP/AAFP
Subcommittee on AOM, March 2004
l Active against S.
pneumoniae:
l Recommended
dose now is 90 mg/kg/day divided BID: achieves adequate MEF levels to
kill pen-I and many pen-R pneumococci
l At this dose,
superior to all other oral antibiotics against pen-NS pneumococci in vitro
l Not effective against β-lactamase producing
H. influenzae or M. catarrhalis (but these are more likely to
resolve spontaneously)
l Decades of
experience: safe, effective, inexpensive, narrow-spectrum; tastes good
l
AOM is
commonly over diagnosed. Thus, if clinicians are going to continue to overuse
antibiotics—because of parental pressure or the lack of diagnostic accuracy—it is better to limit the mistake
to less expensive drugs with a narrower spectrum.
l
l Options for reducing
rates of severe otitis media:
l Additional hygiene practices
l Immunisation
l Antibiotics
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