Otitis Media

Question 1

Subtypes of Otitis Media

Answer 1

Acute Otitis Media (AOM)

Otitis Media with Effusion (OME)

Chronic Otitis Media

Question 2

Factors involved in Otitis Media

Answer 2

Immunology

Infectious disease

Anatomic considerations

Social and socioeconomic issues (crowding)

Genetics

Question 3

Pathophysiology of Otitis Media

Answer 3

1. Obstruction of Eustachian tube
   Mechanical and non-mechanical obstructions
2. Clearance and defense dysfunction
3. Immotile cilia syndrome
4. Weakness of related muscle
5. Clarence and defence dysfunction

Question 4

Etiology (causes?) of Otitis Media

Answer 4

Viral

Bacterial

Insult

Leukocyte

Infiltration

Purulent Exudate

ET Obstructions/abnormalities

Resolving cystic fibrosis

Question 5

Define Otitis Media

Answer 5

Group of inflammation of the middle ear most common in infants and children

Question 6

State the Eustachian Tube’s Function

Answer 6

1. Protection from nasopharyngeal secretions
2. Ventilation
3. Clearance of middle ear secretions

Question 7

What is Acute Otitis Media (AOM)

Answer 7

Acute Otitis Media (AOM) is an infection of the ear with rapid onset, presenting with signs and symptoms of acute inflammation, otalgia, and bulging of the Tympanic Membrane (TM)

Question 8

Define Chronic Otitis Media (OME)

Answer 8

Chronic Otitis Media (OME) is an effusion of the middle ear persisting for ≥ 3 months, which may lead to hearing loss and cholesteatoma formation

Question 9

Define Otitis Media with Effusion (OME)

Answer 9

Otitis Media with Effusion (OME) is not an ear infection, common in children

• accumulation of non infected fluid in middle ear

Can result from:
• clogging of the Eustachian tube
• sore throat
• URTI
•Common cold

Question 10

State the Pathophysiology of Acute Otitis Media (AOM)

Answer 10

1. Usually follows acute viral upper respiratory infection
2. Impairs muco-ciliary system
3. Eustachian tube dysfunction in the middle ear
4. Bacteria present in >90% of cases

Question 11

Acute Otitis Media (AOM) is characterized by?

Answer 11

•an opaque, bulging tympanic membrane
• reduced mobility
• purulent effusion

Question 12

Otitis Media with Effusion (OME)

Answer 12

– relatively asymptomatic middle ear effusion
– Tympanic membrane:
* Translucent or opaque
* Gray/pink
– Reduced mobility
– Effusion present +/- air
– Opacification of the TM
* Best for discrimination of OME from no
effusion

Question 13

Chronic Mucoid OM (Glue Ear)

Answer 13

– Tympanic membrane:
* Opaque/gray
* Retracted, reduced mobility
* Thick effusion, no air
* Hearing loss

Question 14

Cholesteatoma

Answer 14

– accumulation of squamous epithelium in
* middle ear &
* Mastoid
– Osteolytic enzymes
– Often accompanied by chronic otorrhea

Question 15

Chronic Suppurative Otitis Media

Answer 15

– TM perforation+/- cholesteatoma
– Otorrhea

Question 16

Risk factors for Otitis Media

Answer 16

Attending day care

Passive smoking

Congenital birth defect

Immunocompromised status

Question 17

State the Diagnosis of OM

Answer 17

1. Pneumatic examination
2. Tympanometry: Useful for confirming diagnosis (if Pneumatic examination inadequate)
3. PCR of middle ear fluid in chronic middle ear effusion

Question 18

Clinical Presentation of Acute Otitis
Media

Answer 18

• Irritability
• Tugging to the ear
• Otolgia-most specific symptom for AOM esp in older
  children
• Upper respiratory tract (URT) infection symptoms
• • Moderate/severe bulging of TM
• New onset otorrhoea (not d/t otitis externa)
• Mild bulging of TM + ear pain w/in last 48 hours
• Intense erythema of TM
• Fever (T≥ 39 °C)

Question 19

Classification of Otitis Media


Answer 19

Duration of disease: Acute, subacute, chronic

Quality of effusion: Serous, mucoid, purulent

Appearance of tympanic membrane: Pneumatic otoscope

Question 20

AOM-Severity of Symptoms Scale (AOM-SOS scale)

Answer 20

Tugging at ear[s]

Increased crying

Irritability

Disturbed sleep

Diminished activity

Diminished appetite

Fever

Question 21

Goal of management

Answer 21

The goal of treatment includes managing pain
Rational use of antibiotics
Preventing complications and future infection
Ensuring up-to-date vaccination

Question 22

Treatment AOM in children

Answer 22

– commonly resolve spontaneously and
– antibiotics not routinely recommended
– pain treated with adequate and regular simple
analgesia
* Paracetamol or ibuprofen
* ± adjunct, short-term topical analgesia (severe
acute ear pain)
–e.g. 2% lignocaine: 1-2 drops applied to an intact
tympanic membrane, may be effective

Question 23

Treatment of Acute Otitis Media

Answer 23

Initial immediate or delayed antibiotics treatment

1st treatment

• Amoxicillin 80-90mg/kg per day PO in two divided doses
• Amoxicillin-Clavulanate: 90 mg/ kg per day of amoxicillin with 6.4 mg/kg per day of clavulanate in 2 divided doses

Alternative therapy

• Cefdinir 14mg/kg per day in 1 or 2 divided doses
• Cefuroxime: 30 mg/kg per day in 2 divided doses
• Cefpodoxime: 10 mg/kg per day in 2 divided doses
• Ceftriaxone: 50 mg/kg IM or IV per day for 3 days

**Antibiotic treatment after 48-72hrs of failure of initial treatment **

1st treatment

• Amoxicillin-Clavulanate: 90 mg/ kg per day of amoxicillin with 6.4 mg/kg per day of clavulanate in 2 divided doses
• Ceftriaxone: 50 mg/kg IM or IV for 3 days

Alternative therapy

• Clindamycin: 30-40 mg/kg per day in 3 divided doses + 3rd-generation cephalosporin
• Ceftriaxone: 50 mg/kg IM or IV per day for 3 days

Question 24

Treatment of Otitis Media With Effusion

Answer 24

OME usually resolves spontaneously w/in 2 months
* Corticosteroid (orally or intranasally)
– clear chronic middle ear effusion but no efficacy in
AOM
* Antihistamine
* Decongestants
* Antibiotic if none in the last 3 months
* When the effusion is chronic & antibiotic therapy
failure
– surgical intervention
* = placement of tympanostomy tubes
–=> pressure equalization and
–=> drainage of middle ear

Question 25

What are the Monitoring parameters


Answer 25

1. Improvement of symptoms within 72 hours (Ear pain/otalgia, nasal congestion, otorrhea if present) 2. Absence of symptoms at the end of antibiotic course 3. Side effects and adverse effects of medicines used 4. Hearing status 5. Utilize the AOM Scale

Question 26

Indications for Tympanostomy Tubes


Answer 26

• Persistent ME effusion for ≥ 3 months • Complication of OM: OME associated with hearing loss, Impending intracranial complication, Acute Mastoiditis • Failure of antibiotic prophylaxis • Recurrent otitis media with > 3 episodes within a 6 months period or > 4 episodes within a 12 month period

Question 27

Signs and symptoms in children

Answer 27

Cough orrhinitis Rhinitis Cough Irritability Fever