Acute otitis media

2015./2016.akad.gada LOR pulciņa 9.sēdes prezentācija "Acute otitis media". Autors Edžus Urtāns (RSU MF III kursa students).

1. Acute otitis media Author: Edžus Urtāns Mentor: Dr.med . Uldis Urtāns

2. Acute inflammation in middle ear < 3 weeks (month) Often associated with a viral upper respiratory infection Most common reason for medical therapy for children younger than 5 years Recurrent otitis media: At least 4 episodes/ year At least 3 episodes/ 6 months (with adequate therapy) Acute otitis media

3. Most children have at least one episode of AOM (by age 3, 50-85%) Peak incidence age 6-15 months Increased incidence in the fall and winter Only 20% are adults >700 milion cases/year Epidemiology

4. Eustachian tube is lined with respiratory mucosa Responds together with nasopharynx mucosa Edema > narrowed > negative middle lumen ear pressure Influx of pathogens from nasopharynx is possible Causes

5. Causes Inflammatory response in middle ear worsens the obstruction Trigger: Allergies Upper respiratory tract infections GER (especially children) Adenoid hypertrophy Other

6. Viral ( 30- 70 %) RSV Rhinovirus Coronavirus Influenza, parainfluenza Bacterial (55%) Streptococcus pneumoniae (44%) Haemophilus influenzae (41%) Moraxella catarrhalis (14%) Gram negative enteric bacteria S. Aureus Combined (15%) Causes

7. Age: <7
Their Eustachian tubes are short, floppy, horizontal and poorly functioning Risk factors

8. Handbook of Pediatric Otolaryngology : A Practical Guide for Evaluation and Management of Pediatric Ear, Nose, and Throat Disorders

9. Risk factors Genetic predisposition Eustachian tube dysfunction Allergic tendencies Bottle feeding (first 3 months ) ( breast milk contains lactoferrin, oligosaccharide and surface immunoglobulin A that inhibit bacterial colonization ) ( sucking generates negative pressure ) Incorrect posture while breastfeeding

10. Risk factors Underlying pathology Unrepaired cleft palate Parental smoking Large familys/attending daycare Immunocompromised states

11. Otalgia (not always) Fever Hearing loss ( speech delay for children) Headache Nausea Cough Rhinitis Conjunctivitis Signs and symptoms

12. Pneumatic otoscopy/otoscopy: Red or opaque eardrum Retracted eardrum Immobile or hypo-mobile eardrum Presence of fluid behind eardrum ( purulent, serous, mucoid) Retraction pockets Bullous myringitis Physical Examination

13. Otorrhea (in case of tympanostomy tube, perforation ) Mastoid tenderness Anteriorly rotated pinna Tympanometry Audiometry Inspection or pharynx and nasal cavity Physical Examination

14. Diagnosis Acute onset of signs and syptoms The presence of middle ear effusion (hypomobile eardrum, air-fluid level) Signs and symptoms of middle ear inflamation (erythema, otalgia)

15. Acute mastoiditis Abscess formation Facial paralysis Otitis media with effusion Persistent AOM Recurrent AOM Hearing loss Perforation of eardrum Complications

16. Complications (rare) Lateral sinus thrombosis Otitic hydrocephalus Septic shock Meningitis Encephalitis Extradural abscess Labyrinthitis

17. Antibacterial therapy for: Children of age <6months 6 months to 2 years with severe illness Recurrent or billateral AOM Immunocompromised patients Patients with a perforated tympanic membrane Pain management ( Ibuprofen, Diclofenac, paracetamol) Decongestants and/or antihistamines, nasal steroids Treatment

18. After 24-48h (48-72h) If no improvemants: No antibiotics > antibiotics Antibiotics > change to a different antibiotics

19. Antibacterial therapy Amoxicilin 750-1500mg/day 50-100 mg/kg/day (has not recived amoxicilin in past 30 days and has no allergy to penicilin) Amoxicillin-clavulanate 875/125mg/day 90/6.4 mg/kg/day (alternative for amoxicilin) Ceftriaxone 1-2g/day 50mg/kg/day or Cefuroxim 500mg/day 30mg/kg/day Azithromycin, clarithromycin, erythromycin in case of allergy to penicilin 5-7- 10 days

20. Recurrent AOM treatment +Tympanostomy

21. Non-drug Treatment Myringotomy in case of sevare pain Tympanocentesis in case of severe pain and as a diagnostic procedure if there is no improvement with 2nd line of antibiotics (local anesthesia) ( narcosis )

22. Avoiding risk factors if possible Vaccination: ? S. Pneumonia (PCV-7) Influenza Adenoidectomy Polipectomy Preventive measures

23. Differential diagnosis Otitis externa Impacted cerumen or foreign body in ear Tympanosclerosis Otitis media with effusion Injury of the ear

24. Quiz (1) Two most common bacterial causes of AOM: Haemophilus influenzae, S. Aureus; Moraxella catarrhalis , E. Coli; S. Pneumonia, Haemophilus influenzae; S. Pneumonia, Moraxella catarrhalis

25. Quiz (2) Recurrent AOM means: At least 5 episodes of AOM a year; At least 8 episodes of AOM till age of 5 years ; At least 3 episodes of AOM in 6 months ; At least 2 episodes of AOM in a month

26. Quiz (3) What can’t be seen in otoscopy of AOM patient: Retracted eardrum; Perforation of eardrum; Bubbles behind eardrum ; Bullose myringitis All of above can be seen

27. Quiz (4) What is always necessary to treat AOM: (more then one answer is possible) Antibiotics; Analgetics; Tympanostomy ; Tea; None from above

28. Shapiro, Nina L. Handbook Of Pediatric Otolaryngology : A Practical Guide For Evaluation And Management Of Pediatric Ear, Nose, And Throat Disorders. Singapore: World Scientific Publishing Company, 2012. eBook Academic Collection (EBSCOhost). Web. 5 Mar. 2016. https://www.clinicalkey.com.db.rsu.lv/#!/content/medical_topic/21-s2.0-1014193?scrollTo=%23heading0 http://web.a.ebscohost.com.db.rsu.lv/dynamed/detail?vid=2&sid=74b4fa24-4f97-43f1-a411-581c0fcc826e%40sessionmgr4003&hid=4204&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=116345&db=dme https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-B9780323079327000247?scrollTo=%23hl0001072 https://www.clinicalkey.com.db.rsu.lv/#!/ content/book/3-s2.0-B9780323280471005540 http:// www.aafp.org/afp/2007/1201/p1650.html http:// journals.plos.org/plosone/article?id=10.1371/journal.pone.0036226 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC153141/ Sources

29. Thank you for your attention ! (and sorry for terrible english)