Acute Otitis Media (AOM) UG-ENT MBBS.pptx

prepared this presentation for undergraduate MBBS students. Please go through this and provide your valueable suggestions to improve . Thank You Dr Diwash Sunar MBBS, MS - ENT (AIIMS, New Delhi) Lecturer - Birat Medical College Teaching Hospital [email protected]

1. Acute Otitis Media Dr. Diwash Sunar MBBS (Manipal, KU) MS – ENT Head & Neck Surgery ( AIIMS, New Delhi ) Lecturer – BMCTH, KU

2. Learning Objectives Define Acute Otitis Media (AOM) Understand the Etiology and Pathophysiology Discuss Management and Treatment Strategies Identify Complications of AOM Interpret Investigations

3. Pre - Test

4. 1. AOM is most common at which age group? A. 0-6 months age B. 6-12 months age C. 2-4 years age D. 6-8 years age 2. Most common cause for AOM? Streptococcus pneumoniae H. influenzae Moraxella catarrhalis Staph aureus 3. Most common cause for Recurrent AOM? Streptococcus pneumoniae H. influenzae Moraxella catarrhalis Staph aureus

5. 6. The statement is correct for the tubal stage of AOM? a. TMperforates , and middle ear fluid collection occurs by absorption of the middle ear air secondary to the ETocclusion . b. middle ear mucosa becomes hyperemic and edematous . C.Earache and deafness are the symptoms. d.The examination shows retraction of the tympanic membrane with conductive hearing loss on PTA and C type of reflex on impendence audiometry

6. 7. Which is not a complication of AOM? a. Tympanic membrane perforation b. Adhesive otitis media c. Mastoiditis d. Facial nerve palsy

7. A male child in his first decade presented with a history of recurrent OM with persistent snoring and choking episode during sleep. The clinical examination showed crowding of teeth and a high arch palate with features of otitis media. Nasal endoscopy showed enlarged adenoid tissue filling both sides of the choana. What is your treatment plan? a. Myringotomy b. Myringotomy + grommet insertion c. Adenoidectomy + myringotomy + grommet insertion d. Adenotonsillectomy + myringotomy + grommet insertion

8. A child with AOM, was given a course of antibiotic for 10 days, but the symptoms reappeared 3 rd day after finishing the course of antibiotic. This belongs to the subgroup – A. Sporadic AOM B. Resistant AOM C. Persistent AOM D. Recurrent AOM

9. Acute Otitis Media It is an acute inflammation of the middle ear mucosa one of the most common illnesses of childhood Incidence - highest in the 1st year of life, mostly affect 6-12 months old child Incidence gradually reduces with increasing age synonymous with Acute suppurative otitis media (ASOM). In the first 2 years of life AOM occurs bilaterally in 80% of cases. After 6 years of age it is unilateral in 86% Clinicopathological definition - Acute Otitis Media is an inflammation of the middle ear cleft of rapid onset and infective origin, associated with a middle ear effusion and a varied collection of clinical symptoms and signs.

10. ACUTE SUPPURATIVE OTITIS MEDIA (ASOM) It is an acute inflammation of middle ear cleft by pyogenic organisms. M iddle ear cleft = eustachian tube, middle ear, attic, aditus , antrum and mastoid air cells.

11. ROUTES OF INFECTION 1. VIA EUSTACHIAN TUBE most common route ET in infants and young children is shorter, wider and more horizontal and thus account for higher incidence of infections in this age group. In a young infant, Breast or bottle feeding in horizontal position may force fluids through the tube into the middle ear hence the need to keep the infant propped up with head a little higher while feeding Swimming and diving can also force water through the tube into the middle ear. Extension of nasopharyngeal infection via Eustachian tube 2. VIA EXTERNAL EAR Traumatic perforations of tympanic membrane due to any cause open a route to middle ear infection infection from EAC/ microbes from External environment can reach via tympanic membrane perforation 3. BLOOD-BORNE uncommon route, pathogens enters middle ear v ia blood circulation

12. Predisposing Factors for AOM The predisposing factors are the same as mentioned in ET dysfunction.

13. Predisposing Factors / Risk Factors for ET dysfunction Anything that interferes with normal functioning of ETpredisposes to middle ear infection. Cleft palate Down syndrome Smoking Radiation exposure GERD Climate: Common in winter Recurrent attacks of common cold, upper respiratory tract infections Chronic Rhinitis and sinusitis Nasal Allergy Infections of tonsils and adenoids nasopharyngeal mass, tumors

14. Infective Etiology Both viral and bacterial infections are implicated. may occur in isolation or combination. Streptococcus pneumoniae (pneumococcus) is the most common : 18-55% of cases. Haemophilus influenzae : 16-37%, Moraxella catarrhalis : 11-23% Streptococcus pyogenes : upto 13% Staphylococcus aureus : up to 5% where the child is severely immunosuppressed as in case of HIV positive, a higher percentage of Staphylococcus aureus is found.

15. AOM is commonly associated with viral URTIs 60-90% of cases of AOM may be associated with viral infection. The viruses most commonly associated with AOM : R espiratory syncytial virus (RSV) I nfluenza A virus P arainfluenza virus H uman R hinovirus A denoviruse

16. Acute Otitis Media – Clinical Features

17. AOM - Symptoms AOM most commonly develops 3-4 days after the onset of coryzal symptoms. The otalgia will settle within 24 hours in 2/3 rd of children without treatment. The otorrhoea, if present, is mucopurulent and may be blood-stained Symptomatic relief is obtained without treatment in 88% by day 4-7 R apid onset of otalgia Hearing loss Otorrhoea Fever Excessive crying Irritability Coryzal symptoms Vomiting Poor feeding Ear pulling Clumsiness

18. C hild may appear unwell, and may rub his ear On otoscopy – TM Colour, Position and Mobility. In AOM the tympanic membrane is usually opaque. It is most commonly yellow, or yellowish pink in colour, being Red in only 18-19% Bulging TM Hypomobility/Immobility of the TM demonstrated by pneumatic otoscopy Should the drum be perforated, or a ventilation tube be in situ, mucopurulent otorrhoea will be seen. AOM - Signs

19. AOM - Investigations Specific investigations are done only for R ecurrent AOM not responsive to conventional treatment. Tympanometry: used as an adjunct to penumatic otoscopy in the diagnosis of acute otitis media. Tympanometry is ideally performed using low frequency probe tone (220-226 Hz) The curves generated are classified as Jerger type A, B, or C curves Type A represents normal middle ear compliance (As/Ad) Type B indicates no compliance Type C indicates negative middle ear pressure. P ure tone audiometry: PTA is indicated in children when middle ear effusion is present for at least 3 months or when there is delayed speech. The average hearing loss in middle ear effusion ranges between 25 - 35 dB.

20. 2 3 4 1 5

21. Differential diagnosis Otalgia - Pain may be referred from Tonsillitis, Teething, TMJ disorders, or simply be the result of an URTI A cute mastoiditis OME Otitis externa T rauma Ramsay Hunt syndrome B ullous myringitis

22. Pathology/Natural Course of AOM subdivided into 5 stages Stage 1  Stage of tubal occlusion / Tubal Stage Stage 2  P re-suppurative stage Stage 3  S uppurative stage Stage 4  Stage of R esolution Stage 5  Stage of C omplications

23. Stage 1— Stage of tubal occlusion / Tubal Stage URTI Oedema of nasopharyngeal end of ET B locks the tube leading to absorption of air inside ME and results in Negative intratympanic pressure. TM retracts The middle ear mucosa becomes hyperemic and edematous . Symptoms Hearing loss and earache are the 2 predominant symptoms but they are not marked. There is generally no fever at this stage Signs Otoscopy - TM is retracted with handle of malleus assuming a more horizontal position, prominence of lateral process of malleus and loss of light reflex. TFT – Negative (BC>AC) on the affected side PTA – CHL on the affected side Tympanometry – Type C curve

24. Right side - TM is retracted - absence of cone of light - foreshortened handle of malleus (black arrow) - prominent lateral process of malleus (white arrow)

25. Stage 2-presuppurative stage If tubal occlusion is pro-longed, pyogenic organisms invade tympanic cavity causing hyperaemia of its lining. Inflammatory exudate appears in the middle ear. Tympanic membrane becomes congested. The inflammatory exudates collect in the middle ear under pressure. The bacteria are present in the middle ear space from this stage onwards. Symptoms M arked earache – Throbbing nature, disturb sleep Adults - Hearing loss and tinnitus C hild - high degree of fever and is restless. Signs Initially, there is congestion of Pars tensa Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane imparting it a ‘ C art-wheel appearance’ Later, whole of TM including pars flaccida becomes uniformly red TFT, PTA and Tympanometry – same as previous stage

26. Stage 3-suppurative stage This stage is marked by formation of pus in the middle ear and to some extent in mastoid air cells. Tympanic membrane starts bulging to the point of rupture. Symptoms Earache becomes excruciating Deafness and tinnitus increases, child may run fever of 102-103 °F Irritable child may be accompanied by vomiting and even convulsions. Signs Otoscopy - Tympanic membrane appears red and bulging with loss of landmarks. Handle of malleus may be engulfed by the swollen and protruding TM and may not be discernible. A yellow spot may be seen on the tympanic membrane where rupture is imminent. A nipple-like protrusion of tympanic membrane with a yellow spot on its summit. Tenderness may be elicited over the mastoid antrum. TFT – Negative (BC>AC) on the affected side PTA – CHL on the affected side Tympanometry – Type B curve X-rays of mastoid - clouding of air cells because of exudate.

27. Nipple sign (Impending Perforation) Localised protrusion of TM – due to destruction of fibrous layer of TM by continuous pressure of Pus

28. Stage 4- Stage of Resolution The TM ruptures with release of pus into EAC Inflammatory process begins to resolve Symptoms subsides at this stage If proper treatment is started early or if the infection was mild, resolution may start even without rupture of TM Symptoms - With evacuation of pus, earache is relieved, fever comes down and the child feels better. Signs – EAC may contain blood-tinged discharge which later becomes mucopurulent. Usually, a small perforation is seen in anteroinferior quadrant of pars tensa . Hyperaemia of tympanic membrane begins to subside with return to normal colour and landmarks. The sequential examination shows resolution of middle ear mucosal congestion and edema .

29. Red congested right tympanic membrane with ruptured pus point Resolution stage of AOM

30. Stage 5- Stage of complications Complication  when the infection persists and extends beyond the limit of the middle ear cleft Factors favouring Complications Agent factor - If virulence of organism is high Host factor - R esistance of patient is poor # Probable complications A cute mastoiditis, Subperiosteal abscess Facial paralysis Labyrinthitis P etrositis Extra- dural abscess Meningitis Brain abscess Lateral sinus thrombophlebitis. R esolution does not take place and disease spreads beyond the confines of middle ear, resulting in complications

31. Sporadic episode occurring as infrequent isolated events, typically occurring with URTI 2. Resistant AOM persistence of symptoms and signs of middle ear infection beyond 3-5 days of antibiotic treatment 3. Persistent AOM persistence or recurrence of symptoms and signs of AOM within 6 days of finishing a course of antibiotics 4. Recurrent AOM 3 or more episodes of AOM occurring within a 6-month period, or at least 4-6 episodes within a 12-month period 4 broadly defined subgroups of AOM

32. Management of AOM Most cases of AOM - improved within 24-48 hours without treatment. S pontaneous regression of symptoms is noticed in 80% of children. Management include – Treatment of cause Watchful waiting Conservative management Active medical management Surgical management

33. Active Treatment of AOM Antibiotics Decongestants ( Nasal / Oral ) Analgesics and antipyretics Aural Toilet Dry local heat  Eustachian tube ope ning maneuvers Surgical treatment - Myringotomy

34. Role of Antibiotics??? Indications

35. 1. ANTIBACTERIAL THERAPY Which antibiotic? As the most common organisms are S. pneumoniae and H. influenzae, the drugs which are effective in AOM are - A mpicillin (50 mg/kg/day in four divided doses) - Amoxicillin (40 mg/kg/day in three divided doses) Those allergic to these penicillins : - Cefaclor - C o-trimoxazole - Erythromycin In cases where Beta-lactamase-producing H. influenzae or M. catarrhalis are isolated - A moxicillin clavulanate - Cefuroxime axetil - C efixime - Intramuscular : C eftriaxone (US Centre for Disease Control and Prevention). Antibacterial therapy must be continued for a minimum of 10 days, till tympanic membrane regains normal appearance and hearing returns to normal. Early discontinuance of therapy with relief of earache and fever, or therapy given in inadequate doses may lead to Secretory otitis media and Residual hearing loss.

36. 2. Decongestants Decongestants nasal drops (Topical) Ephedrine (1% in adults and 0.5% in children) oxymetazoline ( Nasivion ) xylometazoline ( Otrivin ) By decongestion, helps to relieve ET oedema and promote ventilation of middle ear Oral Decongestants Pseudoephedrine Naphazoline Ephedrin

37. Antihistamines + decongestants??

38. 3. ANALGESICS AND ANTIPYRETICS Paracetamol Ibuprofen helps to relieve pain and bring down temperature.

39. 4. Aural Toileting Dry Mop – with sterile cotton buds, suctioning by machine Wet Mop – Syringing with warm sterile water/saline If there is discharge in the ear i.e. Stage of Suppuration wick moistened with antibiotic may be inserted into EAC after clearing out EAC

40. 5. DRY LOCAL HEAT Helps to relieve pain

41. 6. Eustachian tube ope ning maneuvers

42. 7. SURGICAL TREATMENT Surgery has a limited role in the treatment of an uncomplicated episode of AOM In AOM : role of Antibiotics alone > Myringotomy alone Antibiotics alone = Myringotomy+Antibiotics Myringotomy is reserved for severe cases where complication is present or suspected, to relieve severe pain, or when microbiology is strongly required

43. MYRINGOTOMY It is incising the drum to evacuate pus The incision of myringotomy in AOM is semilunar/curvilinear in shape Commence posterosuperiorly till anteroinferiorly Pus from ME is taken for Culture and sensitivity A strip of ribbon gauze (wick) is inserted to absorb any pus, helping to drain the middle ear by capillary Wick is removed within few hours

44. Myringotomy in AOM v/s OME Very Important

45. Management of recurrent acute otitis media ALTERATION OF RISK FACTORS