ACUTE OTITIS MEDIA IN CHILDREN cme SLIDE SET

ALL ABOUT ACUTE OTITIS MEDIA IN CHILDREN

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2. Acute otitis media in children: From diagnosis to prognosis

3. Epidemiology 2. I nt J Pediatr Otorhinolaryngol . 2020 Oct;137:110201. 3 . Can Fam Physician. 2017;63(9):685-687. 1. Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications?csi=bea4d3f2-98c1-4030-82ae-ef7af5099093&source=contentShare last accessed on 31 st January, 2021 Leading cause of acute care visits; most common reason for abx 1 Prime cause of preventable hearing 2 Worldwide estimated incidence 11% (709 million cases/year) 3 Slightly more common in boys than girls 1 Before 2 yrs of age, 94% will have at least 1 episode of OM 2 Infrequent in school-age children, and adolescents 1

4. Etiology % N = 79 children with AOM and new onset otorrhea Viral : RSV, rhinovirus, influenza viruses, adenoviruses, human metapneumovirus Other pathogens :  Anaerobes & mycoplasma (rare); C. trachomatis (in < 6 mo age); E. coli (1 st mo of life); P. aeruginosa (in CSOM); M. tuberculosis ,  C. diphtheriae , and  C. tetani (additionally in developing countries) Bacterial: S. pneumoniae , nontypeable  H. influenzae  ( NTHi ), M. catarrhalis   --S. pneumoniae   and  H. influenzae seen in persistent and/or recurrent OM ( biofilms ) Young infants : Similar to those in older children; Infants < 2 two weeks - pathogens similar to neonatal sepsis Adapted from https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications?csi=bea4d3f2-98c1-4030-82ae-ef7af5099093&source=contentShare last accessed on 31 st January, 2021

5. Pathogens: Bacterial Post-PCV7 ↑ NTHi (44 to 55%); ↓ S. pneumoniae ( 45 to 30%) Post-PCV10  No statistically significant ↓ in NTHi AOM  Post-PCV13 Possible dominance of non-vaccine serotypes of  S. pneumoniae ; ↓ PCV13 serotypes S. pneumoniae (15 to 25 %) Causes early episodes; A ssociated with ↑ clinical severity (high fever, more intense otalgia ); potential for complications like mastoiditis ; ↑ peripheral blood and middle ear fluid WBC counts H. influenzae   (50 to 60%) More common in bilateral OM; NTHi associated with concurrent conjunctivitis, lower fever, less inflamed tympanic membrane; associated with more complex otitis media, including increased risk for treatment failure, recurrence and chronicity M. Catarrhalis (12 to 15%) Isolated in children immunized with PCV; all strains produce beta- lactamase ; less severe than pneumococcal Group A Streptococcus (2 to 10 %) In older children; more frequently associated with local complications (TM perforation, mastoiditis ); less frequently associated with fever and systemic or respiratory symptoms S. aureus Uncommon, found often as a cause of acute otorrhea with tympanostomy tubes in place Adapted from https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications?csi=bea4d3f2-98c1-4030-82ae-ef7af5099093&source=contentShare last accessed on 31 st January, 2021

6. Risk factors Age: Prematurity and low birth weight; Young age (6 to 12 mo ; 5-6 yrs) Family history: ↑ in child with sibling or either parent with AOM (odds ratio 3.7); ↑ dizygotic than monozygotic twins (0.49 versus 0.04%) Adapted from https://www.medscape.com/answers/859316-30595/what-are-the-risk-factors-for-acute-otitis-media-aom last accessed on 30th January, 2021 Adapted from https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications?csi=bea4d3f2-98c1-4030-82ae-ef7af5099093&source=contentShare last accessed on 31 st January, 2021 Day care: ↑ risk of AOM with odds ratio ranging from 2.8 to 5.0 Tobacco/pollutant exposure: Risk ratio 1.66 in children with smoking parents Use of pacifier (RR 1.24)/Absence of breastfeeding, prolonged bottle use Crowded living conditions/ Low socioeconomic status Other: Winter season; Neuromuscular disease; Allergy, Down’s; Prone sleeping position; Craniofacial abnormalities; Cleft palate or midface anomalies (in OME) Crowded living conditions/ Low socioeconomic status Other: Winter season; Neuromuscular disease; Allergy, Down’s; Prone sleeping position; Craniofacial abnormalities; Cleft palate or midface anomalies (in OME)

7. Clinical features Ear pain: Most common, best predictor Ear rubbing, Hearing loss, and Ear drainage: Not always present Fever: in one- to two-thirds of children Neonates: Irritability/feeding difficulties may be only indication of a septic focus Infants: Fever, fussiness, disturbed or restless sleep, poor feeding/anorexia, vomiting, diarrhea Older children: Demonstrates a consistent presence of fever (with or without URTI) and otalgia , or ear tugging; ear stuffiness noted before detection of ME fluid History varies with age, but number of constant features manifest during the otitis -prone years Adapted from: https://emedicine.medscape.com/article/859316-overview last accessed on 30th January, 2021 Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 30 th January, 2021

8. Intratemporal – Hearing loss, TM perforation, mastoiditis , facial nerve palsy, acute labyrinthitis , petrositis , CSOM, myringosclerosis , retraction or collapse, cholesteatoma Intracranial - Meningitis, encephalitis, epidural abscess, brain abscess, otitis hydrocephalus, subarachnoid abscess, subdural abscess, or sigmoid sinus thrombosis Systemic - Bacteremia , septic arthritis, or bacterial endocarditis Adapted from: https://www.medscape.com/answers/859316-30606/what-are-the-potential-complications-of-acute-otitis-media-aom last accessed Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications?csi=bea4d3f2-98c1-4030-82ae-ef7af5099093&source=contentShare last accessed on 30 th January, 2021 Complications by location

9. Complications by signs and symptoms Signs and symptoms Complications Postauricular swelling and protrusion of the auricle Mastoiditis (rare) Vestibular symptoms (dizziness, vertigo, balance and motor problems) with or without tinnitus or nystagmus Labyrinthitis , mastoiditis , or cholesteatoma Cranial nerve palsies (facial nerve, abducens nerve)  Scute mastoiditis , petrositis , cholesteatoma , or intracranial complications. Meningeal signs, cranial nerve deficits, and/or focal neurologic findings  Intracranial complications ( eg , meningitis, brain abscess, epidural or subdural abscess, lateral or cavernous sinus thrombosis). Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 30th January, 2021

10. Pneumatic otoscopy Remove obstructing cerumen under direct vision from external canal   Otoscope with adequate light source and a round head Ear specula of various sizes - 4 mm speculum works for most children; put a small piece rubber tubing to tip to increase diameter Check leaks by occluding tip of speculum; squeezing rubber bulb to check resistance Insufflator bulb - compress for +’ ve pressure, release for –’ ve Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 30 th January, 2021  ASSESS each quadrant of TM for position, mobility, translucency, color, and other findings (air-fluid levels, perforation, retraction pockets, cholesteatoma ) I: incus , long process; L: lateral process of the malleus ; LR: light reflex; M: manubrium of the malleus ; PF: pars flaccida ; PT: pars tensa ; U: umbo .

11. Definite diagnosis of AOM: Meet all 3 criteria 3 CRITERIA History of acute onset of signs & symptoms LOOK FOR ASK FOR ASK FOR Fever ( oral/ rectal/ axillary ) Ear pain; Ear tugging/ pulling in non verbal child Background acute respiratory infection ( sore throat , throat congestion, rhinitis ) Irritability Vomiting / dizzines s Constitutional symptoms (reduced appetite &/or sleep) Presence of middle ear effusion (MEE) LOOK FOR --Hallmark of AOM - Bulging tympanic membrane (posterior quadrants); scalded appearance of the superficial epithelial layer -- Perforated tympanic membrane (most frequently in posterior or inferior quadrants) --Limited/ absent mobility (in posterosuperior quadrant or pars flaccida ) --Air fluid level behind tympanic membrane --Purulent Otorrhea Middle ear inflammation sign & symptoms LOOK FOR ASK FOR Erythema of tympanic membrane Otalgia disturbing sleep Adapted from: https://emedicine.medscape.com/article/859316-overview last accessed on 31st January, 2021 Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 31 st January, 2021

12. Normal TM Classic findings in AOM Whitish effusion, vascular engorgement, and dimpling at the attachment of the malleus umbo ; bulging TM, opaque, yellow, or white , decreased or absent mobility Normal left tympanic membrane with pearly gray color and in neutral position Pneumatic otoscopy findings Needed: --In overlapping URTI symptoms --Non specific symptoms in young children --To distinguish AOM with OME

13. 1. Cloudy or opaque TM Bubbles or air-fluid levels indicate MEE; more suggestive of OME than AOM When negative pressure in the middle ear cavity ( Eg : Eustachian tube dysfunction) 2. Retracted TM 3. Bullous myringitis Painful bullae ; Inflammation occurs in association with AOM ; 5% of cases of AOM < 2 yrs age 1 3 2 4 4. Cholesteatoma Cyst like, greasy white debris, or as a mass; retracted pockets 

14. Tympanometry and acoustic reflectometry Rarely performed in primary care setting  Tympanometry – for TM compliance, Eustachian tube function, and middle ear function; Acoustic reflectometry – for reflection of sound from TM Neither of them differentiates infected from uninfected middle ear fluid. If either one or both are normal, both AOM and OME are unlikely. Imaging studies Not necessary CT to determine complication; MRI for suspected intracranial complications. Adapted from: https://emedicine.medscape.com/article/859316-workup#showall last accessed on 31 st January, 2021 Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 31 st January, 2021

15. Tympanocentesis (For etiologic diagnosis) In neonates <6 wks (and therefore are more likely to have an unusual or more invasive pathogen) In immunosuppressed or immunocompromised In child who appear toxic/ continue to show signs of local/systemic sepsis In whom previous antimicrobial treatment has failed Who have a complication requiring culture for adequate therapy Not necessary in most cases Rarely performed in the primary care setting  Adapted from: https://emedicine.medscape.com/article/859316-workup#showall last accessed on 31 st January, 2021 Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 31 st January, 2021

16. Otitis Media with Effusion (OME) Otoscopic findings: No active signs of inflammation + MEE Retracted or neutral position TM Often cloudy TM with distinctly impaired mobility Amber/Grey/ Blue clear or serous colored fluid and bubble air-fluid level (arrow) behind TM   Presentation : Mild, fluctuating hearing loss; those with speech and language delays Persists for few wks after acute symptoms resolved Refer to ENT specialist, if fluid PERSISTS AFTER 3 MO If OME is mistaken as AOM, antibacterial may be unnecessarily prescribed Adapted from: https://www.uptodate.com/contents/otitis-media-with-effusion-serous-otitis-media-in-children-clinical-features-and-diagnosis?csi=05a86489-cff5-4a41-b8d6-f9f439ae6ea8&source=contentShare last accessed on 30 th January, 2021 Prevalence 10 -17 % among children 2-4 yrs; 3-4% between 6-8 yrs

17. Rule out/Differential diagnosis Ear pain: Otitis externa , ear trauma, throat infections, foreign body, or temporomandibular joint syndrome Decreased or absent mobility of TM: Sign of MEE; Myringosclerosis and high negative pressure within ME cavity. Redness of TM: Vascular engorgement due to crying, high fever, URTIs with congestion, inflammation of mucosa lining entire respiratory tract, trauma, and/or cerumen removal Dental pain Adapted from: https://www.medscape.com/answers/859316-30610/which-other-conditions-should-be-considered-in-the-workup-of-acute-otitis-media-aom last accessed on 30th January, 2021 Myringosclerosis Areas of wispy, noncalcified changes (W) as well as a dense calcified region (D) Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-clinical-manifestations-and-diagnosis?csi=1e4df92c-89e3-413f-8d32-60e14ed7bb23&source=contentShare last accessed on 31 st January, 2021

18. Under 2 yrs Above 2 yrs Analgesia irrespective of abx Paracetamol in adequate doses as good as ibuprofen Mainstay of treatment Topical procaine or  lidocaine   as alternative Decongestants/ Antihistamines No role No role  > 6 yrs: Symptomatic relief in known or suspected nasal allergy; Nasal glucocorticoids   Externally apply heat/cold, olive oil/ herbal extracts Not recommended Not recommended Antibiotics Use antibiotic with strong suspicion or confirmed diagnosis of uni - or bi-lateral AOM Wait and watch for 48-72 hrs (normal hosts, unilateral AOM/ mild symptoms, no otorrhea ) Start antibiotics only if deterioration/severe* 1 st line Amoxicillin 90 mg/kg per day  2 divided dose Amoxicillin 90 mg/kg per day  2 divided dose 2 nd line Coamoxyclav 90 mg/kg/d amoxicillin and 6.4 mg/kg/d clavulanate divided in 2 doses Coamoxyclav 90 mg/kg/d amoxicillin and 6.4 mg/kg/d clavulanate divided in 2 doses Continue for: 10 days 5- 7 days If deterioration, change to IV ceftriaxone for 3 days *severe otalgia , fever >102°F, toxicity, otorrhea ANTIBIOTIC THERAPY VERSUS OBSERVATION Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment?csi=ed17ab28-11c0-4420-b3c2-d09fb4d8ffd8&source=contentShare last accessed on 01 st February, 2021

19. Antibiotic Selection No recent beta-lactam therapy, no concomitant purulent conjunctivitis, and no h/o recurrent AOM Amoxicillin 90 mg/kg/ d divided in 2 doses Recent beta- lactam therapy, concomitant purulent conjunctivitis, or h/o recurrent AOM unresponsive to amoxicillin Coamoxyclav 90 mg/kg/d amoxicillin and 6.4 mg/kg/d clavulanate divided in 2 doses Penicillin allergy (non-type 1) ( Mild delayed reaction) Oral Cefdinir , cefpodoxime , cefuroxime , IM ceftriaxone (severe cases) Penicillin allergy (Type 1) (Immediate reaction or serious delayed reaction) Oral Azithromycin , Clarithromycin , clindamicin AOM with perforation (in absence of tympanostomy tube) Oral Amoxicillin for 10 days For GAS, TMP-SMX Beta- lactam antibiotics are most successful against gram-positive pathogens for both disruption of adhesion and postantibiotic effect. Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment?csi=ed17ab28-11c0-4420-b3c2-d09fb4d8ffd8&source=contentShare last accessed on 01 st February, 2021

20. Follow up (F/U) Evaluate every child with AOM by routine otoscope at end of treatment (usually 10-14 days) F/U those who worsen/ fail to improve after 48-72 h of with or without antibiotics In resolved cases, check age, language delays/ problems Expect persistent MEE at initial follow-up visit (only 30% show complete resolution) No further treatment in absence acuity; patient to return until resolves Emergency prescription for acute symptoms prior to next scheduled visit Provide specific indications for urgent F/U (signs of meningismus , cranial nerve palsy) Adapted from: https://emedicine.medscape.com/article/859316-treatment#d11 last accessed on 31 st January, 2021 Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment?csi=ed17ab28-11c0-4420-b3c2-d09fb4d8ffd8&source=contentShare last accessed on 01 st February, 2021

21. Treatment failure/ Resistant OM Persistence of fever, otalgia with red & bulging drum after 3 days of antibiotic treatment  Persistent MEE after resolution of acute symptoms not   indication of treatment failure/ additional antibiotics Treatment failure when initially treated with Pathogens Antibiotic of choice High dose amoxicillin Beta- lactamase -producing H. influenzae and M. catarrhalis High-dose coamoxyclav ( 90 mg + amoxicillin + 6.4 mg clavulanate kg/d in 2 divided dose) High dose coamoxyclav or oral cephalosporins Penicillin-resistant S. pneumoniae IM/ IV Ceftriaxone 50 mg/kg OD for 2-3 doses Macrolides , clindamycin , or ceftriaxone NTHi (Beta- lactamse producing) or MDR S. pneumoniae Consult ENT Tympanocentesis for culture/ ear pain relief Levofloxacin (refractory case); TMP-SMX Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment?csi=ed17ab28-11c0-4420-b3c2-d09fb4d8ffd8&source=contentShare last accessed on 01 st February. 2021

22. Antibiotic prophylaxis Reserve prophylaxis for otitis -prone children who are younger than 2 years or in day care Those who have had 3 or more attacks in a 6-month period Both amoxicillin and sulfisoxazole can cause serum sickness reactions Adapted from: https://www.medscape.com/answers/859316-30642/when-is-antibiotic-prophylaxis-indicated-in-the-management-of-acute-otitis-media-aom last accessed on 01st February, 2021

23. Recurrent OM ( otitis prone) Signs/ symptoms within 30 days after completion of successful treatment.  Within 15 days of treatment completion for previous episode >15 days after treatment completion for previous episode Due to persistence of the original pathogen Due to different pathogen than the previous episode IM or IV Ceftriaxone  50 mg/kg/d for 3 days High-dose  coamoxyclav  as initial therapy, even if child received coamoxyclav for previous episode IM or IV Ceftriaxone 50 mg/kg per dose for a total of two doses (limited studies) Tympanostomy tube insertion Oral Levofloxacin 6 mo – 5 yrs: 10 mg/kg q12h 10 days > 5 yrs: 10 mg/kg OD 10 days Evaluate immune system Adapted from: https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment?csi=ed17ab28-11c0-4420-b3c2-d09fb4d8ffd8&source=contentShare last accessed on 31 st January, 2021 First AOM episode before 6 mo age or who have siblings with history: ↑ risk

24. Chronic supporative OM (CSOM) Management: Good aural toilet Combination of oral and local quinolones ( ofloxacin / ciprofloxacin) for at least 2 weeks Ototopical corticosteroids: Controversial Early referral to ENT service (to prevent intracranial complications/hear loss) Adapted from: https://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-clinical-features-and-diagnosis?csi=63456aea-9a91-4210-b842-4dd8200b9fd9&source=contentShare last accessed on 31 st January, 2021 ME inflammation, TM perforation and atleast > 2 to 6 wks persistent purulent ear discharge 31 million new cases per year worldwide, ¼ in <5 years old; Prevalence in India is 7.8% Hearing loss occurs in approximately 50 to 60% Follows a neglected ear infection; more poor socio-economic Adapted from: https://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-treatment-complications-and-prevention?csi=e3817d0f-7abe-4944-9fb2-173c20e904f6&source=contentShare last accessed on 31 st January, 2021

25. Surgical procedures Therapeutic tympanocentesis : --Creates pathway to permit drainage ( otorrhea ), reduces pressure and severe pain -- Decreases risk of treatment failure, becoming otitis prone, when combined with antibiotics Myringotomy : --Incision and drainage procedure; reduces severe pain Myringotomy with ventilation tube -- Used in mastoiditis ; those with h/o repetitive attacks -- In such patients tympanostomy tube placement is done at time of myringotomy Adopted from: https://emedicine.medscape.com/article/859316-treatment#d9 last accessed on 31 st , January, 2021 Adenoidectomy: beneficial in recurrent OM; in older child requiring tympanostomy tube replacement 2 Adapted from: https://www.medscape.com/answers/859316-30647/what-is-the-role-of-adenoidectomy-in-the-treatment-of-acute-otitis-media-aom last accessed on 01st February, 2021

26. Prognosis Fever, lethargy, pain: Dissipate, within 48 hours. Fewer than 3 episodes or AOM in non winter: 3 times more likely to resolve with single course of abx MEE and conductive hearing loss can be expected to persist well beyond the duration of therapy Persistent MEE can merely be observed without antibiotics; 2 nd course of same antibiotic or of different MOA may prevent relapse Children (%) with MEE persisting up to 12 weeks after AOM Adapted from: https://www.medscape.com/answers/859316-30599/what-is-the-prognosis-of-acute-otitis-media-aom last accessed 01 st January, 2021

27. AAP 2013 guidelines

28. Thank you