Otitis Media

1. Otitis MediaOtitis Media

2. Otitis MediaOtitis Media
n$3.5 billion in expenditures$3.5 billion in expenditures
nMost common reason for visit to Most common reason for visit to
pediatricianpediatrician
nTympanostomy tube placement is 2nd Tympanostomy tube placement is 2nd
most common surgical procedure in most common surgical procedure in
childrenchildren
nDevelopment of multidrug-resistant Development of multidrug-resistant
bacteria bacteria

3. Otitis Media - HistoryOtitis Media - History
nEgyptian mummies have perforations of Egyptian mummies have perforations of
TM and mastoid destructionTM and mastoid destruction
nPrehistoric Iranian population has Prehistoric Iranian population has
evidence of middle ear diseaseevidence of middle ear disease
nOM accounted for 27% of admissions to OM accounted for 27% of admissions to
Bellevue Hospital in 1932 Bellevue Hospital in 1932

4. Otitis Media - DefinitionOtitis Media - Definition
Inflammation of the middle earInflammation of the middle ear
May also involve inflammation of May also involve inflammation of
mastoid, petrous apex, and mastoid, petrous apex, and
perilabyrinthine air cellsperilabyrinthine air cells

5. Otitis Media - ClassificationOtitis Media - Classification
nAcute OM - rapid onset of signs & sx, < Acute OM - rapid onset of signs & sx, <
3 wk course3 wk course
nSubacute OM - 3 wks to 3 mosSubacute OM - 3 wks to 3 mos
nChronic OM - 3 mos or longer Chronic OM - 3 mos or longer

6. OM - EpidemiologyOM - Epidemiology
nAgeAge
nSexSex
nRaceRace
nDay careDay care
nSeasonsSeasons
nGeneticsGenetics
nBreast-feedingBreast-feeding
nSmoke exposureSmoke exposure
nMedical conditions Medical conditions

7. OM - EpidemiologyOM - Epidemiology
nIncreasing incidence?Increasing incidence?
nIncreases after newborn periodIncreases after newborn period
n2/3 with AOM by one year of age2/3 with AOM by one year of age
n1/2 with >3 episodes by three years1/2 with >3 episodes by three years
nmost common in 6 - 11 mos most common in 6 - 11 mos

8. OM - persistent middle ear OM - persistent middle ear
effusion (MEE)effusion (MEE)
nHigh incidence of MEE, avg of 40 daysHigh incidence of MEE, avg of 40 days
nChildren less that 2 years much more Children less that 2 years much more
likely to have persistent MEElikely to have persistent MEE
nWhite children with higher incidence of White children with higher incidence of
MEEMEE

9. Otitis Media - RaceOtitis Media - Race
nHigher incidence in:Higher incidence in:
–EskimosEskimos
–Native AmericansNative Americans
–Australian and African aboriginesAustralian and African aborigines

10. OM - Day Care OM - Day Care
nGreater risk of AOM in children < 3 Greater risk of AOM in children < 3
yearsyears
nHome care best, large group day care Home care best, large group day care
worstworst
–more exposures with wider range of floramore exposures with wider range of flora
–increased URI’sincreased URI’s
–more frequent visits to MD to decrease more frequent visits to MD to decrease
parental leave time from workparental leave time from work

11. OM - Breast-feedingOM - Breast-feeding
nDecreases incidence of URI and GI Decreases incidence of URI and GI
diseasedisease
nInverse relationship between incidence Inverse relationship between incidence
of OM and duration of breast-feedingof OM and duration of breast-feeding
nProtective factor in breast-milk?Protective factor in breast-milk?

12. OM - smoke exposureOM - smoke exposure
nInduces changes in respiratory tractInduces changes in respiratory tract
nCotinine marker associated with Cotinine marker associated with
increased AOM and persistent effusionincreased AOM and persistent effusion
nIncreased PET, otorrhea, chronic and Increased PET, otorrhea, chronic and
recurrent AOM in children with hx of recurrent AOM in children with hx of
parental smokingparental smoking

13. OM - Medical ConditionsOM - Medical Conditions
nCleft palateCleft palate
–decreases after decreases after
repairrepair
nCraniofacial Craniofacial
disordersdisorders
–Treacher-CollinsTreacher-Collins
nDown’s syndromeDown’s syndrome
nCiliary dysfunctionCiliary dysfunction
nImmune dysfunctionImmune dysfunction
–AIDSAIDS
–steroids, chemosteroids, chemo
–IgG deficiencyIgG deficiency
nObstructionObstruction
–NG tubesNG tubes
–NT intubationNT intubation
–adenoidsadenoids
–malignancymalignancy

14. Eustachian TubeEustachian Tube
nConnects middle ear and nasopharynxConnects middle ear and nasopharynx
nLumen shaped like two cones with apex Lumen shaped like two cones with apex
directed toward middledirected toward middle
nMucosa has mucous producing cells and Mucosa has mucous producing cells and
ciliated cellsciliated cells

15. Eustachian tubeEustachian tube
nAdultsAdults
–ant 2/3- cartilaginousant 2/3- cartilaginous
–post 1/3- bonypost 1/3- bony
–45 degree angle45 degree angle
–isthmus 1-2 mmisthmus 1-2 mm
–nasopharyngeal nasopharyngeal
orifice 8-9 mmorifice 8-9 mm
nChildrenChildren
–longer bony portionlonger bony portion
–10 degree angle10 degree angle
–isthmus largeristhmus larger
–nasopharyngeal nasopharyngeal
orifice 4-5 mm in orifice 4-5 mm in
infantsinfants

16. Eustachian tubeEustachian tube
nUsually closedUsually closed
nOpens during swallowing, yawning, and Opens during swallowing, yawning, and
sneezing sneezing
nOpening involves cartilaginous portionOpening involves cartilaginous portion
nTensor veli palatini responsible for Tensor veli palatini responsible for
active tubal openingactive tubal opening
nNo constrictor functionNo constrictor function

17. Eustachian tubeEustachian tube
nProtection from nasopharyngeal sound Protection from nasopharyngeal sound
and secretionsand secretions
nclearance of middle ear secretionsclearance of middle ear secretions
nventilation (pressure regulation) of ventilation (pressure regulation) of
middle earmiddle ear

18. PathologyPathology
nEdema, capillary engorgement, and PMN Edema, capillary engorgement, and PMN
infiltrationinfiltration
nEpithelial ulceration and granulation tissueEpithelial ulceration and granulation tissue
nFibrosis, influx of chronic inflammatory cellsFibrosis, influx of chronic inflammatory cells
nIncreased columnar and goblet cellsIncreased columnar and goblet cells
nOsteitisOsteitis
nEdema and polypoid changesEdema and polypoid changes

19. PathologyPathology
nEustachian tube abnormalitiesEustachian tube abnormalities
–Impaired openingImpaired opening
–open in DS and American Indiansopen in DS and American Indians
–shorter tubeshorter tube
nImpaired immunityImpaired immunity
–children have poorer immune responsechildren have poorer immune response
–less cytokines in nasopharynx in children with OMless cytokines in nasopharynx in children with OM
nInflammatory mediatorsInflammatory mediators
–Bacterial products induce inflam response with Bacterial products induce inflam response with
IL-1, IL-6, and TNFIL-1, IL-6, and TNF
nAllergyAllergy

20. MicrobiologyMicrobiology
nS. pneumoniaeS. pneumoniae - 30-35% - 30-35%
nH. influenzaeH. influenzae - 20-25% - 20-25%
nM. catarrhalisM. catarrhalis - 10-15% - 10-15%
nGroup A strep - 2-4%Group A strep - 2-4%
nInfants with higher incidence of gram Infants with higher incidence of gram
negative bacillinegative bacilli

21. VirologyVirology
nRSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates
nRhinovirusRhinovirus
nParainfluenza virusParainfluenza virus
nInfluenza virusInfluenza virus

22. MicrobiologyMicrobiology
nPCN-resistant StrepPCN-resistant Strep
–1979 - 1.8%1979 - 1.8%
–1992 - 41%1992 - 41%
–Altered PCN-binding Altered PCN-binding
proteinsproteins
–Lysis defectiveLysis defective
–Age, day-cares, and Age, day-cares, and
previous txprevious tx
nH. flu and M. H. flu and M.
catarrhaliscatarrhalis
–beta-lactamase beta-lactamase
productionproduction
–All All M. catarrhalisM. catarrhalis + +
–45-50% 45-50% H. fluH. flu

23. Chronic MEE Chronic MEE
nPreviously thought sterilePreviously thought sterile
n30-50% grow in culture30-50% grow in culture
nover 75% PCR +over 75% PCR +
nUsual organismsUsual organisms

24. DiagnosisDiagnosis
nAcute OMAcute OM
–preceding URIpreceding URI
–fever, otalgia, fever, otalgia,
hearing loss, hearing loss,
otorrheaotorrhea
–may have assoc may have assoc
constitutional sxconstitutional sx
nChronic MEEChronic MEE
–poss asymptomaticposs asymptomatic
–hearing losshearing loss
–““plugged”plugged”
–““popping”popping”

25. DiagnosisDiagnosis
nPneumatic otoscopy is gold standardPneumatic otoscopy is gold standard
–Color - opaque, yellow, blue, red, pinkColor - opaque, yellow, blue, red, pink
–Position - bulging, retractedPosition - bulging, retracted
–Mobility - normal, hypomobile, neg Mobility - normal, hypomobile, neg
pressurepressure
–Assoc pathology - perfs, cholesteatoma, Assoc pathology - perfs, cholesteatoma,
retraction pocketsretraction pockets
nHead & neck examHead & neck exam

26. DiagnosisDiagnosis
nAudiogramAudiogram
–document CHL, SNHL, baseline, preopdocument CHL, SNHL, baseline, preop
–sooner if high risksooner if high risk
nImpedanceImpedance
nAcoustic reflexesAcoustic reflexes

27. Treatment - AOMTreatment - AOM
nAdults and older children - observation?Adults and older children - observation?
nAntibiotics - consider drug resistance Antibiotics - consider drug resistance
patternspatterns
–Amoxil - not for Amoxil - not for BB lactamase + lactamase +
–TMP-SMT - not for group A strepTMP-SMT - not for group A strep
–Need high middle ear concentrationsNeed high middle ear concentrations

28. AntibioticsAntibiotics
nFirst lineFirst line
–Amoxil - 60-90 mg/kg divided tidAmoxil - 60-90 mg/kg divided tid
–Ceftin - B lactam stableCeftin - B lactam stable
–Augmentin - B lactam stableAugmentin - B lactam stable
–Bactrim, PediazoleBactrim, Pediazole
nSecond lineSecond line
–AugmentinAugmentin
–CeftinCeftin
–RocephinRocephin
–Macrolides - Zithromax, BiaxinMacrolides - Zithromax, Biaxin

29. Treatment - Recurrent AOMTreatment - Recurrent AOM
nChemoprophylaxisChemoprophylaxis
–Sulfisoxazole, amoxicillin, ampicillin, pcnSulfisoxazole, amoxicillin, ampicillin, pcn
–less efficacy for intermittent propylaxisless efficacy for intermittent propylaxis
nMyringotomy and tube insertionMyringotomy and tube insertion
–decreased # and severity of AOMdecreased # and severity of AOM
–otorrhea and other complicationsotorrhea and other complications
–may require prophylaxis if severemay require prophylaxis if severe
nAdenoidectomyAdenoidectomy
–28% and 35% fewer episodes of AOM at first and 28% and 35% fewer episodes of AOM at first and
second yearssecond years

30. Treatment - OMETreatment - OME
nMEE > 3 mos or assoc hearing loss, vertigo, MEE > 3 mos or assoc hearing loss, vertigo,
frequency, ME pathology, discomfortfrequency, ME pathology, discomfort
nAntibioticsAntibiotics
–shown to be of benefit, 75% PCR + bacterial DNAshown to be of benefit, 75% PCR + bacterial DNA
nAntibiotics + steroidAntibiotics + steroid
–21% improvement compared to abx alone21% improvement compared to abx alone
–prednisone 1 mg/kg day x 7 daysprednisone 1 mg/kg day x 7 days
–varicella?varicella?
nMyringotomy & tympanostomy +/- Myringotomy & tympanostomy +/-
adenoidectomyadenoidectomy

31. Tympanostomy tube insertionTympanostomy tube insertion
nUnresponsive OME >3 mos bil, or >6 Unresponsive OME >3 mos bil, or >6
mos uni, sooner if assoc hearing mos uni, sooner if assoc hearing
problemsproblems
nRecurrent MEE with excessive Recurrent MEE with excessive
cumulative durationcumulative duration
nRecurrent AOM - >3/6 mos or >4/12 Recurrent AOM - >3/6 mos or >4/12
mosmos
nEustachian tube dysfunctionEustachian tube dysfunction
nSuppurative complicationSuppurative complication

32. ComplicationsComplications
nIntratemporalIntratemporal
–hearing losshearing loss
–TM perforationTM perforation
–CSOMCSOM
–retraction pocketsretraction pockets
–cholesteatomacholesteatoma
–mastoiditismastoiditis
–petrositispetrositis
–labyrinthitislabyrinthitis
–adhesive OMadhesive OM
–tympanosclerosistympanosclerosis
–ossicular dyscontinuity and ossicular dyscontinuity and
fixation fixation
–facial paralysisfacial paralysis
–cholesterol granulomacholesterol granuloma
–necrotizing OEnecrotizing OE
nIntracranialIntracranial
–meningitismeningitis
–extradural abscessextradural abscess
–subdural empyemasubdural empyema
–focal encephalitisfocal encephalitis
–brain abscessbrain abscess
–lateral sinus thrombosislateral sinus thrombosis
–otitic hydrocephalusotitic hydrocephalus

33. Case historyCase history
n1 1/2 year old wm presents to ENT clinic with 1 1/2 year old wm presents to ENT clinic with
2nd episode of “ear infections” in last month2nd episode of “ear infections” in last month
nNormal history with no medical problems and Normal history with no medical problems and
no prior surgical proceduresno prior surgical procedures
nMother describes a “cold” for the last few Mother describes a “cold” for the last few
days and then started running a fever and days and then started running a fever and
pulling at ears. Describes the child as very pulling at ears. Describes the child as very
irritable irritable

34. Physical ExamPhysical Exam
nTemp 100 F, VS wnlTemp 100 F, VS wnl
nIrritable childIrritable child
nEars - eac clear, tms erythematous, Ears - eac clear, tms erythematous,
bulging with yellowish MEE AUbulging with yellowish MEE AU
nNose - clear rhinorrheaNose - clear rhinorrhea
notherwise wnlotherwise wnl

35. Case historyCase history
nReturns to clinic one month later with Returns to clinic one month later with
same complaints againsame complaints again
nDx as AOMDx as AOM
n3rd episode in last 2 mos and 5th in last 3rd episode in last 2 mos and 5th in last
yearyear

36. Case historyCase history
nPlaced on sulfisoxizol prophylaxisPlaced on sulfisoxizol prophylaxis
n3 wks later presents with recurrent AOM 3 wks later presents with recurrent AOM

37. Case historyCase history
nBM&T performed, doing well at 3 wksBM&T performed, doing well at 3 wks
nMother calls at 3 mos and says has had Mother calls at 3 mos and says has had
to be tx with po abx and ear gtts 3 to be tx with po abx and ear gtts 3
times by pcp for bilateral otorrhea times by pcp for bilateral otorrhea

38. New FrontiersNew Frontiers
nPrevention more cost effective than Prevention more cost effective than
treatmenttreatment
nEven slight decrease would have Even slight decrease would have
profound economic impactprofound economic impact
–VaccinesVaccines
–XylitolXylitol

39. VaccinesVaccines
nPneumococcal vaccinePneumococcal vaccine
–poorly immunogenic in childrenpoorly immunogenic in children
–did exhibit antibody response did exhibit antibody response
nH. influenzaeH. influenzae
–no polysaccharide capsuleno polysaccharide capsule
–serum bactericidal antibodyserum bactericidal antibody
n M. catarrhalisM. catarrhalis
–human pathogen human pathogen

40. VaccinesVaccines
n150 viral immunotypes150 viral immunotypes
n100 rhinoviruses with poor prognosis 100 rhinoviruses with poor prognosis
for vaccine developmentfor vaccine development
nRSV most common - developing RSV most common - developing
intranasal delivery systemintranasal delivery system

41. XylitolXylitol
nSweetening substituteSweetening substitute
nInhibits growth of pneumococcus and Inhibits growth of pneumococcus and
inhibits adhesion of pneumococcus and inhibits adhesion of pneumococcus and
H. flu in nasopharynxH. flu in nasopharynx
nGum and syrup reduced incidence of Gum and syrup reduced incidence of
AOM 40% and 30% AOM 40% and 30%

42. Otitis MediaOtitis Media