Acute Otitis Media Case: An otherwise healthy 17 month old boy had a cold accompanied by two days of rhinorrhea,

cough, and fever (temperature of up to 38.8 C). On day 5 he became fussy and woke up crying multiple times during the night. The following day he was afebrile, and a physical exam was normal except for findings of slight redness of the left tympanic membrane with no middle ear fluid and a bulging right tympanic membrane with white fluid behind it obstructing the umbo. How should this child be treated?

Questions: 1. Background info on otitis media. 2. What is the etiology and pathophysiology of otitis media? 3. What are the risk factors associated with otitis? 4. What are the most common pathogenic organisims? 5. What are the differences between acute otitis media and otitis media with effusion? 6. When do you treat? References: 1. BienJ, Seigel R. Acute Otitis Media in Children: A Continuing Story. Pediatrics in Review June 2004. 2. Cohen R et al. Current approaches to otitis media. Current Opinion in Infectious Disease 2001, 14: 337-342. 3. Harrison C. How will the new guidelines for mananging otitis media work in your practice? Contemporary Pediatrics June 2004. 4. Hendley J. Otitis Media. NEJM October 2002, Vol 347: 1169-1174. 5. Klein, Jerome O. Epidemiology, pathogenesis, clinical manifestations, and complications of acute otitis media. Up to Date. January 2009. 6. McCracken G. Diagnosis and Management of Acute Otitis Media in Urgent Care Setting. Annals of Emergency Medicine April 2002, p 413-421. 7. Subcommitee on Management of Acute Otitis Media. Diagnosis and Management of Acute Otitis Media. Pediatrics May 2004, p 1451-1464. 8. Wald, Ellen R. Diagnosis of Acute Otitis Media. Up to Date. August 2009.

1. Background info on Otitis Media: First lets get the terminology straight 1. Middle ear effusion Middle ear effusion refers to the presence of fluid or liquid in the middle ear cavity. Middle ear effusion is present in both otitis media with effusion and acute otitis media. 2. Otitis media with effusion When fluid in the middle ear is not infected, the process is referred to as otitis media with effusion (OME), which can also be called secretory, serous, or nonsupparitive otitis media. OME frequently precedes the development of AOM or follows its resolution: OME is by far more common that AOM. 3. Acute otitis media When fluid in the middle ear becomes infected with bacteria the process is referred to as AOM. This kid is screaming in my face How do I remember the important aspects of the otoscopic exam? The COMPLETES mnemonic: Color gray, white, pale, yellow, amber, pink, red, blue Other conditions for example fluid level, bubbles, perforation, otorrhea, bullae, tympanosclerosis, atrophic areas, retratction pocket, cholesteatoma Mobility Position full/bulging, neutral, retratcted Lighting use a halogen light source with fully charged battery Entire surface the four quadrants of the tympanic membrane should be examined Translucency External auditory canal and auricle deformed, displaced, inflamed, foreign body Seal a good seal requires an airtight pneumatic system and a speculum that is large enough to prevent air leak Acute otitis media is the most frequent diagnosis in sick children visiting physicians offices. AOM results in more than 24 million office visits, accounts for most outpatient antibiotic prescriptions provided to children and costs an estimated $5.3 billion annually. 50% of infants in the U.S. will have their first episode before 6 months of age and 90% experience at least 1 episode by age 2 years. 2. What is the etiology/pathophysiology of otitis media? The patient has an antecedent event (viral URI or allergy) the event results in congestion of the respiratory mucosa of the nose, nasopharynx, and eustachian tube congestion of the mucosa in the Eustachian tube obstructs the narrowest portion of the tube, the isthmus obstruction of the isthmus causes negative pressure followed by accumulation of secretions produced by the mucosa of the middle ear these secretions have no egress and accumulate n the middle ear space viruses and bacteria that colonize the upper respiratory tract can reach the middle ear via aspiration, reflux, or insufflation mircrobial growth in the middle ear secretions may result in suppuration

with clinical signs of AOM the middle ear effusion may persist for weeks to months following sterilization of the middle ear infection. 3. Risk Factors for AOM Male gender Atopic disease Immune deficiency Craniofacial abnormalities Genetic tendency Child care attendance Older sibs Smoke exposure Pacifier use Bottle feeding 4. Name the most common pathogenic organisims Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis are the three leading bacterial pathogens in AOM (90-95%). Streptococcus pneumoniae causes approximately 25-50% of cases, H. Flu 25%, and M. Catarrhalis 12% of cases. Viruses are responsible for infections in 40% of children with AOM. Most common viruses are RSV, rhinovirus, adenovirus, and influenza. 5. Compare Acute otitis media with otitis media with effusion. A diagnosis of AOM requires 1) a history of acute onset of signs and symptoms, 2) the presence of MEE, and 3) signs and symptoms of middle ear inflammation. 1. Recent, usually abrupt, onset of signs and symptoms of middle ear inflammation and MEE. 2. The presence of MEE that is indicated by any of the following: a. Bulging of the tympanic membrane b. Limited or absent mobility of the tympanic membrane c. Air fluid level behind the tympanic membrane d. Otorrhea 3. Signs or symptoms of middle ear inflammation as indicated by either a. Distinct erythema of the tympanic membrane or b. Distinct otalgia ** Of note Marked redness of the tympanic membrane without bulging is an unusual finding in AOM. A distinctly red tympanic membrane in the absence of bulging or impaired morbility has a PPV of only 15% for AOM. 6. Discuss treatment options for AOM. A. The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. Acetaminophen and ibuprofen

Benzocaine (Auralgan, Americaine Otic) only proven to be effective if > 5y Naturopathic agents (Otikon Otic Solution) only in patients >6y Tympanostomy/myringotomy requires skill B. Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up: Not eligible: Any child with recurrent, persistent or frequent AOM Any child with a condition that predisposes to AOM Any child younger than 6 months with any AOM, regardless of severity/certainty Any child with severe AOM (severe otalgia or fever 39 C) Children 6 to 24 months with certain AOM Considered eligible: Children 6 to 24 months with mild but uncertain AOM Children older than 24 months with mild AOM regardless of certainty Additional mandatory criteria for withholding antibiotics Parent/caregiver is comfortable about withholding Follow-up opportunity is assured Parent or caregiver is able to take advantage of follow-up so that antibiotics can be promptly started if symptoms persist or become worse C. Otitis with effusion should not be treated with antibiotics. If a decision is made to treat AOM with an antibacterial agent, the clinician should prescribe Amoxicillin for most children, 80mg/kg/day. D. If the patient fails to respond to the initial management option within 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibiotics. If the patient was initially managed with antibiotics, the clinician should change the antibacterial agent. Initial Author: Emily Dawson M.D. Modified by: Jessica Hersman M.D. Reviewed by: Barret Fromme M.D.