Group 2

PGI Gio Balisi

PGI Rishanne Meire Mabborang
CSU JI Jethro Tamayao
SPUP JI Julienne Santos
SPUP JI Shaira Verzosa

Acute Otitis Media and Otitis Media with Effusion

I. ANATOMY
THE EAR

MIDDLE EAR
● Air-containing cavity in the petrous part of temporal bone and is lined with mucous
membrane.
● Contains the auditory ossicles whose function is to transmit the vibrations of the
tympanic membrane to the perilymph of the internal ear.
● The middle ear can be divided into two parts:
○ Tympanic cavity – located medially to the tympanic membrane. It contains three
small bones known as the auditory ossicles: the malleus, incus and stapes. They
transmit sound vibrations through the middle ear.
○ Epitympanic recess – a space superior to the tympanic cavity, which lies next to
the mastoid air cells. The malleus and incus partially extend upwards into the
epitympanic recess.

BOUNDARIES
 - The middle ear can be visualised as a rectangular box, with a roof and floor, medial and
lateral walls and anterior and posterior walls.

ROOF – formed by a thin bone from the petrous part of the temporal bone. It separates the
middle ear from the middle cranial fossa.
FLOOR – known as the jugular wall, it consists of a thin layer of bone, which separates the
middle ear from the internal jugular vein.
LATERAL WALL– made up of the tympanic membrane and the lateral wall of the epitympanic
recess.

MEDIAL WALL – formed by the lateral wall of the internal ear. It contains a prominent bulge,
produced by the facial nerve as it travels nearby.
ANTERIOR WALL – a thin bony plate with two openings; for the Eustachean tube and the
tensor tympani muscle. It separates the middle ear from the internal carotid artery.
POSTERIOR WALL – it consists of a bony partition between the tympanic cavity and the
mastoid air cells. Superiorly, there is a hole in this partition, allowing the two areas to
communicate. This hole is known as the aditus to the mastoid antrum.

II. EPIDEMIOLOGY
Acute Otitis Media
● One of the most common infectious disease in young children
● The incidence of otitis media (OM) is highest in the first years of life and declines as
children grow older and the functions of the immune system and eustachian tube
mature.
● Almost all children experienced at least 1 AOM episode:
○ 6 months old - 20%
○ 3 y/o - 50%
● Global AOM rates are highest in children aged 1 to 4 years old
○ More common in children <3 years old
● Highest prevalence in Philippines: 9.6%, 0-2 years old

Otitis Media with Effusion

● Incidence and prevalence: difficult to established accurately because OME is often
asymptomatic
● Highest incidence: 1 year old
● Nearly all children have experienced at least 1 episode by 3 years old

III. RISK FACTORS

● risk of OM is influenced by a range of host-related and environmental factors
● Powerful predictor of recurrence: Onset of first AOM before 12 months of age
● Host related factors:
○ Male
○ Borigonal ancestry
○ Genetic predisposition
○ Craniofacial abnormalities
○ Immunodeficiency
○ Hypertrophy of adenoids
● Environmental factors:
○ Low socioeconomic status
○ Recurrent upper respiratory tract infection
○ seasonality
○ Daycare attendance
○ Having older siblings
○ Tobacco smoke exposure
○ Pacifier use

IV. DIAGNOSIS
● Natural History
○ Stage of Hyperemia/Retraction
○ Stage of Exudation
○ Stage of Suppuration/Perforation
○ Stage of Coalescence and Surgical Mastoiditis
○ Stage of Complication
○ Stage of Resolution
● Clinical Parameters
 ○ Good clinical history and physical examination
● Pneumatic otoscopy- gold standard
● Tympanometry
● Acoustic reflectometry
● Audiometry

HOW TO DIAGNOSE ACUTE OTITIS MEDIA AND OTITIS MEDIA EFFUSION

● Clinical Parameters
DIAGNOSIS OF ACUTE OTITIS ANY OF THE FOLLOWING ANY OF FOLLOWING
MEDIA REQUIRES; OTOSCOPIC FINDING FINDINGS

History of acute (w/in 3 weeks) Limited or absent mobility of the otalgia

onset AND tympanic membrane

Signs and symptoms of middle Cloudiness of tympanic Fever

ear inflammation AND membrane

Presence of middle ear effusion Bulging of the tympanic

membrane

Markedly retracted tympanic

membrane

Distinct erythema of the tympanic

membrane

Air-fluid level or air bubbles

behind the tympanic membrane

Perforation with otorrhea

● Pneumatic otoscopy
○ Gold standard
○ Primary tools in the diagnosis
○ Allows assessment of tympanic membrane and its mobility
○ Normal tympanic membrane moves briskly with application of slight positive and
negative pressure
■ To ascertain the mobility of tympanic membrane, a good airtight seal
must be obtained between the speculum and the ear canal
■ Largest speculum that fits comfortably should be used.
■ A bulb through which air is puffed should be attached to the otoscope,
allowing for visualization of tympanic membrane mobility.
● Tympanometry
○ Not routinely recommended
○ Provides information about tympanic membrane mobility
○ Presence or absence of middle ear effusion
○ Estimates the equivalent ear canal volume (0.3 To 0.9mL) in children
● Acoustic reflectometry
○ Measures the amount of sound reflected off the tympanic membrane
 ■ Higher value indicates greater probability of MEE
● Audiometry
○ MEE usually results in mild to moderate conductive hearing loss
○ Assessment of the child’s hearing is essential to OME management
V. PATHOPHYSIOLOGY AND PATHOGENESIS
● Multifactorial:
○ Eustachean tube function
○ Immunology
○ Bacterial Colonization and Biofilms
○ Viruses
○ Genetics
○ Allergy
○ GERD
*First 2 PLAYS CENTRAL ROLE IN THE YOUNG CHILD’s SUSCEPTIBILITY TO MIDDLE
EAR INFECTION AND EFFUSION*

EUSTACHIAN TUBE FUNCTION

● Not only protects the middle ear against influx of respiratory viruses and bacterial
otopathogens, but also essential for draining secretions from the middle ear space and
for equalizing pressure.
● Frontline defense against the passage and colonization of otopathogens from the
nasopharynx.
● INFANTS: shorter, wider, more floppy and more horizontal which facilitates
transmission of pathogens from nasopharynx to the middle ear and increases the risk of
OM. Frequent Supine positioning of infants may also enhance infection risk.
● Consists of 2 cell types:
○ Ciliated respiratory epithelial cells- produce antimicrobial proteins
○ Goblet cells- produce mucoid and serous mucus.
IMMUNOLOGY
● Innate immunity
○ Frontline responders; physical barriers
○ Mucociliary flow of mucus, lysozymes, cytokines, chemokines,, defensins and
complement factors.
● Adaptive immunity
○ Mucosal and systemic immune responses
○ IgA, IgG, mannose- binding lectin (only present in children with chronic recurrent
OM)
BACTERIAL COLONIZATION AND BIOFILMS
● S. pneumoniae, H. influenzae, M. catarrhalis
● S. pneumoniae is the most common, however, with the advent of vaccine, the
prevalence of H. influenzae and M. catarrhalis increased.
● Bacterial biofilms
○ Communities of interacting bacteria encased in a protective matrix of
exopolysaccharides and adherent to a surface.
○ Protects bacteria against the host’s immune response which renders them
resistant
○ Present in patients with persistent OME, CSOM, and cholesteatoma.
VIRUSES
 ● Predisposing viruses include RSV, rhinovirus, adenovirus, coronavirus, bocavirus,
influenza virus, parainfluenza virus, enterovirus, and human metapneumovirus, all of
which causes common cold or viral URTI.

GENETICS
● The heritability of AOM and OME vary from 40-70%, with boys slightly higher than girls.
● It may be due to pathogen-specific cytokine polymorphisms
○ IL-6, IL-10 and TNF polymorphisms- RSV and rhinovirus infection
○ TLR signaling polymorphisms
ALLERGY
● There is still debate on the role of allergy in the pathogenesis of OM.
● Atopic conditions, such as allergic rhinitis, are common among children with OM.
GERD
● GERD has been reported in half of children with persistent OME and 2 in 3 in those with
recurrent AOM.
● Pepsin/pepsinogen has been detected in the middle ear fluid of children with persistent
and/or recurrent OM.
● However, most studies were uncontrolled, and the pH level required to activate pepsin
and for occurrence of mucosal damage is unknown.

VI. PREVENTION
● Strategies on prevention mainly focus on reducing the modifiable risk factors such as
environmental risks and viral and bacterial infections.
● Modification of Environmental Risk Factors:
○ Breastfeeding protects against OM for the first 2 years of life (especially in
children who are exclusively breastfed)
○ Current guidance recommendation:
■ exclusive breastfeeding for at least 6 months
■ avoidance of tobacco smoke exposure
■ discussion of lifestyle changes such as reducing pacifier use and altering
child care arrangements so that the child is exposed to fewer children
● Vaccines directed against Bacterial Otopathogens - aims to reduce or eliminate
nasopharyngeal colonization of S. pneumoniae, nontypeable H. influenzae, and M.
catarrhalis
○ S. Pneumoniae Vaccine
■ PCV 7
● serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F
● recommended for use in children younger than 6 years of age
○ Given at 2, 4, and 6 months, and booster at 12 to 15
months
● Reduction of 6-7% overall AOM episodes, 20% in tympanostomy
tube insertions for chronic recurrent OM
■ PCV 13
● 6 additional serotypes: 1,3,5,6A,7F, and 19A
● associated with a further reduction of AOM, mastoiditis, and
tympanostomy tube insertions
■ PCV 11 - Showed overall reduction in all causes of AOM
■ Pneumococcal serotypes targeted by the vaccine in young children
results in a reduction of subsequent and more complex disease caused
by non-vaccine serotypes and nontypeable H. influenzae
● Vaccines directed against Respiratory Viruses
○ Influenzae vaccine
 ■ To prevent URTI - may result in AOM in young children
● Administration of influenza vaccine demonstrated efficacy in the
prevention of influenza assoc AOM by 67%
■ 2 types of vaccine available:
● Trivalent inactivated vaccine - given intramuscularly to patients
aged 6 months and older
○ In the Philippines, given as 2 doses with an interval of 4
weeks if receiving the vaccine for the 1st time, then
annually thereafter.
● Live attenuated influenza vaccine - given intranasally for healthy
persons 2 through 49 years of age
● Both TIV and LAIV have been associated with reductions in AOM
during the influenza seasons

VII. TREATMENT
MEDICAL TREATMENT
● PARACETAMOL (10-15 mg/Kg/dose) AND IBUPROFEN (5-10mg/Kg/dose)
○ mainstay of treatment that can provide analgesia for mild to moderate pain
INDICATIONS FOR ANTIBACTERIAL TREATMENT VERSUS OBSERVATION IN
CHILDREN WITH UNCOMPLICATED AOM

Age Moderate or Severe AOM Mild AOM

< 6 months Antibacterial Antibacterial

Treatment Treatment

6 months to 2 Antibacterial Antibacterial treatment

years Treatment in bilateral AOM
Observation in unilateral AOM

≥ 2 years Antibacterial Observation

Treatment

● AMOXICILLIN (80-90 mg/Kg/day in 2 divided doses)

○ recommended as first line therapy among most patients with mild AOM
■ Favorable pharmacologic profile against drug-resistant pneumococcI
■ proven efficacy
■ safety profile
■ narrow spectrum of activity
■ low cost

● AMOXICILLIN AND CLAVULANIC ACID (90mg/Kg/ day amoxicillin plus 6.4mg/Kg/day

of clavulanic acid)
○ recommended as a first line treatment for severe AOM or when a child’s
symptoms worsen or fail to respond to initial amoxicillin treatment
 ALTERNATIVE DRUGS TO AMOXICILLIN FOR ALLERGIC PATIENTS

Type I Hypersensitivity Reaction* Non-Type I Hypersensitivity Reaction**

Azithromycin (10 mg/Kg/day once daily on Day 1,
followed by 5 mg/Kg/day
on day 2-5)
Clarithromycin (15 mg/Kg/day in 2 divided doses
for 10 days)
Erythromycin (30-50 mg/Kg/day in 3 divided
doses)
Sulfamethoxazole-Trimethoprim (6-12 mg/Kg/day
trimethoprim in 2 divided doses)
***Cefdinir (14 mg/Kg/day in 1 or 2 doses)
Cefpodoxime (10 mg/Kg/day once daily)
Cefuroxime (30 mg/Kg/day in 2 divided
doses)
Cefixime (8 mg/Kg/day once a day or in 2 divided
doses)

● Antimicrobial treatment for 10-14 days continues to be the current clinical practice for
AOM.

ANTIBIOTIC TREATMENT AFTER 48-72H OF FAILURE OF INITIAL ANTIBIOTIC TREATMENT

FIRST-LINE TREATMENT ALTERNATIVE TREATMENT

Amoxicillin-Clavulanate (90mg/Kg/day Ceftriaxone, 3 days

amoxicillin with 6.4 mg/Kg/day clavulanate in 2 Clindamycin (30-40 mg/Kg/day in 3 divided
divided doses) doses) w/ or w/o third-generation
cephalosporin

Ceftriaxone (50 mg/Kg IM or IV once a day Clindamycin (30-40 mg/Kg/day in 3 divided

for 3 days) doses) plus third generation cephalosporin

Tympanocentesis or Myringotomy

Specialist consultation
SURGICAL MANAGEMENT
A. Myringotomy
● Myringotomy without tube insertion has been shown to be ineffective for long-term
management and is not recommended for OME.
B. Myringotomy With Tympanostomy Tube Insertion
● Tympanostomy tubes alleviate conductive hearing loss by allowing fluid to drain from the
middle ear
● In children with persistent MEE, the decision of whether to insert tympanostomy tubes is
based on the child’s hearing status and risk for developmental problems

Tympanostomy tubes are considered:

● in children with OME with documented hearing difficulties after 3 months
● those who are at particular risk for, or who already have, speech and language or
learning disabilities
Risk Factors for Developmental Problems in Children With Otitis Media With
Effusion

● Permanent hearing loss independent of OME

● Suspected or confirmed speech and language delays
● Autism-spectrum disorder and other pervasive developmental disorders
● Syndromes (e.g., Down syndrome) or craniofacial disorders that include
cognitive, speech or language delays
● Cleft palate, with or without associated syndrome
● Blindness or uncorrectable visual impairment
● Developmental delay
Tympanostomy Tube Insertion
Procedure
1. Removal of cerumen and debris
● entire TM should be inspected to rule out any abnormalities
2. Myringotomy incision is performed in the anterior-inferior quadrant of the pars tensa
3. Radial incision
● small enough to prevent premature tube extrusion but large enough that
the tube can be easily inserted using an alligator forceps
Types of Tympanostomy Tubes and Indications
● In most children, a grommet-type tube is preferable.
● T-tubes or long-term tubes are used in older children who have:
■ an atrophic TM or who have had multiple sets of tympanostomy tubes
due to comorbidities
Postsurgical Follow-up
● within 2 to 3 months after the surgery
● evaluated 6 to 12 months after the insertion of the tubes and every 6 months thereafter,
or when problems occur

VIII. COMPLICATIONS AND SEQUELAE

I. Acute Tympanostomy Tube Otorrhea
● 25% to 75% of children develop one or more episodes of acute otorrhea
● middle ear infection with middle ear fluid draining through the tube into the external
auditory canal
Risk factors
● young age
 ● rAOM- as the prime indication for tube insertion
● recent history of recurrent URTIs,
● and the presence of older siblings
Management involves prevention of immediate postoperative otorrhea episodes and treatment
of subsequent episodes

Prevention of Otorrhea Episodes Occurring in the Immediate Postoperative Period

These include:
● multiple saline washouts of the middle ear
● single application of antibiotic-corticosteroid ear drops during surgery
● Prolonged use of topical or oral antibiotics with or without corticosteroids during the early
postoperative period
● application of 6% ciprofloxacin otic suspension in the middle ear during tube insertion

Treatment of Otorrhea Episodes Occurring Outside the Immediate Postoperative Period.

● ototopical antibiotic drops as the first-line treatment for this condition
● quinolone ear drops are the treatment of choice
● If the otorrhea does not resolve in 2 weeks, recommended that a culture specimen from
the opening of the tube is obtained
● If yeast is the predominant organism treatment with a topical antifungal drop
(clotrimazole)
● In case of persistent or frequently recurring otorrhea, removal of the tubes should be
considered
II. Tympanosclerosis, Atrophy, and Retraction Pockets
32% rate of tympanosclerosis
25% rate of focal atrophy
3.1% rate of retraction pockets
III. Persistent Perforation
● 4.8% Incidence
● usually are small and consequently associated with mild hearing loss.
● Persistent perforations can be surgically managed by myringoplasty or conventional
fascia or perichondrium myringoplasty
IV. Cholesteatoma
● uncertain whether cholesteatoma is caused by the underlying middle ear pathology or by
the tympanostomy tubes
may result from ingrowth or transplantation of keratinized epithelium into the
middle ear cleft or Surgical manipulation of the TM
V. Early Extrusion
● occurs in approximately 3.9% of ears
● potentially related to infection in the middle ear that pushes the tube into the external ear
canal
● tube may not have been properly inserted
● Atrophy of the TM may also contribute to early tube extrusion
VI. Tube Blockage
● incidence of 6.9%
● become obstructed from dried blood or mucus, granulation tissue or polyps caused by
infections in the middle ear
● The tube sometimes can be unplugged using a pick, suction, a Rosen needle, or
ototopical drops for 10 to 14 days
VII. Tube Displacement Into the Middle Ear
● incidence of displacement is 0.5%
 ● occurs most commonly at the time of surgery
● also occur at a later stage due to infection or trauma
VIII. Retained Tympanostomy Tubes
● usually is not removed surgically, because most tubes extrude spontaneously
● recommend removing tubes that have failed to extrude after 3 years
IX. Water Precautions
● will prevent contamination of the middle ear from water during bathing and swimming
● do not recommend routine water precautions, but advice to parents may be
individualized
C. Adenoidectomy.
● may be performed in children with OME to improve eustachian tube and middle ear
function
● is most beneficial in children aged 4 years and over with OME
Procedure
1. requires general anesthesia
2. curettage, electrocautery, microsurgical debridement, or coblation to remove the midline
adenoid tissue
3. Completed when the choanae are completely opened and the nasopharynx has a
smooth, level contour
D. Eustachian Tube Dilatation
● Balloon dilatation of the eustachian tube has been, but there is currently no evidence
to support this management option

VIII. Complications
COMPLICATIONS AND SEQUELAE OF OTITIS MEDIA
● may be extracranial,( that is, within the temporal bone or neck), or intracranial (within the
cranial cavity).
Intratemporal Complications
1. Hearing Loss and Balance Problems
● mild and transient conductive hearing loss
● Rarely, a permanent sensorineural hearing loss
● Children may have delayed development of motor coordination skills, such as walking,
and may appear to be “clumsy.”
2. Speech-Language and Child Development
● recommend that children with OME undergo hearing testing every 3 to 6 months and be
assessed for tympanostomy tube placement if they are at risk for any developmental
delays in speech, language, or learning
3. Mastoiditis.
● most common suppurative complication of AOM
acute mastoiditis with periosteitis, the infection involves the periosteum overlying the
mastoid process
acute mastoiditis with osteitis with and without subperiosteal abscess, the infection can
cause destruction of the mastoid cells, leading to “coalescence” of the cells and present
as a subperiosteal abscess
● The diagnosis is made by physical examination and imaging studies
Early-stage symptoms of mastoid infection
-erythema and tenderness over the mastoid area and then to edema or a
subperiosteal abscess with anterior-inferior displacement of the pinna and
obliteration of the postauricular crease
The CT scan in the early stage most frequently shows opacified mastoid air cells;
 - the inflammatory process may progress and develop into osteitis, with destruction
of the mastoid bone
Mastoiditis with and without periosteitis often responds to antibiotic treatment
with tympanocentesis or tympanostomy tube insertion,
Mastoiditis with osteitis and bone destruction usually requires cortical
mastoidectomy and tympanostomy tube placement.

Intracranial Complications
1. Meningitis
● Hematogenous spread is the most common route of spread of infection
● from direct extension through a preformed pathway or retrograde thrombophlebitis

Treated with high doses of broad-spectrum antibiotics, with adjustment of the dose
according to cerebrospinal fluid (CSF) culture results
Urgent tympanocentesis or tympanostomy tube insertion is indicated
Cortical mastoidectomy & tympanoplasty with mastoidectomy may be necessary once
the patient is stabilized.

2. Epidural Abscess
● from bony destruction from cholesteatoma or infection with an accumulation of
granulation tissue and purulent material adjacent to the dura.

Treatment consists of broadspectrum antibiotics and possible surgical drainage

3. Subdural Empyema
● accumulation of purulent material between the dura and the arachnoid membrane

Treatment consists of broadspectrum antibiotics and possible surgical drainage

4. Brain Abscess
● develop directly from an acute or chronic middle ear infection or from the development of
an adjacent infection
● The diagnosis is based on the presence of clinical signs and symptoms and on CT and
MRI findings

Treatment includes broadspectrum antimicrobial agents and surgical treatment

5. Lateral Sinus Thrombosis

● Lateral and sigmoid sinus thrombophlebitis arises from an adjacent mastoid infection in
contact with the sinus wall through inflammation of the adventitia and is followed by
penetration of the venous wall
● thrombus is formed after the infection
● may become infected and may occlude the lumen

Treatment includes parenteral broad-spectrum antimicrobial agents

Anticoagulants are recommended by some experts, but consensus is lacking.

Surgical treatment :
tympanostomy tube insertion alone or with tympanoplasty and mastoidectomy.