Diagnosis and Management of Otitis Media in Primary Care

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Diagnosis and Management of Otitis Media in
Primary Care

• Elizabeth A Harvey
• GPR
• Ardblair Medical Practice
• Blairgowrie

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Anatomy of the Ear
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Normal Ear
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Acute Otitis Media

• Inflammation of the middle ear of rapid onset
  presenting most often with local symptoms
  (commonly earache and rubbing or tugging of the
  infected ear) and systemic signs (such as fever,
  irritability and poor sleep).
• There may be a preceding history of upper
  respiratory symptoms including cough and
  rhinorrhoea.

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Facts and Figures

• Cause of great morbidity in children
• 75 of all cases of acute otitis media occur in
  children under the age of 10 years
• 25 of children will have at least one episode of
  acute otitis media before their 10th birthday
• Peak incidence of diagnosis between ages of 3 and
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• Streptococcus pneumoniae, Haemphilius influenzae
  and Moraxella catarrhalis most common bacterial
  causes

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Risk Factors

• Young age
• Attendance at nursery or school
• Caucasian
• Male sex
• History of enlarged adenoids, tonsils
• History of asthma
• Multiple previous episodes
• Bottle feeding
• History in parents or siblings

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Diagnosis

• Acute Otitis Media
• Earache
• Fever
• Irritability
• Middle ear effusion
• Opaque drum
• Possible bulging drum
• Impaired drum mobility
• Hearing loss

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Complications of Acute Otitis Media

• Mastoiditis
• Labyrinthitis
• Facial Palsy
• Meningitis
• WHO estimates that each year 51,000 children
  under age of 5 years die from complications in
  developing countries

• Subdural abscess
• Extradural abscess
• Brain abscess
• Petrositis

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Management

• In the majority of cases, acute otitis media is
  self limiting
• However, studies have shown on average 97
  receive antibiotics

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Antibiotic Usage

• Some studies suggest that antibiotics reduce
• the time to cessation of fever by 24 hours
• the time to cessation of pain or crying by 24
  hours

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However

• Acute otitis media has a favourable natural
  history regardless of antibiotic use
• A meta-analysis of studies conducted concluded
  that the overall rate of spontaneous resolution
  of acute otitis media was 81 percent
• Side effects of antibiotics not to be forgotten
• Most commonly Gastrointestinal upset rash

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Acute Otitis Media- SIGN

• Children diagnosed with acute otitis media should
  not routinely be prescribed antibiotics as the
  initial treatment
• If an antibiotic is to be prescribed, a 5 day
  course is recommended at dosage levels indicated
  by the BNF
• Children with acute otitis media media should not
  be prescribed decongestants or antihistamines
• Parents should give paracetamol for reducing pain
  in children with acute otitis media

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Referral for Acute Otitis Media

• Children with frequent episodes (more than four
  in six months) of acute otitis media, should be
  referred to ENT

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Otitis Media with Effusion

• Inflammation of the middle ear, accompanied by
  the accumulation of fluid in the middle ear cleft
  without the signs and symptoms of acute
  inflammation. OME is often asymptomatic, and
  earache is relatively uncommon

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Facts and Figures

• Otitis media with effusion glue ear is also
  prevalent
• About 80 of children are reported to have otitis
  media with effusion before the age of 4 years
• Otitis media with effusion has important
  implications for child development

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Diagnosis

• Otitis media with effusion
• No earache
• No fever
• No irritability
• Middle ear effusion
• Not always opaque drum
• Not usually a bulging drum
• Impaired drum mobility
• Usually hearing loss

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Management

• Children with otitis media with effusion should
  not be treated with antibiotics
• Decongestants, antihistamines and mucolytics
  should not be used in the management of OME
• The use of topical or systemic steroid therapy is
  not recommended
• Autoinflation may be of benefit in the management
  of some children

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Autoinflation

• Process by which the Eustachian tube is forced
  open to allow drainage of fluid from the middle
  ear

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Using Autoinflation
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How does Autoinflation Work?

• Aim of nasal balloon is to drain fluid from
  middle ear
• Once the child stops blowing up the balloon and
  breathes normally, the air rushes back up child's
  nostril into the eustachian tube
• The air pressure from the deflating balloon
  forces open the eustachian tube, clearing the
  blockage, allowing fluid to drain down throat
• Eardrum becomes free of fluid, therefore the
  ossicles move easily again, hearing improves

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Otovent Kit
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Autoinflation
Prior to Treatment
Post Treatment
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Referral of Otitis Media with Effusion

• Children with persistent bilateral otitis media
  with effusion who are over three years of age or
  who have speech and language, developmental or
  behavioural problems should be referred to ENT

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Referral of Otitis Media with Effusion

• Children under three years of age with persistent
  bilateral otitis media with effusion and hearing
  loss of 25dB, but no speech and language,
  developmental or behavioural problems, can be
  safely managed by watchful waiting
• If watchful waiting is being considered, child
  should undergo audiometry to exclude a more
  serious form of hearing loss

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Whilst Waiting for Specialist Opinion

• Discourage passive smoking
• Encourage drinking from a cup not a bottle
• Sit at childs level and keep instructions short
  and simple
• Reduce background noise whilst talking to the
  child
• Inform school teachers which ear hears best

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Surgical Management of OME

• Usually by insertion of a Grommet

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Questions