Otitis Media To Treat or Not to Treat

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Otitis MediaTo Treat or Not to Treat

• Cheryl Pollock PGY2
• 21 January 2003

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Outline

• Introduction
• Definition
• Pathophysiology
• Symptoms and Signs
• Diagnosis
• Treatment
• Prevention
• Pneumococcal vaccination
• Tympanostomy tubes

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Introduction

• Otitis media (AOM) is a middle ear infection
• Most commonly occurs in children
• Symptoms are neither sensitive nor specific
• Acute otitis media is overdiagnosed

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Definition

• Acute otitis media (AOM)
• Presence of symptoms of acute illness and signs
  of TM under positive pressure (full or bulging)
• Otitis media with effusion (OME)
• Effusion persists for several weeks post-AOM
• No acute infection, maybe reduced hearing
• Signs of TM under negative or no pressure
  (retracted or neutral position) and fluid in
  middle ear space

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Definition

• Recurrent otitis media (ROM)
• Three episodes of AOM within six months or four
  or more episodes in a year
• Chronic supparative otitis media (CSOM)
• a.k.a. chronic OME
• Continuing inflammation in the middle ear causing
  otorrhea and a perforated TM

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Epidemiology

• Very common
• Canada
• 1.8 million MD visits epr year for AOM
• USA
• 50-60 of children have one episode of AOM by age
  1 year
• 25 MD visits in first three years of life
• WHO
• 51 000 children lt5 years die from OM annually in
  developing nations

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Pathophysiology

• Complication of preceding viral URTI
• Secretions and inflammation cause relative
  occlusion of eustachian tube
• Generates negative pressure and leads to serous
  effusion
• Effusion provides media for microbial growth
• With URTI, introduction of the upper airway
  viruses and/or bacteria into the middle ear

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Etiology of AOM

• Anatomic and immunologic factors in the presence
  of acute infectious states
• Lower angle of the eustachian tube in relation to
  nasopharynx
• Lack of pneumococcal antibodies
• Most common agents
• Streptococcus pneumoniae (30-55)
• Haemophilus influenzae (12-30)
• Moraxella catarrhalis (4-15)
• Less common
• Mycoplasma, viruses

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Risk Factors

• Age
• Daycare
• Bottle-feeding
• Second-hand smoke
• Race
• Sex
• Family history of middle ear disease
• Patient history of allergies or asthma
• Immunosupression

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Symptoms of AOM

• Ear-related
• Earache, tugging, sensation of fullness
• Fever
• Current or preceding URTI symptoms
• Cough, rhinorrhea
• Decreased hearing
• Fever, earache, crying, and irritability present
  in 90 with AOM, and 72 without AOM.
• No difference in duration

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Symptoms

• AOM in infants
• May be asymptomatic
• May present only with irritability
• Otitis media with effusion
• Usually asymptomatic
• Decreased hearing (can be demonstrated on
  audiometry)

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Signs of AOM

• Problems
• Uncooperative patient
• Cerumen blockage of the auditory canal
• Hallmarks of AOM
• Bulging, opaque, immobile TM 99 PV
• Red TM with normal position and mobility 7
• AOM with perforation
• Suspicious history and auditory canal full of
  purulent exudate

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Other Factors to Consider

• Coexistent conjunctivitis
• Acute hearing loss
• Tympanosclerosis
• Erythema caused by crying
• Referred pain from teeth or jaw
• Parotitis (e.g. mumps)

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Differential Diagnosis

• Otitis externa
• Sinusitis
• Peritonsillar abscess
• Mastoiditis
• Ear foreign bodies
• Labyrinthitis
• Herpes zoster
• Brain abscess

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Improving Diagnostic Accuracy

• Otoscopy
• Tympanometry
• Tympanocentesis

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Otoscopy

• Four characteristics of TM
• Position, mobility, colour, translucency
• Normal neutral position, pearly gray,
  translucent, and briskly responding to positive
  and negative pressure
• Pneumatic otoscopy
• Cuffed ear speculums for insufflation
• Pitfalls
• Light source
• Cerumen
• cooperation

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Tympanometry

• Information about actual pressure in middle ear
  space
• Portable models
• In a difficult examination, normal tympanometry
  can support absence of AOM
• Overall, not commonly used in family medicine
  setting

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Tympanocentesis

• The gold standard for the diagnosis of AOM in
  clinical trials
• Determines the presence of middle ear fluid, with
  subsequent culture for identification of
  causative pathogens
• Pitfalls
• Cost, effort, availability- ENT consult
• No consensus guidelines for routine use in AOM
• In refractory or recurrent middle ear disease, it
  can improve accuracy of diagnosis and guide
  treatment

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Other Diagnostic Aides

• Lab studies
• No role for routine CBC or blood cultures
• Imaging studies
• No role in diagnosis of AOM

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Treatment

• Parental Education
• Role of antibiotics
• Need for compliance and follow-up
• No resolution of symptoms in 48 hours requires
  reevaluation
• Analgesia
• NSAIDs and acetaminophen equally effective
• Antibiotics

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Impact of Antibiotics on Outcome

• AOM has a favourable natural history regardless
  of antibiotic use
• Three systematic reviews
• Spontaneous resolution in 81 cases AOM
• Antibiotics reduce both the proportion of kids in
  pain at 2-7 days and risk of contralateral AOM
• Antibiotics have no effect on pain within 24h,
  and no effect on incidence of AOM or deafness at
  one month

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Impact of Antibiotics on Outcome

• No evidence that antibiotics improve outcomes in
  children aged under 2 years with uncomplicated
  AOM
• One systematic review and one subsequent RCT

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Impact of Antibiotics on Outcome

• Proposed non-treatment of AOM
• Two day delay in treatment to see if symptoms
  resolve spontaneously
• However, these approaches may be flawed because
  the data on which they are based does not reflect
  the current era of bacterial resistance

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Impact of Antibiotics

• Canadian Paediatrics Society states that because
  it is not possible to predict which cases of AOM
  will result in supparative complications (e.g.
  mastoiditis), all cases of AOM should be
  considered for antimicrobial therapy

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Principles of Antibiotic Use

• Empiric coverage for common pathogens
• S. pneumoniae, H. influenzae, M. catarrhalis
• Amoxicillin still drug of choice
• Antibiotic resistance
• Geographic factors
• Patient factors
• Patient compliance
• Less frequent dosing
• Shorter courses (5 days vs. 10 days) with higher
  doses (amoxicillin 80 mg/kg/day) now endorsed by
  CDC

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Antibiotic Resistance

• Geographic factors
• Not yet an issue in NF
• In Toronto, 17 of S. pneumoniae isolates from
  daycare were penicillin resistant
• In USA 30-60 of S. pneumoniae strains have
  reduced susceptibility to amoxicillin
• Patient factors
• Recent antibiotic treatment of AOM
• Daycare
• Wintertime infections
• AOM in children lt2 years of age

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Empiric Antibiotic SelectionWithout
Tympanocentesis

• Drug efficacy
• Safety
• All antibiotics indicated for AOM generally very
  safe
• Compliance potential
• Palatability
• Less frequent dosing, shorter course
• Cost

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Antibiotic Selection for AOM

• First-line
• Amoxicillin 40 mg/kg/day divided t.i.d. x 10 d
  (recommended by the Can. Paediatric Society)
• Amoxicillin 80 mg/kg/day divided t.i.d. x 5 d

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Antibiotic Selection for AOM

• Second-line
• If penicillin allergy
• TMP/SMX 8 mg/kg/day of TMP div b.i.d. x 10 d
• erythromycin/sulfisoxazole 40mg/kg/day div qid 10
  d
• Clarithromycin 15 mg/kg/day div b.i.d. x 10 d
• Azithromycin 10 mg/kg once daily x 5 d
• Amoxicillin/clavulanate 40 mg/kg/day of
  amoxicillin divided t.i.d. x 10 d
• Ceftriaxone

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Complications

• OM with effusion
• Most common complication
• Mild discomfort
• if bilateral, significant hearing loss and speech
  delay
• Mastoiditis
• Very rare due to antibiotic treatment
• Mastoid tenderness plus edema plus AOM treat
  aggressively in consult with ENT

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Complications

• TM perforation
• Frequent, not usually serious
• Most heal in a few weeks
• Follow-up essential
• Intracranial complications
• e.g. epidural abscess, cavernous sinus thrombosis
  exceedingly rare
• Usually present primarily rather than as a late
  complication of a treated AOM

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Prevention of AOM

• Long term antibiotic prophylaxis
• Xylitol syrup or gum
• Pneumococcal conjugate vaccine

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Long Term Antibiotic Prophylaxis

• One systematic review found that it does have an
  effect in preventing recurrence of AOM
• 1993, 33 RCTs
• ARR 11, 95 CI 3-19
• No significant difference between antibiotics
• One RCT (1997) found no significant difference
  between antibiotic prophylaxis and placebo

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Xylitol Syrup or Gum

• Limited evidence from one RCT (1998) that xylitol
  syrup or gum taken five times per day may reduce
  incidence of AOM
• No evidence for optimum duration
• Abdominal discomfort
• No information on long term effects of xylitol

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Pneumococcal Vaccine

• S. pneumoniae causes a wide spectrum of disease
• URTI to invasive diseases such as meningitis and
  bacteremia
• 30-55 of AOM caused by S. pneumoniae
• Role of vaccination in preventing AOM and more
  invasive disease

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Pneumococcal Vaccine

• PCV7 Heptavalent pneumococcal polysaccharide-prot
  ein conjugate vaccine
• Licensed in Canada and USA for use in children lt2
  years
• The 7 valances account for 87 of S. pneumoniae
  isolates identified in Canadian children aged
  6-23 months who had invasive disease, and 65 of
  isolates in children lt6 months

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Pneumococcal Vaccine

• In Canada, the National Advisory Committee on
  Immunization has recommended that the new vaccine
  be administered to all children younger than two
  years, and to high-risk children aged 24-59
  months for prevention of invasive pneumococcal
  disease
• Canadian Communicable Disease Report 200228ACS-2

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Pneumococcal Vaccine

• The Finnish Otitis Media Vaccine Trial
• Eskola et al. Efficacy of a pneumococcal
  conjugate vaccine against acute otitis media.
• New England Journal of Medicine 2001 344403-9

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Finnish Otitis Media Vaccine Trial

• Prospective randomized, double-blind trial of the
  efficacyof the heptavalent conjugated
  pneumococcal vaccine (PCV7)
• Lasted three years
• 1662 infants randomized at two months to receive
  either the pneumococcal vaccine or the hepatitis
  B vaccine at 2, 4, 6, and 12 months

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Finnish Otitis Media Vaccine Trial Conclusions

• Administration of heptavalent pneumococcal
  vaccine did not significantly reduce the overall
  risk of AOM by all causes
• It did reduce pneumococcal episodes by 34
• the number of episodes caused by the serotypes
  contained in the vaccine were reduced by 57
• The number of episodes due to all other serotypes
  increased by 33
• Vaccine appears to be safe
• Relatively low incidence of local side effects

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Finnish Otitis Media Vaccine Trial Conclusions

• About 1800 children need to be vaccinated per
  year to prevent one case of invasive disease
• Cost 400 for a series of four vaccinations

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Cochrane Review

• 2002
• Assess the effect of pneumococcal vaccination in
  preventing AOM in children up to 12 years of age
• Two arms PPV and PCV
• Ten RCTs fit inclusion criteria
• Only two relate to the heptavalent pneumococcal
  conjugate vaccine (PCV7)

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Cochrane Review Conclusions

• Effects of PPV and PCV on prevention of AOM are
  minimal
• PPV only prevents 10 AOM episodes, irrespective
  of age
• PCV effective against pneumococcal serotypes
  included in PCV
• AOM episodes due to non-vaccine pneumococcal
  serotypes increased in vaccinated children
• Potential pneumococcal shift

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At the End of the Day

• AOM is over-diagnosed
• Crying, cerumen removal, and fever can all cause
  TM redness in the absence of disease
• The colour of the TM is of lesser importance than
  its position and mobility
• A red TM alone does not indicate a diagnosis of
  AOM

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At the End of the Day

• Amoxicillin is the initial drug of choice
• Canadian Paediatric Society recommends a 10 day
  course dosed by weight
• All cases of AOM should be considered for
  antimicrobial therapy
• Tympanocentesis, culture and sensitivity may be
  indicated in cases not responding to empiric
  treatment

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Ventilation Tubes

• Myringotomy with insertion of tympanostomy tubes
  (TT)
• Most common surgical procedure in children that
  requires GA
• Potential treatment for
• Chronic otitis media with effusion
• And recurrent acute otitis media

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Indications for TT Placement

• Resolution of hearing loss secondary to
  persisting effusions
• Otitis media with effusion gt3 months
• Recurrent AOM
• Chronic retraction of TM
• Barotitis syndrome

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Early Complications of TT

• Persistent otorrhea
• TT blockage
• Early extrusion
• Hearing loss
• Ossicular disruption
• Bleeding

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Late Complications of TT

• Persistent perforation after tube extrusion
• Scarring of the TM
• Granuloma
• Tympanosclerosis
• Cholesteatoma
• Migration of TT into middle ear canal

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Water Precautions in Children with TT

• Debatable
• No universal guidelines exist
• No evidence that unprotected swimming with TT
  increases the risk of otorrhea

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Water Precautions Suggestions

• Surface swimming (above 180cm depth) in fresh
  water and pools is okay without earplugs
• Earplugs when washing hair and bathing
• If soapy water enters ear canal, apply antibiotic
  drops
• Recommend custom made or premanufactured earplugs
  /- bathing cap