Otitis Media: Clinical Practice Guidelines and Current Management

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Otitis Media Clinical Practice Guidelines and
Current Management

• Tamekia L. Wakefield, MD
• Pediatric Otolaryngologist
• ENT Allergy Associates, LLP

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Disclosures

• Tamekia Wakefield, MD is a member of the speakers
  bureau for Alcon. The makers of Ciprodex otic.

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Otitis Media

• 4 billion in combined direct and indirect cost
  annually
• 2.2 million episodes diagnosed annually
• Most common reason for visit to pediatrician
• Tympanostomy tube placement is 2nd most common
  surgical procedure in children

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Definitions

• OME the presence of fluid in the middle ear
  without acute signs or symptoms
• AOM the presence of fluid in the middle ear
  with the acute onset of signs and symptoms of
  middle ear inflammation.

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Microbiology/Virology

• S. pneumoniae - 30-35
• H. influenzae - 20-25
• M. catarrhalis - 10-15
• Group A strep - 2-4
• Infants with higher incidence of gram negative
  bacilli
• RSV - 74 of middle ear isolates
• Rhinovirus
• Parainfluenza virus
• Influenza virus

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aom

• Risk factors
• Daycare
• Tobacco smoke exposure
• Inverse relationship between length of
  breastfeeding and number of AOM episodes

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Acute otitis media

• Clinical Indicators Myringotomy and Tubes
• Severe acute otitis media (myringotomy)
• Poor response (describe) to antibiotic for otitis
  media (myringotomy or tube)
• Impending mastoiditis or intra-cranial
  complication due to otitis media (myringotomy)
• Recurrent episodes of acute otitis media (more
  than 3 episodes in 6 months or more than 4
  episodes in 12 months) (tympanostomy tube)

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OME Etiology

• Eustachian tube dysfunction
• Post-AOM

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Natural history

• Most episodes resolve spontaneously within 3
  months
• 30-40 Recurrent OME
• 5-10 Persistent OME gt 1 year

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Why do we need CPG?

• High prevalence of OME
• Difficulties in diagnosis and assessing duration
• Increased risk of CHL
• Potential impact on language and cognition
• Significant practice variations in management

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Diagnosis

• Clinicians should use pneumatic otoscopy as the
  primary diagnostic method for OME. OME should be
  distinguished from AOM. Strong recommendation
• Pneumatic otoscopy is gold standard
• Color
• Position
• Mobility
• Tympanic membrane appearance
• Sensitivity of 94 and specificity of 80 versus
  myringotomy
• Readily available, cost effective and accurate in
  experienced hands

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diagnosis

• Tympanometry can be used to confirm diagnosis.
  Option
• When diagnosis is uncertain, consider
  tympanometry
• Cost associated with equipment
• Painless
• Reliable for ages 4 months or older

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Screening

• Population-based screening programs for OME are
  not recommended in healthy, asymptomatic
  children. Recommendation Against
• Highly prevalent in young children. 15-40 point
  prevalence in healthy children under 5 yr
• No influence on short-term language outcomes
• No benefit from treatment that exceeds the
  favorable natural history of the disease
• Risk of inaccurate diagnoses, overtreatment,
  parental anxiety, and increased cost

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Documentation

• Clinicians should document the laterality,
  duration of effusion, and presence and severity
  of associated symptoms at each assessment of the
  child with OME. Recommendation
• Medical decision making depends on these features
• 40-50 of OME cases no symptoms
• Preponderance of benefit over harm

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At risk child

• Clinicians should distinguish the child with OME
  who is at risk for speech, language, or learning
  problems from other children with OME, and should
  more promptly evaluate hearing, speech, language,
  and need for intervention. Recommendation
• Permanent hearing loss
• Speech and language delay or disorder
• Autism-spectrum disorder/PDD
• Syndromes with cognitive, speech, and language
  delays
• Blindness
• Cleft Palate
• Developmental delay

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Watchful waiting

• Clinicians should manage the child with OME who
  is not at risk with watchful waiting for 3 months
  from the date effusion onset (if known) or from
  the date of diagnosis (if onset is unknown).
  Recommendation
• OME is usually self-limited
• 75-90 of OME after AOM resolves spontaneously
  by 3 months
• Waiting results in little harm to child
• Optimize listening and learning environment until
  effusion resolves

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Medication

• Antihistamines and decongestants are ineffective
  for OME and are not recommended for treatment.
  Antimicrobials and corticosteroids do no have
  long-term efficacy and are not recommended for
  routine management. Recommendation Against
• Short-term, small magnitude benefits
• Significant adverse effects

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Hearing and language

• Hearing testing is recommended when OME persists
  for 3 months or longer, or at any time that
  language delay, learning problems, or a
  significant hearing loss is suspected in a child
  with OME. Language testing should be conducted
  for children with hearing loss. Recommendation

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Hearing and language

• HL may impair early language acquisition
• Extended periods of CHL may result in
  developmental and academic sequelae
• Early language delays are associated with later
  delays in reading and writing.

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Surveillance

• Children with persistent OME who are not at risk
  should be reexamined at 3- to 6-month intervals
  until the effusion is no longer present,
  significant hearing loss is identified, or
  structural abnormalities of the TM or middle ear
  are suspected. Recommendation
• Resolution rates decrease the longer the effusion
  has been present
• Risk factors for non-resolution
• Summer or fall onset
• HLgt30dB
• H/O prior tympanostomy tubes
• Not having had an adenoidectomy

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referral

• When children with OME are referred by the
  primary care clinician for evaluation by an
  otolaryngologist, audiologist, or speech-language
  pathologist, the referring clinician should
  document the effusion duration and specific
  reason for referral (evaluation vs. surgery), and
  provide additional relevant information such as
  history of AOM and developmental status of the
  child. Option

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Surgery

• When a child becomes a surgical candidate,
  tympanostomy tube insertion is the preferred
  initial procedure adenoidectomy should not be
  performed unless a distinct indication exists
  (nasal obstruction, chronic adenoiditis). Repeat
  surgery consists of adenoidectomy plus
  myringotomy, with or without tube insertion.
  Tonsillectomy alone or myringotomy alone should
  not be used to treat OME. Recommendation

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surgery

• OME gt 4 months with persistent hearing loss
• Recurrent or persistent OME in at risk child
• OME with structural damage to TM or ME

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• Alternative Medicine
• No recommendation
• Limited evidence
• Few studies
• Medications are unregulated

• Allergy Management
• No recommendation
• Few studies

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Consequences

• Inappropriate antibiotic treatment of OM
• Multidrug-resistant strains
• Drug side effects
• Parental/caregiver confusion

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Biofilms

• Communities of sessile bacteria embedded in a
  matrix of extracellular polymeric substances of
  their own synthesis that adhere to a foreign body
  or a mucosal surface
• Chronic ear infections or persistent effusion in
  the middle ear are biofilm related

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Biofilms

• Unable to culture with traditional methods
• Traditional antibiotics are relatively
  ineffective for eradicating biofilm infection
• Higher doses of antibiotics required to treat
• Macrolides (clarithromycin/erythromycin)
• Physical disruption is beneficial
• Non-antibiotic therapies may be more successful

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Acute otitis media with tubes

• Diagnosis
• Acute purulent otorrhea1
• Commonly occurs after insertion of tympanostomy
  tubes
• Risk Factor
• Occurs more frequently in children with upper
  respiratory infections2,3

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AOMT

• Ototopical antibiotics are appropriate therapy
  in uncomplicated cases
• Fluoroquinolones
• Adjunctive systemic antibiotics may be used
• When infection has spread beyond middle ear or
  external ear canal
• With lack of adherence to ototopical therapy
• When ototopical treatment fails (after 7-10 days)
• In children with associated streptococcal
  pharyngitis
• Special populations (e.g. immunocompromised
  patients) require additional consideration

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Conclusion

• High prevalence
• Accurate diagnosis
• At risk children
• Hearing loss
• Speech and language assessment
• Antibiotic use
• Surgery
• Referral