261_Acute_otitis_media.pdf

WHAT IS ACUTE OTITIS MEDIA?
Available from : http://www.ahrq.gov/downloads/pub/evidence/pdf/otitis/otitisup.pdf. Accessed on December 6, 2016.
Qureishi A, et al. Update on otitis media – prevention and treatment. Infect Drug Resist. 2014; 7: 15–24.
• Acute Otitis Media (AOM) is a viral
and/or bacterial infection of the middle
ear and represents the most common
childhood infection
• It is usually a complication of eustachian
tube dysfunction which occurs during a
viral upper respiratory tract infection
• It is an acute inflammation, and may be
caused by bacteria or viruses. A particular
subtype of AOM is acute suppurative OM,
which is characterized by the presence of
pus in the middle ear.
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Content developed by Magna Health Solutions for Abbott Healthcare Private Limited. © 2016 Abbott. All rights reserved.

ACUTE OTITIS MEDIA
In otitis media, pressure from the accumulation of fluid in the middle
ear can lead to tearing or rupturing of the tympanic membrane.
Trauma, such as from a blow to the head or from water pressure can
also cause perforations in the membrane. Although tympanic
membrane perforations often are self-healing, a patch or surgery may
be needed to close the tear.
Available from: https://www.britannica.com/science/tympanic-membrane. Accessed on December 8, 2016
Failure of the membrane to heal can
result in varying degrees of hearing
loss and increased susceptibility to
otitis media.
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ACUTE OTITIS MEDIA
S. pneumoniae is the most common bacterial pathogen followed by H.
influenzae and M. catarrhalsis.
Minority of children with otitis and effusion will show bacteria on culture
of middle ear fluids.
Otitis externa is usually due to infection with Pseudomonas aeruginosa,
which is associated with excessive moisture and poor drainage of the
external ear.
Other bacterial pathogens which commonly cause skin infections are
group A streptococci or staphylococci which cause otitis externa
Root RK. Clinical infectious diseases: Upper respiratory tract infections.Oxford university press.;1998, pp.521
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PATHOPHYSIOLOGY
Available at http://www.mayoclinic.org/diseases-conditions/chronic-hives/basics/causes/con-20031634. Accessed on June 10, 2016.
Ascending bacterial
(±viral) infection via
ET
AOM
Viral URTI
Mucociliary defense
Bacterial colonization
Bacterial adhesion
Altered immune response
Nose blowing
Sniffing
Mucus Accumulation:
Medium for bacterial
growth
Secretions and edema
ET dysfunction
Reflux of nasopharynx
microbes into ME
Negative ME pressure
Adenoids: Bacterial
reservoir?
ACO: Acute otitis media, ET : Eustachian tube, ME: Middle ear; URTI: Urinary tract infection
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PATHOPHYSIOLOGY
Upper respiratory tract infections can lead to mucosal congestion in the
eustachian tube and nasopharynx.
This results in congestion which prevents normal eustachian tube
function, and pressure regulation is altered within the middle ear.
If sustained, aspiration of nasopharyngeal pathogens can occur into the
middle ear.
The presence of these pathogens then stimulate inflammation and pus
collection within the middle ear, resulting in clinical symptoms of AOM.
Root RK. Clinical infectious diseases: Upper respiratory tract infections.Oxford university press.;1998, pp.521
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SEVERITY OF INFECTIONS
• The occurrence of AOM peaks in the youngest children, who suffer an
average of six to eight respiratory tract infections per year, and it
decreases rapidly after the age of 2 to 3 years
• Everyday clinical experience clearly indicates that AOM is closely
associated with upper respiratory tract infections
• As a rough estimate across all viral infections, AOM can be
considered to occur in approximately 20% of children with upper
respiratory infection
Available at http://patient.info/doctor/AOM-pro. Accessed on June 10, 2016.
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SEVERITY OF INFECTION
These infections may lead to other causes such as,
•Recurrent ear infections
•Enlarged adenoids
•Enlarged tonsils
•Ruptured eardrum
•Speech delays (in children who have recurrent otitis media infections)
•In rare cases, an infection in the mastoid bone in the skull (mastoiditis)
or an infection in the brain (meningitis) can occur
Godse KV. Chronic Urticaria And Treatment Options. Indian J Dermatol.2009; 54(4):310–312.
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EPIDEMIOLOGY
•Acute Otitis Media (AOM) is the commonest pediatric bacterial infection,
affecting up to 75% of children at some time before age 5 years
•Streptococcus pneumoniae and Haemophilus influenzae, in particular the non-
typable H. influenzae strains (NTHI), are responsible for up to 80% of bacterial
AOM
•It is thought that between 50% and 85% of children experience at least one
episode of AOM by 3 years of age with the peak incidence being between 6 and
15 months
•A recent worldwide systematic review estimated that there are 709 million new
cases of AOM annually, with greater than half in children under 5 years of age
,
. Available from: http://www.topalbertadoctors.org/download/366/AOM_guideline.pdf. Accessed on December 9, 2016
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PREVALENCE OF BIOFILM-PRODUCING ORGANISMS
•Zulani, et al., study revealed the biofilm causing organisms in AOM.
•In children, the mucosal surface of the adenoid was covered in the biofilm in
93.53% of children with recurrent AOM with their age ranging from 3 months to
15 years, where as the rate was as low as 1.01% in children with sleep apnea
•Another study by Moriyama, et al., reported that 84% of the strain of non-
typeable H. influenzae harvested from children with AOM was biofilm-forming
strain.
•The rate of the biofilm-forming strain was higher in drug-sensitive bacteria
than in drug-resistant bacteria
Kania R and Ars B. Biofilms in otitis. Kugler Publications. 2015; pp.294–296.
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PREVALENCE OF BIOFILM-PRODUCING ORGANISMS
•Torretta, et al., examined Biofilm-producing Otopathogens (BPOs) by
nasopharyngeal swab culture using spectrophotometric analysis in 113 children
with non-severe RAOM ( Recurrent Attacks of Acute Otitis Media) and found
that a greater number of bacteria (H. influenzae and Streptococcus pyogenes)
were observed in the culture of children where H. influenzae was also higher in
RAOM patients
•Takei, et al., study pointed out that minimum biofilm eradication of Ampicillin
(AMPC) and cefditoren pivoxil (CDTR-PI) was much higher in biofilm-forming
non-typable H. influenzae strains than in usual H. influenzae , while it was low
in fluoroquinolones and macrolides. Thus, biofilm has been found to play a
considerable role in the pathogenesis and pathophysiological aspects of AOM
Kania R and Ars B. Biofilms in otitis. Kugler Publications. 2015; pp.294–296.
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SIGNS AND SYMPTOMS
•Pulling on the ears
•Headache
•Neck pain
•A feeling of fullness in the ears
•Fluid drainage from the ears
•Fever
•Vomiting
•Diarrhea
•Irritability
•Lack of balance
•Hearing loss
Available from: http://www.healthline.com/health/ear-infection-acute#Symptoms2. Accessed on December 6, 2016.
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INVESTIGATIONS
•Signs of inflammation in the tympanic membrane
•Bulging in the posterior quadrants of the tympanic membrane; scalded
appearance of the superficial epithelial layer
•Perforated tympanic membrane (most frequently in posterior or
inferior quadrants)
•Presence of an opaque serum like exudate oozing through the entire
tympanic membrane
•Pain with/without pulsation of otorrhea
Available from: http://emedicine.medscape.com/article/859316-overview . Accessed on December 5, 2016.
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TREATMENTS STRATEGY
Testing
Culture and sensitivity of a specimen from fresh perforation or
tympanocentesis may be helpful.
Imaging Studies
Radiologic studies are generally unnecessary in uncomplicated AOM.
However, CT scanning may be necessary to determine if complication
has occurred. MRI might be more appropriate for diagnosing suspected
intracranial complications.
Available from: http://emedicine.medscape.com/article/859316-overview Accessed on December 5, 2016.
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EMPERICAL THERAPY
Uncomplicated Acute Otitis Media in Non-immunocompromised
Adults
Amoxicillin 875 mg PO b.i.d. or 500 mg t.i.d. for 5–7 days or
Cefuroxime 500 mg PO b.i.d. for 5–7 days or
Cefpodoxime 200 mg PO b.i.d. for 5–7 days or
Cefdinir 300 mg PO b.i.d. for 5–7 days or
Ceftriaxone 2 g IM/IV once
Penicillin-allergic Patients
Levofloxacin 500 mg/day PO for 7–10 days or
Moxifloxacin 400 mg/day PO for 7–10 days or
Clindamycin 300 mg PO t.i.d./q.i.d. for 7–10 days or
Available at http://emedicine.medscape.com/article/2012143-overview. Accessed on December 9, 2016.
PO: Per oral; b.i.d: Two times a day; t.i.d.: Thrice a day;
q.i.d..: Four times a day; IM: Intramuscular; IV:
Intravenous
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EMPIRICAL THERAPY
Uncomplicated Acute Otitis Media in Immunocompromised
Adults
Amoxicillin-clavulanate 875 mg/125 mg PO b.i.d. or 500 mg PO t.i.d.
for 10–14 days or
Clindamycin 300 mg PO t.i.d. for 7–10 days
PO: Per oral; b.i.d: Two times a day; t.i.d.: Thrice a day; q.i.d.: Four times a day
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EMPIRICAL THERAPY
Recurrent Acute Otitis Media
No antibiotics within past month:
Amoxicillin-clavulanate 875 mg/125 mg PO b.i.d. for 7–10 days or
Cefprozil 500 mg PO b.i.d. for 10 days or
Cefuroxime 500 mg PO b.i.d. for 7–10 days or
Ceftriaxone 1 g/day IM for 3 days
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ROLE AND SCOPE OF CLARITHROMYCIN
Results from the Lino Y, et al., study validated that clarithromycin has
greatest efficacy against otoscopic findings, especially regarding
diminished light reflex.
Hotomi, et al., reported that the eardrum change including reduced light
reflex was one of the very important indicators to predict the outcome of
AOM.
The proportion of patients with this finding was significantly lower in
the clarithromycin + S-carboxymethylcysteine (S-CMC) group than in
the S-CMC group at 1 week following completion of additional treatment
(p < 0.05).
. Available at http://www.mayoclinic.org/diseases-conditions/chronic-hives/basics/treatment/con-20031634. Accessed on June 10, 2016.
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• It is also possible that the higher eradication rate of other common bacterial
species in the clarithromycin group was reflected in the better outcome
observed in this group
• Takaki, et al., reported that in adenoidal fibroblasts, clarithromycin inhibited
production of IL-8 through NF-kB activation in response to endotoxin. The
author’s suggestion that the inhibitory effects of clarithromycin are mediated
through NF-kB activation and IL-8 inhibition in adenoidal fibroblasts might
explain, in part, the mechanism of this drug in improving otitis media with
effusion.
• The proportion of patients with redness of the tympanic membrane also tended
to be lower in the Clarithromycin (CAM) + S-carboxymethylcysteine (S-CMC)
group (p = 0.097).
• These findings suggest that clarithromycin ameliorates otoscopic findings that
are likely to persist after acute treatment and accelerates resolution of
inflammation.
Lino Y, et al. Clinical effects of clarithromycin on persistent inflammation following Haemophilus influenzae-positive acute otitis media. Acta Otolaryngol. 2015;135(3):217-25
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The results of the present study suggest that clarithromycin may be a
suitable candidate drug for preventing persistent or recurrent otitis
media in children following acute treatment for AOM.
Lino Y, et al. Clinical effects of clarithromycin on persistent inflammation following Haemophilus influenzae-positive acute otitis media. Acta Otolaryngol. 2015;135(3):217-25
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GUIDELINE RECOMMENDATION
Practice Recommendations
• High-dose amoxicillin (80 to 90 mg/kg per day divided twice daily)
remains the drug of choice for treatment of acute otitis media despite
increasing antimicrobial resistance
• For persistent or recurrent acute otitis media, guidelines recommend
high-dose amoxicillin/clavulanate (90/6.4 mg/kg per day), cefdinir,
cefprozil, cefpodoxime, cefuroxime or ceftriaxone
Pichichero ME and Casey JR. Acute otitis media: Making sense of recent guidelines on antimicrobial treatment. JFP.2005;54(4):313-322
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GUIDELINE RECOMMENDATION
• Increasing the dose of amoxicillin does not cover infection with β-
lactamase-producing pathogens; add the β-lactamase inhibitor
clavulanate to amoxicillin or choose a cephalosporin with good
activity against S. pneumoniae and good β-lactamase stability
• Key factors for enhancing compliance are taste of suspension, dosing
frequency and duration of therapy
Pichichero ME and Casey JR. Acute otitis media: Making sense of recent guidelines on antimicrobial treatment. JFP.2005;54(4):313-322
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GUIDELINE RECOMMENDATIONS
• For acute otitis media and recurrent acute otitis media, the first-line
agents are used
Available at http://www.topalbertadoctors.org/download/366/AOM_guideline.pdf. Accessed on December 8, 2016.
Standard Dose Duration
Amoxicillin 40 mg/kg per day PO t.i.d. 5 days
High-dose amoxicillin
90 mg/kg per day PO t.i.d.
5 days
Azithromycin 10 mg/kg, then 5 mg/kg PO daily 1st day, then 4 days
Clarithromycin 15 mg/kg PO b.i.d. 5 days
Cefuroxime axetil 30 mg/kg per day PO divided
b.i.d.
5 days
Cefprozil 30 mg/kg per day PO divided b.i.d. 5 days
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DEFINITIVE MANAGEMENT
Myringotomy
Myringotomy is a surgical procedure of the eardrum or tympanic
membrane.
The procedure is performed by making a small incision with the
myringotomy knife through the layers of tympanic membrane.
This surgical procedure permits direct access to the middle ear space
and allows the release of middle-ear fluid, which is the end product
of Otitis Media with Effusion (OME), whether acute or chronic.
Available at http://emedicine.medscape.com/article/1890977-technique Accessed on December 8, 2016.
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Myringotomy
• The patient’s head is tilted slightly towards the ear opposite the one
undergoing myringotomy
• The operative microscope is brought into field and focused on the
external auditory meatus
• An appropriately-sized speculum is carefully placed into the external
auditory canal, and cerumen is removed so that the entire tympanic
membrane can be visualized
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Myringotomy
• Either the anteroinferior quadrant or the
posteroinferior quadrant of the tympanic
membrane is carefully incised with the
myringotomy knife; the incision should be
approximately 3–5 mm in length
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FOLLOW UP
If the patient remains symptomatic for 48 to 72 hours (following
treatment with analgesics or first-line antibiotics) or is deteriorating,
follow-up is recommended.
Reassess patient for:
• Acute complications of AOM (e.g., mastoiditis, meningitis, facial
paralysis)
• Other diagnoses
• Compliance with medications
Available at http://www.topalbertadoctors.org/download/366/AOM_guideline.pdf. Accessed on December 8, 2016
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FOLLOW UP
Follow-up in 3 months post AOM episode is recommended to assess
for persistent OME, which may lead to hearing loss.
• Perform hearing evaluation if effusion is present at 3 months post
AOM
• Refer to an ear, nose and throat specialist if hearing loss
• Given the increasing incidence of resistant organisms, diagnostic
tympanocentesis should be considered where there has been failure
of 2 consecutive course of antibiotics with persistent symptoms
Available at http://www.topalbertadoctors.org/download/366/AOM_guideline.pdf. Accessed on December 8, 2016
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SUMMARY
• Acute otitis media is extremely common in children and also occurs
in adults which is caused by bacteria
• Biofilm has been found to play a considerable role in the
pathogenesis and pathophysiological aspects of AOM
• Culture and sensitivity of a specimen from fresh perforation or
tympanocentesis may be helpful for diagnosing AOM
• Medical management of Acute Otitis Media (AOM) is based on the
guideline recommendations, mainly first-line agents such as
amoxicillin, azithromycin, clarithromycin and cefuroxime axetil
• In severe cases, surgery should be informed for tympanic membrane
such as myringotomy
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DISCLAIMER
• The scientific content of this publication has been developed and designed by Magna Health
Solutions -India for educational purpose through monetary assistance of Abbott Healthcare Private
Limited . This publication is made available free of cost as a service to the medical profession for
educational purpose only. Medical practitioners are advised to take decisions based on their own
clinical judgment. The content herein has been developed by clinicians and/or medical writers
and/or experts. Magna Health Solutions-India has obtained consent and statutory permissions
from the respective authors and content generators for publishing the material appearing in this
publication, as necessary. Although greatest possible care has been taken in compiling, checking
and developing the content to ensure that it is accurate and complete, the authors, the publisher, its
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