About AOM ,OME and COM Complication, infection Tymoanic membrane

17. Clinical Finding
• The normal TM is pearly gray, translucent, and
concave
• A visible landmark
• A red but translucent TM…. Crying
• A pink, yellow, or blue TM ,lack of translucency
and Bulging TM is key diagnostic feature of AOM
• shagrination (cobble stoning) of the TM

23. Tympanometry (Immittance Testing)
• Normally 0.3 to 0.9 mL in children
• generally performed using a 226-Hz tone
• 1000-Hz probe best for young chil less than 6mo
• Due to increased compliance of EAC
• Compared to pneumatic otoscopy, tympanometry is
easier to perform and has a comparable sensitivity
but a lower specificity for diagnosing OME

26. Risk Factors
• Range of host-related and environmental factors
• Onset of first AOM before 12 months of age is a
powerful predictor of recurrence
• Host related: male sex, genetic, craniofacial
abnormalities, immunodeficiency, hypertrophy of the
adenoids,
• Environmental: socioeconomic status, recurrent URTI,
fall and winter season, daycare, having older siblings,
tobacco smoke exposure, pacifier use
• Breastfeeding protects against OM.
• Debate regarding the role of: prematurity, allergy,
obesity, gastroesophageal reflux

28. The eustachian tube
• Epithelium predominantly consists of ciliated
• Which produce antimicrobial proteins
• Goblet cells, produce both mucoid and serous
• The direction flow from the middle ear
through the eustachian tube to the
nasopharynx
• Against bacterial colonization of the middle
ear.

30. Bacterial Colonization and Biofilms
• Bacterial biofilms: sessile communities of
interacting bacteria encased in protective matrix
of exopolysaccharides and adherent to surface.
• The matrix protects bacteria against host's
immune response, and reduced metabolic rate of
bacteria renders them resistant to antibiotics.
• Mucosal biofilms have been isolated from middle
ear of patients with persistent OME, CSOM, and
cholesteatoma

31. • Low IgA, IgG2 and mannose-binding lectin
levels
• Allergy There is still debate on the role in the
pathogenesis of OM
• Genetics: Estimates of heritability of AOM
and OME vary from 40% to 70%
• A cause-effect relationship between
gastroesophageal reflux and OM remains
unclear, antireflux treatment is currently not
recommended

38. Prevention
• Breastfeeding
• Avoidance
• Vaccines
• Antivirals
• Echinacea
• Xylitol
• Probiotics

39. Treatment
Acute Otitis Media
Observation With Close Monitoring (Watchful Waiting)
• An option for young children (6 to 23 months of age) with
nonsevere unilateral AOM
• Children 24 months and older with nonsevere unilateral or
bilateral AOM.
• “Nonsevere” is defined as “without severe signs or symptoms,
mild otalgia for less than 48 hours, temperature less than
39°C ”
• Follow-up is recommended in case the child worsens or fails
to improve within 48 to 72 hours of the onset of symptoms.

40. Medical Treatment
• Analgesics.
• Antibiotics.
• Decongestants and Antihistamines
(routine use not recommended)
• Corticosteroids (not recommended)

41. Antibiotics.
• Reduce the duration and severity
• Associated with adverse effects
• Emerging antimicrobial resistance
• Benefits and costs of antibiotic treatment
• are most effective in:
1. children below 2 years
2. with bilateral AOM
3. any age presenting with AOM and otorrhea
4. children with severe illness
5. AOM who are below 6 months of age
6. Immunocompromised
7. have craniofacial malformations

42. Amoxicillin is still the first-line
• 80 to 90 mg/kg /day in two divided doses
• including resistant strains
• Amoxicillin–clavulanic acid (amoxicillin 90 mg/kg/day
and clavulanic acid 6.4 mg/kg/day in two divided doses
• recommended for children:
1. who have been treated with amoxicillin in the previous 30
days
2. for those with concurrent purulent conjunctivitis (e.g.,
otitis-conjunctivitis syndrome typically caused by
nontypeable H. influenzae)
3. for those with a history of recurrent AOM unresponsive to
amoxicillin.

43. For patients with penicillin ALLERGY
• Cephalosporins such as cefdinir, cefuroxime,
cefpodoxime, and ceftriaxone are acceptable
first-line treatment
• If initial treatment failure occurs:
– broader-spectrum agent such as amoxicillin–
clavulanic acid
1. ceftriaxone, 50 mg intramuscularly or
intravenously for 3 days if amoxicillin–clavulanic
acid was not effective
• Tympanocentesis

44. Course
Standard 10-day therapy for younger children
and for children with severe disease
A 7-day course in children 2 to 5 years of age
with mild to moderate AOM
6 years of age and older with mild to moderate
disease, 5- to 7-day course

45. Surgical Treatment
• Myringotomy/Tympanocentesis
Diagnostic procedure rather than a primary
treatment modality
• Myringotomy With Tym Tube Insertion
Considered for symptomatic AOM that is refractory
to antibiotic therapy

49. Recurrent Acute Otitis Media
• Defined as three or more episodes in 6
months or four in 1 year with at least one
episode in the last 6 months

50. Antibiotic Prophylaxis
• Older studies efficacy of prophylactic
antibiotics
• Mostly amoxicillin and sulfisoxazole
• Given at half of the therapeutic daily
dose for months
• Prophylaxis reduces AOM recurrences by
one to two episodes per year
• Routine use is not recommended
• Given the adverse effects
• Emerging antibiotic resistance.

51. Surgical Treatment
• Myringotomy With Tympanostomy Tube
Insertion
• 2013 guidelines American Academy recommend
against rAOM without MEE
• Recommend for rAOM with MEE
rAOM

52. Adenoidectomy
• A recent meta-analysis combining individual
patient data of 10 randomized controlled
trials:
 a standalone procedure or as an adjunct to
tympanostomy tubes
• is most beneficial in children below 2 years of
age with rAOM

53. Otitis Media With Effusion
• Observation With Close Monitoring
(Watchful Waiting)
• A 3-month period of observation
– who are not at particular risk for speech and
language or learning disabilities
– Examination at 3- to 6-month intervals
– surgical intervention for high risk child (delay
development)

58. Medical Treatment
1. Antibiotics (are not recommended for
routine treatment)
2. Decongestants and Antihistamines ( not
recommended )
3. Corticosteroids (Both oral and topical are
therefore not recommended )
4. Auto-inflation (larger trials are required)
• Hearing Aids (are recommended in UK, but
not in US)

59. Surgical Treatment
• Myringotomy
ineffective for long-term management and is not
recommended
• Myringotomy With Tympanostomy Tube
Insertion
• Adenoidectomy
• Eustachian Tube Dilatation

60. Myringotomy With Tympanostomy
Tube Insertion
• Effect on hearing is modest and diminishes after 6 to 9
months
1. Largest effect in young children that grow up in an
environment with a high infection load (e.g., children
daycare)
2. In older children with a hearing level of 25 dB HL or
greater in both ears persisting for at least 3 months
3. in children with OME with documented hearing
difficulties after 3 months
4. Those who are at particular risk for, or who already
have, speech and language or learning disabilities

61. Adenoidectomy
• As a standalone procedure or as an adjunct to
tympanostomy tube insertion
• Is most beneficial in children aged 4 years

63. Eustachian Tube Dilatation
• Novel treatment for children with persistent
OME
• Currently no evidence to support

65. Surgical Issues
• A follow-up visit is recommended within 2 to 3 months
after the surgery
• Evaluated 6 to 12 months after the insertion of the tubes
• Every 6 months thereafter
• T-tubes or longterm tubes are used in older children
who have an atrophic TM or who have had multiple sets
of tympanostomy tubes due to comorbidities such as
cleft palate, because a regular grommet tube may be
very quickly extruded.

66. If MEE is too thick:
• Large suction tip through the myringotomy
incision, a counterincision is made in the
inferior part of the TM, or sterile saline may
be irrigated in the canal or through the
myringotomy to enhance theaspiration of the
viscous fluid.

67. What is your option for VT in the ME?

68. Complications and Sequelae
• Acute Tympanostomy Tube Otorrhea
• An estimated 25% to 75%
• Risk factors include:
– Young age
– rAOM
– Recent history of recurrent URTIs
– Presence of older siblings

69. Prevention of Otorrhea Episodes
Occurring in the Immediate
Postoperative Period.
1) Multiple saline washouts of the middle ear
2) A single application of antibiotic-
corticosteroid ear drops during surgery
3) Prolonged use of topical or oral antibiotics
with or without corticosteroids during the
early postoperative period
4) Single application of 6% ciprofloxacin otic
suspension in the middle ear during tube
insertion

70. Treatment of Otorrhea Episodes
Occurring Outside the Immediate
Postoperative Period
• Nontypeable H. influenzae, Staphylococcus
aureus, and Pseudomonas
• Current guidance recommends: ototopical
antibiotic drops as the firstline treatment
• If the otorrhea does not resolve in 2 weeks, it
is recommended that a culture specimen
• In case of persistent or frequently recurring
otorrhea, removal of the tubes

73. Notes
• Persistent Perforation can be surgically managed
if: As a rule, the TM in the opposite ear should be
intact and free of infection for 1 year
• Early Extrusion: infection in the middle ear, tube
may not properly inserted, TM thick, Atrophy of
the TM
• Tube Blockage: pick, Rosen needle, drop 14 days,
left in place and watched,.. replacement of the
tube

74. • Many clinicians recommend removing tubes
that have failed to extrude after 3 years to
reduce the risk of long-term perforation.
• Recent systematic reviews found no significant
impact of water precautions on the risk of
tympanostomy tube-associated otorrhea
• May be prudent for some children such as
those with
– Recurrent episodes of otorrhea, particularly with
Pseudomonas or S. aureus, and those with risk
factors for infections and complications.