Otitis MediaOtitis Media

Otitis MediaOtitis Media $3.5 billion in expenditures$3.5 billion in expenditures Most common reason for visit to Most common reason for visit to

pediatricianpediatrician Tympanostomy tube placement is Tympanostomy tube placement is

2nd most common surgical 2nd most common surgical procedure in childrenprocedure in children

Development of multidrug-resistant Development of multidrug-resistant bacteria bacteria

Otitis Media - HistoryOtitis Media - History Egyptian mummies have Egyptian mummies have

perforations of TM and mastoid perforations of TM and mastoid destructiondestruction

Prehistoric Iranian population has Prehistoric Iranian population has evidence of middle ear diseaseevidence of middle ear disease

OM accounted for 27% of admissions OM accounted for 27% of admissions to Bellevue Hospital in 1932 to Bellevue Hospital in 1932

Otitis Media - Otitis Media - DefinitionDefinition

Inflammation of the middle Inflammation of the middle earear

May also involve May also involve inflammation of mastoid, inflammation of mastoid,

petrous apex, and petrous apex, and perilabyrinthine air cellsperilabyrinthine air cells

Otitis Media - Otitis Media - ClassificationClassification

Acute OM - rapid onset of signs & Acute OM - rapid onset of signs & sx, < 3 wk coursesx, < 3 wk course

Subacute OM - 3 wks to 3 mosSubacute OM - 3 wks to 3 mos Chronic OM - 3 mos or longer Chronic OM - 3 mos or longer

OM - EpidemiologyOM - Epidemiology AgeAge SexSex RaceRace Day careDay care SeasonsSeasons

GeneticsGenetics Breast-feedingBreast-feeding Smoke exposureSmoke exposure Medical conditions Medical conditions

OM - EpidemiologyOM - Epidemiology Increasing incidence?Increasing incidence? Increases after newborn periodIncreases after newborn period 2/3 with AOM by one year of age2/3 with AOM by one year of age 1/2 with >3 episodes by three years1/2 with >3 episodes by three years most common in 6 - 11 mos most common in 6 - 11 mos

OM - persistent middle OM - persistent middle ear effusion (MEE)ear effusion (MEE)

High incidence of MEE, avg of 40 High incidence of MEE, avg of 40 daysdays

Children less that 2 years much Children less that 2 years much more likely to have persistent MEEmore likely to have persistent MEE

White children with higher incidence White children with higher incidence of MEEof MEE

Otitis Media - RaceOtitis Media - Race Higher incidence in:Higher incidence in:

EskimosEskimos Native AmericansNative Americans Australian and African aboriginesAustralian and African aborigines

OM - Day Care OM - Day Care Greater risk of AOM in children < 3 Greater risk of AOM in children < 3

yearsyears Home care best, large group day Home care best, large group day

care worstcare worst more exposures with wider range of more exposures with wider range of

floraflora increased URI’sincreased URI’s more frequent visits to MD to decrease more frequent visits to MD to decrease

parental leave time from workparental leave time from work

OM - Breast-feedingOM - Breast-feeding Decreases incidence of URI and GI Decreases incidence of URI and GI

diseasedisease Inverse relationship between Inverse relationship between

incidence of OM and duration of incidence of OM and duration of breast-feedingbreast-feeding

Protective factor in breast-milk?Protective factor in breast-milk?

OM - smoke exposureOM - smoke exposure Induces changes in respiratory tractInduces changes in respiratory tract Cotinine marker associated with Cotinine marker associated with

increased AOM and persistent increased AOM and persistent effusioneffusion

Increased PET, otorrhea, chronic Increased PET, otorrhea, chronic and recurrent AOM in children with and recurrent AOM in children with hx of parental smokinghx of parental smoking

OM - Medical ConditionsOM - Medical Conditions Cleft palateCleft palate

decreases after decreases after repairrepair

Craniofacial Craniofacial disordersdisorders Treacher-CollinsTreacher-Collins

Down’s syndromeDown’s syndrome Ciliary dysfunctionCiliary dysfunction

Immune Immune dysfunctiondysfunction AIDSAIDS steroids, chemosteroids, chemo IgG deficiencyIgG deficiency

ObstructionObstruction NG tubesNG tubes NT intubationNT intubation adenoidsadenoids malignancymalignancy

Eustachian TubeEustachian Tube Connects middle ear and Connects middle ear and

nasopharynxnasopharynx Lumen shaped like two cones with Lumen shaped like two cones with

apex directed toward middleapex directed toward middle Mucosa has mucous producing cells Mucosa has mucous producing cells

and ciliated cellsand ciliated cells

Eustachian tubeEustachian tube AdultsAdults

ant 2/3- ant 2/3- cartilaginouscartilaginous

post 1/3- bonypost 1/3- bony 45 degree angle45 degree angle isthmus 1-2 mmisthmus 1-2 mm nasopharyngeal nasopharyngeal

orifice 8-9 mmorifice 8-9 mm

ChildrenChildren longer bony portionlonger bony portion 10 degree angle10 degree angle isthmus largeristhmus larger nasopharyngeal nasopharyngeal

orifice 4-5 mm in orifice 4-5 mm in infantsinfants

Eustachian tubeEustachian tube Usually closedUsually closed Opens during swallowing, yawning, Opens during swallowing, yawning,

and sneezing and sneezing Opening involves cartilaginous Opening involves cartilaginous

portionportion Tensor veli palatini responsible for Tensor veli palatini responsible for

active tubal openingactive tubal opening No constrictor functionNo constrictor function

Eustachian tubeEustachian tube Protection from nasopharyngeal Protection from nasopharyngeal

sound and secretionssound and secretions clearance of middle ear secretionsclearance of middle ear secretions ventilation (pressure regulation) of ventilation (pressure regulation) of

middle earmiddle ear

PathologyPathology

Edema, capillary engorgement, and PMN Edema, capillary engorgement, and PMN infiltrationinfiltration

Epithelial ulceration and granulation tissueEpithelial ulceration and granulation tissue Fibrosis, influx of chronic inflammatory Fibrosis, influx of chronic inflammatory

cellscells Increased columnar and goblet cellsIncreased columnar and goblet cells OsteitisOsteitis Edema and polypoid changesEdema and polypoid changes

PathologyPathology Eustachian tube abnormalitiesEustachian tube abnormalities

Impaired openingImpaired opening open in DS and American Indiansopen in DS and American Indians shorter tubeshorter tube

Impaired immunityImpaired immunity children have poorer immune responsechildren have poorer immune response less cytokines in nasopharynx in children with OMless cytokines in nasopharynx in children with OM

Inflammatory mediatorsInflammatory mediators Bacterial products induce inflam response with IL-1, Bacterial products induce inflam response with IL-1,

IL-6, and TNFIL-6, and TNF AllergyAllergy

MicrobiologyMicrobiology S. pneumoniaeS. pneumoniae - 30-35% - 30-35% H. influenzaeH. influenzae - 20-25% - 20-25% M. catarrhalisM. catarrhalis - 10-15% - 10-15% Group A strep - 2-4%Group A strep - 2-4% Infants with higher incidence of Infants with higher incidence of

gram negative bacilligram negative bacilli

VirologyVirology RSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates RhinovirusRhinovirus Parainfluenza virusParainfluenza virus Influenza virusInfluenza virus

MicrobiologyMicrobiology PCN-resistant PCN-resistant

StrepStrep 1979 - 1.8%1979 - 1.8% 1992 - 41%1992 - 41% Altered PCN-Altered PCN-

binding proteinsbinding proteins Lysis defectiveLysis defective Age, day-cares, and Age, day-cares, and

previous txprevious tx

H. flu and M. H. flu and M. catarrhaliscatarrhalis beta-lactamase beta-lactamase

productionproduction All All M. catarrhalisM. catarrhalis + + 45-50% 45-50% H. fluH. flu

Chronic MEE Chronic MEE Previously thought sterilePreviously thought sterile 30-50% grow in culture30-50% grow in culture over 75% PCR +over 75% PCR + Usual organismsUsual organisms

DiagnosisDiagnosis Acute OMAcute OM

preceding URIpreceding URI fever, otalgia, fever, otalgia,

hearing loss, hearing loss, otorrheaotorrhea

may have assoc may have assoc constitutional sxconstitutional sx

Chronic MEEChronic MEE poss asymptomaticposs asymptomatic hearing losshearing loss ““plugged”plugged” ““popping”popping”

DiagnosisDiagnosis Pneumatic otoscopy is gold standardPneumatic otoscopy is gold standard

Color - opaque, yellow, blue, red, pinkColor - opaque, yellow, blue, red, pink Position - bulging, retractedPosition - bulging, retracted Mobility - normal, hypomobile, neg Mobility - normal, hypomobile, neg

pressurepressure Assoc pathology - perfs, cholesteatoma, Assoc pathology - perfs, cholesteatoma,

retraction pocketsretraction pockets Head & neck examHead & neck exam

DiagnosisDiagnosis AudiogramAudiogram

document CHL, SNHL, baseline, preopdocument CHL, SNHL, baseline, preop sooner if high risksooner if high risk

ImpedanceImpedance Acoustic reflexesAcoustic reflexes

Treatment - AOMTreatment - AOM Adults and older children - Adults and older children -

observation?observation? Antibiotics - consider drug Antibiotics - consider drug

resistance patternsresistance patterns Amoxil - not for Amoxil - not for BB lactamase + lactamase + TMP-SMT - not for group A strepTMP-SMT - not for group A strep Need high middle ear concentrationsNeed high middle ear concentrations

AntibioticsAntibiotics First lineFirst line

Amoxil - 60-90 mg/kg divided tidAmoxil - 60-90 mg/kg divided tid Ceftin - B lactam stableCeftin - B lactam stable Augmentin - B lactam stableAugmentin - B lactam stable Bactrim, PediazoleBactrim, Pediazole

Second lineSecond line AugmentinAugmentin CeftinCeftin RocephinRocephin Macrolides - Zithromax, BiaxinMacrolides - Zithromax, Biaxin

Treatment - Recurrent Treatment - Recurrent AOMAOM

ChemoprophylaxisChemoprophylaxis Sulfisoxazole, amoxicillin, ampicillin, pcnSulfisoxazole, amoxicillin, ampicillin, pcn less efficacy for intermittent propylaxisless efficacy for intermittent propylaxis

Myringotomy and tube insertionMyringotomy and tube insertion decreased # and severity of AOMdecreased # and severity of AOM otorrhea and other complicationsotorrhea and other complications may require prophylaxis if severemay require prophylaxis if severe

AdenoidectomyAdenoidectomy 28% and 35% fewer episodes of AOM at first and 28% and 35% fewer episodes of AOM at first and

second yearssecond years

Treatment - OMETreatment - OME MEE > 3 mos or assoc hearing loss, vertigo, MEE > 3 mos or assoc hearing loss, vertigo,

frequency, ME pathology, discomfortfrequency, ME pathology, discomfort AntibioticsAntibiotics

shown to be of benefit, 75% PCR + bacterial DNAshown to be of benefit, 75% PCR + bacterial DNA Antibiotics + steroidAntibiotics + steroid

21% improvement compared to abx alone21% improvement compared to abx alone prednisone 1 mg/kg day x 7 daysprednisone 1 mg/kg day x 7 days varicella?varicella?

Myringotomy & tympanostomy +/- Myringotomy & tympanostomy +/- adenoidectomyadenoidectomy

Tympanostomy tube Tympanostomy tube insertioninsertion

Unresponsive OME >3 mos bil, or >6 Unresponsive OME >3 mos bil, or >6 mos uni, sooner if assoc hearing mos uni, sooner if assoc hearing problemsproblems

Recurrent MEE with excessive Recurrent MEE with excessive cumulative durationcumulative duration

Recurrent AOM - >3/6 mos or >4/12 Recurrent AOM - >3/6 mos or >4/12 mosmos

Eustachian tube dysfunctionEustachian tube dysfunction Suppurative complicationSuppurative complication

ComplicationsComplications IntratemporalIntratemporal

hearing losshearing loss TM perforationTM perforation CSOMCSOM retraction pocketsretraction pockets cholesteatomacholesteatoma mastoiditismastoiditis petrositispetrositis labyrinthitislabyrinthitis adhesive OMadhesive OM tympanosclerosistympanosclerosis ossicular dyscontinuity and ossicular dyscontinuity and

fixation fixation facial paralysisfacial paralysis cholesterol granulomacholesterol granuloma necrotizing OEnecrotizing OE

IntracranialIntracranial meningitismeningitis extradural abscessextradural abscess subdural empyemasubdural empyema focal encephalitisfocal encephalitis brain abscessbrain abscess lateral sinus lateral sinus

thrombosisthrombosis otitic hydrocephalusotitic hydrocephalus

Case historyCase history

1 1/2 year old wm presents to ENT clinic 1 1/2 year old wm presents to ENT clinic with 2nd episode of “ear infections” in with 2nd episode of “ear infections” in last monthlast month

Normal history with no medical problems Normal history with no medical problems and no prior surgical proceduresand no prior surgical procedures

Mother describes a “cold” for the last few Mother describes a “cold” for the last few days and then started running a fever days and then started running a fever and pulling at ears. Describes the child and pulling at ears. Describes the child as very irritable as very irritable

Physical ExamPhysical Exam Temp 100 F, VS wnlTemp 100 F, VS wnl Irritable childIrritable child Ears - eac clear, tms erythematous, Ears - eac clear, tms erythematous,

bulging with yellowish MEE AUbulging with yellowish MEE AU Nose - clear rhinorrheaNose - clear rhinorrhea otherwise wnlotherwise wnl

Case historyCase history Returns to clinic one month later Returns to clinic one month later

with same complaints againwith same complaints again Dx as AOMDx as AOM 3rd episode in last 2 mos and 5th in 3rd episode in last 2 mos and 5th in

last yearlast year

Case historyCase history Placed on sulfisoxizol prophylaxisPlaced on sulfisoxizol prophylaxis 3 wks later presents with recurrent 3 wks later presents with recurrent

AOM AOM

Case historyCase history BM&T performed, doing well at 3 BM&T performed, doing well at 3

wkswks Mother calls at 3 mos and says has Mother calls at 3 mos and says has

had to be tx with po abx and ear gtts had to be tx with po abx and ear gtts 3 times by pcp for bilateral otorrhea 3 times by pcp for bilateral otorrhea

New FrontiersNew Frontiers Prevention more cost effective than Prevention more cost effective than

treatmenttreatment Even slight decrease would have Even slight decrease would have

profound economic impactprofound economic impact VaccinesVaccines XylitolXylitol

VaccinesVaccines Pneumococcal vaccinePneumococcal vaccine

poorly immunogenic in childrenpoorly immunogenic in children did exhibit antibody response did exhibit antibody response

H. influenzaeH. influenzae no polysaccharide capsuleno polysaccharide capsule serum bactericidal antibodyserum bactericidal antibody

M. catarrhalisM. catarrhalis human pathogen human pathogen

VaccinesVaccines 150 viral immunotypes150 viral immunotypes 100 rhinoviruses with poor 100 rhinoviruses with poor

prognosis for vaccine developmentprognosis for vaccine development RSV most common - developing RSV most common - developing

intranasal delivery systemintranasal delivery system

XylitolXylitol Sweetening substituteSweetening substitute Inhibits growth of pneumococcus Inhibits growth of pneumococcus

and inhibits adhesion of and inhibits adhesion of pneumococcus and H. flu in pneumococcus and H. flu in nasopharynxnasopharynx

Gum and syrup reduced incidence of Gum and syrup reduced incidence of AOM 40% and 30% AOM 40% and 30%

Otitis Otitis MediaMedia