Otitis media - ear cleaning

Otitis media

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A 2 year old presents to ED with pyrexia – he’s pulling at his ear constantly in the waiting room.  You know where this heading, but are you supposed to treat him with antibiotics or not?

Do you know the difference between AOM and OME?

 

Bottom Line

  • Treat acute otitis media (AOM) < 2 yrs old with antibiotics
  • Treat AOM > 2 yrs if systemically unwell
  • Re-evaluate at 48 hours if needed
  • Don’t forget the pain relief

What is it?

Otitis media is a general term that has been used to describe multiple disorders of middle ear inflammation

Acute otitis media (AOM)

Otitis media with effusion (OME)

Chronic otitis media (COM)

Establishing diagnosis is important as antibiotic treatment is not recommended for OME

The definition of acute otitis media requires three equally important components, which must all be present.

  1. Acute onset (<48 hours) of signs and symptoms
  2. Middle ear effusion (MEE)
  3. Signs and symptoms of middle ear inflammation (as least one of: fever, otalgia, irritability in an infant; red TM not due to crying or fever)
Normal eardrum

Normal eardrum (Hawke Library)

Who gets it?

There is considerable overlap between presenting signs and symptoms of upper respiratory illnesses and acute otitis media, especially in the preverbal child.

The peak incidence of otitis media is between 6 and 18 months of age. Neonatal acute otitis media is uncommon. Most effusions of the middle ear in this age are sterile and develop in the in utero environment.

Environmental insults, such as tobacco smoke, lack of breastfeeding, and exposure to children in day care who frequently receive antibiotics, may lead to episodes that would not otherwise occur.

Prevention of the disease burden is possible through the use of newer vaccines such as the contemporary pneumococcal vaccine that includes protection from seven serotypes of Streptococcus pneumoniae.

What are the most common bugs?

Bacteria from the nasopharynx are the most common cause of acute otitis media and can be isolated from middle ear fluid in a majority of cases. The most common pathogens in the postpneumococcal vaccine era are:

  • Nontypeable Haemophilus influenzae (56%)
  • S. pneumoniae (31%)
  • Moraxella catarrhalis
  • Mycoplasma may cause a bullous myringitis

Neonates may be affected by gram negative organisms and Staph aureus.

The role of viruses is unclear.

These data were obtained in the postpneumococcal vaccine era and represent a change from before this vaccination program was initiated. Of importance is a major change in the increased prevalence of β-lactamase organisms such as M. catarrhalis (almost 100%) and nontypeable H. influenzae (35% to 40%).

What is otitis media with effusion (OME)?

OME usually follows an episode of acute otitis media, and both are processes of the same disease continuum. OME may persist for weeks to months after an episode of acute otitis media.

Close to 90% of episodes of OME  resolve spontaneously after an acute otitis media episode is diagnosed.

Guidelines recommend watchful waiting without immediate use of antibiotics for children with uncomplicated otitis media with effusion.

Children with permanent hearing loss, craniofacial anomalies, or underlying speech delays may receive immediate antibiotics or have close outpatient follow-up by the primary care clinician.

Should I treat it?

Consensus guidelines strongly recommend the treatment of pain associated with acute otitis media.

Prescribing only an antibiotic for the treatment of acute otitis media is inappropriate care, as antibiotics are not analgesic medications.

The primary systemic analgesics and antipyretics used to treat acute otitis media are ibuprofen and paracetamol. In one randomised trial comparing ibuprofen, acetaminophen, and placebo, only ibuprofen was found to be superior to placebo.

Opioid medications may be used at night during the sleeping hours, although no studies have demonstrated the effectiveness of this medication class for the treatment of acute otitis media.

High-dose amoxicillin, 80 to 90 mg/kg PO per day divided into two daily doses for 5 to 7 days, is the first-line recommended antibiotic for the treatment of uncomplicated acute otitis media.

The higher dose achieves concentrations in the middle ear that exceed the minimum inhibitory concentration for highly resistant forms of S. pneumoniae, the most common bacteria found in acute otitis media.

M. catarrhalis and nontypeable H. influenzae, although the addition of clavulanic acid increases the likelihood of vomiting and diarrhoea.

IM ceftriaxone for three daily doses may be considered if children cannot tolerate oral medications. Children with a known allergy to the penicillin class may consider the use of a macrolide agent, such as azithromycin.

A 10-day course of antimicrobials has been recommended for decades without any evidence to support an exact duration of therapy. Shortened treatment regimens (5 to 7 days) may reduce resistance to antibiotics and reduce side effects by decreasing total drug exposure.

What is the evidence for treatment?

Two randomised double-blinded placebo-controlled trials of young children diagnosed with AOM

Hoberman et al, University of Pittsburgh

Tahtinen et al, Turku University Hospital in Turku, Finland

In children between 6 months and 2 years of age with certain AOM, the use of antibiotics result in faster recovery and less treatment failure (reduced by 42-62% in the severe group)

Although a majority of patients receiving placebo also recovered spontaneously (53% in Hoberman et al, 55% in Tahtinen et al), a physician cannot predict at the onset of illness which patients will improve without antibiotics.

Even in patients with non-severe illness, antibiotics were associated with a decrease rate of treatment failure.

Summary of Treatment

Antibiotics are advised for:

All infants under 6 months
Age 6 months – 2 years with certain diagnosis or uncertain diagnosis and severe illness
Age 2 years and over with certain diagnosis and moderate/severe illness

Observation:

Age 6 months onwards with uncertain diagnosis and follow up assured observation without antibiotics is an option for mild illness (no systemic features) with re-evaluation at 48 hours & antibiotics if no improvement

Summary of Antibiotic Choice

Antibiotic in the studies was amoxicillin-clavulanate

1st line treatment is high dose amoxicillin, due to reduced side effects & drug exposure

Whether amoxicillin alone will yield the same benefit is unclear, although in previous studies  80% were successfully treated with amoxicillin

In severe disease amoxicillin-clavulanate is preferred first line

What are the complications?

Perforation

As in the photo below, there can still be a perforation that does not heal with in a few weeks.  This is considered to be a ‘natural myringotomy’ and usually heals well.  Only GP follow-up is needed.

 

Small perforation

from Hawke Library

 

Facial Palsy

The facial nerve descends over the posterior wall (mastoid) of the middle ear and can be affected by OM

 

from Facial Palsy UK

 

Mastoiditis

The infection can extend into the mastoid (posterior to the middle ear).  It can cause bone destruction, brain abscess, meningitis, VI and VII nerve palsies, lateral venous sinus thrombosis.  It is very unlikely if the ear exam is normal as it is linked to OM.

A CT is advised along for IV antibiotics (usually ampicillin)

 

Mastoiditis

 

Cholesteatoma

Cystic cholesterol lesions are linked to chronic OM and can erode local structures.

 

http://otitismedia.hawkelibrary.com/

from Hawke Library

 

Sepsis

Bacteraemia occurs in 3%.

 

Deafness

Conductive deafness can follow a persistent effusion. 

Resolution and Follow-Up

Fever and ear pain should be expected for 24 to 48 hours after an ED evaluation. If symptoms persist 72 hours after antibiotic therapy has been initiated, reevaluation is needed. Routine, scheduled visits are not recommended for uncomplicated acute otitis media if symptoms have resolved.

An improvement should be evident by 2-3 days. Treatment failure may indicate incorrect diagnosis, development of a complication or presence of a resistant organism. If the initial treatment was amoxycillin, change to amoxycillin/calvulanate.

All children should be reviewed by the local doctor at 2 weeks for presence of a persistent effusion (glue ear) or healing of the tympanic membrane (if ruptured).

ENT consultation is advised for children with persistent hearing loss or speech delay, chronic effusion for more than 3 months, frequent episodes of otitis media or underlying pathology such as cleft palate or adenoidal hypertrophy.

 

References

Best Bets – Otitis Media

Hawke Library – otitis media guide

 

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About 

James Miers is a paediatric trainee at Sydney Children’s Hospital.

Author: James Miers

James Miers is a paediatric trainee at Sydney Children’s Hospital.

One Response to "Otitis media"

  1. […] (Bronchus (including ear!)) Pneumonia/URTI/OM – Here is a Q&A quick review of paediatric pneumonia from Life in the Fastlane – Link. Another good resource is the management chart on the RCH website – Link – There is a great summary article on Otitis media on dontforgetthebubbles.com – Link […]

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