Continuity Clinic

Acute Otitis Media

Continuity Clinic

Objectives

• Define otitis media (OM), acute otitis media (AOM) and otitis media with effusion (OME)

• Be familiar with the epidemiology of AOM

• List causative pathogens in children with AOM and current bacteriologic resistance patterns

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Terms and DefinitionsOtitis Media (OM) Inflammation of the middle ear without reference to cause or pathogenesis.1

Middle Ear Effusion (MEE) Liquid in the middle ear but not the etiology, pathogenesis, or duration (recent onset, acute, subacute or chronic).1

Serous: thin, watery liquid Mucoid: a thick, viscid mucus-like liquid Purulent: a pus-like liquid A combination of these

Otitis Media with Effusion (OME) Inflammation of the middle ear with a collection of liquid in the middle ear space. Signs and symptoms of acute infection absent.1

Serous, secretory or non-suppurative otitis media are terms that are no longer recommended.

Acute Otitis Media (AOM) Inflammation of the middle ear that is of rapid and short onset in association with signs and symptoms indicating acute infection. The tympanic membrane is full or bulging, opaque, and has limited mobility. Erythema is an inconsistent finding.1

One or more local or systemic signs are present: otalgia, otorrhea, fever, irritability, anorexia, vomiting or diarrhea.

Otorrhea Discharge from:1

external auditory canal middle ear mastoid inner ear or intracranial cavity

Eustachian Tube Dysfunction Middle ear disorder that can have symptoms similar to otitis media, such as hearing loss, otalgia, and tinnitus, but middle ear effusion is usually absent.1

1999 7th International Symposium on Recent Advances in Otitis Media

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Distinguishing AOM from OME

1. Distinct fullness or bulging of the TM 2. Substantial ear pain, including unaccustomed tugging or rubbing of the ear 3. Distinct erythema of the TM

At least two of : 1. Abnormal color: white, yellow,

amber, blue 2. Opacification not due to scarring 3. Decreased or absent mobility

Bubbles or air-fluid interfacesbehind the TM

Acute purulent otorrheanot due to otitis externa

Middle Ear Effusion(MEE)

Acute Otitis Media(AOM)

Otitis Media with Effusion(OME)

Yes Yes

No AcuteInflammation

Acute Inflammation

Yes

Yes

Or

Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission)

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• 1993 - 1995 (NCHS),2 OM accounted for 18% ambulatory visits (1-4 yr) 14% visits during the 1st yr of life

• AOM episodes diagnosed2

81% in pediatric practices 13% in hospital ED 6% in hospital outpatient departments

Prevalence of Otitis Media

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• Peak incidence of OM occurs during the first 2 years

• 60%-70% of children have >1 AOM before 1st birthday4,5

• Early onset (<6 mo) associated with recurrent AOM and chronic OME

• Recurrent AOM, >3 episodes/6 mo or >4 episodes/yr, ~ 20% of children

Prevalence of Otitis Media

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Prevalence of Otitis Media

AOM and OME, segments of a disease

continuum7

Mean cumulative time with MEE (AOM or

OME)5

20.4% in 1st yr

16.6% in 2nd yr

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Risk Factors for OM• Host factors

Age/Gender Genetic predisposition Cleft palate/Down syndrome Allergy/Immunity

• Environmental factors Daycare/Siblings Bottle (versus breast) feeding Pacifier use Smoking Low socioeconomic status Season/Upper respiratory infections

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Host-Related Risk Factors

Age/Gender

AOM most prevalent between 6 and 11 mo

Shorter, horizontal lying eustachian tube

Males, higher cumulative time with OME

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Environmental Risk Factors

Day Care Attendance Most important risk factor

50-70% children 6-18 mo attending day care have

bilaterally persistent OME

Number of children in day care, hours spent, age at

entry and siblings in daycare influence risk

Day care increases risk of infection, use of antibiotics,

thus increasing selection of resistant organisms

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Exposure to Household Cigarette Smoke

Positive relationship between smokers in

household and OM during 1st but not 2nd year5

Increased levels of cotinine in saliva correlated

with abnormal tympanograms and number of

smokers

Association between early AOM onset and

cotinine in urine not found

Environmental Risk Factors

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Pathophysiology of AOM

Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission)

Otitis Media

Anatomic/Physiologic Dysfunction

• Eustachian tube dysfunction• Cleft Palate

EnvironmentalFactors

Allergy

Host Factors

• Immature/impaired immunology• Familial predisposition• Type of milk (breast or formula)• Gender

• Race

Infection

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• Eustachian tube (ET) functions include ventilation,

protection and clearance of secretions

• Impairment ET function MEE

• URI inflammation of nasopharynyx (NP) and ET

• Inflammation ET dysfunctionnegative middle

ear pressure

• Organisms colonizing NP aspirated into middle ear

resulting in AOM

Pathophysiology of AOM

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0

5

10

15

20

25

30

35

Res

ista

nce

(%)

Resistant (MICs 2 µg/mL)

Intermediate (MICs 0.12-1 µg/mL)

Microbiology: Antimicrobial Resistance

1988-891

4761990-911

5241992-931

7991994-952

15271997-982

16011999-002

15312001-023

1925Year# Isolates

1. Doern GV. Am J Med. 1995; 99:3S-7S2. Doern GV. ACC. 2001;45:17213. Doern GV. Unpublished data

β-lactamase enzymes inactivate

β-lactam antibiotics

Bacterial Resistance Against β-Lactam Abx

Cytoplasm

Altered PBPs

Peptidoglycan cell wall

Plasma membrane

Clavulanic acid irreversibly binds to β-lactamase protecting β-lactam antibiotics from enzymatic cleavage

Antibioticβ-lactamaseClavulanic acid

Normal PBPAltered PBP

Resistance increases as altered PBPs accumulate

Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661.

Cytoplasm

Ribosomes

5030

5030

5030

Bacteria alter macrolide binding site(ermAM gene, MLSB phenotype)

Macrolide unable to block protein

synthesis

Bacterial Resistance Against Macrolides

Macrolide

Bacterial efflux pumps(mefE gene, M phenotype)

Macrolide excreted from

cell

Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661

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Antibiotic Options

• 1st Line– Amoxicillin : low versus high dose– Augmentin– PC allergy Zithromax

• 2nd Line– Cephalosporins– Zithromax

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The Observation Option

Limited to healthy kids over the age of 6mos

May observe age group 6 months to 2 years if AOM is uncertain and pt has nonsevere illness.

What defines a severe illness?

fever ≥ 39 C or 102.2 F, severe otalgia

Older than 2 years if nonsevere illness

Family has access to doctor, and family member to close eye on patient

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A picture is worth a thousand words…….

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Acute Otitis Media?

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Acute Otitis Media?

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What is your diagnosis?

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What is your diagnosis?

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Bonus Question -What is this?