Acute Otitis Media Maria Agustina S.W. (1301-1010-0119)Definition Kondisi inflamasi middle ear akibat disfungsi eustachian tube karena local infection (upper respiratory infections, chronic rhinosinusitis) Acuteotitismedia: acute onset of middle-ear inflammation

Epidemiology Prevalence >25 juta pasien acuteotitismediadi Amerika pada tahun 1990 80% anak Amerika pernah mengalami paling sedikit 1 kali pada umur 3 tahun. Age Lebih sering terjadi pada infants dan anak-anak, tapi bisa terjadi pada umur berapa saja.

Risk Factors Age (highest risk, 618 months) Upper respiratory infection Chronic rhinosinusitis Low socioeconomic status Day care attendance Smoke exposure

Etiology Respon inflamasi dari upper respiratory infection atau chronic rhinosinusitis dengan disfungsi eustachian tube Produksi sterile transudate dalam middle-ear Transudate bisa terinfeksi oleh pathogens dari nasopharynx. Viruses:respiratory syncytial virus,influenza virus, rhinovirus,enterovirus Bacteria:Streptococcus pneumoniae(in up to 35% of cases),Haemophilus influenzae(nontypable strains), Moraxella catarrhalis

Symptoms & Signs Otalgia Diminished hearing Fever Irritability Vertigo Nystagmus Tinnitus Fluid in middle ear Dampened movement of tympanic membrane Otorrhea Bacterial Tympanic membrane erythematous, bulging, or retracted Tympanic membrane can perforate.

Differential Diagnosis Erythema of tympanic membrane Bullous myringitis Trauma to the ear or tympanic membrane Other conditions that present with earache Otitisexterna Referred pain:pharyngitis,sinusitis, tooth pain Glossopharyngeal neuralgia Temporomandibular joint syndrome Foreign body Cholesteatoma Herpes zosteroticus

Diagnostic Approach

Physical Examination Acute signs and symptoms of middle-ear inflammation Indications of middle-ear effusion1. Bulging of tympanic membrane1. Limited or absent mobility of tympanic membrane1. Airfluid level behind tympanic membrane1. Otorrhea Signs and symptoms of middle-ear inflammation1. Distinct erythema of tympanic membraneor1. Distinct otalgia

Laboratory Tests Tympanocentesis with culture of middle-ear fluid may be useful in: Newborns Severely ill or immunocompromised patients Persistent infection despite multiple courses of antibiotics

Classification Acuteotitismedia Recurrent acuteotitismedia Serousotitismedia Chronicotitismedia Mastoiditis

Treatment Approach Pengunaan antibiotics masih controversial. Kebanyakan kasus resolve dalam 1 minggu tanpa treatment. Observation without antimicrobial therapy is considered a reasonable option for: Mild to moderate disease in children 6 months to 2 years of age with an uncertain diagnosis Children 2 years of age

Specific TreatmentsAcuteotitismedia Recommended criteria for antimicrobial treatment (based on illness severity and diagnostic certainty) All patients < 6 months of age Patients between 6 months and 2 years if the diagnosis is certain Patients with severe infection Patients who are immunocompromised Observation (deferring antibacterial treatment for 4872 hours and limiting management to symptom relief) is an option if: Disease is mild to moderate (mild otalgia, fever < 39C [102.2F] in previous 24 hours) in children 6 months to 2 years of age with an uncertain diagnosis and for children 2 years of age Follow-up is ensured so that antibiotic therapy can be started promptly if the condition persists or worsens Antibiotics should be prescribed if the condition persists or worsens over 4872 hours of observation.Mild to moderate disease Diagnostic criteria Fluid in the middle ear (as evidenced by decreased tympanic membrane mobility, air/fluid level behind tympanic membrane, bulging tympanic membrane, purulent otorrhea)and Acute onset of signs and symptoms of middle-ear inflammation, including fever, otalgia, decreased hearing, tinnitus, vertigo, erythematous tympanic membrane Initial therapy Many agents are approved by the U.S. Food and Drug Administration for this indication. Trials have shown no clear superiority of 1 agent over another. Selection is based on cost, safety, and minimization of the microbiologic spectrum. Observation alone (symptom relief only) (see above)or Amoxicillin, 8090 mg/kg qd (up to 2 g) PO in divided doses (bid or tid),or In penicillin-allergic patients Nontype I allergy1. Cefdinir, 14 mg/kg PO qd (1 dose or divided doses);orcefpodoxime, 10 mg/kg qd;orcefuroxime, 30 mg/kg PO daily in 2 divided doses (bid)6. Type I allergy2. Concerns exist about pneumococcal resistance for all these choices.2. Clindamycin, 20 mg/kg daily PO in divided doses (tid);plustrimethoprimsulfamethoxazole, 10 mg/kg daily, PO in divided doses (bid);or2. Macrolide (clarithromycin, azithromycin) alone3. Azithromycin, 10 mg/kg qd PO on day 1 followed by 5 mg/kg qd PO for 4 d3. Clarithromycin, 15 mg/kg per day (max 1 g/day) PO daily in 2 divided doses (bid) for 10 days Exposure to antibiotics within 30 d or recent treatment failure (failure to improve and/or clinical worsening after 4872 h of observation or treatment) Amoxicillin, 90 mg/kg daily (up to 2 g);plusclavulanate, 6.4 mg/kg daily; both PO in divided doses (bid) for 10 days,or Ceftriaxone, 50 mg/kg IV or IM qd for 3 days,or Clindamycin, 3040 mg/kg qd PO in divided doses (tid) for 10 daysSevere disease Diagnostic criteria As above, with temperature 39.0Cor Moderate to severe otalgia Initial therapy Amoxicillin, 90 mg/kg daily (up to 2 g);plusclavulanate, 6.4 mg/kg daily; both PO in divided doses (bid) for 10 days,or Ceftriaxone, 50 mg/kg IV or IM qd for 3 days Exposure to antibiotics within 30 d or recent treatment failure (failure to improve and/or clinical worsening after 4872 h of observation or treatment) Ceftriaxone, 50 mg/kg IV or IM qd for 3 days,or Clindamycin, 3040 mg/kg qd PO in divided doses (tid) Consider tympanocentesis with culture.Duration Unless specified otherwise for a particular regimen above 10 days for patients < 6 years of age or for complicated/severe cases 57 days for patients > 6 years of age with mild to moderate uncomplicated disease Consider observation only in previously healthy persons with mild disease. Switch regimen (because of possible antibiotic resistance) if there is no clinical improvement by the third day of therapy.Other agents Decongestants and antihistamines are used as adjunctive therapy. Clinical trials have yielded no significant evidence of benefit with either class of agents. Useibuprofenoracetaminophenfor pain.

Monitoring Patients who do not respond to treatment should be reassessed. Persistent middle-ear effusion Common after resolution of symptoms of acuteotitismedia(6070% at 2 weeks, 1025% at 3 months) Requires monitoring (can cause hearing loss), but is not an indication for further antibiotic therapy Hearing and language testing is recommended in children with:[1] Suspected hearing lossor Persistent effusion for at least 3 monthsand Developmental problems

Complications Acuteotitismedia Perforated tympanic membrane Mastoiditis Labyrinthitis Chronicotitismedia Serousotitismedia Significant hearing loss causing cognitive or developmental delay Chronicotitismedia Bony erosion Mastoiditis Subperiosteal abscess (after tracking of infection under periosteum of temporal bone) Deep neck abscess (after erosion through mastoid tip) Septic thrombosis of lateral sinus (from posterior extension) Meningitis Brain abscess Paralysis of cranial nerve VII

Prognosis Most cases of acuteotitismediaresolve clinically 1 week after onset of symptoms. ~80% of children with acuteotitismediarespond to high-doseamoxicillintreatment. Persistent (sterile) middle-ear effusion for 3 months after resolution of symptoms is documented in 1025% of patients with acuteotitismedia. Mastoiditis usually responds to medical therapy.

Prevention Breast-feeding for at least the first 6 months of life Avoidance of cigarette smoke exposure Influenza vaccination decreases rates of acuteotitismediain some studies. Heptavalent pneumococcal conjugate vaccine Licensed in U.S. in 2000 Prevents vaccine-serotype pneumococcal disease but may be associated with increase in nonvaccine-serotyperelated disease Has led to modest decreases in overall rates of respiratory tract infections (otitismedia, pneumonia) with greater decreases in rates of invasive pneumococcal disease (bacteremia, meningitis) Has decreased numbers of office visits forotitismediain some studies Has reduced rates of tympanostomy tube placement in children in some studies Chemoprophylaxis (with a half-dose ofamoxicillindaily) for patients with severe and recurrent infections (during fall, winter, and early spring) can reduce recurrences in patients with recurrent acuteotitismediaby an average of 1 episode per year. Benefit is small compared with the cost of the drug and the high likelihood of colonization with antibiotic-resistant pathogens. Antibiotic treatment of acuteotitismediaprevents mastoiditis.

PEARLS Acuteotitismediatypically follows an upper respiratory tract infection, occurring when pathogens from the nasopharynx are introduced into the sterile transudative inflammatory fluid collected in the middle ear. A diagnosis of acuteotitismediarequires acute signs and symptoms of middle-ear inflammation and a middle-ear effusion. Many cases of acuteotitismediaare caused by viral pathogens; common contributing bacterial organisms areS. pneumoniae,H. influenzae, andM. catarrhalis. Observation without antibiotic treatment is an option for selected patients; this decision is based on age, diagnostic certainty, illness severity, and reliability of follow-up. Amoxicillinremains the initial treatment of choice for acuteotitismedia; a response in clinical symptoms is expected within 4872 hours. Middle-ear effusion may persist for weeks thereafter and requires monitoring to avoid the risk of hearing loss that can contribute to cognitive and developmental delay. Chronic suppurativeotitismedia, associated with tympanic membrane perforation, can be associated with bony erosion promoting invasive infection. Pneumococcal and influenza vaccines may be effective in decreasing the rate of acuteotitismedia.