“Acute Otitis Media” by Alex Ruan for OPENPediatrics

“Acute Otitis Media” by Alex Ruan for OPENPediatrics

Acute Otitis Media, by Alex Ruan and Dr. Jennifer
Cheng. Learning Objectives. By the end of this video, the student will
be able to describe the common risk factors and basic epidemiology of acute otitis media;
understand the interplay of anatomy and microbiology as it relates to the pathophysiology of the
illness; differentiate between acute otitis media, otitis media with effusion, and middle
ear effusion; recognize the common clinical presentation, describe the ear exam, understand
diagnostic criteria, and create a differential for otitis media and otalgia; understand the
basics of acute otitis media management. Introduction and Definitions. Acute otitis media is a very common reason
for sick visits and antibiotic administration in the pediatric population. It is most prevalent among children between
6 and 24 months old. And more than 80% of children have at least
one episode of otitis media by the time they reach school age. Besides young age, other risk factors include
family history, presence of siblings, daycare attendance, tobacco smoke, bottle propping,
lower socioeconomic status, and underlying immunodeficiency. While the incidence of acute otitis media
is increased during the fall and winter, the overall incidence of acute otitis media has
decreased over time with the introduction of pneumococcal conjugate vaccine and more
stringent diagnosis guidelines. It is important to define acute otitis media,
otitis media with effusion, and middle ear effusion. The most recent American Academy of Pediatric
guidelines define acute otitis media as moderate to severe bulging of the tympanic membrane,
or new onset of otorrhea not due to acute otitis externa, accompanied by acute signs
of illness and signs or symptoms of middle ear inflammation. Recurrent acute otitis media is defined as
three separate episodes in the last six months, or four or more episodes in the past 12 months. Otitis media with effusion is defined as inflammation
of the middle ear with liquid collected in the middle ear. Signs and symptoms of infection are absent. Middle ear effusion simply refers to fluid
in the middle ear and is found in both acute otitis media and otitis media with effusion. Anatomy. The middle ear is the portion of the ear between
the tympanic membrane and the oval window of the internal ear. It consists of three ossicles, the tympanic
cavity and the eustachian tube. The eustachian tube connects the tympanic
cavity to the nasopharynx and normally functions to ventilate and clear secretions from the
middle ear. Pathophysiology. The pathogenesis of acute otitis media typically
occurs as follows. First, the child develops a viral upper respiratory
infection, or some other preceding infection. This then leads to inflammation and edema
of the mucosa of the nose, nasopharynx, and, because of its connection, the eustachian
tube. This edema leads to the obstruction of the
eustachian tube, which prevents the drainage of middle ear secretions. As a result, fluid starts to collect in the
middle ear. Viral upper respiratory infections are actually
one of the most common causes of such dysfunction. Viruses and bacteria from the upper respiratory
tract enter the middle ear space through aspiration or reflux. The microbes then proliferate in this environment,
leading to the signs and symptoms of acute otitis media. Anatomically, a child’s use eustachian tube
is shorter and forms a shallower angle, thus making it easier for microbes to ascend to
the middle ear. The three most common bacteria in acute otitis
media are strep pneumoniae, nontypeable haemophilus influenzae, and moraxella catarrhalis. Other less common bacteria include group A
streptococcus and staph aureus. Viruses commonly seen include respiratory
syncytial virus, picornaviruses, coronaviruses, influenza, adenovirus, and metapneumovirus. Clinical Presentation. The presentation of acute otitis media depends
on the age of the child. An older child will classically present with
rapid onset otalgia, or ear pain. More commonly, especially in the young, preverbal
child, the presenting symptoms and signs are more non-specific. There may be a history of initial upper respiratory
infection symptoms, such as fever, rhinorrhea, or congestion. Other symptoms may include irritability or
fussiness, changes in sleep patterns, poor PO intake, vomiting, and/or even diarrhea. Otalgia may present as tugging or rubbing
of the ear. Other aspects of the history that should be
ascertained include daycare attendance, recent sick contacts, history of prior ear infections
and whether or not they were successfully treated, the presence of antibiotic allergies,
and, as with every sick visit, PO intake and urine output. Diagnosis. The diagnosis of acute otitis media is a clinical
one. It depends on being able to visualize the
tympanic membrane with the pneumatic otoscope. Before examining the ear, start with a review
of the child’s vital signs and general appearance. Is the child febrile, tachycardic, or tachypneic? Is the child happy and content, in no apparent
distress? Or is the child irritable and lethargic and
actively tugging on his or her ear? Next, make sure that the child is comfortably
positioned. Older children who are cooperative can be
easily examined on the exam table. Younger children will generally be more comfortable
in their caregiver’s arms or lying on the exam table with the caregiver by their side. When using the otoscope, ensure that the hand
with the otoscope is anchored securely against the child’s head to ensure a stable hold and
to prevent sudden movement. When viewing the to tympanic membrane, try
and examine these four characteristics– contour, color, translucency, and mobility. What is the contour of the tympanic membrane? Is it in a neutral position, or is it bulging
or retracted? What is the color? Is it translucent or opaque? How mobile is the tympanic membrane with air
insufflation? Normal is typically described as translucent,
pearly gray, in a neutral position without bulging or retraction with a visible light
reflex and good mobility. The view of the tympanic membrane may be obstructed
by cerumen, and this should be removed via a curette, gentle suction, or irrigation. The diagnosis of acute otitis media requires
signs of middle ear inflammation and presence of a middle ear effusion. Bulging of the tympanic membrane is the most
specific sign of middle ear inflammation. Insufflation of air with a pneumatic otoscope
can show decreased mobility, and this is one of the most sensitive and specific tests to
determine the presence of a middle ear effusion. In order to perform pneumatic otoscopy, gently
squeeze the insufflator attachment while observing the movement of the tympanic membrane. If fluid is present in the middle ear, membrane
movement will be impeded. In addition to acute otitis media, the differential
diagnosis for a child with otalgia should include otitis media with effusion, acute
otitis externa, foreign body, and ear trauma. Management. Isolation of the causative microbe is usually
not necessary unless the child is toxic, has an underlying immunodeficiency, or has a history
of failing antibiotic therapy, as treatment is usually empiric. Regardless of antibiotic treatment, age appropriate
analgesia is important, with acetaminophen or ibuprofen typically being first-line agents. Antibiotics are indicated for all infants
less than six months, regardless of mild or severe symptoms. They are also indicated in children six months
or older with unilateral or bilateral acute otitis media with severe signs or symptoms. This includes moderate to severe otalgia,
otalgia for at least 48 hours, or a temperature of 39 degrees Celsius or higher. Antibiotics are also indicated for children
6 to 23 months old with bilateral acute otitis media, irrespective of severe signs or symptoms. Antibiotics or observation with close follow-up
is indicated for children 6 to 23 months old with unilateral acute otitis media. Antibiotics or observation is also indicated
in children 24 months or older with unilateral or bilateral acute otitis media with mild
symptoms. Otherwise, watchful waiting is a reasonable
option for patients not meeting these criteria. With observation, one must ensure close follow-up
and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72
hours of onset of symptoms. The first-line antibiotic is amoxicillin,
assuming no beta-lactam therapy in the past month. No purulent conjunctivitis. Patients typically start to see symptomatic
improvement within 48 to 72 hours. If not, a follow-up appointment should be
made for re-evaluation. In those patients that are successfully treated,
otitis media with effusion is a common sequela that usually resolves in six weeks without
intervention. Therefore, follow-up in about two months is
warranted to evaluate for the resolution of otitis media with effusion as this can be
associated with conductive hearing defects, leading to developmental delay. Purulent conjunctivitis is typically caused
by nontypeable H flu, which is usually resistant to amoxicillin, secondary to production of
beta-lactamase. In these situations, amoxicillin clavulanate
is indicated, given an increased risk of resistance. If allergic to penicillin, alternatives include
cephalosporins, such as cefdinir or cefuroxime, or macrolides, such as azithromycin. Patients with recurrent acute otitis media,
in addition to receiving appropriate antibiotic therapy, can be referred to an ear, nose,
and throat specialist for consideration of tympanostomy tubes in order to decrease the
risk of hearing loss and speech delay. Complications of acute otitis media include
hearing loss, balance or motor issues, tympanic membrane perforation, cholesteatoma, mastoiditis,
meningitis, bacterial abscess, and cavernous sinus thrombosis. Summary. In summary, acute otitis media is a common
reason for pediatric sick visits and antibiotic prescriptions. It’s incidence is higher in the fall and winter
months and is usually preceded by a viral upper respiratory infection, predisposing
to infection of the middle ear space. The diagnosis is dependent on seeing middle
ear effusion and a bulging tympanic membrane or other signs of acute inflammation. This must be successfully distinguished from
otitis media with effusion, as management may require antibiotics with high-dose amoxicillin
being the first-line agent. Proper analgesia is also critical. Thank you for watching this video on acute
otitis media.


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