CONSERVATIVE MANAGEMENT OF OTITIS MEDIA

REZAUR RAHMAN SIDDIQUISENIOR PRODUCT MANAGERUNIMED UNIHEALTH PHARMACEUTICAL LTD

ACUTE OTITIS MEDIA

According to “Scott-Brown's Otorhinolaryngology: Head and Neck Surgery”-The term ‘acute otitis media’ implies a viral or bacterial infection of the mucosal lining of the middle ear and mastoid air-cell system. It is characterized by an otoscopically abnormal tympanic membrane. The clinical presentation is usually with otalgia and systemic illness.

OTITIS MEDIA

According to “Ballenger's Otorhinolaryngology Head and Neck Surgery 17th Edition”-“Otitis media represents an inflammatory condition of the middle ear space without reference to cause or pathogenesis.”The process may be

acute (0 to3 weeks in duration), subacute (3 to 12 weeks in duration), or chronic (greater than 12 weeks in duration)

An effusion may be either serous (thin, watery), mucoid (viscid, thick), or purulent (pus)

ACUTE OTITIS MEDIA

Most frequently reported pediatric bacterial infection, with up to 85% of children experiencing an episode by the age of 3 years .

It is defined by rapid onset of signs/symptoms of inflammation in the middle ear such as pain, discharge, fever or irritability and bulging tympanic membrane (TM)due to an effusion or collection of fluid in the middle ear space.

Ref: Expert Opin. Pharmacother. (2014) 15(8):1069-1083 Otitis media: an

update on current pharmacotherapy and future perspectives

ACUTE OTITIS MEDIA

It is classified according to its onset, response to therapy, duration and complications, each of which calls for a specific management plan.

Generally AOM is defined as uncomplicated (no otorrhea), nonsevere (mild otalgia and temperature < 39C) or severe (moderate-to-severe pain, pain > 48 h, with temperature > 39C/102.2F)

Otitis media with effusion (OME), a different stage in the otitis media continuum, indicates asymptomatic inflammation with fluid collection in the middle ear. It may be a result of Eustachian tube dysfunction (ETD) and precede the onset of AOM, or it may be a result of inflammatory response following AOM

AOM

Uncomplicated AOM Otitis media without the

presence of Otorrhea

Nonsevere AOM Mild pain, Fever < 39C Intense erythema or mild

bulging of the TM

AOM

Severe AOM Moderate-to-severe pain Duration of pain > 48 h, Fever ‡ 39

C Moderate-to-severe bulging of the

TM

OME Asymptomatic Fluid collection in middle ear

Chronic OM

Chronic OM with effusion Persistent effusion > 6 weeks

Chronic suppurative OM Chronic otorrhea Leads to damage of structures and

potential hearing loss

Organisms in Acute and Chronic Suppurative Otitis Media

OUTCOMES OF OTITIS MEDIA

Ref: Diseases of the Ear, Nose and Throat

Factors Affecting Risk of Acute Otitis Media

Age Maximal incidence between six and 24 months of age; eustachian tube shorter and less angled at this age. Underdeveloped physiologic and immunologic responses to infection in children

Breastfeeding Breastfeeding for at least three months is protective; this effect may be associated with position maintained during breastfeeding, suckling movements, and protective factors in breast milk

Daycare attendance* Contact with multiple children and daycare providers facilitates spread of bacterial and viral pathogens

Factors Affecting Risk of Acute Otitis Media

Exposure to cigarette smoke Increased incidence with cigarette smoke and air pollution, especially if parents smoke

Male sex Slightly increased incidence Previous antibiotic use* Increased risk of antibiotic treatment

failure Previous otitis media* Increased risk of antibiotic treatment

failure Season*Increased incidence in fall and winter Underlying pathology* Increased incidence in children with

allergic rhinitis, cleft palate, Down syndrome

Pathophysiology

An allergy or URTI causes obstruction of the ET which results in accumulation of middle ear secretions (effusion).

Secondary bacterial or viral infection of the effusion causes suppuration and features of AOM.

The effusion may persist for wks or months after the infection resolves.

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with AOM.

Penicillin-resistant S. pneumoniae is the most common cause of recurrent and persistent AOM.

Diagnostic criteria for OM (AOM)

Rapid onset of symptoms

Middle ear effusion (bulging TM, limited or absent mobility of membrane and air-fluid level behind membrane)

Signs and symptoms of middle ear inflammation (erythema of TM and otalgia affecting sleep or normal activity)

Diagnostic criteria for OM

AOM

Non-specific symptoms of AOM: Fever, Headache, Irritability, Cough, Rhinitis, Listlessness, Anorexia, Vomiting, Diarrhea

Otoscopy (acute otitis media)

Tympanometry: A flattened tracing (type B tracing) indicating middle ear effusion

Chronic supportive otitis media

Chronic suppurative otitis media presents with persistent or recurrent otorrhea through a perforated TM.

Treatment of AOM

Treatment goals in AOM include symptom resolution and reduction of recurrence.

Most children with AOM have spontaneous resolution within seven to 14 days

Nasal Decongestant Antihistamine Antibiotics

Treatment AOM (Symptomatic)

Pain management is important in the first two days after diagnosis.

Acetaminophen (15 mg/kg every four to six hrs) and ibuprofen (10 mg/kg every six hrs)

.

Treatment AOM (antibiotics)

Antibiotics are recommended for all children younger than six months, for those six months to two years of age when the diagnosis is certain.

All children older than two years with severe infection (defined as moderate to severe otalgia or temperature greater than 39° C.

Treatment AOM (antibiotics)

High-dosage amoxicillin (80 to 90 mg/kg/day BD for 10 days) is recommended as first-line antibiotic therapy in children with AOM.

In children older than six years with mild to moderate disease, a five- to seven day course is adequate.

First-line treatment with amoxicillin is not recommended in children with penicillin allergy.

Treatment AOM (antibiotics)

Cephalosporins may be used in children allergic to penicillin if there is no history of urticaria or anaphylaxis to penicillin.

A single dose of parenteral ceftriaxone (50 mg per kg) may be useful in children with vomiting or in whom compliance is a concern.

If there is no clinical improvement within 48 to 72 hours, initiate antibiotic therapy in those on symptomatic treatment alone. Patients who are already taking antibiotics should be changed to second-line therapy.

Treatment of persistent AOM

Second-line therapy include cephalosporins (Cefdinir), and macrolides.

Parenteral ceftriaxone administered daily over three days is useful in children with emesis or resistance to amoxicillin/ clavulanate.

For children who do not respond to second-line antibiotics, clindamycin and tympanocentesis are appropriate options.

CT is useful if bony extension is suspected. MRI is superior to CT in evaluating potential intracranial complications.

Treatment of recurrent AOM

Most children with recurrent AOM improve with watchful waiting.

Although antibiotic prophylaxis may reduce recurrence, there are no widely accepted recommendations for antibiotic choice or prophylaxis duration.

Treatment of OM with effusion

Persistent middle ear effusion after resolution of AOM requires only monitoring and reassurance.

Children older than two years who have otitis media with effusion must be seen at 3-6 month intervals until effusion resolves.

Children with hearing loss of 40 dB or more should be referred for surgery.

Tympanostomy with ventilation tube insertion is the preferred initial procedure.

Adenoidectomy may be considered in children who have recurrent otitis media with effusion after tympanostomy if chronic adenoiditis is present or if adenoidal hypertrophy causes nasal obstruction.

Treatment of chronic suppurative OM

Topical antibiotics (e.g., quinolones, aminoglycosides, polymyxins) are more effective than systemic antibiotics in clearing the infection in patients with chronic suppurative otitis media.

Oral or parenteral antibiotics are useful in patients with systemic sepsis or inadequate response to topical antibiotics. They should be selected on the basis of culture and sensitivity results.

Tympanoplasty is an option in patients with chronic perforation and hearing

loss.

Mastoidectomy is often recommended for patients with chronic mastoiditis.

Recommended Therapy (American Family Physician)

Antimicrobials

Dosage Comments

Amoxicillin 80 to 90 mg per kg per day, given orally in two divided doses

First-line drug

Amoxicillin/clavulanate

90 mg of amoxicillin per kg per day; 6.4 mg of clavulanate per kg per day, given orally in two divided doses

Second-line drug

Cefdinir 14 mg per kg per day, given orally in one or two doses

As 1st line (in penicillin allergy)

Cefpodoxime 30 mg per kg once daily, given orally

Ceftriaxone 50 mg per kg once daily, given intramuscularly or intravenously

Topical agents Dosage Comments Ciprofloxacin/hydrocortisone

3 drops twice daily

Hydrocortisone/neomycin/ polymyxin B

4 drops three to four times daily

Ofloxacin 5 drops twice daily (10 drops in patients older than 12 years)

Recommended Therapy (American Family Physician)

Recommended Therapy Textbook of Infectious Diseases 2017, 4th ED)

Clinical Practice Guideline: Otitis Media with Effusion (Update) 2016This guideline, however, does not apply to patients <2 months or >12 years old.Action Statements

(1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child;

(2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both;

(3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy;

Clinical Practice Guideline: Otitis Media with Effusion (Update) 2016This guideline, however, does not apply to patients <2 months or >12 years old.Action Statements

(4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset

(5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME;

(7) should recommend against using antihistamines, decongestants, or both for treating OME.

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