Otitis Media

3. 1. Definition, Terminology, Classification Otitis media : inflammation of the middle ear without reference to etiology or pathogenesis Acute otitis media : inflammation of the middle ear with rapid onset of one or more local or systemic signs and symptoms of acute infection within the middle ear (otalgia, otorrhea, fever, anorexia, vomiting or diarrhea) Acute otitis media without effusion (myringitis): erythema and opacification of the eardrum. Blebs or bullae may be present. Recurrent otitis media (5 to 10% of children) > 3 episodes of AOM in 3 months with evidence of cure between episodes > 4 episodes of AOM in 6 months

5. Definition, Terminology, Classification Otitis media with effusion (SOM, OME): inflammation of middle ear with liquid collected in middle-ear space. Signs and symptoms of acute infection are absent; no perforation of the tympanic membrane Middle-ear effusion : liquid in middle ear. Effusion may be serous (thin watery liquid), mucoid (thick viscid mucus-like liquid), purulent or a combination of these An effusion can result from AOM or OME. It can be of recent onset, acute, or long-lasting, subacute or chronic.

7. Definition, Terminology, Classification Eustachian Tube dysfunction : middle ear disorder that can have symptoms similar to those of otitis media such as hearing loss, otalgia and tinnitus, but with no middle ear effusion. The dysfunction may be related to an Eustachian tube that is too closed (i.e. obstructed) or too open (i.e. patulous). The latter condition is most frequently associated with symptoms of autophony.

9. 2. Diagnosis Accurate diagnosis is important to avoid unnecessary treatment ! 1. Medical history 2. Physical examination

10. Diagnosis : Medical history Otalgia : most common, ear pulling, irritability Otorrhea Hearing loss Fever Preceding upper respiratory tract infection Purulent conjunctivitis (Haemophilus influenzae) Vertigo : not common as a complaint, unilateral disease, clumsiness Nystagmus : labyrinthitis ! Tinnitus Swelling about the ear : dd mastoiditis, external otitis, adenitis Facial paralysis

11. Diagnosis AOM preceding URI fever otalgia otorrhea hearing loss OME possible asymptomatic hearing loss “plugged” “popping”

12. Diagnosis : Physical examination Adequate examination of the head and neck region ! associated exanthema predisposing factors alarm symptoms …

13. Diagnosis : otoscopy

15. Epidemiology : risk factors I. Host-Related factors (intrinsic) Age gender : males more prone to persistent MEE race : american natives and inuits > whites > blacks cleft palate/craniofacial abnormality/Down Syndrome genetic allergy and immunity

16. Age highest incidence of AOM between 6 months and 11 months of age onset of first episode before 6 months of age is strong predictor for recurrent OM risk for persistent MEE after AOM inversely correlated with age (>4 times when < 2 years of age)

17. Cleft palate/Craniofacial abnormality/Down Syndrome OM is present in nearly all infants under 2 years of age with unrepaired clefts of the palate occurrence reduces following surgical repair Children with Down : poor active opening function of ET, low resistance of tube

18. Genetic predisposition to recurrent episodes of AOM and chronic MEE may have a significant genetic component suggested by anatomic, physiologic and epidemiologic data twin studies (Norway, Pittsburg) familial clustering genetic markers : G2m(23) associated with rAOM

19. 2. Environmental factors (extrinsic) season and upper respiratory infection day care / home care siblings passive smoking (Etzel et al.) breast feeding / bottle feeding socio-economic status pacifier use

22. OM - smoke exposure Induces changes in respiratory tract Increased dysfunction of ET, otorrhea, chronic and recurrent AOM in children with history of parental smoking

23. 4. Microbiology S. pneumoniae – 50-55% H. influenzae - 20-25% infernal trio M. catarrhalis - 10-15% Group A strep - 2-4% Staph Aureus ? Infants : higher incidence of gram negative bacilli

24.

25. Chronic MEE previously thought sterile 30-50% grow in culture over 75% PCR + usual organisms PCR : polymerase chain reactionPCR : polymerase chain reaction

26. 5. Pathogenesis of OM

30. Eustachian tube Usually closed Opens during swallowing, yawning, and sneezing Opening involves cartilaginous portion Tensor veli palatini responsible for active tubal opening No constrictor function

40.  Pathofysiology (1): Development of otitis media Pathogens must adhere to nasopharyngeal epithelium Pathogens must enter the ME cavity through the Eustachian tube (ET) Pathogens must be able to withstand and overcome the defensive mechanisms of tubotympanum Viruses, IgE-mediated hypersensitivity , overuse (inadequate) use of antibiotics, may trigger changes in nasopharyngeal flora leading to otitis media.

43. 6.1 Treatment Acute otitis media Goals: Decreasing the duration of fever and pain Expediting the resumption of normal activity Limiting the small potential for suppurative complications

44. Spontaneous cure in up to 80 percent of children treated only with analgesics Antibiotics increase cure rate to 94 percent, and decrease duration of symptoms and risk of complications Broad spectrum antibiotics probably offer no advantages over standard antimicrobials

45. Take into account: History of allergy or intolerance to a particular antibiotic or class of antibiotic Presumed causative organism (Streptococcus pneumoniae is most likely in a child previously untreated for AOM)

46. Take into account: Antibiotic exposure within the previous 30 days may have caused resistant organisms to predominate Conjunctivitis/Otitis Syndrome is suggestive of H. influenzae infection

49. Problem of Resistance Strep. Pneumoniae Target resistance H. influenzae and M. catarrhalis beta-lactamase production All M. catarrhalis + 15-25% of H. influenzae Clavulanic acid

50. Blinde start (empirische therapie) of na (kweek) antibiogram ? « Blind » Vooral in routine, ongecompliceerde infectie, goed gedocumenteerd in (rec) literatuur Op basis va kweek/antibiogram Vooral indien ernstig, herhaaldelijk, mislukking (verwekker/antibiogram onvoorspelbaar)

51. Follow-up Once antibiotic treatment is initiated the child should demonstrate symptomatic benefit within 72 hours Failure to show improvement indicates need for re-evaluation. A follow-up examination should be scheduled for one month after the diagnosis and should include: - Inspection of the tympanic membrane - Assessment of hearing

52. Follow-up The purpose of the follow-up exam is to identify persistent otitis media or persistent middle ear effusion Children with persistent otitis media or persistent middle ear effusion should be seen on a monthly basis until their exam is normal

53. 6.2 Treatment Recurrent Otitis media Chemoprophylaxis Sulfisoxazole, amoxicillin, ampicillin less efficacy for intermittent propylaxis Myringotomy and tube insertion Decreased frequency and severity of AOM otorrhea and other complications may require prophylaxis if severe Adenoidectomy 28% and 35% fewer episodes of AOM at first and second years

54. 6.3 Treatment Recurrent Otitis media Spontaneous resolution rates for OME OME persisting after AOM 1m 60% (55-65%) 3m 74% (67-80%) OME of unspecified duration <1m 52% (47-58%) 2-3m 63% (60-66%) 4-6m 76% (73-79%) 7-9m 82% (79-86%) 10-12m 88% (84-90%) 13-15m 92% (89-95%) 16-24m 97% (95-99%)

55. Natural history of OME Extremely dynamic course of OME :30-40% of children have recurrent episodes Spontaneous resolution depending on seasonal variation Seasonal trends < important in long-term cases

56. Natural history of OME 1. Most OME resolves within a few months, prognosis inversely related to duration : newly diagnosed OME does extremely well, OME lasting weeks or months does poorly 2. The chance of spontaneous resolution diminishes greatly after 3-6 months

57. Medical therapy 1. Antibiotic therapy of OME has a modest impact on short-term resolution 2. The impact on long-term resolution is smaller, if not negligible (Mandel, Giebink) 3. Steroid therapy and antihistamine-decongestant therapy have no proven effect on resolution of OME

58. Surgical therapy Ventilation tubes Adenoidectomy Maw, 1993 Beneficial effect of tubes or adenoidectomy compared with no surgery Further improvement when combination of tubes and adenoidectomy Gates, 1987 After adenoidectomy significant less time with effusion longer time to first recurrence fewer surgical re-treatments

60. Tympanostomy tube insertion Unresponsive OME >3 months bilaterally, or > 6 months unilateral, sooner if associated hearing problems Recurrent MEE with excessive cumulative duration Speech – language delay Recurrent AOM - >3/6 monthss or >4/12 months Eustachian tube dysfunction Suppurative complication Severe tympanic membrane retraction

62. Negative Prognostic factors Passive smoking Younger children at onset of OME Craniofacial malformations, Down syndrome Day-care attendance

63. Otitis media klinische directe en indirecte antibioticum gevolgen kosten resistentie PREVENTIE

64. Preventie OMA Beïnvloeden risicofactoren Chirurgie Chemoprofylaxie Immunoprofylaxie

65. 1. Beïnvloeden risicofactoren Gastheer afwijkingen KNO-gebied immunologische afwijkingen Omgeving dagverblijf passief roken fopspeen borstvoeding beschermt Submuceuze cleft (bifide uvula, diastasis van palatale spieren, noth thv posterieur palatum durum - allergie AW hypertrofie sinusitisSubmuceuze cleft (bifide uvula, diastasis van palatale spieren, noth thv posterieur palatum durum - allergie AW hypertrofie sinusitis

66. 2. Chemoprofylaxie Meta-analyse (9 studies) Antibioticum profylaxie 0.11 episodes OMA / maand Williams et al. JAMA 1993 Amoxicillin profylaxis for recurrent AOM has an efficacy no better than placebo durin gthe era of penicillin resistant pneumococci (Block et al 2001)Amoxicillin profylaxis for recurrent AOM has an efficacy no better than placebo durin gthe era of penicillin resistant pneumococci (Block et al 2001)

67. Grafiek profylaxis

68. 1 to 1.5 jaar therapie zijn nodig om een epîsode van AOM te voorkomen. Om 1 AOM te voorkomen moet het kind 1800 lepels Xylitol suiker innemen, 56OO Xylitol kauwgom of 15.200 Xylitol lozenges.1 to 1.5 jaar therapie zijn nodig om een epîsode van AOM te voorkomen. Om 1 AOM te voorkomen moet het kind 1800 lepels Xylitol suiker innemen, 56OO Xylitol kauwgom of 15.200 Xylitol lozenges.

69. 3. Immuunprofylaxie ~ Microbiologie Passieve immuunprofylaxie (immuunglobuline) Actieve immuunprofylaxie (vaccinatie)

70. 3.1. Passieve immuunprofylaxie Gammaglobuline IV - OM model in chinchilla’s (Shurin et al. 1988) - kinderen met rec. OMA (Shurin et al.1993) RSV IG IV - reduce incidence and severity of RSV lower respiratory tract infections (Simoes et al. 1996) Pooled serum van volwassen gevacc met pneumococcen polysacch vaccin, meningococcal en H. influenzae type B) Hoge dosis RSV verrijkt iglob Gammaglob te overwegen bij IgG2 deficientiesPooled serum van volwassen gevacc met pneumococcen polysacch vaccin, meningococcal en H. influenzae type B) Hoge dosis RSV verrijkt iglob Gammaglob te overwegen bij IgG2 deficienties

71. 3.2.Actieve immuunprofylaxie (vaccinatie) Influenza A virus vaccin Finland Kinderen 1-3 jaar Follow-up 6 weken Aan influenza A virus gerelateerd aantal OMA 86% Totaal aantal OMA (in influenzae seizoen) : 36% Heikinen et al. Am J Dis Child 1991

72. Pneumococcen vaccins Pneumococcen polysaccharide vaccin ( Pneumovax / Pneumune) Pneumococcen conjugaatvaccin ( Prevenar)

73. This is the cumulative hazard function for the pneumococcal vaccine group and the control vaccine group for the period starting 1 month after complete vaccination. The dutch and the Belgian group were analyzed independently. For both cohorts we see that vaccination with pneumococcal conjugate vaccine combined with 23-valent pneumococcal polysaccharide vaccine does not prevent AOM episodes in children, aged 1-6 years with previous AOM.(recurrent AOM). This confirms the results of the previous two large cohort trials. This is the cumulative hazard function for the pneumococcal vaccine group and the control vaccine group for the period starting 1 month after complete vaccination. The dutch and the Belgian group were analyzed independently. For both cohorts we see that vaccination with pneumococcal conjugate vaccine combined with 23-valent pneumococcal polysaccharide vaccine does not prevent AOM episodes in children, aged 1-6 years with previous AOM.(recurrent AOM). This confirms the results of the previous two large cohort trials.