Management of Otitis Media & Otitis Externa

1. Management of OtitisMedia & Otitis Externa Done By : Dr. Ali Madkhali Supervisor : Dr. Mohammed Al-Darbi

2. Objectives

3. Acute Otitis Media in Children

4. Diagnosis of AOM in Children

5. A 12-month-old male patient is brought into your office by his mother for fever, cough and pulling on his left ear. He is afebrile in your office, playful and interactive. When you examine his ear, the tympanic membranes are slightly erythematous, but he is uncooperative for pneumatic otoscopy. Your diagnosis is? • URI, acute otitis media uncertain • Otitis media with effusion • Acute otitis media • Ramsay Hunt syndrome A

6. TERMINOLOGY

7. IMPORTANCE OF ACCURATE DIAGNOSIS

8. Must use stringentcriteria • Ensure appropriatetreatment • Avoid overuse ofantibiotics • Three required elements to make the diagnosis • Acute onset of symptomsofotalgia • Acute signs of middle ear inflammation • Presence of a middle eareffusion Diagnosis of Acute OtitisMedia http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488SORTB

9. Symptoms of Acute Otitis Media

10. Signs of Middle Ear Inflammation

11. Diagnosis of Middle Ear Effusion • Decreased or absent mobility of TM • Do not diagnose AOM without demonstrating MEE • Pneumatic otoscopy – standard of care • Must have an air seal in canal and no air leaks in the system • Tympanometry

12. Middle Ear Effusion (MEE) • Bulging of the tympanic membrane remains the single most important sign of AOM and precludes the necessity of pneumatic otoscopy because all bulging membranes have decreased or absent mobility. • Pneumatic otoscopy can be extremely painful in children with AOM UpToDate 2019

13. MEE can be confirmed by one or both of the following findings on otoscopy : 1-     Bubbles or an air-fluid level 2-     Two or more of the following: A.     Abnormal color (white, yellow, amber, or blue) B.     Opacity (involving part or all of the tympanic membrane) not due to scarring C.    Impairment of mobility UpToDate 2019

14. Tympanometry Type Bcurve in MEE

15. AOM Diagnosis in children AAFP 2013 • An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa • Or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema. • AOM should not be diagnosed in children who do not have objective evidence of middle ear effusion.

16. AOM Diagnosis in children American Academy of Pediatrics 2013 • AOM should be diagnosed when there is moderate to severe tympanic membrane bulgingornew-onset otorrhea not caused by acute otitis externa • AOM may be diagnosed frommild tympanic membrane bulging and ear pain for less than 48 hours orfromintense tympanic membrane erythema; in a nonverbal child, ear holding, tugging, or rubbing suggests ear pain • AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show middle ear effusion

17. Tympanic membrane bulging • A- Normal TM. • B- Mild Bulging • C- Moderate Bulging • D- Severe Bulging

18. AOM Diagnosis in children :UpToDate 2019 • Bulging of the tympanic membrane, or • Signsof acute inflammation (eg, marked erythema of the tympanic membrane) Plus middle ear effusion  (MEE) • A diagnosis of AOM also can be established if there is acute purulent otorrhea and otitis externa has been excluded.

19. Otitis Media With Effusion (OME)

20. AOM vs OME • Bulging TM • TM red or yellow • Pus, otorrhea, or bullae • Retracted or neutral TM • TM amber or blue • Air fluid levels or bubbles

21. AOM vsOME (c) B.Welleschik

22. Management of AOM in Children

23. A 22-month-old male patient is brought to you crying and in obvious acute distress from right ear pain. He has a fever of 39.7 °C, has an immobile, bulging, erythematous right TM. The best treatment option would be? • Do not use antibiotics because this is probably a viral illness • Have the parents observe for 24-48 hours and treat with antibiotics if the child does not improve • Treat with antihistamines/decongestants alone • Start antibiotics immediately D

24. Treatment of AOM in children

25. Antibiotics or Observation?

26. Three bacterial pathogens

27. Treatment of AOM2013 AAP/AAFP Guideline

28. UpToDate < 2 years • With unilateral non-severe AOM who are initially managed with observation and analgesia : • We suggest that such children be treated with antimicrobial therapy.

29. Treatment of AOM2013 AAP/AAFP Guideline http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488SORTA

30. UpToDate ≥ 2 years old • Who are normal hosts (eg, immune competent, without craniofacial abnormalities) with mild symptoms and signs and no otorrhea : • initial observation may be appropriate if the caretakers understand the risks and benefits of such an approach. 

31. Observation of AOM2013 AAP/AAFP Guideline

32. You diagnose AOM with severe symptoms in a 22-month-old male patient who weighs 20 kg.What is the most appropriate treatment? • Amoxicillin 900 mg/day • Amoxicillin 1800 mg/day • Amoxicillin-clavulanate 900 mg/day • Amoxicillin-clavulanate 1800 mg/day B

33. Antibiotics forAOM2013 AAP/AAFP Guideline Amoxicillin 80-90 mg/kg per day Divided in two doses • First-line therapy • No recent beta-lactam therapy • No concomitant purulent conjunctivitis • No history of recurrent AOM Amoxicillin-clavulanate 90 mg/kg Divided in two doses for those: • Treated with ATBs (β-lactam) in last 30 days • With concurrent purulent conjunctivitis (Nontypeable H. influenzae) • History of recurrent AOM unresponsive to amoxicillin

34. Amoxicillin-clavulanate: • Dosing based on amoxicillin component • Infants and children ≥3 months • 14:1 formulations like : • Oral suspension (642.9 mg/5 mL) (amoxicillin 600 mg/clavulanate 42.9 mg) are less likely to cause diarrhea than other preparations

35. Penicillin allergy No urticaria or anaphylaxis (Non-type 1)

36. Penicillin allergy with urticaria or anaphylaxis (Type 1) • Macrolides • Erythromycin +sulfisoxazole • Azithromycin,clarithromycin • Clindamycin • Not recommended due toresistance • Trimethoprim-sulfamethoxazole • Levofloxacin

37. Duration of treatment • 10-day course ofantibiotics (AAFP/AAP) • Reduced course of antibiotics showedless favorableoutcomes • Neither adverse effects or emergence of drug resistance was lower with reduced length of treatment UptoDate <2 years For 10 days ≥2 years For 5-7 days • http://www.nejm.org/doi/pdf/10.1056/NEJMoa1606043

38. Persistent AOM UptoDate: Ceftriaxone 50 mg/kg IM or IV once per day (maximum 1g/day) for 2 or 3 doses.

39. AAP 2013

40. An 18-month-old male is brought to your office by his mother. The patient is tugging at both ears and has a temperature of 39.0°C. You diagnose bilateral acute otitis media for the third time in the last 6 months. The most recent infection was 3 weeks ago and resolution of the infection was documented after 10 days of treatment with amoxicillin. Which one of the following antibiotic regimens would be most appropriate at this time? • Amoxicillin, 45 mg/kg/day for 10 days • Amoxicillin, 90 mg/kg/day for 10 days • Amoxicillin, 90 mg/kg/day for 10 days followed by prophylactic treatment with amoxicillin for 6 months • Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day for 10 days • Amoxicillin/clavulanate, 90 mg/kg/day for 10 days followed by prophylactic treatmentwith amoxicillin for 6 months D

41. RecurrentAOM Development of signs and symptoms of AOM within 30 days  after completion of successful treatment

42. RecurrentAOM Antibiotic prophylaxis Minimize risk factors • Specifically NOT recommended • 2013 AAP/AAFP Guidelines • Exposure to cigarette smoke • Pacifier, bottle feeding • Daycare attendance Persistent treatment failure : Refer

43. You treated a child with AOM with antibiotics and see him back 4 weeks later. The child is asymptomatic, but you determine he has a middle ear effusion. Your recommendation would be? • Reassurance and reevaluate in 2 months • Oral antihistamine for 30 days • Re-treat with amoxicillin-clavulanate • Oral low-dose steroids for 30 days • ENT referral A

44. Follow-up forAOM http://www.uptodate.com/online/content/topic.do?topicKey=pedi_id/10593&selectedTitle=1~150&source=search_resultSORTC

45. Treatment of Otitis Media With Effusion (OME) • Watchful waiting for 3 months • Test for hearing loss at three months • Tympanostomy tubes is preferred procedure <4 years • Tympanostomy tubes, adenoidectomy or both >4 years • Do NOT use antibiotics, antihistamines, decongestants or steroids Otolaryngol Head Neck Surg. February 2016;154(suppl 1):S1–S41. Am Fam Physician. 2016 Nov 1;94(9):747-749. SORTA/B

46. Management of Acute Otitis Media in Adults

47. Treatment of AOM in Adults

48. Patients at high risk for severe infections • Older than 65 years • Immunocompromised • Recently hospitalized • Have used antibiotics in the past month • Amoxicillin 1000 mg with clavulanate 62.5 mg, extended-release, orally twice daily • Amoxicillin 2000 mg with clavulanate 125 mg, extended-release, orally twice daily

49. Penicillin allergy : without severe reactions • Who do not have a known allergy to a cephalosporin, : • Cefdinir, 300 mg orally twice daily or 600 mg once daily. • Cefpodoxime, 200 mg orally twice daily. • Cefuroxime, 500 mg orally twice daily. • Ceftriaxone, 1 to 2 g intravenously (IV) or 1 g intramuscularly (IM) once daily for three days.

50. Penicillin allergy