OTITIS MEDIA

Nilson L. Gelbolingo, M.D. FPSO-HNS

 OTITIS MEDIA
• One of the most common childhood diseases
• Leading cause of hearing loss in children
• Most frequent indication for antimicrobial or
surgical therapy in children
 DEFINITION
• Inflammation within the middle ear cleft beginning
behind an intact tympanic membrane (TM).

• Acute otitis media (AOM)

> signs & symptoms of acute infection
- fever
- pain
- bulging TM
- middle ear effusion
 EPIDEMIOLOGY
• 2/3 of all infants have at least one ear
infection before 2 years old

• Highest age-specific incidence:

between 6 & 18 months of age
 PREDISPOSING FACTORS
• Young age
• Male gender
• Heredity
• Poor economic & social conditions
• Season of the year
• Environmental factors
- smoking
- attendance at a daycare center
- food allergies
- bottle- feeding
 MICROBIOLOGY
• Organisms
- Streptococcus pneumoniae
- Haemophilus influenza
- Moraxella catarrhalis
- Group A Streptococcus
- Staphylococcus aureus
 OTHER ORGANISMS
• Mycobacterium tuberculosis
- painless, watery otorrhea through
single or multiple perforations

Chlamydia trachomatis
Pathophysiology
 AOM common before 6 years of age
- maturation effect/ changes in the immune
system
- maturation of the Eustachian tube (ET)

Infancy Adulthood
ET angle 16˚ 45˚
ET length 18 mm 35 mm
 Swelling of ET (Allergy/ Infection)

Resultant absorption of ET

Absorption of air in ME

Negative pressure in ME

Exudation of fluid

Trapping of secretion with proliferation of bacteria

ACUTE OTITIS MEDIA

 NEW THEORY

Abnormally patent/ compliant ET

Bacterial entry into ME

ACUTE OTITIS MEDIA

 STAGES OF AOM
• Stage of hyperemia
 Symptoms
- sense of ear fullness
- mild hearing loss
- fever
- earache
 Sign
- hyperemic TM
 STAGES OF AOM
• Stage of exudation
 Symptoms
- marked hearing loss
- fever
- severe earache
 Sign
- TM thickened & bulging
 STAGES OF AOM
• Stage of suppuration
 TM perforates
 Symptoms
- decrease intensity of
symptoms
- marked hearing loss
 Sign
- TM perforation
 STAGES OF AOM
• Stage of coalescence
 1% to 5% of cases – persistence
of infection
 Symptom
- continued ear discharge
 Signs
- pain & mastoid tenderness
- fever
- leukocytosis
 X-Ray: decalcification &
destruction of mastoid cell
partition
 DIAGNOSIS
• Otoscopy
 Classic sign
- redness & bulging of TM

• Tympanometry
 Demonstrates effusion
(type B tympanogram)
ACUTE OTITIS MEDIA
 DIAGNOSIS
• Tympanocentesis
 not routinely done
 confirm diagnosis by demonstrating
bacteria on culture
• Radiographic imaging
 reserved for cases with possible
suppurative complications
 MANAGEMENT
• Antimicrobial therapy
 Mainstay of treatment
 Amoxicillin
- 1st line treatment given x 10 days
- alternative drugs:
● TMP-SMZ
● Erythromycin-Sulfisoxazole
 MANAGEMENT
• 2nd line drugs:
 Amoxicillin-Clavulanate
 Cefuroxime
 Cefixime
 Cefprozil
 Loracarbef
 Cefpodoxime
 Cefaclor
 MANAGEMENT
• Adjunct medical therapy
 decongestants & antihistamines

• Supportive therapy
 analgesics
 antipyretics
 local heat
 MANAGEMENT
• Amoxicillin x 7 to 10 days as effective as:

• Ceftriaxone IM, single dose

• Azithromycin x 5 days

Rosenfeld RM et al, J Pediatr 1994, 124 355-367

Mc Cracken GH Jr, Pediatr Infect Dis J 1999, 18 1141-6
MANAGEMENT

• Tympanocentesis
 important in the following situations:
- AOM in a critically ill or septic child
- AOM with poor response to antibiotic
- Suppurative complications from AOM
- AOM in a newborn or in a child with
primary or secondary immunodeficiency in
whom an unusual organism may be present
 MANAGEMENT
• Myringotomy
 promptly relieves pain due to severe
AOM
 little effect on remission of infection
 MANAGEMENT

• If with tympanic membrane perforation

oral + topical antibiotics

 COMPLICATIONS
Mechanisms of Extension
 preformed pathways
 hematogenous
 thrombophlebitis
 bony erosions
 COMPLICATIONS

» Extracranial

» Intracranial
 COMPLICATIONS
• Extracranial complications
 TM perforation
 tympanosclerosis
 hearing loss
 serous labyrinthitis
 facial nerve paralysis
 mastoiditis
 subperiosteal abscess
 COMPLICATIONS
• Intracranial complications
 meninigitis
 lateral sinus thrombosis
 otitic hydrocephalus
 abscess
 focal otitic encephalitis
 PREVENTION
• Environmental factors
 risk factors identified – environmental
changes in the child’s home
 discourage bottle-feeding
 choose a daycare center with smaller
settings & with good ventilation
 PREVENTION
• Vaccines
 Pneumococcal vaccine
- effective in reducing the number of episodes of
AOM in children >2 y.o.
 Hemophilus influenzae type B vaccine
- most ear infections caused by non-
typable strains
 PREVENTION
• Vaccines
 33% to 36% reduction in AOM cases
during the period when influenza
virus was in the community

 no effect during the remainder of the

year
THANK YOU