Upper respiratory infections in children 2015
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UPPER RESPIRATORY TRACT INFECTIONS Common cold Pharyngitis Sinusitis Ear infections
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Upper respiratory infections in children 2015
- 3. Upper Respiratory Infections Khaled Saad Zaghloul MD Pediatrics
- 4. UPPER RESPIRATORY TRACT IFECTIONS Common cold Pharyngitis Sinusitis Ear infections
- 5. Common coldCommon cold Young children have 6-8 colds per year, butYoung children have 6-8 colds per year, but 10-15% of children have at least 1210-15% of children have at least 12 infections per year. The incidence of illnessinfections per year. The incidence of illness decreases with age, with 2-3 illnesses perdecreases with age, with 2-3 illnesses per year by adulthood.year by adulthood. Children in out-of-home daycare centersChildren in out-of-home daycare centers during the 1st year of life have 50% moreduring the 1st year of life have 50% more colds than children cared for only at home.colds than children cared for only at home.
- 6. Pathogens Associated with thePathogens Associated with the Common ColdCommon Cold
- 7. Conditions That Can Mimic theConditions That Can Mimic the Common ColdCommon Cold
- 8. Clinical features of common coldClinical features of common cold Rhinorrhea, sore throat, cough, fever andRhinorrhea, sore throat, cough, fever and malaise lasting up to 7 days.malaise lasting up to 7 days. In infants cold may manifest as irritability,In infants cold may manifest as irritability, snuffles and difficulty with feeding.snuffles and difficulty with feeding. Infants under 3 months of a age areInfants under 3 months of a age are susceptible to LRTI.susceptible to LRTI.
- 9. TREATMENTTREATMENT The management of theThe management of the common cold consistscommon cold consists primarily of supportive care asprimarily of supportive care as recommended by Americanrecommended by American Academy of Pediatrics.Academy of Pediatrics.
- 10. Antiviral TreatmentAntiviral Treatment Specific antiviral therapy is not available forSpecific antiviral therapy is not available for rhinovirus infections.rhinovirus infections. Ribavirin, which is approved for treatment ofRibavirin, which is approved for treatment of severe RSV infections, has no role in thesevere RSV infections, has no role in the treatment of the common cold.treatment of the common cold. Oseltamivir and zanamivir have a modest effectOseltamivir and zanamivir have a modest effect on the duration of symptoms associated withon the duration of symptoms associated with influenza viral infections in children.influenza viral infections in children.
- 11. The use of oral nonprescription therapiesThe use of oral nonprescription therapies (often containing antihistamines, antitussives,(often containing antihistamines, antitussives, and decongestants) for cold symptoms inand decongestants) for cold symptoms in children is controversial. Although some ofchildren is controversial. Although some of these medications are effective in adults, nothese medications are effective in adults, no study demonstrates a significant effect instudy demonstrates a significant effect in children, and there may be serious sidechildren, and there may be serious side effects.effects.
- 12. The American Academy ofThe American Academy of Pediatrics recommends thatPediatrics recommends that nonprescription cough andnonprescription cough and cold products not be used forcold products not be used for infants and children youngerinfants and children younger than 6 year of age.than 6 year of age.
- 13. Zinc, given as oral lozenges reduces theZinc, given as oral lozenges reduces the duration of symptoms of a common coldduration of symptoms of a common cold if begun within 24 hr of symptoms. Theif begun within 24 hr of symptoms. The function of the rhinovirus 3C protease, anfunction of the rhinovirus 3C protease, an essential enzyme for rhinovirusessential enzyme for rhinovirus replication, is inhibited by zinc, but therereplication, is inhibited by zinc, but there has been no evidence of an antiviral effecthas been no evidence of an antiviral effect of zinc in vivo.of zinc in vivo.
- 14. RhinorrheaRhinorrhea The first-generation antihistamines may reduceThe first-generation antihistamines may reduce rhinorrhea by 25-30%. The anticholinergic ratherrhinorrhea by 25-30%. The anticholinergic rather than the antihistaminic properties of these drugs, andthan the antihistaminic properties of these drugs, and therefore the second-generation or “nonsedating”therefore the second-generation or “nonsedating” antihistamines have no effect on common coldantihistamines have no effect on common cold symptoms.symptoms. The major adverse effects are sedation or paradoxicalThe major adverse effects are sedation or paradoxical hyperactivity. Overdose may be associated withhyperactivity. Overdose may be associated with respiratory depression or hallucinations.respiratory depression or hallucinations.
- 15. CoughCough Cough suppression is generally not necessaryCough suppression is generally not necessary in patients with colds.in patients with colds. Cough appears to be from postnasal drip, andCough appears to be from postnasal drip, and treatment with a first-generation antihistaminetreatment with a first-generation antihistamine may be helpful.may be helpful. Honey (5-10 mL in children ≥1 year old) has aHoney (5-10 mL in children ≥1 year old) has a modest effect on relieving nocturnal coughmodest effect on relieving nocturnal cough
- 16. In some patients, cough may be a result of virus-In some patients, cough may be a result of virus- induced reactive airways disease. These patientsinduced reactive airways disease. These patients can have cough that persists for days to weekscan have cough that persists for days to weeks after the acute illness and might benefit fromafter the acute illness and might benefit from bronchodilator.bronchodilator. Codeine or dextromethorphan has no effect onCodeine or dextromethorphan has no effect on cough from colds and has potential enhancedcough from colds and has potential enhanced toxicity.toxicity. Expectorants such as guaifenesin are not effectiveExpectorants such as guaifenesin are not effective antitussive agents.antitussive agents.
- 17. Ineffective TreatmentsIneffective Treatments Vitamin C, guaifenesin, and inhalation ofVitamin C, guaifenesin, and inhalation of warm, humidified air are not effective.warm, humidified air are not effective. Echinacea extracts is not effective as aEchinacea extracts is not effective as a common cold treatment.common cold treatment. There is no evidence that the common cold orThere is no evidence that the common cold or persistent acute purulent rhinitis of less thanpersistent acute purulent rhinitis of less than 10 days in duration benefits from antibiotics.10 days in duration benefits from antibiotics.
- 19. Inflammation of the Pharynx andInflammation of the Pharynx and TonsilsTonsils One of the most common pediatric infections.One of the most common pediatric infections.
- 20. Pathogens:Pathogens: Viral:Viral: Rhino/Adeno/Corona/EBV/CMV/ HSVRhino/Adeno/Corona/EBV/CMV/ HSV Bacterial:Bacterial: Streptococcus pyogenes – most serious typeStreptococcus pyogenes – most serious type -Scarlet fever-Scarlet fever -Rheumatic fever-Rheumatic fever -Glomerulonephritis-Glomerulonephritis
- 21. Infectious Agents That Cause PharyngitisInfectious Agents That Cause Pharyngitis
- 22. Pathogens:Pathogens: > 0-2 years Viral ++++ GAS+0-2 years Viral ++++ GAS+ > 5-above Viral +++ GAS++5-above Viral +++ GAS++ (15-20%)(15-20%)
- 24. Streptococcus infection causing inflammation of the throat and tonsils.
- 25. TreatmentTreatment Specific therapy is unavailable for most viralSpecific therapy is unavailable for most viral pharyngitis. However, symptomatic therapy can be anpharyngitis. However, symptomatic therapy can be an important part of the overall treatment plan.important part of the overall treatment plan. An oral antipyretic/analgesic agent can relieve feverAn oral antipyretic/analgesic agent can relieve fever and sore throat pain.and sore throat pain. Anesthetic sprays and lozenges (often containingAnesthetic sprays and lozenges (often containing benzocaine, phenol, or menthol) can provide localbenzocaine, phenol, or menthol) can provide local relief in children.relief in children.
- 26. TreatmentTreatment Most untreated episodes of GAS pharyngitis resolveMost untreated episodes of GAS pharyngitis resolve uneventfully within 5 days, but early antibiotic therapyuneventfully within 5 days, but early antibiotic therapy hastens clinical recovery by 12-24 hr.hastens clinical recovery by 12-24 hr. The primary benefit and intent of antibiotic treatmentThe primary benefit and intent of antibiotic treatment is the prevention of acute rheumatic fever (ARF); it isis the prevention of acute rheumatic fever (ARF); it is highly effective when started within 9 days of onset ofhighly effective when started within 9 days of onset of illness. Antibiotic therapy does not prevent APSGN.illness. Antibiotic therapy does not prevent APSGN. Antibiotic therapy should not be delayed for childrenAntibiotic therapy should not be delayed for children with symptomatic pharyngitiswith symptomatic pharyngitis
- 28. TonsillectomyTonsillectomy Recurrent tonsillitisRecurrent tonsillitis Peritonsillar Abscess (Quinsy)Peritonsillar Abscess (Quinsy) Obstructive Sleep Apnea (KissingObstructive Sleep Apnea (Kissing Tonsils)Tonsils)
- 30. AdenoidectomyAdenoidectomy Chronic Secretory Otitis MediaChronic Secretory Otitis Media Upper Airway ObstructionUpper Airway Obstruction (Snoring)(Snoring)
- 32. SinusitisSinusitis Suppurative infection of the sinusesSuppurative infection of the sinuses
- 33. PredispositionPredisposition Common cold, Allergic rhinitis: Approximately 0.5-Common cold, Allergic rhinitis: Approximately 0.5- 2% of viral upper respiratory tract infections in2% of viral upper respiratory tract infections in children and adolescents are complicated by acutechildren and adolescents are complicated by acute symptomatic bacterial sinusitis.symptomatic bacterial sinusitis. Nasotracheal /nasogastric intubationsNasotracheal /nasogastric intubations Cyanotic heart diseaseCyanotic heart disease C.F, Ig disorders, immotile cilia syndromeC.F, Ig disorders, immotile cilia syndrome HIV, immune compromised patientsHIV, immune compromised patients
- 34. Sinus FormationSinus Formation At birth: Maxillary , Ethmoid andAt birth: Maxillary , Ethmoid and Sphenoid are present.Sphenoid are present. At one year: Frontal sinusAt one year: Frontal sinus Pneumotization comes laterPneumotization comes later
- 36. ETIOLOGYETIOLOGY The bacterial pathogens causing acute bacterialThe bacterial pathogens causing acute bacterial sinusitis in children include Streptococcussinusitis in children include Streptococcus pneumoniae (~30%), Haemophilus influenzaepneumoniae (~30%), Haemophilus influenzae (~20%), and Moraxella catarrhalis (~20%).(~20%), and Moraxella catarrhalis (~20%). Approximately 50% of H. influenzae and 100% ofApproximately 50% of H. influenzae and 100% of M. catarrhalis are β-lactamase positive.M. catarrhalis are β-lactamase positive. Approximately 25% of S. pneumoniae penicillinApproximately 25% of S. pneumoniae penicillin resistant.resistant.
- 37. PresentationPresentation Mucopurulent rhinorrhea.Mucopurulent rhinorrhea. Night cough.Night cough. Nasal speech.Nasal speech. Facial swelling (pain, headache,Facial swelling (pain, headache, tenderness).tenderness). X-Ray/CT shows clouding/air fluidX-Ray/CT shows clouding/air fluid level.level.
- 39. TherapyTherapy Amox- clavulenic acidAmox- clavulenic acid Cephalosporin: cefdinir, cefuroxime axetil,Cephalosporin: cefdinir, cefuroxime axetil, cefpodoxime, or cefixime.cefpodoxime, or cefixime. In older children, levofloxacin is an alternativeIn older children, levofloxacin is an alternative antibiotic.antibiotic. Azithromycin and trimethoprim-sulfamethoxazoleAzithromycin and trimethoprim-sulfamethoxazole are no longer indicated because of a high prevalenceare no longer indicated because of a high prevalence of antibiotic resistance.of antibiotic resistance.
- 40. TherapyTherapy In severe sinusitis, treatmentIn severe sinusitis, treatment with high-dose amoxicillin-with high-dose amoxicillin- clavulanate (80-90 mg/kg/day ofclavulanate (80-90 mg/kg/day of amoxicillin) should be initiated.amoxicillin) should be initiated. Ceftriaxone (50 mg/kg, IV orCeftriaxone (50 mg/kg, IV or IM).IM).
- 41. ComplicationsComplications orbital cellulitis (read it VIP)orbital cellulitis (read it VIP) epidural/ subdural empyemaepidural/ subdural empyema brain abscessbrain abscess dural sinus thrombosisdural sinus thrombosis MeningitisMeningitis osteomyelitis of the frontalosteomyelitis of the frontal bone (Pott puffy tumor)bone (Pott puffy tumor)
- 42. TTT of complicationsTTT of complications DrainageDrainage Broad spectrum antibiotics.Broad spectrum antibiotics.
- 43. Acute Otitis MediaAcute Otitis Media
- 44. Acute Otitis Media - DefinitionsAcute Otitis Media - Definitions The termThe term otitis media (OM)otitis media (OM) has 2 mainhas 2 main categories: acute infection, which iscategories: acute infection, which is termed suppurative ortermed suppurative or acute otitis mediaacute otitis media (AOM),(AOM), and inflammation accompaniedand inflammation accompanied byby middle-ear effusion (MEE),middle-ear effusion (MEE), termedtermed nonsuppurative ornonsuppurative or secretory OM,secretory OM, oror otitisotitis media with effusion (OME).media with effusion (OME).
- 45. These 2 main types of OM areThese 2 main types of OM are interrelated: acute infection usually isinterrelated: acute infection usually is succeeded by residual inflammation andsucceeded by residual inflammation and effusion that, in turn, predisposeeffusion that, in turn, predispose children to recurrent infection. MEE is achildren to recurrent infection. MEE is a feature of both AOM and of OME and isfeature of both AOM and of OME and is an expression of the underlying middle-an expression of the underlying middle- ear mucosal inflammation.ear mucosal inflammation.
- 46. Acute Otitis Media - DefinitionsAcute Otitis Media - Definitions Recurrent otitisRecurrent otitis >3 episodes of AOM within 6 months that middle ear is>3 episodes of AOM within 6 months that middle ear is normal, without effusions, between episodesnormal, without effusions, between episodes Most children with recurrent acute otitis media are otherwiseMost children with recurrent acute otitis media are otherwise healthyhealthy Otitis proneOtitis prone Six or more acute otitis media episodes in the first 6 years ofSix or more acute otitis media episodes in the first 6 years of lifelife 12% of children in the general population12% of children in the general population Persistent Middle-Ear EffusionPersistent Middle-Ear Effusion When an episode of otitis media results in persistence ofWhen an episode of otitis media results in persistence of middle-ear fluid for 3 months, & TM remains immobilemiddle-ear fluid for 3 months, & TM remains immobile More common in white children & < 2 yMore common in white children & < 2 y
- 47. AOM vs. COMAOM vs. COM Chronic otitis mediaChronic otitis media Called chronic serous otitis in the past, this pattern is usually defined asCalled chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.a middle-ear effusion that has been present for at least 3 months. Some sort of Eustachian tube dysfunction is the principal predisposingSome sort of Eustachian tube dysfunction is the principal predisposing factor.factor. Persistent structural changes, such as a persistent eardrum perforation,Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection.imply past otitis but not necessarily chronic infection. Acute otitis media is commonly defined as…Acute otitis media is commonly defined as… 1. Presence of a middle ear effusion (MEE)1. Presence of a middle ear effusion (MEE) 2. TM inflammation2. TM inflammation 3. Presenting with a rapid onset of symptoms such as fever, irritability, or3. Presenting with a rapid onset of symptoms such as fever, irritability, or earacheearache
- 48. Definition of acute otitis mediaDefinition of acute otitis media
- 49. Definition of AOMDefinition of AOM A diagnosis of AOM requires …A diagnosis of AOM requires … 1) History of acute onset of signs and1) History of acute onset of signs and symptomssymptoms 2) Presence of MEE2) Presence of MEE 3) Signs and symptoms of middle-ear3) Signs and symptoms of middle-ear inflammationinflammation
- 50. Acute Otitis MediaAcute Otitis Media The most common infection for which antibacterialThe most common infection for which antibacterial agents are prescribed for children in the USA.agents are prescribed for children in the USA. 1/31/3 of office visits to pediatricians.of office visits to pediatricians. The peak incidence and prevalence of OM is duringThe peak incidence and prevalence of OM is during the 1st 2 y of life. More than 80% of children willthe 1st 2 y of life. More than 80% of children will have experienced at least 1 episode of OM by the agehave experienced at least 1 episode of OM by the age of 3 y.of 3 y.
- 51. Normal TMNormal TM GrayGray PinkPink
- 52. Clinical diagnosisClinical diagnosis A diagnosis of AOM can be established if acute purulentA diagnosis of AOM can be established if acute purulent otorrhea is present and otitis externa has been excluded.otorrhea is present and otitis externa has been excluded. Presence of a middle ear effusionPresence of a middle ear effusion && acute signs of middleacute signs of middle ear inflammationear inflammation in presence ofin presence of acute onset of signs ´ onset of signs & symptomssymptoms
- 53. HistoryHistory Children with AOM usually present with …Children with AOM usually present with … History of rapid onset of otalgia (or pulling of the ear in anHistory of rapid onset of otalgia (or pulling of the ear in an infant), irritability, poor feeding in an infant or toddler, otorrhea,infant), irritability, poor feeding in an infant or toddler, otorrhea, and/orand/or feverfever Except otorrhea other findings are nonspecific i.e.Except otorrhea other findings are nonspecific i.e. Fever, earache, and excessive crying present in children …Fever, earache, and excessive crying present in children … 90%90% with AOMwith AOM 72%72% without AOMwithout AOM
- 54. Laboratory testsLaboratory tests Routine laboratory studies, including completeRoutine laboratory studies, including complete blood count and ESR, are not useful in theblood count and ESR, are not useful in the evaluation of otitis media.evaluation of otitis media.
- 55. OtoscopyOtoscopy The key to distinguishing AOM from OME is theThe key to distinguishing AOM from OME is the performance ofperformance of pneumatic otoscopypneumatic otoscopy usingusing appropriate tools and an adequate light sourceappropriate tools and an adequate light source Use of visual otoscopy alone is discouragedUse of visual otoscopy alone is discouraged
- 56. Pneumatic otoscope - equipmentPneumatic otoscope - equipment
- 59. Systematic assessmentSystematic assessment of the TM by the use of theof the TM by the use of the COMPLETECOMPLETE ColorColor Other conditionsOther conditions Mobility PositionMobility Position LightingLighting Entire surfaceEntire surface TranslucencyTranslucency External auditory canal and auricleExternal auditory canal and auricle
- 60. Normal tympanic membraneNormal tympanic membrane
- 61. Middle-Ear EffusionMiddle-Ear Effusion MEE is commonly confirmed …MEE is commonly confirmed … Directly by…Directly by… TympanocentesisTympanocentesis Presence of fluid in the external auditory canalPresence of fluid in the external auditory canal Indirectly by…Indirectly by… Pneumatic otoscopyPneumatic otoscopy TympanometryTympanometry Acoustic reflectometryAcoustic reflectometry
- 62. Signs of presence of MEESigns of presence of MEE
- 63. Signs of presence of MEESigns of presence of MEE Fluid levelFluid level BobblesBobbles
- 64. Signs of presence of MEESigns of presence of MEE PerforationPerforation Cobble stoningCobble stoning
- 66. Signs of presence of MEESigns of presence of MEE OpaqueOpaqueSemi-opaqueSemi-opaque
- 68. Signs of presence of MEESigns of presence of MEE WhiteWhitePale yellowPale yellow
- 69. Signs of presence of MEESigns of presence of MEE BulgingBulgingDistinct fullnessDistinct fullness
- 71. Signs of middle-ear inflammationSigns of middle-ear inflammation Marked rednessMarked rednessInjectionInjection
- 72. Established acute otitis mediaEstablished acute otitis media
- 73. Differential diagnosis -Differential diagnosis - Other conditionsOther conditions Redness of tympanic membraneRedness of tympanic membrane AOMAOM CryingCrying Upper respiratory infection with congestion and inflammation of the mucosa lining theUpper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tractentire respiratory tract Trauma and/or cerumen removalTrauma and/or cerumen removal Decreased or absent mobility of tympanic membraneDecreased or absent mobility of tympanic membrane AOM and OMEAOM and OME TympanosclerosisTympanosclerosis A high negative pressure within the middle ear cavityA high negative pressure within the middle ear cavity Ear painEar pain Otitis externaOtitis externa Ear traumaEar trauma Throat infectionsThroat infections Foreign bodyForeign body Temporomandibular joint syndromeTemporomandibular joint syndrome
- 74. Uncertainty in diagnosis of AOMUncertainty in diagnosis of AOM The diagnosis of AOM, particularly in infants andThe diagnosis of AOM, particularly in infants and young children, is often made with a degree ofyoung children, is often made with a degree of uncertainty.uncertainty. Common factors …Common factors … Inability to sufficiently clear the external auditoryInability to sufficiently clear the external auditory canal of cerumencanal of cerumen Narrow ear canalNarrow ear canal Inability to maintain an adequate seal for successfulInability to maintain an adequate seal for successful pneumatic otoscopy or tympanometrypneumatic otoscopy or tympanometry An uncertain diagnosis of AOM is caused mostAn uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE.often by inability to confirm the presence of MEE.
- 76. Symptomatic therapy - 1Symptomatic therapy - 1 Pain remediesPain remedies PO analgesicsPO analgesics The efficacy of a topical agentThe efficacy of a topical agent (combination of antipyrine, benzocaine, and glycerin)(combination of antipyrine, benzocaine, and glycerin) Remedies such as distraction, external application of heat orRemedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have beencold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly addressproposed, but there are no controlled trials that directly address the effectiveness of these remediesthe effectiveness of these remedies
- 77. Symptomatic therapy - 2Symptomatic therapy - 2 Decongestants and antihistaminesDecongestants and antihistamines Alone or in combination were associated with…Alone or in combination were associated with… Increased medication side effectsIncreased medication side effects Did notDid not improve healing or prevent surgery or otherimprove healing or prevent surgery or other complications in AOMcomplications in AOM Not approved by AAP for < 2 year oldNot approved by AAP for < 2 year old In addition, treatment with antihistamines mayIn addition, treatment with antihistamines may prolong theprolong the duration of middle ear effusionduration of middle ear effusion
- 79. Which antibiotic ???Which antibiotic ???
- 80. Which antibiotic ???Which antibiotic ???
- 81. Microbiology ofMicrobiology of AOMAOM Bacterial Species Frequency Major Mechanism of Resistance What we can do? S. pneumoniae +++ penicillin-resistant (PBP2a) High Dose PCN H. influenzae ++ beta-lactamase 35-50% beta-lactamase Inhibitors (clavulanate)M. catarrhalis ++ beta-lactamase 55-100%
- 82. Antibacterial therapyAntibacterial therapy If a decision is made to treat with an antibacterial agent,If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for mostthe clinician should prescribe amoxicillin for most children.children. When amoxicillin is used, the dose should beWhen amoxicillin is used, the dose should be 80 - 90 mg/kg/day80 - 90 mg/kg/day
- 83. Predicted treatment failure ratesPredicted treatment failure rates based on PD breakpoints forfor expected pathogens in low- or high-risk AOMexpected pathogens in low- or high-risk AOM
- 84. AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organism In patients who have severe illnessIn patients who have severe illness && AOM high risk for amoxicillin-resistant organismAOM high risk for amoxicillin-resistant organism Children who were received antibiotics in the previous 30 daysChildren who were received antibiotics in the previous 30 days Children with concurrent purulent conjunctivitis (otitis-conjunctivitisChildren with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome)syndrome) Children receiving amoxicillin for chemoprophylaxis of recurrent AOMChildren receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection)(or urinary tract infection) High-dose amoxicillin-clavulanateHigh-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )(90 mg/kg per day of amoxicillin & 6.4 mg/kg / day of clavulanate )
- 85. Algorithm to distinguish AOM from OMEAlgorithm to distinguish AOM from OME
- 86. MalpracticeMalpractice Decongestants may decreased blood flow to the respiratoryDecongestants may decreased blood flow to the respiratory mucosa, which may impair delivery of antibioticsmucosa, which may impair delivery of antibiotics Antihistamines mayAntihistamines may prolong the duration of middle earprolong the duration of middle ear effusioneffusion
- 87. PreventionPrevention Continue exclusive breastfeeding as long asContinue exclusive breastfeeding as long as possiblepossible NO "bottle-propping" or taking a bottle to bedNO "bottle-propping" or taking a bottle to bed Smoke-free environmentSmoke-free environment IF high-risk for recurrent acute otitis mediaIF high-risk for recurrent acute otitis media Prolonged courses of antimicrobial prophylaxisProlonged courses of antimicrobial prophylaxis Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day)Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longergiven once daily at bedtime for 3 to 6 months or longer Pneumococcal vaccine & influenza vaccinePneumococcal vaccine & influenza vaccine marginally benefitmarginally benefit Pneumococcal vaccine reduce all otitis media by 6%.Pneumococcal vaccine reduce all otitis media by 6%.
Editor's Notes
- Nelson Essential 2005 - 5th Edition As defined by the presence of six or more acute otitis media episodes in the first 6 years of life, at least 12% of children in the general population have recurrent otitis media and would be considered otitis prone. Craniofacial anomalies and immunodeficiencies often are associated with recurrent otitis media; most children with recurrent acute otitis media are otherwise healthy. AAP online teaching course for AOM Discussion Acute Otitis Media Acute otitis media (AOM) is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea). Acute otitis media is commonly defined as the presence of a middle ear effusion (MEE) with tympanic membrane (TM) inflammation presenting with a rapid onset of symptoms such as fever, irritability, or earache (1). However, these symptoms are nonspecific and often result from an associated viral upper respiratory infection rather than the ear infection (2). Therefore, the presence or absence of symptoms is not useful in predicting the presence of a MEE with TM inflammation (3,4). Moffet&apos;s Pediatric Infectious Diseases: A Problem-Oriented Approach, 4th Edition Classification Otitis media can be classified on the basis of a number of variables. The onset and course can be acute, subacute, chronic, asymptomatic, or recurrent. Accurate classification on the basis of middle-ear fluid is possible only if fluid is examined directly; that is, only if there is spontaneous perforation with drainage or if tympanocentesis or myringotomy is performed. The middle-ear fluid may be purulent (cloudy, with many white blood cells), serous (clear and yellow like serum), or mucoid (sticky, with threads of mucus). Recurrent otitis media Recurrent AOM has been defined as more than three episodes of AOM within 6 months.68 The middle ear is normal, without effusions, between episodes. Chronic otitis media Called chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.68 Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection. Management of these problems remains difficult for most physicians, and only an introductory discussion of the principles will be given. Some sort of eustachian tube dysfunction is the principal predisposing factor. Chronic Draining Ear The diagnosis of chronic draining ear can be made on the basis of a reliable history. Typically, there is a chronic suppurative otitis media (CSOM) with a perforation. Perforations that occur at the margin are a special problem, because they are often associated with cholesteatomas, discussed later in this section. Chronic draining ear may also be a sign of mastoiditis. CSOM in the child with tympanostomy tubes is a particularly common problem, occurring in 5% to 10% of tube insertions.69 Recurrent Draining Ear Recurrent draining ear should be the working diagnosis when an ear discharge is present intermittently. The diagnosis of otitis externa can be made if a perforation can be excluded, as discussed earlier in the chapter. Persistent Middle-Ear Effusion When an episode of otitis media results in persistence of middle-ear fluid for 3 months, as described in the preceding section, and the tympanic membrane remains immobile, consultation with an ear specialist is advisable.70,71 Persistence of middle-ear fluid after AOM is more common in white children under age 2.72 Terms that imply knowledge about the character of the middle-ear fluid (such as serous otitis) or the mechanism of pathogenesis (such as secretory otitis) should be reserved for cases in which the physician is certain they are correct. Otherwise, the term otitis media with effusion (OME) should be used. Rarely, the drum appears purple or blue as a result of bloody fluid.73 Trauma can also cause this clinical picture. Bone conduction (sound heard through the mastoid) is better than air conduction (sound heard through the external auditory canal). Sound from a tuning fork placed on the top of the skull is lateralized to the ear with the greater impairment of hearing. If the ear is punctured for examination of the fluid early in the course of the illness, the fluid is usually thin and yellow (serous); later in the course, the fluid becomes more viscid and adhesive (glue-like), and the eardrum may appear retracted. Some authorities believe that production of fluid of these two consistencies is caused by different mechanisms rather than by differences in duration of illness,74 but this remains unproved. A spinal fluid leak into the middle ear is a rare cause of unilateral middle-ear fluid and can result from head trauma or without any recognized injury.75
- Nelson Essential 2005 - 5th Edition As defined by the presence of six or more acute otitis media episodes in the first 6 years of life, at least 12% of children in the general population have recurrent otitis media and would be considered otitis prone. Craniofacial anomalies and immunodeficiencies often are associated with recurrent otitis media; most children with recurrent acute otitis media are otherwise healthy. AAP online teaching course for AOM Discussion Acute Otitis Media Acute otitis media (AOM) is an inflammation of the middle ear associated with a collection of fluid in the middle ear space (effusion) or a discharge (otorrhea). Acute otitis media is commonly defined as the presence of a middle ear effusion (MEE) with tympanic membrane (TM) inflammation presenting with a rapid onset of symptoms such as fever, irritability, or earache (1). However, these symptoms are nonspecific and often result from an associated viral upper respiratory infection rather than the ear infection (2). Therefore, the presence or absence of symptoms is not useful in predicting the presence of a MEE with TM inflammation (3,4). Otoscopic findings of middle ear infection include a yellow and/or red color, exudate on the membrane, or bullae associated with decreased tympanic membrane mobility with or without a bulging or full TM position with impaired visibility of the ossicular landmarks. Moffet&apos;s Pediatric Infectious Diseases: A Problem-Oriented Approach, 4th Edition Classification Otitis media can be classified on the basis of a number of variables. The onset and course can be acute, subacute, chronic, asymptomatic, or recurrent. Accurate classification on the basis of middle-ear fluid is possible only if fluid is examined directly; that is, only if there is spontaneous perforation with drainage or if tympanocentesis or myringotomy is performed. The middle-ear fluid may be purulent (cloudy, with many white blood cells), serous (clear and yellow like serum), or mucoid (sticky, with threads of mucus). Recurrent otitis media Recurrent AOM has been defined as more than three episodes of AOM within 6 months.68 The middle ear is normal, without effusions, between episodes. Chronic otitis media Called chronic serous otitis in the past, this pattern is usually defined as a middle-ear effusion that has been present for at least 3 months.68 Persistent structural changes, such as a persistent eardrum perforation, imply past otitis but not necessarily chronic infection. Management of these problems remains difficult for most physicians, and only an introductory discussion of the principles will be given. Some sort of eustachian tube dysfunction is the principal predisposing factor. Chronic Draining Ear The diagnosis of chronic draining ear can be made on the basis of a reliable history. Typically, there is a chronic suppurative otitis media (CSOM) with a perforation. Perforations that occur at the margin are a special problem, because they are often associated with cholesteatomas, discussed later in this section. Chronic draining ear may also be a sign of mastoiditis. CSOM in the child with tympanostomy tubes is a particularly common problem, occurring in 5% to 10% of tube insertions.69 Recurrent Draining Ear Recurrent draining ear should be the working diagnosis when an ear discharge is present intermittently. The diagnosis of otitis externa can be made if a perforation can be excluded, as discussed earlier in the chapter. Persistent Middle-Ear Effusion When an episode of otitis media results in persistence of middle-ear fluid for 3 months, as described in the preceding section, and the tympanic membrane remains immobile, consultation with an ear specialist is advisable.70,71 Persistence of middle-ear fluid after AOM is more common in white children under age 2.72 Terms that imply knowledge about the character of the middle-ear fluid (such as serous otitis) or the mechanism of pathogenesis (such as secretory otitis) should be reserved for cases in which the physician is certain they are correct. Otherwise, the term otitis media with effusion (OME) should be used. Rarely, the drum appears purple or blue as a result of bloody fluid.73 Trauma can also cause this clinical picture. Bone conduction (sound heard through the mastoid) is better than air conduction (sound heard through the external auditory canal). Sound from a tuning fork placed on the top of the skull is lateralized to the ear with the greater impairment of hearing. If the ear is punctured for examination of the fluid early in the course of the illness, the fluid is usually thin and yellow (serous); later in the course, the fluid becomes more viscid and adhesive (glue-like), and the eardrum may appear retracted. Some authorities believe that production of fluid of these two consistencies is caused by different mechanisms rather than by differences in duration of illness,74 but this remains unproved. A spinal fluid leak into the middle ear is a rare cause of unilateral middle-ear fluid and can result from head trauma or without any recognized injury.75
- Epidemiology, pathogenesis, clinical manifestations, and complications of acute otitis media - 2007 UpToDate15.2 Definition of acute otitis media The diagnosis of otitis media requires evidence of 1, 2, and 3 below: 1. Recent, usually abrupt onset of signs and symptoms of middle ear inflammation and effusion AND 2. The presence of middle ear effusion that is indicated by any of the following: Bulging of the tympanic membrane Limited or absent mobility of the tympanic membrane Air fluid level behind the tympanic membrane Otorrhea AND 3. Signs or symptoms of middle ear inflammation as indicated by either: Distinct erythema of the tympanic membrane OR Distinct otalgia (discomfort clearly referable to the ear(s) that results in interference with or precludes normal activity or sleep Adapted with permission from: American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis of acute otitis media. Pediatrics 2004; 113:1451. Copyright © 2004 American Academy of Pediatrics.
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 RECOMMENDATION 1 To diagnose ACM the clinician should confirm a history of acute onset, identify signs of middle-ear effusion (MEE), and evaluate for the presence of signs and symptoms of middle-ear inflammation. (This recommendation is based on observational studies and a preponderance of benefit over risk; see Table 2.) TABLE 2. Definition of AOM A diagnosis of AOM requires 1) a history of acute onset of signs and symptoms, 2) the presence of MEE, and 3) signs and symptoms of middle-ear inflammation. Elements of the definition of AOM are all of the following: 1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE 2. The presence of MEE that is indicated by any of the following: a. Bulging of the tympanic membrane b. Limited or absent mobility of the tympanic membrane c. Air-fluid level behind the tympanic membrane d. Otorrhea 3. Signs or symptoms of middle-ear inflammation as indicated by either a. Distinct erythema of the tympanic membrane or b. Distinct otalgia (discomfort clearly referable to the ear[sJ that results in interference with or precludes normal activity or sleep) A certain diagnosis of AOM meets all 3 of the criteria: rapid onset, presence of MEE, and signs and symptoms of middle-ear inflammation. The clinician should maximize diagnostic strategies, particularly to establish the presence of MEE, and should consider the certainty of diagnosis in determining management. Clinicians may wish to discuss the degree of diagnostic certainty with parents/caregivers at the time of initial AOM management.
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 Acute otitis media (AOM) is the most common infection for which antibacterial agents are prescribed for children in the United States. As such, the diagnosis and management of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents. The illness also generates a significant social burden and indirect cost due to time lost from school and work. The estimated direct cost of AOM was $1.96 billion in 1995. In addition, the indirect cost was estimated to be $1.02 billion.’ During 1990 there were almost 25 million visits made to office-based physicians in the United States for otitis media, with 809 antibacterial prescriptions per 1000 visits, for a total of more than 20 million prescriptions for otitis media—related antibacterials. Although the total number of office visits for otitis media decreased to 16 million in 2000, the rate of antibacterial prescribing was approximately the same (802 antibacterial prescriptions per 1000 visits for a total of more than 13 million prescriptions).2’ An individual course of antibacterial therapy can range in cost from $10 to more than $100. Nelson Essential 2005 - 5th Edition EPIDEMIOLOGY Diseases of the middle ear account for approximately one third of office visits to pediatricians. The peak incidence of acute otitis media is in the second 6 months of life. By the first birthday, 62% of children experience at least one episode. Few first episodes occur after 18 months of age. Treatment of acute otitis media - 2007 UpToDate15.2 INTRODUCTION — Acute otitis media (AOM) is the most frequent diagnosis in sick children visiting physicians&apos; offices in the United States. In 2000, it was estimated that annual expenditures for the diagnosis of otitis media totaled approximately $5 billion in the United States; 40 percent of these costs were for care of children between the ages of 1 and 3 years [1]. Analysis of data from a 1992 national survey indicated that 30 percent of all antibiotic prescriptions for children were for otitis media [2]. With rising rates of antimicrobial resistance, the diagnosis and management of AOM have received considerable attention [3]. A decrease in overall antibiotic prescriptions for children 15 years and younger was documented between 1989-1990 and 1999-2000 (838 versus 503 per 1000 children) [4]. However, the per-visit rates of prescribing antibiotics for otitis media did not change (809 versus 802 per 1000 visits). Diagnosis of acute otitis media - 2007 UpToDate15.2 INTRODUCTION — Acute otitis media (AOM), also called suppurative otitis media, is one of the most frequent diagnoses for children seeking acute medical care. It accounts for a large proportion of pediatric antibiotic prescriptions and is associated with considerable medical expenditures. IMPORTANCE OF ACCURATE DIAGNOSIS — The importance of accurate diagnosis of AOM cannot be overstated. Accurate diagnosis ensures appropriate treatment for children with AOM, who require antibiotic therapy, and those with otitis media with effusion, who do not. Accurate diagnosis also prevents overuse of antibiotics, which leads to the development of resistant organisms . Establishing the diagnosis of AOM in infants and young children can be difficult. The child may not cooperate with the examination and the tympanic membrane may be obscured by cerumen. In addition, symptoms of AOM may overlap with those of upper respiratory tract infection, or may be subtle or absent [8,9]. The diagnosis of AOM is facilitated by systematic assessment of the tympanic membrane using a pneumatic otoscope and the use of stringent diagnostic criteria. Pneumatic otoscopy skills, including accurate interpretation of findings, can be improved through training [10,11]. This observation has led to proposals to formalize training in pneumatic otoscopy for clinicians who provide primary care to children [12]. Otitis Media—Principles of Judicious Use of Antimicrobial Agents – Pediatrics 1998101: 165-171BACKGROUND AND JUSTIFICATION Qtitis media consistently leads the list of the most common indications for outpatient antimicrobial use in the United States.
- Diagnosis of acute otitis media - 2007 UpToDate15.2 DIAGNOSIS Clinical diagnosis — The diagnosis of AOM requires the presence of a middle ear effusion and acute signs of middle ear inflammation [18]. A diagnosis of AOM also can be established if acute purulent otorrhea is present and otitis externa has been excluded. Middle ear effusion — The presence of fluid can be confirmed by one or both of the following findings on otoscopy: Bubbles or an air-fluid level Two or more of the following: - Abnormal color (white, yellow, amber, or blue) - Opacity (involving part or all of the tympanic membrane) not due to scarring - Impairment of mobility The presence of middle ear effusion is necessary but not sufficient for a diagnosis of AOM; evidence of acute inflammation also must be present. Acute inflammation — Signs of acute inflammation are necessary to differentiate AOM from OME. The best and most reproducible sign of acute inflammation is distinct fullness or bulging . Marked redness of the tympanic membrane is another sign of acute inflammation [13]. However, marked redness of the tympanic membrane without bulging is an unusual finding in AOM. A distinctly red tympanic membrane in the absence of bulging or impaired mobility has a predictive value of only 15 percent for AOM . Nonotoscopic symptoms that may satisfy the criteria for acute inflammation include ear pain or unaccustomed tugging or rubbing of the ear. However, these symptoms must be accompanied by abnormal otoscopic findings as described above. As an example, a child who complains of ear pain may be diagnosed with AOM if he or she also has a white or yellow tympanic membrane with marked decrease in mobility. Etiologic diagnosis — An etiologic diagnosis is not necessary in most cases of AOM. The antimicrobial agent can be chosen empirically. However, aspiration of the middle ear fluid is warranted if the patient with AOM appears toxic, has immune deficits, or has failed previous courses of antibiotic therapy.
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 Children with AOM usually present with a history of rapid onset of signs and symptoms such as otalgia (or pulling of the ear in an infant), irritability in an infant or toddler, otorrhea, and/or fever. These findings, other than otorrhea, are nonspecific and frequently overlap those of an uncomplicated viral upper respiratory infection. In a prospective survey among 354 children who visited a physician for acute respiratory illness, fever, earache, and excessive crying were present frequently (90%) in those with AOM. However, these symptoms also were prominent among children without AOM (72%). Other symptoms of a viral upper respiratory infection, such as cough and nasal discharge or stuffiness, often precede or accompany AOM and are nonspecific also. Accordingly, clinical history alone is poorly predictive of the presence of AOM, especially in younger children. Otitis Media—Principles of Judicious Use of Antimicrobial Agents – Pediatrics 1998101: 165-171 Ear-pulling in the absence of other symptoms is not necessarily attributable to AOM. Fever may be indicative of AOM, although in the absence of any other findings, such as ear pain or a red or bulging tympanic membrane, fever often may be unrelated to middle ear effusion. Other signs and symptoms such as rhinorrhea, cough, irritability, headache, anorexia, vomiting, or diarrhea may be present but are not specific for AOM. Although viral upper respiratory infections frequently precede or accompany AOM, the presence of rhinorrhea or other nonspecific signs or symptoms of upper respiratory infection alone is not adequate to differentiate AOM from OME. These nonspecific symptoms usually reflect an underlying or preceding viral illness and do not resolve as rapidly after appropriate antibiotic therapy as do fever and ear pain. Nelson Essential 2005 - 5th Edition CLINICAL MANIFESTATIONS In infants, the most frequent symptoms of acute otitis media are nonspecific and include fever, irritability, and poor feeding. In older children and adolescents, acute otitis media usually is associated with fever and otalgia (acute ear pain).
- Nelson Essential 2005 - 5th Edition LABORATORY AND IMAGING STUDIES Routine laboratory studies, including complete blood count and ESR, are not useful in the evaluation of otitis media.
- Otitis Media—Principles of Judicious Use of Antimicrobial Agents – Pediatrics 1998101: 165-171Pneumatic otoscopy should be used to assess four principal characteristics of the tympanic membrane: position, color, translucency, and mobility.’ 4 The use of visual otoscopy alone is discouraged because of the inability to assess the mobility of the tympanic membrane. Newer diagnostic tools such as tympanometry and acoustic reflectometry can aid in establishing the presence of fluid and in validating the examiner’s skills through repeated use and comparison with visual observation. Diagnosis of acute otitis media - 2011 UpToDate19.1 OTOSCOPY — The key to distinguishing AOM from OME is the performance of pneumatic otoscopy using appropriate tools and an adequate light source (eg, a halogen bulb with brightness 100 foot-candles) [17]. The otoscope bulb should be replaced at least every two years and the battery replaced when outdated [17]. A pneumatic otoscope with a round head is preferred (show picture 3). The nipple on the metal head is the site of attachment for the insufflator bulb, which is used to assess mobility of the tympanic membrane. The magnifying glass can be moved aside if and when cerumen removal is necessary. (See &quot;Cerumen&quot; section on Cerumen removal). Cerumen must be carefully removed from the external canal under direct vision in order to be sure that the view of the tympanic membrane is unobstructed. Once cerumen has been removed, systematic assessment of the tympanic membrane is undertaken, as described below. Overview — The diagnosis of AOM requires the presence of a middle ear effusion and acute signs of middle ear inflammation (show algorithm 1) [18]. The classic findings include a tympanic membrane that is erythematous, white, or pale yellow, bulges into the external auditory canal, and has decreased or absent mobility [19,20]. However, this constellation of findings is not always present. Accurate diagnosis of AOM requires systematic evaluation of the tympanic membrane for color, translucency, position, mobility, and other findings (eg, fluid level, perforation). Systematic assessment of the tympanic membrane is facilitated by the use of the COMPLETES mnemonic: Color (eg, gray, white, pale yellow, amber, pink, red, blue) Other conditions (eg, fluid level, bubbles, perforation, otorrhea, bullae, tympanosclerosis, atrophic areas, retraction pocket, cholesteatoma) Mobility Position (eg, full/bulging, neutral, retracted) Lighting (a halogen light source and fully charged battery should be used) Entire surface (the four quadrants of the tympanic membrane should be examined) Translucency External auditory canal and auricle (eg, deformed, displaced, inflamed, foreign body) Seal (a good seal requires an airtight pneumatic system and a speculum that is large enough to prevent air leak) Although the COMPLETES mnemonic serves as a reminder of the important aspects of the otoscopic examination, it reflects neither the order of the examination nor the importance of the individual components in distinguishing AOM from OME [14].
- Diagnosis of acute otitis media - 2007 UpToDate15.2 Pneumatic otoscope with enlargement of the head of the otoscope delineating the magnifying lens (which is moveable) and the nipple to which the insufflator bulb is attached.
- Diagnosis of acute otitis media - 2011 UpToDate19.1 Accurate diagnosis of AOM requires systematic evaluation of the tympanic membrane for color, translucency, position, mobility, and other findings (eg, fluid level, perforation). Systematic assessment of the tympanic membrane is facilitated by the use of the COMPLETES mnemonic: Color (eg, gray, white, pale yellow, amber, pink, red, blue) Other conditions (eg, fluid level, bubbles, perforation, otorrhea, bullae, tympanosclerosis, atrophic areas, retraction pocket, cholesteatoma) Mobility Position (eg, full/bulging, neutral, retracted) Lighting (a halogen light source and fully charged battery should be used) Entire surface (the four quadrants of the tympanic membrane should be examined) Translucency External auditory canal and auricle (eg, deformed, displaced, inflamed, foreign body) Seal (a good seal requires an airtight pneumatic system and a speculum that is large enough to prevent air leak) Although the COMPLETES mnemonic serves as a reminder of the important aspects of the otoscopic examination, it reflects neither the order of the examination nor the importance of the individual components in distinguishing AOM from OME [14].
- Normal tympanic membrane
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 The presence of MEE is commonly confirmed with the use of pneumatic otoscopy but can be supplemented by tympanometry and/or acoustic reflectometry. MEE also can be demonstrated directly by tympanocentesis or the presence of fluid in the external auditory canal as a result of tympanic membrane perforation. Visualization of the tympanic membrane with identification of an MEE and inflammatory changes is necessary to establish the diagnosis with certainty. To visualize the tympanic membrane adequately it is essential that cerumen obscuring the tympanic membrane be removed and that lighting is adequate. For pneumatic otoscopy, a speculum of proper shape and diameter must be selected to permit a seal in the external auditory canal. Appropriate restraint of the child to permit adequate examination may be necessary also. The findings on otoscopy indicating the presence of MEE and inflammation associated with AOM have been well defined. Fullness or bulging of the tympanic membrane is often present and has the highest predictive value for the presence of MEE. When combined with color and mobility, bulging is also the best predictor of Reduced or absent mobility of the tympanic membrane during performance of pneumatic otoscopy is additional evidence of fluid in the middle ear. Opacification or cloudiness, other than that caused by scarring, is also a consistent finding and is caused by edema of the tympanic membrane. Redness of the tympanic membrane caused by inflammation may be present and must be distinguished from the pink erythematous flush evoked by crying or high fever, which is usually less intense and remits as the child quiets down. In bullous myringitis, blisters may be seen on the tympanic membrane.’5 When the presence of middle-ear fluid is difficult to determine, the use of tympanometry or acoustic reflectometry’6 can be helpful in establishing a diagnosis.
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 Opacification or cloudiness, other than that caused by scarring, is also a consistent finding and is caused by edema of the tympanic membrane. TABLE 2. Definition of AOM A diagnosis of AOM requires 1) a history of acute onset of signs and symptoms, 2) the presence of MEE, and 3) signs and symptoms of middle-ear inflammation. Elements of the definition of AOM are all of the following: 1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE 2. The presence of MEE that is indicated by any of the following: a. Bulging of the tympanic membrane b. Limited or absent mobility of the tympanic membrane c. Air-fluid level behind the tympanic membrane d. Otorrhea
- Established acute otitis media.
- Diagnosis of acute otitis media - 2007 UpToDate15.2 Other conditions — Other conditions share some of the otoscopic and nonotoscopic findings of AOM but the history and physical examination should readily distinguish these conditions from AOM. Redness of tympanic membrane — Redness of the tympanic membrane may be caused by crying, upper respiratory infection with congestion and inflammation of the mucosa lining the entire respiratory tract, trauma, and/or cerumen removal. Decreased or absent mobility of tympanic membrane — In addition to AOM and OME, decreased or absent mobility of the tympanic membrane may be caused by tympanosclerosis or a high negative pressure within the middle ear cavity. Ear pain — Ear pain may be caused by otitis externa, ear trauma, throat infections, foreign body, or temporomandibular joint syndrome.
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 The diagnosis of AOM, particularly in infants and young children, is often made with a degree of uncertainty. Common factors that may increase uncertainty include the inability to sufficiently clear the external auditory canal of cerumen, a narrow ear canal, or inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry. An uncertain diagnosis of AOM is caused most often by inability to confirm the presence of MEE. Acoustic reflectometry can be helpful, because it requires no seal of the canal and can determine the presence of middle-ear fluid through only a small opening in the cerumen. When the presence of middle-ear fluid is questionable or uncertain, a diagnosis of AOM may be considered but cannot be confirmed. Although every effort should be made by the clinician to differentiate AOM from OME or a normal ear, it must be acknowledged that, using all available tools, uncertainty will remain in some cases. Efforts to improve clinician education must be increased to improve diagnostic skills and thereby decrease the frequency of an uncertain diagnosis. Ideally, instruction in the proper examination of the child’s ear should begin with the first pediatric rotation in medical school and continue throughout postgraduate training. Continuing medical education should reinforce the importance of and retrain the clinician in the use of pneumatic otoscopy. By including the degree of certainty into the formation of a management plan, the everyday challenge of pediatric examinations is incorporated into decision-making.
- Treatment of acute otitis media - 2007 UpToDate15.2 SYMPTOMATIC THERAPY Pain remedies — Pain is a common feature of AOM. Guidelines issued in 2004 by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) state that the management of AOM should include an assessment of pain and treatment if pain is present. A number of agents have been evaluated for the treatment of pain associated with otitis media, as illustrated below: A randomized, double-blind, study compared the use of ibuprofen and acetaminophen versus placebo in 219 children ages 1 to 6 years with AOM who also were treated with antibiotics. There was no significant difference in the appearance of the tympanic membrane after two days of treatment between any of the groups. However, by the second day, fewer children treated with ibuprofen had pain than those treated with placebo (7 versus 25 percent). Only 10 percent of children treated with acetaminophen continued to have pain, but this was not statistically significant compared to placebo. The efficacy of a topical agent, Auralgan (combination of antipyrine, benzocaine, and glycerin) was evaluated in a study of 54 children ages 5 to 19 years who presented to an emergency department with ear pain and AOM [9]. Patients were randomly assigned to treatment with Auralgan or olive oil placebo instilled into the external auditory canal of the affected ear. Significantly more children in the Auralgan group reported a 25 percent reduction in ear pain scores at 30 minutes after treatment (96 versus 70 percent). The topical herbal extract Otikon Otic solution was compared with topical anesthetic treatment in a randomized trial of 103 children ages 6 to 18 years with pain associated with AOM [10]. Both groups experienced comparable improvements in pain throughout the three days of the study, but there was no placebo group. Remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been proposed, but there are no controlled trials that directly address the effectiveness of these remedies.
- Treatment of acute otitis media - 2007 UpToDate15.2 SYMPTOMATIC THERAPY Decongestants and antihistamines — An oral decongestant, such as pseudoephedrine may relieve nasal congestion, and antihistamines may help patients with known or suspected nasal allergy. However, the efficacy of antihistamines and decongestants in treating AOM has not been proven. A systematic review found that decongestants and antihistamines alone or in combination were associated with increased medication side effects and did not improve healing or prevent surgery or other complications in AOM [11]. In addition, treatment with antihistamines may prolong the duration of middle ear effusion [12].
- * Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Non-severe illness is mild otalgia and fever &lt;39°C in the past 24 hours. Severe illness is moderate to severe otalgia or fever 39°C. A certain diagnosis of AOM meets all 3 criteria: 1) rapid onset, 2) signs of MEE, and 3) signs and symptoms of middle-ear inflammation. Treatment of acute otitis media - 2007 UpToDate15.2 ANTIBIOTIC THERAPY VERSUS OBSERVATION Two subsequent studies have attempted to address the problems of the studies included in the meta-analyses. At least one-half of the enrollees in each of these studies were younger than 2 years. Criteria for AOM were clearly defined, and included a combination of acute symptoms and otoscopic evidence of MEE. In these studies, more patients treated with amoxicillin (at least 60 mg/kg per day) than with placebo had resolution of symptoms at 14 days (93 versus 84 percent), and clinical cure at 30 days (77 versus 66 percent). There was no difference in adverse effects or parent satisfaction between groups. However, in one study, there was a significant increase in nasopharyngeal carriage of multi-drug resistant Streptococcus pneumoniae in the group treated with antibiotics. Taken together, these studies indicate that some children older than 6 months with AOM can be safely managed initially with observation. Symptoms resolve more rapidly in children who are treated with antibiotics, but the effect of decreased antibiotic use on antibiotic resistance may outweigh the benefit of earlier symptom resolution attributed to antibiotic treatment. Recommendations of various groups — Based upon the available data, the AAP/AAFP 2004 guideline suggests that observation without use of antibacterial therapy is an option for selected children with uncomplicated AOM based upon diagnostic certainty, age, illness severity, and assurance of follow-up (show table 1) [7]. In helping to make the decision, clinicians can share with parents or caregivers that antibacterial therapy prescribed at the first visit may shorten symptoms by one day in 5 to 14 percent of children, but causes side effects in 5 to 10 percent of children. The AAP/AAFP guideline committee recommends the following criteria for selection of patients for observation versus antibacterial therapy (show table 1) [7]: Antibacterial therapy should be administered to any child younger than the age of 6 months, regardless of the degree of diagnostic certainty. For children ages 6 months to 2 years, antibacterial therapy is recommended when the diagnosis of AOM is certain or if the diagnosis is uncertain but illness is severe (moderate to severe otalgia or fever 39ºC in the previous 24 hours). Observation is an option for children in whom the diagnosis is not certain and illness is not severe. For children older than 2 years, antibacterial therapy is recommended if the diagnosis is certain and illness is severe. Observation is an option when the diagnosis is certain but illness is not severe and in patients with an uncertain diagnosis. Observation is only appropriate when follow-up can be ensured and antibiotic therapy initiated if symptoms persist or worsen. Adequate follow-up may include a parent-initiated visit or phone contact if symptoms worsen or do not improve at 48 to 72 hours, a scheduled follow-up appointment in 48 to 72 hours, or giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame. Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hours.
- *Note: Antibiotics are usually well tolerated. However, side effects such as nausea, vomiting, and diarrhea may sometimes occur. The prescribing information for the product should be consulted
- *Note: Antibiotics are usually well tolerated. However, side effects such as nausea, vomiting, and diarrhea may sometimes occur. The prescribing information for the product should be consulted
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed. MICROBIOLOGY Data on the microbiology of sinusitis in pediatric patients are best organized according to the duration of clinical symptoms ( Table 34-2 ). However, literature review is complicated by varying definitions of acute, subacute, and chronic sinusitis. Several studies of ambulatory patients with acute (duration, 10 to 30 days) and subacute (30 to 120 days) [14] [20] illnesses have highlighted the important bacterial pathogens as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. S. pneumoniae is most common in all age groups, accounting for 30% to 40% of isolates. H. influenzae and M. catarrhalis are similar in prevalence and each accounts for approximately 20% of cases. In the last decade there has been an increasing prevalence of penicillin-resistant S. pneumoniae and many of the H. influenzae (35% to 50%) and M. catarrhalis (55% to 100%) are beta-lactamase-producing and also resistant to penicillin. [21] [22] Other less frequently recovered bacterial species are group A streptococcus, group C streptococcus, viridans streptococci, Peptostreptococcus spp., other Moraxella spp., and Eikenella corrodens.[13] Neither staphylococci nor anaerobic respiratory flora are commonly recovered from patients with acute or subacute sinusitis. Respiratory viruses, including adenovirus, parainfluenza virus, influenza virus, and rhinovirus, are identified in approximately 10% of patients (both with and without bacterial species). This percentage might be higher if diagnostic aspirates were obtained earlier in the course of respiratory symptoms. Unfortunately, there are no data that have been generated regarding the microbiology of ABS in children since 1986.[14] However, because of the similarity of the pathogenesis and microbiology of acute otitis media and ABS, it is acceptable to regard recent data generated from cultures of middle-ear fluid, obtained by tympanocentesis, from children with acute otitis media as a surrogate for cultures of the paranasal sinuses.[24] Perhaps attributable in part to the near-universal use of pneumococcal conjugate vaccine in the United States, several recent reports have highlighted a slight decrease in isolates of S. pneumoniae and an increase in isolates of H. influenzae recovered from middle-ear aspirates. [24] [25] Presumably, these changes are occurring in the paranasal sinuses as well. In patients with very protracted (years) or severe sinus symptoms (requiring surgical intervention), Staphylococcus aureus and anaerobic organisms are recovered more frequently. Commonly recovered anaerobic bacteria are anaerobic gram-positive cocci (such as Peptococcus and Peptostreptococcus spp.) and Bacteroides or Prevotella spp.[27] In addition, viridans streptococci and H. influenzae are frequently recovered. a Respiratory anaerobic cocci, Bacteroides spp., Prevotella spp., Veillonella spp. +++, most common; ++, common; +, less common.
- AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 RECOMMENDATION 3B If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. (This recommendation is based on randomized, clinical trials with limitations and a preponderance of benefit over risk.) When amoxicillin is used, the dose should be 80 to 90 mg/kg per day. (This option is based on extrapolation from microbiologic studies and expert opinion, with a preponderance of benefit over risk.) If a decision is made to treat with antibacterial agents, there are numerous medications that are clinically effective. The choice of first-line treatment should be based on the anticipated clinical response as well as the microbiologic flora likely to be present. The justification to use amoxicillin as first-line therapy in most patients with AOM relates to its general effectiveness when used in sufficient doses against susceptible and intermediate resistant pneumococci as well as its safety, low cost, acceptable taste, and narrow microbiologic spectrum. Treatment of acute otitis media - 2007 UpToDate15.2 ANTIMICROBIAL THERAPY — When the decision is made to treat with antimicrobial agents, the selection of drugs is based upon: Clinical and microbiologic efficacy Acceptability (taste, texture) of the oral preparation Absence of side effects and toxicity Convenience of the dosing schedule Cost At least 17 antimicrobial drugs (16 oral and one parenteral preparation) have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of AOM (show table 2). An otic preparation, ofloxacin otic, also is available for treatment of AOM with otorrhea in children with tympanostomy tubes in place [31]. First-line therapy — A 2001 meta-analysis concluded there is no evidence to support any particular antibiotic regimen versus another for treatment of AOM [18]. Nevertheless, amoxicillin remains the drug of choice because it is effective, safe, relatively inexpensive, and has a narrow microbiologic spectrum [32]. Doubling the dose from 40 to 80 mg/kg per day divided into two doses increases the concentration of amoxicillin in the middle ear [33]. The increased concentrations provide activity against most intermediate strains of S. pneumoniae and many of the resistant strains (show table 3). The AAP/AAFP guideline recommends a dose of amoxicillin of 80 to 90 mg/kg per day [7]. Only S. pneumoniae that are highly resistant to penicillin will not respond to this regimen [34]. As a result, more than 80 percent of children with pneumococcal AOM would respond to high-dose amoxicillin treatment [7]. Despite the increasing importance of H. influenzae, including beta-lactamase producing strains, high-dose amoxicillin remains the preferred choice for initial therapy. Continued monitoring of the microbiology of AOM is necessary to determine when and if a change in first-line therapy is necessary.
- Prim Care Clin Office Pract 30 (2003) 109–135 Predicted treatment failure rates based on pharmacodynamic breakpoints for expected pathogens in low- or high-risk AOM patients. Drugs in boldface type are recommended by the ‘‘CDC DRSP group,’’ Dowel S, et al, 1998.
- Treatment of acute otitis media - ANTIMICROBIAL THERAPY — When the decision is made to treat with antimicrobial agents, the selection of drugs is based upon: Clinical and microbiologic efficacy Acceptability (taste, texture) of the oral preparation Absence of side effects and toxicity Convenience of the dosing schedule Cost At least 17 antimicrobial drugs (16 oral and one parenteral preparation) have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of AOM (show table 2). An otic preparation, ofloxacin otic, also is available for treatment of AOM with otorrhea in children with tympanostomy tubes in place [31]. First-line therapy — A 2001 meta-analysis concluded there is no evidence to support any particular antibiotic regimen versus another for treatment of AOM [18]. Nevertheless, amoxicillin remains the drug of choice because it is effective, safe, relatively inexpensive, and has a narrow microbiologic spectrum [32]. Doubling the dose from 40 to 80 mg/kg per day divided into two doses increases the concentration of amoxicillin in the middle ear [33]. The increased concentrations provide activity against most intermediate strains of S. pneumoniae and many of the resistant strains (show table 3). The AAP/AAFP guideline recommends a dose of amoxicillin of 80 to 90 mg/kg per day [7]. Only S. pneumoniae that are highly resistant to penicillin will not respond to this regimen [34]. As a result, more than 80 percent of children with pneumococcal AOM would respond to high-dose amoxicillin treatment [7]. Despite the increasing importance of H. influenzae, including beta-lactamase producing strains, high-dose amoxicillin remains the preferred choice for initial therapy. Continued monitoring of the microbiology of AOM is necessary to determine when and if a change in first-line therapy is necessary. ( Amoxicillin should not be used as first-line therapy in children who are at high risk for AOM caused by an amoxicillin-resistant organism. These include: Children who were treated with antibiotics in the previous 30 days Children with concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome usually is caused by nontypeable H. influenzae, which is frequently resistant to beta-lactam antibiotics) Children receiving amoxicillin for chemoprophylaxis of recurrent AOM (or urinary tract infection) Children in the above categories should start therapy with an agent with activity against beta lactamase producing nontypeable H. influenzae as well as S. pneumoniae such as amoxicillin-clavulanate. AAP& AAFP CLINICAL PRACTICE GUIDELINE– PEDIATRICS 2004 113 (5)1451 - 1461 In patients who have severe illness (moderate to severe otalgia or fever of 39°C or higher) and in those for whom additional coverage for ß-lactamase - positive Haemophilus influenzae and Moraxella catarrhalis is desired, therapy should be initiated with high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses). This dose has sufficient potassium clavulanate to inhibit all ß-lactamase-producing H influenzae and M catarrhalis.
- UPTODATE ADJUNCTIVE THERAPY — Adjunctive therapies for ABS, which may be used to reduce or improve sinus drainage, include [12,28,29]: Saline nasal irrigation Decongestants (topical or systemic) Antihistamines Intranasal corticosteroids There are limited data regarding the efficacy of these therapies in children with ABS [29,30]. Saline nose drops and/or saline nasal sprays may be helpful in preventing crust formation and liquefying sinus secretions. Although the potential benefits are unproven, saline nasal irrigation is unlikely to be harmful or impede recovery and is suggested. Decongestants may reduce tissue edema, improve ostial drainage, and provide symptomatic relief [28]. However, these benefits may be offset by an increased viscosity of secretions and decreased blood flow to the nasal mucosa, which may impair delivery of antibiotics to the sinuses. Similarly, antihistamines have the potential to dry secretions and impair sinus drainage.
- Nelson Essential 2005 - 5th Edition PREVENTION Parents should be encouraged to continue exclusive breastfeeding as long as possible and should be cautioned about the risks of &quot;bottle-propping&quot; and of children taking a bottle to bed. The home should be a smoke-free environment. Children identified at high-risk for recurrent acute otitis media are candidates for prolonged courses of antimicrobial prophylaxis, which can reduce recurrences significantly. Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer is used for prophylaxis. Pneumococcal vaccine and influenza vaccine may reduce marginally the incidence of otitis media. The conjugate S. pneumoniae vaccine seems to reduce pneumococcal otitis media caused by vaccine serotypes by half, all pneumococcal otitis media by one third, and all otitis media by 6%. Annual immunization against influenza virus may be helpful in high-risk children.