PANCE Blueprint EENT (7%)

Otitis media (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Otitis media

3 y/o with unilateral ear pain

Patient will present as → a 3-year-old previously healthy male is brought to your office by her mother. The mother reports the child has been crying and pulling at her right ear over the past 2 days and reports the patient has been febrile the past 24 hours. The patient’s past medical history is unremarkable, although the mother reports the patient had a “common cold” a week ago which resolved without intervention. His temperature is 101.6 F, blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min. The otoscopic exam is seen here.

  • Middle ear effusion (MEE)Fluid in the middle ear cavity; MEE occurs in both AOM and otitis media with effusion (OME)
  • Acute otitis mediaAcute bacterial infection of middle ear fluid (also called suppurative otitis media)
  • Otitis media with effusion (OME)Middle ear fluid that is not infected; also called serous, secretory, or nonsuppurative otitis media. OME frequently precedes the development of AOM or follows its resolution. OME is very common in young children. About 90% of children have OME at some time before school age, most often between ages 6 months and 4 years
  • Chronic suppurative otitis media (CSOM) – when the infection persists in the middle ear space for more than 3 months and is associated with a chronic perforation of the tympanic membrane. Pus may only be visible with a binocular microscope or it may drain into the outer ear, presenting as otorrhea

The majority of all AOM is viral if a bacterial etiology is expected the cause is the same as those seen in bacterial URI:

  • Streptococcus pneumoniae 25%
  • Haemophilus influenzae 20%
  • Moraxella catarrhalis 10%

Acute vs. Chronic vs. Recurrent

  • Acute: inflammation for less than 3 weeks
  • Chronic: inflammation for greater than 3 months
  • Recurrent: 3 episodes in 6 months or 4 episodes in 12 months with clearing between episodes

Chronic OM (> 3 months)

  • Clear serous fluid in the middle ear without signs or symptoms of ear infection.
    • May have hearing loss, may be asymptomatic, does not require antibiotics.

Otoscopic examination may reveal bulging, loss of landmarks, redness, and injection of TM, pus. 

  • Key findings include bulging of the TM and limited mobility of the TM with pneumotoscopy
  • Building and eventual rupture of the TM can occur as well, leading to otorrhea and abruptly decreased pain
Acute Otitis Media

bulging, loss of landmarks, redness and injection of TM, and pus

Children:

Antibiotic therapy vs treatment in children

Age Otorrhea Severe symptoms (unilateral or bilateral) Bilateral disease Unilateral disease, no severe symptoms
< 6 months Antibiotics Antibiotics Antibiotics Antibiotics
6 months to 2 years Antibiotics Antibiotics Antibiotics Antibiotics or observe 48 to 72 hours
≥ 2 years Antibiotics Antibiotics Antibiotics or observe 48 to 72 hours Antibiotics or observe 48 to 72 hours
Treat children <2 years for 10 days and those ≥2 years for 5 to 7 days.

First-line treatment for AOM in children

  • Amoxicillin 90 mg/kg per day divided into two doses (maximum of 3 g/day) is the first-line drug of choice
  • Augmentin 90 mg/kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate divided in two doses is the first-line therapy for children with AOM who are treated with antibiotics and at increased risk of beta-lactam resistance

AOM with perforation —  amoxicillin 90 mg/kg per day orally divided in two doses (we suggest a maximum of 3 g/day)

Children with a mild allergy to penicillin antibiotics

  • Cefdinir 14 mg/kg per day orally in one or two doses (maximum 600 mg/day)
  • Cefpodoxime 10 mg/kg per day orally in two doses (maximum 400 mg/day)
  • Cefuroxime suspension 30 mg/kg per day orally divided in two doses (maximum 1 g/day)
  • Cefuroxime tablets 250 mg orally every 12 hours
  • Ceftriaxone 50 mg/kg intramuscularly once per day (maximum 1 g/day) for one to three doses

Azithromycin or clarithromycin for the treatment of AOM in children who have had an immediate hypersensitivity reaction or serious delayed reaction to amoxicillin or other beta-lactam antimicrobial agents

  • Azithromycin 10 mg/kg per day orally (maximum 500 mg/day) as a single dose on day 1 and 5 mg/kg per day (maximum 250 mg/day) for days 2 through 5
  • Clarithromycin 15 mg/kg per day orally divided into two doses (maximum 1 g/day)

Adults: 

Treatment duration: Patients with mild to moderate infections should be treated for five to seven days, and those with more severe infections (significant hearing loss, severe pain, and/or marked tympanic membrane erythema) with a 10-day course of antibiotics

Since AOM is unusual in adults, and complications may be significant treat all adults patients with antibiotic therapy (no observation)

First-line acute otitis media (AOM) treatment in adults

In most adults, use Augmentin 875/125 mg orally twice daily x 5 - 7 days as first-line abx.

  • In patients at high risk for severe infections or infections with resistant S. pneumonia - high dose of the amoxicillin component:
    • Augmentin 1000 mg/62.5 mg, extended-release, orally twice daily (for lower-weight patients and/or those with milder infections)
    • Augmentin 2000 mg/125 mg, extended-release, orally twice daily (for higher-weight patients and/or those with more severe infections)

For those unable to tolerate Augmentin alternatives include amoxicillin as initial therapy:

    • Amoxicillin 500 mg TID or 875 mg BID x 5-7 days
    • In patients at high risk for severe infections or infections with resistant S. pneumonia Amoxicillin 1000 mg orally three times daily

In PCN allergic patients without severe reactions, and 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

For patients with a known severe allergy to beta-lactam antibiotics or who have a known allergy to cephalosporins, antibiotic choices include:

  • Doxycycline, 100 mg orally every BID x 5-7 days
  • Azithromycin, 500 mg orally on day 1, then 250 mg orally days 2 through 5
  • Clarithromycin, 500 mg orally every BID x 5-7 days

Chronic OM:

  • Treat with myringotomy with ventilation tube insertion of fluid is persistent and or hearing loss.

Picmonic
Otitis media and treatments

IM_NUR_OtitisMediaAssessment_V1.3_Otitis media is an infection of the middle ear caused by a virus or bacteria and is characterized by the presence of fluid in the middle ear, along with symptoms of inflammation. This condition most commonly occurs in children due to the shorter, straighter, and narrower nature of the eustachian tube in childhood. Signs and symptoms of otitis media include a red, bulging tympanic membrane, ear pain, and fever. Children with an upper respiratory infection or those regularly exposed to smoke are at an increased risk of developing an ear infection. Conductive hearing loss may occur in chronic cases of otitis media.  Antipyretics, analgesics, and antibiotics are typically used to treat otitis media, through irrigation of the ear, or procedures such as a myringotomy, or the placement of a tympanostomy tube may be necessary

Otitis Media Assessment Picmonic
Play Video + Quiz
Otitis Media Interventions
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Moraxella catarrhalis
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Streptococcus pneumonia disease
Play Video + Quiz
Haemophilus influenzae disease
Play Video + Quiz
Ampicillin and amoxicillin
Play Video + Quiz
Beta-lactamase inhibitors
Play Video + Quiz

Question 1
There is considerable debate about the use of tympanostomy tubes in the management of recurrent otitis media in children. Tympanostomy tube placement has been proven to
A
improve hearing
B
prevent mastoiditis
Hint:
Mastoiditis is prevented by early treatment of otitis media with antibiotics.
C
prevent recurrence of effusion
Hint:
Effusion can occur even with tympanostomy tubes in place.
D
prevent delayed language development
Hint:
Tympanostomy tubes have not been proven to prevent delayed language development.
Question 1 Explanation: 
Hearing is improved with tympanostomy tubes by eliminating middle ear effusion when the tubes are functioning properly.
Question 2
The most reliable sign of acute otitis media (AOM) is
A
bulging of the tympanic membrane
Hint:
Bulging and air bubbles behind the TM represent OM with effusion.
B
loss of tympanic membrane mobility
C
reddening of the tympanic membrane
Hint:
Reddening of the eardrum is not reliable as it may be due to crying or other vascular changes.
D
air bubbles behind the tympanic membrane
Hint:
See A for explanation.
Question 2 Explanation: 
Loss of tympanic membrane mobility during pneumoinsufflation is the most reliable sign for diagnosing acute otitis media.
Question 3
A patient with Type 1 diabetes mellitus was treated for otitis externa of the right ear for 2 weeks with topical ear drops. The patient presents today with persistent, foul aural discharge, granulations in the ear canal, and deep ear pain. Which of the following is the proper treatment at this time?
A
ciprofloxacin (Cipro) IV
B
cefuroxime (Zinacef) IV
Hint:
Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas.
C
ampicillin-sulbactam (Unasyn) PO
Hint:
Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas.
D
azithromycin (Zithromax) PO
Hint:
Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas.
Question 3 Explanation: 
IV antibiotics directed against Pseudomonas, the most likely etiology, is needed for the treatment of malignant otitis media.
Question 4
Which of the following is the most likely organism in a 2 year-old child with acute otitis media?
A
Staphylococcus aureus
Hint:
See D for explanation.
B
Moraxella catarrhalis
Hint:
See D for explanation.
C
Pseudomonas aeruginosa
Hint:
See D for explanation.
D
Streptococcus pneumoniae
Question 4 Explanation: 
The most common pathogens in children with acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
Question 5
A 3 year-old patient is brought in with a 10 day history of clear nasal drainage and cough which has now developed into otalgia and fever exceeding 101 degrees F for the last 5 days. Mom denies other chronic medical problems. The patient has had similar complaints three times in her life. Which of the following is the most likely causative organism?
A
Mycoplasma pneumoniae
Hint:
Mycoplasma pneumoniae is a common cause of bronchitis and pneumonia.
B
Pneumocystis jiroveci
Hint:
Pneumocystis jiroveci is associated with immunocompromised respiratory illness.
C
Pseudomonas aeruginosa
Hint:
Pseudomonas aeruginosa would most commonly cause otitis externa.
D
Streptococcus pneumoniae
Question 5 Explanation: 
Acute otitis media is a bacterial infection of the mucous lined air-containing spaces of the temporal bone most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
There are 5 questions to complete.
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References: Merck Manual · UpToDate (children) (adults)

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