Acute otitis media: Difference between revisions

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==Background==
==Background==
35-50% are caused by nontypable H inluenza
*Peak incidence: 6-18 months of age
*Etiology
**S. pneumo (30%)
**Nontypable H. flu (55%)
**Moraxella (5-10%)


25-40% are caused Streptococcus pneumonae
==Diagnosis==
 
*Acute Otitis Media
5-10% Moraxella caterallis
**1. Acute onset (<48hr) and
 
**2. Middle ear effusion and
5-15% viruses
**3. Signs of middle ear inflammation


==Diagnosis==
* acute onset <48 hours, chronic cases should be followed by PMD as may represent differnet diagnostic entity
* acute onset <48 hours, chronic cases should be followed by PMD as may represent differnet diagnostic entity
* Middle Ear Effusion: bulging TM, otorrhea, anair/fluid level behind TM, or limited or absent TM mobility
* Middle Ear Effusion: bulging TM, otorrhea, anair/fluid level behind TM, or limited or absent TM mobility
* Middle Ear inflammation: erythema, of the TM or otalgia, but also need above symptoms
* Middle Ear inflammation: erythema, of the TM or otalgia, but also need above symptoms
* Note: Please clean ear of cerumen with 1:1 solution peroxide and water and curette
* Note: Please clean ear of cerumen with 1:1 solution peroxide and water and curette
==DDX==
Common
*Acute otitis media
*Chronic otitis media
*Serous otitis media
*Foreign body in external ear canal
*Otitis externa
Less common
*Accidental trauma
*Oral cavity disease (referred pain)
*Cholesteatoma
*PTA
Rare
*Mastoiditis
*Brain abscess
*Lemierre syndrome
*Herpes zoster oticus


==Treatment==
==Treatment==
* Treat Pain! Acetaminophen and topical Benzocaine
#Analgesia
* Narcotics not recommended because risk or respiratory depression ad altered mental status and generally not indicated unless SEVERE pain
##Acetaminophen/ibuprofen and topical benzocaine (unless perforated TM)
* Some may be observed WITHOUT antibiotics  (meta-analysis showed 7-20 children need to be treated with abx to see benefit)
#Antibiotics
* Infant <6months: treat with abx even if uncertain of diagnosis
##Indications:
* 6 months to 2 years: only if traid present or temp 39 or above and severe otalgia
###Age <6mo
* Well appearing kids may be treated symptomatically if do not meet triad (this assumes reliable caregiver and prompt Peds follow up
###Ill-appearing
*if concern for perforated tympanic membrane, avoid using otic aminoglycoside solution (risk of ototoxicity). In this setting, suspension drops are safer to use.
###Recurrent acute otitis media (w/in 2-4wk)
 
###Concurrent abx tx
==Antibiotic Choices==
###Other bacterial infections
Duration should be 10 days for children under 6yo
###Immunocompromised
 
###Craniofacial abnormalities
Duration should be 5-7 days for older children
##Wait-and-see antibiotic prescription
 
###If symptoms worsen or persist x48-72 then family fills the Rx
* "high-dose" amoxicillin 80-90 mg/kg/day for most children
##Agent
* If pcn allergy and not type 1 reaction may use cefdinir, cefuroxime, or cefpodoxime
###Amoxicillin 80-90mg/kg/day divided into 2 daily doses x5-7days
* If pcn allergy anaphlaxis or uticaria use azithromyin, clarithromycin, or trimethorpin-sulfamethoxazole
####1st line
* ceftriaxone if cannot tolerate POs
###Amoxicillin-clavulanate
####Consider if sxs >72hr after amox begun (covers moraxella, nontypeable H. flu)
####Clavulanate increases vomiting/diarrhea
###Azithromycin
####Consider if penicillin allergic
###CTX
####Use if cannot tolerate PO


==Treatment Failures==
* for fever and sxs > 72 hours after Tx begun (10%) - switch to Augmentin, Ceftriaxone IM x 3 d, Cefuroxime, Clinda.
==See Also==
==See Also==
[[Otitis Externa]]
[[Otitis Externa]]


==Source==
==Source==
Recommendations 2004 by AAP/AAFP (apply to 2 month to 12 years)
Tintinalli


[[Category:Peds]]
[[Category:Peds]]
[[Category:ENT]]
[[Category:ENT]]

Revision as of 03:55, 14 June 2011

Background

  • Peak incidence: 6-18 months of age
  • Etiology
    • S. pneumo (30%)
    • Nontypable H. flu (55%)
    • Moraxella (5-10%)

Diagnosis

  • Acute Otitis Media
    • 1. Acute onset (<48hr) and
    • 2. Middle ear effusion and
    • 3. Signs of middle ear inflammation
  • acute onset <48 hours, chronic cases should be followed by PMD as may represent differnet diagnostic entity
  • Middle Ear Effusion: bulging TM, otorrhea, anair/fluid level behind TM, or limited or absent TM mobility
  • Middle Ear inflammation: erythema, of the TM or otalgia, but also need above symptoms
  • Note: Please clean ear of cerumen with 1:1 solution peroxide and water and curette

DDX

Common

  • Acute otitis media
  • Chronic otitis media
  • Serous otitis media
  • Foreign body in external ear canal
  • Otitis externa

Less common

  • Accidental trauma
  • Oral cavity disease (referred pain)
  • Cholesteatoma
  • PTA

Rare

  • Mastoiditis
  • Brain abscess
  • Lemierre syndrome
  • Herpes zoster oticus

Treatment

  1. Analgesia
    1. Acetaminophen/ibuprofen and topical benzocaine (unless perforated TM)
  2. Antibiotics
    1. Indications:
      1. Age <6mo
      2. Ill-appearing
      3. Recurrent acute otitis media (w/in 2-4wk)
      4. Concurrent abx tx
      5. Other bacterial infections
      6. Immunocompromised
      7. Craniofacial abnormalities
    2. Wait-and-see antibiotic prescription
      1. If symptoms worsen or persist x48-72 then family fills the Rx
    3. Agent
      1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses x5-7days
        1. 1st line
      2. Amoxicillin-clavulanate
        1. Consider if sxs >72hr after amox begun (covers moraxella, nontypeable H. flu)
        2. Clavulanate increases vomiting/diarrhea
      3. Azithromycin
        1. Consider if penicillin allergic
      4. CTX
        1. Use if cannot tolerate PO

See Also

Otitis Externa

Source

Tintinalli

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