Difference between revisions of "Acute otitis media"

(WASP)
(Background)
 
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==Background==
 
==Background==
 +
[[File:Gray907.png|thumb|Ear anatomy]]
 +
[[File:Otitis Media.png|thumb|Anatomy of acute otitis media.]]
 
*Peak incidence: 6-18 months of age
 
*Peak incidence: 6-18 months of age
*Etiology
+
* 2nd most common cause of ED visits after URI
**Viral (70% of cases)
 
**Bacterial
 
***S. pneumo (50%)
 
***Nontypable H. flu (30%)
 
***Moraxella (30%)
 
  
==Diagnosis==
+
===Etiology===
#Acute onset (<48hr) AND
+
*Viral (70% of cases)
#Middle ear effusion AND
+
*Bacterial
#Signs of middle ear inflammation
+
**[[S. pneumo]] (50%)
#Notes
+
**Nontypable [[H. flu]] (30%)
##Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level  
+
**[[Moraxella]] (30%)
##Middle Ear inflammation: erythema of TM or otalgia
+
 
 +
==Clinical Features==
 +
[[File:Otitis media entdifferenziert2.jpg|thumb|A bulging tympanic membrane which is typical in a case of acute otitis media]]
 +
*Symptoms typically include [[Earache|ear pain]], [[fever]]
 +
*Acute onset (<48hr) AND
 +
*Middle ear effusion AND
 +
*Signs of middle ear inflammation
 +
**Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level  
 +
**Middle Ear inflammation: erythema of TM or otalgia
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
Common
+
{{Ear DDX}}
*Acute otitis media
+
 
*Chronic otitis media
+
===Less common===
*Serous otitis media
 
*Foreign body in external ear canal
 
*Otitis externa
 
Less common
 
*Accidental trauma
 
 
*Oral cavity disease (referred pain)
 
*Oral cavity disease (referred pain)
 
*Cholesteatoma
 
*Cholesteatoma
 
*[[PTA]]
 
*[[PTA]]
Rare
+
*[[Brain abscess]]
*[[Mastoiditis]]
 
*Brain abscess
 
 
*[[Lemierre's Syndrome]]
 
*[[Lemierre's Syndrome]]
*Herpes zoster oticus
+
*[[Herpes zoster oticus]]
 +
 
 +
{{Pediatric fever DDX}}
  
{{Ear DDX}}
+
==Evaluation==
 +
*Typically clinical
 +
*Erythema alone not enough to diagnose
 +
*Other clinical features: acute onset pain, bulging TM, opacified TM/loss of landmarks, otorrhea
  
 
==Management==
 
==Management==
===Analgesia===
+
===[[Analgesia]]===
*[[Acetaminophen]]/[[ibuprofen]] and topical benzocaine (unless perforated TM)
+
*[[Acetaminophen]]/[[ibuprofen]] and topical [[benzocaine]] (unless [[perforated TM]])
===[[Antibiotics]] ===
+
 
{{Table
+
===[[Antibiotics]]===
|type=class="wikitable "
+
===2013 AAP Decision to Treat Guidelines<ref>AAP Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf </ref>===
|title=2013 AAP AOM Guidelines<ref>AAP Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf </ref>
+
{| {{table}}
|hdrs=Age!!Otorrhea!!Severe Symptoms (unilateral or bilateral)!!Bilateral w/o Otorrhea!!Unilateral w/o Otorrhea
+
| align="center" style="background:#f0f0f0;"|'''Age'''
|row1=6mo-2y{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics
+
| align="center" style="background:#f0f0f0;"|'''Otorrhea'''
|row2=≥2y{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics or observation period{{!!}}Antibiotics or observation period
+
| align="center" style="background:#f0f0f0;"|'''Severe Symptoms^'''
}}
+
| align="center" style="background:#f0f0f0;"|'''Bilateral without Otorrhea'''
 +
| align="center" style="background:#f0f0f0;"|'''Unilateral without Otorrhea'''
 +
|-
 +
| 6mo-2y||Antibiotics||Antibiotics||Antibiotics||Antibiotics or observation period (wait and see)
 +
|-
 +
| ≥2y||Antibiotics||Antibiotics||Antibiotics or observation period (wait and see)||Antibiotics or observation period (wait and see)
 +
|}
 +
^Fever > 39C or severe otalgia <48 hrs
 +
 
 
'''Also Consider In:'''
 
'''Also Consider In:'''
 
*Age <6mo
 
*Age <6mo
 
*Ill-appearing
 
*Ill-appearing
*Recurrent acute otitis media (w/in 2-4wk)
+
*Recurrent acute otitis media (within 2-4wk)
 
*Concurrent antibiotic treatment
 
*Concurrent antibiotic treatment
 
*Other bacterial infections
 
*Other bacterial infections
Line 57: Line 68:
  
 
====Wait-and-see antibiotic prescription (WASP)====
 
====Wait-and-see antibiotic prescription (WASP)====
*Rather that routine perscription is an option to avoid over use if the patient does not meet any of the prescription criteria''<ref>Spiro DM. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41.</ref>
+
*Rather that routine prescription is an option to avoid over use if the patient does not meet any of the prescription criteria''<ref>Spiro DM. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41.</ref>
 
*If symptoms worsen or persist for 48-72 then caretaker fill the prescription
 
*If symptoms worsen or persist for 48-72 then caretaker fill the prescription
 
*Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group
 
*Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group
  
===Antibiotics===
+
===[[Antibiotics]] Options===
 +
*Consider treating for a standard of 10 days as opposed to a shorter duration of 5 days to reduce treatment failure in young children<ref>Hoberman A et al. Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med 2016; 375:2446-2456.</ref>
 +
**Treatment failure for 10 day at 16% and for 5 day at 34% for [[amoxicillin-clavulanate]]
 +
**RTC of 520 children aged 6-23 months
 
{{Otitis Media Antibiotics}}
 
{{Otitis Media Antibiotics}}
 +
 +
==Disposition==
 +
*Outpatient management
  
 
==Complications==
 
==Complications==
#[[Mastoiditis]]
+
*[[Mastoiditis]]
#[[Meningitis]]
+
*[[Meningitis]]
#[[Brain Abscess]]
+
*[[Brain Abscess]]
#Lateral Sinus Thrombosis
+
*Lateral Sinus Thrombosis
  
 
==See Also==
 
==See Also==
[[Otitis Externa]]
+
*[[Ear diagnoses]]
  
==Sources==
+
==References==
 
<references/>
 
<references/>
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
 
[[Category:ENT]]
 
[[Category:ENT]]
 
[[Category:ID]]
 
[[Category:ID]]

Latest revision as of 16:34, 25 March 2021

Background

Ear anatomy
Anatomy of acute otitis media.
  • Peak incidence: 6-18 months of age
  • 2nd most common cause of ED visits after URI

Etiology

Clinical Features

A bulging tympanic membrane which is typical in a case of acute otitis media
  • Symptoms typically include ear pain, fever
  • Acute onset (<48hr) AND
  • Middle ear effusion AND
  • Signs of middle ear inflammation
    • Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level
    • Middle Ear inflammation: erythema of TM or otalgia

Differential Diagnosis

Ear Diagnoses

External

Internal

Inner/vestibular

Less common

Pediatric fever

Evaluation

  • Typically clinical
  • Erythema alone not enough to diagnose
  • Other clinical features: acute onset pain, bulging TM, opacified TM/loss of landmarks, otorrhea

Management

Analgesia

Antibiotics

2013 AAP Decision to Treat Guidelines[1]

Age Otorrhea Severe Symptoms^ Bilateral without Otorrhea Unilateral without Otorrhea
6mo-2y Antibiotics Antibiotics Antibiotics Antibiotics or observation period (wait and see)
≥2y Antibiotics Antibiotics Antibiotics or observation period (wait and see) Antibiotics or observation period (wait and see)

^Fever > 39C or severe otalgia <48 hrs

Also Consider In:

  • Age <6mo
  • Ill-appearing
  • Recurrent acute otitis media (within 2-4wk)
  • Concurrent antibiotic treatment
  • Other bacterial infections
  • Immunocompromised
  • Craniofacial abnormalities

Wait-and-see antibiotic prescription (WASP)

  • Rather that routine prescription is an option to avoid over use if the patient does not meet any of the prescription criteria[2]
  • If symptoms worsen or persist for 48-72 then caretaker fill the prescription
  • Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group

Antibiotics Options

  • Consider treating for a standard of 10 days as opposed to a shorter duration of 5 days to reduce treatment failure in young children[3]
    • Treatment failure for 10 day at 16% and for 5 day at 34% for amoxicillin-clavulanate
    • RTC of 520 children aged 6-23 months

Initial Treatment

  1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses 7-10 days

Treatment during prior Month

  1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea
  2. Cefdinir 14mg/kg/day BID x7-10 days
  3. Cefpodoxime 10mg/kg PO daily x7-10 days
  4. Cefuroxime 15mg/kg PO BID x7-10 days
  5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

  • Suggestive of non-typeable H.flu
  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
  2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
    • Use if cannot tolerate PO

Penicillin Allergy

  1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
  2. Clarithromycin 7.5mg/kg PO BID x 10 days
  3. Clindamycin 10mg/kg PO three times daily

Disposition

  • Outpatient management

Complications

See Also

References

  1. AAP Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf
  2. Spiro DM. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41.
  3. Hoberman A et al. Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med 2016; 375:2446-2456.