Difference between revisions of "Acute otitis media"

(2013 AAP Decision to Treat GuidelinesAAP 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)
(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
 
* 2nd most common cause of ED visits after URI
 
* 2nd most common cause of ED visits after URI
 +
 
===Etiology===
 
===Etiology===
 
*Viral (70% of cases)
 
*Viral (70% of cases)
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==Clinical Features==
 
==Clinical Features==
 
[[File:Otitis media entdifferenziert2.jpg|thumb|A bulging tympanic membrane which is typical in a case of acute otitis media]]
 
[[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
 
*Acute onset (<48hr) AND
 
*Middle ear effusion AND
 
*Middle ear effusion AND
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*Cholesteatoma
 
*Cholesteatoma
 
*[[PTA]]
 
*[[PTA]]
*Brain abscess
+
*[[Brain abscess]]
 
*[[Lemierre's Syndrome]]
 
*[[Lemierre's Syndrome]]
*Herpes zoster oticus
+
*[[Herpes zoster oticus]]
  
 
{{Pediatric fever DDX}}
 
{{Pediatric fever DDX}}
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==Management==
 
==Management==
===Analgesia===
+
===[[Analgesia]]===
*[[Acetaminophen]]/[[ibuprofen]] and topical benzocaine (unless perforated TM)
+
*[[Acetaminophen]]/[[ibuprofen]] and topical [[benzocaine]] (unless [[perforated TM]])
 +
 
 
===[[Antibiotics]]===
 
===[[Antibiotics]]===
 
===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>===
 
===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>===
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| align="center" style="background:#f0f0f0;"|'''Age'''
 
| align="center" style="background:#f0f0f0;"|'''Age'''
 
| align="center" style="background:#f0f0f0;"|'''Otorrhea'''
 
| align="center" style="background:#f0f0f0;"|'''Otorrhea'''
| align="center" style="background:#f0f0f0;"|'''Severe Symptoms (fever > 39C, sever otalgia <48H)'''
+
| align="center" style="background:#f0f0f0;"|'''Severe Symptoms^'''
 
| align="center" style="background:#f0f0f0;"|'''Bilateral without Otorrhea'''
 
| align="center" style="background:#f0f0f0;"|'''Bilateral without Otorrhea'''
 
| align="center" style="background:#f0f0f0;"|'''Unilateral without Otorrhea'''
 
| align="center" style="background:#f0f0f0;"|'''Unilateral without Otorrhea'''
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| 6mo-2y||Antibiotics||Antibiotics||Antibiotics||Antibiotics or observation period (wait and see)
 
| 6mo-2y||Antibiotics||Antibiotics||Antibiotics||Antibiotics or observation period (wait and see)
 
|-
 
|-
| 2=≥2y||Antibiotics||Antibiotics||Antibiotics or observation period (wait and see)||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:'''
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====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

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.