Acute otitis media: Difference between revisions

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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
* 2nd most common cause of ED visits after URI


===Etiology===
*Viral (70% of cases)
*Bacterial
**[[S. pneumo]] (50%)
**Nontypable [[H. flu]] (30%)
**[[Moraxella]] (30%)


35-50% are caused by nontypable H inluenza
==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


25-40% are caused Streptococcus pneumonae
==Differential Diagnosis==
{{Ear DDX}}


5-10% Moraxella caterallis
===Less common===
*Oral cavity disease (referred pain)
*Cholesteatoma
*[[PTA]]
*[[Brain abscess]]
*[[Lemierre's Syndrome]]
*[[Herpes zoster oticus]]


5-15% viruses
{{Pediatric fever DDX}}


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


==Diagnosis==
==Management==
===[[Analgesia]]===
*[[Acetaminophen]]/[[ibuprofen]] and topical [[benzocaine]] (unless [[perforated TM]])


===[[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>===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Age'''
| align="center" style="background:#f0f0f0;"|'''Otorrhea'''
| 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


* acute onset <48 hours, chronic cases should be followed by PMD as may represent differnet diagnostic entity
'''Also Consider In:'''
* Middle Ear Effusion: bulging TM, otorrhea, anair/fluid level behind TM, or limited or absent TM mobility
*Age <6mo
* Middle Ear inflammation: erythema, of the TM or otalgia, but also need above symptoms
*Ill-appearing
* Note: Please clean ear of cerumen with 1:1 solution peroxide and water and curette
*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''<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
*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


==Treatment==
===[[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}}


==Disposition==
*Outpatient management


* Treat Pain! Acetaminophen and topical Benzocaine
==Complications==
* Narcotics not recommended because risk or respiratory depression ad altered mental status and generally not indicated unless SEVERE pain
*[[Mastoiditis]]
* Some may be observed WITHOUT antibiotics  (meta-analysis showed 7-20 children need to be treated with abx to see benefit)
*[[Meningitis]]
* Infant <6months: treat with abx even if uncertain of diagnosis
*[[Brain Abscess]]
* 6 months to 2 years: only if traid present or temp 39 or above and severe otalgia
*[[Labyrinthitis]]
* Well appearing kids may be treated symptomatically if do not meet triad (this assumes reliable caregiver and prompt Peds follow up
*Lateral Venous Sinus Thrombosis
 
*if concern for perforated tympanic membrane, avoid using otic aminoglycoside solution (risk of ototoxicity). In this setting, suspension drops are safer to use.
 
== ==
 
 
==Antibiotic Choices==
 
 
Duration should be 10 days for children under 6yo
 
Duration should be 5-7 days for older children
 
* "high-dose" amoxicillin 80-90 mg/kg/day for most children
* If pcn allergy and not type 1 reaction may use cefdinir, cefuroxime, or cefpodoxime
* If pcn allergy anaphlaxis or uticaria use azithromyin, clarithromycin, ot trimethorpin-sulfamethoxazole
* ceftriaxone if cannot tolerate POs
== ==
 
 
==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==
*[[Ear diagnoses]]


==References==
<references/>


ENT: Otitis Externa
[[Category:Pediatrics]]
 
[[Category:ENT]]
[[Category:ID]]
 
==Source==
 
 
Recommendations 2004 by AAP/AAFP (apply to 2 month to 12 years)
 
 
 
 
[[Category:Peds]]

Latest revision as of 09:52, 4 January 2022

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.