Childhood Otitis Media
By
Rahul Gladwin, MS3
University of Health Sciences Antigua
School of Medicine
Email: rahul[AT]rahulgladwin.com
Otitis Media definition
Otitis Media is defined as an
inflammation of the middle ear i.e.,
the area between the tympanic
membrane and the inner ear.
Pathogenesis
Infection mostly occurs in infants and
children because of the shorter and
more horizontal orientation of the
Eustachian tube which allows reflux
from the pharynx.
Bacterial Etiology
S. pneumonia.
1. Incidence: 38%
2. Beta Lactamase producing: 15-25%
3. Causes more severe cases with Otalgia and fever.
Nontypeable H. influenzae.
1. Incidence: 27%
2. Beta Lactamase producing: 35%
3. More often associated with eye redness and
discharge.
Moraxella catarrhalis.
1. Incidence: 10%
2. Beta Lactamase producing: 85-100%
Viral Etiology
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57%
35%
33%
30%
28%
18%
10%
of
of
of
of
of
of
of
RSV,
influenza A,
parainfluenza type 3,
adenovirus,
parainfluenza type 1,
influenza B and
parainfluenza type 2 virus infections.
Fungal Etiology
Aspergillus or Candida
Correlation factors
Signs
 Crying,
 Irritability,
 Tugging or pulling on the ear.
Symptoms
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Ear pain,
Rhinitis,
Cough,
Ear drainage,
Hearing loss,
Fever.
Complications
 Acute mastoiditis – infection of the mastoid
process.
 Cholesteatoma – cystic lesion within the
middle ear.
 Meningitis.
 Hearling loss.
 Tympanic membrane perforation.
 Brain abscess.
Ear Anatomy
Ear Anatomy
Types of Otitis Media
 Acute Otitis Media
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Most common type seen in children
Occurs when there is fluid in the middle ear
Occurs with inflammation of the TM
May be bacterial or viral
Phases of Acute Otitis Media
 1st phase - exudative inflammation lasting 1–2 days,
fever, rigors, meningism (occasionally in children),
severe pain (worse at night), muffled noise in ear,
deafness, sensitive mastoid process, ringing in ears
(tinnitus)
 2nd phase - resistance and demarcation lasting 3–8
days. Pus and middle ear exudate discharge
spontaneously and afterwards pain and fever begin to
decrease. This phase can be shortened with topical
therapy.
 3rd phase - healing phase lasting 2–4 weeks. Aural
discharge dries up and hearing becomes normal.
Types of Acute Otitis Media
 Otitis Media without effusion
 Inflammation of the TM with fluid in the middle
ear
 May cause myringitis (cyst on TM)
 Present during the beginning stages of otitis
media
 Formation of painful blisters on the eardrum
(tympanum).
Types of Acute Otitis Media
 Serous Otitis Media or Otitis Media
with effusion
 Inflammation of the TM with fluid in the middle
ear
 Caused by vacuum created by malfunction of the
Eustachian tube
 Can cause hearing impairment and delayed
speech in children
 Since infants cannot hear they cannot learn how
to talk
Chronic Otitis Media
 Occurs when the middle ear infection
perists and causes significant hearing
loss and damage to the middle ear
 May involve a perforation of the TM
 Pus may drain through the ear canal
– a concept called otorrhea
Chronic Otitis Media - Types
 Tubotympanic disease – called safe disease. The
infection is limited to the mucosa and the antero
inferior part of the middle ear cleft, hence the
name. This disease does not have any risk of
bone erosion.
 Atticoantral disease – called unsafe disease.
Fatal intra-cranial and extra-cranial
complications can occur. Disease spreads by
erosion of the bony wall of the attic.
Cholesteatoma may occur. Commonly seen in
sclerosed mastoid cavities.
Recommended Otitis Media Workup
 Laboratory Studies – sepsis workup
 Imaging - study of choice is a contrastenhanced CT scan of the temporal bones
 MRI is more helpful in depicting fluid
collections
 Tympanometry may help with diagnosis in
patients with OM with effusion
Diagnostic criteria for OM
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Bulging TM
Retracted TM
Impaired mobility of the TM
Loss of light reflex
Erythematous TM
Purulent otorrhea
Opacification of the TM
Normal TM Appears as:
 Glistening, translucent (scarring often may
be evident in adults).
 Light reflex extending anteriorly/inferiorly
from the umbo (most depressed part of the
tympanic membrane).
 Pearly gray to pale pink membrane with
cone of light well visualized.
 Mobile (to the air pulses).
 Non-erythematous.
 Handle (manubrium) and short process of
malleus well identified.
Normal Right TM
Acute Otitis Media-TM
Acute Otitis Media
Serous Otitis Media
Serous Otitis Media
Ruptured TM
Ruptured TM
Otorrhea
Myringitis - blisters on TM
Myringitis - blisters on TM
Cholesteatoma
Cholesteatoma
Brain Abscess
Mastoiditis
Mastoiditis
Otitis Media Pathology Video
http://www.youtube.com/watch?v=1km
sPEd2Efk&feature=related
Quick Statistics
 More common in Caucasian children.
 70% of all children have at least 3 infections before
the age of 6.
 Children given antibiotics were 2-6 more likely to
get re-infected.
 About 2 to 3 out of every 1,000 children in the
United States are born deaf or hard-of-hearing.
Nine out of every 10 children who are born deaf are
born to parents who can hear.
 Approximately 188,000 people worldwide have
received cochlear implants. In the United States,
roughly 41,500 adults and 25,500 children have
received them.
Trends on newborn screening
Office visits for OM
Treatment with penicillin
1. Antibiotic duration
1. Age under 6 years
2. First Line
1. Amoxicillin 80-90 mg/kg/day PO divided twice daily for 10 days (7 days
if age>6)
2. If Penicillin Allergy, use Macrolide (e.g. Azithromycin)
3. Second Line (10 day course)
1. Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice
daily for 10 days
2. Cefuroxime (Zinacef, Ceftin) 30 mg/kg/day divided twice daily for 10
days
3. Cefprozil (Cefzil) 30 mg/kg/day divided twice daily for 10 days
4. Cefdinir (Omnicef) 14 mg/kg/day divided one to two times daily fo 10
days
5. Cefpodoxime (Vantin) 30 mg/kg once daily for 10 days
4. Third Line
1. Strongly consider Tympanocentesis for bacterial culture
2. Ceftriaxone (Rocephin) 50 mg/kg IM daily for 3 days
3. Clindamycin 30-40 mg/kg/day divided four times daily for 10 days.
Treatment if allergic to penicillin
1. Consider Tympanocentesis
2. Clindamycin (Cleocin) 30-40 mg/kg/day (max 1800 mg) divided four times
daily for 10 days
3. Macrolide antibiotics (High bacterial resistance rate)
1. Erythromycin
2. Clarithromycin (Biaxin) 15 mg/kg/day divided twice daily for 10 days
3. Azithromycin (Zithromax)
1. One dose of Azithromycin XR (Zmax) at 30 mg/kg (up to 1500 mg)
or
2. Three days of Azithromycin at 20 mg/kg/day once daily (up to 500
mg/day) or
1. This high dose approached Augmentin efficacy in one study
2. Arrieta (2003) Antimicrob Agents Chemother 47:3179
3. Azithromycin 10 mg/kg (max: 500 mg) day 1, then 5 mg/kg/day
(max 250 mg) for 5 days
4. Fluoroquinolones (avoid under age 16 years)
1. Gatifloxacin (Tequin)
2. Levofloxacin (Levaquin)
3. Moxifloxacin (Avelox)
Resources
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Robbins Pathology
Kaplan CK Lecture notes
www.fpnotebook.com
www.ncbi.nlm.nih.gov
www.nidcd.nih.gov
www.medicinenet.com
emedicine.medscape.com
www.webmd.com
kidshealth.org
cme.med.umich.edu
www.audiologynet.com