BAB 1

INTRODUCTION

1. Background Acute Otitis Media

AOM is defined by convention as the first 3 weeks of a process in which the middle ear
shows the signs and symptoms of acute inflammation. OME is defined as the presence of fluid in
the middle ear with accompanying conductive hearing loss and without concomitant symptoms
or signs of acuity. OME is classified as subacute when it persists from 3 weeks to 3 months after
the onset of AOM and is classified as chronic thereafter.

In the United States, acute otitis media (AOM), defined by convention as the first 3 weeks
of a process in which the middle ear shows the signs and symptoms of acute inflammation, is the
most common affliction necessitating medical therapy for children younger than 5 years. In the
United States, acute otitis media (AOM) is the most common affliction necessitating medical
therapy for children younger than 5 years. The total annual cost to society for this disease and for
otitis media with effusion (OME) runs into the billions of dollars. Yet, despite research into
prevention and therapy, the costs of this disease continue to rise while the incidence remains
unabated. The emergence of antimicrobial-resistant bacteria requires reevaluation of traditional
management. Nevertheless, there is still a consensus that antibiotics are the initial therapy of
choice for AOM. Surgical management of AOM can conveniently be divided into 3 related
procedures: tympanocentesis, myringotomy, and myringotomy with insertion of a ventilating
tube. The history of acute otitis media (AOM) varies with age, but a number of constant features
manifest during the otitis-prone years. In the neonate, irritability or feeding difficulties may be
the only indication of a septic focus. Older children begin to demonstrate a consistent presence of
fever (with or without a coexistent upper respiratory tract infection [URTI]) and otalgia or ear
tugging. These latter symptoms are not entirely exclusive to AOM; teething pain or pharyngitis
(particularly coxsackievirus infection) can mimic these symptoms. In older children and adults,
hearing loss becomes a constant feature of AOM and otitis media with effusion (OME), with
reports of ear stuffiness noted even before the detection of middle ear fluid. Otalgia without
hearing loss or fever is observed in adults with external otitis, dental abscess, or pain referred
from the temporomandibular joint. Orthodontic appliances often elicit referred pain as the dental
occlusion is altered. There is no substitute for a thorough clinical examination. Pneumatic
otoscopy is the standard of care in the diagnosis of acute and chronic otitis media. In AOM, the
tympanic membrane normally demonstrates signs of inflammation, beginning with reddening of
the mucosa and progressing to the formation of purulent middle ear effusion and poor tympanic
mobility. The tympanic membrane may bulge in the posterior quadrants, and the superficial
epithelial layer may exhibit a scalded appearancePerforation of the tympanic membrane is not

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unusual as the process advances, most frequently in posterior or inferior quadrants. Before or
instead of a single perforation, an opaque serumlike exudate is sometimes seen oozing through
the entire tympanic membrane.

With perforation and in the absence of a coexistent viral infection, the patient generally
experiences rapid relief of pain and fever. The discharge initially is purulent, though it may be
thin and watery or bloody; pulsation of the otorrhea is common. Otorrhea from acute perforation
normally lasts 1-2 days before spontaneous healing occurs. Otorrhea may persist if the
perforation is accompanied by mucosal swelling or polypoid changes, which can act as a ball
valve. Pneumatic otoscopy is an important diagnostic tool for differentiating AOM from acute
bullous myringitis. The latter condition, in its purest form, manifests 1-14 days after a viral
infection and causes severe localized otalgia without middle ear effusion. The bullae or blebs
may contain serous or hemorrhagic fluid and may extend onto the adjacent canal wall. Pain is
relieved by puncturing the bleb. Similar blebs may occur in association with AOM. These
patients demonstrate more systemic symptoms and continue to have pain associated with
purulent middle ear effusion, which persists following rupture of the blebs. It should be kept in
mind that the findings described above apply to patients who are immunocompetent.

Children who are immunosuppressed, particularly those undergoing chemotherapy, may

not manifest the typical inflammatory responses. In these patients, the simultaneous appearance
of systemic sepsis and a serous middle ear effusion might be the only indicators of AOM. A
finding of AOM does not relieve the practitioner of the responsibility to search for coexistent
related or unrelated conditions. This responsibility is particularly important when antimicrobial
agents are prescribed, in order to ensure appropriate simultaneous coverage of coexistent
infections such as AOM with streptococcal pharyngitis or mycoplasmal pneumonia.
Transtympanic measurements of temperature in children with middle ear effusions have been
shown to be inconsistent. Accordingly, body temperature should be measured by means of oral,
rectal, or axillary methods.

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 BAB II
LITERATURE THEORY

1. Anatomy of Ear

Incision of the tympanic membrane is primarily governed by the relations of the structures
behind the membrane. The tympanic membrane can be divided into quadrants with an imaginary
line drawn vertically along the long process of the malleus and extending to the inferior annulus,
along with a horizontal line at the umbo. Generally, it can safely be incised in all quadrants
except the posterior superior section, behind which lie the incus and stapes, structures that might
be injured inadvertently by incision in this area. The area above the pars tensa, the pars flaccida,
should be avoided. Two other structures, the facial nerve and the round window, are generally
protected from any but the clumsiest of surgeons, the former by its high position in the middle
ear and the latter by the overhanging niche. Tubes are generally placed anteriorly, either
superiorly or inferiorly. Because the posterior segments are deeper and have more vibratory
motion, posterior placement gives a greater dampening effect. Anteriorly, any incision should
avoid exposure of the malleus, the malleolar ligament, and the annulus; such exposure creates a
greater tendency for perforations to persist after extrusion of the tube.

Picture 01. Normal structures of Ear

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 Picture 02. Health structures of Tympanic membrane

2. Epidemiology Acute Otitis Media

In the United States, 70% of all children experience one or more attacks of AOM before
their second birthday. A study from Pittsburgh that prospectively followed urban and rural
children for the first 2 years of life determined that the incidence of middle ear effusion episodes
is approximately 48% at age 6 months, 79% at age 1 year, and 91% at age 2 years. The peak
incidence of AOM is in children aged 3-18 months. Some infants may experience their first
attack shortly after birth and are considered otitis-prone (ie, at risk for recurrent otitis media). In
the Pittsburgh study, the incidence was highest among poor urban children. Differences in
incidence between nations are influenced by racial, socioeconomic, and climatic factors.
Children aged 6-11 months appear particularly susceptible to AOM, with frequency declining
around age 18-20 months. The incidence is slightly higher in boys than in girls. A small
percentage of children develop this disease later in life, often in the fourth and early fifth year.
After the eruption of permanent teeth, incidence drops dramatically, although some otitis-prone
individuals continue to have acute episodes into adulthood. Occasionally, an adult with an acute
viral URTI but no previous history of ear disease presents with AOM. Definite racial differences
exist in the incidence of AOM. Native Americans and Inuits have very high rates of acute and
chronic ear infection, whereas African Americans appear to have a slightly lower rate than white
children living in the same communities.

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3. Etiology Acute Otitis Media
 Viral pathogens

RSV is a large RNA paramyxovirus that is most commonly associated with bronchiolitis
and pneumonia in very young persons, though it may cause acute respiratory disease in persons
of any age group. In northern climates, RSV is normally identified during annual epidemics in
the winter and early spring, but it should be considered in any neonate with lethargy, irritability,
or apnea, with or without otitis media. In older infants and children, respiratory symptoms are
usually more prominent, making diagnosis easier. RSV was identified early as a pathogen that
appeared to create long-term pulmonary complications, primarily asthma, in as many as half of
infants with bronchiolitis. RSV may be particularly lethal for children with congenital heart
disease, cystic fibrosis, immunodeficiency, bronchopulmonary dysplasia, or prematurity of less
than 37 weeks’ gestational age. RSV-specific intravenous (IV) immunoglobulin prophylaxis is
recommended only for high-risk children. When treating a child with concomitant pneumonia or
other systemic disease and otitis media, the practitioner must ensure appropriate diagnosis and
management of all aspects of the child’s illness. Drainage of the ear by tympanocentesis or
myringotomy for culture and therapy may be necessary in some cases. Drainage is mandatory in
neonates who are suspected to be in a septic state or in children who are immunosuppressed.

 Bacterial pathogens

Pathogenic bacteria are recovered from the middle ear effusion in at least half the
children with AOM, and bacterial DNA or cell wall debris is found in another quarter to a third
of specimens previously classified as sterile. Four bacteria—namely, S pneumoniae, H
influenzae, Moraxella catarrhalis, and Streptococcus pyogenes —are responsible for the
majority of episodes of AOM in persons older than 6 weeks. Other bacteria recovered and
implicated in AOM include Staphylococcus aureus, viridans streptococci, and Pseudomonas
aeruginosa. The emergence of resistance to antimicrobial agents is of increasing importance in
the management of AOM and other bacterial illnesses. The various mechanisms used by bacteria
to confer this resistance will be delineated as the common pathologic agents linked to AOM are
described.

Streptococcus pneumoniae

S pneumoniae is the most common etiologic agent responsible for AOM and for invasive
bacterial infections in children of all age groups. It is a gram-positive diplococcus with 90
identified serotypes (classified on the basis of the polysaccharide antigen), the frequency of
which varies between age groups and geography. On direct culture, various studies have shown
these bacteria to be responsible for 29-40% of isolates, but additionally pneumococcal antigens
are recovered from approximately a third of those cultures classified as sterile. Pneumococcal

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infections are probably responsible for at least 50% of AOM episodes. Serotypes 4, 6B, 9V, 14,
18C, 19F, and 23F are responsible for most invasive pneumococcal disease in America; in ear
aspirates from patients with AOM, serotypes 19 (23%), 23 (12.5%), 6 (12%), 14 (10%), 3
(8.5%), and 18 (6%) are isolated most commonly. The polyvalent pneumococcal vaccine confers
immunity to approximately 85% of those serotypes responsible for AOM. S pneumoniae was
once susceptible to almost all common antibiotics, including penicillin G, erythromycin, and
most sulfonamides. Alteration of the cell wall’s penicillin-binding protein (the antimicrobial
target) has led to the appearance of multidrug-resistant S pneumoniae (MDRSP), which is
resistant to beta-lactam compounds, macrolides, and sulfonamides. Resistance rates as high as
40% have been reported for these 3 antimicrobial groups. Serotypes 6B, 9V, 14, 19A, 19F, and
23F have the highest frequency of penicillin resistance. Ceftriaxone, cefotaxime, rifampin, and
vancomycin still appear to have therapeutic efficacy, as does immunization with polyvalent
pneumococcal vaccine for prevention. Unfortunately, polysaccharide antigens are not
immunogenic early in life. To overcome this problem, conjugated antigens, in which the
polysaccharide antigen is attached to a protein carrier, may be administered to induce production
of antibodies to these polysaccharides. Some conjugated antigens (eg, vaccinations for H
influenzae type b [Hib]) are in widespread use. A heptavalent vaccine for S pneumoniae is now
in widespread use and appears to have made an impact on the number of cases of invasive
pneumococcal disease. This vaccine confers long-term immunity to 7 of the most common and
invasive strains. Emerging evidence suggests that other serotypes are beginning to be recovered
more frequently in ear and sinus infections. This might render the vaccine less useful in future
years. In North America, this vaccine has now been replaced by an updated 13-valent vaccine
that contains conjugated antigenic material for 6 of those additional serotypes of the
pneumococcus.

Haemophilus influenzae

In middle ear aspirates from patients with AOM, H influenzae is the second most
frequently isolated bacterium and is responsible for approximately 20% of episodes in preschool
children. The frequency may be higher in otitis-prone children, older children, and adults who
have received the pneumococcal vaccine. The bacterium is a small, pleomorphic, gram-negative
coccobacillus. Those bacteria encapsulated with a polysaccharide coating are classified into 6
distinct types (a-f); nonencapsulated types are referred to as nontypeable and are responsible for
the great majority of AOM episodes. (The nonencapsulated strains have been subtyped
biochemically and antigenically, but, to date, this classification has limited clinical application.)
Traditionally, Hib has been found responsible for most invasive illnesses attributed to these
bacteria and for meningitis, epiglottitis, and septicemia. Hib accounts for only 10% of all
episodes of AOM in which H influenzae is recovered. In areas of the world where the
aforementioned Hib-conjugated vaccine is administered early in life, risks from this potentially
lethal strain have greatly diminished. Antimicrobial resistance in Hib is conferred almost
exclusively (95%) by the formation of a single enzyme, triethylenemelamine 1 lactamase, which,

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in some series, is secreted by as many as 40% of all nontypeable strains. This resistance is
overcome relatively easily by using blocking agents, extended-coverage cephalosporins, broad-
spectrum macrolides, or sulfonamides. H influenzae may participate more widely in head and
neck infections than was once believed. One of the principal mechanisms is related to the ability
of the bacterium to hide and recover from antibiotic action by forming a mucous complex known
as a biofilm. Research has focused on enhancing penetration of or dissolving the protective
biofilm.

Moraxella catarrhalis

In the mid-1970s, M catarrhalis was classified as nonpathogenic in middle ear infections,

even though under its previous name, Neisseria catarrhalis, it constituted approximately 10% of
all isolates from middle ear aspirates. At that time, M catarrhalis was almost universally
susceptible to ampicillin-type penicillins. After 20 years and 2 name changes (from N catarrhalis
to Branhamella catarrhalis to M catarrhalis), it is isolated in up to a quarter of children with
AOM, and resistance to the ampicillin-type beta-lactams is almost universal.

M catarrhalis is a gram-negative diplococcus and is considered part of the normal flora

of the human upper respiratory tract. Resistance is conferred by the secretion of multiple
isoenzymes of lactamase, which may be plasmid or chromosomal in origin and which may be
inducible (ie, present only in low levels until a substrate is provided). More than 1 isoenzyme
may be secreted by a single bacterium. At present, almost all forms are blocked by clavulanic
acid, and most are still susceptible to sulfonamides, lactamase-stable cephalosporins, or broad-
spectrum macrolides. M catarrhalis is often found to coexist with other airway pathogens. The
lactamases (cephalosporinases) that M catarrhalis secretes may protect those other bacteria from
antimicrobial agents to which the second target pathogen might ordinarily be susceptible. A
study by Chonmaitree et al of 367 infants (followed for 286 child-years) indicated that bacterial-
viral interactions are associated with AOM, with such interactions between M catarrhalis and
various respiratory viruses having been found in the report to affect the risk of upper respiratory
tract infection and AOM.

Streptococcus pyogenes

Although S pyogenes (a gram-positive coccus that constitutes the group A streptococci

[GAS] in the Lancefield classification), is still the fourth most commonly isolated bacterial
pathogen from ears with AOM, it has shown a steady decline in frequency of recovery from the
ear and in virulence over the past half-century. Similarly, a substantial decline in the major
complications of streptococcal infection, rheumatic fever, glomerulonephritis, and scarlet fever
has occurred. S pyogenes may be associated with streptococcal toxic shock syndrome, which
may include coagulopathy, soft tissue necrosis or fasciitis, desquamating rash, and liver or renal
involvement. It is primarily a pathogen of the pharynx, with more than 80 distinct M-protein

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strains identified. Currently, with the improvement in primary care and the availability of rapid
identification tests, early aggressive treatment is normally instituted against this bacterium,
which has shown minimal ability to develop resistance to antimicrobial agents. Acute necrotic
otitis media was associated with scarlet fever in the early 1900s; however, the condition was also
associated with measles, pneumonia, and influenza. Generally, the patient was extremely ill with
the systemic component of the disease and presented with a spontaneous perforation shortly after
the onset of otalgia. Early inspection of the ear would show the perforation to be moderate to
large; within days, significant evidence of tissue necrosis would be observed, perhaps including
the entire tympanic membrane, ossicles, the tympanic mucoperiosteum, or the bone of the
mastoid air cells. The patient would demonstrate a marked conductive hearing loss, although
sensorineural loss was not uncommon. Pathologically, the ear showed a marked paucity of the
normal vascular proliferation associated with an inflammatory reaction. Instead, a complete loss
of the vascularity normally associated with vasculitis or toxin exposure occurred. Healing was
never normal; tissue was replaced by epithelial invasion or scar tissue formation. In
industrialized societies, acute necrotic otitis media is now primarily of historic interest. The
disease is still reported in aboriginal populations living in areas where modern medicine has not
yet penetrated.

In the preantibiotic era, S pyogenes also appeared to be the organism most commonly
recovered from patients with acute coalescent mastoiditis. In the 1990s, S pyogenes relinquished
this distinction to S pneumoniae, but it remains a prominent pathogen when this disease is
encountered in very young persons.

Other aerobes

Except in neonates and children with chronic disease, few other pathogens have been
demonstrated in aspirates from the middle ears of immunologically intact individuals. S aureus is
rarely recovered, except in Japan, where studies indicate a somewhat higher incidence (up to
10%). Mycobacterium tuberculosis is most often associated with chronic otitis media but should
be considered when a patient presents with painless otorrhea as an initial complaint and/or has
multiple tympanic perforations. Any patient with a compromised immune system may be at risk
for this opportunistic infection. Chlamydia pneumonia is an uncommon but significant pathogen
in persons with AOM and responds only to macrolide therapy.

Anaerobes

Anaerobic bacteria have been recovered from the middle ears of children with AOM, but
the data do not support a prominent role for these microorganisms in persons with otitis media, at
least in the acute form. They may, however, play a greater role in chronic inflammation of the
adenoid bed and biofilm formation. When recovered from ears of children with AOM, the
anaerobic pathogen most often is not the sole pathogen cultured.

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 Common bacterial pathogens in neonatal period

In the perinatal period, the Escherichia coli, Enterococcus species, and group B
streptococci are the etiologic agents most commonly responsible for sepsis and meningitis. These
agents are often recovered from the middle ear, though the total percentage is probably less than
10% of neonates with AOM. S pneumoniae remains the most common pathogen responsible for
AOM in all age groups, including neonates. The nonencapsulated H influenzae and nontypeable
varieties may be invasive in these infants and constitute the second most common pathogens
recovered from the ear. Because bacteremia is common in all neonates with AOM,
tympanocentesis should be performed for both diagnosis and therapy in any infant with signs of
AOM or generalized sepsis and any middle ear effusion. This should be part of any septic
workup in neonates.

4. Pathophysiology Acute Otitis Media

Obstruction of the eustachian tube appears to be the most important antecedent event
associated with AOM. The vast majority of AOM episodes are triggered by an upper respiratory
tract infection (URTI) involving the nasopharynx.

 Viral and bacterial infection

The infection is usually of viral origin, but allergic and other inflammatory conditions
involving the eustachian tube may create a similar outcome. Inflammation in the nasopharynx
extends to the medial end of the eustachian tube, creating stasis and inflammation, which, in
turn, alter the pressure within the middle ear. These changes may be either negative (most
common) or positive, relative to ambient pressure. Stasis also permits pathogenic bacteria to
colonize the normally sterile middle ear space through direct extension from the nasopharynx by
reflux, aspiration, or active insufflation. The response is the establishment of an acute
inflammatory reaction characterized by typical vasodilatation, exudation, leukocyte invasion,
phagocytosis, and local immunologic responses within the middle ear cleft, which yields the
clinical pattern of AOM. In a minority of otitis-prone children, the eustachian tube is patulous or
hypotonic. Children with neuromuscular disorders or abnormalities of the first or second arch are
most likely “too open” and are therefore predisposed to reflux of nasopharyngeal contents into
the middle ear cleft. To become pathogenic in hollow organs, such as the ear or sinus, most
bacteria must adhere to the mucosal lining. Viral infections that attack and damage mucosal
linings of respiratory tracts may facilitate the ability of the bacteria to become pathogenic in the
nasopharynx, eustachian tube, and middle ear cleft. This theory might explain why viral antigens
are commonly recovered from middle ear aspirates in children with AOM but the actual virus is
only rarely isolated. Data have also been presented indicating that mucosal damage by

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endotoxins secreted by bacterial invaders may similarly enhance the adhesion of pathogens to
mucosal surfaces. Viral infection in the nasopharynx with subsequent inflammation of the orifice
and mucosa of the eustachian tube has long been understood as part of the pathogenesis of AOM,
although the complete role of the virus is not fully understood. Concurrent or antecedent URTIs
are identified in at least a quarter of all attacks of AOM in children, but the virus itself seldom
appears as the pathogen in the middle ear. Administration of trivalent influenza A vaccine has
been shown to reduce the frequency of AOM during the influenza season. Viruses have been
recovered with increasing frequency as techniques to identify them by direct culture and by
indirect means (eg, enzyme-linked immunosorbent assay [ELISA]) have improved. On direct
culture, the yield is less than 10%, with the respiratory syncytial virus (RSV) recovered most
frequently; the influenza virus is a distant second. On ELISA, the presence of viral antigens is
detected in approximately a quarter of middle ear aspirates; again, RSV is the virus most
frequently detected by this method. The presence of viruses in the middle ear effusion may
influence the outcome of therapy for otitis media. Results of outcome studies have been mixed,
ranging from no effect to evidence of prolongation of acuity and effusion when viruses are
present in persons with AOM.

 Immunologic factors

Immunologic activity may play a significant role in the frequency of AOM and its outcome.
Although most research has focused on the immunologic aspects of OME, certain relations
between AOM and the patient’s immune status have been demonstrated, as follows:

a. Production of antibodies may promote clearance of a middle ear effusion after an acute
attack
b. Previous exposure or immunization may have a preventative role by suppressing
colonization of the nasopharynx by pathogens
c. The formation of antibodies during an attack may prevent or modify future attacks;
unfortunately, antibodies to both Streptococcus pneumoniae and Haemophilus influenzae
are of the polysaccharide type and the ability to produce them develops late unless
conjugated to proteins
d. Minor or transient immunologic defects may give rise to recurrent otitis media

Much attention has been focused on the immunoglobulins and the patient’s ability to form
them. Immunoglobulin G2 (IgG2) and immunoglobulin G4 (IgG4) are responsible for immunity
against polysaccharide antigens; deficiencies in the formation of these antibodies invariably lead
to otitis media. Many patients with Down syndrome show decreased function of immunoglobulin
A (IgA), IgG2, or IgG4, which partially explains their increased risk for chronic rhinitis and
otitis media. The immunologic aspects of AOM are not confined to the middle ear. The
nasopharynx plays an important role in the pathogenesis of AOM, and immunologic
modifications in this lymphoid tissue provide some protection from pathogens by preventing

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their adherence to mucosal surfaces. The presence of nasopharyngeal IgA antibodies to
pneumolysin toxin released by pneumococcal autolysis appears to protect against invasion by
healthy pneumococci. On the other hand, not all immunoglobulins in the nasopharynx are
protective. Bernstein describes the effects of immunoglobulin E (IgE) hypersensitivity or
hyperimmune effects on the eustachian tube mucosa. The allergic response in the
nasopharyngeal end of the eustachian tube promotes stasis and the subsequent formation of a
middle ear effusion.

5. Signs and symptoms Acute Otitis Media

Although the history of AOM varies with age, a number of constant features manifest during
the otitis-prone years, including the following:

 Neonates: Irritability or feeding difficulties may be the only indication of a septic focus
 Older children: This age group begins to demonstrate a consistent presence of fever and
otalgia, or ear tugging
 Older children and adults: Hearing loss becomes a constant feature of AOM and otitis
media with effusion (OME); ear stuffiness is noted before the detection of middle ear
fluid

Otalgia without hearing loss or fever is observed in adults with external otitis media, dental
abscess, or pain referred from the temporomandibular joint. Orthodontic appliances often elicit
referred pain as the dental occlusion is altered.

Picture 03. Infection of tympanic membrane

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6. Risk factors Acute Otitis Media

The following are proven risk factors for otitis media:

 Prematurity and low birth weight

 Young age
 Early onset
 Family history
 Race - Native American, Inuit, Australian aborigine
 Altered immunity
 Craniofacial abnormalities
 Neuromuscular disease
 Allergy
 Day care
 Crowded living conditions
 Low socioeconomic status
 Tobacco and pollutant exposure
 Use of pacifier
 Prone sleeping position
 Fall or winter season
 Absence of breastfeeding, prolonged bottle use

7. Diagnosis Acute Otitis Media

Pneumatic otoscopy is the standard of care in the diagnosis of acute and chronic otitis media.
The following findings may be found on examination in patients with AOM:

 Signs of inflammation in the tympanic membrane

 Bulging in the posterior quadrants of the tympanic membrane may bulge; scalded
appearance of the superficial epithelial layer
 Perforated tympanic membrane (most frequently in posterior or inferior quadrants)
 Presence of an opaque serumlike exudate oozing through the entire tympanic membrane
 Pain with/without pulsation of the otorrhea
 Fever

Testing

Testing in the acute phase is generally unhelpful, because all children with AOM have
conductive hearing loss associated with the middle ear effusion. In addition, although
tympanometry may assist in the diagnosis of middle ear effusion, this test is seldom necessary
for the skilled pneumatic otoscopist. Culture and sensitivity of a specimen from a fresh
perforation or a tympanocentesis may be helpful.

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 Imaging studies

Radiologic studies are generally unnecessary in uncomplicated AOM. However, CT

scanning may be necessary to determine if a complication has occurred. MRI might be more
appropriate for diagnosing suspected intracranial complications.

Procedures

Tympanocentesis involves aspiration of the contents of the middle ear cleft by piercing
the tympanic membrane with a needle and collecting that material for diagnostic examination.

Tympanocentesis should be performed in the following patients with AOM:

 Neonates who are younger than 6 weeks (and therefore are more likely to have an
unusual or more invasive pathogen)
 Immunosuppressed or immunocompromised patients
 Patients in whom adequate antimicrobial treatment has failed and who continue to show
signs of local or systemic sepsis
 Patients with a complication that requires a culture for adequate therapy

All children with acute otitis media (AOM) have conductive hearing loss associated with the
middle ear effusion; consequently, testing in the acute phase is probably unhelpful.
Tympanometry may assist in the diagnosis of middle ear effusion but, for the skilled pneumatic
otoscopist, is seldom necessary.

8. Differential Diagnoses Acute Otitis Media

 Acute otitis Media

 External Ear
 Others infections

Diagnostic Considerations

In addition to the differential diagnosis, other problems to be considered include the

following:

 External otitis
 Dental pain
 Temporomandibular joint pain
 Acute viral pharyngitis

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 Trauma to the ear

Diagnostic action statements from the American Academy of Pediatrics (AAP) guidelines
include the following :

 AOM should be diagnosed when there is moderate to severe tympanic membrane bulging
or new-onset otorrhea not caused by acute otitis externa.
 AOM may be diagnosed from mild tympanic membrane bulging and ear pain for less than
48 hours or from intense tympanic membrane erythema; in a nonverbal child, ear holding,
tugging, or rubbing suggests ear pain.
 AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not
show middle ear effusion.

The University of Michigan Health System (UMHS) guidelines include the following
recommendations :

 Symptoms of pain or fever, together with an inflammatory middle ear effusion, are
required to make a diagnosis of AOM.
 The presence of middle ear effusion should be determined through the combined use of
otoscopy, pneumatic otoscopy, and tympanometry when necessary.

9. Complications Acute Otitis Media

The complications of AOM are classified by location as the disease spreads beyond the
mucosal structures of the middle ear cleft. They may be categorized as follows:

 Intratemporal - Perforation of the tympanic membrane, acute coalescent mastoiditis,

facial nerve palsy, acute labyrinthitis, petrositis, acute necrotic otitis, or development of
chronic otitis media
 Intracranial - Meningitis, encephalitis, brain abscess, otitis hydrocephalus, subarachnoid
abscess, subdural abscess, or sigmoid sinus thrombosis
 Systemic - Bacteremia, septic arthritis, or bacterial endocarditis

Danger signs of possible impending complications include (1) sagging of the posterior
canal wall, (2) puckering of the attic, and (3) swelling of postauricular areas with loss of the skin
crease.

A study of 177 children aged 6 months to 7 years suggested that recurrent episodes of
AOM increase the risk of spontaneous tympanic membrane perforation (STMP). In addition, the
study, by Marchisio et al, found a high frequency (50.8%) of nontypeable H influenzae in the
middle ear fluid of patients with AOM with STMP, particularly in those with recurrent STMP. M

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catarrhalis and S pneumoniae (35.0% and 27.1% of cases, respectively) were the next most
common bacterial pathogens found in AOM with STMP.

10. Acute Otitis Media Treatment & Management

Acute otitis media (AOM) has been described as a self-limiting disease, provided that the
patient does not develop a complication. This is an old description that has a renewed relevance.
In the new millennium, practitioners are forced to learn the lessons of history because these may
serve as our models of practice without effective antimicrobial agents. Nevertheless, for the time
being, antibiotics remain the initial therapy of choice for AOM. Other pharmacologic therapies
have also been used to treat AOM. Analgesics and antipyretics have a definite role in
symptomatic management. Decongestants and antihistamines do not appear to have efficacy
either early or late in the acute process, although they may relieve coexistent nasal symptoms.
Systemic steroids have no demonstrated role in the acute phase. Tympanocentesis and
myringotomy are the procedures used to treat AOM. Certain patients require ventilation or
drainage of the middle ear cleft for an extended period or have a history of repetitive attacks;
these patients benefit from placement of a tympanostomy tube at the time of myringotomy.
Consultation is seldom necessary, although some otolaryngologists might be more comfortable
having the pediatrician provide all the primary care.

 Antimicrobial Therapy Acute Otitis Media

A present, a chorus of advocates recommends withholding antibiotic therapy for patients

with AOM and following a “watchful waiting” or “wait and see” approach. As expected from
long-known data, most children managed in this fashion do well, although a study from England
observed an increase in the rate of mastoiditis in children that was, essentially, the inverse of the
rate of decrease in prescriptions for acute otitis.

A literature review by Thomas et al, which included scrutiny of evidence-based AOM

recommendations, particularly those found in current American guidelines, concluded that the
data used to compare the usefulness of prompt antibiotic therapy with 2-3 days of watchful
waiting are not completely consistent. The investigators stated that controlled trials with well-
defined endpoints are still needed to better address the question. Results from a randomized,
placebo-controlled study indicate that antimicrobial treatment of AOM-related middle ear
effusion is effective even in older children. In the Finnish study, of 84 children aged 6 months to
15 years, 50% of the patients were treated with antibiotics, with middle ear effusion resolving an
average of 2 weeks earlier in these children than it did in patients who did not receive antibiotics.
Reduction of mean duration of ear effusion by age was as follows :

15
 a. < 2 years: 8 days
b. Age 2-6 years: 20 days
c. >6 years: 1 day

 General principles

Despite the advocates of watchful waiting, the overwhelming consensus is still that
antibiotics are the initial therapy of choice for AOM, for 3 valid reasons:

a. After the institution of antibiotic therapy, a marked decline in the suppurative

complications of AOM is noted
b. Practitioners cannot predict with certainty which patients will develop complications
c. Studies have demonstrated that the use of antibiotics improves patient outcomes in both
early and late phases of AOM

Some order has been brought to the discussions of antibiotic use under the auspices of the
Centers for Disease Control and Prevention (CDC) and by the Agency for Health Care Policy
and Research (AHCPR), both agencies of the US government. The CDC published 6 principles
of appropriate antibiotic use in an attempt to bring precepts of good public health and responsible
therapy to the discussion while minimizing the selection of resistant strains of bacteria within the
community. These principles are as follows:

a. Episodes of otitis media should be classified as AOM or otitis media with effusion
(OME)
b. Antimicrobials are indicated for treatment of AOM; however, diagnosis requires
documented middle ear effusion and signs or symptoms of acute local or systemic illness
c. Uncomplicated AOM may be treated with a 5- to 7-day course of antimicrobials in
certain patients older than 2 years
d. Antimicrobials are not indicated for the initial treatment of OME; treatment may be
indicated if effusions persist for longer than 3 months
e. Persistent OME after therapy for AOM is expected and does not require repeat treatment
with antimicrobials
f. Antimicrobial prophylaxis should be reserved for controlling recurrent AOM, defined as
3 or more distinct, well-documented episodes in 6 months or 4 or more episodes in 12
months

 Choice of regimen

In the absence of culture results obtained from tympanocentesis, selection of an antibiotic

should have the following 2 objectives:

16
  The antibiotic should cover most of the common bacterial pathogens (see Etiology)
 The antibiotic must be individualized for the child with regard to allergy, tolerance,
previous exposure to antibiotics, cost, and community resistance levels

The duration of therapy is also empirically determined to some degree, and data indicate that
significant numbers of children do not receive prescribed antibiotics beyond relief of acute
symptoms. Traditionally, therapy is continued for 10-14 days; this is convenient for office
scheduling, but it may not necessarily be more efficacious than 5 or even 2 days of therapy.
Short-duration therapy may not be appropriate in children younger than 2 years who appear
prone to failure even after 14 days of therapy. Mandel showed that when an effusion-free ear was
the prime objective, 20 days of antibiotic therapy achieved better outcomes than 10 days of
therapy or placebo; however, after 90 days, no difference in the groups existed and recurrence
was not prevented by the additional therapy.

Recommendations for administration of prescribed antimicrobials to treat AOM may differ

from recommendations for the same antibiotic when used for soft tissue infections. Pulse-dosing
antibiotics, when administered for infections of hollow organs, such as the ear or sinuses, appear
to be efficacious as a result of some more obscure antimicrobial mechanisms, increased
compliance on the part of the patient or parent, and slower penetration into and removal from
middle ear effusion.

Subminimal serum levels of antibiotics have been shown to disrupt adhesive bonds between
bacteria and mucosal cell walls and to provide a postantibiotic effect, in which the reproduction
of bacteria is disrupted for a period of hours after antibiotic exposure. Similarly, a leukocyte-
enhancing action has been demonstrated at these low concentrations. When antibiotics are used
in this manner, marked variations are found in both the effectiveness of individual agents and the
susceptibility of individual pathogens. Generally, beta-lactam antibiotics are most successful
against gram-positive pathogens for both disruption of adhesion and postantibiotic effect.

Amoxicillin (or erythromycin-sulfisoxazole, in patients who are allergic to penicillin)

remains the initial treatment of choice in children with AOM. With the emergence of resistant
strains, the practitioner may need to select an alternative antimicrobial regimen that includes
either a broad-spectrum beta-lactamase–resistant cephalosporin or a combined formulation such
as amoxicillin-clavulanate or trimethoprim-sulfamethoxazole. Combination therapy may help
prevent the emergence of resistance by mutation, provided the pathogen is initially sensitive to
both components With the emergence of multidrug-resistant S pneumoniae (MDRSP), oral
therapy consisting of amoxicillin and amoxicillin-clavulanate may have efficacy when the total
amoxicillin dose reaches 80-100 mg/kg/d. If a child does not respond to an antibiotic within 48
hours and concurrently develops local and systemic signs of toxicity, the pathogen may be
resistant to the selected drug. Treatment options include an empiric change of antimicrobial

17
agent or a drainage procedure with culture. In children with prolonged acute symptoms, failure to
improve with antibiotic therapy may indicate coexistent viral infection.

Antibiotics are the only medications with demonstrated efficacy in the management of AOM.
Most antibiotics can be administered once or twice daily to improve compliance and to avoid the
necessity of sending medication to school or day care centers. The following list excludes
medications that have reduced activity against common pathogens or that have significant
adverse effects without other redeeming features to warrant inclusion Antibiotics. Empiric
antimicrobial therapy must be comprehensive and should cover all likely pathogens in the
context of the clinical setting.

 Amoxicillin (Amoxil, Trimox, Wymox)

DOC for management of AOM. Interferes with synthesis of cell wall mucopeptides
during active multiplication, resulting in bactericidal activity against susceptible bacteria.

 Amoxicillin/clavulanate (Augmentin)

Combination drug that includes a blocking agent (clavulanic acid).

 Erythromycin base / sulfisoxazole (E.E.S. 400)

Doses supplied in 200 mg/5 mL (erythromycin) and 600 mg/5 mL (sulfisoxazole). Widely
used for individuals who are penicillin-sensitive. Well absorbed from GI tract but best
administered on full stomach to avoid GI upset.

 Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

 Cefixime (Suprax)

By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall
synthesis and inhibits bacterial growth.

 Cefuroxime Axetil (Ceftin)

Second-generation cephalosporin that maintains gram-positive activity of first-generation

cephalosporins; adds activity against Proteus mirabilis, H influenzae, E coli, Klebsiella
pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of
microorganism determine proper dose and route of administration.

18
 Cefprozil (Cefzil)

Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall
synthesis and results in bactericidal activity.

 Cefpodoxime (Vantin)

Indicated for management of infections caused by susceptible mixed aerobic-anaerobic

microorganisms.

 Cefdinir (Omnicef)

Third-generation cephalosporin indicated for treatment of uncomplicated skin infections.

 Clindamycin (Cleocin HCl)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also
effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial
growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-
dependent protein synthesis to arrest.

 Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from

ribosomes, causing RNA-dependent protein synthesis to arrest.

 Azithromycin (Zithromax)

Broad-spectrum macrolide antibiotic. Absorption markedly reduced when taken with food.

 Ceftriaxone (Rocephin)

Third-generation cephalosporin. Manufacturer has heavily promoted IM use of this drug to

physicians and directly to the public for routine treatment of AOM. Subsequently, MDRSP
resistance has emerged, making this less effective in many communities. Author believes this
drug is best reserved for IV use for management of severe infections. Avoid widespread use for
AOM.

 Tympanocentesis, Myringotomy, and Tympanostomy

Surgical management of AOM can conveniently be divided into 3 related procedures:

a. Tympanocentesis

19
 b. Myringotomy
c. Myringotomy with insertion of a ventilating tube

Indications for these 3 procedures may be diagnostic, therapeutic, or prophylactic. More than
1 indication for a procedure may have to be considered on a case-by-case basis. Selection of the
appropriate procedure results from evaluation of patient factors, surgeon factors, available
resources, and urgency. Each of these aspects must be examined to select that procedure that
gives the optimal predicted outcome.

Tympanocentesis

Tympanocentesis, in its purest form, is a diagnostic procedure that gives the clinician
access to acute or chronic middle ear effusions for culture and other evaluations. However, it can
also be employed in a therapeutic setting. Additionally, tympanocentesis remains a valuable
research tool in the evaluation of new antimicrobial agents for efficacy in AOM and for
identification of host defense mechanisms or flaws in the middle ear immunochemistry.

Consider tympanocentesis in the following patients:

a. Children who are immunosuppressed or immunocompromised

b. Neonates with AOM (who are more likely to have an unusual or more invasive pathogen)
c. Patients in whom antimicrobial therapy has failed and who continue to experience local
or systemic signs of sepsis
d. Patients who have had a complication of AOM in conjunction with attempts to recover
the etiologic agent from other sites (eg, cerebrospinal fluid [CSF] or blood)

Generally, tympanocentesis is performed without anesthesia after sterilization of the ear

canal with isopropyl alcohol or povidone-iodine solution. Insert a needle through the anterior
portion of the tympanic membrane, and aspirate the contents of the middle ear into a sterile trap
for identification of microbes and their properties. A tympanocentesis may be converted to a
myringotomy and rendered therapeutic by enlarging the hole in the tympanic membrane, often
by spreading the edges with microalligator forceps or suction tip. Instilling antibiotic drops and
suctioning the middle ear are possible through the myringotomy. Typically, the patient
experiences prompt relief of local symptoms. Culture results must be obtained before extension
of the incision.

Myringotomy

Myringotomy is the incision and drainage procedure for AOM. It is a product of

technology that allows the illumination of the tympanic membrane, with or without
magnification. A myringotomy may be an extension of a tympanocentesis or a separate incision
of the tympanic membrane to provide drainage of the middle ear cleft to the ear canal. In this
20
procedure, the tympanic membrane is incised with a knife, and the resulting opening allows a
fluid-filled middle ear to drain to the ear canal and the exterior. Depending on the size of the hole
and the method used to create it, the tympanic membrane usually returns to normal within days
to a few weeks. A number of instruments, from knives to lasers, are available to perform this
task, but the basic principles remain constant. The hole design, established either by size, by the
application of material to retard healing, or by the type of initial tissue damage, is the primary
factor in controlling how long the perforation remains open, which, in turn, is determined by
patient need.

The use of a carbon dioxide laser in myringotomy on children with AOM has been
promoted widely and directly to the consumer by the manufacturers of these instruments;
proponents claim to have ushered in a new treatment for AOM without the use of antimicrobials.
This approach is undoubtedly a boon for the otolaryngologist who is less technically adept, but to
date, it has yielded little or no change in efficacy over standard myringotomy.

Myringotomy with ventilation tube

Some patients with AOM require ventilation or drainage of the middle ear cleft for an
extended period (eg, patients with mastoiditis), whereas others may have a history of repetitive
attacks. These patients benefit with the placement of a tympanostomy tube at the time of
myringotomy. In most instances, general anesthesia or sedation is necessary in older children
because topical anesthesia is relatively ineffective in acutely inflamed tympanic membranes.
Numerous tube designs are now available, each with its own weaknesses and strengths with
respect to retention, reactivity, and complications. Selection of any tympanostomy tube design is
governed by the length of time for which ventilation is likely to be needed. Tubes may be
designed to permit tube placement for 6-9 months, for 9-18 months, or for longer than 2 years.
Selection is also governed by the quality of the tympanic membrane’s fibrous tissue and by
patient need versus the increasing complication rates associated with prolonged ventilation. With
increasing antimicrobial resistance, surgical intervention in the form of tympanostomy tube
placement can be expected to increase in the coming years, after having fallen into disfavor in
the past 2 decades when resistance was less of a factor. In the author’s practice, children younger
than 15 months and those who attend day care centers are most likely to require surgery.

In a report on 248 pediatric patients who received tympanostomy tubes and postoperative
otic drop therapy, Conrad et al found that tube occlusion occurred most frequently in patients
with middle ear fluid and in those with longer time to postsurgical follow-up. The investigators,
who conducted a retrospective medical record review, found that at first follow-up, one or both
tubes were occluded in 10.6% of patients. Children with no serous fluid were found to be 3 times
more likely to have unobstructed tubes than were children with fluid. It was also found that the
chance of occlusion increased in relation to the amount of time that existed between surgery and
follow-up.

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 Mastoidectomy

Mastoidectomy predates the extensive use of tympanic membrane incision, primarily

because of the severity of the disease and the relatively frequent occurrence of spontaneous
perforation in otitis-prone individuals. For example, in Eskimo communities of northern Canada,
native Inuit are often found with large central perforations from chronic otitis.

 Contraindications for surgical therapy

Contraindications for incision of the tympanic membrane are relatively few in the presence
of acute disease. In 25 years of practice, the author has twice managed to tap through “thick
tympanic membranes” to find himself aspirating CSF from low-hanging and exposed dura (one
associated with a porencephalic cyst). Neither resulted in a prolonged complication, but CSF
may be obtained with considerably less excitement via lumbar puncture. Patients with patulous
eustachian tubes most frequently have persistent otorrhea after placement of tympanostomy
tubes. Children with neuromuscular disease, unrepaired cleft palates, or Down syndrome are
more prone to this outcome. Otorrhea may be the lesser evil when the child is septic or
uncomfortable or when damage to the middle ear cleft is imminent. This contraindication is a
relative one, and the parent must be informed of the risk and allowed to participate in the
decision whether to proceed.

11. Complications of surgical therapy Acute Otitis Media

Complications of tympanocentesis and myringotomy are few and rare in appropriately

performed procedures in children with otherwise normal anatomy. They include the following:

a. Immediate complications - Injury to the skin of the ear canal; injury to the ossicular chain
b. Intermediate complications - Persistent otorrhea; persistent perforation; external otitis
from persistent drainage; implantation cholesteatoma
c. Long-term complications - Persistent perforation, with or without otorrhea; ear canal
stenosis

The complications for myringotomy with ventilation tube placement are the same, with the
addition of those related to the tube and to longer perforation. With tubes of modern design,
medialization is now quite rare. Some tube designs have a tendency to collect epithelial debris
and inherently have a higher rate of cholesteatoma formation. As a rule, longer ventilation
increases the likelihood of persistence of the perforation, the formation of aural polyps, and
chronic otorrhea. Most of these complications are reversed by removal of the tube, with or
without repair of the hole with a small myringoplasty.

22
AAP management-related action statements include the following :

 AOM management should include pain evaluation and treatment.

 Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6
months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours
or longer or temperature 39°C or higher) and for nonsevere, bilateral AOM in children
aged 6-23 months
 On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in
children aged 6 -23 months or nonsevere AOM in older children may be managed either
with antibiotics or with close follow-up and withholding of antibiotics unless the child
worsens or does not improve within 48-72 hours of symptom onset
 Amoxicillin is the antibiotic of choice unless the child received it within the previous 30
days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases,
clinicians should prescribe an antibiotic with additional β-lactamase coverage
 Clinicians should reevaluate a child whose symptoms have worsened or not responded to
the initial antibiotic treatment within 48-72 hours and change treatment if indicated
 In children with recurrent AOM, tympanostomy tubes, but not prophylactic antibiotics,
may be indicated to reduce the frequency of AOM episodes
 Clinicians should recommend pneumococcal conjugate vaccine and annual influenza
vaccine to all children according to updated schedules
 Clinicians should encourage exclusive breastfeeding for 6 months or longer

The UMHS guidelines concur overall with those of the AAP and include the following
additional treatment recommendations :

 When antibiotic therapy is deferred, facilitate access to antibiotics if symptoms worsen (ie,
a "back-up" prescription given at visit)
 Amoxicillin is the first choice of antibiotic therapy; if amoxicillin is contraindicated,
azithromycin is the appropriate first-line therapy
 For AOM that is unresponsive to amoxicillin after 72 hours of therapy, administer
amoxicillin-clavulanate or azithromycin
 Patients with significant, persistent symptoms on high-dose amoxicillin-clavulanate or
azithromycin may respond to intramuscular ceftriaxone; the decision to use ceftriaxone
should weigh the negative impact it will have on local antibiotic resistance

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-

HNSF) offers the following guidance on the use of tympanostomy tube insertion for children
with AOM] :

23
 Tympanostomy tube insertion should not be performed in children with recurrent AOM
who do not have middle ear effusion (MEE) in either ear at the time of assessment for tube
candidacy.
 Bilateral tympanostomy tube insertion should be performed in children who have unilateral
or bilateral MEE at the time of assessment for tube candidacy.
 Educate caregivers of children with tympanostomy tubes regarding the expected duration
of tube function, recommended follow-up schedule, and detection of complications.
 Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for
children with uncomplicated acute tympanostomy tube otorrhea.
 Encourage routine, prophylactic water precautions (use of earplugs or headbands;
avoidance of swimming or water sports) for children with tympanostomy tubes.

12. Prevention Acute Otitis Media

Children with recurrent AOM have no effusion within the middle ear cleft between attacks
of acute disease. Management of this condition is confined to either episodic management or
preventive treatment.

In episodic management, each episode is considered a new attack and is treated with
antibiotics; the patient is monitored until the episode resolves. Preventative treatment involves
the administration of a conjugated heptavalent pneumococcal vaccine. Although the vaccine is
intended to combat invasive effects in infants, immunized children have a reduced incidence of
AOM, a reduced need for antibiotic therapy or tympanostomy tubes, and a reduced risk of
invasion or hearing loss.

Since the introduction of the heptavalent pneumococcal vaccine in 2000, researchers have
found that nearly two thirds of invasive pneumococcal disease cases in young children have been
caused by 6 serotypes that were not included in that vaccine. Those serotypes, along with the
original 7, have been incorporated into pneumococcal vaccine valent-13 (Prevnar 13) that was
approved in February 2010. A study by Hasegawa et al indicated that the introduction of a
heptavalent pneumococcal conjugate vaccine to Japan in 2009 significantly reduced the risk of
AOM in infants and young children. The study, in which 614 parents were surveyed, found that,
after adjustment for potentially confounding variables, the hazard ratio for AOM in vaccinated
children was 0.33, with significant risk reduction in children between infancy and age 3 years
and in young children over age 3 years. Similarly, a study by Tawfik et al indicated that since the
introduction of pneumococcal vaccination, hospital admissions for pediatric AOM/complications
of AOM in the United States have decreased in prevalence, as have admission rates for pediatric
pneumococcal meningitis with AOM/complications of AOM. Using information from the Kids’
Inpatient Database from between 2000 and 2012, the study found particularly sharp declines in

24
admissions for children under age 1 years, from 22.647 to 8.715 per 100,000 persons, and for
children aged 1-2 years, from 13.652 to 5.554 per 100,000 persons.

A study by Kaur et al indicated that the introduction of 7-valent and 13-valent

pneumococcal conjugate vaccine (PCV7 and PCV13) has reduced the prevalence of AOM in
children aged 3 years or younger. The report found that out of 615 children, all of whom were
vaccinated with PCV7 or PCV13, 60% suffered one or more episodes of AOM by age 3 years,
and 24% experienced three or more episodes. In comparison, a 1989 study, conducted by Teele
et al prior to the introduction of PCVs, found that by age 3 years, 83% of children followed
experienced at least one episode of AOM, while 46% suffered three or more episodes. Kaur et al
also attributed the change in AOM prevalence to more stringent criteria used to differentiate
AOM from otitis media with effusion. If immunologic therapy to prevent AOM is to be found,
however, vaccines that are effective against nontypeable H influenzae, as well as all serotypes of
S pneumoniae, will have to be developed. Some progress is being made with the former. As yet,
however, no vaccine exists for nontypeable H influenzae. Correspondingly, research has been
commenced on immunization against the common viruses that induce AOM—namely,
respiratory syncytial virus (RSV), adenoviruses, influenza A and B viruses, and rhinoviruses.
Antibiotic prophylaxis is becoming less popular as resistant strains emerge. Amoxicillin and
sulfisoxazole have both been used extensively. The former has better coverage against S
pyogenes but may promote nasopharyngeal colonization with beta-lactam–resistant pneumococci
and H influenzae. Reserve prophylaxis for otitis-prone children who are younger than 2 years or
in day care and who have had 3 or more attacks in a 6-month period. Both amoxicillin and
sulfisoxazole can cause serum sickness reactions. A potential preventative measure is the natural
sugar substitute, xylitol. Studies indicate that xylitol chewing gum, lozenges or syrup may reduce
the occurrence of AOM by as much as 25%. However, a study by Danhauer et al suggested that
most parents are unaware that xylitol can prevent AOM and would be unlikely to use it in their
preschool- and kindergarten-aged children. Nonetheless, the investigators, who employed an
Internet questionnaire, did find that parents who were previously aware of xylitol as a preventive
and who had children with a history of AOM would be more likely to give it to their youngsters.

Tympanostomy tube placement decreases episodes of AOM. Ventilation has been used
more frequently when evidence of MDRSP exists. In the author’s practice, resistance is noted
most frequently in infants and children aged 6-14 months who are in day care. Tympanostomy
tubes are also beneficial in children with recurrent AOM and coexistent reactive airway disease
and should be considered when recurrent episodes of AOM destabilize control of other systemic
conditions. Examples include alterations in seizure thresholds, otitic hydrocephalus, or control of
diabetes. Similarly, early tympanostomy tube placement might be considered for children with
sensorineural hearing loss, speech development abnormalities, or learning dysfunction to give
the child a consistent hearing model. Control of nasal inflammation in children, whether caused
by an allergy or by recurrent infection, appears to decrease the recurrence of AOM. Trials are
being conducted to determine the efficacy of topical nasal steroids for decreasing middle ear

25
disease, in an attempt to confirm anecdotal information that supports this treatment modality.
Some of the risk factors for AOM (see Etiology) can be removed by such efforts as altering child
care arrangements, providing a tobacco-free living space, and stopping bottle use in children
older than 1 year. In children with recurrent AOM, adenoidectomy has demonstrated efficacy.
However, determining which children will benefit from this treatment modality is not yet
possible. Few pediatric otolaryngologists recommend adenoidectomy initially over
tympanostomy tube placement alone, unless coexistent nasal symptoms are present. The
procedure might be considered for older children who require replacement of their
tympanostomy tubes. As additional information on the role of biofilm in the nasopharynx
becomes available, the selection of candidates for adenoidectomy with or without tube placement
is likely to improve.

13. Long-Term Monitoring Acute Otitis Media

Reexamine patients within 48 hours if no evidence of decreasing acuity manifests, if

symptoms become more severe, or if a complication becomes evident. Otherwise, follow-up care
is normally scheduled 10-14 days after the acute event. Persistent middle ear effusion should be
expected at the initial follow-up visit; statistically, only 30% of patients show complete
resolution. In the absence of acuity, further treatment is unwarranted, but the patient should be
scheduled to return at intervals until the effusion resolves. The author often gives parents an
“emergency prescription” to be filled if the child with fluid in the middle ear develops acute
symptoms prior to the next scheduled visit. In addition to decreasing off-hours calls, this
provides the parent with a sense of security. In a study of 1208 children, aged 6-24 months,
Grindler and colleagues concluded that the health-related quality of life in children with
recurrent otitis media was significantly worse than it was in healthy youngsters. In addition, in
children with recurrent otitis media, myringotomy tube placement was associated with increased
quality-of-life scores.

14. Prognosis Acute Otitis Media

Death from AOM is rare in the era of modern medicine. With effective antibiotic therapy,
the systemic signs of fever and lethargy should begin to dissipate, along with the localized pain,
within 48 hours. Children with fewer than 3 episodes are 3 times more likely to resolve with a
single course of antibiotics, as are children who develop AOM in nonwinter months. Typically,
patients eventually recover the conductive hearing loss associated with AOM. Middle ear
effusion and conductive hearing loss can be expected to persist well beyond the duration of
therapy, with up to 70% of children expected to have middle ear effusion after 14 days, 50% at 1
month, 20% at 2 months, and 10% after 3 months, irrespective of therapy. In most instances,
persistent middle ear effusion can merely be observed without antimicrobial therapy; however, a
second course of either the same antibiotic or a drug of a different mechanism of action may be
waranted to prevent a relapse before resolution.

26
 BAB III

CONCLUSION

Acute otitis media (AOM) is defined by convention as the first 3 weeks of a process in
which the middle ear shows the signs and symptoms of acute inflammation. OME is defined as
the presence of fluid in the middle ear with accompanying conductive hearing loss and without
concomitant symptoms or signs of acuity. OME is classified as subacute when it persists from 3
weeks to 3 months after the onset of AOM and is classified as chronic thereafter.

Acute otitis media (AOM) has been described as a self-limiting disease, provided that the
patient does not develop a complication. This is an old description that has a renewed relevance.
In the new millennium, practitioners are forced to learn the lessons of history because these may
serve as our models of practice without effective antimicrobial agents. Nevertheless, for the time
being, antibiotics remain the initial therapy of choice for AOM. Other pharmacologic therapies
have also been used to treat AOM. Analgesics and antipyretics have a definite role in
symptomatic management. Decongestants and antihistamines do not appear to have efficacy
either early or late in the acute process, although they may relieve coexistent nasal symptoms.
Systemic steroids have no demonstrated role in the acute phase. Tympanocentesis and
myringotomy are the procedures used to treat AOM.

27
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