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November 1998, Volume 48, Issue 11

Family Medicine Corner

Evaluation and Management of Otitis Media in Children

Niloufer Sultan Ali  ( Division of Family Medicine, Department of Community Health Sciences, The Aga Khan University Hospital, Karachi. )
Ali Murad  ( Fifth Year Medical Student, Aga Khan University, Karachi. )

Otitis media is one of the most frequent causes for physician visits by children. Over two-thirds of all children will experience at least one episode of otitis media during the first 3 years of life. Most of the cases usually occur during the winter.
Etiology
Streptococcus pneumomae is the most common pathogen, followed by haemophilus influenzae and Moraxella (Bronhamella) catarrhalis.
Pre disposing risk factors
A. Intrinsic factors
1. Male gender
2. Cleft palate
3. Anatomic/physiologic abnormality of the eustachian tube
4. Immune deficiency
5. Allergy
B. Extrinsic factors
1. Child care facilities
2. Large families
3. Exposure to passive smoking
4. Bottle feeding while supine
Types of otitis media Acute otitis media:
Fluid in the middle ear accompanied by signs or symptoms of ear infection1 (bulging ear drum usually accompanied by pain and fever, or perforated ear drum often with pumlent discharge).
Diagnostic criteria for AOM2
AOM is characterized by middle ear effusion (seen on examination and/or confirmed by pneumatic otoscopy) with either(l) signs of local inflammation (e.g. redness, bulging) or (2) typical symptoms (e.g. otolagia, otorrhea, irritability, restlessness, poor feeding, fever). The TM is usually full or bulging (indicated by decreased mobility on pneumatic otoscopy) and usually appears red, yellow or cloudy. Tympanometry is usually not always to establish the diagnosis of AOM, pneumatic otoscopy is highly recommended and should be used routinely.
Otitis media with effusion - OME Fluid in the middle earwithout signs or symptoms of ear Diagnostic criteria for OME2:
1. Tympanic membrane opaque or yellow
2. Tympanic membrane neutral or retracted
3. Decreased mobility
4. Air fluid level behind tympanic membrane
Chronic otitis media with effusion - Come (Serous or non suppurative otitis media)3
1. Intact tympanic membrane
2. Middle ear effusion behind intact tympanic membrane for more than 2-3 months
3. No acute clinical signs or symptoms
4. Tympanic membrane is not red orbulging
5. May be asymptomatic except for hearing loss
Chronic suppurative otitis media - CSOM3
1. Perforated tympanic membrane
2. Purulent discharge for more than 6 weeks
Persistent AOM2
Persistent AOM is defined as continued findings of AOM within 6 days after a course of antibiotics is completed.
A second course of therapy with a different antibiotic
Consider prophylaxis Prophylactic treatment should be considered in a child
1. having recurrent AOM, with Amoxil 20 mg/kg/day, usually Persistence for 2-6 months2. Antibiotic prophylaxis should be started after Refer toENT the therapeutic course of antibiotics is completed is indicated.
Resistent AOM2
Resistant AOM is defined as persistence of moderately severe symptoms (pain and fever) after 3 to 5 days of antibiotic therapy with findings of continued pressure and inflammation behind the tympanic membrane.

A second antibiotic shouldbe tried; the alternative first-line medication may be an appropriate choice. Otolaryngologic referral may be indicated if significant pain and fever continue for 4 to 5 days while the patient is taking the second medication or if complications occur.


Recurrent AOM2
Three or more episodes in 6 months or during respiratory infection season, orfouror more episodes inayear.
Risk factors for recurrent AOM:
- Cleft palate, craniofacial abnonnalities and Down syndrome (very high risk).
- First episode occurring at an early age(<6 months).
- History of recurrent AOM in a sibling or parent.
- Day-care attendance
- Exposure to tobacco smoke Recurrent AOM that fails to respond to medical management with either(1) failure of prophylaxis (recurrence twice during a 2 to 6 month period or (2) high risk of recurrence.
- Refractory AOM with moderate to severe symptoms unresponsive to at least two antibiotics.
- Bilateral or unilateral OME persisting for at least 3 months with a hearing threshold of 20 dB or worse.
- Development of advanced middle ear disease involving tympanic membrane atrophy, retraction pockets, ossicular erosion, orcholesteatoma.
- An impending or actual complication of OM, such as mastoiditis, facial nerve paralysis, lateral sinus thrombosis, meningitis, brain abscess, orlabrynntbitis.

References

1. Stool SE. Managing otitis media with effusion in young children. Quick reference guide for clinicians. Agency for health care policy and research. Arch. Otolaryngol Head Neck Surg., 1994; 120:793-98.
2. Berry P. Otitis media in children: Diagnosis, treatment andprevention. Postgrad. Med., 1998;103:197-204.
3. Maxon S, Yamauchi T. Acute otitis media. Pediatr. Rev., 1996; 17:191-95.
4. Mandel E, Casseibrant M, Rockette H, et al. Efficacy of 20-versus 10 days antimicrobial treatment for acute otitis media. Pediatrics, 1995;96:5- 13.
5. Rosenfeld JA, Clarity G. Acute otitis media in children. Primary care, 1996;23:677.99.

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