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    Otitis Media

     Author: Muhammad Waseem, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP

    BackgroundOtitis media OM! is the second most common disease of childhood, after u""er res"irator# infection$%I!& OM is also the most common cause for childhood 'isits to a "h#sician(s office& Annuall#, anestimated )* million office 'isits are attri+uted to OM; this does not include 'isits to the emerenc#de"artment&OM is an# inflammation of the middle ear -ithout reference to etiolo# or "athoenesis& OM can +eclassified into man# 'ariants on the +asis of etiolo#, duration, s#m"tomatolo#, and "h#sical findins&

     Acute OM AOM! im"lies ra"id onset of disease associated -ith one or more of the follo-in s#m"toms:• Otalia

    • Fe'er 

    • Otorrhea

    • %ecent onset of anore.ia

    • Irrita+ilit#

    /omitin• Diarrhea

    0hese s#m"toms are accom"anied +# a+normal otosco"ic findins of the t#m"anic mem+rane 0M!,-hich ma# include the follo-in:

    • O"acit#

    • 1ulin

    • Er#thema

    • Middle ear effusion MEE!

    • Decreased mo+ilit# -ith "neumatic otosco"# AOM is a recurrent disease& More than one third of children e."erience * or more e"isodes of AOM +#ae 2 #ears&OM -ith effusion OME!, formerl# termed serous OM or secretor# OM, is MEE of an# duration that lac3sthe associated sins and s#m"toms of infection e, fe'er, otalia, irrita+ilit#!& OME usuall# follo-s ane"isode of AOM&Chronic su""urati'e OM is a chronic inflammation of the middle ear that "ersists at least * -ee3s and isassociated -ith otorrhea throuh a "erforated 0M, an ind-ellin t#m"anostom# tu+e 00; see imae+elo-!, or a surical m#rinotom#&

    /arious t#m"anostom# tu+e st#les and si4es&

    Pathophysiology0he most im"ortant factor in middle ear disease is eustachian tu+e E0! d#sfunction& In E0 d#sfunction

    E0D!, the mucosa at the "har#neal end of the E0 is "art of the mucociliar# s#stem of the middle ear&Interference -ith this mucosa +# edema, tumor, or neati'e intrat#m"anic "ressure facilitates directe.tension of infectious "rocesses from the naso"har#n. to the middle ear, causin OM& Eso"haealcontents reuritated into the naso"har#n. and middle ear throuh the E0 can create a direct mechanicaldistur+ance of the middle ear mucosa and cause middle ear inflammation&In children, de'elo"mental alterations of the E0, an immature immune s#stem, and fre5uent infections ofthe u""er res"irator# mucosa all "la# ma6or roles in AOM de'elo"ment& Studies ha'e demonstrated ho-'iral infection of the u""er res"irator# e"ithelium leads to increased E0D and increased +acterialcoloni4ation and adherence in the naso"har#n.&7)8 Certain 'iral infections cause a+normal host immuneand inflammator# res"onses in the E0 mucosa and su+se5uent micro+ial in'asion of the middle ear& 0he

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    host immune and inflammator# res"onse to +acterial in'asion of the middle ear "roduces fluid in themiddle ear and the sins and s#m"toms of AOM&

     Althouh interactions +et-een the common "athoenic +acteria in AOM and certain 'iruses are not full#understood, stron e'idence indicates that these interactions often lead to more se'ere disease, lo-eredres"onse to antimicro+ial thera"#, and OME de'elo"ment follo-in AOM&

    EpidemiologyFrequencyUnited StatesOM, the most common s"ecificall# treated childhood disease, accounts for a""ro.imatel# 9 millionannual "h#sician 'isits& /arious e"idemioloic studies re"ort the "re'alence rate of AOM to +e )29<-ithin the first 9 #ears of life, and =< of children ha'e at least one documented MEE +# ae 9 #ears&OM is a recurrent disease& One third of children e."erience * or more e"isodes of AOM +# ae 2 #ears&InternationalIncidence and "re'alence in other industriali4ed nations are similar to $S rates& In less de'elo"ednations, OM is e.tremel# common and remains a ma6or contri+utor to childhood mortalit# resultin fromlate"resentin intracranial com"lications&

    Mortality/Morbidity$S mortalit# rates are e.tremel# lo- in this era of antimicro+ial thera"# > ) death "er ), cases!& Inde'elo"in nations -ith limited access to "rimar# medical care and modern anti+iotics, mortalit# rates aresimilar to $S rates +efore anti+iotic thera"#& A stud# that e.amined the causes of death in ?os AnelesCount# @os"ital from )=9)=BB, #ears "rior to the ad'ent of sulfa, sho-ed ) in deaths -as caused +#intracranial com"lications of OM&Mor+idit# from this disease remains sinificant, des"ite fre5uent use of s#stemic anti+iotics to treat theillness and its com"lications& Intratem"oral and intracranial com"lications of OM are the 9 ma6or t#"es&

    • Intratem"oral com"licationso @earin loss conducti'e and sensorineural!o 0M "erforation acute and chronic!o Chronic su""urati'e OM -ith or -ithout cholesteatoma!o Cholesteatomao 0#m"anosclerosiso Mastoiditiso Petrositiso ?a+#rinthitiso Facial "aral#siso Cholesterol ranulomao Infectious ec4ematoid dermatitis

    • Intracranial com"licationso Meninitiso Su+dural em"#emao 1rain a+scesso E.tradural a+scesso ?ateral sinus throm+osiso Otitic h#droce"halus

    ace$ntil recentl#, "re'alence of OM in the $nited States -as re"orted to +e hiher in +lac3 and @is"anicchildren than in -hite children& A stud# that controlled for socioeconomic and other confoundin factorssho-ed e5ual incidence in +lac3s and -hites& @is"anic children and Alas3an Inuit and other AmericanIndian children ha'e hiher "re'alence of AOM than -hite and +lac3 children in the $nited States&International studies sho- increased "re'alence of AOM and chronic OM COM! amon Micronesian and

     Australian a+oriinal children&

    http://emedicine.medscape.com/article/994159-overviewhttp://emedicine.medscape.com/article/993966-overviewhttp://emedicine.medscape.com/article/966099-overviewhttp://emedicine.medscape.com/article/994159-overviewhttp://emedicine.medscape.com/article/993966-overviewhttp://emedicine.medscape.com/article/966099-overview

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    Se!Se'eral more recent studies ha'e sho-n e5ual AOM "re'alence in males and females; man# "re'iousstudies had sho-n increased incidence in +o#s&

    "ge

    • Pea3 "re'alence of OM in +oth se.es occurs in children aed *) months&• Some studies sho- +imodal "re'alence "ea3s; a second, lo-er "ea3 occurs at ae #ears

    and corres"onds -ith school entr#&•  Althouh OM can occur at an# ae, =< of cases occur in children #ouner than * #ears&

    • Children -ho are dianosed -ith AOM durin the first #ear of life are much more li3el# to de'elo"recurrent OM and chronic OME than children in -hom the first middle ear infection occurs afterae ) #ear&

    #istory• Sus"ect acute otitis media AOM!, -ith or -ithout effusion, in children -ith a histor# of the

    follo-in s#m"toms:o @ead and nec3

    Otalia: oun children ma# e.hi+it sins of otalia +# "ullin on the affected earor ears or "ullin on the hair& Otalia a""arentl# occurs more often -hen thechild is l#in do-n e, durin the niht, durin na" time!, -hich ma# +e due toincreased E0D -hen the child is in a recum+ent "osition&

    Otorrhea: Dischare ma# come from the middle ear throuh a recentl# "erforated0M, throuh a "ree.istin 00, or throuh another "erforation& For trauma"atients, e.cludin a +asilar s3ull fracture -ith associated cere+ros"inal fluidCSF! otorrhea is im"ortant&

    @eadache Concurrent or recent $%I s#m"toms e, couh, rhinorrhea, sinus conestion!

    o General 0-o thirds of children -ith AOM ha'e a histor# of fe'er, althouh fe'ers reater

    than C are uncommon and ma# re"resent +acteremia or other com"lications& Irrita+ilit# ma# +e the sole earl# s#m"tom in a #oun infant or toddler&  A histor# of lethar#, althouh nons"ecific, is a sensiti'e mar3er for sic3 children

    and should not +e dismissed&o GI tract: S#m"toms include anore.ia, nausea, 'omitin, and diarrhea&

    • OME often follo-s an e"isode of AOM& Consider OME in "atients -ith recent AOM in -hom thehistor# includes an# of the follo-in s#m"toms:

    o @earin loss: Most #oun children cannot "ro'ide an accurate histor#& Parents,carei'ers, or teachers ma# sus"ect a hearin loss or descri+e the child as inattenti'e&

    o 0innitus: 0his is "ossi+le, althouh it is an unusual com"laint from a child&o /ertio: Althouh true 'ertio ie, rooms"innin di44iness! is a rare com"laint in

    uncom"licated AOM or OME, "arents ma# re"ort some unsteadiness or clumsiness in a#oun child -ith AOM&

    o

    Otalia: Intermittent otalia tends to -orsen at niht&• OM treatment -idel# 'aries +ased on the duration of s#m"toms, "ast thera"eutic failures, and

    se'erit# of current s#m"toms&• E."osure to en'ironmental ris3 factors is another im"ortant as"ect of the histor# and includes the

    follo-in:o Passi'e e."osure ie, secondhand! to to+acco smo3eo Grou" da#care attendanceo Seasonalit#: AOM "re'alence is much hiher in -inter and earl# s"rin than in summer

    and earl# fall&

    http://www.medscape.com/resource/headachehttp://emedicine.medscape.com/article/961169-overviewhttp://www.medscape.com/resource/headachehttp://emedicine.medscape.com/article/961169-overview

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    o Su"ine +ottle feedin ie, +ottle "ro""in!

    PhysicalPneumatic otosco"# remains the standard e.amination techni5ue for "atients -ith sus"ected OM& When"erformed correctl#, this techni5ue is =< sensiti'e and < s"ecific for dianosis of AOM, and findinsare more accurate than -ith m#rinotom#& Pro"er "neumatic otosco"# techni5ue is crucial to distinuish

     AOM from OME +ecause recommended thera"ies for these entities are sinificantl# different& Studiessho- that most "ractitioners im"ro"erl# "erform otosco"ic e.aminations& Almost one half of "h#siciansne'er use "neumatic com"ression of the 0M durin routine otosco"ic e.amination, and almost B< useotosco"es -ith inade5uate liht sources&0#m"anometr#, acoustic reflectometr#, and audiometr# are im"ortant ad6uncti'e techni5ues -ith -hich toe'aluate "atients -ith MEE&In addition to a carefull# documented e.amination of the e.ternal ear and 0M, e.aminin the entire headand nec3 reion of "atients -ith sus"ected OM is im"ortant& Se'eral conenital s#ndromes, craniofacialanomalies, and s#stemic diseases ha'e increased incidence associated -ith OM, includin cleft "alate, Do-n s#ndrome, 0reacher Collins s#ndrome ie, mandi+ulofacial d#sotosis!, hemifacial microsomia,dia+etes mellitus, human immunodeficienc# 'irus @I/! infection, and man# t#"es ofmuco"ol#saccharidosis&1elo- are e.amination techni5ues used in the dianosis of OM&

    Pneumatic otoscopy e!amination• $nder direct 'isuali4ation, first remo'e an# cerumen, -hich causes a limited and sometimes

    inaccurate 'ie- of the 0M and inaccurate and confusin results on t#m"anometr# andaudiometr#&

    • 0o mo'e the 0M, the ear s"eculum must create an air seal aainst the e.ternal auditor# canalEAC!, -hich is seldom "ossi+le -ith a standard dis"osa+le s"eculum& All otosco"emanufacturers sell ine."ensi'e cuffed ear s"eculums to "erform insufflation& A ru++er slee'e o'er the s"eculum ma# reduce "atient discomfort durin the e.amination& $suall#, the 0M is in theneutral "osition ie, neither retracted nor +ulin!, "earl# ra#, translucent, and un"erforated& Itres"onds +ris3l# to "ositi'e and neati'e "ressure, indicatin an airfilled s"ace& Man# older te.tsem"hasi4e a 0M liht refle. in an other-ise normal ear& 1ecause this refle. ma# +e a+sent inentirel# normal ears and "resent in ears -ith MEE, the liht refle. does not hel" confirm or

    e.clude an OM dianosis&• E'er# e.amination should include an e'aluation and descri"tion of the follo-in 0M

    characteristics:o Color

     A normal 0M is a translucent "ale ra#&  An o"a5ue #ello- or +lue 0M is consistent -ith MEE& Dar3 red indicates a recent trauma or +lood +ehind the 0M&

     A dar3 "in3 or lihter red 0M is consistent -ith AOM or h#"eremia of the 0Mcaused +# cr#in, couhin, or nose +lo-in&

    Color of the eardrum is less im"ortant dianosticall# than its "osition and mo+ilit#&%edness of the 0M alone does not necessaril# suest AOM +ecause cr#in,remo'al of cerumen -ith associated irritation of the auditor# canal, couhin,

    nose +lo-in, and fe'er can all cause redness of the eardrum -ithout a middleear infection& Hote that most children cr# -hen their ears are e.amined&  A stud# of infants sho-ed that the otosco"ic findin most "redicti'e of AOM

    -as a "oorl# mo+ile, +ulin, #ello-, and o"acified 0M& @o-e'er, thisa""earance -as noted in onl# )=< of "atients& In another anal#sis, a slihtl# red0M in a normal "osition and -ith normal mo+ilit# had a "redicti'e 'alue of onl#2< for AOM&

    o Position: 0he "osition of the 0M ie, +ulin, retracted, neutral, full! is 3e# todifferentiatin AOM from OME&

    In AOM, the 0M is usuall# +ulin&

    http://emedicine.medscape.com/article/995535-overviewhttp://emedicine.medscape.com/article/943216-overviewhttp://emedicine.medscape.com/article/946143-overviewhttp://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/995535-overviewhttp://emedicine.medscape.com/article/943216-overviewhttp://emedicine.medscape.com/article/946143-overviewhttp://emedicine.medscape.com/article/965086-overview

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    In OME, the 0M is t#"icall# retracted or in the neutral "osition&o Mo+ilit#: A+normal mo'ement of the 0M durin "neumatic otosco"# can suest 'arious

    conditions or disorders& Mo'ement durin neati'e "ressure onl# suests E0D&  A 0M that mo'es onl# slihtl# -ith +oth "ositi'e and neati'e "ressure a""lied

    indicates the "ro+a+le "resence of middle ear fluid&

    Ho mo'ement occurs -ith a 0M "erforation or a 00& Studies sho- that the most consistent "h#sical findin in "atients -ith OME is

    im"aired mo+ilit# of the 0M durin "neumatic otosco"#& Pa# s"ecial attention tomo'ement of retracted sements of the 0M +ecause immo+ilit# of these sectionsma# indicate middle ear cholesteatoma in the retraction "oc3ets&

    o Perforation Sinle "erforations are most common, +ut some "atients ma# ha'e multi"le

    "erforations& Hote the location and cause of the "erforation& Perforations in the "osterosu"erior 5uadrant, -hich are the most difficult to

    detect, are im"ortant +ecause the# occasionall# are associated -ithcholesteatoma&

    Pus or other fluid ma# drain throuh a "erforation&

    Multi"le "erforations and otorrhea that does not #ield "athoens on culture ma#indicate tu+erculosis&

    "d$uncti%e screening techniques &or OM: Ad6uncti'e techni5ues hel" identif# "atients -ithas#m"tomatic OME, -hich ma# com"rise )< of cases&

    • 0#m"anometr# ie, im"edance audiometr#!, the most commonl# used ad6uncti'e techni5ue,measures chanes in acoustic im"edance of the 0Mmiddle ear s#stem -ith air "ressure chanesin the EAC&

    o Current recommendations call for screenin t#m"anometr# at the +einnin of schooland ) #ear later to identif# children aed * #ears -ith as#m"tomatic OME&

    o 0#m"anometr# screenin has a hih deree of sensiti'it# J=

    o Further "h#sician e'aluation is indicated in a child in -hom t#m"anometr# screenin failsin +oth ears and -ho has at least a 9d1 hearin loss at ), 9, or 3@4&

    o  After 9 months, retest an# child in -hom t#m"anometr# screenin fails in one ear andhearin loss occurs J9 d1!& Also retest children in -hom t#m"anometr# screenin failsin +oth ears, e'en -ithout mar3ed hearin loss ie, > 9 d1!& A second screenin failureshould lead to "h#sician e'aluation& Assess the child(s hearin, s"eech, and lanuaeand immediatel# start thera"# to correct deficits&

    •  Acoustic reflectometr# uses an acoustic otosco"e to measure reflected sound from the 0M; thelouder the reflected sound, the reater the li3elihood of an MEE& 0he +rea3"oint is defined as thele'el of sound reflecti'it# that correlates -ith the "resence of MEE&

    o  Acoustic reflectometr# is ra"id and eas# to "erform& Amon its ad'antaes o'ert#m"anometr# is that an airtiht seal of the EAC is unnecessar# and that the test isunaffected +# a cr#in "atient or the "resence of cerumen in the EAC&

    o Des"ite these ad'antaes, acoustic reflectometr# has not +een -idel# acce"ted +#otolar#noloists +ecause of the difficult# in settin standards to inter"ret test results&

    o Ho acce"ted +rea3"oint standards ha'e +een esta+lished, so sensiti'it# and s"ecificit#'ar# accordin to the +rea3"oints set for each stud#& A lo- +rea3"oint leads to hih

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    sensiti'it# +ut lo- s"ecificit#& A hih +rea3"oint leads to hiher s"ecificit# +ut lo-ersensiti'it#&

    'auses A multitude of host, infectious, alleric, and en'ironmental factors contri+ute to OM de'elo"ment&

    • @ost factorso Immune s#stem: 0he immature immune s#stems of infants or the im"aired immune

    s#stems of "atients -ith conenital immune deficiencies, @I/ infection, or dia+etes ma#+e in'ol'ed in the de'elo"ment of OM& OM is an infectious disease that "ros"ers in anen'ironment of decreased immune defenses& 0he inter"la# +et-een "athoens and hostimmune defense "la#s a role in disease "roression& Patel et al 9=! found hiherinterleu3in I?!K* le'els in "atients -ith OM -ho also had influen4a and adeno'iralinfections, -hereas I?)+eta I?)+eta! le'els -ere hiher in "atients -ho de'elo"edOM follo-in $%I&798 In another stud#, S3o'+6er et al 9=! found that middle eareffusions -ith cultura+le "athoenic +acteria -ere associated -ith hiher le'els of I?)+eta, I?, and I?) than sterile effusions&7B8

    o Familial enetic! "redis"osition: Althouh familial clusterin of OM has +eendemonstrated in studies that e.amined enetic associations of OM, se"aratin eneticfactors from en'ironmental influences has +een difficult& Ho s"ecific enes ha'e +een

    lin3ed to OM susce"ti+ilit#& As -ith most disease "rocesses, effects of en'ironmentale."osures on enetic e."ression "ro+a+l# "la# an im"ortant role in OM "athoenesis&

    o Mucins: 0he role of mucins in OME has +een descri+ed& Mucins are res"onsi+le for elli3e "ro"erties of mucus secretions& 0he middle ear mucin ene e."ression is uni5uecom"ared -ith the naso"har#n.& A+normalities of this ene e."ression, es"eciall#u"reulation of MUC5B in the ear, ma# ha'e a "redominant role in OME&

    o  Anatomic a+normalit#: Children -ith anatomic a+normalities of the "alate and associatedmusculature, es"eciall# the tensor 'eli "alantini, e.hi+it mar3ed E0D and ha'e hiher ris3for OM& S"ecific anomalies that correlate -ith hih "re'alence of OM include cleft "alate,Crou4on s#ndrome or A"ert s#ndrome, Do-n s#ndrome, and 0reacher Collins s#ndrome&

    o Ph#sioloic d#sfunction: A+normalities in the "h#sioloic function of the E0 mucosa,includin ciliar# d#sfunction and edema, increase the ris3 of +acterial in'asion of themiddle ear and the resultant OME& Children -ith cochlear im"lants ha'e a hih incidence

    of OM, es"eciall# chronic OM and cholesteatoma formation& One stud# descri+ed arelationshi" +et-een lar#no"har#neal reflu. and chronic OM COM!; the authorsconcluded that reflu. -or3u" should +e "erformed as "art of COM in'estiations, and, ifreflu. is confirmed, reflu. treatment should +e initiated in addition to treatment of "rimar#disease&78

    o /itamin A deficienc# is associated -ith "ediatric u""er res"irator# infections and AOM&o O+esit# has +een lin3ed to an increased incidence of OM, althouh the causal factor is

    un3no-n& S"eculations include alteration of intrinsic c#to3ine "rofile, increasedastroeso"haeal reflu. -ith alterations of the oral flora, andor fat accumulation; all ofthese ha'e +een lin3ed -ith an increased incidence of OM& Con'ersel#, OM ma#increase the ris3 of o+esit# +# alterin the taste +uds&78

    • Infectious factorso 1acterial "athoens

    0he most common +acterial "athoen in AOM is Streptococcus pneumoniae, follo-ed +# nont#"ea+le Haemophilus influenzae and Moraxella catarrhalis&0hese B oranisms are res"onsi+le for more than =< of all AOM cases -ith a+acterial etiolo#&

    In infants #ouner than * -ee3s, ramneati'e +acilli e, Escherichia coli,Klebsiella s"ecies, and Pseudomonas aeruinosa! "la# a much larer role in

     AOM, causin 9< of cases& S pneumoniae and H influenzae are also the mostcommon "athoens in this ae rou"& Staph!lococcus aureus has also +eenfound as a "athoen in this ae rou" in some studies, +ut more recent studies

    http://emedicine.medscape.com/article/942989-overviewhttp://emedicine.medscape.com/article/941723-overviewhttp://emedicine.medscape.com/article/1982450-overviewhttp://emedicine.medscape.com/article/942989-overviewhttp://emedicine.medscape.com/article/941723-overviewhttp://emedicine.medscape.com/article/1982450-overview

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    suest that the flora in these #oun infants ma# +e that of usual AOM in childrenolder than * -ee3s&

    Man# e."erts had "ro"osed that the MEE associated -ith OME -as sterile+ecause cultures of middle ear fluid o+tained +# t#m"anocentesis often did notro- +acteria& 0his 'ie- is chanin as ne-er studies sho- B< incidence of "ositi'e results in middle ear +acterial cultures in "atients -ith chronic MEE&

    0hese cultures ro- a -ide rane of aero+ic and anaero+ic +acteria; S pneumoniae, H influenzae, M catarrhalis, and rou" A stre"tococci are the mostcommon&

    M catarrhalis Kinduced AOM differs from AOM caused +# other +acterial"athoens in se'eral -a#s& It is characteri4ed +# hiher a "ro"ortion of mi.edinfections, #ouner ae at the time of dianosis, lo-er ris3 of s"ontaneous"erforation of the t#m"anic mem+rane, and an a+sence of mastoiditis&7*8

    Further e'idence for the "resence of +acteria in the MEE of "atients -ith OME-as "ro'ided +# studies usin "ol#merase chain reaction PC%! assa# to detect+acterial DHA in MEE sam"les that -ere determined to +e sterile usin standard+acterial culture techni5ues& In one such stud# usin PC% assa#, 22&B< of theMEE sam"les had "ositi'e results for one or more common AOM "athoens e,S pneumoniae, H influenzae, M catarrhalis!&

    In chronic su""urati'e OM, the most fre5uentl# isolated oranisms include Paeruinosa, S aureus, Cor!nebacterium s"ecies, and Klebsiella pneumoniae& Anunans-ered 5uestion is -hether these "athoens in'ade the middle ear from thenaso"har#n. 'ia the E0 as do the +acteria res"onsi+le for AOM! or -hether the#enter throuh the "erforated 0M or a 00 from the EAC&

    0he role of Helicobacter p!lori  in children -ith OME has +een increasinl#reconi4ed& E'idence that this aent miht +e res"onsi+le for OME comes fromits isolation from middle ear and tonsillar and adenoidal tissue in "atients -ithOME&

     "lloiococcus otitidis is a ne-l# reconi4ed s"ecies of ram"ositi'e +acteriumthat has +een recentl# disco'ered as a "athoen associated -ith OME&72, 8 0hisoranism is the most fre5uent +acterium in AOM, as -ell as in OME& It has also+een detected in "atients -ho had +een treated -ith anti+iotics, such as +etalactams or er#throm#cin, suestin that these aents ma# not +e sufficientl#effecti'e to eliminate this oranism& Further in'estiation is needed to re'eal theclinical role of the oranism in OM&

    • /iral "athoenso 1ecause acute 'iral $%I is a "rominent ris3 factor for AOM de'elo"ment, most

    in'estiators ha'e sus"ected a role for res"irator# 'iruses in AOM "athoenesis&o Man# studies ha'e su+stantiated this sus"icion +# sho-in ho- certain res"irator#

    'iruses can cause inflammator# chanes to the res"irator# mucosa that lead to E0D,increased +acterial coloni4ation and adherence, and, e'entuall#, AOM& Studies ha'e alsosho-n that 'iruses can alter the hostimmune res"onse to AOM, there+# contri+utin to"roloned middle ear fluid "roduction and de'elo"ment of chronic OME&

    o 0he 'iruses most commonl# associated -ith AOM are res"irator# s#nc#tial 'irus %S/!,influen4a 'iruses, "arainfluen4a 'iruses, rhino'irus, and adeno'irus&

    o @uman "arecho'irus ) @Pe/)! infection is associated -ith OM and couh in "ediatric"atients&7=8 OM de'elo"ed in < of Bmonth follo-u" "eriods that #ielded e'idence of@Pe/) infection +ut in onl# )< of the @Pe/)neati'e "eriods; in recurrin OM, themiddle ear fluid sam"les -ere "ositi'e for @Pe/ in )< of e"isodes&

    • Factors related to allerieso 0he relationshi" +et-een alleries and OM remains unclear& In children #ouner than

    #ears, the immune s#stem is still de'elo"in, and alleries are unli3el# to "la# a role inrecurrent AOM in this ae rou"& Althouh much e'idence suests that alleriescontri+ute to the "athoenesis of OM in older children, e.tensi'e e'idence refutes therole of alleries in the etiolo# of middle ear disease&

    http://emedicine.medscape.com/article/971488-overviewhttp://emedicine.medscape.com/article/971488-overview

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    o 0he follo-in is a +rief list of e'idence for and aainst the etioloic role of aller# in OM: Man# "atients -ith OM ha'e concomitant alleric res"irator# disease e, alleric

    rhinitis, asthma!& Man# "atients -ith OM ha'e "ositi'e results to s3in testin or radioallerosor+ent

    testin %AS0!&  Althouh mast cells are found in the middle ear mucosa, most studies fail to

    sho- sinificant le'els of immunolo+ulin E IE! or eosino"hils in the MEE of"atients -ith OM& OM is most common in the -inter and earl# s"rin, #et most ma6or allerens e,

    tree and rass "ollens! "ea3 in the late s"rin and earl# fall& Most "atients -ith concomitant OM and aller# sho- no mar3ed im"ro'ement in

    middle ear disease -ith aressi'e aller# manaement, des"ite mar3edim"ro'ements to nasal and other aller#related s#m"toms&

    • En'ironmental factorso Infant feedin methods

    Man# studies re"ort that +reastfeedin "rotects infants aainst OM& 0he mostrecent and +est of these studies indicates that this +enefit is e'ident onl# inchildren -ho are +reastfed e.clusi'el# for the f irst B* months of life&1reastfeedin of this duration reduces the incidence of OM +# )B

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    (i&&erentials•  Alleric %hinitis

    •  A"ert S#ndrome

    • 1acteremia

    • Cholesteatoma

    • Cleft ?i" and Palate

    • Colic

    • Diarrhea

    • Do-n S#ndrome

    • Fe'er in the 0oddler 

    • Fe'er in the oun Infant

    • Fe'er Without a Focus

    • Gastroenteritis

    • Gastroeso"haeal %eflu.

    • @aemo"hilus Influen4ae Infection

    • @ead 0rauma

    • @earin Im"airment

    •@uman Immunodeficienc# /irus Infection

    • Mastoiditis

    • Meninitis, 1acterial

    • Hasal Pol#"s

    • Haso"har#neal Cancer 

    • Otitis E.terna

    • Otosclerosis

    • Parainfluen4a /irus Infections

    • Passi'e Smo3in and ?un Disease

    • Phar#nitis

    • Pneumococcal Infections

    • Primar# Ciliar# D#s3inesia

    • %es"irator# S#nc#tial /irus Infection• %hino'irus Infection

    • Sinusitis

    )aboratory Studies• ?a+orator# e'aluation is usuall# unnecessar#, althouh man# e."erts recommend a full se"sis 

    -or3u" in infants #ouner than )9 -ee3s -ho "resent -ith fe'er and associated acute otitismedia AOM!&

    • OM is associated -ith multi"le s#stemic diseases and conenital s#ndromes& AOM ma# +e thefirst "resentin illness in some of these diseases; therefore, order a""ro"riate la+orator# studiesto confirm or e.clude "ossi+le s#stemic or conenital diseases&

    Imaging Studies• Imain studies are not indicated in "atients -ith OM unless intratem"oral or intracranial

    com"lications are sus"ected&• In "atients in -hom an OM com"lication is sus"ected, the imain stud# of choice is a contrast

    enhanced C0 scan of the tem"oral +ones& C0 findins hel" dianose man# com"lications e,mastoiditis, e"idural a+scess, simoid sinus throm+o"hle+itis, meninitis, +rain a+scess, su+durala+scess!& Finel# cut C0 sections throuh the tem"oral +one can re'eal ossicular disease andcholesteatoma& M%I is more hel"ful in de"ictin fluid collections, es"eciall# small middle ear

    http://emedicine.medscape.com/article/889259-overviewhttp://emedicine.medscape.com/article/941723-overviewhttp://emedicine.medscape.com/article/961169-overviewhttp://emedicine.medscape.com/article/993966-overviewhttp://emedicine.medscape.com/article/995535-overviewhttp://emedicine.medscape.com/article/927760-overviewhttp://emedicine.medscape.com/article/928598-overviewhttp://emedicine.medscape.com/article/943216-overviewhttp://emedicine.medscape.com/article/970788-overviewhttp://emedicine.medscape.com/article/964131-overviewhttp://emedicine.medscape.com/article/930029-overviewhttp://emedicine.medscape.com/article/964317-overviewhttp://emedicine.medscape.com/article/907273-overviewhttp://emedicine.medscape.com/article/994159-overviewhttp://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/966099-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/994274-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/994550-overviewhttp://emedicine.medscape.com/article/994891-overviewhttp://emedicine.medscape.com/article/967189-overviewhttp://emedicine.medscape.com/article/1005579-overviewhttp://emedicine.medscape.com/article/967384-overviewhttp://emedicine.medscape.com/article/967694-overviewhttp://emedicine.medscape.com/article/1002319-overviewhttp://emedicine.medscape.com/article/971488-overviewhttp://emedicine.medscape.com/article/971592-overviewhttp://emedicine.medscape.com/article/232670-overviewhttp://www.medscape.com/resource/sepsishttp://emedicine.medscape.com/article/889259-overviewhttp://emedicine.medscape.com/article/941723-overviewhttp://emedicine.medscape.com/article/961169-overviewhttp://emedicine.medscape.com/article/993966-overviewhttp://emedicine.medscape.com/article/995535-overviewhttp://emedicine.medscape.com/article/927760-overviewhttp://emedicine.medscape.com/article/928598-overviewhttp://emedicine.medscape.com/article/943216-overviewhttp://emedicine.medscape.com/article/970788-overviewhttp://emedicine.medscape.com/article/964131-overviewhttp://emedicine.medscape.com/article/930029-overviewhttp://emedicine.medscape.com/article/964317-overviewhttp://emedicine.medscape.com/article/907273-overviewhttp://emedicine.medscape.com/article/994159-overviewhttp://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/966099-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/994274-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/994550-overviewhttp://emedicine.medscape.com/article/994891-overviewhttp://emedicine.medscape.com/article/967189-overviewhttp://emedicine.medscape.com/article/1005579-overviewhttp://emedicine.medscape.com/article/967384-overviewhttp://emedicine.medscape.com/article/967694-overviewhttp://emedicine.medscape.com/article/1002319-overviewhttp://emedicine.medscape.com/article/971488-overviewhttp://emedicine.medscape.com/article/971592-overviewhttp://emedicine.medscape.com/article/232670-overviewhttp://www.medscape.com/resource/sepsis

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    Man# "arents ha'e concerns reardin this o"tion, +ut education and in'ol'ement in medicaldecisions increases acce"ta+ilit#&

    •  Althouh instant access is a'aila+le to clinical uidelines that recommend an e."ectantmanaement for children -ith OM -ho are older than )9 #ears, the anti+iotic "rescri"tion rate isstill hih in most emerenc# de"artments& If a decision is made to treat -ith an anti+acterialaent, amo.icillin should +e "rescri+ed for most children& When amo.icillin is used, the dose

    should +e = m3d&• In 'itro anti+acterial acti'it# of amo.icillin aainst "enicillinsusce"ti+le and nonsusce"ti+le S

     pneumoniae strains isolated from children -ith AOM has sho-n that "enicillin resistance cannot+e e.tra"olated to amo.icillin& 0herefore, minimal inhi+itor# concentrations of "enicillinnonsusce"ti+le S pneumoniae for amo.icillin should +e e'aluated, and this antimicro+ial aentstill remains a f irstline choice for children -ith AOM&

    • If the "atient fails to res"ond to the initial manaement o"tion -ithin 29 hours, the clinicianmust reassess the "atient to confirm AOM and e.clude other causes of illness& If AOM isconfirmed in a "atient initiall# treated -ith o+ser'ation, the clinician should +ein anti+acterialthera"#& If the "atient -as initiall# treated -ith one or more anti+acterial aents, the clinicianshould chane the anti+acterial aents!&

    • He- alternati'e treatments for OM are desira+le +ecause of the relati'el# hih "re'alence ofrecurrent and "ersistent AOM& 0he "resence of the most "re'alent etioloic aent, S

     pneumoniae, es"eciall# "enicillinnonsusce"ti+le strains in children, also su""orts alternati'etreatment reimens&• ?aredose cefdinir thera"# can +e used in com+ination -ith t#m"anocentesis and has hih

    efficac# aainst "enicillinsusce"ti+le S pneumoniae&7)8 0he effecti'eness is lo- fornonsusce"ti+le and H influenzae strains&

    • Clinicians should encourae the "re'ention of AOM throuh reduction of ris3 factors&

    • E'idence is insufficient to ma3e a recommendation reardin the use of Com"lementar# and Alternati'e Medicine CAM! for AOM&

    Earlier recommendations from the American Academ# of Pediatrics and the CDC -or3in rou" on AOM"u+lished in )=== are summari4ed as follo-s:

    • First, distinuishin AOM from OME is critical& Prom"t anti+iotic thera"# has +een thecornerstone of thera"# for AOM for decades; ho-e'er, anti+iotics are not indicated for initialtreatment of OME&

    • Second, antimicro+ials should not +e "rescri+ed in "atients in -hom AOM is onl# sus"ected or inres"onse to "arental "ressure on "ro'iders for s"ecific thera"#& A dianosis of AOM should +esu""orted +# a careful histor# and "h#sical e.amination that document the "resence of MEE andconcurrent sins or s#m"toms of acute illness see @istor# and Ph#sical!&

    • 0hird, "atients -ith uncom"licated AOM -ho are #ouner than 9 #ears should +e treated -ith a)da# course of antimicro+ials; children older than 9 #ears ma# +e treated -ith a to 2da#course of antimicro+ials& All "atients -ith se'ere or recurrent AOM or -ith com"lications of AOMshould +e treated for a minimum of ) da#s&

    • Fourth, reser'e antimicro+ial "ro"h#la.is for selected children -ith recurrent AOM& %ecurrent AOM is defined as B or more documented e"isodes -ithin the "rior * months or or moree"isodes in the "recedin )9 months&

     A metaanal#sis of * randomi4ed trials that studied the effects of anti+iotic use in AOM sho-ed thatchildren older than 9 #ears -ith mild AOM can +e o+ser'ed -ithout the need for anti+iotic administration&7)*8 Anti+iotic administration seemed to ha'e a +eneficial effect in "atients #ouner than 9 #ears -ith+ilateral OM and in "atients -ith AOM and otorrhea&

     A recent stud# determined the clinical "ractices related to the dianosis of OM +ased on American Academ# of Pediatrics uidelines&7)28 Authors re'ie-ed studies on OM dianosis and treatment from)==9& At least one American Academ# of Pediatrics criteria -ere used in )< of the studies,-hereas 9< of the studies used all B criteria& $se of these criteria can hel" "ro'ide uniformit# to thedianosis and treatment of OM amon 'arious centers& 0he 9 uidelines ha'e also +een sho-n toreduce the rate of anti+iotic "rescri+in "ractices amon "rimar# care "h#sicians&7)8

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    Medical therapy &or "OMIn )===, the CDC thera"eutic -or3in rou" on D%SP "u+lished consensus recommendations for AOMmanaement&7)=8 0he recommendations su""ort the use of amo.icillin as the firstline antimicro+ial aentof choice in "atients -ith AOM& 0he rou" recommended increasin the dose used for em"iric treatmentfrom m3d to = m3d +ecause of concerns a+out increasinl# resistant strains of S

     pneumoniae, -hich are theoreticall# susce"ti+le to this hiher dose&

    0he recommendations for secondline thera"# -ere more contro'ersial, des"ite their reasona+lenessfrom a scientific 'ie-"oint& Stressin the im"ortance of documentin true clinical failure of thera"# after atleast B da#s of treatment -ith hihdose amo.icillin, the -or3in rou" suests t#m"anocentesis foridentification and susce"ti+ilit# testin of the etioloic +acteria to uide alternate anti+iotic thera"#& Incases in -hich secondline thera"# is em"iricall# chosen a common occurrence, +ecause fe- "rimar#care "h#sicians routinel# "erform t#m"anocentesis in the office!, the recommendations suestadministerin the follo-in B "re"arations:

    • @ihdose oral amo.icillincla'ulanate = m3d of amo.icillin com"onent, *& m3d ofcla'ulanate com"onent!

    • Oral cefuro.ime a.etil sus"ension: B mmd; ta+let 9 m +id!

    • Intramuscular IM! ceftria.one administered as a sinle IM in6ection of m3 on Bconsecuti'e da#s!

    0he choice of these B "re"arations from amon the )* antimicro+ials currentl# a""ro'ed +# the $S Food

    and Dru Administration FDA! for OM thera"# -as +ased on studies that re"orted that these drusachie'e sufficient concentrations in middle ear fluid for +acteriocidal action aainst the common"athoens in AOM, includin D%SP and +etalactamaseK"roducin H influenzae& Similar studies for theother )B a""ro'ed aents either ha'e not +een com"leted or failed to sho- similar efficac# aainstresistant +acteria&0hese recommendations rel# hea'il# on the "harmacod#namics model of dru efficac#& In this model,clinical cure is +elie'ed to correlate -ith demonstrated "enetrance of the anti+iotic into the middle ear at ale'el +elie'ed to +e sufficient to 3ill the +acterial "athoens that cause AOM& He'ertheless, this model hasthe follo-in shortcomins:

    •  Althouh +acterioloic eradication correlates -ith a successful clinical outcome, clinical successoccurs in more than *< of "atients, e'en -hen +acterioloic eradication is not achie'ed&E'entuall#, almost all "atients im"ro'e&

    • /alidation of the "harmacod#namic model relies on t#m"anocentesis to identif# the causati'e

    +acteria and to measure anti+iotic le'els in middle ear fluid& Some anti+iotics e, a4ithrom#cin7Lithroma.8, clarithrom#cin 71ia.in8! concentrate intracellularl#, not in middle ear fluid, and are+acteriostatic, not +actericidal& A model "redicated on certain dru le'els and +acterial eradicationma# underestimate the efficac# of these aents&

    • 0he dru le'els used +# the CDC to define +acterial 3illin -ere +ased on standards thatchaned * months after the CDC "u+lication&

    0he follo-in crucial issues in AOM treatment -ere not clearl# addressed +# the CDC recommendations:• Patient com"liance and the associated factors of dosin fre5uenc#, duration of thera"#,

    "alata+ilit#, and dru cost• Guidance for s"ecial situations e, aller# to "enicillins, +etalactam drus, or +oth!

    • Discussion of the o"tion of -ithholdin anti+iotic thera"# for 9B da#s in a su+set of "atients -ith AOM -ho are li3el# to e."erience s"ontaneous resolution of disease -ith onl# su""orti'e careand analesic thera"# a -ides"read "ractice in the Hetherlands and Scandina'ia +ut a "ractice

    -ith fe- "ro"onents in the $nited States!Com"liance, duration of thera"#, and cost are im"ortant issues in treatin children -ith AOM& 0he "rimar#determinants of com"liance a""ear to +e fre5uenc# of dosin, "alata+ilit# of the aent, and duration ofthera"#& ?ess fre5uent doses ie, 5d or +id! are more desira+le than more fre5uent doses, -hich interfere-ith dail# routines& Shorter duration of thera"# ie, 2 d 's )) d! increases com"liance +ut should +eused onl# -hen e5ual clinical efficac# can +e assured& In man# instances, "alata+ilit# ultimatel#determines com"liance in children&For children -ho are alleric to "enicillin or +etalactam, the onl# currentl# a'aila+le "roducts arece"halos"orins, trimetho"rimsulfametho.a4ole, or macrolides& Patients -ho are alleric to "enicillin sho-))< crossreacti'it# -hen treated -ith ce"halos"orins& ?e'oflo.acin has demonstrated hiher efficac#

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    in the treatment of AOM -hen com"ared -ith amo.icillincla'ulanate and can +e used in "atients -ho arealleric to "enicillin&798

    • Pneumococcal resistance to trimetho"rimsulfametho.a4ole is increasin and has +ecome morecommon than "enicillin resistance in some areas& $se this dru to treat AOM onl# in reions-here it remains effecti'e&

    • Of the macrolides, er#throm#cinsulfiso.a4ole is a ood choice, +ut man# children refuse this

    aent +ecause of taste; a da# course of a4ithrom#cin or )da# course of clarithrom#cin ma# +e"referred&• If D%SP is the sus"ected etioloic +acterium, do not use macrolides +ecause "neumococcal

    resistance is a+solute -ith macrolides and, unli3e the use of some +etalactam anti+iotics,resistance cannot +e o'ercome +# increasin the dose&

    Man# children -ith AOM do not +enefit from antimicro+ial thera"#, either +ecause the etiolo# of theillness is not +acterial or +ecause their immune s#stem clears the infection -ithout use of a dru& Hoclinical criteria currentl# distinuish -hich children do not re5uire anti+iotic thera"# for AOM& $ntil suchcriteria are a'aila+le, man# "ractitioners are unli3el# to -ithhold initial antimicro+ial thera"# for "ro'encases of AOM& Increasin a-areness of the "atho"h#siolo# of the disease amon "arents andhealthcare "ro'iders has resulted in an increase in an o+ser'ationonl# a""roach in emerenc#de"artments -ith less "arental an.iet#&79)8

    Medical therapy &or OMEMost cases of OME occur after an e"isode of AOM, and *2< of "atients de'elo" an MEE& 0he meanduration of the effusions is 9B da#s, +ut man# "ersist much loner& Most cases of OME s"ontaneousl#resol'e& Studies of the natural histor# of this disease re"ort the follo-in:

    •  An MEE is har+ored in < of ears ) month after an e"isode of acute OME&

    •  An MEE is har+ored in 9< of ears after 9 months&

    •  An MEE continues to +e har+ored in ))< of ears after B months&

    • OMEs that "ersist loner than B months ha'e s"ontaneous resolution rates of onl# 9B

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    o  A reasona+le first choice in a "atient -ith anti+iotic e."osure durin the "rior month istrial administration of a +etalactamaseKsta+le aent e, amo.icillincla'ulanate! or asecond or thirdeneration ce"halos"orin&

    o  As -ith antimicro+ial selection, no recommendations ha'e +een made reardin durationof thera"#; ) da#s is reasona+le for amo.icillin, amo.icillincla'ulanate, andce"halos"orins& Studies of "roloned treatment in "atients -ith OME sho- no ad'antae

    in thera"ies that last loner than ) da#s&• Steroid thera"#

    o 0he literature on steroid treatment is inconclusi'e& In )==, the Aenc# for @ealth CarePolic# and %esearch A@CP%! re'ie-ed more than articles concernin themanaement of OME and "u+lished a clinical "ractice uideline on the to"ic& 7998 0here'ie- re"orted that a com+ination of steroids "lus anti+iotics im"ro'ed clearance ofMEE in 9&)< of "atients& 0his difference did not meet statistical sinificance standards,and the "anel felt the ris3s of steroid administration out-eihed "otential +enefits& 0hefinal uideline states, steroid medications are not recommended for treatment of OME ina child of an# ae&

    o Since "u+lication of the A@CP% uideline, another in'estiation of steroids "lusanti+iotics to treat OME has +een "u+lished +# %osenfeld&79B8 %osenfeld re"orted thatsurer# -as a'oided or "ost"oned for * months in ) of children treated -ith steroids&

    0herefore, steroid administration ma# ha'e a role in "atients -ho are not ood suricalcandidates&o 0he steroid reimen should +e oral "rednisone or "rednisolone at a dose of ) m3d for 

    2 da#s, administered in com+ination -ith a +etalactam anti+iotic&o Steroids are contraindicated in "atients -ith e."osure to 'aricella -ho ha'e not recei'ed

    the 'aricella 'accine +ecause of the "ossi+ilit# of lifethreatenin disseminated disease&Contro'ers# continues o'er the o"timal manaement of OME& 0he A@CP% uideline, althouh critici4edfor ha'in a narro- sco"e, for fa'orin medical rather than surical manaement of OME, and forminimi4in the "ro+lem of druresistant +acteria, "ro'ides a frame-or3 -ith -hich to considermanaement o"tions&

    Surgical 'areFrom the +einnin, interate surical manaement of AOM and OME -ith medical treatment for these

    diseases& Earl# surical inter'entions e, t#m"anocentesis! ma# +e "erformed +# "rimar# care "ro'iders,+ut more in'asi'e "rocedures e, m#rinotom#, 00 insertion, adenoidectom#! re5uire anotolar#noloist& In "atients -ith intratem"oral or intracranial com"lications of OM, surical consultation iscritical& Certain s"ecial "atient "o"ulations, such as those -ith cleft "alate, Do-n s#ndrome, or othercraniofacial a+normalities, ma# re5uire earl# surical inter'ention to "re'ent OM&

    • Indications for t#m"anocentesiso OM in "atients -ho ha'e se'ere otalia, -ho are seriousl# ill, or -ho a""ear to.ico $nsatisfactor# res"onse to antimicro+ial thera"#o Onset of AOM in a "atient recei'in antimicro+ial thera"#o OM associated -ith a confirmed or "otential su""urati'e com"licationo OM in a ne-+orn, sic3 neonate, or "atient -ho is immunoloicall# deficient, an# of -hom

    ma# har+or an unusual oranism•

    %ecommendations for 00 insertion in childreno Chronic OME: 00 insertion is recommended in children in -hom OME is unres"onsi'e to

    a trial of anti+iotic thera"# and has "ersisted for at least B months, -hen +ilateral, or atleast * months, -hen unilateral& In "atients -ith unilateral OM, * months of "ersistentOME is not an a+solute indication for 00 "lacement& If the "atient has e'idence of 0Mstructural a+normalit# secondar# to OME or if the "atient has recurrent infections, 00"lacement is indicated& If these criteria are not met and hearin is normal in the affectedear, careful o+ser'ation is "ro+a+l# sufficient&

    o %ecurrent AOM: 00 insertion is recommended in children -ith recurrent AOM, es"eciall#-hen antimicro+ial "ro"h#la.is fails& A minimum fre5uenc# of B or more e"isodes of AOM

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    • Otoloist: Children -ho "resent -ith su+6ecti'e e'idence of hearin loss should recei'e a formalhearin test ie, audioram!& Su+6ecti'e e'idence of hearin loss is often "ro'ided +# a "arent orcarei'er in #ouner children or, "ossi+l#, +# a school teacher in older children&

    • S"eech thera"ist: S"eech thera"# is indicated for "atients in -hom COM has caused s"eech andlanuae dela#s +ecause of hearin loss&

    Medication Summary• 0he FDA has a""ro'ed more than a do4en anti+iotics to treat otitis media OM!&

    • Some clinicians ad'ocate administerin corticosteroids in com+ination -ith a +etalactamKsta+leanti+iotic& 1efore "rescri+in such thera"#, o+tain a histor# of 'aricella, 'accination aainst'aricella, and recent e."osure to a "atient -ith 'aricella to a'oid the ris3 of disseminated'aricella&

    • Studies of other ad6uncti'e thera"# for acute OM AOM! and OME ha'e sho-n that HSAIDs,deconestants, and antihistamines "ro'ide no o+'ious +enefits&

    "ntimicrobial agents'lass Summary0hese aents remo'e "athoenic +acteria from middle ear fluid&

    "mo!icillin ,Biomo!- "mo!il- *rimo!.Mainl# +actericidal& As -ith "enicillins, inhi+its third and final stae of +acterial cell -all s#nthesis +#"referentiall# +indin to s"ecific P1Ps located inside the +acterial cell -all&PO semis#nthetic amino"enicillin similar to am"icillin& Amino"enicillins are not sta+le in +etalactamases of either ram"ositi'e or ramneati'e +acteria; more sta+le in astric acid than"enicillin and more +ioa'aila+le than PO am"icillin&

     Amo.icillin is associated -ith a lo-er "re'alence of diarrhea than is am"icillin administered PO+ecause of the reater +ioa'aila+ilit# of amo.icillin& Commonl# used to treat infections e, OM,+ronchitis, sinusitis, +acterial c#stitis! caused +# susce"ti+le oranisms& 0o increase efficac# aainstP%SP in OM or res"irator# infections, hiher dosin reimens ha'e +een recommended&

    "mo!icillin and cla%ulanate ,"ugmentin.

     As a +etalactam anti+iotic, amo.icillin is mainl# +actericidal& Inhi+its third and final stae of +acterialcell -all s#nthesis +# "referentiall# +indin to s"ecific P1Ps located inside the +acterial cell -all& As-ith all +etalactam anti+iotics, a+ilit# to interfere -ith P1Pmediated cell -all s#nthesis ultimatel#leads to cell l#sis&Cla'ulanic acid is a +etalactamase inhi+itor that "ossesses -ea3 anti+acterial acti'it# and acts as acom"etiti'e suicide inhi+itor of man# "lasmidmediated and chromosomemediated +acterial +etalactamases&E.cellent choice for secondline thera"# in AOM or initial thera"# in OME& Dru com+ination treats+acteria resistant to +etalactam anti+iotics& Com+ination -ith cla'ulanic acid reesta+lishesamo.icillin(s acti'it# aainst +etalactamase"roducin +acteria& E.cellent for treatin infections dueto +etalactamase"roducin H influenzae and "enicillinase"roducin anaero+es&Commonl# used to treat infections e, AOM, acute sinusitis, acute +acterial c#stitis, uncom"licatedonorrhea, chancroid! caused +# susce"ti+le oranisms&

    For children JB mo, +ase dosin "rotocol on amo.icillin content& 1ecause of differentamo.icillincla'ulanic acid ratios in 9m ta+ 9)9! 's 9m che-a+le ta+ 9*9&!, do notuse 9m ta+ until child -eihs J 3& $se the 2:) formulation ie, +id formulation! in hiher dosesto minimi4e GI tract effects&

    'e&aclor ,'eclor.Secondeneration PO ce"halos"orin indicated for infections caused +# susce"ti+le ram"ositi'ecocci and ramneati'e rods& @as slihtl# im"ro'ed acti'it# aainst H influenzae com"ared toce"hale.in& Althouh mar3eted after firsteneration aents, causin some clinicians to consider it asecondeneration aent, its s"ectrum more closel# resem+les firsteneration ce"halos"orins&

    http://reference.medscape.com/drug/amoxil-moxatag-amoxicillin-342473#1http://reference.medscape.com/drug/augmentin-amoxicillin-clavulanate-342474#1http://reference.medscape.com/drug/ceclor-raniclor-cefaclor-342494#1http://reference.medscape.com/drug/amoxil-moxatag-amoxicillin-342473#1http://reference.medscape.com/drug/augmentin-amoxicillin-clavulanate-342474#1http://reference.medscape.com/drug/ceclor-raniclor-cefaclor-342494#1

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    Clinicall#, used "rimaril# to treat OM, sinusitis, and $%Is caused +# H influenzae that are resistant toam"icillin or amo.icillin&$se hiher doses for se'ere infections e, "neumonia, OM!, less susce"ti+le strains of "athoens,and in "atients -ho are o+ese&

    'e&proil ,'e&il.

    PO, semis#nthetic, secondeneration ce"halos"orin& 1inds to one or more P1Ps, -hich, in turn,inhi+it cell -all s#nthesis and result in +actericidal acti'it#& Possi+le secondline thera"# for AOM orinitial thera"# for OME& 0hera"eutic uses include OM, soft tissue infections, and res"irator# tractinfections&

    'e&uro!ime ,'e&tin.Secondeneration ce"halos"orin maintains the ram"ositi'e acti'it# of firstenerationce"halos"orins and adds acti'it# aainst Proteus mirabilis, H influenzae, E coli, K pneumoniae, andM catarrhalis&Common clinical uses include se'ere u""er and lo-er res"irator# tract infections, s3in infections, OM,and surical "ro"h#la.is&Condition of "atient, se'erit# of infection, and susce"ti+ilit# of microoranism determine "ro"er doseand route of administration& Sus" is less +ioa'aila+le than ta+& 1ioa'aila+ilit# is enhanced -henadministered -ith food or infant formula&

    'e&i!ime ,Supra!.0hirdeneration ce"halos"orin a'aila+le in an PO formulation& As -ith ceftria.one, has enhancedanti+acterial acti'it# and increased sta+ilit# aainst man# +etalactamases& 1# +indin to one or moreP1Ps, it arrests +acterial cell -all s#nthesis and inhi+its +acterial ro-th&Commonl# used to treat OM, res"irator# tract infections, and $%Is caused +# susce"ti+le oranisms&When treatin OM, sus" is "referred due to hiher serum concentrations achie'ed -ith this dosaeform com"ared -ith ta+s&

    'e&tria!one ,ocephin.0hirdeneration ce"halos"orin -ith +roads"ectrum ramneati'e acti'it#; lo-er efficac# aainstram"ositi'e oranisms; hiher efficac# aainst resistant oranisms& Arrests +acterial ro-th +#+indin to one or more P1Ps& @as lonest halflife of all ce"halos"orins, allo-in oncedail# dosinand ma3in it a useful anti+iotic for out"atient thera"#&In Dec )==2, the FDA a""ro'ed IM ceftria.one to treat +acterial AOM caused +# H influenzae +etalactamase neati'e!, H influenzae +etalactamase "ositi'e!, M catarrhalis includin +etalactamase"roducin strains!, and S pneumoniae& A""ro'al -as +ased on the follo-in data in children aed months to #ears: A "ros"ecti'e, randomi4ed, dou+le+lind, clinical trial com"ared the effecti'enessof a m3 sinle dose of IM ceftria.one n))*! -ith a )d course of PO amo.icillin n))2!& 0heauthors concluded that a sinle IM in6ection of ceftria.one is as effecti'e as PO amo.icillin to treatuncom"licated OM in children&0he CDC(s D%SP thera"eutic -or3in rou" suests this dose for B consecuti'e da#s in cases ofsus"ected resistant +acteria&

    'e&podo!ime ,0antin.Cef"odo.ime "ro.etil is an PO "rodru for the e.tendeds"ectrum, semis#nthetic, ce"halos"orin

    anti+iotic cef"odo.ime& S"ectrum is similar to thirdeneration ce"halos"orins and "rimaril# hasramneati'e co'erae +ut also co'ers some ram"ositi'e oranisms& @ihl# sta+le in the"resence of +etalactamase en4#mes; as a result, man# oranisms resistant to "enicillins and somece"halos"orins due to +etalactamases! ma# +e susce"ti+le to cef"odo.ime&Indicated for treatment of u""er and lo-er res"irator# tract infections, $0Is, S0Ds, and s3in and s3instructure infections& @as lon halflife, allo-in t-icedail# administration& A""ro'ed +# the FDA in)=&

    'larithromycin ,Bia!in.

    http://reference.medscape.com/drug/cefzil-cefprozil-342499#1http://reference.medscape.com/drug/ceftin-zinacef-cefuroxime-342500#1http://reference.medscape.com/drug/suprax-cefixime-342503#1http://reference.medscape.com/drug/rocephin-ceftriaxone-342510#1http://reference.medscape.com/drug/vantin-cefpodoxime-342498#1http://reference.medscape.com/drug/biaxin-xl-clarithromycin-342524#1http://reference.medscape.com/drug/cefzil-cefprozil-342499#1http://reference.medscape.com/drug/ceftin-zinacef-cefuroxime-342500#1http://reference.medscape.com/drug/suprax-cefixime-342503#1http://reference.medscape.com/drug/rocephin-ceftriaxone-342510#1http://reference.medscape.com/drug/vantin-cefpodoxime-342498#1http://reference.medscape.com/drug/biaxin-xl-clarithromycin-342524#1

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    PO macrolide anti+iotic similar to er#throm#cin and a4ithrom#cin& Commonl# used in infections of theres"irator# tract, S0Ds, OM, and infections in "atients -ith AIDS& As -ith other macrolides, +inds toS su+unit of the 2S ri+osome, there+# +loc3in %HAmediated +acterial "rotein s#nthesis& Can +e+acteriostatic or +actericidal in action, de"endin on concentration and the "articular oranism and itsinoculum& Also "enetrates "haoc#tes and macro"haes efficientl#, and, as a result, is effecti'eaainst a -ide 'ariet# of oranisms in res"irator# infections&Generall# acti'e aainst oranisms that are usuall# susce"ti+le to er#throm#cin, includin moststa"h#lococcal and stre"tococcal strains& In addition, clarithrom#cin is acti'e aainst M catarrhalis,M!coplasma pneumoniae, #eionella s"ecies, and Chlam!dia pneumoniae& 1etalactamase"roduction should ha'e no effect on acti'it#& Most strains of methicillinresistant and o.acillinresistantsta"h#lococci are resistant to clarithrom#cin&Oriinall# a""ro'ed +# the FDA in Oct )==)&

    "ithromycin ,1ithroma!.Semis#nthetic anti+iotic +elonin to the macrolide su+rou" of a4alides& Similar in structure toer#throm#cin& Inhi+its "rotein s#nthesis in +acterial cells +# +indin to the S su+unit of +acterialri+osomes& Action is enerall# +acteriostatic +ut can +e +actericidal in hih concentrations or aainstsusce"ti+le oranisms&

     Althouh sinificantl# more e."ensi'e, it can +e administered as a oncedail# dose and "roduces lessGI tract intolerance than er#throm#cin& A""arent ad'antae o'er er#throm#cin is that it reacheshiher intracellular concentrations, thus increasin efficac# and duration of action& 0hese ad'antaesare demonstrated in studies that sho- that sinle doses are effecti'e for the treatment of S0Dscaused +# chlam#dial and onorrheal oranisms&

     A""ro'ed +# FDA in Ho' )==)& PO sus" -as introduced in A"r )==& In late )==, -as a""ro'ed fortreatment of "ediatric OM and "har#nitis and, in mid )==*, -as a""ro'ed for MAC "ro"h#la.is in"atients -ith ad'anced @I/ disease&I/ form is also a'aila+le for initial treatment of communit#ac5uired "neumonia and "el'icinflammator# disease&

    *rimethoprim and sul&ametho!aole ,Bactrim (S- Septra (S. Also 3no-n as cotrimo.a4ole& Com+ination "roduct of 0MP and SML in a fi.ed ): ratio& %atio"roduces serum concentrations of ):9, -hich o"timi4e anti+acterial acti'it# aainst some oranisms&1oth 0MP and SML are s#nthetic folate antaonists that are effecti'e antimicro+ials as indi'idual

    aents& 0MP is usuall# +actericidal and acts +# inhi+itin se5uential en4#mes of the folic acidKs#nthesis "ath-a#& SML is a structural analo of PA1A and com"etiti'el# inhi+its formation ofdih#drofolic acid from PA1A& 0MP +inds to and re'ersi+l# inhi+its the en4#me dih#drofolatereductase, -hich "re'ents formation of 0@F from dih#drofolic acid&0@F is a meta+olicall# acti'e form of folic acid& Without 0@F, +acteria cannot s#nthesi4e th#midine,-hich leads to interference -ith +acterial nucleic acid and "rotein formation&Com+ination of 0MP -ith SML is s#neristic aainst some +acteria& $suall# acti'e aainstStaph!lococcus epidermidis, S aureus, S pneumoniae, Streptococcus $iridans, mostEntero+acteriaceae, Salmonella and Shiella s"ecies, H influenzae, M catarrhalis, andStenotrophomonas maltophilia%Enterococcus s"ecies, &eisseria onorrhoeae, P aeruinosa, andanaero+es are usuall# resistant or less susce"ti+le& Also effecti'e aainst Pneumoc!stis carinii,#isteria monoc!toenes, man# &ocardia s"ecies, 'ersinia enterocolitica, and #eionella

     pneumophila&

    Initiall# used in the treatment of $0Is +ut has since "ro'ed to +e a 'ersatile aent and is no- -idel#used in the "re'ention and treatment of P carinii  "neumonia& A""ro'ed +# FDA in )=2B&

    Erythromycin ,E2Mycin- Eryc- Ery2*ab- Erythrocin.Macrolide anti+iotic "roduced +# Streptom!ces er!thraeus( first of se'eral macrolide anti+iotics no-on the mar3et&Inhi+its +acterial ro-th, "ossi+l# +# +loc3in dissociation of "e"tid#l t%HA from ri+osomes, causin%HAde"endent "rotein s#nthesis to arrest& For treatment of sta"h#lococcal and stre"tococcal

    http://reference.medscape.com/drug/zithromax-zmax-azithromycin-342523#1http://reference.medscape.com/drug/ery-tab-pce-dispertab-erythromycin-base-342526#1http://reference.medscape.com/drug/zithromax-zmax-azithromycin-342523#1http://reference.medscape.com/drug/ery-tab-pce-dispertab-erythromycin-base-342526#1

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    infections& Effecti'e aainst -ide rane of microoranisms and, as -ith other anti+iotics that inhi+it"rotein s#nthesis, is mainl# +acteriostatic&

     Acti'it# aainst ram"ositi'e oranisms is usuall# reater than aainst ramneati'e oranisms+ecause of su"erior "enetration into ram"ositi'e oranisms&Gram"ositi'e oranisms susce"ti+le to er#throm#cin include S aureus, Streptococcus aalactiae,Streptococcus p!oenes, S pneumoniae, S $iridans, and Cor!nebacterium diphtheriae& Gramneati'e co'erae is limited& In eneral, should not +e used aainst H influenzae, althouh, in somecases, oranism ma# +e susce"ti+le& Althouh er#throm#cin is acti'e aainst man# micro+es, itsclinical a""lications are relati'el# fe-&In children, ae, -eiht, and se'erit# of infection determine "ro"er dosae& When +id dosin isdesired, half of the total dail# dose ma# +e ta3en 5)9h& For more se'ere infections, dou+le the dose&

    Further Inpatient 'areIn"atient care is indicated onl# in "atients -ith intratem"oral or intracranial com"lications of otitismedia OM!&

    Further Outpatient 'areMost acute OM AOM! cases resol'e -ith anti+iotic thera"#, +ut recurrences are fre5uent& 1# the time

    children are aed 2 #ears, more than one third ha'e e."erienced * or more e"isodes of AOM& Inaddition, man# "atients -ho are treated for AOM su+se5uentl# de'elo" as#m"tomatic OME&Monitorin +# otosco"ic e.amination, acoustic reflectometr#, andor t#m"anometr# is necessar# todetermine -hich children re5uire further follo-u" care and thera"# to "re'ent hearin loss andresultant s"eech and learnin disa+ilities&

     Althouh the "recise timin of follo-u" 'isits is a matter of de+ate, e.amination after * -ee3s isreasona+le& At the -ee3 to *-ee3 follo-u" 'isit, children in -hom OME has not resol'ed should+e rescheduled for a second follo-u" a""ointment * -ee3s after the first&If effusion "ersists as lon as )9 -ee3s, "erform a hearin test&%efer an# child in -hom the hearin loss in +oth ears e.ceeds 9 d1 for surical treatment -ith a+ilateral m#rinotom# and 00 "lacement&Children -ith a hearin loss of less than 9 d1 and an MEE that "ersists +e#ond )9 -ee3s can +emonitored, -ith the understandin that sinificant s"ontaneous im"ro'ement of the MEE after )9-ee3s is unli3el#, or the# can recei'e anti+iotic thera"# usin a +etalactamKsta+le aent&

    Inpatient 3 Outpatient Medications Anti+iotics eradicate +acteria in the middle ear that cause the inflammator# res"onse leadin to MEEand the s#m"toms of AOM see Medication!& 0he most common +acteria are S pneumoniae, Hinfluenzae, and M catarrhalis&

    (eterrence/Pre%entionMedical strateies to "re'ent OM include eliminatin ris3 factors for AOM, immunoloic inter'entions, andanti+iotic "ro"h#la.is& Surical strateies to "re'ent recurrent OM include "ro"h#lactic m#rinotom# and00 insertion&

    • %is3 factors: 0hese include da#care attendance, secondar# e."osure to to+acco smo3e, "acifier

    use, and +reastfeedin for less than B months +reastfeedin JB mo decreases ris3!&o Da#care attendance

     A recent metaanal#sis of studies of ris3 factors for AOM re"orted care outsidethe home increases the relati'e ris3 of recurrent AOM +# a""ro.imatel# 9& fold,"ro+a+l# due to reater e."osure to res"irator# infections& Children in da#careha'e an increased fre5uenc# of $%Is, and their infections are often more"roloned&

     AOM ris3 correlates -ith the num+er of contacts -ith other children rather thanthe a+solute num+er of children enrolled in a center& %ates of res"irator#

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    infections, includin AOM, are hiher amon children in da#care centers thanamon those recei'in famil# care&

    0he ris3 of increased infection associated -ith rou" da#care is reatest in thefirst 9 #ears of life and "articularl# in the first #ear&

    o 0o+acco smo3e e."osure 0o+acco smo3e is an u""er res"irator# irritant, and multi"le studies ha'e sho-n

    that "assi'e smo3e e."osure "laces children at increased ris3 for "neumonia,+ronchitis, +ronchiolitis, chronic MEE, and more fre5uent and se'ere asthma& Most of the "rior contro'ers# reardin the relationshi" +et-een to+acco smo3e

    e."osure and OM resulted from fault# stud# desin and a failure to o+6ecti'el#5uantif# to+acco smo3e e."osure& Studies ha'e controlled for confoundinfactors more carefull#, and man# ha'e measured serum or urine concentrationsof cotinine, a nicotine meta+olite, to o+6ecti'el# determine e."osure to "assi'eto+acco smo3e& 0hese studies consistentl# esta+lish a direct relationshi"+et-een "arental smo3in and increasin ris3 of AOM&

     A recent metaanal#sis of ris3 factors determined that "arental smo3inincreases the ris3 of AOM +# **

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    recommended at ae )9) months or at least * da#s after com"letion of the"rimar# series& PC/2 "ro'ides "otential serot#"e and serorou" cross"rotectione, *A! in < of cases of +acteremia, 9< of cases of meninitis, and 2)< ofcases of "neumococcal OM e"isodes in children #ouner than * #ears in the$nited States&

    PC/2 had decreased the num+er of e"isodes of S pneumoniae AOM caused +#

    the serot#"es included in the 'accine& It had reduced the naso"har#nealcarriae of 'accinet#"e S pneumoniae, "articularl# anti+acterialresistantoranisms, and had also "re'ented the s"read to contacts in the communit#& Arecent o+ser'ation of increased rates of anti+acterialresistant non'accineserot#"e S pneumoniae ma# erode the success of PC/2&

    Since the initiation of the he"ta'alent "neumococcal 'accine in 9,researchers ha'e found that nearl# t-o thirds of in'asi'e "neumococcal diseasecases in #oun children ha'e +een caused +# * serot#"es not co'ered +# that'accine& 0hose serot#"es, alon -ith the oriinal 2, ha'e +een incor"orated into"neumococcal 'accine 'alent)B Pre'nar )B!, -hich -as a""ro'ed in Fe+ruar#9)&

    Pneumococcal "ol#saccharide 'accines ha'e +een recommended since )= for children older than 9 #ears -ho are at hih ris3 for in'asi'e disease, +ut these'accines -ere not recommended for #ouner children and infants +ecause of"oor anti+od# res"onse in children #ouner than 9 #ears&

    Pr#mula et al ha'e descri+ed the effecti'eness of a ne- 'accine that contains"neumococcal ca"sular "ol#saccharides con6uated to H influenzae) deri'ed"rotein D in the "re'ention of a first e"isode of AOM&798 Accordin to their data, at"resent, the full effecti'eness of the 'accine in treatin children is 5uestiona+le,e'en in hihris3 children&

    Pneumococcal con6uate 'accines, such as PC/2, induce "ro"osed "rotecti'eanti+od# res"onses J&) mcm?! in more than =< of infants after a series ofB doses administered at aes 9, , and * months& Follo-in the "rimin doses,sinificant +ooster res"onses ie, immunoloic memor#! are a""arent -henadditional doses are administered in "atients aed )9) months& In efficac#trials, this ne- 'accine -as associated -ith a 2< decrease in OM and a )9<decrease in 00 "lacement&

    Most anti+iotics are effecti'e in treatin AOM des"ite chaned micro+iolo# dueto the use of PC/2&79*8

    o Influen4a 'accine Influen4a is a hihl# infectious 'iral illness that is common durin the -inter

    months& A small "ro"ortion of AOM is directl# caused +# influen4a 'iruses andma# +e directl# "re'ented +# immuni4ation -ith influen4a 'accine& In addition,an# influen4a infection of the u""er res"irator# tract leads to res"irator# e"ithelialinflammation and associated E0D, -hich "redis"oses the host to +acterial AOM&

    Influen4a 'accine is stronl# recommended for an# "erson older than * monthsin -hom ae or an underl#in medical condition creates increased ris3 forcom"lications of influen4a&

    Influen4a 'accine can +e administered to an# "erson -ho -ishes to reduce thechance of infection +# the 'irus& 0he 'accine can +e administered to children as#oun as * months& Man# e."erts recommend that children -ho are "rone to OMrecei'e the annual 'accine, "articularl# those in rou" da#care -ho ha'eincreased ris3 of $%Is and AOM&

    •  Anti+iotic "ro"h#la.iso Man# studies in the )=2s and )=s sho-ed the effecti'eness of anti+iotic "ro"h#la.is

    in children -ith recurrent AOM& 0he most common reimens -ere sulfiso.a4ole Bm3dose 5d or +id! or amo.icillin 9 m3dose 5d or +id!& 0hese thera"ies -ereusuall# administered in "atients -ho had B or more e"isodes of AOM -ithin a *month"eriod or or more e"isodes -ithin )9 months&

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    o 0he use of anti+iotic "ro"h#la.is for AOM has +ecome -idel# 5uestioned +ecause of theincreasin anti+iotic resistance amon +acterial "athoens res"onsi+le for middle earinfections& E'en +efore the drastic rise in druresistant +acteria, the clinical effecti'enessof anti+iotic "ro"h#la.is for AOM -as unim"ressi'e&

    o  A metaanal#sis of )==B studies sho-ed that a child must +e treated for = months to"re'ent 6ust one e"isode of AOM&7928 0he metaanal#sis -as +ased on decadeold data

    that are almost irrele'ant no- +ecause of the ne- "re'alence of druresistant +acteria&Most e."erts -ho su""orted anti+iotic "ro"h#la.is no loner recommend routineanti+iotic "ro"h#la.is for all children -ith recurrent AOM&

    'omplications• Mastoiditis

    o Mastoid infections ha'e 9 forms, namel#, acute coalescent mastoiditis or chronicmastoiditis -ith osteitis& 0reatment for +oth t#"es of mastoiditis is a mastoidectom#&

    o  Acute coalescent mastoiditis occurs -hen o+struction of the aditus the small o"enin+et-een the e"it#m"anum and the mastoid antrum! creates a sealed s"ace in themastoid antrum the air s"ace in the mastoid "ortion of the tem"oral +one thatcommunicates -ith the t#m"anic ca'it# and mastoid air cells!& Acute infection of the fluidin this s"ace usuall# occurs as an e.tension of middle ear infection& Dianosis isconfirmed -ith a C0 scan of the head that re'eals loss of se"tation +et-een mastoid aircells&

    o Chronic mastoiditis occurs -hen acute mastoiditis remains undetected, -ith su+se5uentchanes in the mucosal linin of the mastoid air cells& Granulation tissue filled -ithinflammator# cells re"laces the air s"aces of the mastoid and middle ear, and +onenecrosis -ith erosion ma# result, leadin to an e.tracranial 1e4old a+scess see imae+elo-! or intracranial com"lication& Chronic mastoiditis ma# not +e de"icted on C0 scans&M%I re'eals reions of nons"ecific +riht sinal, consistent -ith inflammation&

     Acute coalescent mastoiditis -ith a 1e4old a+scess ina #oun irl -ho "resented -ith chronic riht ear "ain and multi"le untreated middle earinfections&

    • Cholesteatomao Cholesteatomas are c#stli3e e."andin lesions of the tem"oral +one, lined +# stratified

    s5uamous e"ithelium and containin des5uamated 3eratin and "urulent material& 0heetiolo# of cholesteatoma is contro'ersial& Althouh cholesteatoma de'elo"ment iscom"licated and incom"letel# understood, contri+utin factors include E0D, increasedneati'e "ressures in the middle ear, re"eated infection, chronic MEE, loss of collaen

    fi+ers and structural su""ort of the 0M, colla"se of the 0M, and formation of chronicretraction "oc3ets&

    o Dianosis is difficult +ut can +e made +# an e."erienced clinician usin a "neumaticotosco"ic e.amination in "atients -ith chronic middle ear disease and "roressi'econducti'e hearin loss&

    o 0reatment is surical e.cision or e.teriori4ation& In 'er# rare cases e, the "atient is nota surical candidate +ecause the cholesteatoma is secondar# to a comor+id disease!,re"eated cleansin under a surical microsco"e ma# tem"oraril# control thecholesteatoma&

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    • ?a+#rinthitiso Inflammation of the la+#rinth "roduces 'esti+ular and auditor# s#m"toms& In "atients -ith

    COM, +acteria ma# infiltrate the +on# la+#rinth and "roduce a condition of su""urati'ela+#rinthitis& Acute s#m"toms include hearin loss and 'ertio, -hich usuall# im"ro'eafter the +od# oes throuh a "hase of central com"ensation for the damaed 'esti+ularorans& Proloned la+#rinth infection leads to 'esti+ular endoran damae and

    "ermanent hearin loss&o Dianosis of la+#rinthitis in "atients -ith COM is most often retros"ecti'el# confirmed&

    /ertio and sensorineural hearin loss in these "atients is "resum"ti'e e'idence forla+#rinthitis&

    o In "atients in -hom hearin or 'esti+ular function reco'ers, la+#rinthitis is classified asserous rather than su""urati'e; reco'er# indicates that the +acteria ne'er trul# in'adedthe la+#rinth and that the s#m"toms -ere caused +# se'ere inflammation of the'esti+ular orans -ithout +acterial in'asion&

    o ?a+#rinthitis treatment includes intra'enous anti+iotics directed aainst the common"athoens in COM to limit damae to 'esti+ular orans& /esti+ular su""ressants areused in the acute "eriod to relie'e di44iness and nausea&

    • Facial "aral#siso In "atients -ith in'asi'e OM es"eciall# OM -ith cholesteatoma!, infection and

    inflammation of the facial ner'e leads to edema and ner'e fi+er com"ression that causesfacial "aral#sis& 0he facial ner'e courses throuh the tem"oral +one in the fallo"iancanal, "rotected +# +one and e"ineurium& Haturall# occurrin +on# dehiscences of thefallo"ian canal and reacti'e osteitis often due to cholesteatoma! "lace the facial ner'e atris3 in in'asi'e OM&

    o 0he com+ination of OM -ith concurrent i"silateral facial "aral#sis suests an o+'iousdianosis, +ut other entities in the differential dianosis for acute facial "aral#sis should+e considered& 0reatment is immediate administration of intra'enous anti+iotics andorsurical treatment of the cholesteatoma in'ol'in the facial ner'e&

    • Meninitiso Meninitis is amon the most common intracranial com"lications of OM, occurrin in

    children -ith either AOM or COM&o Fe'er accom"anied +# nec3 stiffness should immediatel# "rom"t a search for an

    intracranial com"lication& As -ith all intracranial com"lications, "erform a contrastenhanced C0 scan or M%I&

    o ?um+ar "uncture and e.amination of the CSF is mandator# in "atients in -hommeninitis is sus"ected& CSF leu3oc#tosis, -ith lo- lucose and hih "rotein and lactatele'els, is characteristic of meninitis& Studies of the CSF should include Gram stainin,culturin, and testin for +acterial antiens&

    o 0he treatment of choice is immediate administration of +roads"ectrum intra'enousanti+iotics, follo-ed +# directed thera"# +ased on CSF culture results& Some e."ertsha'e reduced neuroloic and auditor# se5uelae resultin from meninitis +#administerin de.amethasone earl# in the treatment course&

    • E"idural a+scesso E"idural a+scesses secondar# to OM occur near the tem"oral +one& Infection e.tends to

    the e"idural s"ace throuh 'enous channels in the +one or +# +one erosion& 0he most

    common routes for e.tension are throuh the thin +one of the temen to the middlecranial fossa or throuh the +one ad6acent to the simoid sinus and "osterior cranialfossa&

    o Most intracranial com"lications are accom"anied +# a concomitant e"idural a+scess+ecause of the "ath-a#s in'ol'ed in OM s"read&

    o Dianosis relies on hih clinical sus"icion and is confirmed usin contrastenhanced C0scan or M%I&

    o 0reatment re5uires surical e."loration, -ith a cortical mastoidectom# and thinnin of the+one o'erl#in the temen t#m"ani, simoid sinus, and "osterior fossa to allo- the

    http://emedicine.medscape.com/article/80773-overviewhttp://emedicine.medscape.com/article/80773-overview

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    e"idural s"ace to +e seen& If ranulation tissue or "urulent fluid is disco'ered in thee"idural s"ace, continue remo'in +one until noninflamed dura is encountered&

    • ?ateral sinus throm+o"hle+itiso ?ateral and simoid sinuses are relati'el# un"rotected from direct e.tension of infections

    from the middle ear and mastoid& Direct e.tension occurs secondar# to +one erosionfrom osteitis or necrosis& Indirect e.tension occurs 'ia retrorade throm+o"hle+itis of the

    mastoid emissar# 'eins&o O+struction of 'enous drainae +# throm+osis can "roduce ele'ated intracranial "ressure

    ICP! and headache& Otitic h#droce"halous can com"licate the course of lateral sinusthrom+osis, leadin to 'ision chanes and si.th cranial ner'e CH /I! "als#& Se"ticem+oli can disseminate the infection to distant +od# sites, and the constant +acteremia"roduces fe+rile e"isodes&

    o 0he classic clinical "icture of hih s"i3in fe'ers, headache, and acti'e ear disease israre& Dianosis of this com"lication relies on hih clinical sus"icion and is confirmed +#M%I or contrastenhanced C0 scan demonstratin the throm+osis&

    o Earl# administration of intra'enous anti+iotics and surical e."loration are the mainsta#sof thera"#& After e."osin the simoid sinus, a needle ma# +e used to as"irate the sinus&If freeflo-in +lood returns, no further surer# is needed& If no +lood returns, o"en anddrain the sinus&

    1rain a+scesso 1rain a+scess is the first or second most common intracranial com"lication of COM& Most

    a+scesses form in the tem"oral lo+e or cere+ellum, su""ortin the theor# that +raina+scesses associated -ith OM are "ro+a+l# caused +# direct e.tension of infection andnot hematoenous s"read of +acteria&

    o In addition to fe'er from the infectious "rocess, s#m"toms and sins of +rain a+scessrelate to a+scess location and the o'erall mass effect of the a+scess& @eadache,'omitin, and lethar# ma# indicate increased ICP& Sinificant locali4in sins includesei4ures, hemi"aresis, cranial ner'e "alsies, and a"hasia& A+scesses in the tem"orallo+e or cere+ellum can e.ist -ith relati'el# fe- earl# locali4in s#m"toms&

    o  A contrastenhanced C0 scan or M%I is the dianostic stud# of choice&o 0he initial thera"# of choice is administration of +roads"ectrum anti+iotics& Consult -ith

    a neurosureon for decisions a+out a+scess drainae& In some "atients, mastoid surer#

    can +e "erformed -ith a neurosurical "rocedure& Otoloic surer# can +e dela#ed in"atients -ho are less sta+le until neuroloic sta+ilit# is esta+lished&

    Prognosis• 0he "ronosis for almost all "atients -ith OM is e.cellent; the e.ce"tions are "atients in -hom

    OM in'ol'es intratem"oral and intracranial com"lications > )

    • Education for health care "ro'iders should focus on the follo-in to"ics:o  Anti+ioticresistant +acteria and the need to a'oid o'er"rescri+in anti+ioticso Im"ortance of "neumatic otosco"e e.amination to distinuish AOM from OME

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    o 0reatment differences +et-een AOM and OME