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Dr. ahmed athab al-zubiadi

acute otitis media

Acute otitis media

Dr. ahmed athab al-zubiadi acute otitis media Acute otitis media 1
Dr. ahmed athab al-zubiadi acute otitis media Acute otitis media 1
Dr. ahmed athab al-zubiadi acute otitis media Acute otitis media 1
Dr. ahmed athab al-zubiadi acute otitis media Acute otitis media 1
Dr. ahmed athab al-zubiadi acute otitis media Acute otitis media 1

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Dr. ahmed athab al-zubiadi acute otitis media Acute otitis media 1

Dr. ahmed athab al-zubiadi

Definitions:

acute otitis media

The term acuteacuteacuteacute otitisotitisotitisotitis mediamediamediamedia include a lot of information

AcuteAcuteAcuteAcute : rapid onset of signs and symptom less than 3weeks including otalgia with or without deafness and changes in the normal otoscopic appearance of TM

and changes in the normal otoscopic appearance of TM AOM Normal O t i t i

AOM

Normal

Otitis:Otitis:Otitis:Otitis: inflammation of mucoperiostial lininig of middle ear cleft.

When it go beyond mucosa (ex: bone) the complication start.

It is otitis not osteitis.

MediaMediaMediaMedia : not only middle ear cavity but the whole cleft(middle earcavity+attic+aditus+antrum+ET)

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e d i a M e d i a : not only middle ear cavity but

Dr. ahmed athab al-zubiadi

acute otitis media

Dr. ahmed athab al-zubiadi acute otitis media Epidemiology: ∑ 2 n d most common infection in

Epidemiology:

2 nd most common infection in childhood after URTI

19 -62% of children have one episode of AOM in the first year

85% of children have at least on episode by 3 years old

The peak incidence of AOM is found in the tow year of life.

1 st

Risk factors:

I. HostHostHostHost factorsfactorsfactorsfactors

Age < 2 years(more short,more horizontal ET

and more URTI)

Gender ( Males > Females)

Sibling with history of recurrent disease

Genetics

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short,more horizontal ET and more URTI) Gender ( Males > Females) Sibling with history of recurrent

Dr. ahmed athab al-zubiadi

Immunodeficiency

Birth defects

Cleft palate

Down syndrome

III:EnvironmentalIII:EnvironmentalI:EnvironmentalI:Environmental factorsfactors:factorsfactors

Day-care attendance

Not being breast-fed

Exposure to tobacco smoke

acute otitis media
acute otitis media

Seasonal variation in respiratory infections

Allergies

Low socioeconomic group

Etiology:

Although viral infection is important the pathogenesis of AOM, the majority of patients develop subsequent bacterial colonization, and therefore AOM should be considered a predominantly bacterial infection.

The organisms most commonly responsible for AOM. Are:

S. pneumoniae (up to 40%),

a predominantly bacterial infection. The organisms most commonly responsible for AOM. Are: S. pneumoniae (up to

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a predominantly bacterial infection. The organisms most commonly responsible for AOM. Are: S. pneumoniae (up to

Dr. ahmed athab al-zubiadi

acute otitis media

Dr. ahmed athab al-zubiadi acute otitis media Haemophilus influenzae (% ٣٠ – ٢٥ ) Moraxella catarrhalis

Haemophilus influenzae (%٣٠٢٥) Moraxella catarrhalis (10–20%)

Viruses can be isolated in approximately 4% of middle ear effusions, with respiratory syncytial virus and influenza virus being the most common.

Pathogenesis:Pathogenesis:Pathogenesis:Pathogenesis:

TheTheTheThe sequencesequencesequencesequence ofofofof eventseventseventsevents inininin acuteacuteacuteacute otitisotitisotitisotitis mediamediamediamedia isisisis asasasas follows:follows:follows:follows:

organismsorganismsorganismsorganisms invadeinvadeinvadeinvade thethethethe mucousmucousmucousmucous membranemembranemembranemembrane causingcausingcausingcausing inflammation,inflammation,inflammation,inflammation, oedema,oedema,oedema,oedema, exudateexudateexudateexudate andandandand later,later,later,later, pus;pus;pus;pus;

oedemaoedemaoedemaoedema closesclosesclosescloses thethethethe EustachianEustachianEustachianEustachian tube,tube,tube,tube, preventingpreventingpreventingpreventing aerationaerationaerationaeration andandandand drainage;drainage;drainage;drainage;

pressurepressurepressurepressure fromfromfromfrom thethethethe puspuspuspus rises,rises,rises,rises, causingcausingcausingcausing thethethethe drumdrumdrumdrum totototo bulge;bulge;bulge;bulge;

necrosisnecrosisnecrosisnecrosis ofofofof thethethethe tympanictympanictympanictympanic membranemembranemembranemembrane resultsresultsresultsresults inininin perperforation;perperforation;foration;foration;

thethethethe earearearear continuescontinuescontinuescontinues totototo draindraindraindrain untiluntiluntiluntil thethethethe infectioninfectioninfectioninfection resolvesresolvesresolvesresolves

ClinicalClinicalClinicalClinical featuresfeatures:featuresfeatures

Cycle of events can be divided into 4 phases

In both adults and children the new onset of AOM precedes by URTI.

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Cycle of events can be divided into 4 phases In both adults and children the new

Dr. ahmed athab al-zubiadi

I.

Stage of tubal occlusion

II.

Stage of presuppuration

III.

Stage of suppuration

IV.

Stage of resolution

acute otitis media

I. Stage of tubal occlusion:

Inflammatory swelling of opening of Eustachian tube.

Inflammatory swelling of opening of Eustachian tube. Unreplaced absorption of air the cleft After absorbtion of

Unreplaced absorption of air the cleft

of Eustachian tube. Unreplaced absorption of air the cleft After absorbtion of oxygen remain CO2 only

After absorbtion of oxygen remain CO2 only which is irritant to mucosa,stimulate it to form transudate.

Symptom of deafness and possibly pain start Deafness may pass unnoticed especially in children

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it to form transudate. Symptom of deafness and possibly pain start Deafness may pass unnoticed especially

Dr. ahmed athab al-zubiadi

acute otitis media

Pain,if occur , not so sever and may describe as fullness.

Signs:

Retraction of tympanic membrane

describe as fullness. Signs: Retraction of tympanic membrane Normal retracted signs of retraction: 1. Handle of

Normal

retracted

signs of retraction:

1. Handle of malleus due to inward movement assume horizontal-seeming position

2. Prominent lateral process

3. Scattered cone of light

Conductive deafness(Renne –tv and weber lateralization to bad ear). patient more than

4years

4. Impaired mobility of tympanic membrane (pneumatic otoscopy) objective test

II :Stage of presuppuration:

Invasion of mucosal lining of tympanic cavity by pyogenic organisims

Hyperaemia

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test II :Stage of presuppuration: Invasion of mucosal lining of tympanic cavity by pyogenic organisims Hyperaemia

Dr. ahmed athab al-zubiadi

acute otitis media

Increasing earache and deafness

Earache become sever(prevent sleep and cause distressful crying in children)

Systemic disturbances start(fever, restlessness, loss of appetite and sometime vom _ting)

At this stage the patient often seen by doctor.

vom _ting) At this stage the patient often seen by doctor. Signs of this stage: 1.

Signs of this stage:

1. At first Injection of tympanic membrane due to engorgement circumferential and manburial vessels

Signs of this stage: 1. At first Injection of tympanic membrane due to engorgement circumferential and

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Signs of this stage: 1. At first Injection of tympanic membrane due to engorgement circumferential and

Dr. ahmed athab al-zubiadi

acute otitis media

2. As the inflammation progress the vessels tend to become confluent and the membrane to become uniformly red (angry red).

and the membrane to become uniformly red (angry red). III Stage of suppuration : When the

III Stage of suppuration :

When the inflammation has advanced to true suppuration with pus formation , AOM has become a disease with serious potential.

The presence of pus may be suspected if TM is tense grossly bulging , or if yellow area of necrosis preceded rupture.

The presence of pus may be suspected if TM is tense grossly bulging , or if

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The presence of pus may be suspected if TM is tense grossly bulging , or if

Dr. ahmed athab al-zubiadi

acute otitis media

A further sign which indicate the presence of pus is tenderness over the mastoid antrum (McEwen triangle), in concha cymba.

over the mastoid antrum (McEwen triangle), in concha cymba. Earache increase Pulsitile tinnitus Fever may reach

Earache increase

Pulsitile tinnitus

Fever may reach 39.5

IV Stage of resolution:

After spontaneous rupture of membrane the clinical picture changes dramatically from acute tension to spontaneous relief.

Discharge could be purulant,mucopurulant or bloody.

Temperature fall

Rush of pus slow and stop Within day or tow.

Resolution without ruptureOf TM occurs in mild infection Or under the influence of AB

All symptoms resolve during This stage except for hearing impairment due to residual effusion

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the influence of AB All symptoms resolve during This stage except for hearing impairment due to

Dr. ahmed athab al-zubiadi

Dr. ahmed athab al-zubiadi Diagnostic workup : ruptured TM acute otitis media For most patient with

Diagnostic workup :

ruptured TM

acute otitis media

For most patient with AOM ,a history and physical examination are all that needed to make correct diagnosis.

Further diagnostic study are

indicated in:

1. Unclear diagnosis

2. Ineffective treatment

3. Presence or suspicion of complication

study are indicated in: 1. Unclear diagnosis 2. Ineffective treatment 3. Presence or suspicion of complication

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study are indicated in: 1. Unclear diagnosis 2. Ineffective treatment 3. Presence or suspicion of complication

Dr. ahmed athab al-zubiadi

Diagnostic studies:

Pneumatic otoscopy

athab al-zubiadi Diagnostic studies: Pneumatic otoscopy Otomicroscopy acute otitis media Audiology

Otomicroscopy

Diagnostic studies: Pneumatic otoscopy Otomicroscopy acute otitis media Audiology testing(PTA,tympanometry) type

acute otitis media

Audiology testing(PTA,tympanometry)

acute otitis media Audiology testing(PTA,tympanometry) type B tympanogram Radiological study(CT,MRI)

type B tympanogram

Radiological study(CT,MRI)

Tympanocentesis

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acute otitis media Audiology testing(PTA,tympanometry) type B tympanogram Radiological study(CT,MRI) Tympanocentesis 12

Dr. ahmed athab al-zubiadi

Myringotomy

Dr. ahmed athab al-zubiadi Myringotomy Microbiological testing acute otitis media Note : these tests not need

Microbiological testing

acute otitis media

Note : these tests not need routinly.

Differential diagnosis:

1. In the stage of tubal occlusion

1. Adenoid hypertrophy

2. Allergic swelling of mucosal lining

3. Barotrauma

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1. In the stage of tubal occlusion 1. Adenoid hypertrophy 2. Allergic swelling of mucosal lining

Dr. ahmed athab al-zubiadi

acute otitis media

2. In the presuppurative stage(red tympanic membrane)

1. Glomus jugulare

stage(red tympanic membrane) 1. Glomus jugulare 2. High jugular bulb 3. Aberrant carotid artery 4. Acute

2. High jugular bulb

3. Aberrant carotid artery

4. Acute barotrauma

3. In the suppurative stage:

1. Meatal furuncle

2. High jugular bulb 3. Aberrant carotid artery 4. Acute barotrauma 3. In the suppurative stage:

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2. High jugular bulb 3. Aberrant carotid artery 4. Acute barotrauma 3. In the suppurative stage:

Dr. ahmed athab al-zubiadi

2. Bullus myringitis

Dr. ahmed athab al-zubiadi 2. Bullus myringitis 3. Herpes zoster oticus acute otitis media 4. In

3. Herpes zoster oticus

al-zubiadi 2. Bullus myringitis 3. Herpes zoster oticus acute otitis media 4. In neonates and infants

acute otitis media

4. In neonates and infants with a high fever and systemic upset, the possibility of meningitis should be considered.

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4. In neonates and infants with a high fever and systemic upset, the possibility of meningitis

Dr. ahmed athab al-zubiadi

Treatment

acute otitis media

A. NONSURGICAL MEASURES:

WatchfulWatchfulWatchfulWatchful waiting:waiting:waiting:waiting: meansmeansmeansmeans usingusingusingusing supportivesupportivesupportivesupportive treatmenttreatmenttreatmenttreatment onlyonlyonlyonly butbutbutbut nononono ABABABAB

IndicationIndicationIndicationIndication ::::

healthy 2-year-olds or older children with nonsevere illness (mild otalgia and fever < 39 °C) because AOM symptoms improve in most within 1–3 days.

Watchful waiting is not recommended for children < 2 years old if AOM is certain.

22.22 AntibioticAntibioticAntibioticAntibiotic therapy:therapy:therapy:therapy:

1111 stststst line:line:line:line:

Amoxicillin (40 mg/kg/d given in three divided doses for 10 days).

Macrolides for penicillin-sensitive patients

Trimethoprim-sulfamethoxazoleis good alternative

TreatmentTreatmentTreatmentTreatment failure:failure:failure:failure:

11-11--- symptomsymptomsymptomsymptom &&&& signsignsignsign persistpersistpersistpersist moremoremoremore thanthanthanthan 4848-4848--72-727272 hrhrhrhr

22-22--at-atatat thisthisthisthis pointpointpointpoint thinkthinkthinkthink aboutaboutaboutabout resistantresistantresistantresistant organisimsorganisimsorganisimsorganisims

2 nd line

Increase the dose of Amoxicillin to 80mg/kg/day

Or shift to other drug (intra-muscular ceftriaxone) or

amoxicillin-clavulonate(augmintine)

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Amoxicillin to 80mg/kg/day Or shift to other drug (intra-muscular ceftriaxone) or amoxicillin-clavulonate(augmintine) 16

Dr. ahmed athab al-zubiadi

3. AdjunctiveAdjunctiveAdjunctiveAdjunctive therapy:therapy:therapy:therapy:

acute otitis media

analgesics and antipyretics

There is no role for oral decongestants or antihistamines in the treatment of AOM.

The role of 0.5% ephedrine nasal drops is traditional but its value is uncertain.

Ear drops are of no value in acute otitis media with an intact drum.

SURGICALSURGICALSURGICALSURGICAL TREATMENTTREATMENTTREATMENTTREATMENT

Surgery has a limited role in the treatment of an uncomplicated episode of AOM.

Myringotomy was practised in the pre-antibiotic era, and indeed was continued until the late 1980s

episode of AOM. Myringotomy was practised in the pre-antibiotic era, and indeed was continued until the

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episode of AOM. Myringotomy was practised in the pre-antibiotic era, and indeed was continued until the

Dr. ahmed athab al-zubiadi

acute otitis media

However, there are now a number of good studies showing that myringotomy plus antibiotics offers no advantage over antibiotics alone.

Myringotomy is reserved for severe cases where complication is present or suspected, to relieve severe pain or when microbiology is strongly required.

FollowFollow-FollowFollow--up-upup:up most children with AOM should receive follow-up examination between 1 and 3 month to ensure resolution of effusion.

RecurrentRecurrentRecurrentRecurrent otitisotitisotitisotitis media:media:media:media:

Definition : multiple episode of AOM seperated by interval of normal middle ear status(no effusion).

3 or more episodes of AOM in 6-12 months

Predisposing factors:

Nasal allergy

Group day care

Secondhand smoke exposure

Immune status

Management:

Antibiotic prophylaxis:

Long-term ,low-dose AB to maximum of 6month through high risk winter month

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status Management: Antibiotic prophylaxis: Long-term ,low-dose AB to maximum of 6month through high risk winter month

Dr. ahmed athab al-zubiadi

Xylitol

acute otitis media

Xylitol is a commonly used sweetener that inhibits pneumococcal growth and the attachment of pneumococciand Haemophilus to nasopharyngeal cells.

Vaccination

Immunoglobulins

Benign commensals:

spraying benign commensals (alpha streptococci) into the nose to recolonize the nasopharynx following antibiotics might reduce AOM by inhibiting the growth of pathogenic bacteria.

SURGICAL PROPHYLAXIS:

Ventilation tubes

antibiotics might reduce AOM by inhibiting the growth of pathogenic bacteria. SURGICAL PROPHYLAXIS: Ventilation tubes 19

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antibiotics might reduce AOM by inhibiting the growth of pathogenic bacteria. SURGICAL PROPHYLAXIS: Ventilation tubes 19

Dr. ahmed athab al-zubiadi

acute otitis media

Adenoidectomy andadenotonsillectomy:

adenoidectomy may be beneficial in children who had previously had ventilation tube insertion and suffered subsequent AOM.

Tonsillectomy has not been shown to be effective for recurrent otitis media

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tube insertion and suffered subsequent AOM. Tonsillectomy has not been shown to be effective for recurrent