Update on Otitis Media –

Prevention and Treatment

Source :
Infection and Drug Resistance 2014:7;15-24
 
Writers :
Qureishi A, Lee Y, Belfield K, Birchall JP, Daniel M
 
Presented by :
Angeline Bongelia Friska (112015390)
Samdaniel Sutanto (112016350)
 INTRODUCTION
• Otitis media (OM) → inflammatory conditions
affecting the middle ear
• Prevention → reduce risk of hearing loss
• Type : acute otitis media (AOM) (otalgia, fever)
→ chronic suppurative otitis media (CSOM)
(pus +)
• AOM is the commonest childhood infectious
disease
 INTRODUCTION
• Complications of AOM : acute mastoiditis
(post-auricular swelling + mastoid tenderness)
• OM with effusion (OME) → chronic
inflammatory condition (effusion +, acute
inflammation signs -, hearing loss)
• Hearing loss due to OME → frequently
resolves spontaneously, esp. if follows an
episode of AOM
 INTRODUCTION
• OME has lower prevalence in adults
• Paranasal sinuses disorders are dominant
factor
• Other causes: nasopharyngeal lymphoid
hyperplasia (due to smoking) and adenoidal
hypertrophy, head & neck tumors (mainly
nasopharyngeal carcinomas).
 INTRODUCTION
• CSOM, (long-term suppurative middle ear
inflammation, usually w/ persistent tympanic
membrane perforation, cholesteatoma) →
persistent otorrhea, hearing loss, tinnitus,
otalgia, & pressure sensation
• Multifaceted treatment → antimicrobial
agents and surgery
 EPIDEMIOLOGY

• 50%-85% of children experienced at least one

episode of AOM by 3 years of age.
• OME → commonest cause of pediatric hearing
impairment in developing country
• Young children are more prone to AOM &
OME due to an anatomical predisposition
 ETIOLOGY

Interaction
Anatomical between microbe
variations and host immune
response

Cell biology of the Viral upper

middle ear and respiratory tract
nasopharynx infection
 ETIOLOGY

Streptococcus Haemophilus Moraxella Staphylococcus Streptococcus

pneumoniae influenzae catarrhalis aureus pyogenes

Source:
http://microbe-canvas.com
http://creative-diagnostics.com
http://asm.org
http://emedicine.medscape.com
• Inflammation→ production of more mucin,
altered more viscous mucin → blockage of
eustachian tube→ accumulation of effusion in
the middle ear
• Overexpression of mucin genes can be
exacerbated by cigarette smoke
 Other Theory

• Eustachian tube dysfunction→ middle ear

effusion through negative pressure
• Gastroesophageal acid reflux
• Genetic factors → influencing host immune
response
 ETIOLOGY

• CSOM → chronic middle ear infection

• Role of immunological & genetic factors,
eustachian tube characteristics is important
• Cholesteatoma → more complex than CSOM
• CSOM is often a complication of AOM w/
perforation
• Chronic or inadequately treatment→
permanently perforated
 DIAGNOSIS OF AOM
• AOM → purulent middle ear process (short
history, fever, otalgia, irritability, otorrhea,
lethargy, anorexia, vomiting).
• American Academy of Pediatrics → moderate
to severe bulging of the tympanic membrane
or new onset of otorrhea not secondary to
otitis externa (w/ pneumatic otoscopy or
tympanometry)
 DIAGNOSIS OF AOM

• Pneumatic otoscopy and tympanometry

assess mobility of the ear drum
• Non-perforated ear drum is immobile→
indicates middle ear effusion
• Tympanometry assessing mobility by means of
sound reflection
 DIAGNOSIS OF OME
• Clinical features: hearing difficulties, poor attention,
behavioral problems, delayed speech and language
development, clumsiness, poor balance
• Otoscopy → abnormal color, retracted/concave
tympanic membrane, and air-fluid level.
• Further evidence can be obtained w/ audiogram and
tympanogram
 DIAGNOSIS OF CSOM
• Permanent tympanic perforation with or
without persistent otorrhea should be present
for a minimum of 2-6 weeks
• Pain is not usually a predominate feature and
ear discharge is likely to be of a longer
duration
• Diagnosis is confirmed with otoscopy
 CURRENT TREATMENT
• Current USA guidelines for the treatment of
AOM :
– Antibiotic should be prescribed if:
• severe unilateral/bilateral AOM in children aged > 6
months
• Bilateral AOM in children aged 6-23 months
– Non severe unilateral AOM (age 6-23 months) /
unilateral-bilateral AOM (age ≥ 24 months) →
antibiotic or observation offered
 CURRENT TREATMENT

• Antibiotic of choice: amoxicillin

• Antibiotic + beta-lactamase cover → recurrent
AOM (RAOM), unresponsive to amoxicillin,
suffering from purulent conjunctivitis
• In RAOM → surgically inserted ventilation
tube should be considered
 CURRENT TREATMENT

• OME → needs treatment if OME is bilateral

and persistent more than 3 months
• Current UK and USA guidelines:
– Recommend 3-month period of observation
– Serial audiometry
– Assessment of the degree of hearing loss
– Surgery is also recommended
 CURRENT TREATMENT

• CSOM → surgical usually recommended

• Conservative treatment → ear toilet +
antibiotic, antiseptics & topical steroids
• Topical quinolones→ most effective treatment
• Depends on many factors
EMERGING STRATEGIES IN PREVENTION AND
TREATMENT

• Better treatment of AOM and OME would

therefore be welcome
• Ideal treatment would be preventative,
effective, immediate, with sustained activity,
and nontoxic → still on focusing
 GENETICS

• Mixture of innate defense molecules→ lead to

OM susceptibility
• Potential therapeutics target:
– Genes regulating mucin expression
– Host immune response
– HIF-VEGF (play role for hypoxia in OME)
 PNEUMOCOCCAL VACCINES

• Are proven useful in targeting the commonest

cause of AOM (S. pneumoniae)
• There is a reduction in AOM, antibiotic
prescription, and AOM-related costs
• Reduce risk of complications of AOM
 DEVELOPMENTS IN MICROBIOLOGY AND
BACTERIAL RESISTANCE

• Need an attention
• Mechanism of emerging bacterial resistance:
– Antibiotic-induced genetic transformation
– Increasing of mutation rate due to exposure to
sub-minimum-inhibitory-concentration levels of
antibiotics
• Biofilm in OME→ block antibiotics from
reaching bacteria population in biofilm
DRUG DELIVERY TO THE MIDDLE EAR

Transtympanic
Drug delivery delivery
to the middle
ear Intratympanic
delivery
 Conclusion

• OME and AOM are significant cause of morbidity and

the cost to the health service
• Current treatment guidelines still have significant
shortcomings
• Recent advances in medicine offer the potential for
better treatments in the future
THANK YOU FOR YOUR
ATTENTION