Otitis Media: Clinical Practice Guidelines and Current Management

Tamekia L. Wakefield, MD Pediatric Otolaryngologist ENT & Allergy Associates, LLP

Disclosures:

Tamekia Wakefield, MD is a member of the speakers bureau for Alcon. The makers of Ciprodex otic.

► $4 billion in combined direct and indirect cost annually ► 2.2 million episodes diagnosed annually ► Most common reason for visit to pediatrician ► Tympanostomy tube placement is 2nd most common surgical procedure in children

► OME: the presence of fluid in the middle ear without acute signs or symptoms ► AOM: the presence of fluid in the middle ear with the acute onset of signs and symptoms of middle ear inflammation.

Microbiology/Virology

► ► ► ► ► ► ► ► ► S. pneumoniae H. influenzae M. catarrhalis - 30-35% - 20-25% - 10-15% Group A strep - 2-4% Infants with higher incidence of gram negative bacilli RSV - 74% of middle ear isolates Rhinovirus Parainfluenza virus Influenza virus

► Risk factors:    Daycare Tobacco smoke exposure Inverse relationship between length of breastfeeding and number of AOM episodes

Acute otitis media

► Clinical Indicators: Myringotomy and Tubes:     Severe acute otitis media (myringotomy) Poor response (describe) to antibiotic for otitis media (myringotomy or tube) Impending mastoiditis or intra-cranial complication due to otitis media (myringotomy) Recurrent episodes of acute otitis media (more than 3 episodes in 6 months or more than 4 episodes in 12 months) (tympanostomy tube)

► Eustachian tube dysfunction ► Post-AOM

► Most episodes resolve spontaneously within 3 months ► 30%-40% Recurrent OME ► 5%-10% Persistent OME > 1 year

► High prevalence of OME ► Difficulties in diagnosis and assessing duration ► Increased risk of CHL ► Potential impact on language and cognition ► Significant practice variations in management

► Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME. OME should be distinguished from AOM. Strong recommendation  Pneumatic otoscopy is gold standard  ► ► ► ► Color Position Mobility Tympanic membrane appearance Sensitivity of 94% and specificity of 80% versus myringotomy  Readily available, cost effective and accurate in experienced hands

► Tympanometry can be used to confirm diagnosis.

Option

 When diagnosis is uncertain, consider tympanometry ► Cost associated with equipment ► Painless ► Reliable for ages 4 months or older

► Population-based screening programs for OME are not recommended in healthy, asymptomatic children. Recommendation Against  Highly prevalent in young children. 15%-40% point prevalence in healthy children under 5 yr    No influence on short-term language outcomes No benefit from treatment that exceeds the favorable natural history of the disease Risk of inaccurate diagnoses, overtreatment, parental anxiety, and increased cost

► Clinicians should document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME.

Recommendation

  Medical decision making depends on these features 40%-50% of OME cases no symptoms  Preponderance of benefit over harm

► Clinicians should distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME, and should more promptly evaluate hearing, speech, language, and need for intervention. Recommendation  Permanent hearing loss       Speech and language delay or disorder Autism-spectrum disorder/PDD Syndromes with cognitive, speech, and language delays Blindness Cleft Palate Developmental delay

► Clinicians should manage the child with OME who is not at risk with watchful waiting for 3 months from the date effusion onset (if known) or from the date of diagnosis (if onset is unknown). Recommendation  OME is usually self-limited    75%-90% of OME after AOM resolves spontaneously by 3 months Waiting results in little harm to child Optimize listening and learning environment until effusion resolves

► Antihistamines and decongestants are ineffective for OME and are not recommended for treatment. Antimicrobials and corticosteroids do no have long-term efficacy and are not recommended for routine management.

Recommendation Against

  Short-term, small magnitude benefits Significant adverse effects

► Hearing testing is recommended when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME. Language testing should be conducted for children with hearing loss.

Recommendation

► HL may impair early language acquisition ► Extended periods of CHL may result in developmental and academic sequelae ► Early language delays are associated with later delays in reading and writing.

► Children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the TM or middle ear are suspected. Recommendation   Resolution rates decrease the longer the effusion has been present Risk factors for non-resolution: ► Summer or fall onset ► HL>30dB ► H/O prior tympanostomy tubes ► Not having had an adenoidectomy

► When children with OME are referred by the primary care clinician for evaluation by an otolaryngologist, audiologist, or speech language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation vs. surgery), and provide additional relevant information such as history of AOM and developmental status of the child.

Option

► When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis). Repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME.

Recommendation

► OME > 4 months with persistent hearing loss ► Recurrent or persistent OME in at risk child ► OME with structural damage to TM or ME

► Alternative Medicine  No recommendation: ► Limited evidence ► Few studies ► Medications are unregulated ► Allergy Management  No recommendation: ► Few studies

Consequences

► Inappropriate antibiotic treatment of OM    Multidrug-resistant strains Drug side effects Parental/caregiver confusion

Biofilms

► Communities of sessile bacteria embedded in a matrix of extracellular polymeric substances of their own synthesis that adhere to a foreign body or a mucosal surface ► Chronic ear infections or persistent effusion in the middle ear are biofilm related

Biofilms

► Unable to culture with traditional methods ► Traditional antibiotics are relatively ineffective for eradicating biofilm infection ► Higher doses of antibiotics required to treat ► Macrolides (clarithromycin/erythromycin) ► Physical disruption is beneficial ► Non-antibiotic therapies may be more successful

Acute otitis media with tubes

► Diagnosis  Acute purulent otorrhea 1 ► Commonly occurs after insertion of tympanostomy tubes ► Risk Factor  Occurs more frequently in children with upper respiratory infections 2,3

AOMT

► Ototopical antibiotics are appropriate therapy in uncomplicated cases ►  Fluoroquinolones Adjunctive systemic antibiotics may be used ►     When infection has spread beyond middle ear or external ear canal With lack of adherence to ototopical therapy When ototopical treatment fails (after 7-10 days) In children with associated streptococcal pharyngitis Special populations (e.g. immunocompromised patients) require additional consideration

► High prevalence ► Accurate diagnosis ► At risk children ► Hearing loss ► Speech and language assessment ► Antibiotic use ► Surgery ► Referral