B3.054 Otitis Media

Question 1

most common condition for which antimicrobial agents are prescribed in the US for children

Answer 1

otitis media

Question 2

when do children usually get AOM?

Answer 2

coincident with or following a viral upper respiratory tract infection

Question 3

what happens in 75% of kids with an URI

Answer 3

Eustachian tube dysfunction

Question 4

discuss the breakdown of viral vs bacterial AOM cases

Answer 4

96% virus and/or bacteria
66% both
27% bacteria alone
4% viruses alone

Question 5

4 most common bacterial pathogens of URIs

Answer 5

S. pneumoniae
H. influenzae
M. catarrhalis
S. pyogenes

Question 6

what has caused certain serotypes of S. pneumo to decrease?

Answer 6

conjugate pneumococcal vaccine

pen resistant isolates also decreased

Question 7

most likely cause of otitis-conjunctivitis

Answer 7

non typeable H. influenzae (NTHi)

Question 8

best way to confirm AOM

Answer 8

tympanocentesis and bacterial culture of middle ear fluid

Question 9

what factors increase the risk of AOM

Answer 9

daycare
non-Hispanic white
atopy (allergies, asthma)
siblings/ fam history of recurrent AOM

Question 10

risk factors for RECURRENT AOM

Answer 10

male sex
day car
fam history
first episode within first 6 mo of life

Question 11

what qualifies as recurrent AOM

Answer 11

> 3 episodes in 6 months or >4 in 1 year

Question 12

protective against AOM

Answer 12

breastfeeding in first 6 months

Question 13

strong recommendation

Answer 13

follow unless a clear and compelling rationale for an alternate approach is present

Question 14

recommendation

Answer 14

prudent to follow but should remain alert to new info and sensitive to patient preferences

Question 15

option

Answer 15

consider the option in their decision making and patient preference may have a substantial role

Question 16

no recommendations

Answer 16

be alert to new published evidence that clarifies balance of benefit vs harm

Question 17

symptoms of AOM

Answer 17

rapid onset of ear pain

preverbal: tugging/rubbing/holding of the war, crying, fever, changes in sleep/ behavior

Question 18

most useful symptom in AOM diagnosis

Answer 18

ear pain
+ likelihood ratio 3-7.3
present in 50-60% of kids w AOM

Question 19

physical signs of AOM

Answer 19

cloudy, bulging TM with impaired mobility
impaired mobility highest sensitivity
bulging highest specificity
bulging associated with bacterial pathogen

Question 20

what is OME

Answer 20

otitis media w/ effusion

Question 21

distinguish OME from AOM

Answer 21

can occur either as an aftermath of AOM or as a consequence of Eustachian tube dysfunction attributable to an URI
can also precede and predispose to development of AOM
segments of a disease continuum

Question 22

does OME benefit from antibiotics? why or why not?

Answer 22

no

not an acute infectious process

Question 23

AOM diagnostic criteria

Answer 23

moderate to severe bulging of the tympanic membrane or new onset of otorrhea not due to acute otitis externa
ORRR
mild bulging of the TM and recent onset of ear pain or intense erythema of the TM

Question 24

when should you not diagnose AOM?

Answer 24

children who DO NOT have middle ear effusion based on pneumatic otoscopy and/or tympanometry

Question 25

how can you detect the presence of MEE

Answer 25

bulging of the TM limited or absent mobility of the TM air-fluid level behind the TM otorrhea

Question 26

how does a retracted tympanic membrane in OME appear

Answer 26

short process points to 9 o clock instead of 8

Question 27

tenants of AOM treatment

Answer 27

assessment of pain | treatment to reduce pain

Question 28

what % of AOMs clear on their own?

Answer 28

19% of S. pneumo 48% of H.influenzae 75% M. catarrhalis cleared 2-7 days after initial tympanocentesis

Question 29

when is there a clinically significant benefit of immediate antimicrobial therapy?

Answer 29

bilateral AOM S. pneumo AOM with otorrhea

Question 30

how is severe AOM classifies

Answer 30

moderate to severe otalgia | fever >39 C

Question 31

when do you have an observational option?

Answer 31

>2 yr old not severe uni or bilateral AOM 6 mo - 2 yr not severe unilateral AOM no otorrhea

Question 32

most common drug/dose prescribes to children

Answer 32

amoxicillin | 80-90 mg/kg/day

Question 33

when should you use additional beta lactamase coverage?

Answer 33

kids who have had amoxicillin in the past 30 days purulent conjunctivitis recurrent AOM unresponsive to amoxicillin

Question 34

what do you do if a patient fails to respond to initial management option within 48-72 hours?

Answer 34

reassess, exclude other causes of illness start antimicrobials if it wasn't already switch antimicrobials if they were started already

Question 35

alternative treatment for people w penicillin allergies

Answer 35

cephalosporin | more broad spectrum, more expensive, and not necessarily better

Question 36

define OME

Answer 36

present of fluid in the middle ear without signs or symptoms of acute ear infection may occur during URI from poor Eustachian tube function or as an inflamm response following AOM

Question 37

what % of people get OME

Answer 37

90% of kids before school age | >50% in first year of life

Question 38

how long does OME usually last?

Answer 38

most resolve within 3 months 30-40% of kids can have repeat episodes 5-10% of episodes last >1 year 25% of OME episodes last >3 mo

Question 39

what is a consequence of OME?

Answer 39

persistent OME results in decreased mobility of the TM and serves as a barrier to sound conduction most common cause of hearing impairment in children in developing countries perm hearing loss prevalence 2-35 per 100,000

Question 40

when do you perform pneumatic otoscopy?

Answer 40

diagnosis of OME | child w otalgia, hearing loss, or both

Question 41

when do you do tympanometry?

Answer 41

suspected OME when diagnosis is uncertain after performing/attempting pneumatic otoscopy

Question 42

when do you do a hearing test?

Answer 42

OME persists >3 mo OR OME of any duration in an at risk child

Question 43

what are factors accounted for in surgical candidacy for OME

Answer 43

hearing status associated symptoms developmental risk anticipated chance of timely spontaneous resolution of effusion