CPG ON ACUTE OTITIS MEDIA (AB)

Question 1

Who are the Philippine Clinical Practice Guidelines for Acute Otitis Media in Children intended for?

Answer 1

PSO-HNS and children aged 2-12 years

Question 2

What are the objectives of the Philippine Clinical Practice Guidelines for Acute Otitis Media in Children?

Answer 2

1. To emphasize requisites for diagnosis of AOM in children\n2. To describe treatment options based on current evidence

Question 3

Which sources were used to develop the guidelines for Acute Otitis Media in children?

Answer 3

National Guideline ClearingHouse, Society for Middle Ear Disease Organization, Cochrane Ear, Nose and Throat Disorders Group of NIHR

Question 4

What additional search strategies were used for developing AOM guidelines?

Answer 4

Electronic databases (Cochrane, Medline, PubMed, ScienceDirect, etc.), local libraries, search for unpublished literature (19,653 articles)

Question 5

How many articles were chosen as the foundation for the Clinical Practice Guidelines for AOM?

Answer 5

Total of 45 articles

Question 6

What is the definition of acute otitis media (AOM)?

Answer 6

Acute middle ear inflammation characterized by signs and symptoms of middle ear inflammation with or without effusion lasting less than 3 weeks

Question 7

What are the most common bacterial pathogens causing AOM?

Answer 7

S. pneumoniae (25-50%), H. influenzae (15-30%), M. catarrhalis (3-20%)

Question 8

Which viral pathogens are associated with AOM?

Answer 8

RSV, Rhinovirus, Coronavirus, Parainfluenza, Adenovirus (most common), Enterovirus

Question 9

What are the stages in the natural history of AOM?

Answer 9

1. Hyperemia/Retraction\n2. Exudation\n3. Suppuration/Perforation\n4. Coalescence & Surgical Mastoiditis\n5. Complication\n6. Resolution

Question 10

What characterizes the stage of hyperemia/retraction in AOM?

Answer 10

Generalized hyperemia of mucoperiosteum, mild earache, ear fullness, fever, erythematous & markedly retracted eardrum on otoscopy

Question 11

What characterizes the stage of exudation in AOM?

Answer 11

Outpouring of fluid from capillaries, pain, fever, red and thickened bulging eardrum with loss of light reflex

Question 12

What characterizes the stage of suppuration/perforation in AOM?

Answer 12

Eardrum rupture, severe pain and fever, hearing loss worsens due to tympanic membrane perforation, pressure relieved

Question 13

What are the risk factors for AOM?

Answer 13

Non-modifiable: age, sex, race, genetics\nModifiable: smoke exposure, low SES, crowded living, daycare, previous antibiotic use, bottle feeding, pacifier use

Question 14

What additional host-related factors increase the risk of AOM?

Answer 14

Prematurity, allergies, immunodeficiency, cleft palate, craniofacial abnormalities, adenoid hypertrophy, seasonal changes

Question 15

What is the main basis for diagnosing acute otitis media?

Answer 15

Clinical parameters including history, otoscopy, and pneumatic otoscopy (Grade B Recommendation, Level 3A Evidence)

Question 16

What are the key diagnostic criteria for AOM?

Answer 16

1. History of acute onset (within 3 weeks)\n2. Signs & symptoms of middle ear inflammation\n3. Presence of middle ear effusion

Question 17

What is the best predictor of AOM based on otoscopic findings?

Answer 17

Limited or absent mobility of the tympanic membrane (high sensitivity 95%, specificity 85%)

Question 18

What are other otoscopic findings suggestive of AOM?

Answer 18

Cloudiness of tympanic membrane, bulging tympanic membrane, retracted tympanic membrane, erythema, air-fluid level, perforation with otorrhea

Question 19

What symptoms suggest otalgia in children with AOM?

Answer 19

Older children: rapid onset ear pain\nYoung preverbal children: ear tugging, rubbing, holding\nSubtle signs: excessive crying, sleep disturbances

Question 20

What is the role of fever in diagnosing AOM?

Answer 20

Fever supports AOM diagnosis but is nonspecific (sensitivity 54%, specificity 82%). Fever >39°C for >48 hrs suggests moderate to severe AOM

Question 21

What tool is recommended for diagnosing middle ear effusion in AOM?

Answer 21

Pneumatic otoscopy (70-90% sensitivity and specificity)

Question 22

What is the role of tympanometry in AOM diagnosis?

Answer 22

Not routinely recommended, but can help assess tympanic membrane compliance and perforation if needed (Grade C Recommendation, Level 2B Evidence)

Question 23

What is the role of tympanocentesis in AOM diagnosis?

Answer 23

Not routinely recommended; bacterial culture is gold standard for bacteremia but not for AOM diagnosis (Grade C Recommendation, Level 2B Evidence)

Question 24

What is the recommended approach for pain relief in Acute Otitis Media (AOM)?

Answer 24

Pain should be addressed within the first 24 hours upon diagnosis using Paracetamol (10-15 mg/kg/dose) or Ibuprofen (5-10 mg/kg/dose).

Question 25

When is initial observation an option for AOM?

Answer 25

For children ≥2 years with mild symptoms and for infants 6-23 months with unilateral mild AOM.

Question 26

What is the recommended course of action for initial observation in AOM?

Answer 26

Defer antibacterial treatment for 48-72 hours while providing symptomatic relief; a mutual decision between parent and physician.

Question 27

What is a Safety Net Antibiotic Prescription (SNAP) in AOM?

Answer 27

An antibiotic prescription given to parents to use only if symptoms persist or worsen after 48-72 hours.

Question 28

When should initial antibiotic therapy be prescribed for AOM?

Answer 28

For children ≥6 months with severe symptoms (unilateral or bilateral) and for children <2 years with bilateral disease without severe symptoms.

Question 29

What is the treatment recommendation for AOM in children <6 months?

Answer 29

Antibacterial treatment for both mild and moderate/severe cases.

Question 30

What is the treatment recommendation for AOM in children 6 months to 2 years?

Answer 30

Antibacterial treatment for moderate/severe AOM; for mild AOM, antibiotics for bilateral cases and observation for unilateral cases.

Question 31

What is the treatment recommendation for AOM in children ≥2 years?

Answer 31

Antibacterial treatment for moderate/severe AOM; observation for mild AOM.

Question 32

What is the first-line antibiotic treatment for mild AOM?

Answer 32

High-dose Amoxicillin (80-100 mg/kg/day in 2 divided doses).

Question 33

Why is high-dose Amoxicillin recommended for AOM?

Answer 33

It inhibits most non-susceptible strains of pneumococci and achieves adequate drug concentration in middle ear fluid.

Question 34

What is the first-line antibiotic treatment for severe AOM or treatment failure?

Answer 34

Amoxicillin-Clavulanic acid (90 mg/kg/day Amoxicillin + 6.4 mg/kg/day Clavulanic acid).

Question 35

When should antibiotic therapy be changed in AOM?

Answer 35

If there is no resolution of symptoms after 3 days, shift to an antibiotic with β-lactamase activity.

Question 36

What is an alternative treatment for AOM in patients allergic to Amoxicillin?

Answer 36

Clindamycin (30 mg/kg/day TID), single-dose parenteral Ceftriaxone (50 mg/kg), or a 5-day single-dose Azithromycin regimen.

Question 37

What is the preferred antibiotic for β-lactamase-producing H. influenzae and M. catarrhalis in AOM?

Answer 37

Cefixime, though it has weaker activity against S. pneumoniae.

Question 38

What are the Type I Hypersensitivity alternatives for AOM?

Answer 38

Azithromycin, Clarithromycin, Erythromycin, or Sulfamethoxazole-Trimethoprim.

Question 39

What are the Non-Type I Hypersensitivity alternatives for AOM?

Answer 39

Cefdinir, Cefpodoxime, Cefuroxime, or Cefixime.

Question 40

What is the recommended duration of antibiotic treatment for AOM?

Answer 40

10-14 days for younger than 2 years, 7 days for 2-5 years, and 5-7 days for 6 years and older.

Question 41

When should clinicians reassess AOM patients after starting treatment?

Answer 41

If symptoms worsen or fail to improve within 48-72 hours.

Question 42

What are the management options if an AOM patient fails to respond to initial observation?

Answer 42

Initiate antibacterial therapy.

Question 43

What are the management options if an AOM patient fails to respond to initial antibiotics?

Answer 43

Change antibiotics, consider tympanocentesis or myringotomy, and reassess for complications.

Question 44

What are the criteria for a positive response to AOM treatment?

Answer 44

Defervescence within 48-72 hours, decreased irritability, normalization of sleep and eating patterns.

Question 45

What procedures may provide immediate pain relief for AOM?

Answer 45

Tympanocentesis or Myringotomy.

Question 46

What are the first-line antibiotics for AOM treatment failure after 48-72 hours?

Answer 46

Amoxicillin-Clavulanate (90 mg/kg/day) or Ceftriaxone (50 mg/kg IV/IM for 3 days).

Question 47

What are alternative treatments for AOM treatment failure?

Answer 47

Ceftriaxone for 3 days, Clindamycin (30 mg/kg/day) ± a third-generation cephalosporin, tympanocentesis, or specialist consultation.

Question 48

Are antihistamines and decongestants recommended for AOM?

Answer 48

No, they are not recommended for AOM treatment but may be used for concomitant conditions like allergies.

Question 49

What is the role of pneumococcal conjugate vaccines in AOM?

Answer 49

They reduce the incidence of Otitis Media by preventing upper respiratory tract infections.

Question 50

How effective is the influenza vaccine in preventing AOM?

Answer 50

It reduces AOM incidence by 30-55%, with an 83% efficacy against influenza-associated AOM in children 7-50 months old.

Question 51

What is the recommendation regarding breastfeeding for AOM prevention?

Answer 51

Exclusive breastfeeding for at least 6 months reduces AOM incidence by up to 50%.

Question 52

What are key prevention strategies for reducing AOM risk?

Answer 52

Vaccination, breastfeeding, personal hygiene, avoiding overcrowding, reducing exposure to smoke, and improving socioeconomic status.

Question 53

Are probiotics recommended for preventing AOM?

Answer 53

No, probiotics are not recommended for AOM prevention.