Epidemiology and Etiology
Otitis media is one of the most common diagnoses in pediatrics.
Immaturity of the eustachian tubes, coupled with a viral upper respiratory infection, can lead to stasis, congestion, and ultimately eustachian tube obstruction. Persisting obstruction of the eustachian tube can result in bacteria being aspirated and trapped in the middle ear, producing a suppurative infection. Because of the frequency of upper respiratory infections in childhood, a child in daycare or with many siblings may experience as many as 6 to 12 episodes of otitis media a year.
Pain is considered a common feature of otitis media, which may cause disruptions in sleeping or increased irritability. Although only 25% of children with otitis media are febrile, younger children are more likely to have fever than older children.
The diagnosis of acute otitis media requires several findings to be present. The first is evidence of middle ear effusion demonstrated by pneumatic otoscopy: middle ear effusion associated with acute otitis media shows impaired or absent mobility of the tympanic membrane. The second is evidence of acute inflammation of the tympanic membranes, usually as opacified bulging of the tympanic membrane or the appearance of a distinct purulent fluid level. Serous otitis media, in which the fluid behind the tympanic membrane is clear without accompanying tympanic membrane bulging, is not considered an acute infectious process and does not require treatment.
General Difficulties in Management of Otitis Media
Antibiotic Therapy for Otitis Media
Although there are only three major pathogens and only two major mechanisms of resistance, there are many oral antibiotics available for treatment of acute otitis media (Table 6.1). Several generalizations can be made about the many oral antibiotics available for the treatment of acute otitis media. It is important to realize that many of the newer, more expensive second- and third-generation cephalosporins actually have reduced activity against the increasing numbers of penicillin-intermediate and penicillin-resistant S. pneumoniae.
pyogenes and Staphylococcus aureus. Generally, first-generation cephalosporins are not used in the treatment of acute otitis media.
TABLE 6.1. Major Classes of Antibiotics Used to Treat Otitis Media
lower respiratory infections in children who are likely to have atypical pathogens, such as Mycoplasma pneumoniae and Chlamydia pneumoniae.
In 1999, the Centers for Disease Control and Prevention convened a working group that published recommendations regarding the treatment of acute otitis media. Initial treatment was recommended with amoxicillin at a dose of 80 to 100 mg/kg per day. Amoxicillin given at the previous standard doses of 40 to 45 mg/kg per day was determined not to achieve middle ear fluid levels that would eradicate the increasingly prevalent penicillin nonsusceptible pneumococcal strains. The increase in dosing to 80 to 100 mg/kg per day was thought to achieve higher antibiotic levels in the middle ear and be effective against these strains. This regimen would also be efficacious against M. catarrhalis and H. influenzae strains that did not produce β-lactamase.
Treatment failures, defined as lack of clinical improvement after 3 days of therapy, would likely be secondary to resistant pneumococcus or β-lactamase–producing H. influenzae or M. catarrhalis. The panel recommended the following treatment options:
There was excellent logic to these recommendations. However, it should be remembered that these were guidelines developed at a certain time. The panel did state that, at the time of publication, there was not enough evidence of efficacy for certain drugs against the resistant pneumococcus that may be responsible for most treatment failures. In the subsequent years, the rates of resistance of S. pneumoniae have only increased. Additional developments regarding treatment of penicillin-nonsusceptible and penicillin-resistant S. pneumoniae also include the following:
Recommendations for treatment of otitis media have recently been revised. Amoxicillin remains the initial choice for primary therapy. Children at low risk for infection with penicillin-nonsusceptible S. pneumoniae can be treated with 40 mg/kg per day in two divided doses. Even with the S. pneumoniae classified as resistant to penicillin, it is thought that high-dose amoxicillin (80 to 90 mg/kg per day) achieves sufficiently high levels in the middle ear to achieve cure. In children with increased risk for infection with penicillin-resistant S. pneumoniae, including those younger than 2 years of age, attending daycare, or having received antibiotics within the preceding 30 days, therapy should be started using the high dose of 80 to 90 mg/kg per day in two divided doses.
For children with clinically defined treatment failure at 48 to 72 hours, several antibiotics have been recommended as second-line therapy. Treatment options include the following:
As resistance patterns change, recommendations will need to be updated.
As antibiotic resistance becomes more prevalent, there is continued discussion about treatment delay in otitis media. It has been determined that a significant percentage of acute otitis media resolves in 2 to 7 days without antibiotic therapy. An increasing strategy, particularly in foreign countries, is to withhold treatment in a patient with early otitis media. Children are then rechecked in 48 to 72 hours to determine whether infection has resolved. Delaying treatment does not substantially increase the risk for complications, including the rate of severe mastoiditis.
Surgical Management of Otitis Media
The role of surgical intervention in patients with otitis media, particularly recurrent otitis media, is often debated. There is concern about the effect of recurrent otitis media and persistent middle ear effusions in young children at the age of language development. Various studies have addressed the issue of developmental outcomes in children with persistent otitis media and effusions. Although a variety of conclusions have been drawn, a recent study reported no improvement in the developmental outcomes at 3 years in children who had prompt insertion of tympanostomy tubes by 9 months of life. Tympanostomy tube insertion in children is often still considered if there is chronic effusion lasting 3 months or longer, documented hearing loss, or recurrent otitis media, defined as three or more episodes during the previous 6 months or four or more episodes during the past year.
Chronic Suppurative Otitis Media
Epidemiology and Etiology
Chronic ear drainage (otorrhea) is defined as drainage lasting greater than 6 weeks.
The most common cause of chronic ear drainage in pediatrics is chronic suppurative otitis media (CSOM). CSOM is defined as a chronic infection of the middle ear and mastoid associated with a nonintact tympanic membrane or a tympanostomy tube. CSOM may develop following an episode of acute otitis media with perforation and subsequent development of chronic drainage. CSOM may also be caused by a chronic perforation of the tympanic membrane in which the middle ear becomes infected by environmental organisms. The bacteria causing CSOM often differ from those of acute otitis media; the most common organisms involved include Pseudomonas aeruginosa and S. aureus. Rarely, this condition can be caused by Candida species or anaerobic bacteria.
Affected children present with a history of ear drainage for many weeks. Typically, these children have had numerous courses of oral antibiotics.
Diagnosis is usually suggested by the history. Culture of the ear drainage that yields the typical bacteria in the correct clinical context also suggest the diagnosis.
Management of the chronic draining ear can begin on an outpatient basis. Culture of ear drainage can be obtained to document the typical pathogens of CSOM. In the past, a variety of ototopical agents were used. These medications were often ophthalmologic drops, which lacked efficacy against the typical CSOM pathogens and were potentially ototoxic. Ofloxacin is a topical fluoroquinolone that has been approved for use in children with tympanostomy tubes. This is now often considered a front-line ototopical agent when CSOM is diagnosed. In addition to antimicrobial therapy, good aural toilet is necessary. Children may need daily visits to the otolaryngologist for suctioning and installation of appropriate topical agents in the middle ear.
If a patient fails to respond to ototopical therapy, consideration of parental antibiotics may be needed. Because there is no approved oral antimicrobial for treatment of
Pseudomonas species infection in children, hospitalization may be needed for administration of an appropriate intravenous drug such as ceftazidime. Computed tomography may be necessary at this time to document chronic osteomyelitis or a mass lesion.
Like otitis media, bacterial sinusitis is believed to be the result of a preceding viral upper respiratory infection that predisposes to a secondary bacterial infection.
Sinusitis is similar to otitis media in that it is a common upper respiratory infection in which the diagnosis is based on clinical parameters rather than isolation of a causal organism.
The diagnosis of bacterial sinusitis is based on the history of upper respiratory infection. Children with high fever and purulent nasal discharge for 3 to 4 days should have the diagnosis considered. Children with persistent symptoms that last longer than 10 to 14 days are considered to have a high probability of a bacterial infection.
The gold standard of the diagnosis of sinusitis is the recovery of more than 104 colony forming units/mL from a sinus aspirate, although this procedure will not be routinely employed in the pediatric office. Thus, the diagnosis of bacterial sinusitis is based on clinical criteria. As mentioned earlier, the basis for the clinical diagnosis of sinusitis is the presence of persistent symptoms. An upper respiratory infection that has lasted longer than 10 to 14 days is the best feature distinguishing sinusitis from a routine viral infection. Severe symptoms, defined as a temperature of at least 38.8°C (102°F) with purulent nasal discharge for at least 3 consecutive days, are also acceptable clinical criteria.
The physical examination is not particularly helpful in distinguishing between viral upper respiratory infection and sinusitis. Transillumination of the sinuses has been proposed, although reviews have suggested that this is difficult to perform correctly and is not reliable in young children. Imaging studies are not necessary to establish a diagnosis of sinusitis in children younger than 6 years of age. Plain films and computed tomography of the paranasal studies show mucosal thickening in both viral and bacterial upper respiratory disease. For the general practitioner, the history and duration of symptoms are the basis for an accurate diagnosis of bacterial sinusitis.
The microbiology of acute sinusitis is similar to that of acute otitis media. The principal bacterial pathogens include S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. The increasing resistance of S. pneumoniae to penicillin and the large percentage of Moraxellaand Haemophilus strains that produce β-lactamase also affect the treatment of sinusitis in children. Because organisms and resistance profile are similar, current recommendations for the treatment of otitis media can generally be applied to sinusitis.
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