Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

Otitis Media:
Classification, Rx and Complications

Introduction: Otitis media is the most common diagnosis for which antibiotics are prescribed in pediatrics.  25 million yearly visits related to OM.  In 1975 there were 9.9 million visits, and in 1990 there were 24.5 million visits. 65% of antibiotics given to children are prescribed for OM. There are 313,000 tube operations/year in the US.

There are many reasons for this increase: change in disease pattern, more child care, increased awareness, improved technical capabilities including improved illumination with halogen lights and pneumatic bulbs in otoscopes, and the use of sensitive tests such as tympanometry.

Risk Factors for Developing Otitis Media: allergies, daycare, smoking, lying down or propping bottle, lack of breastfeeding, recent episode of otitis, pacifier use

Prevention of Otitis Media: vaccines (influenza and pneumococcal), Xylitol (?) Prophylactic antibiotics could be effective, but no longer recommended.

Diagnosis of Otitis Media: 1. Inability to see umbo; 2. Presence of effusion

Classification of Otitis Media:

• AOM- suppurative or purulent – or AOM with effusion strep pneumo (30-50%), non-typeable H. Flu (20-30%), and Moraxella (1-5%).  Anaerobic infections unimportant, though now good evidence for influence of viral causes – e.g. RSV, rhinovirus, influenza, and adenovirus.

Treatment: constantly changing: now approach is the following:

• No antibiotics in prior month: low dose (40/kg) or high dose (80/kg) of Amoxicillin depending on incidence of resistant strep pneumo in area.
• Antibiotics in prior month: high dose Amoxicillin (Amox alone or in combination with Augmentin), Augmentin alone (45/kg), Ceftin.
• Failure of treatment day 3 or day 10-28: High dose Amoxicillin, Augmentin, Ceftin, or IM Rocephin once a day for three days. 
• Not recommended: Azithromycin, Clarithromycin, Septra
• Failure of medication: consider tympanocentesis (some think that this procedure should be done by pediatricians – many workshops: www.OMEW.com)

Cost of Treating Otitis Media

• OM with effusion (OME) – a useful term that includes serous, secretory, mucoid, nonsuppurative and glue ear – often results from acute infection. No evidence that any of the following works: po steroids, more antibiotics, nasal topical antihistamines, eustacian tube insufflation. 
  Treatment: If OME persists for 4-6 months, refer for tubes.  Tonsillectomy and Adenoidectomy: recommend only after need 2nd set of tubes.  Prospective studies of the effects of  T and A: 11.5% complications, no long-term benefit, but did receive fewer antibiotics and had fewer episodes of AOM. Reasons for surgery: delayed speech, decreased hearing, recurrent otitis media.  No evidence that development affected by OME.
• Chronic suppurative OM with or without cholesteatoma- nonintact TM with 6 weeks or more of middle ear drainage.
  Treatment: Now recommended: drops only: Cipro (Ofloxacin otic solution or Floxin Otic drops).  This is the only preparation recommended now.

Complications and Sequelae of Otitis:

Frequent: Hearing loss (conductive), perforation (1/200 children with tubes develop long-term perforation), otorrhea

Infrequent: mastoiditis, cholesteatoma (saclike structure with desquamated epithelium or keratin – requires surgery), adhesive otitis, tympanosclerosis, ossicular discontinuity, facial paralysis, intracranial suppurative complications, meningitis (direct invasion), extradural abscess (destruction of bone adjacent to the dura by cholesteotoma), subdural empyema (direct extension), lateral sinus thrombosis (from inflammation of mastoid) and otitic hydrocephalus.

List of Cephalosporins: with some help from Dr. White

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004