acute otitis

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<div>  <A NAME="0"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Acute otitis media</div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="626" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="622"><bR> <bR> </tD> </tR> </TABLE></div> <div> <IMG SRC="0f677650.gif" border=0 width="375" height="357" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0f8775b0.gif" border=0 width="375" height="347" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0fa77680.gif" border=0 width="375" height="360" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">CHRONIC<IMG SRC="0fc775c0.gif" border=0 width="375" height="348" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">SEROUS<IMG SRC="0fe775d0.gif" border=0 width="375" height="349" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">SEROUS</div> <DIV ALIGN="LEFT"></DIV> <div> <IMG SRC="10060380.gif" border=0 width="864" height="56" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="1049" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 5426 WIDTH="1037"><div> OTITIS<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT>MEDIA<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> DEFINITION:</div> <div> Infection of the middle ear. </div> <div> EPIDEMIOLOGY:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">incidence: ? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">age of onset: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">any </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">risk factors: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">craniofacial malformations </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">congenital disorders </div> <div> PATHOGENESIS:</div> <div> 1. Background</div> <div> 1. Types of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Media</FONT> (OM)</div> <div> 1. Acute <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Media</FONT> (AOM)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">painful middle ear infection associated with toxicity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">natural history of untreated cases </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">otalgia with fever +/- toxicity lasts from hours to 2-3 days then the tympanic membrane ruptures spontaneously with the symptoms disappearing - ear discharges pus through a small hole for 3 days which then closes and heals over - the remaining middle ear effusion disperses down the eustachian tube over the next 3 months </div> <div> 2. Otits <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Media</FONT> with Effusion (OME)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">painless middle ear infection not associated with toxicity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">also called chronic serous <FONT SIZE="3" COLOR="#800000" FACE="Arial" >otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >media</FONT> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">may be acute (<3 weeks), subacute (3 weeks-3 months), or chronic (>3 months) </div> <div> 2. Organisms (% of cases)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Strep. pneumoniae (27-52%) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">H. influenzae* (16-52%) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Moraxella catarrhalis+ (2-15%) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Staph. aureus (0-16%) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Strep. pyogenes (0-11%) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">* 15-33% of strains produce beta-lactamase </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">+ 66-85% of strains produce beta-lactamase </div> <div> CLINICAL FEATURES:</div> <div> <B>Signs & Symptoms</B></div> <div> <I><B>Acute Otitis Media</B></I> [SSE BELOW DETAILS]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> otalgia,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> decreased hearing, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fever, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">unsteadiness, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and occasionally otorrhea if the tympanic membrane bursts. </div> <bR> <div> Signs include, most importantly, an immobile tympanic membrane, which can be dull,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> opaque, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">red, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bulging,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> or even show pus through it.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There may be a demonstrable conductive hearing loss, thus the use of tuning forks in patients with otalgia can be helpful! </div> <bR> <bR> <div> <I><B>Otitis media with Effusion</B></I> </div> <div> Symptoms include</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> decreased hearing,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> tinnitus, unsteadiness,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> but OME can be entirely asymptomatic.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Effusions persist for several weeks after AOM. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Only 60% of ears with acute otitis media are clear of effusion at 2 weeks, and 80% are clear by 8 weeks. </div> <bR> <div> Signs include a conductive hearing loss, and a tympanic membrane which can be retracted or bulging, and may show an air-fluid level. </div> <div> <IMG SRC="102d6b50.jpg" border=0 width="470" height="437" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Very well developed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >otitis</FONT> with middle ear filled with pus and hefty swelling over malleus handle - said to resemble "a prawn" in appearance.</div> <bR> <div> <IMG SRC="103b6d30.jpg" border=0 width="438" height="467" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Pusfilled middle ear, malleus handle not visible.</div> <bR> <bR> <div> <IMG SRC="104f5b80.jpg" border=0 width="501" height="440" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Acute <FONT SIZE="3" COLOR="#800000" FACE="Arial" >otitis</FONT>, simplex. Discrete signs with widened blood vessels on eardrum. Air in the middle ear.</div> <bR> <div> <IMG SRC="1059bb60.jpg" border=0 width="411" height="438" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Pusfilled middle ear with 2 myringitis blisters.</div> <bR> <div> <IMG SRC="106bfa50.jpg" border=0 width="447" height="421" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">Pusfilled middle ear with 3 myringitis blisters. The blisters are so big that it is difficult to see the plane of the ear drum.</div> <bR> <div> <IMG SRC="108fa250.gif" border=0 width="1018" height="37" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> 1. Acute <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Media</FONT></div> <div> 1. Symptoms</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rapid onset of ear pain (otalgia) with fever +/- </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">irritability </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vomiting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rapid onset of purulent discharge through a tympanotomy tube </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">longstanding tympanic membrane perforation </div> <div> 2. Signs</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">erythematous and opaque tympanic membrane ™ </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TM immobile on pneumatic otoscopy </div> <div> 3. Complications (in 5-15% of untreated cases)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acute labyrinthitis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acute mastoiditis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acute meningitis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lateral sinus thrombosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">persistent TM perforation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">temperal lobe abscesses </div> <div> 2. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Media</FONT> with Effusion</div> <div> 1. Symptoms</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">feeling of fullness in the ears (plugged) but painless </div> <div> 2. Signs</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TM red, yellow, white, purple, and/or opaque </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TM immobile on pneumatic otoscopy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">effusion may be serous, mucoid, or purulent </div> <div> INVESTIGATIONS:</div> <div> 1. For Hearing Loss</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">see file on "Hearing Loss" </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Behavioural Observational Audiometry (BOA) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tympanometry (Impedance Audiometry) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Brainstem Auditory-Evoked Responses (BAER) </div> <div> MANAGEMENT:</div> <div> 1. Supportive</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">85-95% of OM will resolve spontaneously without treatment but there is an increased incidence of complications if no medications are used </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tylenol 15 mg/kg/dose q4h prn for analgesia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cleaning out of ear wax </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5 capsules of colace powder (100 mg/capsule) into 45 cc of normal saline; 3 drops in each ear tid x 3 days </div> <div> 2. Antibiotics</div> <div> 1. Amoxicillin (Amoxil)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">25 mg/kg/day po tid </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">10-15% of organisms will be resistant to amoxil </div> <div> 2. Trimethoprim-Sulfamethoxazole (Septra)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">6 mg trimethoprim/kg/day + 30 mg sulfamethoxazole/kg/day po bid </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ineffective against Strep. pyogenes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">side effects: blood dyscrasias, aplastic anemia due to sulfa component </div> <div> 3. Amoxicillin/Clavulanate (Clavulin)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">50 mg/kg/day po tid </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">side effects: diarrhea </div> <div> 4. Erythromycin Ethylsuccinate-Sulfisoxazole Acetyl (Pediazole)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">50 mg/kg/day (erythromycin component) po qid </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">side effects: blood dyscrasias, aplastic anemia due to sulfa component </div> <div> 5. Topical Antibiotics</div> <div> 1. Garasone Otic Preparation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">topical corticosteroid + gentamicin </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3-4 drops into affected ear tid as long as discharge is present </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">indications: discharging tympanotomy tube, permanent tympanic membrane perforation </div> <div> 3. Acute OM</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">antibiotic x 10 days with follow-up in 3 weeks if asymptomatic or after 72 hours if remains symptomatic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">most children will still have a middle ear effusion after 10 days of therapy and 20% still have an effusion 2 weeks after the initiation of therapy; it may take 3 months for some effusions to clear </div> <div> 4. Recurrent AOM</div> <div> 1. More Than 2 Months Apart</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">antibiotic therapy as above with each attack treated as if it were the first </div> <div> 2. Less Than 2 Months Apart</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">prophylactic antibiotics (use also if there are more than 3 attacks in a 6 month period): </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Septra at 50% treatment dosage po od </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Pediazole at 50% treatment dosage po od </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Amoxil at 50% treatment dosage po od </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">treat for 3-6 months in the fall and winter </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">treat for 6-8 weeks in the spring and summer </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">if an AOM develops during prophylactic therapy, discontinue the prophylactic antibiotic and switch to another anti-biotic at full strength, treat for 10 days, then resume prophylaxis </div> <div> 5. Surgery</div> <div> 1. Tympanotomy Tubes</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">indications for: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">recurrent AOM and have failed prophylaxis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">chronic OME (lasting >3 months) with hearing loss </div> <div> 2. Adenoidectomy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">indications for: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">if tympanotomy tubes are required for a 3rd or 4th time </div> <bR> <bR> <div> What are the potential complications of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >media</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Adhesive <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Otitis</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Media</FONT> - Glue Ear </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mastoiditis - infection of the skull bone containing the middle ear </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Labrynthitis - infection of the vestibular (balance) system </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hearing loss and speech problems </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Meningitis - infection of the membranes surrounding the brain </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sepsis (systemic infection) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Brain Abscess - longer term infection of the brain itself </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lateral Sinus Thrombophlebitis - infection of a blood vessel returning blood from the brain to the heart </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Otic Hydrocephalus - an increased pressure in the skull leading to brain damage </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Facial nerve problems </div> <bR> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Otitis media is a common diagnosis which is most likely to occur during early childhood, between the ages of<B> 6 and 36 months.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The frequency of this problem can be illustrated by the following observations that have been made in the United States:</div> <bR> <bR> <div> • In pediatrics, otitis media accounts for 25 percent of all visits, 50 percent of ill visits, and up to 40 percent of all antibiotic prescriptions.</div> <bR> <div> • By the age of five years, 75 to 95 percent of children will experience at least one episode and 20 to 26 percent will have more than six episodes</div> <bR> <div> Otitis is less common among older children, adolescents, and adults. However, adults may be affected by the sequelae of otitis media from early childhood.</div> <bR> <div> <B><U> <A NAME="1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>PATHOPHYSIOLOGY</U></B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute otitis media (AOM) is defined as<B> fluid in the middle ear accompanied by signs or symptoms of ear infection.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B>AOM is a result of a multifactorial process characterized by inflammation of </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the lining of the middle ear, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">eustachian tube dysfunction, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">retention of fluid, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and bacterial proliferation.</B></div> <div> <B><IMG SRC="10107dc0.gif" border=0 width="263" height="220" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most episodes of AOM are <B>preceded by a viral upper respiratory tract infection which causes sufficient inflammation and edema to obstruct the Eustachian tube.</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clearance of secretions in the middle ear is impaired, resulting in retention of fluid that can become infected by organisms colonizing the nasopharynx </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. The respiratory viruses implicated in the pathogenesis of AOM include </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">respiratory syncytial virus,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> rhinovirus, Coxsackie,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> influenza A, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and parainfluenza viruses</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >.</FONT></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AOM is more common in children because, compared to adults, the Eustachian tube is shorter, wider, straighter, and horizontally placed.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> As a result, organisms in the nasopharynx have easier access to the middle ear.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Furthermore nasopharyngeal carriage of a potential pathogen may be a risk factor for AOM.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Additional factors which predispose to AOM include anatomic anomalies such as </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cleft palate or ciliary dysmotility,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> underlying immunodeficiency,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> allergies, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lack of breast feeding, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">exposure to tobacco smoke,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> increased exposure to upper respiratory infections (especially in daycare settings), </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">early age at first infection, and race </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Native Americans are 15 times more likely than white children to have AOM</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Why this occurs is not known.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Possible risk factors for otitis media in adults include a history of chronic otitis and underlying illnesses, such as </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diabetes,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> cancer, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and intravenous drug abuse </B></div> <bR> <div>  <A NAME="2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Genetics — The anatomic and epidemiologic risk factors cited above for predisposition to the development of otitis media have lead investigators to speculate on a genetic component for this infection.</div> <div>  </div> <div>  <A NAME="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Microbiology — The bacteriology of otitis media in children has been studied extensively </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. <B>Streptococcus pneumoniae is the most common bacterial pathogen isolated from infected middle ears</B>, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Nontypable Haemophilus influenzae and Moraxella catarrhalis are isolated in 15 to 20 percent of patients,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> while the frequency of isolation of Group A streptococcus varies with the season. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The latter organism accounts for less than 5 percent of cases overall, but the incidence approaches 10 percent during the winter months </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There are no significant geographic differences in the organisms responsible for AOM </div> <bR> <div> Culture of fluid obtained by tympanocentesis fails to identify a bacterial pathogen in 40 percent of cases </div> <div>  The negative culture results may reflect a viral etiology or sterile inflammation. </div> <bR> <bR> <div> <B><U> <A NAME="4"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>CLINICAL MANIFESTATIONS </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> AOM usually presents with </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fever, otalgia,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> irritability,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> anorexia,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> loose stools,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and vomiting in children.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In adults, the most common symptom of otitis media is ear pain.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Otorrhea due to spontaneous perforation of the tympanic membrane occurs in a minority of cases </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. In some patients, middle ear infection is asymptomatic, especially in infants less than one year of age </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Examination of the tympanic membrane reveals an </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">erythematous, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">often bulging membrane with purulent fluid behind it</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. There is loss of the usual landmarks, and mobility with pneumatic otoscopy is decreased. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tympanograms show decreased compliance.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="5"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Diagnosis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The diagnosis of otitis media is made by the combination of an abnormal tympanic membrane and decreased mobility.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Erythema of the tympanic membrane alone is not diagnostic since it can be caused by crying</B>. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is no way to identify the 40 percent of patients with AOM who have sterile cultures.</B></div> <bR> <div> <IMG SRC="0f0c3c80.jpg" border=0 width="195" height="200" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0f1c8c70.jpg" border=0 width="200" height="199" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="6"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Chronic otitis media with effusion </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> <B>Chronic otitis media with effusion is defined as presence of middle ear fluid for more than three months. </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The tympanic membrane is characteristically minimally discolored, a fluid level is present, and the tympanic may appear retracted </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The pathogenesis of chronic otitis media with effusion is unclear. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Approximately one-half are sterile by culture but bacterial DNA has been identified in some culture-negative effusions.,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </div> <bR> <div>  <A NAME="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>TREATMENT </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The most important goal of therapy in AOM is to prevent sequelae.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These include suppurative infectious complications such as </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mastoiditis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> meningitis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and brain abscess.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In the preantibiotic era, the rate of suppurative sequelae ranged from 3 to 44 percent </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> With effective therapy, these complications now occur in less than 0.15 percent of cases</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Hearing loss and speech problems can also result from repeated or prolonged episodes of AOM.</div> <bR> <div> <B>Complications: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Serous OM is the most common complication.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It may cause mild discomfort in some patients; however, if it is bilateral, there may be significant hearing loss with resultant speech delay in infants.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Treatment of this condition is not the responsibility of an ED physician, and the patient should be referred.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mastoiditis used to be a common complication, but now, with antibiotic treatment, it is very rare. Patients with any mastoid tenderness or edema accompanying <FONT SIZE="3" COLOR="#800000" FACE="Arial" >otitis</FONT> should be treated aggressively in consultation with an ENT specialist.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Perforation of the tympanic membrane is a frequent, but usually not serious, complication. Treatment is not changed from that described above, but follow-up care is more important. With proper treatment, most perforations heal within a couple of weeks with no residual complications.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intracranial complications, such as epidural abscess or cavernous sinus thrombosis, are exquisitely rare, and should be treated with admission to a critical care unit. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They usually present primarily, rather than as a late complication of treated <FONT SIZE="3" COLOR="#800000" FACE="Arial" >otitis</FONT></div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="8"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Guidelines for initiation of antibiotic therapy — Our conclusion is that, until better predictors of complications are identified in clinical trials, antibiotic therapy is generally recommended in AOM. Antibiotics should be prescribed after diagnosing AOM based upon the clinical presentation and otoscopic examination. In contrast, antibiotics should not be prescribed over the telephone or in a patient without evidence of AOM on examination in an attempt to prevent its development.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antibiotic treatment may be withheld after carefully evaluating the patient for risks of complications. Although the risk factors for complications are only partly understood, patients with the following clinical features are at lower risk for complications </div> <bR> <div> • Children over the age of two years</div> <div> • Nontoxic clinical appearance</div> <div> • Normal host defenses</div> <div> • Patient likely to comply with follow-up appointment</div> <bR> <div> Antibiotics should be used in any patient who does not have all four of these favorable features. If antibiotic therapy is not initiated, the patient should be reassessed in 48 to 72 hours and treatment begun if the patient is not clinically improved.</div> <bR> <bR> <div> Immunoglobulin therapy has been studied in children for the prevention of otitis media with varying results.</div> <bR> <bR> <div> Tympanostomy tubes are frequently inserted when medical management for recurrent AOM fails. The tubes shorten the duration of middle ear effusions, but do not reduce the recurrence rate of AOM compared to prophylactic antibiotics. In one randomized trial of 264 such children, the average rate of new episodes of AOM or otorrhea per child year was 0.60 with <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>amoxicillin</U></FONT> versus 1.02 and 1.08 with tympanostomy tubes and placebo, respectively </div> <div>  The reduction in the duration of middle ear effusions may lessen the likelihood of developing conductive hearing loss and subsequent language and speech problems. Additional studies are needed to better establish the effect of tympanostomy tubes on speech development.</div> <bR> <div> Tubes should be placed for chronic otitis media with effusion that is unresponsive to medical management as per the panel guidelines  for recurrent otitis media despite antibiotic prophylaxis for six to eight weeks, especially if there is evidence of hearing loss.</div> <bR> <div> Adenoidectomy has been advocated in children over the age of four years, if enlarged adenoids are interfering with eustachian tube function Adenoidectomy may also remove a source of chronic bacterial infection in these children </div> <div> . However, two randomized clinical trials run in parallel failed to demonstrate a substantial effect of adenoidectomy or adenotonsillectomy on the occurrence of acute otitis media in patients with recurrent otitis media with or without evidence of enlarged tonsils or adenoids </div> <bR> <div> Active immunization is an important preventive strategy. Immunization against influenza virus and S. pneumoniae has been shown to decrease the incidence of otitis media</div> <div> . In one controlled trial, for example, influenza vaccination during an epidemic lowered the total incidence of AOM from 29.4 percent in the control group to 18.7 percent at six weeks</div> <div>  The currently licensed pneumococcal vaccine is poorly immunogenic in patients under the age of two years, but conjugate pneumococcal vaccine holds great promise for reducing the incidence of otitis media in this age group. </div> <bR> <div> <IMG SRC="09341890.gif" border=0 width="321" height="393" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="09483c00.gif" border=0 width="387" height="448" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="09515160.gif" border=0 width="533" height="278" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B><U><IMG SRC="0f2f4d30.gif" border=0 width="500" height="467" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="0f4775e0.gif" border=0 width="375" height="350" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">NORMAL</U></B></div> </td> </tr></table></body>