Otitis Media, Emergency Medicine

Basics

Description

- Exclude associated conditions - Consider full septic workup for sick patients with fever - Otoscopic exam for appearance and mobility of TM: - Full visualization essential - Increased vascularity, erythema, purulence - Obscured landmarks " ”bony, light reflex - Pneumatic otoscopy " ”bulging, retracted, decreased mobility

- Tympanocentesis " ”indications: - Severe pain or toxicity - Failure of antimicrobial therapy - Suspicion of suppurative complication - Sick neonate - Immunocompromised patient

- Trauma: - Perforation of the TM - Foreign body in ear - Barotrauma - Instrumentation

- Antibiotics: - Amoxicillin: 500 " “875 mg PO q12h (peds: 80 " “90 mg/kg/d PO div. q12h) for 10 days - Amoxicillin " “clavulanic acid: 500 " “875 mg PO q12h (peds: 90 mg/kg/d PO q12h) for 10 days - Azithromycin: 10 mg/kg PO day 1, then 5 mg/kg/d PO days 2 " “5 - Cefuroxime: 500 mg PO q12h (peds: 30 mg/kg/d PO div. q12h)

- Analgesia: - Acetaminophen: 500 mg PO q6h (peds: 15 mg/kg per dose orally/rectally every 4 " “6 hr); not to exceed 4 g/24 h - Antipyrine/benzocaine (5.4%/1.4% solution): 2 " “4 drops in ear QID PRN - Ibuprofen: 400 " “600 mg PO q6 " “8h (peds: 10 mg/kg per dose orally every 6 hr)

• Inflammation of the middle ear
• Most commonly occurs in children 6 " “36 mo
• Rapid onset of local and/or systemic symptoms
• More than 1/3 of children experience >5 episodes by the age of 7 yr

Etiology

• Usually associated with (or as a result of) upper respiratory tract infections
• Viral:ParainfluenzaRespiratory syncytial virusInfluenzaAdenovirusRhinovirus
• Bacterial:Streptococcus pneumoniaeMoraxella catarrhalisHaemophilus influenzaeStreptococcus pyogenesMycoplasma pneumoniae
• Associated with blockage of eustachian tube
• Predisposing factors:Deficient mucus, cilia, or antibodiesIntubation, especially nasotrachealAmerican Indians, EskimosDown syndromeCleft palateDiabetesVitamin A deficiencyHIV
• Risk factorsFamily historyDaycareParental smokingPacifier useBottle-feeding

Diagnosis

From the American Academy of Pediatrics 2013 Guidelines: ‚

• Diagnose otitis media (OM) when:Moderate to severe bulging of tympanic membrane (TM)Mild bulging of TM and recent onset of ear pain (tugging, pulling, rubbing in nonverbal child)New otorrhea not due to acute otitis externa
• Should not diagnose if no middle ear effusion (pneumatic otoscopy and/or typanometry)
• Recurrent OM:3 episodes in 6 mo or4 episodes in the last year with 1 in the past 6 mo

Signs and Symptoms

History

• Ear pain (otalgia)
• Irritability
• Rhinitis
• Vomiting, diarrhea
• Poor feeding
• Fever
• Sensation of plugged ear
• Pulling at ear
• Vertigo, tinnitus
• Conjunctivitis

Physical Exam

• TM inflammation, bulging, and limited mobility
• New onset otorrhea without evidence of otitis externa
• Decreased visibility of the landmarks of the middle ear

Essential Workup

• Exclude associated conditions
• Consider full septic workup for sick patients with fever
• Otoscopic exam for appearance and mobility of TM:Full visualization essentialIncreased vascularity, erythema, purulenceObscured landmarks " ”bony, light reflexPneumatic otoscopy " ”bulging, retracted, decreased mobility

Diagnosis Tests & Interpretation

Lab

Cultures unhelpful unless done by tympanocentesis ‚

Imaging

CT scan if associated mastoiditis is suspected ‚

Diagnostic Procedures/Surgery

• Tympanocentesis " ”indications:Severe pain or toxicityFailure of antimicrobial therapySuspicion of suppurative complicationSick neonateImmunocompromised patient
• Tympanometry and acoustic otoscopy may be useful with difficult exams

Differential Diagnosis

• Infection:Otitis externaMastoiditisDental abscessAllergic rhinitisCholesteatomaPeritonsillar abscessSinusitisLymphadenitisParotitisMeningitis
• Trauma:Perforation of the TMForeign body in earBarotraumaInstrumentation
• Serous OM or eustachian tube dysfunction
• Impacted ear cerumen
• Impacted 3rd molar
• Temporomandibular joint dysfunction

Treatment

Ed Treatment/Procedures

• Most mild cases could resolve without antibiotics
• Antibiotics are indicated for:All infants <6 moChildren <2 yr with bilateral OMBilateral OM in kids <2 yrChildren >6 mo with severe infection (otalgia for >48 hr or temperature 102.2 ‚ °F or higher)Bilateral OM in kids <2 yrChildren >6 mo with ruptured TM with drainage
• For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2 " “3 days:For reliable parents, may provide a prescription for oral antibiotics, which the family can fill if the childs symptoms get worse or persist after 2 days
• Considerations should include recurrent nature of OM, lack of clinical response, and resistance patterns in community
• Parenteral antibiotics are indicated in febrile toxic children <1 yr or with immunocompromise
• Antihistamines, decongestants, and steroids have no proven efficacy
• Antipyretics and analgesics are important (avoid local analgesics in perforated TMs)

Medication

• Antibiotics:Amoxicillin: 500 " “875 mg PO q12h (peds: 80 " “90 mg/kg/d PO div. q12h) for 10 daysAmoxicillin " “clavulanic acid: 500 " “875 mg PO q12h (peds: 90 mg/kg/d PO q12h) for 10 daysAzithromycin: 10 mg/kg PO day 1, then 5 mg/kg/d PO days 2 " “5Cefuroxime: 500 mg PO q12h (peds: 30 mg/kg/d PO div. q12h)
• Analgesia:Acetaminophen: 500 mg PO q6h (peds: 15 mg/kg per dose orally/rectally every 4 " “6 hr); not to exceed 4 g/24 hAntipyrine/benzocaine (5.4%/1.4% solution): 2 " “4 drops in ear QID PRNIbuprofen: 400 " “600 mg PO q6 " “8h (peds: 10 mg/kg per dose orally every 6 hr)

Follow-Up

Disposition

Admission Criteria

Febrile toxic children who are: ‚

• <1 yr, immunocompromised
• Moderately or severely dehydrated
• Unable to tolerate oral fluids or medications
• Suspected or proven associated significant infection
• Suspected abuse
• Unreliable caretaker

Discharge Criteria

Children without any of the aforementioned criteria ‚

Follow-Up Recommendations

• Follow-up in 10 " “14 days to ensure resolution
• Indications for earlier follow-up:Child does not get better in 24 " “48 hrAny progression of signs or symptomsNew problems develop, including a rashAny concerns arise

Complications

• Recurrent OM:3 episodes within 6 mo or4 episodes in 1 yr with the last within 6 mo
• Perforated TM
• Serous OM
• Hearing loss (conductive and sensorineural)
• Facial nerve injury
• Mastoiditis
• Cholesteatoma
• Meningitis
• Subdural empyema
• Labyrinthitis
• Epidural abscess
• Venous sinus thrombosis

Pearls and Pitfalls

For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2 " “3 days. ‚

Additional Reading

• American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451 " “1465.
• Coker ‚ TR, Chan ‚ LS, Newberry ‚ SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: A systematic review. JAMA. 2010;304:2161 " “2169.
• Fischer ‚ T, Singer ‚ AJ, Lee ‚ C, et al. National trends in emergency department antibiotic prescribing for children with acute otitis media, 1996 " “2005. Acad Emerg Med. 2007;14:1172 " “1175.
• Greenberg ‚ D, Hoffman ‚ S, Leibovitz ‚ E, et al. Acute otitis media in children: Association with day care centers " “antibacterial resistance, treatment, and prevention. Paediatr Drugs. 2008;10:75 " “83.
• Gunasekera ‚ H, Morris ‚ PS, McIntyre ‚ P, et al. Management of children with otitis media: A summary of evidence from recent systematic reviews. J Paediatr Child Health. 2009;45:554 " “562.
• Lieberthal ‚ AS, Carroll ‚ AE, Chonmaitree ‚ T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964 " “e999.
• Powers ‚ JH. Diagnosis and treatment of acute otitis media: Evaluating the evidence. Infect Dis Clin North Am. 2007;21:409 " “426.
• Spiro ‚ DM, Arnold ‚ DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr. 2008;20:72 " “78.

Codes

ICD9

• 381.4 Nonsuppurative otitis media, not specified as acute or chronic
• 381.60 Obstruction of Eustachian tube, unspecified
• 382.9 Unspecified otitis media

ICD10

• H65.90 Unspecified nonsuppurative otitis media, unspecified ear
• H66.90 Otitis media, unspecified, unspecified ear
• H68.109 Unspecified obstruction of Eustachian tube, unspecified ear
• H65.91 Unspecified nonsuppurative otitis media, right ear
• H65.92 Unspecified nonsuppurative otitis media, left ear
• H65.93 Unspecified nonsuppurative otitis media, bilateral
• H65.9 Unspecified nonsuppurative otitis media
• H66.91 Otitis media, unspecified, right ear
• H66.92 Otitis media, unspecified, left ear
• H66.93 Otitis media, unspecified, bilateral
• H66.9 Otitis media, unspecified

SNOMED

• 65363002 otitis media (disorder)
• 80327007 Serous otitis media (disorder)
• 48145001 obstruction of Eustachian tube (disorder)
• 194287004 Recurrent acute otitis media