Page 1 OTITIS MEDIA AND SINUSITIS I. OTITIS MEDIA A. Definition: 1. Inflammatory reaction to foreign antigens in the middle ear that cannot adequately drain via the eustachian tube. 2. Three major divisions a) Acute otitis media with effusion (AOME) b) Otitis media with effusion (OME) c) Chronic draining otitis media (CDOM) 3. AOME or OME may be intermittent, persistent, or recurrent B. Pathogenesis: 1. Altered ear toilet : secretions and refluxing bacteria inadequately cleared 2. Stagnation of middle ear contents 3. Bacteria multiply in middle ear 4. Inflammatory/immune response (as much as 1 cc/hr) 5. Systemic/local signs and symptoms C. AOME Epidemiology: 1. 1.5 episodes of AOME/year in average child 2. Daycare, passive smoke, or wood burning heat increase risk 3-7 times 3. Age variable attack rate, most <2yo, big drop at 5yo 4. Males > females, 1.8:1 5. Otitis prone children average 3 episodes/6 months 6. Seasonal (less in summer) 7. Association with conjunctivitis or sinusitis 8. Viral prodromes frequently noted 9. Immunodeficiency predisposes: Ig deficiency, HIV 10. Genetic predisposition: Down syndrome, cleft palate, Native American, family history D. Diagnosis: 1. AOME a) Decreased mobility on + and pressure by pneumatic otoscopy, tympanometry b) Altered color: red to yellow c) Bulging by pressurized effusion d) Usually with hearing deficit 2. OME a) Decreased mobility mostly on positive pressure b) Altered color: may be only change to opaque c) Neutral to retracted position d) Variable hearing deficit 3. CDOM a) Lack of integrity of TM b) Chronic drainage c) Usually with hearing deficit E. Equipment: 1. Pneumatic otoscopy and flexible curette, necessary 2. Suction equipment, extremely helpful 3. Tympanometer, becoming necessary 4. Audiometer and working (operating) otoscope are ideal
Page 2 F. AOME Treatment: 1. Organisms isolated from middle ear aspirates in AOME differ geographically. No growth =10-15%: viral or innate defenses killed bacteria S. pneumoniae =30-50: ~1/5 PCN resistant NT. H.influenzae =25-30%: ~1/3 produce β-lactamase Branhamella (Moraxella) catarrhalis =8-45%: >95% produce β-lactamase Group A streptococcus =5-8%: almost never in persistent or recurrent 2. Antibiotics for acute episodes need spectrum for the pathogens above a) First line drugs for intermittent (no AOME for 6 weeks) Slightly impaired eustachian tube function Least chance of resistant pathogens due to less antibiotic pressure in host In patient with no symptoms or at least no fever or otalgia, can consider not using antibiotics ( Masterful Inactivity ) because of ~90% spontaneous remission rate. Otherwise, use of first line antibiotics is reasonable. 1) Amoxicillin high dose 2) Trimethoprim/sulfa (Bactrim, Septra) 3) Erythromycin/sulfisoxazole (Pediazole) b) Second line drugs for persistent (failed during first line antibiotic) or recurrent (new AOME within 6 weeks of previous episode). Marginal eustachian tube function Increased chance of resistant pathogen 1) Amox/Clavulanate (Augmentin) 2) Cefuroxime (Ceftin) or Cefpodoxime (Vantin) 3) Cefixime (Suprax) if S. pneumo not likely c) Most potent regimens of Recalcitrant (failed two consecutive antibiotic regimens or more than one recurrence per month) AOME Worst eustachian tube function Highest risk of resistant pathogen 1) Amoxicillin/Clavulanate 10 mg/kg/dose plus booster of 10 mg/kg amoxicillin per dose 2) Clindamycin plus sulfisoxazole 3) As last resort Ceftriaxone (50 mg/kg IM) if not able to do tympanocentesis Requires 3-4 daily doses for PCN resistant S.Pneumo G. AOME Prophylaxis: 1. If >3 episodes in 6 months, consider prophylaxis a) 70-85% reduction in recurrences b) H.S.> dose of amoxicillin (30 mg/kg) or gantrisin (60 mg/kg) c) Use for 6 to 12 weeks H. AOME Indications for P.E. Tubes: 1. If >2 episodes on prophylaxis, P.E. tubes. a) 80-85% reduction in recurrences b) 3-5% do worse and 5% no better with tubes c) Average duration ~6 months I. OME Treatment: 1. Decongestants and/or antihistamines useless 2. Antibiotics only for de novo OME, i.e., not immediately following AOME 3. Tincture of time is 90% effective by 90 days 4. If hearing deficit impairing development or classroom performance, P.E. tubes are effective for the time they are in place 5. 50% of children who require one set of tubes will need second set within 1 year, and 15% will require a third set 6. Some evidence that prolonged or repeated tube placement leads to excessive scarring of TM and permanent damage to TM
Page 3 7. No evidence of long-term improvement in hearing due to tube placement J. CDOM: 1. Requires ENT specialty consultation 2. Need to rule out cholesteatoma 3. Rare that surgery will help until post puberty 4. Interim care: a) Keep ear dry b) Selective use of topical agents c) External drainage cultures always yield Pseudomonas or Enterics II. PURULENT URI A. No antibiotics unless nasal culture grows group A streptococcus B. Nearly always viral in origin III. IV. SINUSITIS ACUTE A. Clinical diagnosis 90% of time 1. Symptoms: a) Cough (~90%) b) Halitosis (~50%) c) Nasal drainage (>95%) d) Fever (50%) e) Headache in adolescents/adults (70%) f) Associated with recurrent otitis media <3 yo (~30%) g) Recently labile reactive airway disease B. Physical Examination Criteria: 1. Purulent nasal secretion in middle meatus (>95%) 2. Facial tenderness in older children/adults 3. Lower eyelid swelling in young children (70%) C. X-rays reliable in childhood (>1 yo) and adults but rarely necessary D. Acute sinusitis organisms Incidence Comments S. pneumoniae 30% 1/5 PCN resistant NT. H.influenzae 25% 1/3 to ½ produce β-lactamase Branhamella (Moraxella) catarrhalis 30% nearly all produce β-lactamase E. Treatment = 14 days of antibiotics that cover β-lactamase producing organisms F. Continue prophylactic dose H.S.. for 2-4 additional weeks if sinusitis is recurrent, because cilia take 4-6 weeks to regenerate, then x-ray at 6 weeks to ensure resolution SINUSITIS CHRONIC A. Respiratory epithelium gone 1. Signs and Symptoms a) Fever rare unless acute exacerbation superimposed on chronic process b) Facial pain rare unless acute exacerbation c) Headache rare d) Most common symptom = chronic cough and morning sore throat plus fatigue 2. Dx * Usually requires X-ray a) >4 mm mucosal thickening b) Air fluid level c) Opacification d) Optimal: CT cut through ostiomeatal complex 3. Pathogens: Those in acute sinusitis plus gram positives (S. aureus) and mouth flora including anaerobes 4. Antibiotics treatment for chronic sinusitis a) Need coverage of normal respiratory pathogens, oral flora, and anaerobes 1) Rx at least 4-6 weeks 2) May need 6 weeks longer for the prophylaxis
Page 4 b) Drugs: 1) Augmentin 2) Clindamycin plus sulfisoxazole 5. Follow-up x-ray every 6-12 weeks until clear 6. If not clear by 3 months, consider ENT referral V. ENT ANTIBIOTICS A. FIRST LINE: LOW POTENCY 1. Amoxicillin 60-80 mg/kg/day divided t.i.d. in children (500 mg-1 gm/t.i.d. in adults) a) Lower dosing losing efficacy in some areas b) ~9% diarrhea c) No effect on anaerobes, not active vs. most β-lactamase producing pathogens 2. Cefaclor (Ceclor) 50 mg/kg/day divided b.i.d. for children (500 mg t.i.d. for adults) a) Poor penetration, inoculum effect, serum sickness b) Incompletely effective with M. catarrhalis c) Losing effect on H. flu, no activity vs. β-lactamase producing H. flu in vivo d) No effect on penicillin resistant S. pneumo (PR. S. pneumo) 3. Doxycycline (Vibramycin) 100 mg b.i.d. first day then q.d. or b.i.d. (>8 yo only) a) No effect on anaerobes b) Losing activity vs. H. flu, M. cat and little activity vs. PR. S.pneumo 4. Tmp/sulfa (Septra, Bactrim) based on 8 mg/kg/day divided b.i.d. for children (One DS tab b.i.d. for adults) a) Stevens-Johnson may be fatal if taken >2/day after onset of rash b) No effect on anaerobes c) Up to 50% S. pneumo in daycare are resistant 5. Erythro-sulfa (Pediazole) based on 150 mg/kg/day of sulfa divided t.i.d. a) GI side effects up to 50% FOR CHILDREN ONLY b) Little effect on anaerobes erythro as succinate penetrates sinuses poorly c) In some areas, still effective vs. penicillin resistant S. pneumo (PR. S. pneumo) B. SECOND LINE MID TO HIGH POTENCY 1. Loracarbef (Lorabid) 30 mg/kg/day divided b.i.d. in children (Adults 400 mg b.i.d.) a) Very few side effects (capsules not for AOM) b) Incompletely stable to β-lactamase of H. flu 2. Cefpodoxime (Vantin) 10 mg/kg/day divided b.i.d. in children (200 mg b.i.d. maximum adult dose) a) β-lactamase stable b) Taste difficult to mask 3. Cefuroxime axetil (Ceftin) 30 mg/kg divided b.i.d. for children (500 mg b.i.d. for adults) a) β-lactamase stable b) Taste difficult to mask 4. Clarithromycin (Biaxin) 15 mg/kg/day divided b.i.d. (500 mg b.i.d. for adults) a) Active against PCN susceptible S. pneumo, M.cat, Group A streptococcus, Erythro susceptible b) S. aureus, and marginally active vs. H. influenzae c) Also active vs. mycoplasma and chlamydia (preferred when lower respiratory infections occur with acute otitis media) d) Accumulates in respiratory epithelium, non-linear kinetics 5. Amox/clavulanate (Augmentin) 30-35 mg/kg/day of amox divided t.i.d., (In adults 500 mg t.i.d.) a) Spectrum includes aerobes of otitis media and sinusitis plus anaerobes b) Diarrhea if not prescribed correctly c) Doses at least 6 hours apart after meal or snack with 2-4 oz. water chaser d) Don t double dose to make up for missed doses 6. Cefixime (Suprax) 8 mg/kg/day q.d. or divided b.i.d. for children (1 tab b.i.d. for adults) a) Tablets not for AOM b) More diarrhea when q.d. dosing c) Lowest MIC s for M.cat and H.flu d) No Staph or PR.S.pneumo coverage e) Marginal coverage of PCN susceptible pneumococcal and anaerobes
7. Ciprofloxacin (Cipro) 250-500 mg b.i.d.: NOT FOR CHILDREN a) Poor pneumococcal coverage, recent staph resistance b) Predominantly a gram negative drug 8. Clindamycin 40 mg/kg/day plus sulfisoxazole (15 mg/kg/day) a) Best for PR. S.pneumo and also covers anaerobes b) No aerobic gram negative activity ENT Lecture Page 5