Otitis Media - QUESTIONS December, 2002 1.

Regarding pathophysiology of acute otitis media (AOM), classify the following as TRUE or FALSE. a. Since AOM is most often caused by viruses, antibiotic therapy is typically not required. b. The most common bacterial etiologies are Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis. c. Pneumococcal vaccination markedly reduces incidence of AOM. 2. Regarding the pathophysiology of otitis media with effusion (OME), classify the following as TRUE or FALSE. a. OME most frequently occurs as a consequence of AOM. b. OME effusions may be mucoid or serous. c. Unilateral OME without preceding AOM is alarming in adults. 3. Regarding diagnosis of acute otitis media (AOM), classify the following as TRUE or FALSE. a. On physical exam, the tympanic membrane (TM) will show poor mobility, signs of inflammation, loss of landmarks, and may be bulging or retracting. b. After diagnosing otitis media by exam & history, CBC and ESR should be ordered. c. Typanometry is helpful when visual examination of the tympanic membrane is impaired by excessive cerumen. 4. Regarding treatment of otitis media, classify these statements as TRUE or FALSE. a. When combined with antibiotics, oral steroids improve the rate of middle ear effusion clearance. b. Antihistamine/decongestant combination therapy has been proven to improve middle ear effusion clearance. c. Antimicrobials are not indicated for initial treatment of OME. d. The recommended first-line antibiotic for AOM is amoxicillin/clavulanate. e. Second-line antimicrobial agents should be used when AOM has been unsuccessfully been treated within the last month. f. Failure of antibiotic response can be diagnosed after 48 hours and should prompt empirical change to another antibiotic. 5. Who should receive antimicrobial prophylaxis for recurrent AOM?

Otitis Media - ANSWERS December, 2002 1. Regarding pathophysiology of acute otitis media (AOM), classify the following as TRUE or FALSE. a. Since AOM is most often caused by viruses, antibiotic therapy is typically not required. FALSE. Viruses are etiologic only in 5% of cases. However, viral URI is a risk factor for bacterial AOM due to associated eustachian tube obstruction. When a virus is isolated, it is typically RSV or influenza. FALSE AGAIN: Although there are advocates for withholding antibiotic therapy for patients with AOM, the overwhelming consensus remains that antibiotics are the initial therapy of choice. They markedly reduce suppurative complications and improve patient outcomes in early & late phases of AOM. b. The most common bacterial etiologies are Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis. TRUE. These are listed in order of frequency and account for 85% of acute ear infections. Acute sinusitis shares a similar etiology. c. Pneumococcal vaccination markedly reduces incidence of AOM. FALSE. It is most effective for pneumoccocal bacteremia & meningitis. 2. Regarding the pathophysiology of otitis media with effusion (OME), classify the following as TRUE or FALSE. a. OME most frequently occurs as a consequence of AOM. TRUE. Persistent OME after therapy of AOM is expected and does not require re-treatment with antimicrobials. 70% of patients have OME 14 days after AOM therapy, 50% at one month, 20% at 2 months, 10% at 3 months. OME without preceding AOM is theorized to result from antigenic stimulation of sensitized middle ear mucosa. The antigenic challenge results from occasional eustachian tube reflux. b. OME effusions may be mucoid or serous. TRUE. Serous effusions result from rapid decreases in middle ear pressure, inducing transudate formation. This fluid is watery & clear. c. Unilateral OME without preceding AOM is alarming in adults. TRUE. This must be considered a nasopharyngeal mass until proven otherwise. 3. Regarding diagnosis of acute otitis media (AOM), classify the following as TRUE or FALSE. a. On physical exam, the tympanic membrane will show poor mobility, signs of inflammation, loss of landmarks, and may be bulging or retracting. TRUE. In OME, there are no signs of acute inflammation, pain, or systemic symptoms. Both have conductive hearing loss. OME is labeled subacute if 3 weeks to 3 months, chronic thereafter. b. After diagnosing otitis media by exam & history, CBC and ESR should be ordered. FALSE. Exam & history are sensitive & specific enough alone. ESR is used only in rare cases where bony destruction is being considered.

c. Typanometry is helpful when visual examination of the tympanic membrane is impaired by excessive cerumen. FALSE. Cerumen impaction prevents successful use of tympanometry. 4. Regarding treatment of otitis media, classify these statements as TRUE or FALSE. a. When combined with antibiotics, oral steroids improve the rate of middle ear effusion clearance. FALSE. 3 randomized clinical studies have proven this. However, new studies suggest benefit from nasal steroid sprays in middle ear effusion clearance. b. Antihistamine/decongestant combination therapy has been proven to improve middle ear effusion clearance. FALSE. However, they are still recommended for symptomatic care. c. Antimicrobials are not indicated for initial treatment of OME. TRUE. Treat if effusions persist longer than 3 months. d. The recommended first-line antibiotic for AOM is amoxicillin/clavulanate. FALSE. Amoxicillin (875mg BID x 7 days) alone is recommended. Septra or azithromycin is given if PCN-allergic. e. Second-line antimicrobial agents should be used when AOM has been unsuccessfully been treated within the last month. TRUE. This is a risk factor for PCN-resistant Strep pneumo or beta-lactamase positive H influenza or M catarrhalis. Second-line agents include amox/clavulanate (Augmentin) and cefuroxime (Cefzil). Third-line agents include ceftriaxone (Rocephin) and levofloxacin (Levaquin). f. Failure of antibiotic response can be diagnosed after 48 hours and should prompt empirical change to another antibiotic. TRUE. Tympanocentesis is recommended if multiple failures or AOM in an immunocompromised host. 5. Who should receive antimicrobial prophylaxis for recurrent AOM? Patients with 3 distinct episodes in 6 months, or 4 in 12 months.