Update on Otitis Media

Prevention and Treatment

Source :
Infection and Drug Resistance 2014:7;15-24

Writters :
Qureishi A, Lee Y, Belfield K, Birchall JP, Daniel M

Presented by :
Angeline Bongelia Friska (112015390)
Samdaniel Sutanto (112016350)
 INTRODUCTION
Otitis media (OM) inflammatory conditions
affecting the middle ear
Prevention reduce risk of hearing loss
Type : acute otitis media (AOM) (otalgia, fever)
chronic suppurative otitis media (CSOM)
(pus +)
AOM is the commonest childhood infectious
disease
 INTRODUCTION
Complications of AOM : acute mastoiditis
(post-auricular swelling + mastoid tenderness)
OM with effusion (OME) chronic
inflammatory condition (effusion +, acute
inflammation signs -, hearing loss)
Hearing loss due to OME frequently
resolves spontaneously, esp. if follows an
episode of AOM
 INTRODUCTION
OME has lower prevalence in adults
Paranasal sinuses disorders are dominant
factor
Other causes: nasopharyngeal lymphoid
hyperplasia (due to smoking) and adenoidal
hypertrophy, head & neck tumors (mainly
nasopharyngeal carcinomas).
 INTRODUCTION
CSOM, (long-term suppurative middle ear
inflammation, usually w/ persistent tympanic
membrane perforation, cholesteatoma)
persistent otorrhea, hearing loss, tinnitus,
otalgia, & pressure sensation
Multifaceted treatment antimicrobial
agents and surgery
 EPIDEMIOLOGY

50%-85% of children experienced at least one

episode of AOM by 3 years of age.
OME commonest cause of pediatric hearing
impairment in developing country
Young children are more prone to AOM &
OME due to an anatomical predisposition
 ETIOLOGY

Interaction
Anatomical between microbe
variations and host immune
response

Cell biology of the Viral upper

middle ear and respiratory tract
nasopharynx infection
 ETIOLOGY

Streptococcus Haemophilus Moraxella Staphylococcus Streptococcus

pneumoniae influenzae catarrhalis aureus pyogenes

Source:
http://microbe-canvas.com
http://creative-diagnostics.com
http://asm.org
http://emedicine.medscape.com
 Inflammation production of more mucin,
altered more viscous mucin blockage of
eustachian tube accumulation of effusion in
the middle ear
Overexpression of mucin genes can be
exacerbated by cigarette smoke
 Other Theory

Eustachian tube dysfunction middle ear

effusion through negative pressure
Gastroesophageal acid reflux
Genetic factors influencing host immune
response
 ETIOLOGY

CSOM chronic middle ear infection

Role of immunological & genetic factors,
eustachian tube characteristics is important
Cholesteatoma more complex than CSOM
CSOM is often a complication of AOM w/
perforation
Chronic or inadequately treatment
permanently perforated
 DIAGNOSIS OF AOM
AOM purulent middle ear process (short
history, fever, otalgia, irritability, otorrhea,
lethargy, anorexia, vomiting).
American Academy of Pediatrics moderate
to severe bulging of the tympanic membrane
or new onset of otorrhea not secondary to
otitis externa (w/ pneumatic otoscopy or
tympanometry)
 DIAGNOSIS OF AOM

Pneumatic otoscopy and tympanometry

assess mobility of the ear drum
Non-perforated ear drum is immobile
indicates middle ear effusion
Tympanometry assessing mobility by means of
sound reflection
 DIAGNOSIS OF OME
Clinical features: hearing difficulties, poor attention,
behavioral problems, delayed speech and language
development, clumsiness, poor balance
Otoscopy abnormal color, retracted/concave
tympanic membrane, and air-fluid level.
Further evidence can be obtained w/ audiogram and
tympanogram
 DIAGNOSIS OF CSOM
Permanent tympanic perforation with or
without persistent otorrhea should be present
for a minimum of 2-6 weeks
Pain is not usually a predominate feature and
ear discharge is likely to be of a longer
duration
Diagnosis is confirmed with otoscopy
 CURRENT TREATMENT
Current USA guidelines for the treatment of
AOM :
Antibiotic should be prescribed if:
severe unilateral/bilateral AOM in children aged > 6
months
Bilateral AOM in children aged 6-23 months
Non severe unilateral AOM (age 6-23 months) /
unilateral-bilateral AOM (age 24 months)
antibiotic or observation offered
 CURRENT TREATMENT

Antibiotic of choice: amoxicillin

Antibiotic + beta-lactamase cover recurrent
AOM (RAOM), unresponsive to amoxicillin,
suffering from purulent conjunctivitis
In RAOM surgically inserted ventilation
tube should be considered
 CURRENT TREATMENT

OME needs treatment if OME is bilateral

and persistent more than 3 months
Current UK and USA guidelines:
Recommend 3-month period of observation
Serial audiometry
Assessment of the degree of hearing loss
Surgery is also recommended
 CURRENT TREATMENT

CSOM surgical usually recommended

Conservative treatment ear toilet +
antibiotic, antiseptics & topical steroids
Topical quinolones most effective treatment
Depends on many factors
EMERGING STRATEGIES IN PREVENTION AND
TREATMENT

Better treatment of AOM and OME would

therefore be welcome
Ideal treatment would be preventative,
effective, immediate, with sustained activity,
and nontoxic still on focusing
 GENETICS

Mixture of innate defense molecules lead to

OM susceptibility
Potential therapeutics target:
Genes regulating mucin expression
Host immune response
HIF-VEGF (play role for hypoxia in OME)
 PNEUMOCOCCAL VACCINES

Are proven useful in targeting the commonest

cause of AOM (S. pneumoniae)
There is a reduction in AOM, antibiotic
prescription, and AOM-related costs
Reduce risk of complications of AOM
 DEVELOPMENTS IN MICROBIOLOGY AND
BACTERIAL RESISTANCE

Need an attention
Mechanism of emerging bacterial resistance:
Antibiotic-induced genetic transformation
Increasing of mutation rate due to exposure to
sub-minimum-inhibitory-concentration levels of
antibiotics
Biofilm in OME block antibiotics from
reaching bacteria population in biofilm
DRUG DELIVERY TO THE MIDDLE EAR

Transtympanic
Drug delivery delivery
to the middle
ear Intratympanic
delivery
 Conclusion

OME and AOM are significant cause of morbidity and

the cost to the health service
Current treatment guidelines still have significant
shortcomings
Recent advances in medicine offer the potential for
better treatments in the future
THANK YOU FOR YOUR
ATTENTION