Course Authors
Craig Brown, M.D.
Dr. Brown is Assistant Professor of Family Practice, Southern Illinois University, and a family physician in Mt. Zion, IL.
Dr. Brown reports no commercial conflict of interest.
Note: Cyberounds® is grateful for this opportunity to publish a Guest Author's manuscript. If you have special expertise in a subject and wish to be published on Cyberounds®, please e-mail editor@cyberounds.com.
Estimated course time: 1 hour(s).
Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Upon completion of this Cyberounds®, you should be able to:
List the hallmark signs of otitis media
List major contributing factors to otitis media
Discuss the treatment, management and prevention of otitis media.
Otitis media is the most common disease that is seen at the physician's office during the first year of life. The associated colic can be very trying for both the infant and the caregiver. The incidence and prevalence of otitis media in children have remained very significant over time -- fifty percent of infants develop an ear infection by one year of age and an increased risk of recurrent acute otitis and chronic disease is seen in infants who have an infection in the first year of life.(1)
An infection before age one is the highest predictor of future infections. The incidence is higher in males than in females, in whites than blacks, in lower socioeconomic groups, in native Americans and Alaskan natives, and higher in children with cleft palate and other craniofacial anomalies. The incidence is also higher in early spring and winter, as compared to summer and early fall.(2)
Description
The hallmark finding in otitis media is decreased tympanic membrane mobility, which can be measured by the pneumatic otoscopy or by impedance tympanometry. Bulging of the tympanic membrane is frequently noted. Other findings, often seen on examination, are tympanic membrane erythema, elevated temperature and irritability, which are not specific or sensitive.
It is imperative to obtain an excellent view of the tympanic membrane. The wax that is occluding optimal visualization should be removed. The bulb in the tympanoscope should be bright and the pneumatic bulb should be used to assess membrane mobility.
Pathogenesis
One of the most important functions of the Eustachian tube is to protect the middle ear from pressure fluctuations in the airways. Minor nasopharyngeal pressure variations occur with breathing. High positive nasopharyngeal pressures are caused by Valsalva-type maneuvers and nose blowing, while significant negative pressures occur commonly on sniffing. These positive and negative pressures can be transmitted to the middle ear. Evacuation of the middle ear cavity during sniffing frequently leads to locking of the Eustachian tube. In this case, the tube commonly displays a one-way valve characteristic, that is, one direction of passage through the tube is favored, namely, the "down direction" from the middle ear to the nasopharynx. This has been referred to as "Eustachian tube closing failure."(3)
Sniffing as a possible cause of ear disease, such as secretory otitis media (SOM), atelectasis, adhesive otitis and cholesteatoma, has been extensively investigated in different study groups.(4),(5),(6),(7),(8),(9),(10) In one study, 156 ears in 100 children with persistent SOM were investigated. In 63% of ears (73% of individuals), evacuation of the middle ear took place by the act of sniffing.(3)
Digital measurements showed that a vacuum formed in most reusable feeding bottles, which are either non-ventilated or under-ventilated, through various configurations of holes and slits in the nipple rim or nipple proper.(11) The non-vented bottle is simply a solid walled vessel with a nipple held in place with a cap. The cap holds the enlarged flange end of the nipple (the portion of the nipple in contact with the feeding device) firmly against the top of the bottle forming a tight seal. This arrangement constitutes a solid walled container which does not permit any air entry, resulting in the liquid being held within the feeding vessel by the vacuum which is formed while sucking. Fluid may only be removed by the infant in small amounts by overcoming the stiffness of the wall of the nipple or bottle and collapsing one or the other with a resulting small amount of liquid leaving the bottle. The high negative pressure formed at the very onset of feeding is the exact opposite of the positive pressure which occurs during physiological breast feeding.
Presentation
Infants will sometimes have a temperature, be irritable, not eat well or may present in a nonspecific manner. Older infants may rub their ear. Sometimes, infants show minimal symptoms, if any.
Attenuated symptoms may be present with infants who have had antibiotics prior in the course of their illness. The spinal tap in a "toxic" infant may have subtle findings or be "normal."
Treatment of Non-toxic O.M.
The treatment of otitis media doesn't necessarily involve antibiotics. Otitis media with effusion is simply observed.(12)
There is a growing consensus to observe infants with otitis media who aren't "toxic."(13),(14)
Prevention and Management
Middle ear evacuation and subsequent locking of the Eustachian tube, as a result of the intensified and forceful sucking against the increasing vacuum present in under-vented or non-vented bottles, may also be expected when sucking on pacifiers, toys, thumbs and similar objects. The common denominator in all of these activities is that a negative pressure is generated in the oral cavity and the vacuum may then be transferred via the Eustachian tube to the middle ear.
In terms of otitis media, breast-feeding has multiple advantages over other methods of nutrition. When using standard baby feeding bottles that are non-ventilated or under-ventilated through various configurations of holes and slits in the nipple rim or nipple proper, studies have clearly shows a direct correlation between the negative pressure in the feeding bottle and negative pressure in the middle ear.(11) A causal relationship between the induced negative intratympanic pressure and development of ear disease is suggested. The negative pressure may lead to development of secretory otitis causing hearing impairment and a risk for delayed speech development. The negative pressure may predispose for purulent otitis media and even contribute to development of irreversible retraction type middle ear disease such as atelectasis, adhesive otitis, and cholesteatoma. In order to more closely simulate physiological breast-feeding, it is necessary to avoid vacuum formation and air bubbles. This may be done by using feeding bottles with continuous positive pressure at the nipple during the entire feeding cycle.
Treatment of "Toxic" Otitis Media
The primary goal is to treat only documented cases of acute otitis media. It is imperative that physicians examine any infant suspected of having otitis media.
Unfortunately, antibiotic resistance to the organisms seen in otitis media is sharply on the rise.(15),(16),(17) Between 30 to 60 percent of Streptococcus pneumoniae show a reduced susceptibility to penicillin as well as amoxicillin. Beta-lactamase-producing strains of Haemophilus influenzaeand Morexalla catarrhalis strains have nearly tripled in the last decade. With a resistant and rapidly changing milieu of organisms causing infection, the U.S. Center for Disease Control (CDC) has released recommendations concerning treatment. The recommendations are categorized according to whether or not the patient has received antibiotics in the last month.
If the infant has not received antibiotics in the last onth, it is recommended that the infant be started on usual-dose or high-dose amoxicillin.A If there is clinically defined treatment failure on day three, then it is recommended that the infant be started on high-dose amoxicillin-clavulanate (Augmentin)B or cefuroxime axetil (Ceftin®) or intramuscular ceftrianone in three daily doses. The recommendations for clinically defined treatment failure on days 10 to 28 are the same as those for treatment failure on day three. The criteria for "treatment failure" vary but reflect consensus clinical judgment.
For an infant who has received antibiotics in the last month, it is recommended that high-dose amoxicillin,A high dose amoxicillin-clavulanateB or cefuroxime axetil be started. If there is clinically defined treatment failure on day three, treatment options include intramuscular ceftrianone (in three daily doses), clindamycinC or tympanocentesis. For clinically defined treatment failure in days 10 to 28, options include high-dose amoxicillin-clavulanate, cefuroxime axetil, intramuscular ceftriaxone or tympanocentesis.
- High-dose amoxicillin = 80 to 90 mg per kg per day. return
- High-dose amoxicillin-clavulanate = 80 to 90 mg per kg per day of amoxicillin component, with 6.4 mg per kg per day of clavulanate (requires newer formulations or combination with amoxicillin. return
- Clindamycin is not effective against Haemophilus influenzae or Moraxella catarrhalis. return
Conclusion
Simultaneous pressure variations in the middle ear and nipple of the feeding bottle were measured and digitally plotted. The results showed that breast-feeding has additional advantages over other methods of nutrition. Clearly, when using feeding bottles, nipple collapse and air bubble formation should be avoided. Both are indicators that negative pressure has formed in the feeding container. Studies have shown that this pressure is tranferred into the middle ear. Negative intratympanic pressure is similarly introduced during pacifier use and thumb sucking.
The negative pressure formation from this mechanisms may lead to the development of secretory otitis, causing hearing impairment and a risk for delayed speech development. The negative pressure may predispose for purulent otitis media and even contribute to development of irreversible retraction type middle ear disease such as atelectasis, adhesive otitis and cholesteatoma.
Treatment varies and includes close observation of "non-toxic" infants. Medication options are guided by clinical effectiveness in a constantly changing milieu of organisms and resistance.