1. CONSERVATIVE
MANAGEMENT OF
OTITIS MEDIA
REZAUR RAHMAN SIDDIQUI
SENIOR PRODUCT MANAGER
UNIMED UNIHEALTH PHARMACEUTICAL LTD

2. ACUTE OTITIS MEDIA
According to “Scott-Brown's Otorhinolaryngology: Head
and Neck Surgery”-
The term ‘acute otitis media’ implies a viral or bacterial
infection of the mucosal lining of the middle ear and mastoid
air-cell system.
It is characterized by an otoscopically abnormal tympanic
membrane.
The clinical presentation is usually with otalgia and systemic
illness.

3. OTITIS MEDIA
According to “Ballenger's Otorhinolaryngology Head and Neck Surgery 17th
Edition”-
“Otitis media represents an inflammatory condition of the middle ear space
without reference to cause or pathogenesis.”
The process may be
 acute (0 to3 weeks in duration),
 subacute (3 to 12 weeks in duration), or
 chronic (greater than 12 weeks in duration)
 An effusion may be either serous (thin, watery), mucoid (viscid, thick), or
purulent (pus)

4. ACUTE OTITIS MEDIA
 Most frequently reported pediatric bacterial infection, with up to 85% of children
experiencing an episode by the age of 3 years .
 It is defined by rapid onset of signs/symptoms of inflammation in the middle ear such
as pain, discharge, fever or irritability and bulging tympanic membrane (TM)due to an
effusion or collection of fluid in the middle ear space.
 Ref: Expert Opin. Pharmacother. (2014) 15(8):1069-1083 Otitis media: an update on
current pharmacotherapy and future perspectives

5. ACUTE OTITIS MEDIA
 It is classified according to its onset, response to therapy, duration and
complications, each of which calls for a specific management plan.
 Generally AOM is defined as uncomplicated (no otorrhea), nonsevere (mild
otalgia and temperature < 39C) or severe (moderate-to-severe pain, pain > 48 h,
with temperature > 39C/102.2F)
 Otitis media with effusion (OME), a different stage in the otitis media continuum,
indicates asymptomatic inflammation with fluid collection in the middle ear. It may
be a result of Eustachian tube dysfunction (ETD) and precede the onset of AOM,
or it may be a result of inflammatory response following AOM

6. AOM
 Uncomplicated AOM
 Otitis media without the
presence of Otorrhea
 Nonsevere AOM
 Mild pain, Fever < 39C
 Intense erythema or mild
bulging of the TM

7. AOM
 Severe AOM
 Moderate-to-severe pain
 Duration of pain > 48 h, Fever ‡ 39 C
 Moderate-to-severe bulging of the TM
 OME
 Asymptomatic
 Fluid collection in middle ear

8. Chronic OM
 Chronic OM with effusion
 Persistent effusion > 6 weeks
 Chronic suppurative OM
 Chronic otorrhea
 Leads to damage of structures and
potential
 hearing loss

9. Organisms in Acute and Chronic
Suppurative Otitis Media

10. OUTCOMES OF OTITIS MEDIA
Ref: Diseases of the Ear, Nose and
Throat

11. Factors Affecting Risk of Acute Otitis Media
 Age Maximal incidence between six and 24 months of age;
eustachian tube shorter and less angled at this age. Underdeveloped
physiologic and immunologic responses to infection in children
 Breastfeeding Breastfeeding for at least three months is protective;
this effect may be associated with position maintained during
breastfeeding, suckling movements, and protective factors in breast
milk
 Daycare attendance* Contact with multiple children and daycare
providers facilitates spread of bacterial and viral pathogens

12. Factors Affecting Risk of Acute Otitis Media
 Exposure to cigarette smoke Increased incidence with
cigarette smoke and air pollution, especially if parents smoke
 Male sex Slightly increased incidence
 Previous antibiotic use* Increased risk of antibiotic treatment
failure
 Previous otitis media* Increased risk of antibiotic treatment
failure
 Season* Increased incidence in fall and winter
 Underlying pathology* Increased incidence in children with
allergic rhinitis, cleft palate, Down syndrome

13. Pathophysiology
 An allergy or URTI causes obstruction of the ET which results in accumulation
of middle ear secretions (effusion).
 Secondary bacterial or viral infection of the effusion causes suppuration and
features of AOM.
 The effusion may persist for wks or months after the infection resolves.
 Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis are the most common bacterial isolates from the middle ear fluid of
children with AOM.
 Penicillin-resistant S. pneumoniae is the most common cause of recurrent and
persistent AOM.

14. Diagnostic criteria for OM (AOM)
 Rapid onset of symptoms
 Middle ear effusion (bulging TM, limited or absent mobility of
membrane and air-fluid level behind membrane)
 Signs and symptoms of middle ear inflammation (erythema of TM
and otalgia affecting sleep or normal activity)

15. Diagnostic criteria for OM

16. AOM
Non-specific symptoms of AOM:
 Fever,
 Headache,
 Irritability,
 Cough,
 Rhinitis,
 Listlessness,
 Anorexia,
 Vomiting,
 Diarrhea

17. Otoscopy (acute otitis media)

18. Tympanometry: A flattened tracing (type B tracing)
indicating middle ear effusion

19. Chronic supportive otitis media
Chronic suppurative otitis media presents with persistent or recurrent
otorrhea through a perforated TM.

20. Treatment of AOM
 Treatment goals in AOM include symptom resolution and
reduction of recurrence.
 Most children with AOM have spontaneous resolution within
seven to 14 days
 Nasal Decongestant
 Antihistamine
 Antibiotics

21. Treatment AOM (Symptomatic)
 Pain management is important in the first two days after
diagnosis.
 Acetaminophen (15 mg/kg every four to six hrs) and ibuprofen
(10 mg/kg every six hrs)
.

22. Treatment AOM (antibiotics)
 Antibiotics are recommended for all children younger than six
months, for those six months to two years of age when the
diagnosis is certain.
 All children older than two years with severe infection (defined as
moderate to severe otalgia or temperature greater than 39° C.

23. Treatment AOM (antibiotics)
 High-dosage amoxicillin (80 to 90 mg/kg/day BD for 10 days) is
recommended as first-line antibiotic therapy in children with AOM.
 In children older than six years with mild to moderate disease, a
five- to seven day course is adequate.
 First-line treatment with amoxicillin is not recommended in
children with penicillin allergy.

24. Treatment AOM (antibiotics)
 Cephalosporins may be used in children allergic to penicillin if there is no
history of urticaria or anaphylaxis to penicillin.
 A single dose of parenteral ceftriaxone (50 mg per kg) may be useful in
children with vomiting or in whom compliance is a concern.
 If there is no clinical improvement within 48 to 72 hours, initiate
antibiotic therapy in those on symptomatic treatment alone. Patients
who are already taking antibiotics should be changed to second-line
therapy.

25. Treatment of persistent AOM
 Second-line therapy include cephalosporins (Cefdinir), and macrolides.
 Parenteral ceftriaxone administered daily over three days is useful in
children with emesis or resistance to amoxicillin/ clavulanate.
 For children who do not respond to second-line antibiotics, clindamycin and
tympanocentesis are appropriate options.
 CT is useful if bony extension is suspected. MRI is superior to CT in
evaluating potential intracranial complications.

26. Treatment of recurrent AOM
 Most children with recurrent AOM improve with watchful waiting.
 Although antibiotic prophylaxis may reduce recurrence, there are no
widely accepted recommendations for antibiotic choice or
prophylaxis duration.

27. Treatment of OM with effusion
 Persistent middle ear effusion after resolution of AOM requires only monitoring
and reassurance.
 Children older than two years who have otitis media with effusion must be seen
at 3-6 month intervals until effusion resolves.
 Children with hearing loss of 40 dB or more should be referred for surgery.
 Tympanostomy with ventilation tube insertion is the preferred initial procedure.
 Adenoidectomy may be considered in children who have recurrent otitis media
with effusion after tympanostomy if chronic adenoiditis is present or if adenoidal
hypertrophy causes nasal obstruction.

28. Treatment of chronic suppurative OM
 Topical antibiotics (e.g., quinolones, aminoglycosides, polymyxins) are more effective
than systemic antibiotics in clearing the infection in patients with chronic suppurative
otitis media.
 Oral or parenteral antibiotics are useful in patients with systemic sepsis or inadequate
response to topical antibiotics. They should be selected on the basis of culture and
sensitivity results.
 Tympanoplasty is an option in patients with chronic perforation and hearing loss.
 Mastoidectomy is often recommended for patients with chronic mastoiditis.

29. Recommended Therapy
(American Family Physician)
Antimicrobials Dosage Comments
Amoxicillin 80 to 90 mg per kg per day, given orally in
two divided doses
First-line drug
Amoxicillin/
clavulanate
90 mg of amoxicillin per kg per day; 6.4 mg
of clavulanate per kg per day, given orally
in two divided doses
Second-line drug
Cefdinir 14 mg per kg per day, given orally in one or
two doses
As 1st line (in penicillin
allergy)
Cefpodoxime 30 mg per kg once daily, given orally
Ceftriaxone 50 mg per kg once daily, given
intramuscularly or intravenously

30. Topical agents Dosage Comments
Ciprofloxacin/hydrocortisone 3 drops twice daily
Hydrocortisone/neomycin/
polymyxin B
4 drops three to four times
daily
Ofloxacin 5 drops twice daily (10
drops in patients older than
12 years)
Recommended Therapy
(American Family Physician)

31. Recommended Therapy
Textbook of Infectious Diseases 2017, 4th ED
)

32. Clinical Practice Guideline: Otitis
Media with Effusion (Update) 2016
This guideline, however, does not apply to patients <2 months
or >12 years old.
Action Statements
(1) should document the presence of middle ear effusion with pneumatic
otoscopy when diagnosing OME in a child;
(2) should perform pneumatic otoscopy to assess for OME in a child with
otalgia, hearing loss, or both;
(3) should obtain tympanometry in children with suspected OME for
whom the diagnosis is uncertain after performing (or attempting)
pneumatic otoscopy;

33. Clinical Practice Guideline: Otitis
Media with Effusion (Update) 2016
This guideline, however, does not apply to patients <2 months
or >12 years old.
Action Statements
(4) should manage the child with OME who is not at risk with watchful waiting
for 3 months from the date of effusion onset
(5) should recommend against using intranasal or systemic steroids for
treating OME;
(6) should recommend against using systemic antibiotics for treating OME;
(7) should recommend against using antihistamines, decongestants, or both
for treating OME.

34. Thank You All