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OT38 Otolaryngology
Pediatric Otolaryngology Toronto Notes 2019 Pediatric Otolaryngology
Acute Otitis Media
Definition
• allof:presenceofmiddleeareffusion(MEE);presenceofmiddleearinflammation(MEI);acuteonset of symptoms of MEE and MEI
Epidemiology
• mostfrequentdiagnosisinsickchildrenvisitingclinicians’officesandmostcommonreasonfor antibiotic administration
• peakincidencebetween6-15mo:~85%ofchildrenhave>1episodeby3yrold
• seasonalvariability:peaksinwinter
Etiology
• primarydefectcausingAOM:Eustachiantubedysfunction/obstruction→stasis/colonizationby pathogens
• bacterial:S.pneumoniae,non-typableH.influenzae,M.catarrhalis,GroupAStreptococcus,S.aureus
• viral: RSV, influenza, parainfluenza, adenovirus
• commonlyduetobacterial/viralco-infection
Predisposing Factors
• Eustachiantubedysfunction/obstruction ■ swelling of tubal mucosa
◆ upper respiratory tract infection (URTI) ◆ allergic rhinitis
◆ chronic rhinosinusitis
■ obstruction/infiltration of Eustachian tube ostium
◆ tumour: nasopharyngeal carcinoma (adults)
◆ adenoid hypertrophy (by maintaining a source of infection rather than obstruction) ◆ barotrauma (sudden changes in air pressure)
■ inadequate tensor palati function: cleft palate (even after repair) ■ abnormal Eustachian tube
◆ Down syndrome (horizontal position of Eustachian tube), Crouzon syndrome, cleft palate, and Apert syndrome
• disruptionofactionof:
■ cilia of Eustachian tube: Kartagener’s syndrome
■ mucus secreting cells
■ capillary network that provides humoral factors, PMNs, phagocytic cells
• immunosuppression/deficiencyduetochemotherapy,steroids,DM,hypogammaglobulinemia,cystic fibrosis
Risk Factors
• non-modifiable:youngage,familyhistoryofOM,prematurity,orofacialabnormalities, immunodeficiencies, Down syndrome, race, and ethnicity
• modifiable:lackofbreastfeeding,daycareattendance,householdcrowding,exposuretocigarettesmoke or air pollution, pacifier use
Pathogenesis
• obstructionofEustachiantube→airabsorbedinmiddleear→negativepressure(anirritanttomiddle ear mucosa) → edema of mucosa with exudate/effusion → infection of exudate from nasopharyngeal secretions
Clinical Features
• triadofotalgia,fever(especiallyinyoungerchildren),andconductivehearingloss • rarelytinnitus,vertigo,and/orfacialnerveparalysis
• otorrheaiftympanicmembraneperforated
• infants/toddlers
■ ear-tugging (this alone is not a good indicator of pathology) ■ hearing loss, balance disturbances (rare)
■ irritable, poor sleeping
■ vomiting and diarrhea
■ anorexia
• otoscopyofTM
■ hyperemia
■ bulging, pus may be seen behind TM
■ loss of landmarks: handle and long process of malleus not visible
Clinical Assessment of AOM in Pediatrics
JAMA 2010;304:2161-69
In assessment of AOM in pediatrics, ear pain is the most useful symptom with a likelihood ratio (LR) between 3.0-7.3. Useful otoscopic signs include erythematous (LR 8.4, 95% CI 7-11), cloudy (LR 34, 95% CI 28-42), bulging (LR 51, 95% CI 36-73), and immobile tympanic membrane (LR 31, 95% CI 26-37) on pneumatic otoscopy.