Acute otitis media: Difference between revisions
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===Analgesia===
===Analgesia===
*[[Acetaminophen]]/[[ibuprofen]] and topical benzocaine (unless perforated TM)
*[[Acetaminophen]]/[[ibuprofen]] and topical benzocaine (unless perforated TM)
===[[Antibiotics]] (See also AAP Guidelines below)===
===[[Antibiotics]] ===
'''Indications:'''
{{Table
|type=class="wikitable "
|title=2013 AAP AOM Guidelines<ref>AAP Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf </ref>
|hdrs=Age!!Otorrhea!!Severe Symptoms (unilateral or bilateral)!!Bilateral w/o Otorrhea!!Unilateral w/o Otorrhea
|row1=6mo-2y{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics
|row2=≥2y{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics or observation period{{!!}}Antibiotics or observation period
}}
'''Also Consider In:'''
*Age <6mo
*Age <6mo
*Ill-appearing
*Ill-appearing
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*Immunocompromised
*Immunocompromised
*Craniofacial abnormalities
*Craniofacial abnormalities
'''Wait-and-see antibiotic prescription:'''
 
*If symptoms worsen or persist x48-72 then family fills the Rx
====Wait-and-see antibiotic prescription (WASP)====
*Rather that routine perscription is an option to avoid over use if the patient does not meet any of the prescription criteria''<ref>Spiro DM. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41.</ref
*If symptoms worsen or persist for 48-72 then caretaker fill the prescription
*Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group


===Antibiotics===
===Antibiotics===
{{Otitis Media Antibiotics}}
{{Otitis Media Antibiotics}}
===AAP Guidelines<ref>AAP Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf </ref>===
{{Table
|type=class="wikitable "
|title=2013 AAP AOM Guidelines
|hdrs=Age!!Otorrhea!!Severe Symptoms (unilateral or bilateral)!!Bilateral w/o Otorrhea!!Unilateral w/o Otorrhea
|row1=6mo-2y{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics
|row2=≥2y{{!!}}Antibiotics{{!!}}Antibiotics{{!!}}Antibiotics or observation period{{!!}}Antibiotics or observation period
}}


==Complications==
==Complications==

Revision as of 13:16, 13 April 2015

Background

  • Peak incidence: 6-18 months of age
  • Etiology
    • Viral (70% of cases)
    • Bacterial
      • S. pneumo (50%)
      • Nontypable H. flu (30%)
      • Moraxella (30%)

Diagnosis

  1. Acute onset (<48hr) AND
  2. Middle ear effusion AND
  3. Signs of middle ear inflammation
  4. Notes
    1. Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level
    2. Middle Ear inflammation: erythema of TM or otalgia

Differential Diagnosis

Common

  • Acute otitis media
  • Chronic otitis media
  • Serous otitis media
  • Foreign body in external ear canal
  • Otitis externa

Less common

  • Accidental trauma
  • Oral cavity disease (referred pain)
  • Cholesteatoma
  • PTA

Rare

Ear Diagnoses

External

Internal

Inner/vestibular

Management

Analgesia

Antibiotics

class="wikitable" Also Consider In:

  • Age <6mo
  • Ill-appearing
  • Recurrent acute otitis media (w/in 2-4wk)
  • Concurrent antibiotic treatment
  • Other bacterial infections
  • Immunocompromised
  • Craniofacial abnormalities

Wait-and-see antibiotic prescription (WASP)

  • Rather that routine perscription is an option to avoid over use if the patient does not meet any of the prescription criteria<ref>Spiro DM. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41.</ref
  • If symptoms worsen or persist for 48-72 then caretaker fill the prescription
  • Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group

Antibiotics

Initial Treatment

High Dose Amoxicillin

  • <2 months
    • 30mg/kg/day PO divided q12h x 10 days
    • First Dose: 15mg/kg PO x 1
  • 2 months - 5 years
    • 80-90mg/kg/day PO divided q12h x 10 days
    • First Dose: 40-45mg/kg PO x 1
    • Max: 1000mg/dose
  • 6-12 years
    • 80-90mg/kg/day PO divided q12h x 5-10 days
    • First Dose: 40-45mg/kg/day PO x 1
    • Max: 1000mg/dose

Treatment during prior Month

  1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea
  2. Cefdinir 14mg/kg/day BID x7-10 days
  3. Cefpodoxime 10mg/kg PO daily x7-10 days
  4. Cefuroxime 15mg/kg PO BID x7-10 days
  5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

  • Suggestive of non-typeable H.flu
  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
  2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
    • Use if cannot tolerate PO

Penicillin Allergy

  1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
  2. Clarithromycin 7.5mg/kg PO BID x 10 days
  3. Clindamycin 10mg/kg PO three times daily

Complications

  1. Mastoiditis
  2. Meningitis
  3. Brain Abscess
  4. Lateral Sinus Thrombosis

See Also

Otitis Externa

Sources

  • Tintinalli
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