What is Acute Otitis Media?

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·         The term otitis media is an inflammation of the middle ear.
·         There are three subtypes of otitis media:
o   acute otitis media,
o   otitis media with effusion, and
o   Chronic otitis media.
·         The three are differentiated by onset, signs and symptoms of infection, and the presence of fluid in the middle ear.
·         Most of acute otitis media cases are causedby viral pathogens.
·         Some cases are caused by bacteria and common bacterial pathogens include Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis
Pathophysiology
Acute bacterial otitis media usually follows a viral upper respiratory tract infection that causes eustachian tube dysfunction and mucosal swelling in the middle ear.
The middle ear is the space behind the tympanic membrane, or eardrum.
A noninfected ear has a thin, clear tympanic membrane.
In otitis media, this space becomes blocked with fluid, resulting in a bulging and erythematous tympanic membrane.
Bacteria that colonize the nasopharynx enter the middle ear and are not cleared properly by the mucociliary system.

The bacteria proliferate and cause infection.

Children tend to be more susceptible to otitis media than adults because the anatomy of their eustachian tube is shorter and more horizontal, facilitating bacterial entry into the middle ear

Clinical Presentation and Diagnosis of Acute Otitis Media

General
Acute onset of signs and symptoms of middle ear infection following cold symptoms of runny nose, nasal congestion, or cough
Signs and Symptoms
Ear pain that can be severe (>75% of patients)
Children may be irritable, tug on the involved ear, and have difficulty sleeping
Fever is present in less than 25% of patients and, when present, occurs more often in younger children
Examination shows a discolored (gray), thickened, bulging eardrum
Pneumatic otoscopy or tympanometry demonstrates an immobile eardrum
Draining middle ear fluid occurs in less than 3% of patients and usually has a bacterial etiology
Laboratory Tests
Gram stain, culture, and sensitivities of draining fluid or aspirated fluid if tympanocentesis is performed

General Approach to Treatment
·         The first step in the treatment of otitis media is to differentiate acute otitis media from otitis media with effusion or chronic otitis media, as the latter two types do not benefit substantially from antibiotic therapy.
·         The second step is to address pain with oral analgesics.
·         Acetaminophen or a nonsteroidal antiinflammatory drug (NSAID), such as ibuprofen,
·         should be offered early to relieve pain in acute otitis media
·         In addition, eardrops with a local anesthetic, such as ametocaine, benzocaine, or lidocaine, provide pain relief when administered with oral pain medication to children ages 3 to 18 years
·         The third step is to consider if a brief observation period is warranted or if the disease severity or patient characteristics require immediate antibiotic therapy


Monitoring of the therapy
·         Pain and fever tend to resolve after 2 or 3 days, with most children becoming asymptomatic at 7 days.
·         Treatment failure is a lack of clinical improvement in the signs and symptoms of infection,
·         Including pain, fever, and erythema/bulging of the tympanic membrane, after 3 days.
·         If antibiotics were withheld initially, they should be instituted now.
·         If the patient initially received an antibiotic, then the antibiotic should be changed.

Macro Photo of Stethoscope and Pens

 References

Wells BG, DiPiro J, Schwinghammer T (2013), Pharmacotherapy Handbook (6th Ed). New York, NY: McGraw-Hill.
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey ML, (2008): Pharmacotherapy: A Pathophysiologic Approach (7th ed): New York, NY: McGraw-Hill.
Katz M D., Matthias KR., Chisholm-Burns M A., Pharmacotherapy(2011) Principles & Practice Study Guide: A Case-Based Care Plan Approach: New York, NY: McGraw-Hill.
Schwinghammer TL, Koehler JM (2009) Pharmacotherapy Casebook: A Patient-Focused Approach (7th ed): New York, NY: McGraw-Hill.

 

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