Tag Archives: otitis media with effusion

Winter Worries of Mother-Crying Child with ?Ear Infection (When To Use Antibiotic?)

With onset of winter season ENT clinic are flooded with children with ear pain, because upper respiratory infections and ear infections in children are most common with colder temperature during the winter months. An anxious Mother of 3 year-old boy with fever says he has cold and his ear hurts, she than inquires with concern does he need an antibiotic?

To decide we need to make a diagnosis first…


Otitis media is the second most common reason after the common cold for visits to doctor and the most frequent reason for prescribing antibiotics to children. About 90% of children have OME (Otitis Media with effusion) at some time before school age and 75% of children have at least one episode of AOM (Acute Otitis Media) by the age of 2 years which usually resolves spontaneously
Appropriate treatment of children with “ear infection” requires distinguishing AOM from OME by careful history and pneumatic otoscopic examination (single most important tool).
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To understand the definitions- What is AOM and OME?

Acute otitis media AOM – an acute bacterial infection of the middle ear of less than 6 weeks duration

There is usually pain in the ear and fever. If ear drum ruptures there may be pus discharge (Otorrohea) from the ear with rapid relief of pain. Pus may be mixed with blood.

Chronic suppurative otitis media (CSOM) – If ear drum infection persists for more than 3 months and is associated with a chronic perforation of the tympanic membrane.

Otitis media with effusion (OME) – Fluid in the middle ear without signs or symptoms of inflammation

It can occur just prior to AOM or persist after AOM for a few days or up to many weeks.

How we decide about giving antibiotic?

Age and severity of symptoms are deciding factors but most important is correct diagnosis.

  • If it is OME antibiotics are unnecessary.
  • Uncomplicated AOM in an otherwise healthy child above 2 years of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic.
  • If child is less than 6 months of age antibiotics are to be given even if diagnosis is not certain. (Contrary to parent’s belief that small kid should not be given antibiotics).
  • Most controversies exists in treating child above 6 months but less than 2 years of age where current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians) advises to avoid antibiotic for uncertain diagnosis or if illness is mild.

So How Do We Diagnose Ear Infection?

Distinguishing OME (Otitis Media with Effusion) and AOM (Acute Otitis Media)

OME is usually caused when the eustachian tube is blocked or mucus production is more and fluid becomes trapped in the middle ear. This often occurs after a common cold or viral infection, but it can also occur after an episode of AOM.

It is common in a child because eustachian tubes are shorter and more horizontal as compare to adults and muscles to close the tube are not properly developed in children.

Symptoms – The child with OME does not have ear pain or draining ear. He may have slight hearing impairment. There may be history of frequent URTI & mouth breathing.

Examination of Ear by Pneumatic otoscope– Single most important diagnostic tool –

  • Tympanic membrane may be dull looking, Pulled in (retracted) and immobile.
  • Ear drum is not red or bulging as it is in AOM.
  • Air Fluid level seen as bubbles

Tympanometry can be advised to confirm the diagnosis of OME

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AOM occurs when fluid in the middle ear becomes infected, usually following a common cold or viral upper respiratory infection.

Symptoms – Child usually have fever and sudden ear pain after a common cold or stuffy nose. Infant may be irritable with pulling of ear. If tympanic membrane gets ruptured liquid may be coming out from ear (Otorrhoea/ear discharge).

Examination of ear–  symptoms alone are not enough to diagnose AOM and examination of ear drum with otoscope to see the signs of inflammation (redness or erythema) and pneumatic otoscopy to conform the fluid in the middle ear is necessary. (Opacification & Bulging of ear drum with reduced mobility)

If tympanic membrane is ruptured Ear discharge may be present, and hole (Perforation) in the ear drum may be seen

Audiogram may show mild to moderate conductive hearing impairment.

Tympanogram may show type “B” curve

How to treat AOM and OME?

Management of children with OME

  • Aim is resolution of fluid, restoration of ear drum mobility and restoration of hearing
  • As OME usually resolves without treatment for 3 months it is just wait and watch.
  • Antihistamines and decongestants are not effective and antibiotics are not recommended for routine management.
  • Steroids with beta lactame antibiotics are proven to be beneficial in few studies and and no benefit in others.
  • Children with persistent effusion reexamined at 3-6 months interval till it resolve.
  • Hearing testing is done if OME persists for more than 3 months or if Child is at risk of speech or language delay.
  • If the effusion persists for more than 3 months and/or hearing loss exceeds 20 dB surgery Tympanostomy tube (Grommet) insertion is done.
  • Adenoidectomy is done if indication for surgery is present.

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Management of Children with acute otitis media

Aim is to relieve pain and fever, to treat infection and restore hearing along with prevention of recurrence.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline for OME emphasizes the management of pain as a major management goal.

  • Analgesics are usually prescribed to provide relief from pain; acetaminophen and ibuprofen are commonly given medicines.
  • Uncomplicated AOM in an otherwise healthy child above 2 years of age or very mild infection in children below 2 yrs but more than 6 months of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic or amoxicillin can be used.
  • If there is no response within 2-3 days antibiotic is to be started or antibiotic is changed.
  • Ear drops (Ototopical formulations) antibiotic with or without steroid are prescribed if ear drum is ruptured as steroid reduces inflammation and antibiotic improves infection eradication.
  • Tympanic membrane perforation in children usually heals spontaneously in 1-2 months. During this time child should come for periodic follow to visits to assess the healing process, water entry in the ears should be avoided and all possible preventive measure to reduce chances of catching common cold are to be taken.

Role of Surgery in brief

Surgical management of otitis media is indicated for recurrent AOM, AOM with complications, chronic suppurative otitis media (CSOM) and otitis media with effusion where chances of hearing and speech problem are predicted

Most common surgical procedure is placement of tympanostomy tubes (Grommets).

Tympanostomy tubes allow drainage of fluid in the middle ear and ventilaton of middle earspace. Grommets usually fall out of the tympanic membrane within 6-14 months.

Coming Back to original question

It is important to distinguish between the presence of middle ear fluid (OME) and the presence of middle ear fluid with infection (AOM) by pneumatic otoscopy. If wax is obscuring the view of ear drum it has to be removed.

OME does not benefit from antibiotic therapy; child should be carefully monitored for recurrent AOM and hearing loss, which, if chronic, can impair speech and language development. AOM, if it does not resolve spontaneously, can result in serious complications, and benefits from antibiotic therapy.

So with utmost patience and gentleness we examine the crying 3 year old of worried parents and find that ear drum is red and bulging, our diagnosis is AOM.

So again the question of mother – Is Antibiotic Required?

We reassess the situation, explain the risk and benefit of antibiotic and we feel parents are anxious but motivated to come for follow up visit after 2 days, we give symptomatic treatment and avoid antibiotic.

Child of more than 2 years age observation without use of antibiotics is an option for treatment of acute otitis media but children must be followed carefully and antibiotics should be prescribed if spontaneous resolution does not occur.

Child if less than 2 years but more than 6 months of age and diagnosis of AOM is certain I usually prefer to give appropriate antibiotics in proper dose after explaining to parents as usually child has already waited or took treatment with family doctor or pediatrician with pain medicines and because there is chance of ear drum rupture unless parents are concerned about use of antibiotics or it is first day of onset of symptom which are mild. We keep a strict watch and wait in these children with assurance of prompt visit in case of worsening symptoms, fever, or drainage from the ear.


Special consideration

Antibiotics should be prescribed if child is —

  • Less than 6 month of age
  • Cleft palate
  • Downs syndrome
  • Immunodeficiency
  • Cochlear implant


Summary

Most of the parents usually scared of the word ‘antibiotic’. Antibiotic does have side effects like loose stools or stomach upset but most feared side effect is development of resistance means antibiotic becomes ineffective to kill the bacteria.  Thus when there is nothing to fix it should not be fixed but parents should be given time in busy opd hours and explained to understand what doesn’t need to be done and why?

During the winter months, viral upper respiratory infection is the most common cause of Eustachian tube dysfunction and ear infection in children. Adenoids may also cause obstruction.

Though this winter is prolonged and there are more number of children with ear infection but in general awareness about preventive measures and vaccination against influenza and pneumococcus have decreased the incidence of winter AOM.

According to current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians for use of antibiotics –

“Otitis Media with effusion does not require antibiotics and Acute Otitis Media does not always require antibiotics“.

How ‘otitis media with effusion’ is diagnosed?

Ear has three parts outer, middle and inner ear.

Middle ear is air filled cavity, separated from external ear by ear drum and is connected to space behind the back of nose (nasopharynx) by Eustachian tube.

Function of Eustachian tube is to drain fluid from middle ear which then can be swallowed and to provide ventilation of middle ear space.

If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear, condition known as otitis media with effusion.

Diagnsis is important specially to differentiate it (fig on right hand side) from incipient acute otits  media (fig on left side)-

glueear

incipient acute-otitis-media

1. Clinical History is important in diagnosis.

Otitis media with effusion may have no symptoms at all.

Most frequent presentation is covert and overt hearing loss which is mostly fluctuating with season and may be affected with changing position. Child may describe it as plugged ear or stuffy or wooly feeling in the ear.

Only sign by which parents come to know that the condition exists may be loud talking, not responding to verbal commands and turning up the volume of the television or music system,  sometimes it is detected on routine audiometry (test of hearing).

Hearing loss can slow up language and academic skill development; children may develop behavioral and social problems like he may appear to be distracted, or inattentive.

Infant and young children may present as delayed or defective speech development.

There may be mild earache (pain in the ear) especially with upper respiratory tract infection.

2. Otoscopy and pneumatic otoscopy:

Otoscope is an instrument to see magnified view of ear drum.

Doctor first removes any ear wax in order to visualize ear drum clearly.

Ear drum may be dull and opaque instead of usual transparent or pearly white colour. It may be pulled inside or may be bulged out. Sometimes characteristic fluid level or air-bubble may be seen.

Pneumatic otoscope has a rubber bulb attachment, air is pushed inside on pressing the bulb and reduced mobility of ear drum can be judged.

3. Use of operating microscope:

It gives more magnification and better visualization of minute details of ear drum.

4. Hearing tests:

Tuning fork tests and pure-tone audiometry may be helpful in children above 4 years and may show some conductive type of deafness.

Tympanometry is rapid and reliable even in infants.

5. Definitive and direct evidence of diseases is only when presence of fluid in the middle ear is confirmed by myringotomy.

<a href=”http://technorati.com/tag/otitis-media-with-effusion&#8221; rel=”tag”><img style=”border:0;vertical-align:middle;margin-left:.4em” src=”http://static.technorati.com/static/img/pub/icon-utag-16×13.png?tag=otitis-media-with-effusion&#8221; alt=” ” />otitis media with effusion</a>

Risk factors for development of fuid in middle ear

Certain factors predispose a child for development of fluid in the middle ear like:-

  • Allergy
  • Enrolment in day care
  • Exposure to second hand smoke
  • Bottle feeding
  • Use of pacifier
  • Lower socioeconomic group because of overcrowding and poor hygiene
  • Certain syndromes like downs, hunter and hurler’s syndrome, some kids with skull base or nasopharyngeal abnormalities like cleft palate and immunosuppressive disorders, such as HIV are more likely to develop OME.
  • Parents who smoke or pregnant woman who drink alcohol put their babies at risk.

Management of fluid in middle ear or ‘glue ear’

fluid in middle earPopularly known as ‘glue ear’,  Otitis media with Effusion or fluid in the middle ear is the commonest cause of hearing difficulty and most frequent reason for visits to Otorhinolaryngology (ENT) clinic in children. More common during the age when child is developing speech and language skills by hearing to his surroundings,  because it is not painful, it may present as speech and language delay or defects.

Underlying mechanism in collection of fluid in the middle ear may be either Blockage of Eustachian tube or Increased production of mucus in middle ear:

Children have shorter and more horizontal tubes and immune system are not well developed, that is the reason which explains more common ear infection in a child. If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear.

This could be basis of effusion in Baro-trauma, adenoids, viral infections (as evidenced by association of OME with influenza), second hand smoke, allergy, immunological factors, birth defects(such as cleft palate), cystic fibrosis, or cilia abnormality (as in Kartageners syndrome).

In some cases Eustachian tube is patent; here other factors like increased mucus production in the middle ear as is seen in upper respiratory infection or allergy, may play a role.

Benign and malignant tumor should always be ruled out in adult having otitis media with effusion in one ear.

Treatment: –

Medical treatment:

There is high rate of spontaneous resolution; most episodes are short lived and 75% of cases resolve in 3 months so normally a ‘wait and watch’ policy is advised.

According to ‘American Academy of Otorhinology-Head and Neck Surgery’ (AAO-HNS): –

  • Child is kept under observation with regular follow ups for first three months.
  • If condition lasts longer than 3 months, a hearing test is conducted and child re-evaluated. If hearing is within normal range (below 20 decibels) child is prescribed with antibiotics and kept on periodic check-ups for 4-6 months.

Management is aimed to encourage natural process; useful measures are control of environment factors, management of allergy, nasal decongestant drops, and  Valsalva’s maneuver (Forced expiration with both the mouth and nose closed à Increased air pressure in nasopharynx à opening of the Eustachian tube).

Surgical treatment:

Child is considered for surgical treatment if OME lasts for more than 4-6 months, or there is hearing loss more than 20 decibels or child is at risk of developmental delays because of recurrent problem.

Mainstay of treatment is myringotomy (a small incision is made in ear drum and fluid is suctioned out) and placement of ventilation tubes (Grommets).

Procedure takes less than 30 minutes, ear tube falls out after few months and incision heals spontaneously. Ear tube relieves pain and restores hearing.

There are chances of relapses in 20%-50% children and tube placement may have to be repeated.

Sometimes removal of adenoids is to be done along with tubal placement.

Management of risk factors: –

  • Well balanced healthy diet with fresh fruits and vegetables rich in antioxidants and lacto bacillus.
  • Avoidance of bottle feeding and pacifiers
  • Restricting exposure to day care
  • Wash hands and toys frequently
  • Avoidance of passive smoking
  • Management of associated nasal conditions
  • Avoidance and management of allergy
  • Pneumococcal and flu vaccine

Studies have evaluated that antibiotics and other medicines have short term effect and no long term cure. Putting ventilation tubes is effective but some newer studies have questioned the role in view of spontaneous resolution and frequent need for repeat tubal placement.

Several studies are being conducted but there are still so many unanswered questions and still need for proper research.