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New Treatments for Ear Infection

Otitis media is very common. Risk factors that you may see; viral upper respiratory infection is often an antecedent for otitis media because of eustachian tube dysfunction. Feeding when supine, so if you bottle prop a baby, can lead to otitis media. Parental smoking can contribute and then craniofacial abnormalities, particularly patients with cleft palate or other palatal defects, can have problems recurrently with otitis media. Etiologic agents: it appears that viruses may cause up to one-third.

The problem is, we canít tell which third of the cases that they are and, at least here in the United States, what we continue to do is treat all children who have signs and symptoms that are compatible with otitis media, we continue to treat with antibiotics. Bacteria: the most common ones are Pneumococcus, H. flu, and Moraxella.

Things like beta hemolytic strep, Staph. aureus, Pseudomonas, and even gram negatives. Mycoplasma and Chlamydia are also possible and one of the things that used to be felt that if you saw bullous myringitis.

The symptoms are fairly obvious. Fever, ear pain, loss of hearing, fussiness, irritability, may also see some GI symptoms not uncommonly; some mild vomiting, mild diarrhea. Otitis media is not likely to cause severe vomiting, severe diarrhea, but some loose stools and some spitting up may be seen. Physical exam changes depending on Ö what you see here is this band of erythema going across the malleus. This is a left side tympanic membrane. Very difficult to see here whether there is fluid here or not, but that is the initial stage which is essentially tubal tympanitis and then hyperemia where you get injection of the blood.

On to diagnosis. Generally rely on symptoms a fair amount and then otoscopy with insufflation. And that insufflation part is very strongly recommended, though I have difficulty with it. Because the kids who you really want to insufflate and see if you can get that eardrum moving are the kids who are going completely ballistic and trying to slug you in the face, and trying to get that seal perfect and trying to see if that eardrum can move well, it can be challenging. Tympanometry may be an alternative. 

Differential diagnosis: there are a number of different things that can cause painful ears, or ear pain. Things like otitis externa. You kind of get a sense of that before you stick the speculum in the kidís ear. So pressing on the tragus or pulling on the pinna, if they have significant pain, suggests otitis externa and you should be very careful about how you examine that child if you want to keep that child relatively happy. Otalgia, so just ear pain, may be seen with upper respiratory infection.

So on to treatment. Just a few things to say about this. Over one month of age, fairly obviously you are used to choosing antibiotics and I think if you get asked on the Boards, choose the cheaper, less aggressive, less broad spectrum initially and then move to bigger gun antibiotics if you get recurrent otitis media. Less than one month of age, it gets to be a little bit tricky. I think most people, certainly below two weeks of age - if you are fairly certain the child has an otitis media- I think most people will admit for IV antibiotics, certainly if they are febrile and even below a month of age I think you need to seriously consider.

This is a case where a child has had otitis media, which we have the other ear in this picture, because this child does not just have goofy looking ears. This ear is downwardly displaced and outwardly displaced. And if you could palpate behind that ear there would be swelling, erythema and tenderness over the mastoid. So this is a nice example of mastoiditis.

Cholesteatoma: pathogenesis for this problem is essentially you have epidermis from the ear canal, grows through a perforation in the tympanic membrane into the middle ear and then that epidermis in the middle ear will desquamate and cause an accumulation of debris, you get persistent infection, excessive tissue growth in the middle ear and essentially destruction of the middle ear structure. Symptoms that you are going to see: otorrhea, persistent otorrhea is the most common sign.

The most common complication of otitis media, though, is otitis media with effusion. Previously called serous otitis media. I have a couple of slides. One of the ways to look for fluid isnít actually to look for fluid levels but to look for air bubbles. Because if you can see air bubbles it means fluid is present. And this is a good example of air bubbles that you see.

Sinusitis. Development of the sinuses: I think the two to remember is that ethmoids and maxillary are present at birth and frontals donít develop until more about six or seven years of age. Etiologic agents are similar to otitis media. Risk factors, again like otitis media, viral upper respiratory infection can be complicated by sinusitis. Allergic kids are more likely to have sinusitis. Children with cystic fibrosis may have recurrent sinusitis, and then Kartagenerís is another one of those syndromes thatís worth remembering, the immotile cilia syndrome where they will have immotile cilia and then recurrent sinusitis and then also males will be infertile.

Clinical presentation is interesting. Older kids are similar to adults, where you think of the adults with headache, pressure, that kind of thing. But younger kids, probably less than 3,4,5 years of age, generally donít have localized symptoms. This table, which I think illustrates pretty nicely, that if you look down at the bottom, for example, headache first: only about 30%.