|Year : 2014 | Volume
| Issue : 1 | Page : 1-3
Drug therapy for otitis media
MK Taneja1, Vivek Taneja2
1 Editor-in-Chief IJO, Indian Institute of Ear Diseases, Meerut, Uttar Pradesh, India
2 Department of Otorhinolaryngology, Subharti Medial College, Meerut, Uttar Pradesh, India
|Date of Web Publication||1-Apr-2014|
M K Taneja
Editor-in-Chief IJO, Indian Institute of Ear Diseases, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Taneja M K, Taneja V. Drug therapy for otitis media. Indian J Otol 2014;20:1-3
Otitis media (OM) (Latin for "infection of the middle ear") is inflammation or infection of the middle ear. It occurs in the area between the ear drum (the end of the outer ear) and the inner ear, including a duct known as the Eustachian tube More Details (ET). It is one of the two categories of ear inflammation that can underlie what is commonly called an earache, the other being Otitis externa. Diseases other than ear infections can also cause ear pain, including cancers of any structure that shares nerve supply with the ear and shingles which may be manifested by herpes zoster oticus. OM has many degrees of severity, and various names are used to describe it. The terminology is sometimes confusing because of multiple terms being used to describe the same condition. 
Acute bacterial OM can cause pain that leads to sleepless nights for both children and parents, can cause eardrum perforations, not all of which heal, and can spread to cause mastoiditis and/or meningitis, brain abscess, and even death if a severe infection goes untreated long enough. High fever can occur and can cause febrile seizures. Appropriate antibiotic administration prevents most such complications. OM is very common in childhood, with the average toddler having two to three episodes a year, almost always accompanied by a viral upper respiratory infection, mostly the common cold.
The rhinoviruses (nose viruses) that cause the common cold it promotes the production of inflammatory mediators, reduced ciliary clearance, altered bacterial adherence leading to ET dysfunction  which through the ET goes from the back of the nose to the middle ear, causing swelling and compromise the pressure equalization, which is one of the physiological functions of the tube. The other main function is the lateral drainage of fluids from tissues on either side of the skull. It has to be remembered that the ET dimension also changes along with its anatomical and physiological appearance during the early growth period of the child. In the newborn, the tube is more slanting making it more difficult to drain naturally and simultaneously milk may go into the middle ear on feeding in lying down position, the ET initially is of cartilage, with a lining of lymphatic tissue, which is an extension of the adenoidal tissue from the back of the nose. As the early years pass by the superior (upper) part of the tube ossifies to bone, but the lower remains the same. The angulation of the tubes changes and descends to roughly a 45° angle promoting more downward flow of fluids from the middle ear. It should be noted that individuals with Down's syndrome (DS) anatomically have more severe curves to their tubes, hence why DS children tend to have more grommet operations than other children. In general, the more severe and prolonged the compromise of ET function, the more severe consequences are to the middle ear and ossicles. If a person is born with poor ET function, this greatly increases the likelihood of more frequent and severe episodes of OM. Progressions to chronic OM and cholosteatoma are much more common in this group of people and often have a family history of middle ear disease.
| Acute Otitis Media|| |
Acute otitis media (AOM) is most often purely viral and self-limiting, as is its usually accompanying viral upper respiratory infection (URI) usually caused by respiratory syncytial virus, rhinovirus influenza, parainfluenza and adenovirus.  There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI. If the middle ear, which is normally sterile, becomes contaminated with bacteria, pus and pressure in the middle ear may result, and this is termed as acute bacterial otitis media (OM).
It is necessary to establish whether it is viral or bacterial in nature. Viral AOM usually presents as congestion and middle ear fluid accumulation. Fluid may persist even for months leading to deafness while bacterial infection presents with sign and symptoms of acute inflammation, pain in ear, congestion and bulging of the tympanic membrane with yellow turbid fluid behind it, may be associated with malaise and/or mild pyrexia.  Bacterial infection may lead into perforation of the ear drum, infection of the mastoid space (mastoiditis) and in very rare cases further spread to cause meningitis The principle bacteriological organism in AOM are Haemophilus influenzae (42.8%), Streptococcus pneumonia (35.71%) and Streptococcus pyogenus (7.14%), Moraxella More Details catarrhalis (21.42).
- "1 st phase" - exudative inflammation lasting 1-2 days, fever, rigors, meningism (occasionally in children), severe pain (worse at night), muffled noise in ear (tinnitus), deafness, sensitive mastoid process
- "2 nd phase" - resistance and demarcation lasting 3-8 days. Pus and middle ear exudates, discharges spontaneously through the tympanic membrane, afterwards pain and fever begin to subside. This phase can be shortened with therapy
- "3 rd phase" - healing phase lasting 2-4 weeks. Aural discharge dries up and hearing improves
- 4 th phase of complication - If the virulence of an organism is high, infection may spread to surrounding structures leading to intra temporal or/and intra cranial complications.
| Otitis Media with Effusion|| |
Otitis media with effusion (OME), also called serous or secretory otitis media (SOM), is a collection of fluid within the middle ear space as a result of the negative pressure due to altered Eustachian tube (ET) function. This can occur purely by a viral URI, with no pain or by bacterial infection, or it can also precede and/or follow acute bacterial OM. The diagnosis is confirmed by tympanometry which shows "B" type curve and absent reflex. Myringotomy finally confirms it. Pneumatic otoscopy and acoustic reflexometry are important diagnostic tool. 
Fluid in the middle ear may cause conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle ear fluid can become thick and glue-like (thus the name glue ear), which increases the likelihood of conductive hearing impairment.
Early-onset OME is associated with feeding while lying down and early entry into group child care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in group child care increases the duration of OME in the first 2 years of life. Prior to the invention of antibiotics, severe AOM was mainly remedied surgically by myringotomy. An outpatient procedure, it consists of making a small incision in the tympanic membrane to relieve the pressure built-up by the fluid.
| Chronic Suppurative Otitis Media|| |
Chronic suppurative OM presents as a central, marginal or attic perforation (hole) in the tympanic membrane and active bacterial infection within the middle ear space for more than four 6 weeks with pus that drains to the outside of the ear (otorrhea), The purulence may be minimal enough to only be seen on examination using an otoscope (cholesteatoma). Chronic OM is much more common in persons with poor ET function and in lower socio-economic status. Hearing impairment often accompanies the disease. Etiologically Staphylococcus aureus 30.7%, betahemolytic streptococci 26%, Pseudomonas aeruginosa 16%, Escherichia More Details coli 10.6% and Klebsiella species 7% and has been observed by the author as a causative organism.
| Management and Treatment of Otitis Media|| |
Medical management of OM is actively debated in the medical literature, primarily because of a dramatic increase in AOM prevalence over the past 10 years caused by drug resistant S. pneumonia and beta-lactamase-producing H. influenzae or M. catarrhalis S. pneumonia.
Beta-lactamases are enzymes that hydrolyze amoxicillin and some, but not all, oral cephalosporins, leading to in vitro resistance to these drugs. Currently, 90% of M. catarrhalis isolates and 40-50% of H. influenzae isolates produce beta-lactamases. As a result, empiric antibiotic therapy for this disease has become more complex. Many opinions have been expressed regarding which drugs are best for first- and second-line therapy or whether antibiotics should be prescribed in all patients with AOM. Compliance, duration of therapy, and cost are important issues in our scenario but palatability ultimately determines compliance in children.
| Guidelines for Management of Acute Otitis Media|| |
Keeping in mind the bacteria amoxicillin is the drug of choice which may be prescribed for unilateral AOM with symptoms, moderate to severe otalgia with pyrexia and in bilateral cases even without pyrexia. In recurrent or resistant cases amoxicillin 80-90 mg/kg/day along with 6.4 mg/kg/day potassium clavunate/clavulanic acid may be prescribed but authors choice is cefuroxime axetil 30 mg/day with potassium clavunate 6.4 mg/kg/day, rarely injectables are required in cases of associated diarrhea or severe URI. Supportive therapy viz. nasal decongestants, analgesics tincture benzoin steam inhalations enhances the recovery. Seldom, the pain may be so severe that, narcotic analgesics may be required. 
In recurrent cases feeding in lying down position either of breast/bottle feeding including history of digital sucking should be evaluated. Worm infestation leading to poor immunity and eosinophilia may be a major factor. Anemia and vitamin D deficiency may be a cofactor. ,
Steroids use has been controversial but methyl prednisolone and deflazacort has been used with some success, to be used cautiously weighting its disadvantages especially when vaccine for varicella has not been given which may lead to life-threatening disseminated disease.
| Medical Therapy for Otitis Media with Effusion|| |
Most cases of OME occur after an episode of AOM, and good number of patients develops a SOM middle ear effusion (MEE). The mean duration of the effusion is around 3 weeks, but may persist even longer. Most cases of OME resolve spontaneously.
Most cases of chronic OME are associated with conductive hearing loss, averaging approximately 25 dB. With complication of hearing loss (e.g., language delay, behavioral problems, and poor academic performance) ,,, have led to investigations of multiple medical and surgical treatments for MOE. For medical management: Antimicrobials, antihistamine-decongestants, intranasal and systemic steroids, nonsteroidal anti-inflammatory drugs, mucolytics and aggressive management of allergic symptoms may be required.
Patients in whom OME is unresponsive to medical therapy and with an MEE that persists more than 12 weeks should go for tympanocentesis.
| Surgical Intervention|| |
From the beginning, integrate surgical management of AOM and OME with medical treatment may be a modality for prompt relief and to avoid complications.
Indications for tympanocentesis
- OM in patients who have severe otalgia, who are seriously ill, who appear toxic
- Unsatisfactory response to antimicrobial therapy.
- OM associated with a confirmed or potential suppurative complication.
- OM in a newborn, sick neonate, or patient who is immunologically deficient, any of whom may harbor an unusual organism.
- Myringotomy and tympanostomy tube (TT) placement are the initial surgical techniques in recurrent AOM/OME. Adenoidectomy to be avoided unless the patient has a nasal obstruction). Some experts advocate simultaneous adenoidectomy in patients older than 3 years because this has been shown to improve ET function
- Tonsillectomy: Although, it does not benefit in ET function, tonsillectomy may be performed concurrently if indications are present (e.g., frequent recurrent tonsillitis, and pharyngeal obstruction)
- In patients with cleft palate, Down's syndrome (DS), and other craniofacial abnormalities Myringotomy and TT placement are warranted in most children. In cleft palate patients because of inherent ETD and increased risk of OM  the TT may be placed with initial lip repair or may be prior to palate repair
- Children with DS often exhibit ETD, conductive and sensorineural hearing loss, external auditory canal (EAC) stenosis, and subtle immunologic deficiencies. These conditions create a high risk of personality and child development due to profound language and learning difficulties. Hence myringotomy/TT may be required at an early stage. To prevent recurrent otitis externa, wax impaction or cholesteatoma of EAC, canaloplasty should be performed. ,
- The incidence of OM and deafness could be prevented by maternal education specifically of contributing factors and early management modalities of ear involvement. Public health efforts should be made to promote breast feeding. Proper feeding position, avoiding pacifiers and digital sucking, dairy products should be discouraged and rather abandoned as they led to biochemical changes in the pathogenesis of recurrent OM. Smoking should be discouraged and no smoking around the children. Harsh climate, crowded housing, poor sanitary conditions, and lack of personal hygiene should be adequately dealt with.  The exposure to cold to avoided in winter months which may lead to silent OME was observed in a normal school going children in school health survey without any sign or symptom. 
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