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Slide 1 - Clinical Guidelines: Acute Otitis Media Baylor College of Medicine Anoop Agrawal, M.D.
Slide 2 - Objectives Review criteria for diagnosis of AOM Understand pitfalls in diagnosis Assessment and management of pain Understand available treatment options The Future
Slide 3 - Overview AOM accounts for 25 million office visits - of which 804 out of 1000 result in an antibiotic being prescribed Guidelines created by AAP and AAFP in conjunction with specialists (ENT) Guidelines apply only to healthy kids Based on evidence reviewed through September 2003
Slide 4 - Case One - Andy Biotic A 3 year old male presents with fever to 101 F since yesterday. His mother thinks he has an ear infection because ‘he keeps pulling on his ears.’ What are the criteria needed to make the diagnosis of AOM? Three main criteria: acute onset middle ear effusion middle ear inflammation
Slide 5 - Diagnosis of AOM Otitis media with effusion (OME) vs. AOM: which condition is more common? OME is far more common MEE accompanied by constitutional signs of illness (fever, irritability, vomiting) is NOT sufficient for diagnosis of AOM By adhering to strict criteria of AOM and improving otoscopic exam skills, overuse of antibiotics can be avoided
Slide 6 - Middle Ear Effusion Defined as: bubbles or an air fluid level OR at least TWO of the following: abnormal color (white, yellow, amber, blue) opacification of part or all of TM decreased or absent mobility of TM
Slide 7 - Middle Ear Inflammation Requires at least one of the following: bulging TM or distinct fullness of TM (i.e. without bulging) - this alone is the best positive predictor of AOM otalgia (a non-otoscopic finding) erythema/hyperemia of TM - however, if no bulging or TM immobility associated, then PPV of only 15%
Slide 8 - ppt slide no 8 content not found
Slide 9 - What is not considered AOM? Middle ear effusion alone The best negative predictor of AOM is a retracted TM - even if concurrent opacity, erythema or reduced mobility is present. The least predictive factor of AOM is TM erythema alone. To be of significance it must be differentiated from hypervascularity seen on the rim of the TM annulus
Slide 10 - Case A.B. Cont. On your exam, the patient appears playful and in no distress. You visualize the TM as seen on the right. What is your diagnosis?
Slide 11 - Case A.B. Cont. Diagnosis: Acute Otitis Media What pathogens can cause this condition? #1: Strep pneumoniae #2: H. influenzae #3: Moraxella catarrhalis
Slide 12 - Case A.B. Cont. Andy’s mom says he had a throat infection 3 months ago and received amoxicillin. She wants to know if he needs antibiotics again. What treatment will you prescribe? Two options: antibiotics (first line - amoxicillin) observation therapy
Slide 13 - The Observation Option Limited to healthy kids over the age of 6mos May observe age group 6 months to 2 years if AOM is uncertain and pt has nonsevere illness. What defines a severe illness? fever ≥ 39 C or 102.2 F, severe otalgia Older than 2 years if nonsevere illness Family has access to doctor, and family member to close eye on patient
Slide 14 - Why observation? The European Experience Dutch study: 2.7% of 4860 patients older than 2 years had persistent symptoms (fever, pain, discharge after 3-4 days). Only 2 developed mastoiditis. UK - in randomized trial: 76% kids in delayed group never required antibiotics. Study limited by imprecise criteria of AOM, and a set dosing of Amox (125mg tid x7 days for all ages)
Slide 15 - Recent Data 2006 study conducted in the ER setting evaluated a ‘wait-and-see prescription’ for antibiotics in AOM. Parents asked to not fill prescription unless child either did not improve or worsened in 48 hours. Results showed substantial reduction in use of antibiotics in the ‘wait-and-see’ group (62% vs. 13%; P<.001). Spiro, DM. et al. Wait-and-See Prescription for the Treatment of Acute Otitis Media. JAMA. Sep 2006;296:1235:1241.
Slide 16 - Porque Observacion? Incidence of mastoiditis - no clear data Incidence does not increase if patient is observed for initial 48 to 72 hours Most cases of mastoiditis develop despite therapy with antibiotics Observation has greater failure rate in younger patients
Slide 17 - When to give antibiotics All kids under 2 years of age with certain diagnosis of AOM Kids over 2 years of age if illness is severe Social or clinical barriers to accessing medical care and follow up Any child with genetic/immune/anatomic condition should be treated with antibiotics.
Slide 18 - Case 2 A 15 month old girl presents with fever to 101.5 F. Your otoscopic exam is seen to the right. What is your diagnosis and treatment? Bullous Myringitis,Treatment with amoxicillin given patient’s age.
Slide 19 - Case 2 continued You prescribed high dose Amox. Her mother calls after 2 days and states the fever has not resolved and child is still having decreased oral intake and is fussy. What is your recommendation? Change to augmentin or 2nd generation cephalosporin; other option: tympanocentesis Mom calls again after another 2 days and states there is still no improvement...what next? Ceftriaxone 50mg/kg/d IM x 3 days
Slide 20 - Case 3 A 4 yo girl presents with fever of 102F, severe left ear pain and discharge since yesterday. She denies pain with tugging of ear auricle. View of TM is obstructed by purulent discharge. What is the diagnosis? If OE ruled out and acute purulent otorrhea is present due to TM perforation, then diagnosis of AOM may be made.
Slide 21 - Case 4 12 month old male presents for routine well child exam. He is afebrile and doing well. Physical exam reveals accompanying TM. The TM is immobile with insufflation. How do you approach treatment for this child?
Slide 22 - Case 4 Diagnosis: Otitis media with effusion Treatment: assess for any signs/symptoms of hearing deficits watchful waiting, re-evaluate in 3 months
Slide 23 - Assessment of Pain Management of pain is a cornerstone of AOM therapy Acetaminophen and ibuprofen strongly recommended Topical anesthetic (i.e., Auralgan) and oral narcotics are other options in older children
Slide 24 - The Future Guidelines will continue to be refined in aspects of how to diagnose AOM and therapies (quinolones?). New vaccines for pneumococcus: currently we have PCV-7 a 9 serotype and 13 serotype are in the near future
Slide 25 - Conclusion Strict criteria for diagnosis of AOM: acute onset, middle ear effusion and middle ear inflammation Guidelines are designed to reduce unnecessary exposure to antibiotics in specific clinical scenarios. Children who are automatically excluded from observation option: all under 6mos, AOM in prior 30 days, known underlying OME, or has an immune/genetic/anatomic problem The option to withhold antibiotics is just that - it is an option.
Slide 26 - References Subcommittee on Management of Acute Otitis Media, Diagnosis and Management of Acute Otitis Media, Pediatrics, Vol. 113, No 5, May 2004, 1451-1462. Harrison, C. How will the new guideline for managing otitis media work in your practice?, Contemporary Pediatrics, June 1, 2004. Spiro, DM. et al. Wait-and-See Prescription for the Treatment of Acute Otitis Media. JAMA. Sep 2006;296:1235:1241. UpToDate Online. Diagnosis of acute otitis media. Accessed March 2009.