Ear

• Causative organisms for ear infections

  • Streptococcus Pneumoniae
  • Haemophilus influenza
  • Moraxella catarrhalis
• Streptococcus Pneumoniae


  • Gram positive diplococci
  • Most common cause of Community Acquired Pneumonia - Also the most common bacterial cause of OM and sinusitis
  • 70% of children and 30% of adults have nasopharyngeal colonization
  • Disease results from a microaspiration
• Streptococcus pneumoniae

  • Many mechanisms for resistance
  • Most common mechanism: Resistance from an alteration in the penicillin binding proteins which reduce/eliminate binding of penicillin to the proteins
• Streptococcus pneumoniae

  • Erythromycin resistance: ribosome modification
  • 25% - 50% is not fully responsive to penicillin
  • 20% - 33% is resistant to macrolides
• Streptococcus pneumoniae is most likely to be present with recurrent disease and least likely of all pathogens to resolve without treatment
• Streptococcus pneumoniae has a 30% chance to resolve spontaneously; some sources say 10%
• Haemophilus influenzae

  • Gram negative coccobacillus
  • Bronchotrachial tree becomes colonized and microaspiration occurs
  • Most commonly seen among smokers, children of smokers and daycare children
  • 33% - 35% of H. influenzae is beta lactamase producing
• Moraxella catarrhalis

  • Gram negative bacillus
  • Implicated in recurrent OM and Sinusitis
  • Will often spontaneously resolve if left untreated
  • 90% - 98% beta lactamase producing
• Otitis Media (OM)

  Inflammation of the middle ear due to any cause
• Otitis media is the second most common disease diagnosed in young children
• Variants of otitis media

  • Acute otitis media (AOM)
  • Otitis media with effusion (OME)
• Otitis media is an anatomical problem
• Diagnosis of Acute Otitis Media (AOM)

  • Evidence 1A: Moderate - severe bulging of TM with otalgia OR new otorrhea NOT due to otitis externa and otalgia
  • Evidence 1B: Mild bulging of TM and recent ( < 48 hours) onset of ear pain or intense erythema of TM with otalgia
• Otoscopic view of ear

  • Otitis media with purulent material seen behind the tympanic membrane
  • Normal tympanic membrane
  • Otitis media with effusion
  • AOM with bulging tympanic membrane
  • AOM with perforation draining
  • Myringitis during AOM

  
• Beneficial factors for otitis media

  • Breastfeeding
  • Immunizations
• Predisposing factors for otitis media

  • Exposure to tobacco smoke
  • Daycare attendance
  • Younger siblings in the home
• Who needs antimicrobials for otitis media

  • Any child < 6 months of age
  • Any child with severe AOM
  • Any child < 24 months of age with bilateral AOM
  • Any child in whom follow up cannot be ensured
• Severe AOM

  Moderate or severe otalgia for at least 48 hours OR temperature: 102.2 (39 degrees Celsius)
• First line treatment options for otitis media

  • Amoxicillin
  • Cefdinir
  • Cefuroxime
• Alternative treatment options (if penicillin allergy)

  • Amoxicillin/clavulanate
  • Cefpodoxime
  • Ceftriaxone
• Antibiotic treatment after 48-72 hours of failure of initial antibiotic

  • Amoxicillin/clavulanate
  • Ceftriaxone 3 day
  • Clindamycin with or without concomitant third generation cephalosporin
  • Tympanocentesis (consult specialist)
• Duration of antibiotic treatment

  • AOM and < 2 years: 10 days
  • Age 2 years and older: 5-7 days (If severe, minimum of 7 days)
• Topical medications for OM with tympanostomy tubes

  • Ofloxacin (Floxin Otic) 0.3% solution
  • Ciprofloxacin (Ciprodex)
• Complications of acute otitis media

  • Perforation of TM
  • Tympanosclerosis - May lead to conductive hearing loss
  • Mastoiditis
  • Meningitis
• With increasing antibiotic resistance, especially Streptococcus pneumoniae, these complications may again become more common
• Otitis Media with Effusion (OME)

  Fluid in the middle ear with no signs and symptoms of AOM
• Treatment options for OME

  • Observation
  • Hearing evaluation and referral to ENT if still present at 12 weeks
  • Myringotomy tubes for high risk individuals
• Otitis externa (OE)

  Inflammation or infection of the external auditory canal, the auricle, or both
• Causative pathogens for otitis externa

  • Bacterial: Pseudomonas, Staphylococcus, Streptococcus
  • Fungal: Aspergillus, Candida albicans
• Classifications of otitis externa

  • Acute diffuse
  • Acute localized
  • Chronic
  • Eczematous
  • Necrotizing/Malignant
  • Otomycosis
• Antibiotic/steroid ear drops for otitis externa

  • Ciprofloxacin + hydrocortisone (Cipro HC Otic)
  • Ciprofloxacin 0.3% and dexamethasone 0.1% (Ciprodex Otic)
  • Neomycin sulfate, polymyxin b sulfate and hydrocortisone (Cortisporin Otic)
  • Dexamethasone + tobramycin (TobraDex)
  • Gentamicin ophthalmic (Garamycin, Gentak)
  • Hyrocortisone and acetic acid (VoSol HC)
  • Ofloxacin solution (Floxin Otic)
• Oral or parenteral antibiotics may be needed for severe cases of otitis externa
• Fungal Otitis Externa (Otomycosis)

  • 10% of OE caused by fungi, not bacteria
  • Two most common pathogens: Aspergillus (80% to 90%) and Candida
  • Intense pruritus and erythema with or without pain or hearing loss
  • Managed with thorough cleansing and acidifying drops
  • 1% clotrimazole used if acidifying drops are not effective
  • Oral antifungal therapy (itraconazole or fluconazole) may be needed if infection fails to respond