Episode 166.0 – Acute Otitis Media - a podcast by Core EM

A look at this common and controversial topic.

Hosts:

Brian Gilberti, MD

Audrey Bree Tse, MD







https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Otitis_Media.mp3







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Tags: Pediatrics











Show Notes

Background:



* The most common infection seen in pediatrics and the most common reason these kids receive antibiotics

* The release of the PCV (pneumococcal conjugate vaccine), or Prevnar vaccine, has made a big difference since its release in 2000 (Marom 2014)



* This, along with more stringent criteria for what we are calling AOM, has led to a significant decrease in the number of cases seen since then

* 29% reduction in AOM caused by all pneumococcal serotypes among children who received PCV7 before 24 months of age





* The peak incidence is between 6 and 18 months of age

* Risk factors: winter season, genetic predisposition, day care, low socioeconomic status, males, reduced duration of or no breast feeding, and exposure to tobacco smoke.

* The predominant organisms: Streptococcus pneumoniae, non-typable Haemophilus influenzae (NTHi), and Moraxella catarrhalis.



* Prevalence rates of infections due to Streptococcus pneumoniae are declining due to widespread use of the Prevnar vaccine while the proportion of Moraxella and NTHi infection increases with NTHi now the most common causative bacterium

* Strep pneumo is associated with more severe illness, like worse fevers, otalgia and also increased incidence of complications like mastoiditis.







Diagnosis



* The diagnosis of acute otitis media is a clinical one without a gold standard in the ED (tympanocentesis)

* Ear pain (+LR 3.0-7.3), or in the preverbal child, ear-tugging or rubbing is going to be the most common symptom but far from universally present in children. Parents may also report fevers, excessive crying, decreased activity, and difficulty sleeping.

* Challenging especially in the younger patient, whose symptoms may be non-specific and exam is difficult

* Important to keep in mind that otitis media with effusion, which does not require antibiotics, can masquerade as AOM



AAP: Diagnosis of Acute Otitis Media (2013)*



* In 2013, the AAP came out with a paper to help guide the diagnosis of AOM

* Moderate-Severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa (grade B)



* The presence of bulging is a specific sign and will help us distinguish between AOM and OME, the latter has opacification of the tympanic membrane or air-fluid level without bulging (Shaikh 2012, with algorithm)

* Bulging of the TM is the most important feature and one systematic review found that its presence had an adjusted LR of 51 (Rothman 2003)

* Classic triad is bulging along with impaired mobility and redness or cloudiness of TM

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