Otitis Media and URI

Objectives

Otitis media and upper respiratory infection are among the most common diagnoses in pediatric age patients. In spite of this, there remains considerable controversy about the pathogenesis, natural course, and therapeutic approach in both - particularly in otitis media.

Upper Respiratory Infections (URIs)

URIs manifest themselves, in infants and children as well as adults, with nasal congestion, malaise, low grade fever with or without cough, and at times anorexia. While none of these symptoms are life threatening, they cause sufficient concern, particularly in infants and small children, to cause the parents to bring the baby to the doctor. When they do so, THREE THINGS ARE IMPORTANT to consider in management:

1. The etiology may be viral or bacterial. Antibiotics are used for bacterial infections. Bacterial superinfection is indicated by purulent (yellow to green) rhinorrhea.

2. Nasal congestion in young infants causes problems with nursing, interferes with sleep, and may increase risk of aspiration. It is therefore helpful to advise the use of nasal suction with saline nose drops and/or humidifiers to clear nasal passages of mucus.

3. Antihistamine-decongestant mixtures provide symptomatic relief but have not been shown to alter the course of otitis. Adverse side effects (overstimulation and excessive sedation), particularly in young children <1-2 years of age, restrict their usefulness.

Avoid inhaled decongestants such as Afrin nasal spray, because the nasal mucosa can become addicted to them. This condition is called rhinitis medicamentosa, a reactive swelling of the nasal mucosa. If a patient uses inhaled decongestants, limit their use to 3 days.

External Ear Canal

Some patients will present complaining of hearing loss, dizziness, or ear pain, and your examination will reveal a cerumen impaction (refer to box in Otitis Media section for wax removal instructions). Have these patients avoid using Q-tips, since this can impact ear wax. Occasionally you will find foreign objects, such as beads and insects, in the canal.

Another condition involving the ear canal is external otitis ("swimmer's ear"). This results in swelling, irritation, and exudate of the canal. It is common among swimmers because of the increased risk of moisture in the canal. Another predisposing factor is trauma; i.e., fingernails, bobby pins, or Q-tips. Common causes are e. coli, pseudomonas, proteus, staph, and fungus. Symptoms include ear pain (frequently severe), drainage, and loss of hearing.

Tests used in diagnosis include elicitation of pain by pushing on the tragus or pulling on the pinna. Treatment is Cortosporin or Vosol antibiotic drops, 4 drops 3 times a day for -7 days. If there is marked swelling, hydrocortisone (Cortosporin HC or Vosol HC) can be added. Also, if swelling is extreme, the patient may need to be referred to ENT to have a cotton wick inserted (this soaks up the medicine and allows it to reach the entire canal). If the pain is severe, the patient may need p.o. narcotics, such as Tylenol #3.

Bullous Myringitis

Usually a viral (occasionally bacterial) infection, bullous myringitis produces vesicles on the TM. It is treated with erythroymycin since it can be caused by mycoplasma.

Otitis Media

Otitis media is one example of the many common conditions seen in ambulatory settings in which precise etiologic diagnosis is not always feasible.

Under most circumstances, the DIAGNOSIS DEPENDS MAINLY ON OTOSCOPIC FINDINGS. Symptoms of ear pain, fever, recent URI, or previous history of otitis may direct attention to the ear, but they are often vague or subtle, especially in the young. In order to obtain a comfortable level of diagnostic confidence, it is necessary to learn not only the characteristic appearance of the drum (redness, dullness, bulging or retraction, loss of landmarks, or fluid present), but also how to use the PNEUMATIC OTOSCOPE to determine the mobility. Two basic factors affect the success of both of these:

1. Young children are predictably uncooperative during ear examinations, and assistance in restraining them is required.

2. Wax in the canal, which prevents adequate visualization of the drum, should be removed. This can usually be done safely by adhering to the following:

Once good visibility is obtained, it is relatively simple to suspect otitis by assessing the redness, dullness, or loss of landmarks referred to earlier, if one remembers that vigorous crying can cause the drum to flush or appear red. The use of the pneumatic otoscope can best be appreciated when demonstrated on a patient. In essence, it enables us to assess not only drum mobility, as mentioned, but also helps determine whether there is fluid or abnormal pressure within the middle ear.
The instrument fits a bulb to the head of the otoscope.

NORMAL TYMPANIC MEMBRANE can be described as:

Distinguish from early otitis where there are many hyperemic vessels across the membrane.
 
 

Bulging Tympanic Membrane

Retracted Membrane

Perforated Tympanic Membrane

Serous Otitis

The patient most often experiences a pressure sensation and conductive hearing loss rather than pain, and may describe "clicks" and "popping" sounds.
Therapy:

Air bubbles in Serous Otitis

The AIM of THERAPY in otitis media is two-fold: The RATIONALE OF THERAPY is based on the etiology described above.

Antibiotics
(see table on last page)

The importance of hemophilus infection in young children (< 5 years of age) accounts for the use of amoxicillin as the first line anti-biotic. This is followed by trime-phoprim-sulfa (Bactrim or Septra), erythromycin-sulfamethoxazole (Pediazole) or cephalosporins. Current resistance trends suggest use of Trim-Sul as first line drug.

Successful therapy depends on close follow-up and continuation of anti-biotics for 10 days to 2 weeks in many cases. Resistant/persistent infection should be a consideration only after adequate duration of therapy (3 courses of different antibiotics).

Patients with persistent or recurrent otitis media (3 to 4 episodes within a 6 to 12 month period) need referral to ENT for PE tubes. The patient should be placed on suppression doses of antibiotics (usually half the normal dose of amoxicillin or Bactrim). The child may need adenoidectomy (when the adenoids are enlarged, they can block the eustachean tube).

Impedance Tympanometry

Impedance tympanometry is useful in detecting persistence of fluid, as well as in following the resolution of transient fluid collections which accompany many cases. For otitis, you will usually have a straight line (see graph - Stiff Ear). For serous otitis with retraction, the graph will shift into the negative range, indicating negative pressure.

 


D. Nelson, MD
updated 8/30/05


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