Otitis Media and Sinusitis
Otitis Media and Sinusitis: Excerpt from Pediatric Infectious Disease
Epidemiology and Etiology
Immaturity of the eustachian tubes, coupled with a viral upper respiratory
infection, can lead to stasis, congestion, and ultimately eustachian tube
obstruction. Persisting obstruction of the eustachian tube can result in
bacteria being aspirated and trapped in the middle ear, producing a suppurative
infection. Because of the frequency of upper respiratory infections in
childhood, a child in daycare or with many siblings may experience as many as 6
to 12 episodes of otitis media a year.
Presentation
Pain is considered a common feature of otitis media, which may cause disruptions
in sleeping or increased irritability. Although only 25% of children with
otitis media are febrile, younger children are more likely to have fever than
older children.
Diagnosis
The diagnosis of acute otitis media requires several findings to be present. The
first is evidence of middle ear effusion demonstrated by pneumatic otoscopy:
middle ear effusion associated with acute otitis media shows impaired or absent
mobility of the tympanic membrane. The second is evidence of acute inflammation
of the tympanic membranes, usually as opacified bulging of the tympanic
membrane or the appearance of a distinct purulent fluid level. Serous otitis
media, in which the fluid behind the tympanic membrane is clear without
accompanying tympanic membrane bulging, is not considered an acute infectious
process and does not require treatment.
Management
General Difficulties in Management of Otitis Media
1. There are increasing numbers of oral antibiotics available for the treatment
of otitis media, all claiming to be the
“best.” It should be remembered that most clinical trials evaluating antibiotics for
acute otitis media are designed to show the
“equivalency” necessary for U.S. Food and Drug Administration (FDA) approval. Most clinical
trials do not demonstrate superiority, and because of the relatively small
sample size in most clinical studies, antibiotics with limited efficacy can
actually appear to be equal to superior drugs.
2. Unlike many infectious diseases, clinical specimens are not routinely
collected for culture and sensitivity. The clinician, therefore, needs to
examine the tympanic membrane and make a best guess as to the bacteria
responsible.
3. There is increasing resistance to Streptococcus pneumoniae, the most common pathogen of otitis media. Two mechanisms of resistance have
emerged. For
S. pneumoniae, the most common cause of otitis media, resistance is due to alterations in
penicillin-binding proteins. Resistance to
S. pneumoniae is defined by the minimal inhibitory concentration (MIC) to penicillin and to
third-generation cephalosporins. Penicillin nonsusceptibility in the
pneumococcus is defined when the MIC to penicillin is greater than 0.1
µg/mL. The overall rate of penicillin nonsusceptibility for pneumococcus is at
least 30%. Pneumococcus isolates considered resistant to penicillin usually
have MICs greater than or equal to 2.0
µg/mL; these resistant pneumococcal strains have a high likelihood of resistance
to many antibacterial agents. For nonmeningeal infections, pneumococcus
nonsusceptibility to third-generation cephalosporins is defined as an MIC
greater than 2.0
µg/mL.
4. The other two major pathogens of otitis media are Haemophilus influenzae and Moraxella catarrhalis. For these organisms, resistance is due to β-lactamase formation. Forty percent of Haemophilus strains and virtually all Moraxella strains produce β-lactamase, making them resistant to amoxicillin.
Antibiotic Therapy for Otitis Media
Although there are only three major pathogens and only two major mechanisms of
resistance, there are many oral antibiotics available for treatment of acute
otitis media (Table 6.1). Several generalizations can be made about the many
oral antibiotics available for the treatment of acute otitis media. It is
important to realize that many of the newer, more expensive second- and
third-generation cephalosporins actually have reduced activity against the
increasing numbers of penicillin-intermediate and penicillin-resistant
S. pneumoniae.
1. The first-generation cephalosporins (Cephalexin) have little gram-negative
coverage and are usually used to treat gram-positive organisms such as
Streptococcus pyogenes and Staphylococcus aureus. Generally, first-generation cephalosporins are not used in the treatment of
acute otitis media.
2. The second-generation cephalosporins have moderate activity against
gram-positive infections with increasing activity against gram-negative
bacteria such as
M. catarrhalis and nontypeable H. influenzae. Cefaclor is the least potent of these antibiotics and, because of its
association with serum sickness, is generally not used. Cefuroxime (Ceftin) is
the most potent of these second-generation cephalosporins against penicillin
nonsusceptible pneumococcus, although it has the disadvantage of being
difficult for children to accept because of poor taste. Cefprozil (Cefzil) is
intermediate in both taste and potency.
3. The third-generation cephalosporins have excellent gram-negative activity.
However, activity against gram-positive organisms is variable. Cefixime
(Suprax) and ceftibuten (Cedax) have reduced efficacy against penicillin
nonsusceptible
S. pneumoniae and are poor choices for the treatment of acute otitis media caused by this
organism. These agents have good activity against penicillin-sensitive
pneumococcus as well as
β-lactamase–producing H. influenzae and M. catarrhalis.
4. The macrolide antibiotics include erythromycin, clarithromycin, and
azithromycin. Although these were formerly front-line therapies for sinusitis
and acute otitis media, there has been increasing resistance of pneumococcus,
group A streptococci, and
H. influenzae to macrolide antibiotics. Currently, about 30% of all strains of S. pneumoniae demonstrate in vitro resistance to macrolides. Although the exact relationship of in vitro macrolide resistance to actual clinical outcome is not always clear, many
specialists believe that these drugs are poor agents for the treatment of upper
respiratory infections and should be reserved for use in the management of
lower respiratory infections in children who are likely to have atypical
pathogens, such as
Mycoplasma pneumoniae and Chlamydia pneumoniae.
5. Trimethoprim-sulfamethoxazole (Bactrim) was previously a mainstay of therapy
for the treatment of sinusitis and acute otitis media. There has been increased
resistance of
S. pneumoniae to trimethoprim-sulfamethoxazole (more than 30%), and it is no longer
recommended as front-line therapy.
Treatment Recommendations
In 1999, the Centers for Disease Control and Prevention convened a working group
that published recommendations regarding the treatment of acute otitis media.
Initial treatment was recommended with amoxicillin at a dose of 80 to 100 mg/kg
per day. Amoxicillin given at the previous standard doses of 40 to 45 mg/kg per
day was determined not to achieve middle ear fluid levels that would eradicate
the increasingly prevalent penicillin nonsusceptible pneumococcal strains. The
increase in dosing to 80 to 100 mg/kg per day was thought to achieve higher
antibiotic levels in the middle ear and be effective against these strains.
This regimen would also be efficacious against
M. catarrhalis and H. influenzae strains that did not produce β-lactamase.
Treatment failures, defined as lack of clinical improvement after 3 days of
therapy, would likely be secondary to resistant pneumococcus or
β-lactamase–producing H. influenzae or M. catarrhalis. The panel recommended the following treatment options:
• Cefuroxime axetil (Ceftin)
• Intramuscular ceftriaxone (Rocephin)
• Amoxicillin clavulanate (Augmentin)
• Clindamycin
There was excellent logic to these recommendations. However, it should be
remembered that these were guidelines developed at a certain time. The panel
did state that, at the time of publication, there was not enough evidence of
efficacy for certain drugs against the resistant pneumococcus that may be
responsible for most treatment failures. In the subsequent years, the rates of
resistance of
S. pneumoniae have only increased. Additional developments regarding treatment of
penicillin-nonsusceptible and penicillin-resistant
S. pneumoniae also include the following:
1. There remains limited clinical experience using clindamycin, and no consensus
exists on the actual number of injections of intramuscular ceftriaxone required
for treatment of acute otitis media. Some investigators have found that up to
three intramuscular injections are needed for resolution of acute otitis media.
2. New formulations of antibiotics have become available, including high-dose
amoxicillin combined with clavulanic acid (Augmentin ES, 600 mg per 5 mL).
3. Experience has increased in the treatment of resistant S. pneumoniae with several third-generation oral cephalosporins, such as cefdinir and
cefpodoxime.
Recommendations for treatment of otitis media have recently been revised.
Amoxicillin remains the initial choice for primary therapy. Children at low
risk for infection with penicillin-nonsusceptible
S. pneumoniae can be treated with 40 mg/kg per day in two divided doses. Even with the S. pneumoniae classified as resistant to penicillin, it is thought that high-dose amoxicillin
(80 to 90 mg/kg per day) achieves sufficiently high levels in the middle ear to
achieve cure. In children with increased risk for infection with
penicillin-resistant
S. pneumoniae, including those younger than 2 years of age, attending daycare, or having
received antibiotics within the preceding 30 days, therapy should be started
using the high dose of 80 to 90 mg/kg per day in two divided doses.
For children with clinically defined treatment failure at 48 to 72 hours,
several antibiotics have been recommended as second-line therapy. Treatment
options include the following:
• Amoxicillin clavulanate, using the high-dose formulation of 600 mg per 5 mL,
given as 90 mg/kg per day of the amoxicillin component in two divided doses
• Oral therapy with cefdinir, cefuroxime axetil, or cefpodoxime
• Intramuscular ceftriaxone, 50 mg/kg for one to three doses
As resistance patterns change, recommendations will need to be updated.
Treatment Delay
As antibiotic resistance becomes more prevalent, there is continued discussion
about treatment delay in otitis media. It has been determined that a
significant percentage of acute otitis media resolves in 2 to 7 days without
antibiotic therapy. An increasing strategy, particularly in foreign countries,
is to withhold treatment in a patient with early otitis media. Children are
then rechecked in 48 to 72 hours to determine whether infection has resolved.
Delaying treatment does not substantially increase the risk for complications,
including the rate of severe mastoiditis.
Surgical Management of Otitis Media
The role of surgical intervention in patients with otitis media, particularly
recurrent otitis media, is often debated. There is concern about the effect of
recurrent otitis media and persistent middle ear effusions in young children at
the age of language development. Various studies have addressed the issue of
developmental outcomes in children with persistent otitis media and effusions.
Although a variety of conclusions have been drawn, a recent study reported no
improvement in the developmental outcomes at 3 years in children who had prompt
insertion of tympanostomy tubes by 9 months of life. Tympanostomy tube
insertion in children is often still considered if there is chronic effusion
lasting 3 months or longer, documented hearing loss, or recurrent otitis media,
defined as three or more episodes during the previous 6 months or four or more
episodes during the past year.
Chronic Suppurative Otitis Media
Epidemiology and Etiology
The most common cause of chronic ear drainage in pediatrics is chronic
suppurative otitis media (CSOM). CSOM is defined as a chronic infection of the
middle ear and mastoid associated with a nonintact tympanic membrane or a
tympanostomy tube. CSOM may develop following an episode of acute otitis media
with perforation and subsequent development of chronic drainage. CSOM may also
be caused by a chronic perforation of the tympanic membrane in which the middle
ear becomes infected by environmental organisms. The bacteria causing CSOM
often differ from those of acute otitis media; the most common organisms
involved include
Pseudomonas aeruginosa and S. aureus. Rarely, this condition can be caused by Candida species or anaerobic bacteria.
Presentation
Affected children present with a history of ear drainage for many weeks.
Typically, these children have had numerous courses of oral antibiotics.
Diagnosis
Diagnosis is usually suggested by the history. Culture of the ear drainage that
yields the typical bacteria in the correct clinical context also suggest the
diagnosis.
Management
Management of the chronic draining ear can begin on an outpatient basis. Culture
of ear drainage can be obtained to document the typical pathogens of CSOM. In
the past, a variety of ototopical agents were used. These medications were
often ophthalmologic drops, which lacked efficacy against the typical CSOM
pathogens and were potentially ototoxic. Ofloxacin is a topical fluoroquinolone
that has been approved for use in children with tympanostomy tubes. This is now
often considered a front-line ototopical agent when CSOM is diagnosed. In
addition to antimicrobial therapy, good aural toilet is necessary. Children may
need daily visits to the otolaryngologist for suctioning and installation of
appropriate topical agents in the middle ear.
If a patient fails to respond to ototopical therapy, consideration of parental
antibiotics may be needed. Because there is no approved oral antimicrobial for
treatment of
Pseudomonas species infection in children, hospitalization may be needed for administration
of an appropriate intravenous drug such as ceftazidime. Computed tomography may
be necessary at this time to document chronic osteomyelitis or a mass lesion.
Sinusitis
Etiology
Like otitis media, bacterial sinusitis is believed to be the result of a
preceding viral upper respiratory infection that predisposes to a secondary
bacterial infection.
Presentation
The diagnosis of bacterial sinusitis is based on the history of upper
respiratory infection. Children with high fever and purulent nasal discharge
for 3 to 4 days should have the diagnosis considered. Children with persistent
symptoms that last longer than 10 to 14 days are considered to have a high
probability of a bacterial infection.
Diagnosis
The gold standard of the diagnosis of sinusitis is the recovery of more than 104 colony forming units/mL from a sinus aspirate, although this procedure will not
be routinely employed in the pediatric office. Thus, the diagnosis of bacterial
sinusitis is based on clinical criteria. As mentioned earlier, the basis for
the clinical diagnosis of sinusitis is the presence of persistent symptoms. An
upper respiratory infection that has lasted longer than 10 to 14 days is the
best feature distinguishing sinusitis from a routine viral infection. Severe
symptoms, defined as a temperature of at least 38.8
°C (102°F) with purulent nasal discharge for at least 3 consecutive days, are also
acceptable clinical criteria.
The physical examination is not particularly helpful in distinguishing between
viral upper respiratory infection and sinusitis. Transillumination of the
sinuses has been proposed, although reviews have suggested that this is
difficult to perform correctly and is not reliable in young children. Imaging
studies are not necessary to establish a diagnosis of sinusitis in children
younger than 6 years of age. Plain films and computed tomography of the
paranasal studies show mucosal thickening in both viral and bacterial upper
respiratory disease. For the general practitioner, the history and duration of
symptoms are the basis for an accurate diagnosis of bacterial sinusitis.
Management
The microbiology of acute sinusitis is similar to that of acute otitis media.
The principal bacterial pathogens include
S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. The increasing resistance of S. pneumoniae to penicillin and the large percentage of Moraxella and Haemophilus strains that produce β-lactamase also affect the treatment of sinusitis in children. Because organisms
and resistance profile are similar, current recommendations for the treatment
of otitis media can generally be applied to sinusitis.
Selected Readings
American Academy of Pediatrics. Subcommittee on Management of Sinusitis and
Committee on Quality Improvement. Clinical practice guideline: management of
sinusitis.
Pediatrics 2001;108(3)798–808.
Bluestone CD, Klein JO. Chronic suppurative otitis media. Pediatr Rev 1999;20(8):277–279.
Bluestone CD. Role of surgery for otitis media in the era of resistant bacteria.
Pediatr Infect Dis J 1998;17(11):1090–1098.
Faden H, Duffy L, Boeve M. Otitis media: back to basics. Pediatr Infect Dis J 1998;17:1105–1112.
Paradise JL, Dollaghan CA, Campbell TF, et al. Otitis media and tympanostomy
tube insertion during the first three years of life: developmental outcomes at
the age of four years.
Pediatrics 2003;112(2):265–277.
Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial
drugs for acute otitis media: meta-analysis of 5,400 children from thirty-three
randomized trials.
J Pediatr 1994;124(3):355–367.
Pictures
Book Source Details
- Book Title: Pediatric Infectious Disease
- Author(s): Donald Janner MD
- Year of Publication: 2004
- Copyright Details: Pediatric Infectious Disease, Copyright © 2004 Lippincott Williams & Wilkins.
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Title: Pediatric Infectious Disease
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