Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 18:

Otitis Media and Otitis Externa

Otitis Media (OM)

Acute otitis media (AOM)

An acute onset of signs and symptoms of a middle ear infection and inflammation, such as middle ear effusion and erythema, respectively

Most common bacterial respiratory tract infection in children

Chronic OME

Inflammation of the middle ear with fluid collection behind the TM, symptoms of AOM are absent

Otitis Externa (OE)

Definition: inflammation of the outer ear and ear canal

Causes: most often associated with swimming, local trauma, use of hearing aids, and high, humid temperatures

Therapy: topical antibiotic therapy is usually adequate for treatment of OE

Types: acute and chronic; necrotizing

Comparison of Types of Otitis

Question

A pediatric patient presents with otalgia, ear pulling, erythema, and bulging of the TM following an acute URI infection. What type of ear infection would the practitioner suspect?

OME

AOM

Necrotizing OE

Answer

C. AOM

Rationale: Acute otitis media (AOM) presents with symptoms of otalgia, ear pulling, URI symptoms, diffuse erythema, and bulging of the TM. Symptoms of OME are hearing loss, ear fullness, popping sensations, and fluid behind the TM. Symptoms of OE are erythema and swelling of the external canal with otalgia and itching, muffled hearing, and watery or thick discharge from the ear. Necrotizing OE is characterized by persistent, foul-smelling discharge and deep ear pain.

Diagnostic Criteria for Acute Otitis Media

History of acute onset of signs/symptoms

Presence of middle ear effusion:

Bulging of TM and limited or absent TM mobility

Otorrhea

Air–fluid level behind TM

Signs and symptoms of middle ear inflammation

Erythema of TM and otalgia

Risk Factors for AOM

Congenital defects such as cleft palate and Down syndrome

Young age (highest incidence in children below age 2)

Family history; male sex

Children who attend day care or are relatives of children in day care

Exposure to secondhand smoke; allergies

Lack of exclusive breast-feeding first 6 months of life

Antibiotics to Treat Acute Otitis Media: Amoxicillin and Amoxicillin/Clavulanate

Amoxicillin: pediatric: 80 to 90 mg/kg/d PO divided into two doses per day; adult: 2 to 3 g/d PO divided into two to three doses per day

Adverse effects: abnormal taste, diarrhea, headache, skin rash

Amoxicillin–clavulanate (Augmentin): pediatric: 80 to 90 mg/kg/d based on amoxicillin component PO divided into two doses per day; adult: 250 to 500 mg PO every 8 hours; or 875 mg PO every 12 hours

Adverse effects: abnormal taste, diarrhea, headache

Antibiotics to Treat Acute Otitis Media: Ceftriaxone and Cefdinir

Ceftriaxone (Rocephin): pediatric: 50 mg/kg/d IM once daily for 1 or 3 days; adult: 1 g IM once daily for 1 or 3 days

Adverse events: skin rash, injection site reactions

Cefdinir (Omnicef) pediatric: 7 mg/kg/day PO divided into two doses per day; adult: 300 mg PO twice a day

Adverse events: skin rash and GI upset, otherwise well tolerated

Antibiotics to Treat Acute Otitis Media: Cefpodoxime and Cefuroxime

Cefpodoxime (Vantin): pediatric: 10 mg/kg/d PO once daily; adult: 200 mg PO twice a day

Adverse effects: skin rash and GI upset, otherwise well tolerated

Cefuroxime (Ceftin) pediatric: 30 mg/kg/d PO divided into two doses per day; adult: 250 to 500 mg PO twice a day

Adverse effects: skin rash and GI upset, otherwise well tolerated

Antibiotics to Treat Acute Otitis Media: Clindamycin

Clindamycin (various): pediatric: 30 mg/kg/d PO divided into three doses per day; adult: 300 to 450 mg PO every 6 to 8 hours

Adverse effects: diarrhea, C. difficile–associated diarrhea, rash

Antimicrobial Resistance Affecting Treatment of AOM

The increasing incidence of resistance warrants the judicious use of antibiotics.

Mechanisms of resistance include alteration of drug binding sites and the production of antibiotic inactivating enzymes, for example, beta-lactamases.

Drug-resistant S. pneumoniae (DRSP) remains a threat in the treatment of AOM.

Beta-lactamase production is the mechanism by which organisms such as H. influenzae and M. catarrhalis develop resistance.

Goals of Drug Therapy

Symptomatic pain relief

Appropriate use of antibiotics to prevent complications

Judicious use of antibiotics to prevent future antimicrobial resistance

Eradication of the infecting organism

Prevention of complications such as mastoiditis and hearing impairment

Recurrent Acute Otitis Media

Defined as more than three episodes within 6 months or four episodes within 12 months, with one episode in the preceding 6 months

Most commonly due to relapse or reinfection

Management remains controversial

Antibiotic prophylaxis is no longer recommended.

Support evidence for placement of tympanostomy tube is limited.

Otitis Externa Diagnostic Criteria

Ear canal inflammation such as ear pain, itching, or fullness.

Ear canal inflammation such as tenderness of tragus and/or pinna, and erythematous ear canal with occasional otorrhea.

Hearing is usually unaffected; jaw pain may occur.

Differentiation from other possible causes of otalgia, otorrhea, and inflammation of the ear canal, such as AOM is important.

Goals of Drug Therapy for OE

Clearing any obstructing debris or excess cerumen from the canal (i.e., aural toilet)

Checking the integrity of the TM to determine if extension beyond the ear canal is present

Use of topical therapy as the mainstay of OE treatment (i.e., antibiotics, steroids, or combination treatments)

Use of topical antimicrobials over systemic administration

Achievement of pain relief through OTC analgesics

Treatment for Otitis Externa

Drug: polymyxin B sulfate, neomycin, and hydrocortisone

Dosage: children: 3 drops into ear canal three to four times daily for maximum of 10 days; adults: 4 drops into ear canal three to four times daily for maximum of 10 days

Adverse events: superinfection, contact dermatitis, ototoxicity with prolonged use

Contraindications: herpes simplex, fungal, tubercular, or viral otic infections, perforated eardrum, caution in pregnancy (category C drug) and in breast-feeding patients

Treatment for Otitis Externa (cont.)

Drug: ofloxacin (Floxin)

Dosage: children 1 to 12 years: 5 drops into ear canal bid for 10 days; children >12 years and adults: 10 drops bid for 10 days maximum

Adverse events: pruritus, site reaction, dizziness, earache, vertigo, taste perversion, paresthesia, rash

Contraindications: patients <1 year, perforated eardrum, caution in pregnancy (category C drug) and in breast-feeding patients

Recommended Order of Treatment for Otitis Externa

First line: fluoroquinolone drops: not recommended for patients <1 year; use all otic drops for maximum 10 days.

Second line: combination neomycin/polymyxin B drops: Vosol is not recommended for patients <3 years; all drops are contraindicated in cases of perforated eardrum.

Third line: antifungal drops: consider if a patient fails to respond to initial topical antibiotic therapy; systemic antipseudomonal or antistaphylococcal agent: consider if ear canal obstruction cannot be relieved or if infection extends beyond the ear canal.

Question

A pediatrician is prescribing medication for a child with otitis externa, who failed to respond to initial topical antibiotic therapy. What is the recommended therapy?

Antifungal drops

Combination neomycin/polymyxin B drops

Fluoroquinolone drops

Systemic antipseudomonal agent

Answer

A. Antifungal drops

Rationale: Antifungal drops are third-line therapy for a patient with otitis externa who fails to respond to initial topical antibiotic therapy. Combination neomycin/polymyxin B drops are second-line therapy, fluoroquinolone drops are first-line therapy, and systemic antipseudomonal agents are third-line therapy that should be considered if ear canal obstruction cannot be relieved or if infection extends beyond the ear canal.

Patient Education

Drug information

Nutrition/lifestyle changes

Complementary and alternative medications

Summary

Infections of the ear, such as OM, AOM, OME, and OE, are a common problem in children due to anatomical predisposition, but they can also affect adults.

Although antibiotics and vaccination programs have decreased the frequency of infections, identification, diagnosis, and management of these infections are essential to prevent permanent hearing loss, chronic or recurrent ear infections, mastoiditis, meningitis, and speech or language delay.