Otitis Media VICKI A. PAPADEAS,
Acute purulent otitis media (APOM) occurs frequently during childhood, particularly in the first two years of life.le5 However, this infection seems to develop less often in infants less than three months of age. Additionally, APOM in the child during the first three months is difficult to diagnose and may lead to serious complications. It is often necessary to attempt to isolate a specific etiologic agent and to begin treatment with intravenous antibiotics. Because APOM affects young infants less often than older children, the emergency physician may not be fully aware of its manifestations during the first few months of life; yet, an accurate diagnosis assumes even greater importance because of the potential for life-threatening complications. We describe a neonate seen in our emergency department with bacteriologically confirmed APOM and discuss the clinical manifestations, diagnostic modalities, bacteriology, complications, and treatment regimens in the young infant. CASE REPORT A 4-week-old infant was brought to the emergency department for evaluation of irritability. Four days previously, he had begun to cough. The cough persisted but did not worsen in the interval before the visit. His mother had noticed increasing irritability during the prior 24 hours. She did not report fever, vomiting, or diarrhea. Physical examination showed an alert and cranky but consolable infant in no acute distress. The rectal temperature was 38.6”C, the heart rate, 160 beats min, and the respiratory rate, 68/min. The infant had a profuse, clear nasal discharge. The right tympanic membrane was dull and slightly erythematous, but mobile with pneumatization; the left tym-
From the Department of Pediatrics and the Emergency Department, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. Manuscript 1983.
8, 1983; accepted
Address reprint requests to Dr. Fleisher: The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104. Key Words: Neonate,
in Early Infancy
MD, GARY R. FLEISHER,
panum, however, was yellow, bulging, and showed limited mobility. The remainder of the examination was noncontributory. In the emergency department, specimens of blood, urine, and cerebrospinal fluid were obtained for culture. A tympanocentesis yielded 0.5 ml of purulent material, which was sent for microscopic and bacteriologic examination. Laboratory results were as follows: hemoglobin, 11.7 gm/dl; hematocrit, 35.5; platelets, 216,000/mm3, and leukocyte count 9,200/mm3 with a normal differential. There were no cells in the cerebrospinal fluid or urine, and a chest radiograph was normal. Gram stain of the material from the middle ear showed many polymorphonuclear leukocytes but no bacteria. Intravenous ampicillin and gentamicin therapy was begun. After 24 hours, the child became afebrile. Hemophilus influenzae grew from the middle ear exudate on the third hospital day, and oral amoxicillin was given in place of the intravenous antibiotic combination. He was discharged shortly thereafter and his mother was instructed to continue the amoxicillin for a total of ten days. The infection resolved without complications.
DISCUSSION Signs and Symptoms. The clinical spectrum of APOM may vary from an incidental finding in an otherwise well child to a source of sepsis in the ill-appearing infant. The manifestations are particularly likely to be nonspecific in the first few months of life, as with many illnesses in the neonatal period and as illustrated by this patient. The nonverbal infant lacks the ability to localize pain, and APOM has no outward signs. The most commonly reported findings with APOM in the neonate, according to several recent studies,le4 are rhinorrhea (70%), irritability or lethargy (60%), fever (35%), cough (35%), anorexia (300/o), vomiting (30%), diarrhea (25%), and tachypnea (20%). Diagnosis. The. first step in the diagnosis of APOM in the young infant, all too often neglected in the neonate, is careful otoscopic examination of the ears. Pneumatic otoscopy is mandatory for a satisfactory appraisal of the tympanic membranes and requires a speculum with an appropriately small diameter (2 or 3 mm). The examiner must evaluate three characteristics of the tympanum: color, contour, and compliance (mobility). While the bulging, beefy red or 2.51
III appearing? no 1 Fever >38”C -
n Volume 2, Number 3 W May 1984
Evaluation for sepsis Tympanocentesis Intravenous antibiotic therapy’ ?Tympanocentesis (age 4 weeks)
Oral antibiotic therapyt Reevaluation in 24 hours
yes 1 Age <4 weeks? no yes-Oral 1 Evaluation for sepsis
Evaluation for sepsis antibiotic therapyt (if no laboratory evidence of sepsis) Reevaluation in 24 hours therapy*
FIGURE 1. Otitis media in the ambulatory weeks of age.
infant less than 12
yellow, immobile tympanic membrane clearly distinguishes APOM from a normal middle ear cavity in the older child, the diagnosis of an infection in this location may be more elusive in the infant. The narrow lumen of the external auditory canal makes an adequate otoscopic examination difficult during the first few months of life, particularly in the neonatal period, when vernix caseosa may obstruct the view. Additionally, as noted by McClellan et al,‘j,’ the normal tympanum in early infancy is a dull white rather than pearly gray and often lacks a consistent light reflex. Unless the eardrum is bulging outward or appears yellow and immobile, the examiner may have difficulty deciding with certainty that a purulent collection has formed in the middle ear. Tympanometry has proved to be very useful in the examination of the middle ear cavity of children. However, several factors limit its contribution during infancy. Most important, the elasticity of the wall of the external auditory canal at a very young age allows this structure to move in response to the application of a positive or negative pressure in the canal. Thus, a tracing that appears to be indicative of a normally compliant tympanum may instead be detecting motion of the wall of the external canal. Additionally, the requirement for a quiet child, neither crying nor sucking on a bottle, demands a patient, experienced examiner, committed to spending time to achieve a technically satisfactory result. Neither the peripheral leukocyte count nor culture of the nasopharynx contribute to the diagnosis of APOM.4,8 Abnormal results in both these tests are nonspecific and have a poor positive predictive value. Additionally, the inherent delay in the availability of ’ Recommended intravenous antibiotic therapy: Ampicillin, 200 mg/kg/day, and Moxalactam, 200 mglkglday, gentamicin, 7.5 mglkgiday. T Recommended oral antibiotic Amoxicillin, 50 mg/kg/day 252
the results of the nasopharyngeal culture further limits its usefulness for the clinician. Tympanocentesis provides the diagnostic standard for APOM, particularly in the neonatal period, when other modalities are not as useful as in older children. Diagnostic tympanocentesis should not be undertaken lightly but may be invaluable and should be performed for the appropriate indications, as discussed in the section on management. The procedure requires an operating otoscopic head and at least one assistant to restrain the child securely, even when a papoose device is being used. In preparation for the tympanocentesis, a 2$‘2 inch, 20 gauge spinal needle is attached to a 3 ml syringe (or suction system) and bent at a 90 degree angle at a distance of 1 inch from the hub. After the external auditory canal has been cleansed with 70% alcohol, the needle is inserted through the operating head. The middle ear is pierced in the posterior inferior quadrant, and the tip of the needle is advanced just beyond the tympanic membrane. With gentle suction, fluid is aspirated for Gram stain and culture. Potential complications of tympanocentesis include hemorrhage into the middle ear or external canal, significant laceration of the tympanum, disarticulation of the ossicular chain, and introduction of infection. Bacteriology. In a discussion of the bacteriology of APOM in young infants, it is necessary to consider the precise age of the patient-whether younger or older than 4 weeks -and the setting-whether the child is ambulatory or hospitalized. In infants 4 weeks old and younger, an increased incidence of infection with gram-negative enteric organisms and Stuphylococcus aureus has been reported. l-3 Bland isolated enteric pathogens, predominantly Ewherichia coli and Klebsiella pneumoniae, were obtained from 72% of the infants in the first 3 months of life studied by tympanocentesis, and S. aureus from 28%. Although subsequent investigators have not found an equally high incidence of infections with these organisms, they have recovered them in 10% to 18% of cases; more often, Streptococcus pneumoniae and H. injluenzae have been cultured. Additionally, isolation of nonrespiratory pathogens was limited almost exclusively to the first 4 weeks of life.2,3+5 Prematurity and hospitalization, independently or in combination, influence the likelihood that nonrespiratory pathogens will be recovered by tympanocentesis in cases of APOM in infancy. Berman et apI noted that severely ill neonates. particularly premature infants requiring endotracheal tubes, have a high incidence of APOM, which is frequently caused by gramnegative enteric organisms. In a series of ten neonates in whom APOM developed while they were residing in the intensive care nursery, these workers isolated S. aureus from two, K. pneumoniae from two, E. coli from one, and Enterobacter cloacae from one.
Complications. Infants are able to localize infection poorly, and bacteria which invade the middle ear cavity initially may disseminate subsequently. Tetzlaff et aP recovered bacteria from the blood in two of 49 infants with APOM and found evidence of meningitis in six. Associated respiratory infections, particularly pneumonia, occur in almost half of the cases. Management. The plan of management for the infant with APOM must take into account multiple factors, including (1) age, (2) clinical appearance, (3) temperature, and (4) geographic location, whether the emergency department or the inpatient units of the hospital. Figure 1 presents a schema for the outpatient . The most important consideration is the clinical appearance of the child. If sepsis is suspected, a full evaluation should be performed, including a blood culture, urine culture, chest radiograph, lumbar puncture, and tympanocentesis. However, this extensive battery of tests is not necessary for all infants who do not appear to be in a toxic state. Rather, the presence of fever and the age must be considered next. While all infants under 3 months of age who are febrile with APOM should receive evaluation for sepsis, only those in the first 4 weeks of life require tympanocentesis, since the enteric pathogens occur predominantly during this period. The afebrile, well-appearing infant with APOM can be treated with oral antibiotic therapy and discharged to the home, provided that close follow-up is assured. Tympanocentesis may be considered for those less than 4 weeks old and is mandatory for those who fail to improve. The recommended oral antibiotic therapy for the infant with APOM is amoxicillin, 50 mg/kg/day. The child who is sufficiently ill to require intravenous therapy, as defined in the algorithm, should receive
n OTITIS MEDIA IN INFANCY
the combination of ampicillin, 200 mg/kg/day, and either gentamicin, 7.5 mg/kg/day, or moxalactam, 200 mg/kg/day; moxalactam would be preferred for the child with associated meningitis. When these drugs are given to an infant who is premature or has impaired renal function, appropriate dosage modifications are necessary. Young infants with APOM must be observed closely for an adequate response to therapy. While dissemination of the infection may occur, with potentially fatal complications, the prognosis is generally excellent. REFERENCES 1. Bland RD. Otitis media in the first six weeks of life: Diagnosis, bacteriology and management. Pediatrics 1972;49:187-197. 2. Tetzlaff TR, Ashworth C, Nelson JD. Otitis media in children less than twelve weeks of age. Pediatrics 1977;59:827832. 3. Schwartz R, Barsanti R, Rodriquez WJ. Private practice view of otitis media. Pediatrics 1978;81:837-838. 4. Berman SA, Balkany TJ, Simmons MA. Otitis media in the neonatal intensive care unit. Pediatrics 1978;62:198-201. 5. Shurin PA, Howie VM, Pelton St, et al. Bacterial etiology of otitis media during the first six weeks of life. J Pediatr 1978;92:893-898. 6. McClellan MS, Struck A. Ear studies in the premature infant: A statistical description of otoscopic landmarks. J Pediatr 1985;67:122-124. 7. McClellan MS, Webb CH. Ear studies in the newborn infant: Age of spontaneous visibility of the auditory canal and tympanic membrane, and the appearance of these structures in healthy newborn infants. J Pediatr 1961;58:523527. 8. Paradise JL. Otitis media in infants and children Pediatrics 1980;65:917-943. 9. Berman SA, Balkany TJ, Simmons MD. Otitis media in infants less than 12 weeks of age: Differing bacteriology among in-patients and out-patients. J Pediatr 1978; 93:453-454.