ACUTE OTITIS MEDIA: INDICATIORS OF DISEASE SEVERITY

Tal Marom, MD1

Sharon Ovnat Tamir, MD2

1Department of Otolaryngology-Head and Neck Surgery,Assaf Harofeh Medical Center;

2Department of Otolaryngology-Head and Neck Surgery,Edith Wolfson Medical Center;

Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Tel Aviv University

Outline• AOM risk factors• Severity Scores

– Assessment of signs – Assessment of symptoms – Assessment of signs and symptoms – Assessment of physical examination findings– Assessment of laboratory findings

• Conclusion

Classic Risk Factors for AOM

Factors that can not be modified :• Boys• Age < 2 years• Older siblings• Lack of breastfeeding • Season (fall, winter)

Factors that can be modified: • Pacifier use• Passive smoke exposure• Day care attendance • Low socioeconomic status

Risk Factors for Treatment Failure or Recurrence

• Antibiotic therapy within the last 1 month• Any AOM diagnosis within the last 1 month• > 3 AOM episodes / last 6 months• Age < 2 years• Age at 1st AOM episode < 6 months• Day care attendance • Bilateral AOM (?)

Reports Linking Severity of AOM to Streptococcus pneumoniae

• Coffey et al. reported an association between Streptococcus pneumoniae with bullous myringitis.

• Howie et al. reported more pain and fever in children with pneumococcal AOM.

• Rodriguez et al. described higher fever and more intensely yellow/red and bulging tympanic membranes (TMs) in AOM associated with S. pneumoniae.

Acute Otitis Media Severity of Symptoms (AOM SOS) Score

• This Score indicates the severity of the following 7 directly observable behaviors:– Ear tugging – Crying– Fussiness– Disturbed sleep– Decreased play– Eating less– Fever

• Children with pneumococcal AOM had higher scoresShaikh et al. Acute otitis media severity of symptom score in a tympanocentesis study. PIDJ 2011

AOM Facies Score

Friedman et al. Development of a Practical Tool for Assessing the Severity of Acute Otitis Media. Pediatric Infectious Disease Journal. 25(2):101-107, February 2006.

• No correlation stated between AOM – FS and pneumococcal disease

Ear Treatment Group – 5 Items (ETG-5)

• Parents use this scale to grade the following:– fever, 0 = <38°C, 4 = 38–39°C or 7 = >39°C

– ear ache (tugging), 0 = none, 4 = occasional or 7 = frequent

– irritability, 0 = none, 4 = occasional, or 7 = frequent

– 0 = feeds well, 4 = mild decrease in appetite or 7 = very poor appetite

– 0 = normal sleep, 4 = somewhat restless sleep or 7 = very poor sleep

• Symptom score did not differ between bacterial and non-bacterial pathogens

McCormick et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J. 2000;

Otologic System – 8 (OS-8)• 0 = normal, or effusion without erythema• 1 = erythema only, no effusion• 2 = erythema, air fluid level, clear fluid• 3 = erythema, complete effusion, no opacification• 4 = erythema, opacification with air-fluid level or air bubble(s), no bulging• 5 = erythema, complete effusion, opacification and no bulging• 6 = erythema, bulging rounded doughnut appearance of the tympanic

membrane• 7 = erythema, bulging, complete effusion and opacification with bulla

formation

Friedman et al. Development of a Practical Tool for Assessing the Severity of Acute Otitis Media. Pediatric Infectious Disease Journal. 25(2):101-107, February 2006.

In the presence of erythema, complete effusion and opacification (grade 5 or above), physicians were more likely to diagnose and treat with antibiotics. Physical examination rather than history has a major influence on AOM management decisions.

Otologic System – 8 (OS-8)• Children aged 6-35 months with parental suspicion of AOM were included.

A structured questionnaire pertaining the reasons for parental suspicion of

AOM, symptoms, and score components was filled.

Laine MK. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics. 2010 May;125(5):e1154-61.

• AOM cannot be predicted by the occurrence, duration, or severity of

symptoms at otitis-prone age. Symptom-based scores do not differentiate

between respiratory tract infections with or without AOM.

• TM examination is crucial in the diagnosis and severity classification of

AOM in clinical practice and research settings.

Tympanic Membrane Bulging

• A bulging TM was highly associated with isolation of bacterial pathogens or bacterial/viral combinations as compared with pure viral or negative cultures (P = 0.01).

• The finding of a bulging ear predicted a bacterial otitis with a positive predictive value of 74% and a negative predictive value of 45%.

• Bulging TMs were also noted somewhat more often in ears infected with S. pneumoniae

McCormick et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J. 2000

So how can we practically differentiate pneumococcal vs non-pneumococcal AOM?

• Risk factors – do not differentiate • Parental scoring systems – do not differentiate• Facial Expressions – do not differentiate• Symptoms and signs scores – do not

differentiate• Otoscopic findings – only TM bulging seems to

somewhat differentiate ??

Laboratory Findings

• In children presenting with AOM, the ability to rely on laboratory findings is of interest and can be pragmatic for decision-making purposes, particularly in order to differentiate pneumococcal and non-pneumococcal AOM.

Laboratory Findings

• Studies, dating from the pre-pneumococcal conjugate vaccine (PCV) era, foundsignificantly higher WBC counts and neutrophil count in pneumococcal AOM episodes, when compared to Haemophilus influenza positive or in culture-negative AOM episodes

• High CRP levels were more frequently associated with AOM caused by a bacterial origin than viral origin

Polachek et al. Relationship among peripheral leukocyte counts, etiologic agents and clinical manifestations in acute otitis media. Pediatr. Infect. Dis. J 2004

Laboratory Findings • Studies from the PCV era found that pneumococcal

AOM was associated with higher WBCs and CRP levels than non-pneumococcal AOM.

• In pneumococcal AOM, unimmunized children had higher WBC counts when compared with PCV13-immunized children (P = 0.04), but there were noappreciable differences in CRP levels between unimmunised and PCV7/PCV13-immunized children.

•Tamir et al. Severity of pneumococcal versus non-pneumococcal acute otitis media in children. Clin Otolaryngol 2015

Conclusions

• No real indicators for AOM severity on real time• No reliable parameters predicting severe AOM• Non vaccine-type Streptococcus pneumoniae

strains causing AOM episodes in PCV immunized children yield lower inflammatory responses when compared with unimmunized children.