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SOURCE

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Source: Frei C, Frei B. Upper respiratory tract infections. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146071422. Accessed March 22, 2017.

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DEFINITION

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  • Acute onset of inflammation of middle ear.

    • Three subtypes differentiated by onset, signs and symptoms of infection, and presence of fluid in middle ear:

      • Acute otitis media.

      • Otitis media with effusion.

      • Chronic otitis media.

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ETIOLOGY

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  • Bacteria have been found in approximately 70% of cases.

  • Bacterial causes:

    • Streptococcus pneumoniae

      • Develops resistance through alteration of penicillin-binding proteins.

      • Up to 40% of isolates are penicillin nonsusceptible, with half of these having high-level penicillin resistance.

      • Incidence may be declining due to use of pneumococcal conjugate vaccine.

    • Haemophilus influenzae

      • 30–40% of isolates from upper respiratory tract produce β-lactamases.

    • Moraxella catarrhalis

      • 90% of isolates from upper respiratory tract produce β-lactamases.

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PATHOPHYSIOLOGY

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  • Usually follows viral upper respiratory tract infection that causes eustachian tube dysfunction and mucosal swelling in middle ear.

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EPIDEMIOLOGY

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  • One of the leading reasons for physicians’ office visits and emergency room visits in the United States.

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PREVENTION

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  • Seven-valent pneumococcal conjugate vaccine.

    • Reduced occurrence by 6–7% during infancy.

    • Did not benefit older children with history of acute otitis media.

  • Surgical insertion of tympanostomy tubes (T tubes) to prevent recurrent otitis media.

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RISK FACTORS

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  • Viral respiratory tract infection.

  • Nasotracheal intubation.

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CLINICAL PRESENTATION

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  • Rapid onset of signs and symptoms of inflammation in middle ear that manifests clinically as one or more of the following:

    • Otalgia (denoted by pulling of ear in some infants)

    • Hearing loss.

    • Fever.

    • Irritability.

  • If effusion (accumulation of liquid in middle ear cavity) present, signs and symptoms of acute infection are absent.

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SIGNS AND SYMPTOMS

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  • Otalgia.

    • Infants may pull on ear(s).

  • Fever.

    • Considered severe if temperature is 39°C or higher.

  • Irritability.

  • Discolored, thickened, bulging eardrum.

  • Immobile eardrum.

    • Bilateral in 50% of cases.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Clinical diagnosis.

  • Diagnosed if the patient has:

    • Middle ear effusion and either.

      • Moderate to severe bulging of the tympanic membrane or new onset otorrhea not due to acute otitis externa.

      • Mild bulging of the tympanic membrane and onset of ear pain within the last 48 hours or intense erythema of the tympanic membrane.

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LABORATORY TESTS
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  • Draining or aspirated fluid:

    • Gram stain.

    • Culture.

    • Sensitivity.

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DIAGNOSTIC PROCEDURES
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  • Tympanocentesis—optional.

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DIFFERENTIAL DIAGNOSIS
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  • Otitis externa.

  • Eustachian tube dysfunction.

  • Mastoiditis.

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DESIRED OUTCOMES

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  • Pain management.

  • Prudent antibiotic use.

  • Secondary ...

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