VIÊM TAI GIỮA cấp

VIÊM TAI GIỮA CẤP• OME otitis media with effusion • Chronic Suppurative OM CSOM... VIÊM TAI GIỮA CẤPYẾU TỐ NGUY CƠ – Mùa thu đông – Viêm nhiễm đường hô hấp trên cấp – Đi nhà trẻ – Khói t

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VIÊM TAI GIỮA CẤP

VIÊM TAI GIỮA CẤP

NGUYỄN HOÀNG NAM

BỘ MÔN TAI MŨI HỌNG ĐẠI HỌC Y DƯỢC TP HỒ CHÍ MINH

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• OME (otitis media with effusion)

• Chronic Suppurative OM (CSOM)

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DỊCH TỄ HỌC

• AOM có khẳ năng tự khỏi rất tốt

• 60% hết các triệu chứng sau khi điều trị

mà không cần dùng KS trong 24 giờ đầu

• Sau 2-3 ngày 80% hết các triệu chứng ngoại trừ dịch trong tai giữa

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Residual MEE

PERSISTENT MEE

• Di chứng không phải biến chứng

• 60 % - 70% có dịch vô khuẩn trong TG sau hai tuần

• Tự hết

• Kéo dài 1 đến 3 tháng

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RECURRENT AOM

• 3 đợt VTG chẩn đoán chính xác / 6 tháng hoặc 4 đợt /12 tháng

• 15 to 20% trẻ dưới 6 tuổi

• Diễn tiến tự nhiên tốt

• Giáo dục cha mẹ

• Kháng sinh dự phòng :

– refractory recurrent AOM

– sulfisoxazole hoặc amox

– Theo mùa viêm đường hô hấp trên cấp

– Không kéo dài quá ba đến sáu tháng

– Tympanostomy tubes;

– adenoidectomy is of benefit only after prior tubes

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YẾU TỐ NGUY CƠ

– Mùa thu đông

– Viêm nhiễm đường hô hấp trên cấp

– Đi nhà trẻ

– Khói thuốc lá

– Bú bình

– Tình trạng kinh tế

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OM : Short Term Complications

• brain abscesses

• sigmoid sinus thrombophlebitis

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OM Long Term Complications

 Speech and Language delay

 Tympanic membrane perforation

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Tác nhân vi trùng

• Streptococcus pneumoniae,

• H influenzae,

• M catarrhalis

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Otitis Media : Antimicrobial Resistance

• S pneumoniae 30-40% penicillin resistant

• H influenzae 30-40% -lactamase positive

• M catarrhalis 80-90% -lactamase (+)

• Levels of resistance vary with different

geographic areas

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influenzae and M catarrhalis affecting

penicillins and cephalosporins

• Transformation of new genetic material by

S pneum, affecting macrolides, TMP/SMX

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Reasons for Increasing Resistance

• Inappropriate drugs: resistant

organism, wrong or unusual pathogen

• Appropriate drug but inadequate dose

– Poor compliance

– Subinhibitory concentrations with

inadequate trough levels

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Ways to Reduce Resistance

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AOM : To treat or not to treat?

• Spontaneous cure rate for :

– S pneumoniae is 19%

– H influenzae is 48%

– M catarrhalis is 75%

– All causes approaches 60%

• 93% of bacteriologic resolution, clinically

cured

• Studies show antibiotics reduce symptoms

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AOM : No treatment

• Risks

– follow up difficult

– risk of complications

– symptoms take longer to resolve

– parental anxiety, lost work days

• Benefits

– reduce emergence of resistant pathogens – enhanced immune response

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• Assess severity of infection

• May opt not to treat older children who are afebrile

• Ensure you have adequate follow up if

patient is not treated

• Treat children < 2 years, with increased

risk of otitis media, recent antibiotic use, large day care attendance

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MỤC TIÊU

• Chẩn đoán xác định VTG cấp trên bệnh nhân cụ thể không có biến chứng

• Lập kế hoạch điều trị cho từng bệnh nhân

cụ thể

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CÁC CÂU HỎI TRƯỚC MỘT TRƯỜNG HỢP

– Dùng KS trong bao lâu

– Khi nào cần đổi KS

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Chẩn đoán VTG cấp

• Chẩn đoán xác định

• Chẩn đoán mức độ

• Chẩn đoán biến chứng

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Chẩn đoán VTG cấp

• Đánh giá bệnh nhân

• Khám tai giữa bằng đèn soi tai có bơm khí

• Kiểm tra các biến chứng

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– Thay đổi thói quen sinh hoạt

• Thời điểm khởi phát : đột ngột, sau một đợt Viêm mũi cấp

• Tiền sử dị ứng

• Lịch chủng ngừa

• Môi trường sống

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Khám tai

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Chẩn đoán xác định : tam chứng

• Khởi phát đột ngột ≤48h

• Có bằng chứng dịch trong tai giữa

• Có bằng chứng viêm trong tai giữa

Chẩn đoán phân biệt với OME

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KẾ HOẠCH ĐIỀU TRỊ VTG CẤP

• Điều trị :

– Giảm đau, điều trị nâng đỡ : càng sớm càng tốt, paracetamol

– Khi nào dùng Kháng sinh

– Khi nào đổi KS

– Dùng ks trong bao lâu

• Theo dõi cho đến khi hết dịch trong tai

giữa

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AOM : CDC guidelines

• Amoxicillin remains first line antibiotic

Standard versus high doses ??

• Follow up in 48 - 72 days

• Treatment failures should be treated with

– amoxicillin-clavulinic, cefuroxime axetil or

ceftriaxone

• Tympanocentesis is indicated only for

treatment failures

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AOM : Dutch guidelines

• Children > 2 years

– symptomatic therapy for 3 days

– re-evaluate if symptoms persist

– antibiotics for 7 days

• Children < 2 years

– symptomatic treatment for 1 day

– re-evaluate ; if symptoms persist, then give antibiotics

• Continued observation in all cases

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Diagnosis and Management

of Acute Uncomplicated Otitis

Media (2 mos – 12 yoa )

• American Academy of Pediatrics 2004

• American Academy of Family Physicians

Pediatrics 2004; May, 113: 1451-65

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Acute Otitis Media : Amoxicillin

• Still drug of choice (standard/high dose)

• Safe and well tolerated and inexpensive

• Usually effective against S pneumoniae and

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• Nâng cao chất lượng nhà trẻ

• Đánh giá nguy cơ

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DỊCH CHỨNGTRIỆU KHÁNG SINH

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-VIÊM TAI GIỮA CẤP

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– A Bottle feeding E Passive smoking – B Endotracheal intubation

– C Group child care

– D Pacifier use

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Case 2

• You are discussing with a Resident antibiotic resistance encountered in the bacterial pathogens most commonly isolated from infected middle ears You correctly state that:

– Most isolates of H Influenzae are resistant to

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Case 4

• You diagnosed AOM in the 9-month-old infant The best choice for therapy at this time is:

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Case 5

A 9-month old boy has just completed successful

therapy for his third episode of AOM in the past 5

months The most appropriate option for preventing an early recurrence is administration of:

– A Bacterial polysaccharide immune globulin

– B Decongestant-antihistamine combination at the onset of a cold

– C Multivalent pneumococcal vaccine

– Amox/ 6

– Trimethoprim-sulfamethoxazole, 1 tsp BID for 6 months

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Case 5

– C Multivalent pneumococcal vaccine

– Sulfasoxazole, 3/4 tsp BID for 6 months

– Trimethoprim-sulfamethoxazole, 1 tsp BID for

6 months

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of the tympanic membrane comes from the ear canal superiorly Prominent blood vessels on the rim

superiorly are within normal limits.

FIGURE 2

Wax, or cerumen, is a normal secretion in the cerumenous glands in the outer part of the meatus, and can obscure or partially obscure the drum When it is first

produced it is colourless and semi-liquid in consistency, but with time it changes from pale yellow to golden yellow, to light brown and finally black As the wax darkens it also hardens and the darker the colour the denser the consistency.

Acute otitis media with no recognisable land marks There is considerable bulging of the ear drum with purulent fluid behind a tense tympanic membrane which

sometimes heralds perforation In some cases incision of the drum is required.

Resolution of middle ear effusion The handle of the malleus is still foreshortened and horizontal Signs in the upper half of the eardrum suggest that fluid is still present

in the middle ear.

Grommet -Tympanostomy tube Grommets can be inserted in the tympanic membrane if medical treatment and myringotomy are unsuccessful and the child has

persistent middle ear effusion The illustration is a silicone tube retained in an opening in the drum by inner and outer flanges.

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£6.75 per pack

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• Ear Candles have become amazingly popular over the last few years with many enthusiasts claiming remarkable physical and spiritual effects from Ear Candling treatment

• That being said it seems that nobody is quite sure where Ear Candles came from and what their original usage was Various sources claim they were used in ancient cultures such as China, India, Syberia and North America

• Ear candles may have beneficial effects treating the symptoms of earaches, headaches, mild middle ear inflammation, ear itching, ear buzzing, pressure

in the ears and head, migraine, colds, loss of smell, tonsillitis, irritability and stress Improves hearing, lymphatic circulation, stimulates energy flow and generally invigorates the immunity system.

• Aurecon Plus ear candles come packed in pairs in their own box Also

included is a protective card disc and two sets of instructions The Aurecon Plus Ear Candle features a filter system at the base of the candle to protect against any falling debris entering the ear

• Candle Length = approx 180mm

• Always read instructions before use CE approved

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How does it work?

The Ear Popper directs a steady, controlled stream of air into the nose Swallowing diverts the air into the Eustachian tube, opening the Eustachian tube and relieving pressure imbalance in the middle ear (The effectiveness of this technique was originally discovered by Dr Adam Politzer in the nineteenth century)

Price: $313.20

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to Otitis Media with Effusion, Aerotitis/Barotitis.

- Aerotitis/Barotitis is a result of negative middle ear pressure

caused by rapid elevation changes (airplane, diving, mountain

climbing, etc.).

The user places the EarPopper firmly against one nostril, blocks his/her other nostril, activates the device, and swallows while the device is running For simple pressure imbalance, relief can be

instantaneous When fluid is present, the treatment is repeated

twice in each nostril, twice a day and is recommended for seven

weeks or until the hearing returns The actual treatment needs to be prescribed by a physician

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• Tình trạng viêm nhiễm trong TG

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Chronic Otitis Media (COM)

• COM with Effusion or nonsuppurative OM :

– Middle ear effusion behind an intact eardrum – Persist for more than 2-3 months

– Asymptomatic except for hearing loss

– No acute symptoms

– May follow AOM

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Definitions

Chronic Suppurative OM (CSOM) :

– chronic perforation of the TM

– purulent discharge for >6 weeks

– insidious onset

– may follow AOM

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Acute Otitis Media

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Acute Otitis Media Diagnosis

• Identification of middle ear effusion

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Otitis Media Signs & Symptoms

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Otitis Media : Pneumatic Otoscopy

• Used to assess the landmarks (mốc, ranh giới),

mobility, color, transparency (độ trong

sáng-đục) , vascularity and position of the tympanic membrane

• Fluid levels or bubbles (bong bóng, bọt nước)

can be seen if membrane is translucent (trong mờ=đục)

• Confirms middle ear effusion by assessing

mobility when + or – pressure is applied

• Needs an adequate seal (bịt kín, đóng kín) with ear canal

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Otitis Media Epidemiology

• Most common bacterial infection in

children and most commonly diagnosed

• Half of all children will have an episode before the first birthday, and 80% before the third birthday

• The most frequent reason for prescribing antibiotics

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Otitis Media Epidemiology

• It accounts for more than 1/3 of office

visits to pediatricians each year

• The number of office visits continues to

rise, in 1997 it reached 25.9 billion

• 4-5 billion dollars spent each year in direct care costs

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Otitis Media Risk Factors

• Host factors

• Environmental factors

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Otitis Media Host Factors

• Age < 2 years

• Gender ( Males > Females)

• Race (Native Americans, Alaskan>AA and Caucasian)

• Genetic predisposition

• Sibling with history of recurrent disease

• Down’s syndrome, cleft palate, tumors,

immunodeficiency states

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Otitis Media Environmental Factors

• Allergies

• Second hand smoke + wood burning stoves

• Not breastfeeding

• Seasonal

• Large group day care

• Low socioeconomic group

• Use of pacifiers

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Otitis Media Natural History

• Upper respiratory tract mucosal congestion

spreads to eustachian tube obstruction leading

to stasis, effusion and multiplication of bacteria

• Spontaneous resolution with drainage via the eustachian tubes or with perforation of the

tympanic membrane

• Effusion may remain if tube still obstructed

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OM : Short Term Complications

• brain abscesses

• sigmoid sinus thrombophlebitis

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OM Long Term Complications

 Speech and Language delay

 Tympanic membrane perforation

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Otitis Media Etiology

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Otitis Media : Antimicrobial Resistance

• S pneumoniae 30-40% penicillin resistant

• H influenzae 30-40% -lactamase positive

• M catarrhalis 80-90% -lactamase (+)

• Levels of resistance vary with different

geographic areas

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influenzae and M catarrhalis affecting

penicillins and cephalosporins

• Transformation of new genetic material by

S pneum, affecting macrolides, TMP/SMX

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Reasons for Increasing Resistance

• Inappropriate drugs: resistant

organism, wrong or unusual pathogen

• Appropriate drug but inadequate dose

– Poor compliance

– Subinhibitory concentrations with

inadequate trough levels

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Ways to Reduce Resistance

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• Spontaneous cure rate for :

– S pneumoniae is 19%

– H influenzae is 48%

– M catarrhalis is 75%

– All causes approaches 60%

• 93% of bacteriologic resolution, clinically

cured

• Studies show antibiotics reduce symptoms

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AOM : No treatment

• Risks

– follow up difficult

– risk of complications

– symptoms take longer to resolve

– parental anxiety, lost work days

• Benefits

– reduce emergence of resistant pathogens – enhanced immune response

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• Assess severity of infection

• May opt not to treat older children who are afebrile

• Ensure you have adequate follow up if

patient is not treated

• Treat children < 2 years, with increased

risk of otitis media, recent antibiotic use, large day care attendance

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AOM : Antibiotic Selection

Accurate diagnosis

Antibiotic options Local resistance

patterns Assess for risk factors for resistance

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AOM : Antimicrobial Selection

Antibiotics

Convenience Cost

Efficacy Palatability

Safety

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AOM : Antibiotics Used

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Acute Otitis Media : Amoxicillin

• Still drug of choice (standard/high dose)

• Safe and well tolerated and inexpensive

• Usually effective against S pneumoniae and

H influenzae

• Higher doses have greater efficacy against more strains of S pneumoniae

• Studies show comparative clinical efficacy

when compared with newer antibiotics

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Acute Otitis Media : Cephalosporins

• Clinical efficacy varies

• Cefprozil, cefuroxime, cefpodoxime and

ceftriaxone IM have greater efficacy

against pneumococci

• Cefuroxime, cefpodoxime and ceftriaxone

IM effective against both S pneumoniae

and H influenzae

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