Purulent otitis media in a child

The inflammatory process in the middle ear is called otitis media. Young children suffer it very painfully, especially since they cannot tell their parents where it hurts. There is a catarrhal and purulent form of the disease, the latter is very dangerous for the health of babies due to the greater likelihood of relapse. Let's try to figure out, what is purulent otitis media in children dangerous?

Epidemiology

The incidence of otitis media worldwide is estimated to be 11% (709 million cases per year), and half of the cases are in children under 5 years of age. [1]Following the introduction of the heptavalent pneumococcal conjugate vaccine in the United States in 2000, national hospitalization rates for children under the age of 21 with acute otitis media and its complications decreased from 3.9 to 2.6 per 100,000 (p <0.0001), especially in children under 2 years old (from 13.6 to 5.5 per 100,000 people from 2000 to 2012, respectively; P <0.0001). [2]

Causes of the purulent otitis media in a child

Otitis can develop for a number of reasons, among which the most common are:

• hypothermia, cold water during bathing;
• diseases of the paranasal sinuses, nasopharynx, leading to swelling of the mucous membrane of the middle ear;
• complications of serious infectious diseases (flu, measles);
• allergic reactions (purulent is rare);
• injuries that damage the eardrum and contribute to infection.

Risk factors

Risk factors that contribute to the development of otitis media include decreased immunity, anatomical features, including curvature of the nasal septum, overwork, lack of vitamins, passive smoking, a high level of colonization of the nasopharynx with potentially pathogenic bacteria, and inadequate and inaccessible medical care. [3]

Pathogenesis

Otitis media is rarely primary. The most common pathogen is Pseudomonas aeruginosa. [4],  [5]Usually, cocci (staphylococci, pneumococci) and other pathogenic bacteria (Streptococcus pneumoniae, non-typable Haemophilus influenzae and Moraxella catarrhalis) [6], [7]penetrate the middle ear from the nasal mucosa with viral or bacterial inflammation (pharyngitis, laryngitis, tonsillitis, measles, tonsillitis, measles) less often as a result of injury to the eardrum. Infection occurs through the auditory tube connecting the hearing organs with the nasopharynx, when sneezing, blowing your nose, coughing. Young children are susceptible to purulent otitis media due to their shorter and more horizontal Eustachian tubes through which pathogens rise from the nasopharynx to the middle ear. [8], [9]

Symptoms of the purulent otitis media in a child

At an early age, the symptoms of otitis media are not always obvious. Babies are usually anxious, capricious, cry, but they calm down a little near their chest. Suspicion of otitis media increases if, when you click on the cartilage near the ear canal, the child begins to cry more, because the pain intensifies. 

In children who are able to describe their condition, the first signs are expressed in lumbago in the ears, paroxysmal pain, rolling in the waves and giving to the teeth, eyes, neck, headache. Hearing may also decrease, dizziness, vomiting, which is associated with violations of the vestibular apparatus, appetite worsen, weakness, drowsiness appear.

With purulent otitis media, the temperature may rise in the child, sometimes it reaches 40º, but it happens that the disease of the middle ear goes away without temperature.

Purulent otitis media with perforation of the eardrum is a common occurrence in a child. Suppuration in the ear extends to its tissues, in the end they become thinner, their integrity is violated. Perforation is partial or complete. Manifested by pain in the ear, hearing impairment. [10]

Stages

In its development, purulent otitis media passes through several stages:

• preperforative, with characteristic pain, tinnitus, fever, chills. On examination, the doctor observes a reddening of the eardrum;
• perforated - a hole appears in the membrane, purulent discharge comes from the ear, the symptoms subside, the temperature decreases, the pain subsides;
• reparative - pus becomes smaller, the hole is scarred, hearing is restored.

Forms

Depending on the localization of inflammation, the duration of the course of the disease in children, purulent otitis media is divided into types:

• acute purulent otitis media - a manifestation of an infectious disease of the body in the middle ear with the formation of pus, the duration of which is on average 3 weeks;
• chronic purulent otitis media - most often occurs after untreated acute and lasts up to three months, or is associated with gastroesophageal reflux - permanent entry of aggressive stomach contents into the nasopharynx; WHO defines chronic suppurative otitis media as "otorrhea through a perforated eardrum present for at least two weeks." [11]
• one-sided, affecting one ear;
• bilateral - the spread of infection in both ears is most susceptible to infants, as well as small children up to a year. This is due to the structure of the auditory organ at this age: the Eustachian tube - the channel connecting the middle ear to the pharynx, wide and short, is located horizontally relative to them. Through it, infections are easier to penetrate into the middle ear, the mucous tissue of which is also very loose and susceptible to pathogenic microorganisms. By two years of life, the hearing aid develops, and cases of bilateral purulent otitis media are reduced by 2 times.

Complications and consequences

The consequences of purulent otitis media are possible with improper treatment or therapy that has begun late. These factors lead to damage to the auditory nerve, bones, which is dangerous by hearing loss or complete loss of hearing, conductive or sensorineural hearing loss. [12]This can affect your child’s language development and performance. More threatening complications include meningitis, mastoiditis.

Diagnostics of the purulent otitis media in a child

In addition to the clinical picture characteristic of purulent otitis media, its diagnosis is based on an examination by the otolaryngologist of the external auditory canal, eardrum using special tools (otoscopy). Other instrumental methods include tympanometry, which determines the patency of the auditory tube, the mobility of the membrane by applying different air pressure to the auditory canal. [13]

Determining the prevalence of the process and the degree of bone destruction is carried out using x-ray, tomography of the temporal bones. [14]

The general condition of the body and the effect of the focus of infection on it is estimated by the results of a clinical analysis of urine and blood. Purulent discharge of their ear is examined for bacteriological flora to determine sensitivity to antibiotics.

Differential diagnosis

Purulent otitis media, especially chronic, differentiates with a number of pathologies, in which pus in the ear is also formed:

• bacterial, fungal myringitis;
• external auditory canal cholesteatoma;
• perforated tuberculous otitis media;
• hemodectomy.

Treatment of the purulent otitis media in a child

The main goal of treating purulent otitis media in a child is to eliminate the focus of infection, eliminate pain, prevent complications, and correct hearing loss, if any. In parallel, the treatment of diseases of the nasopharynx is carried out.

Drug treatment consists in the use of antibiotics, local treatment with ear drops.

Antimicrobial treatment is recommended for all children under two years of age, as well as for children over two years of age whose temperature is above 39 ° C; there are signs of intoxication, otalgia for more than 48 hours; bilateral otitis media or otorrhea, have craniofacial disorders, with weakened immunity.  [15]

To appoint their reception for purulent otitis in children can only be a doctor after examining a small patient. It can be tablets inside or another pharmacological form, as well as drops in the ear. A long course is indicated (at least 7-10 days) for the accumulation of drugs in the problem area.

Medication

Cephalosporins (cefixime, ceftibuten), ampicillin, amoxicillin are prescribed as antibiotics.

Cefixime is a powder for suspension. The bottle is poured with boiled water in the volume of half its content (30-35 ml), closed with a lid and shaken. For children from six months to 12 years (weight up to 50 kg), the recommended dose is 8 ml per kg of body weight. It can be taken either once a day, or divided into 2 times with an interval of 12 hours. After this age, the volume of the drug is 400 mg once or 200 mg twice a day.

The drug can cause side effects such as dry mouth, intestinal cramps, diarrhea, abdominal pain, skin reactions, dizziness. Contraindicated in case of hypersensitivity to antibiotics of this series.

Amoxicillin - from the group of penicillins, a broad-spectrum antibiotic in the form of granules from which the suspension is prepared. Amoxicillin is the drug of choice. Water is added to the vial to the mark on it and a volume of 100 ml is obtained. Children under 2 years old are given 125 ml, which corresponds to half a scoop, from 2 to 5 years old - 125-250 ml, 5-10 years old - 250-500 ml, older than 10 years old - 500 ml three times a day. The course of treatment lasts up to two weeks. Contraindicated in infectious mononucleosis, lymphocytic leukemia, allergies to drug components. Of the side effects, urticaria, itching, nausea, vomiting, diarrhea, headache, and insomnia are possible.

Along with antibiotics, ear drops are used in the complex treatment, sometimes the doctor is limited only to them. It can be otinum otipaks, sonopaks.

Otipax is a combined drug that has analgesic and anti-inflammatory effects. Drops are applied to children older than 1 month. Dripped in 4 drops 2-3 times a day. The maximum course of treatment is 10 days. When perforation of the eardrum is contraindicated.

Dioksidin - ear drops, an effective antibacterial agent for adults in the form of a liquid in ampoules, but it is not applied to children due to its increased toxicity.

At high body temperature, ibuprofen, paracetamol are taken, cefecone candles are placed.

Tsefekon D - suppositories, antipyretic, has a small anti-inflammatory property. Indicated for children from 3 months to 12 years. Dosage depends on body weight. So, children with a weight of 5-10 kg (3-12 months) are recommended 1 suppository 100 mg each, 11-16 kg (1-3 years) - 1-2 suppositories 100 mg each, 17-30 kg (3-10 years) - 1 pc.. 250 mg each, 31-35 kg (10-12 years) - 2 pcs. 250 mg each.

Adverse reactions rarely occur in the form of rashes on the body, swelling, pain in the epigastrium, nausea, shortness of breath, bronchospasm.

Concerns about ototoxicity with aminoglycosides have prompted the American Academy of Otolaryngology to not recommend aminoglycosides for topical treatment of middle ear inflammation when other options are available with at least equivalent efficacy. [16]Quinolones have a better safety profile than other drugs. [17], 

Vitamins

Saturation of the body with vitamins will help to quickly cope with the infection. Nursing mothers need to take care of a nutritious diet, the beneficial substances of which get into the baby with milk. Older children include a lot of vegetables and fruits containing vitamin C in the diet, as well as give vitamin-mineral complexes (Multi-Tabs baby, VitaMishki immune plus Sea buckthorn, Supradin Kids Bears, etc.) that increase immunity.

Physiotherapeutic treatment

Physiotherapeutic treatment also takes place in the treatment of purulent otitis media. It can be UHF, low-frequency magnetic field,  [18]drug electrophoresis, ultraviolet radiation.

Alternative treatment

With purulent otitis media, it is dangerous to rely on alternative methods, their use must necessarily be agreed with the doctor. For washing the ears using decoctions of herbs that have anti-inflammatory, antiseptic effect. It can be medicinal chamomile,  [19]sage,  [20]calendula.[21] 

To bury the ear, use the juice of bear onions, aloe. Tampons dipped in propolis tincture are placed in the sore ear. Warming compresses for purulent otitis media are not used. 

Herbal medicine in the treatment of otitis media has been sharply criticized by many doctors, since the alleged anti-inflammatory properties could not be tested or confirmed in vitro. [22], [23]

Homeopathy

Studying the effects of homeopathic treatment of otitis media is scarce, and its quality is limited. [24]Homeopathy in this case does not replace the antibacterial, but will contribute to a speedy recovery. Among such homeopathic remedies are Hamomilla, Magnesia of Phosphorus, Mercury, Hepar Sulfur, which will relieve severe pain, throbbing, and tinnitus. The dosage is determined by the homeopath individually, but the general recommendations contain the following scheme: 3 granules from the 12th to the 30th potency every 4 hours until the condition improves.

Surgery

The progression of purulent otitis media sometimes leads to the need to perform a puncture of the tympanic membrane (paracentesis). Paracentesis is recommended in the diagnosis of perforation of the middle ear in infants. [25]Other surgical interventions in an emergency are carried out in order to remove purulent masses and damaged tissues. In a delayed manner, they resort to eliminating the complications that have arisen.

Prevention

Preventive measures include strengthening the protective forces of the baby's body, avoiding hypothermia, balancing nutrition. The child needs to be taught to blow his nose properly so that nasopharyngeal infections do not fall into the ear: each nostril should be separately blowed.

Forecast

The prognosis of the disease is favorable with timely and competent treatment. Otherwise, you can lose your hearing and even create dangerous situations for life.