Purulent otitis media in a child

The inflammatory process in the middle ear is called otitis. Small children experience 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 children due to the higher probability of relapse. Let's try to figure out why purulent otitis is dangerous in children?

Epidemiology

The incidence of otitis media worldwide is estimated to be 11% (709 million cases per year), and half of the cases occur 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 acute otitis media and its complications in children under 21 years of age decreased from 3.9 to 2.6 per 100,000 persons (P < 0.0001), particularly in children under 2 years of age (13.6 to 5.5 per 100,000 persons between 2000 and 2012, respectively; P < 0.0001).[ 2 ]

Causes of purulent otitis media in a child

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

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

Risk factors

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

Pathogenesis

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

Symptoms of purulent otitis media in a child

At an early age, the symptoms of otitis are not always obvious. Babies usually show anxiety, are capricious, cry, but calm down a little near the breast. The suspicion of otitis increases if, when pressing 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 shooting pains in the ears, paroxysmal pain, rolling in waves and radiating to the teeth, eyes, neck, headache. Hearing may also decrease, dizziness may occur, nausea may occur, which is associated with vestibular disorders, appetite may worsen, weakness and drowsiness may appear.

With purulent otitis, a child's temperature may rise, sometimes reaching 40º, but it happens that the disease of the middle ear passes without a fever.

A common occurrence in children is purulent otitis with perforation of the eardrum. Suppuration in the ear spreads to its tissues, eventually they become thinner, their integrity is compromised. Perforation can be partial or complete. It manifests itself as pain in the ear, hearing loss. [ 10 ]

Stages

In its development, purulent otitis goes through several stages:

• pre-perforative, with characteristic pain, tinnitus, fever, chills. During examination, the doctor observes redness of the eardrum;
• perforative - a hole appears in the eardrum, purulent discharge comes from the ear, symptoms weaken, the temperature decreases, the pain subsides;
• reparative – there is less pus, the hole is scarred, hearing is restored.

Forms

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

• acute purulent otitis is 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 suppurative otitis media – most often occurs after untreated acute otitis 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 ]
• unilateral, affecting one ear;
• bilateral - infants and small children under one year of age are most susceptible to the spread of infection to both ears. This is due to the structure of the auditory organ at this age: the Eustachian tube is a canal connecting the middle ear with the pharynx, wide and short, located horizontally relative to them. It is easier for infections to penetrate into the middle ear through it, the mucous tissue of which is also very loose and susceptible to pathogenic microorganisms. By the age of two, the hearing apparatus develops, and cases of bilateral purulent otitis are reduced by 2 times.

Complications and consequences

Consequences of purulent otitis are possible with improper treatment or late initiation of therapy. These factors lead to damage to the auditory nerve, ossicles, which is dangerous for hearing loss or complete hearing loss, conductive or sensorineural hearing loss. [ 12 ] This can affect the development of language and the child's academic performance. More threatening complications include meningitis, mastoiditis.

Diagnostics of purulent otitis media in a child

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

Determination of the prevalence of the process and the degree of bone destruction is carried out using radiography and tomography of the temporal bones. [ 14 ]

The general condition of the body and the impact of the infection source on it are assessed based on the results of clinical analysis of urine and blood. Purulent discharge from the ear is examined for bacteriological flora to determine sensitivity to antibiotics.

Differential diagnosis

Purulent otitis, especially chronic, is differentiated from a number of pathologies in which pus also forms in the ear:

• bacterial, fungal myringitis;
• choleasteatoma of the external auditory canal;
• tuberculous perforated otitis media;
• chemodectoma.

Treatment of purulent otitis media in a child

The main goal of treating purulent otitis in a child is to eliminate the source of infection, relieve pain, prevent complications, and correct hearing loss if it occurs. In parallel, nasopharyngeal diseases are treated.

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

Antimicrobial treatment is recommended for all children under two years of age, and for children over two years of age who have a temperature above 39°C; signs of intoxication, otalgia for more than 48 hours; bilateral otitis media or otorrhea, have craniofacial abnormalities, and are immunocompromised. [ 15 ]

Only a doctor can prescribe their use for purulent otitis in children after examining the little patient. These can be tablets or another pharmacological form, as well as ear drops. A long course (at least 7-10 days) is indicated for the accumulation of the medicine in the problem area.

Medicines

Of the antibiotics, cephalosporins (cefixime, ceftibuten), ampicillin, and amoxicillin are prescribed.

Cefixime is a powder for suspension. The bottle is filled with boiled water to half its volume (30-35 ml), closed with a lid and shaken. For children from six months to 12 years old (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 medicine is 400 mg once or 200 mg twice a day.

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

Amoxicillin is a penicillin, a broad-spectrum antibiotic in the form of granules used to make a suspension. Amoxicillin is the drug of choice. Water is added to the bottle up to the mark on it, making a volume of 100 ml. Children under 2 years old are given 125 ml, which is half a measuring spoon, from 2 to 5 years old - 125-250 ml, 5-10 years - 250-500 ml, over 10 years - 500 ml three times a day. The course of treatment lasts up to two weeks. Contraindicated in infectious mononucleosis, lymphocytic leukemia, allergies to the components of the drug. Side effects may include urticaria, itching, nausea, vomiting, diarrhea, headache, insomnia.

Along with antibiotics, ear drops are used as part of a complex treatment, sometimes the doctor limits himself to them. This can be otinum otipax, sonopax.

Otipax is a combination drug that has an analgesic and anti-inflammatory effect. The drops are used for children over 1 month old. 4 drops are dripped 2-3 times a day. The maximum course of treatment is 10 days. Contraindicated in case of perforation of the eardrum.

Dioxidine is an ear drop, an effective antibacterial agent for adults in the form of liquid in ampoules, but it is not used for children due to its increased toxicity.

If the body temperature is high, take ibuprofen, paracetamol, and use cefecon suppositories.

Cefekon D – suppositories, antipyretic agent, has a slight anti-inflammatory property. Indicated for children from 3 months to 12 years. The dosage depends on body weight. Thus, children weighing 5-10 kg (3-12 months) are recommended 1 suppository of 100 mg, 11-16 kg (1-3 years) – 1-2 suppositories of 100 mg, 17-30 kg (3-10 years) – 1 pc. of 250 mg, 31-35 kg (10-12 years) – 2 pcs. of 250 mg.

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

Concerns about ototoxicity with aminoglycoside use have prompted the American Academy of Otolaryngology to recommend against aminoglycosides for topical treatment of otitis media when other options with at least equivalent efficacy are available.[ 16 ] Quinolones have a better safety profile than other drugs.[ 17 ]

Vitamins

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

Physiotherapy treatment

Physiotherapeutic treatment also takes place in the treatment of purulent otitis. This may be UHF, low-frequency magnetic field, [ 18 ] medicinal electrophoresis, ultraviolet irradiation.

Folk remedies

In case of purulent otitis, relying on folk methods is dangerous, their use must be agreed with a doctor. For ear rinsing, use herbal decoctions that have anti-inflammatory, antiseptic effects. This can be chamomile, [ 19 ] sage, [ 20 ] calendula. [ 21 ]

For ear drops, use the juice of bear onion and aloe. Tampons soaked in propolis tincture are placed in the sore ear. Warming compresses are not used for purulent otitis.

Herbal medicine in the treatment of otitis media has been heavily criticized by many physicians because the purported anti-inflammatory properties could not be tested or confirmed in vitro.[ 22 ],[ 23 ]

Homeopathy

The study of the effects of homeopathic treatment of otitis media is scant and its quality is limited. [ 24 ] Homeopathy in this case will not replace antibacterial treatment, but will promote a faster recovery. Among such homeopathic preparations are "Chamomilla", "Magnesia phosphorica", "Mercurius", "Gepar sulfur", which will relieve severe pain, pulsation, and tinnitus. The dosage is determined by the homeopath individually, but general recommendations include the following scheme: 3 granules from the 12th to the 30th potency every 4 hours until the condition improves.

Surgical treatment

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

Prevention

Preventive measures include strengthening the baby's body's defenses, avoiding hypothermia, and a balanced diet. The child should be taught to blow his nose correctly so that nasopharyngeal infections do not get into the ear: blow each nostril separately.

Forecast

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