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Home , Otitis media

LINVITED ARTICLE UPPER RESPIRATORY TRACT - MEDIA, AND HMLOh

ABSTRACT Management of the patient with , sinusitis or pharyngotonsillitis is based on information about the host, the organism and the antimicrobial agent. Otitis media (0M) is a common in children but selected children have recurrent and chronic OM. The predomi- nant organisms responsible for OM are , and catarrhalis. Changes in the antimicrobial susceptibility govern the choice of antimicrobial agents. Surgical treatment should be considered if the child has persistent in both . Sinusitis shares with OM similar pathogenesis, microbiology and choices of antimicrobial therapy. Endoscopic surgery is the treatment of choice for chronic sinusitis. Pharyngitis may be either viral or bacterial in origin. Penicillin remains the treatment of choice for bacterial pharyngotonsillitis. In patients with recurrent infection, the emergence of B-lactamase producing strains has to be considered and erythromycin or oral cephalosporins might be indicated.

Keywords: 8-lactamase, recurrent, , surgery.

SINGAPORE MED A 1995; Vol 36: 428-431

Upper respiratory tract infections (URTIs) are the most Table I - Risk factors associated with recurrent otitis common human infections. Management of patients with otitis media media, sinusitis or pharyngitis is based on information about the host, the organism and the antimicrobial agent. Male gender Native American or Alaskan or Canadian Eskimo OTITIS MEDIA (OM) Otitis media is a bacterial infection of the middle cleft. Sibling or parent history of recurrent ear infections Acute Otitis Media is one of the most frequently diagnosed Early onset at time of initial episode of acute otitis media infectious diseases of childhood, but becomes less frequent Not breast fed with advancing age. The annual OM incidence ranges between In group day care 14% and 62%or. Acute OM usually follows a viral URTI which results in Altered host defence: anatomical, physiologic or congestion of the respiratory mucosa throughout the immunologic respiratory tract. Congestion of the eustaehian tube leads to Exposure to environmental antigens () or pollutants accumulation of middle car secretions. Microbial (tobacco smoke) proliferate in the secretions and result in a suppurative and symptomatic otitis mediata. Effusion persists in the middle to drain. There is with the ear for weeks to months after every episode of acute otitis effusion. media. Some children are subject to recurrent OM and chronic can be isolated from the middle ear fluid in 50- OM with effusion. Longitudinal studies have provided 70% of cases with acute OM. The predominant pathogens in information regarding the characteristics of children who have children are (20-40%), recurrent OM (Table I)trl. Haemophilus influenzae (10-30%) and The diagnosis of acute OM is made based on clinical (5-15%)t'1.sr. In a recent study on acute OM in adults, H. findings of inflammatory changes of the tympanic membrane influenzae and S. pneumoniae were the two most common and acute purulent effusion in the middle ear plus associated organisms isolated with only 9% of the isolates producing 13- symptoms such as earache and . The tympanic membrane lactamaset6r. During the past 10 years, there has been an appears erythematous in the early stage and appears opaque, increase in the prevalence of penicillin -resistant S. full or bulging with diminished mobility due to accumulations pneumoniae in acute OM and a progressive rise in the of purulent effusion in the middle ear as the infection percentage of ß-lactamase producing H. influenzae and M. progresses. The membrane may rupture allowing the effusion catarrhalistsr. Microbiological efficacy should be defined for each bacterial by the cultures of pretreatment middle Department of Infectious Disease car aspirates. Communicable Disease Centre Adults and children with acute OM should be treated with Tan Tock Seng Hospital . The antimicrobial of choice for initial empiric Moulmein Road therapy is for 10 days since it is inexpensive and Singapore 1130 provides coverage for the majority of the relevant organisms. H M L Oh, MBBS, M Med (Int Med), MRCP (UK) Second -line therapeutic agents should be used in patients Consultant who are responding poorly to treatment with amoxicillin and

428 include axetil, amoxicillin-clavulanate, respiratory tract infection or chronic nasal allergy ie nasal and -sulphamethoxazole. Second -line agents polyps and large "blue" inferior turbinatcs. The presence of should also be used in patients with penicillin hypersensitivity, yellow or green discharge in the middle or superior meatus in patients at high risk of complications (such as diabetic or with oedematous and erythematous mucosa is diagnostic. immunocompromised individuals) or if the organisms are Palpation and percussion of the acutely invoked sinuses may resistant to amoxicillin. Recent studies have shown that a reveal tenderness. Ophthalmologic examination is essential in shorter duration of treatment may be effectivet8.'t. patients with sinus disease and orbital or intracranial A significant improvement should occur within 48-72 complications (Table III). hours. If such a response is not observed, the patient should

be evaluated for the possibility of complications (Table II). Table III - Complications of sinusitis Some patients may develop persistent otitis media with middle car effusion despite 2 courses of antibiotics and a minority I. Mucoceles - chronic cystic lesion of the paranasal may develop chronic OM. sinuses 2. Orbital complications - result from direct extension Table II - Complications of otitis media through neurovascular foramina or through bone

Intratcinporal Inflammatory edema - lid edema Orbital cellulitis Petrositis Subperiostial - globe displaced downwards Facial palsy and laterally Labyrinthitis Orbital abscess - exophthalmos and chemosis, Intracranial complete ophthalmoplegia Extradural abscess Cavernous sinus thrombosis - bilateral eye findings Subdural abscess Sigmoid sinus thrombophlebitis 3. Intracranial complications - result from direct Cerebral abscess extension, septic thrombophlebitis and haematogenous Otitis hydrocephalus spread Meningitis Current recommendations for paediatric otitis media with Epidural abscess effusion persisting for >_ 3 months include a 2-3 week course Subdural empyema of antibiotics with or without 7 -day regimen of prednisolone. Venous sinus thrombosis the If child fails to improve and especially so if there is Cerebral abscess persistence of conductive hearing loss of 30dB or more in both ears, then surgical treatment should be considered. This The presence of sinus inflammation with fluid can be includes myringotorny with insertion and confirmed by: adenoidectomyt10t. Before embarking on surgical a treatment, I. transillumination in patients older than 10 years search for an underlying cause like paranasal sinusitis should 2. radiographic findings (such as complete or partial be made. Ear drops (antibiotic/steroid) are sometimes used in opacification, mucosal swelling of at least 5mm or an air - persons with chronic suppurative OM, but car drops have the fluid level), or potential to cause complications and . 3. needle aspiration of the sinus cavity yielding bacteria in Chemoprophylaxis with a sulphonamide or amoxicillin high density (colony count of at least 104 bacteria/ml)tl'). has been effective in children with recurrent otitis media, reducing new episodes by 40% to 90%t1°1. Conventional CT scanning is helpful in evaluating the and extent of disease in patients with chronic SINUSITIS sinusitis and in patients requiring surgical intervention. CT Approximately 0.5% of common colds are complicated by scans arc excellent for defining bony anatomy. However the development of paranasal sinusitis. Sinusitis is one of the magnetic resonance imaging (MRI) and CT scans tend to most common infectious diseases seen in outpatient clinics. overexaggeratc the extent of soft tissue involvement in Normal sinus function is related to 3 factors: sinusitis. MRI is worse in this respect. 1. patency of the sinus ostia Most acute sinus infections in adults and children are 2. function of epithelial cilia, and caused by Streptococcus pneumonlae, non-typable 3. quality of secretions which arc required for the normal Haemophilus influenzae, Moraxella catarrhalis and Group A functions of cilia. Ostial obstruction leads to negative beta -haemolytic streptococcit" .' t. Staphylococci and intrasinal pressure resulting in bacterial invasion of a respiratory anaerobes are usually present in chronic normally sterile sinus cavity. The most commonly sinusnist141. involved sinus is the maxillary sinus. Medical treatment of acute sinusitis is generally indicated. Occasionally antral washout under antibiotic cover is Patients with sinusitis usually complain of in necessary to relieve the congestion and pain and to prevent the area of the involved sinus, , purulent complications. In the presence of intraorbital or intracranial rhinorrhoea, postnasal drip, productive and pharyngitis. complications, open or endoscopie drainages" .1Gt combined Pertinent historical features include recent upper respiratory with antimicrobial treatment are required. Several tract infections, trauma, allergy, swimming, flying, dental antimicrobial agents or drug combinations are licensed repair and recent work in a poorly ventilated area with volatile internationally with approved indication for sinusitis treatment or noxious material. (Table IV). In uncomplicated cases, amoxicillin is appropriate Physical examination may yield signs of recent upper as it is active in the majority of uncomplicated acute sinusitis

429 with an overall cure rate of 80% in one study". be made by direct antigen tests (DAT) and throat cultures. A Trimethoprim-sulphamethoxazole is efficacious in adults with small but highly significant fraction of patients with acute acute maxillary sinusitis as well as paediatric acute bacterial streptococcal pharyngitis/tonsillitis progress to develop sinusitis. This antimicrobial agent may, however, be complications (Table V). ineffective in patients with Group A streptococcal pharyngitisp8r. 'fable V - Complications of streptococcal pharyngotonsillitis Table IV - Antimicrobial drugs licensed internationally with indications for treatment of sinusitis 1. Suppurative peritonsillar abscess Beta-lactams Cephalosporins Macrolides and retropharyngeal abscess sulphonamides suppurative cervical lymphadenitis Amoxicillin Cefaclor Trimethoprim + otitis media sulphamethoxazolc sinusitis mastoiditis Amoxicillin + Cefuroxime Erythromycin + Clavulanatc Cefixime sulphisoxazole 2. Toxin mediated Cefprozil scarlet fever streptococcal toxic shock -like syndrome (TSLS) - hypotension and multisystem (organ) failure is expected in 48 to 72 hours after Clinical improvement 3. Nonsuppurative (presumably immune -mediated) initiating treatment with the appropriate antimicrobial agent. post -streptococcal glomerulonephritis In general, antibiotics are continued for 2 to 3 weeks. Broader rheumatic fever spectrum beta-lactam and cephalosporins are available to treat amoxicillin nonresponders and chronic sinusitis. Further The treatment of viral pharyngitis is rest, an and treatment should be guided by bacterial culture sensitivity such as acetaminophen or aspirin, plus plenty of liquids, results. including intravenous fluids, if necessary. Penicillin V has Adjuvant treatment with saline nose drops, long been regarded as the treatment of choice in bacterial (oral and nose drops) and mucolytics have not been properly pharyngotonsillitis. In Sweden, the recommended dosage in evaluated in subjects with acute bacterial sinusitis. Current the treatment of streptococcal pharyngotonsillitis in an adult lavage include: indications for antral aspiration and is 12.5 mg/kg body weight twice a day for 10 dayst2'r. 1. sinusitis in an immunocompromised or chronically Streptococci arc not easily eliminated as they are able to debilitated host, "hide" within the tonsillar crypts which are not easily 2. failure of resolution of symptoms after 24 to 48 hours of accessible to antibiotics. In the penicillin -sensitive patients, empiric antibiotic therapy, one may consider erythromycin 500mg qid for 10 days or 3. progression of symptoms while on antibiotics, one of the newer maciolides or newer cephalosporins. 4. an orbital or intracranial of maxillary After treatment with penicillin, approximately 10% of sinusitis, patients will have recurrence within 2 weeks and as many as 5. refractory chronic sinusitis. 25% of patients will have recurrence within 2 months. Recurrent pharyngitis is a multifaceted problems. Patient The treatment for chronic sinusitis is surgery. Endoscopie compliance, inadequate length of treatment, bacterial tolerance sinus surgery is generally accepted as the treatment of choice. to penicillin, emergence of beta-lactamase producing bacteria and erythromycin resistant beta -streptococci have been cited PHARYNGITIS (PHARYNGOTONSILLITIS) as reasons for recurrence. Tonsillitis is defined as inflammation of the tonsils and Certain alpha -streptococci have shown the ability to emit viral of bacterial in pharyngitis. Pharyngitis may be either a bacteriocin with the capability to influence the growth of origin. that commonly cause pharyngitis include certain beta -streptococci. Reimplantation of alpha -streptococci , herpes simplex, Coxsackie A viruses, Epstein -Barr with high interference capacity were recently shown to have (EBV) and cytomegalovirus (CMV). Bacterial some protective effect in patients with recurrent streptococcal by A beta - pharyngitis is almost always caused Group tonsil 1itis92r. haemolytic streptococcus (Streptococcus pyogenes). Other The objective of treatment of recurrent pharyngotonsillitis and causative bacteria include Group C and G streptococci, is to lower frequency of recurrences anti to avoid a beta-lactamase-producing Morarella catarrhalisun. tonsillectomy. Tonsillectomy is performed for recurrent Streptococcal pharyngitis uncommonly occurs below the infection confined to the tonsils. Erythromycin or oral 15% 20% age of two and beyond age 50. By school age, to cephalosporins might be considered antibiotics of choice for of children apparently harbour group A streptococci in the patients with recurrent pharyngitis. Studies by Paradise et al throat. The peak incidence of streptococcal pharyngitis is 5- have pointed out the importance of using strict criteria for 8 and 11-13 years of age. It usually results from contact with tonsillectomyC». However, because the indications for individuals who have active or convalescent disease. It is tonsillectomy remain controversial, each patient must be nasal Viral spread by droplets of saliva or secretion/2pt. considered on a case -by -case basis. pharyngitis can occur at any age but it seems less common with increasing age. ACKNOWLEDGEMENTS with pharyngitis usually complains of a severe The patient I wish to thank Dr A B John for reading through the original , and sometimes headache, fever, chills manuscript and for his useful comments. I also with to thank and . The diagnosis of streptococcal pharyngitis can Ms Nor'ain Bte Mohd Yusoff for typing this manuscript.

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