Guía de práctica clínica para el diagnóstico y el tratamiento de la otitis media aguda en niños / Clinical practice guidelines for diagnosis and management of acute otitis media in children

Resumen Introducción: La otitis media aguda (OMA) es uno de los padecimientos agudos más prevalentes en la población pediátrica a escala global. El objetivo de este trabajo fue elaborar una guía de práctica clínica con recomendaciones para asistir la toma de decisiones de médicos especialistas, pacientes, cuidadores de pacientes y elaboradores de políticas públicas involucrados en el manejo de la OMA en niños. Métodos: El documento ha sido desarrollado por parte del Colegio de Otorrinolaringología y Cirugía de Cabeza y Cuello Pediátricas de México (COPEME) en cumplimiento con los estándares internacionales. Se empleó la clasificación de calidad de la evidencia de SIGN. En representación del COPEME, se integró el Grupo de Desarrollo de la Guía (GDG), que incluyó otorrinolaringólogos, infectólogos, pediatras, médicos generales y metodólogos con experiencia en revisiones sistemáticas de la literatura y el desarrollo de guías de práctica clínica. Resultados: Se consensuaron 18 preguntas clínicas que abarcaron lo establecido previamente por el GDG en el documento de alcances de la Guía. Se identificó la evidencia científica que responde a cada una de estas preguntas clínicas y se evaluó críticamente. El GDG acordó la redacción final de las recomendaciones clínicas mediante la técnica Delphi de panel. Se llevó a cabo una validación externa por colegas especialistas y representantes de pacientes. Conclusiones: En esta Guía de Práctica Clínica se presentan recomendaciones clínicas para la prevención, el diagnóstico y el manejo de la OMA, con el fin de asistir la toma de decisiones compartidas entre médicos, pacientes y cuidadores con la intención de contribuir a mejorar la calidad de la atención clínica.

Abstract Background: Acute otitis media (AOM) is one of the most prevalent acute conditions in the pediatric population worldwide. This work aimed to elaborate a Clinical Practice Guideline with clinical recommendations systematically developed to assist decision-making of specialists, patients, caregivers, and public policymakers involved in managing patients with AOM in children. Methods: This document was developed by the College of Pediatric Otorhinolaryngology and Head, and Neck Surgery of Mexico (COPEME) in compliance with international standards. The SIGN quality of evidence classification was used. On behalf of the COPEME, the Guideline Development Group (GDG) was integrated, including otolaryngologists, infectologists, pediatricians, general practitioners, and methodologists with experience in systematic literature reviews and the development of clinical practice guidelines. Results: A consensus was reached on 18 clinical questions, covering what was previously established by the GDG in the scope document of the guidelines. Scientific evidence answering each of these clinical questions was identified and critically evaluated. The GDG agreed on the final wording of the clinical recommendations using the modified Delphi panel technique. Specialists and patient representatives conducted an external validation. Conclusions: This Clinical Practice Guideline presents clinical recommendations for the prevention, diagnosis, and management of AOM to assist shared decision-making among physicians, patients, and caregivers and improve the quality of clinical care.

What is the effectiveness of beta-glucan for treatment of acute otitis media? / Qual é a eficácia do beta-glucano no tratamento da otite média aguda?

Abstract Introduction: As a supplement, beta-glucan has various therapeutic healing effects generated by the immune cells. It has been scientifically approved and proven to be a biological defense modifier. The aim of this study was to investigate the effects of beta-glucan on treatments administered in an acute otitis media model Objectives: This study investigated the effect of beta-glucan on the treatment of acute otitis media in an acute otitis media -induced animal model. Efficacy was evaluated both immunologically and histologically. Methods: The study sample comprised 35 adult rats, randomly separated into 5 groups of 7: Group 1 (control), Group 2 (acute otitis media, no treatment), Group 3 (acute otitis media + antibiotic), Group 4 (acute otitis media + beta-glucan) and Group 5 (acute otitis media + beta-glucan + antibiotic). Analyses were made of the histopathology and immunology examination results in respect of thickening of the tympanic membrane, epithelium damage, inflammation, and sclerosis. In all groups the serum levels of TNF-α, IL-4, IL-6 and IL-1β were evaluated. Results: All serum cytokine levels were significantly lower in the beta-glucan and antibiotictreated groups compared to the acute otitis media Group. Significant differences in tympanic membrane thickness, inflammation, epithelium damage, and sclerosis values were observed between the acute otitis media + antibiotic and acute otitis media + beta-glucan Groups. According to these parameters, the values in aute otitis media + antibiotic + beta-glucan Group were markedly lower than those of the other groups. There was a significant difference in the acute otitis media + antibiotic + beta-glucan Groups compared to acute otitis media Group (p < 0.001). Conclusions: Both antibiotic and beta-glucan treatment reduced acute otitis media signs of inflammations in an acute otitis media-induced rat model, decreasing histological damage and cytokine levels. Co-administration of antibiotic and beta-glucan led to a significant reduction in tympanic membrane thickness, inflammation, and epithelium damage. Antibiotic + beta-glucan treatment resulted in a greater decrease in tympanic membrane thickness, inflammation, and epithelium damage than in the other groups. From these results, it can be suggested that beta-glucan, in combination with antibiotics may provide an alternative for the treatment of acute otitis media.

Resumo Introdução: Como suplemento, o beta-glucano apresenta vários efeitos terapêuticos gerados pelas células imunológicas. Cientificamente aprovado, mostrou ser um modificador de defesa biológica. Objetivo: Investigar os efeitos do beta-glucano nos tratamentos administrados em um modelo de otite média aguda induzida em um modeloanimal. A eficácia foi avaliada imunológica e histologicamente. Método: A amostra do estudo foi composta por 35 ratos adultos, divididos aleatoriamente em 5 grupos de 7: grupo 1 (controle), grupo 2 (otite média aguda, sem tratamento), grupo 3 (otite média aguda + antibiótico), grupo 4 (otite média aguda + beta-glucano) e grupo 5 (otite média aguda + beta-glucano + antibiótico). Foram feitas análises dos resultados dos exames histopatológicos e imunológicos em relação ao espessamento da membrana timpânica, dano ao epitélio, inflamação e esclerose. Os níveis séricos de TNF-α, IL-4, IL-6 e IL-β foram avaliados em todos os grupos. Resultados: Todos os níveis séricos de citocinas foram significativamente mais baixos nos grupos tratados com beta-glucano e antibióticos em comparação com o grupo otite média aguda. Diferenças significativas na espessura da membrana timpânica, inflamação, dano do epitélio e esclerose foram observadas entre os grupos otite média aguda + antibiótico e otite média aguda + beta-glucano. De acordo com esses parâmetros, os valores no grupo otite média aguda + antibiótico + beta-glucano foram acentuadamente inferiores aos dos demais grupos. Houve uma diferença significante no grupo otite média aguda + antibiótico + beta-glucano em comparação ao grupo otite média aguda (p < 0,001). Conclusão: Ambos os tratamentos com antibiótico e com beta-glucano reduziram os sinais de inflamação da otite média aguda em um modelo de rato com otite média aguda induzida, diminuíram os danos histológicos e os níveis de citocinas. A administração concomitante de antibiótico e beta-glucano levou a uma redução significativa na espessura da membrana timpânica, inflamação e danos ao epitélio. O tratamento com antibióticos + beta-glucano resultou em maior diminuição na espessura da membrana timpânica, inflamação e danos no epitélio do que nos outros grupos. A partir desses resultados, pode-se sugerir que o beta-glucano, em combinação com antibióticos, pode fornecer uma opção para o tratamento da otite média aguda.

Crisis febril como manifestación inicial de COVID-19 / Febrile crisis as initial manifestation of COVID-19

Introducción: La COVID-19 es una enfermedad que ha mostrado una baja morbilidad y mortalidad en pediatría. Las crisis febriles constituyen una de las causas más frecuentes de admisión en los servicios de urgencia y de interconsultas con el neuropediatra. Objetivo: Interpretar la presencia de crisis febril simple en pacientes admitidos en servicios de urgencia pediátricos como manifestación inicial de COVID-19. Presentación del caso: Paciente femenina de un año de edad, con antecedentes de salud anterior que acude al cuerpo de guardia con fiebre de 38 ℃; y crisis motora, de inicio generalizada, tónico-clónica, que cedió con medidas antitérmicas. Por protocolo se realiza punción lumbar la cual resulta negativa. Se ingresa, 24 horas después comienza con manifestaciones catarrales, se hace otoscopia y se diagnostica una otitis media aguda, por lo que se inicia tratamiento antibiótico. Se realiza la prueba de reacción en cadena de la polimerasa para la COVID-19 con resultado positivo, por lo que se remite para el Hospital Pediátrico San Miguel del Padrón. Conclusiones: Se debe sospechar la presencia de COVID-19 ante paciente que acude a servicio de urgencias por una crisis febril, como único problema de salud. LA COVID-19 es una enfermedad que ha demostrado que se puede presentar de diversas formas(AU)

Introduction: COVID-19 is a disease that has shown low morbidity and mortality in pediatrics. Febrile crises are one of the most common causes of admission to emergency services and consultations with the neuropediatrician. Objective: Interpret the presence of simple febrile crisis in patients admitted to pediatric emergency services as an initial manifestation of COVID-19. Case presentation: One-year-old female patient, with a previous health history, who is attended in the emergency service with a fever of 38 ℃; and motor crisis, of widespread onset, with tonic-clonic seizures, which yielded with antypiretic measures. By protocol, lumbar puncture is performed which is negative. She was admitted, and 24 hours later there is an onset of catarrhal manifestations; an otoscopy is performed and acute otitis media is diagnosed, so antibiotic treatment is initiated. The polymerase chain reaction test for COVID-19 (PCR) is performed with a positive result, so, the patient is referred to the San Miguel del Padrón Pediatric Hospital. Conclusions: COVID-19 should be suspected in patients who attend to the emergency services due to a febrile crisis as the only health problem. COVID-19 is a disease that has been shown to occur in a variety of ways(AU)

Manejo de Otitis Media Aguda en los Servicios de Pediatría y Otorrinolaringología y Cirugía de Cabeza y Cuello del Hospital de Clínicas / Treatment of Acute Otitis Media in the Pediatrics and Otorhinolaryngology, Head and Neck services in the Clinical Hospital

La otitis media aguda (OMA) es una patología muy común en pediatría y constituye la indicación más frecuente de prescripción de antibióticos en la infancia. Para el diagnóstico se tienen en cuenta hallazgos en la otoscopia, diversos signos clínicos y el tiempo de evolución de los síntomas principales. La decisión de iniciar antibioticoterapia debe determinarse según cada paciente. La espera vigilante como alternativa a la antibioticoterapia inmediata en casos seleccionados reduce el uso de antibióticos sin aumentar el riesgo de daño al paciente y ha demostrado ser una medida costo-efectiva. El fármaco de elección para el tratamiento empírico de la OMA es la amoxicilina, aunque según nuestros resultados es la amoxicilina-IBL la utilizada como primera línea en ambos servicios.

Acute otitis media (AOM) is a pathology commonly found in pediatrics, and the most frequent cause of antibiotics prescription in infants. For its diagnostics, several criteria are taken in consideration, such as otoscopy observations, diverse clinical signs, and the time of evolution of the main symptoms. The decision to initiate antibiotic therapy must be determined particularly for each patient. As an alternative to immediate antibiotic therapy, watchful waiting is preferred in certain cases to reduce the antibiotic use without elevating the patients' risk and has been proven to be a cost-effective approach. The preferred drug for empiric antibiotic therapy in AOM is amoxicillin, although we have observed that the first choice in both our services, pediatrics and otorhinolaryngology, is amoxicillin-IBL.

Clinical characteristics and risk factors of acute otitis media in infants under one-year-old / 上海交通大学学报（医学版）

Objective: To analyze the symptoms and signs of acute otitis media (AOM) in infants under one-year-old and the risk factors of AOM. Methods: Care information and clinical characteristics of a total of 304 full-term delivery infants with normal hearing who were examined in Shanghai Children's Hospital from January to December 2018 were included in the analysis. All infants were followed up to one-year-old and the clinical characteristics of AOM infants were collected. χ2 test was used to analyze whether there was a statistically significant difference between the AOM group (AOM infants) and the control group (infants without AOM) in terms of feeding status, daily care, going out, living environment, pneumococcal vaccination, and so on. Logistic regression model was used to explore the risk factors for AOM in infants under one-year-old. Results: In 304 infants, 177 developed AOM, and the age of AOM infants was (5.65±2.03) months. Compared with the control group, AOM group had higher rates of spitting up milk (P=0.000), frequent ears digging (P=0.021), participation in early education activities (P=0.000) and recurrent respiratory infection (P=0.000), and lower rate of pneumococcal vaccination (P=0.000). Logistic regression analysis showed that vomiting (OR=2.774, P=0.002), participation in early education activities (OR=3.785, P=0.000) and recurrent respiratory infection (OR=3.638, P=0.000) were risk factors for AOM in infants, and pneumococcal vaccination was a protective factor (OR=0.320, P=0.000). Conclusion: AOM is a high-incidence disease in infants under one-year-old in Shanghai. Insisting on scientific feeding position, reducing spitting and paying attention to the extra protection when participating in public activities such as early education may reduce the occurrence of AOM. Pneumococcal vaccination may help prevent AOM.

Drug use in acute otitis media: a prospective study at a tertiary care teaching hospital

Background: Drug use study identifies the problems that arise from prescription and highlights the current approaches to the rational use of drugs. The objective of the study was to assess drug use pattern in patients diagnosed of acute otitis media in tertiary care teaching hospital.Methods: This prospective observational study was carried in the Otorhinolaryngology department of a tertiary care teaching hospital over a period of twelve months. The data collected for patients with acute otitis media included the patient's demographic details and the drugs prescribed. Data were analysed for drug use pattern and cost per prescription and assessment of rationality of prescription.Results: Total 153 patients were analysed, 100 (65.35%) belonged to male patients and 53 (34.65%) belonged to female patients. Children less than 2years age were the most diagnosed with AOM 47.71%, the major diagnostic symptoms were earache (58.16%) and fever (54.90%) and signs were congestion (52.94%) and discharge (43.13%). In a total 153 prescriptions (469 drugs), 33.68% were antimicrobials, followed by mineral supplements (23.67%). Average number of drugs per prescription was found to be 3.0. Most common antibiotic prescribed was amoxicillin (with or without clavulanate) in 142 (92.81%) patients. Paracetamol alone or in fixed dose combination with antihistaminics were prescribed in 131 patients. Average cost per prescription was 87.74(±35.67) Indian rupees. Seventeen (11.11%) prescriptions were rational in all the aspects based on standard guidelines.Conclusions: The present study showed that paracetamol and amoxicillin with or without clavulanate were mostly commonly prescribed in children with AOM. Irrational prescribing was seen in maximum number of cases.

Aspectos clínicos y bacteriológicos de las mastoiditis agudas como complicación de otitis media aguda y crónica en pediatría, Experiencia en 10 años / Clinical and bacteriological features of acute mastoiditis as a complication of acute and chronic otitis media in pediatrics. A 10-years experience

Antecedentes. Cualquier paciente pediátrico o adulto que presente otitis media aguda (OMA) u otitis media crónica (OMC), particularmente colesteatomatosa, puede desarrollar complicaciones intratemporales y endocraneales, especialmente mastoiditis aguda (MA). Objetivo. Describir las características clínicas y bacteriología de los pacientes asistidos por MA como complicación de OMA y OMC. Lugar de aplicación: Servicio de Otorrinolaringología. Hospital de Pediatría Juan P. Garrahan. Diseño. Descriptivo, retrospectivo, transversal y observacional. Población. Pacientes con mastoiditis aguda por OMA y por OMC asistidos en el Servicio de ORL durante 10 años. Material y métodos. Revisión de historias clínicas de todos los pacientes tratados entre enero de 1999 y diciembre de 2008. Resultados. Se estudiaron 57 pacientes con MA, 40/57 por OMA y 17/57 por OMC. Hubo 40 niños hospitalizados con signos y síntomas de MA por OMA. Se diagnosticó complicación endocraneal en el 12,5% (5/40) de los casos. Los aislamientos bacterianos más frecuentes fueron Streptococcus pyogenes, Streptococcus pneumoniae, H. influenzae y Turicella otitidis. Se registraron 17 casos de niños hospitalizados con diagnóstico de MA y OMC. Ocurrieron complicaciones supurativas intracraneales en el 35,3% (6/17) de los casos. Los aislamientos bacterianos más frecuentes fueron las enterobacterias, P. aeruginosa y los gérmenes anaerobios. Conclusión. El diagnóstico de tipo y estadio de otitis media previa o coexistente a la complicación es fundamental para encarar el tratamiento antimicrobiano empírico inicial, sospechar complicaciones endocraneales asociadas y proponer procedimientos quirúrgicos menores, medianos o mayores oportunamente (AU)

Background. Any pediatric or adult patient presenting with acute otitis media (AOM) or chronic otitis media (COM), especially cholesteatomatous, may develop intratemporal and intracranial complications, mainly acute mastoiditis (AM). Objective. To describe the clinical and bacteriological features of patients seen for AM as a complication of AOM and COM. Setting: Department of Otolaryngology, Hospital de Pediatría Juan P. Garrahan. Design. A descriptive, retrospective, cross-sectional, observational study. Population. Patients with AM because of AOM and COM seen at the Department of Otolaryngology over a 10-year period. Material and methods. Review of the clinical charts of all patients treated between January 1999 and December 2008. Results. 57 Patients with AM, 40/57 due to AOM and 17/57 due to COM, were evaluated. Forty children were admitted to hospital with signs and symptoms of AOM-related AM. Intracranial complications were observed in 12.5% (5/40) of the patients. The most frequently isolated pathogens were Streptococcus pyogenes, Streptococcus pneumoniae, H. influenzae, and Turicella Otitidis. Seventeen children were hospitalized because of COM-related AM. Suppurative intracranial complications occurred in 35.3% (6/17) of the cases. The most frequently isolated pathogens were Enterobacteriaceae, P. aeruginosa, and anaerobic bacteria. Conclusion. The diagnosis of type and stage of otitis media prior to or coexisting with the complication is essential to address the initial empirical antimicrobial treatment, associated intracranial complications should be suspected and minor, intermediate, or major surgical procedures should be proposed at the appropriate time (AU)

Bacterias causantes de otitis media aguda antes y después de la aplicación de la vacuna antineumococica 13-valente / Acute otitis media-causing bacteria before and after the application of the 13-valent pneumococcal conjugate vaccine

Los microorganismos más frecuentemente responsables de la otitis media aguda (OMA) (Streptococcus pneumoniae y Haemophilus influenzae) son los mismos en los países en vías de desarrollo que en los desarrollados. En los países que administraron la vacuna antineumocócica conjugada, los neumococos disminuyeron como causa de OMA, pero con el tiempo comenzaron a resurgir, sobre todo a expensas de cepas pertenecientes a serotipos no incluidos en la vacuna. El objetivo de este trabajo fue documentar el cambio generado en la bacteriología de la OMA a partir de la incorporación en el calendario oficial argentino de la vacuna conjugada antineumocócica 13-valente en el año 2012. Se realizaron dos estudios prospectivos, descriptivos, transversales, uno previo a la incorporación de la vacuna al calendario nacional (mayo 2009-agosto 2010) donde la población estudiada no se encontraba cubierta para S. pneumoniae y otro posterior, donde la mayoría de los pacientes se encontraban inmunizados (enero-diciembre 2016). Se obtuvieron 433 muestras de 324 pacientes en el primer período y 461 de 246 pacientes en el segundo. Se aisló un total de 326 bacterias en el primer período y 388 en el segundo. Los microorganismos respectivamente aislados en ambos períodos fueron S. pneumoniae (39,5-21,1%), H. influenzae (37,4-44,6%), Moraxella catarrhalis (6,1-7,5%), Staphylococcus aureus (8,6-9,8%), Streptococcus pyogenes (3,0-5,9%), Turicella otitidis (1,8-2,1%), Pseudomonas aeruginosa (0,9-4,1%) y otros (2,4-4,9%). Los neumococos pertenecientes a serotipos vacunales sufrieron una disminución significativa, especialmente el 6A, 9V, 14, 18C, 19A, mientras que los serotipos no vacunales aumentaron significativamente, en particular el 15B, el 11A, el 7C, el 16F y el 22F (AU)

Organisms most frequently responsible for acute otitis media (AOM) (Streptococcus pneumoniae and Haemophilus influenzae) are the same in developing countries as in developed ones. In countries that administered the pneumococcal conjugate vaccine, pneumococci decreased as a cause of AOM, but over time began to re-emerge, especially due to strains belonging to serotypes not included in the vaccine. The objective of this work was to document the change generated in the bacteriology of the OMA from the incorporation of the 13-valent pneumococcal conjugate vaccine in 2012 in the official Argentinean calendar. Two prospective, descriptive, cross-sectional studies were carried out prior to the incorporation of the vaccine into the national calendar (May 2009-August 2010), where the population studied was not covered for S. pneumoniae and a subsequent one, where most of the patients were immunized (January 2016-December 2016). We obtained 433 samples from 324 patients in the first period and 461 from 246 patients in the second. A total of 326 bacteria were isolated in the first period and 388 in the second. The microorganisms respectively isolated in both periods were S.pneumoniae (39.5-21.1%), H.influenzae (37.4-44.6%), Moraxella catarrhalis (6.1-7.5%), Staphylococcus aureus (8.6-9.8%), Streptococcus pyogenes (3.0-5.9%), Turicella otitidis (1.8-2.1%), Pseudomonas aeruginosa (0.9-4.1%) and others (2.4-4.9%). Pneumococci belonging to vaccine serotypes suffered a significant decrease, especially 6A, 9V, 14, 18C, 19A, while nonvaccine serotypes increased significantly, particularly 15B, 11A, 7C, 16F, and 22F (AU)

How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel / Como evitar o uso inadequado de antibióticos nas infecções de vias aéreas superiores? Posição de um painel de especialistas

Abstract Introduction: Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. Objectives: To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. Methods: A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. Results: Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. Conclusions: Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.

Resumo Introdução: A resistência bacteriana a antibióticos nos processos infecciosos é um fato crescente nos últimos anos, especialmente devido ao seu uso inapropriado. Ao longo dos anos vem se tornando um grave problema de saúde pública devido ao prolongamento do tempo de internação, elevação dos custos de tratamento e aumento da mortalidade relacionada às doenças infecciosas. Quase a metade das prescrições de antibióticos em unidades de pronto atendimento é destinada ao tratamento de alguma infecção de vias aéreas superiores, especialmente rinossinusites, otite média aguda supurada e faringotonsilites agudas, sendo que uma significativa parcela dessas prescrições é inapropriada. Nesse contexto, os otorrinolaringologistas têm um papel fundamental na orientação de pacientes e colegas não especialistas, para o uso adequado e racional de antibióticos frente a essas situações clínicas. Objetivos: Realizar uma revisão das atuais recomendações de utilização de antibióticos nas otites médias, rinossinusites e faringotonsilites agudas adaptadas à realidade nacional. Método: Revisão na base PubMed das principais recomendações internacionais de tratamentos das infecções de vias aéreas superiores, seguido de discussão com um painel de especialistas. Resultados: Os antibióticos devem ser utilizados de maneira criteriosa nas infecções agudas de vias aéreas superiores não complicadas, a depender da gravidade da apresentação clínica e dos potenciais riscos associados de complicações supurativas e não supurativas. Conclusões: Constantes revisões a respeito do tratamento das principais infecções agudas são necessárias para que sejam tomadas medidas coletivas no uso racional e apropriado de antibióticos. Somente com orientação e transformações no comportamento de médicos e pacientes é que haverá mudanças do paradigma de que toda infecção de vias aéreas superiores deva ser tratada com antibióticos, minimizando por consequência os efeitos de seu uso inadequado.

A prospective observational cohort study to assess the incidence of acute otitis media among children 0-5 years of age in Southern Brazil

Abstract Objectives: To estimate acute otitis media incidence among young children and impact on quality of life of parents/caregivers in a southern Brazilian city. Methods: Prospective cohort study including children 0-5 years of age registered at a private pediatric practice. Acute otitis media episodes diagnosed by a pediatrician and impact on quality of life of parents/caregivers were assessed during a 12-month follow-up. Results: During September 2008-March 2010, of 1,136 children enrolled in the study, 1074 (95%) were followed: 55.0% were ≤2 years of age, 52.3% males, 94.7% white, and 69.2% had previously received pneumococcal vaccine in private clinics. Acute otitis media incidence per 1000 person-years was 95.7 (95% confidence interval: 77.2-117.4) overall, 105.5 (95% confidence interval: 78.3-139.0) in children ≤2 years of age and 63.6 (95% confidence interval: 43.2-90.3) in children 3-5 years of age. Acute otitis media incidence per 1000 person-years was 86.3 (95% confidence interval: 65.5-111.5) and 117.1 (95% confidence interval: 80.1-165.3) among vaccinated and unvaccinated children, respectively. Nearly 68.9% of parents reported worsening of their overall quality of life. Conclusion: Acute otitis media incidence among unvaccinated children in our study may be useful as baseline data to assess impact of pneumococcal vaccine introduction in the Brazilian National Immunization Program in April 2010.

Otitis media crónica supurada complicada / Complicated chronic suppurative otitis media

Se describe el caso clínico de una paciente de 18 años de edad, con antecedentes de otitis media crónica supurada. Fue ingresada en el Servicio de Otorrinolaringología del Hospital Provincial Docente Clinicoquirúrgico "V.I. Lenin de Holguín" por sospecha clínica de complicación de su enfermedad de base. Se le indicaron estudios según se requieren en estos casos y antibioticoterapia endovenosa. Se comprobó el diagnóstico de otitis media crónica supurada con complicación endocraneana siendo sometida de urgencia a tratamiento quirúrgico (antroaticotomía), teniendo evolución favorable y egresando a los 19 días fuera de peligro.

Describes the clinical case of a patient of 18-year-old with a history of otitis media Chronic suppurative. Clinical and surgical teaching "V.I. Lenin de Holguín" was entered into the service of Otolaryngology of the Provincial Hospital by clinical suspicion of complication of their underlying disease. Studies were identified as required in these cases and intravenous antibiotic therapy. Found the diagnosis of otitis media chronic definition with complication endocranial still undergoing emergency surgical treatment (Antroaticotomy), least favourable and graduating at 19 days out of danger.

Otitis Media Aguda. Un enfoque clínico y terapéutico / Acute otitis media: A clinical and therapeutic approach

Resumen La otitis media aguda (OMA) es una enfermedad con alta prevalencia a nivel mundial principalmente en pacientes en edad pediátrica, debido a factores de riesgo propios del grupo etario, como los factores anatómicos y condiciones ambientales (asistencia a guardería, ausencia de lactancia materna y exposición al humo del tabaco, entre otros). El diagnóstico de certeza de la OMA es clínico y se basa en el inicio súbito del padecimiento, signos y síntomas de otitis media y líquido en el oído medio. El método más certero para evaluar la integridad de la membrana timpánica es la otoscopia simple, aunque la variante neumática es la más efectiva para establecer el compromiso en la movilidad de la membrana timpánica. Para la elección del tratamiento adecuado de la OMA se deben considerar diversos factores, entre ellos la edad del paciente, el estadio clínico, si existen tratamientos previos y el tiempo de evolución. La estrategia "esperar y ver" acompañada de analgésicos sistémicos por 48 a 72 horas disminuye la tasa de prescripción innecesaria de antibióticos en los casos de enfermedad no grave. El tratamiento antibiótico de primera línea, en el caso de que no haya mejoría con la primera estrategia o en forma directa es la amoxicilina a dosis de 80-90 mg/kg, y la combinación de amoxicilina con ácido clavulánico es el siguiente escalón cuando hay falla terapéutica con el primero, y una cefalosporina como la ceftriaxona, cuando se ha tenido falla terapéutica con amoxicilina y otro antimicrobiano previo. El tratamiento recomendado en pacientes alérgicos a la penicilina es claritromicina. La incidencia de complicaciones de la OMA es baja, éstas pueden ser: otitis media recurrente, hipoacusia conductiva, mastoiditis, parálisis del nervio facial, meningitis y absceso cerebral. Se recomienda realizar un seguimiento 3 a 6 meses después de un episodio sin complicaciones.

Abstract Acute otitis media (AOM) is a highly prevalent disease worldwide, primarily in pediatric patients due to the inherent risk factors in their age group, anatomical and environmental conditions such as day care attendance, lack of breastfeeding and exposure to cigarette smoke, among others. The definitive diagnosis of AOM is clinical and is based on a sudden onset of the disease, signs and symptoms of otitis media and fluid in middle ear. The most accurate method to evaluate the integrity of the patient's tympanic membrane is a simple otoscopy, although its pneumatic variant is the most effective tool to determinate loss of tympanic membrane mobility. Several factors, including the patient's age, clinical stage, previous treatment and time evolution should be considered in order to choose the right treatment for AOM. The "wait-and-see prescription" in addition to systemic analgesics for 48-72 hours reduces unnecessary antibiotic prescription in non-severe cases. Amoxicillin 80-90 mg/kg is the first-line antibiotic in case of no improvement with the first strategy. A combination of amoxicillin and clavulanate is the next step when first antibiotic therapy fails. A cephalosporin like Ceftriaxone is indicated in treatment failure with amoxicillin in addition to other previous antimicrobial. The recommended treatment in patients allergic to penicillin is clarithromycin. The incidence of complications of AOM is low, these include: recurrent otitis media, conductive hearing loss, mastoiditis, facial nerve paralysis, meningitis and brain abscess. Monitoring 3-6 months after an episode without complications is recommended.

Clinical observation of budesonide suspension combined with antibiotics in the treatment of children with acute otitis media / 中国基层医药

Objective To observe the clinical efficacy of budesonide suspension combined with antibiotics in the treatment of children with acute otitis media.Methods 256 children with acute otitis media in Shaoxing Central Hospital from January 2016 to December 2016 were selected,and they were randomly divided into observation group and control group by using the method of random number table,128 cases in each group.Both two groups were given antibiotic therapy (azlocillin sodium),on this basis,the observation group was given budesonide suspension,the control group was given chloramphenicol ear drops.At the end of treatment,the treatment effect of the two groups was compared.Results Compared with the control group,the improvement of hearing in the observation group was significantly improved (x2 =21.05,P ＜ 0.01),the rate of tympanic effusion was significandy lower (t =15.30,P ＜ 0.01),and the effective decrease rate of tympanic cavity pressure was significantly higher (t =10.61,P ＜ 0.01).The clinical symptom score of the observation group was significantly reduced,and the degree of improvement was much better than that of the control group (t =16.99,P ＜ 0.01).The onset time and hospitalization time of the observation group were significantly shortened,and the differences were statistically significant (t =13.37,13.89,all P ＜ 0.01).The total effective rate of the observation group was 95.3％,which of the control group was 78.9％,and there was statistically significant difference between the two groups (x2 =20.19,P ＜0.01).The incidence rate of adverse reactions in the observation group was significantly lower than that in the control group,the difference was statistically significant (x2 =8.07,P ＜ 0.05).Conclusion Budesonide suspension combined with antibiotics in the treatment of children with acute otitis media has significant effect,it is conducive to reduce the formation of tympanic effusion,improve children's hearing and treatment effect,and worthy of further clinical application.

The Clinical Application of Eucalyptol, Limonene and Pinene Enteric Soft Capsules in the Treatment of the Prophylaxis of Tympanum Fluid in Secretory Otitis Media in Children / 听力学及言语疾病杂志

Objective To investigate the effects of the eucalyptol,limonene and pinene enteric soft capsules (mucoregulatory agents) in preventing from tympanum fluid in children.Methods A total of 341 children (497 ears) with acute otitis media were randomly divided into two groups:the experimental group and the control group.The experimental group was given symptomatic treatment and oral in-take of the eucalyptol,limonene and pinene enteric soft capsules,while the control group with acute otitis media received conventional symptomatic treatment.All the patients were followed-up 7 and 14 days after treatment.Clinical data were collected,including symptoms,and tympanogram changes.Results Seven days after the initial treatment,tympanum fluid occurred in 110 cases of 170 ears(65.09％,110/170) in the control group,and in 51 cases of 70 ears (29.65％,51/172) in the experimental group.The difference was statistically significant (P＜0.01).After 14 days,41 cases (66 ears)of tympanum fluid occurred in the control group (24.26％,41/169),32 cases(36 ears) of otitis media (18.60％,32/172) occurred in the experimental group.The difference was statistically significant (P＜0.01).In the control group,the tympanum fluid disappeared in 54 cases(60 ears) after regular treatment 72.0％,54/75),and reliefed in 15 cases(22 ears) with irregular treatment (42.86％,15/35).The difference was statistically significant (P＜0.01).Conclusion Eucalyptol,limonene and pinene enteric soft capsules can effectively reduce the incidence of tympanum fluid in children with acute otitis media.Mucoregulatory agents may promote the eduction of effusion.

Diagnostic and Surgical Treatment Outcome of Acute Mastoiditis in Pediatric Age Group.

Background: The incidence of Acute Mastoiditis in children has diminished, but it is not uncommon in clinical practice. Clinical presentation includes a history of otorrhea, pain in the ear, post aural swelling, a shift in pinna position and tenderness over the mastoid. The etiology includes acute and chronic suppurative otitis media, trauma and rarely hematogenous infection. Otoscopy is difficult in this age group due to edema of the EAM skin, pain and non-cooperation. Temporal bone CT scan is very useful in evaluating the pathology in the middle ear cleft such as cortical necrosis, Ossicular erosion and Cholesteatoma. Conservative medical management is useful in tiding over the crisis but surgical exploration of middle ear cleft, eradication of the disease and Tympanoplasty alone leads to cure prevents recurrence. The study aimed at analyzing retrospectively clinical and etio-pathological characteristics of pediatric acute mastoiditis and mastoid abscess in 62 children and to plan a strategy for the management in our Hospital. Methods: Retrospective evaluation of the medical records of 62 children aged below 14 years was scrutinized to record demographic data, history, investigations, etiological factors and treatment outcomes to establish a treatment protocol for future adaptation. Results: 62 patient records were taken up in the present study; patients mean age was 9± 2.4 years. In 18 children (29.03%) previous history of CSOM was reported. All children had clear evidence of post-auricular inflammation. Other clinical features like shift in pinna position, otorrhea, fever and otalgia were noted. Increase in WBC count in 69.35% of the cases, anemia with Hb less than 8 gms% was noted in 19 (30.64%) patients. Total cell count more than 11000 was observed in 69.35% of the patients. C T scan temporal bones in the present study showed 11 (17.74%) children showed signs of Cholesteatoma, clouding of mastoid air cells was noted in 17 (27.41%) and 7 (11.29%) children presented intracranial complications. Immediate medical treatment with 3rd generation parenteral Cephalosporins, NSAIDS was initiated. Abscess drainage was done in 18 (29.03%) children. Cortical Mastoidectomy and/or MRM with Tympanoplasty were performed in 39 (62.90%) of the children. Conclusion: Surgical exploration of the middle ear cleft after initial stabilization of the child with medical treatment gave statistical significant cure rate with low recurrence rate. CT scan was significant in accurately diagnosing the mastoid involvement correlated per operatively in 71.79% of CSOM and 100% of ASOM in children undergoing surgical exploration. Surgical approach is required in cases of complications or failure of medical treatment. Watchful clinical monitoring to rule out intracranial complications is always essential in all patients with Acute Mastoiditis.

Pneumococcal conjugate vaccine (Non-Typeable Haemophilus influenzae (NTHi) protein D, diphtheria or tetanus toxoid conjugates) in prevention of acute otitis media in children: A cohort study

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To compare the incidence of acute otitis media among children aged 2 to 6 months old in Sampaloc, Manila who were previously given 3 doses of pneumococcal conjugate vaccine (Non-Typeable Haemophilus influenzae (NTHi) protein D, diphtheria or tetanus toxoid conjugates) and those who did not receive the vaccine over a period of one year.<br /><strong>METHODS:</strong> <br /><strong>Design:</strong> Cohort Study<br /><strong>Setting:</strong> Primary Health Center in Sampaloc, Manila, Philippines<br /><strong>Participants:</strong> Medical records of well children aged 2 to 6 months were reviewed for inclusion. Participants were categorized into vaccinated and unvaccinated groups. Both groups underwent baseline history and physical examination including otoscopy and any signs and symptoms of active ear infection were noted. Subjects were followed up for a period of one year on a monthly basis for signs or symptoms of acute otitis media. <br /><strong>RESULTS:</strong> A total of 176 subjects participated in the study. The overall incidence of AOM among participants was 5.11% (9 out of 176). An AOM incidence of 3.75% (3 out of 80) and 6.25% (6 out of 96) was found among the exposed and unexposed groups, respectively. Fisher's exact test (one-tailed) p value= .34, relative risk (RR) .6 (95% Cl 0.155, 2.323).<br /><strong>CONCLUSION:</strong> The results of this study showed no difference in the development of AOM in the two groups. However, based on the relative risk, Pneumococcal conjugate vaccine is still beneficial in preventing AOM in children.</p>

Otomastoiditis por Streptococcus pneumoniae en trillizos: Reporte de un caso y revisión de la literatura

Introducción: La mastoiditis aguda es un proceso infeccioso-inflamatorio que afecta a las celdas mastoideas. En los últimos años se ha descrito un incremento en su incidencia. La razón principal, para algunos autores, parece ser un aumento de la resistencia bacteriana (Streptococcus pneumoniae) a la penicilina y otros antibióticos. Caso Clínico: Trillizos masculinos de 2 años y 3 meses, con antecedentes de prematuridad de 28 semanas. Hijo #1 ingresa con historia de 15 días de evolución caracterizada por otalgia, otorrea asociado a ebre no cuanti cada. En sus primeros días intrahospitalarios presentó parálisis facial izquierda. Evaluado por el servicio de otorrinolaringología, se realiza CAT de mastoides en el cuál se reporta: otomastoiditis izquierda sin compromiso intracraneano. Hijo #2 e hijo #3 con cuadro similar de otitis media bilateral y otorrea por lo que se toma cultivo de la secreción y se ingresan a sala para manejo con Ceftriaxona a 80mg/kg/día. Cultivos de secreción con aislamiento de Streptococcus pneumoniae (Serotipo 19F) resistente a Penicilina y Ceftriaxona, sensible a Vancomicina y quinolonas. Se inicia terapia antibiótica con Vancomicina. Comentarios: Los trillizos recibieron 3 dosis de la vacuna antineumocócica conjugada 13 Valente (PCV13) la cobertura de esta vacuna antineumocócica incluye el serotipo 19F.

Introduction: Acute mastoiditis is an infectious-inflammatory process involving the mastoid air cells. In recent years an increase in incidence has been reported. The main reason for some authors, seems to be due to an an increase in bacterial resistance (Streptococcus pneumoniae) to penicillin and other antibiotics. Case report: Male triplets of 2 years and 3 months of age, with a history of 28 weeks of prematurity. Son# 1 is admitted with a history of 15 days of evolution characterized by otalgia and otorrhea associated to unquantifiable fever. During his first days in the hospital he presented left side facial paralysis. Evaluated by the otolaryngology service, a mastoid CAT scan is conducted which further reports a left otomastoiditis without intracranial e ects. Son#2 and son# 3 exhibit a similar mid-bilateral otitis and otorrhea by which a discharge simple is taken and both are admitted and are given 80mg / kg of Ceftriaxone per day. Discharge samples isolated from Streptococcus pneumoniae (serotype 19F) are resistant to Penicillin and Ceftriaxone and sensitive to Vancomycin and quinolones. A Vancomycin antibiotic therapy is initiated. Comments: The triplets received 3 doses of pneumococcal conjugate vaccine 13 Valente (PCV13). This coverage includes pneumococcal vaccine serotype 19F.

Effects of Antibiotics on Children with Acute Otitis Media / 听力学及言语疾病杂志

Objective To study whether the usage of antibiotics and white -blood -cell counts affect the effects of 2~12-year-old children with acute otitis media (AOM ) .Methods A total of 126 children (2~12 years old)with AOM ,from Jan 2013 to Dec 2013 ,were retrospectively analyzed .Usage of antibiotics and white -blood-cell count were recorded at first ,and the relationships between two factors and outcomes of children with AOM were studyed in one week ,one month and three months after treatment ,respectively .Results White blood cell counts were higher than normal in 59 .52% (75/126) 2~12 -year -old children with AOM ,and antibiotics were used in 73 .81% (93 /126) .Ninty three cases were followed -up until 3 month or more .Antibiotics were used in 74 cases ,and watchful waiting were used in the other 19 patients .The effective rates of two groups were 59 .45% and 52 .63% ,75 .68% and 84 .21% ,85 .14% and 78 .95% in one week ,one month and 3 months after treatment ,re‐spectively .There were no statistically significant differences(χ2 values were 0 .295 ,0 .903 ,0 .799 ,P>0 .05) .But the effective rates were signifantly higher in 1 and 3 months than that of in one week (P0 .05) between one and three months .Whether white-blood-cell count higher than normal or not ,the difference in efficacy was not statistically significant in 1 week ,1 month and 3 months after treatment (P >0 .05) .Conclusion In 2~12-year-old children with acute otitis media (AOM ) ,the final outcomes were inde‐pendent of the usage of antibiotics and white -blood-cell count .

Pathogenic Bacteria Distribution and Antimicrobial Susceptibility of Children with Acute Otitis Media / 听力学及言语疾病杂志

Objective To analyze pathogenic bacteria distribution and antimicrobial susceptibility in children with acute otitis media(AOM ) .Methods Otorrhea samples from 146 episodes of AOM were cultured .The antimi‐crobial susceptibility of the main pathogenic bacteria was determined .The results were analyzed by SPSS19 .0 .Re‐sults 1) The strains of bacteria were isolated from 109 children with the positive rate of 74 .66% .Streptococcus pneumoniae (SP ) was the major bacteria(64 episodes ,58 .72% ) ,followed by staphlococcus aureus(SA) (19 epi‐sodes ,17 .43% ) .2) Sp was all sensitive to vancomycin ,levofloxacin ,moderate to penicillin ,amoxicillin ,cefo‐taxime ,and highly resistent to erythromycin and clindamycin .Staphlococcus aureus were all sensitive to vancomy‐cin ,tetracycline ,and Amy card ,and moderate to amoxicillin clavulanic acid potassium ,cefoxitin ,and oxacillin ,all resistent to penicillin and ampicillin .3) The strains of SP in age≤1year ,>1 -3years ,and >3 years respectively were 31(50 .82% ) ,25(56 .82% ) ,8 (19 .51% ) .There were significant differences between them(χ2 =14 .073 ,P=0 .001) .4)The strains of SP in 2012 ,2013 ,2014 respectively were 16(30 .19% ) ,22(48 .89% ) ,26(54 .17% ) ,There were significant differences between them(χ2 =6 .557 ,P=0 .038) .The antimicrobial susceptibility of SP had no sig‐nificant differences among 2012 ,2013 ,2014 ,but a yearly resistance decreasing trend was seen .Conclusion SP was the main bacterial contributor for AOM in Wuhan children .SP detection rate increases every year ,mainly in chil‐dren less than 3 years old .T he antimicrobial susceptibility is stable .