Pathophys
Diagnostics
Clinical Presentation
Treatment/Mgmt
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100

What is the epidemiology for AOM?

Epi: 10.8 new cases per 100 people, by 1 year old 23-62% of children have had 1 episode, by age 3 60-83% have had 1 episode, 1/3 of kids have 6 recurrent episodes by age 7, accounts for 20 mil physician visits in the US

100

What are overall differentials for AOM?

  1. Otitis media with effusion (OME)
  2. Acute exacerbation of chronic otitis media
  3. Myringitis associated with external auditory meatus inflammation
  4. Otitis externa
  5. Viral otitis media
  6. Temporomandibular joint dysfunction (in adults)
  7. Cholesteatoma
  8. Tympanic membrane perforation
  9. Traumatic disruption of ossicles
  10. Hemotympanum
  11. Basilar skull fractures
100

What is wrong here?

AOM: Bulging, erythema, decreased mobility, opacity, scant blood and purulent 

Also can be found: retraction pockets, tympanosclerosis, perforation (severe cases)

100

What are OTC treatment/symptom management for AOM? 

  1. Pain relievers:
    • Acetaminophen 
    • Ibuprofen 
  2. Warm compresses:
    • Apply a warm, damp washcloth to the affected ear
  3. Cold compresses:
    • Alternate with warm compresses to reduce pain and inflammation
  4. Ear drops:
    • OTC ear drops for pain relief containing homeopathic ingredients
    • Swimmer's ear drops with isopropyl alcohol or glycerin for drying
  5. Saltwater gargle:
    • Gargle to reduce inflammation if ear infection is related to a swollen throat
  6. Elevation:
    • Sleep with the head elevated to help ears drain faster
100

What is the team mascot in High School Musical?

Wildcats

200

What is the sequalae of AOM?

Hearing Loss: due to fluid accumulation or damage of middle ear strx, can be temporary or permanent 

Tympanic Membrane Complications: perforation of eardrum, scarring of eardrum

Middle Ear Damage: Progressive damage to middle ear structures, formation of aural polyps, cholesteatoma development (cyst formation in the middle ear or mastoid).

Chronic Conditions: Chronic suppurative otitis media with persistent drainage, recurrent acute otitis media episodes.

Developmental Issues: Speech and language delays, cognitive and psychosocial developmental problems.

Intracranial Complications: Mastoiditis, Meningitis (rare), Brain abscess (rare)

Behavioral and Educational Impact: Attention and hyperactivity problems, learning difficulties, increased likelihood of anxiety and emotional issues

200

What are bacterial differentials for AOM?


Bonus: How do you differentiate them?

Differentials: S. pneumoniae, H. influenzae, Moraxella Catarrhalis

S. pneumonia is Gram +, H. influenzae is Gram - and pleimorphic (typically rod shaped), Moraxella Catarrhalis is Gram - diplococci 

200

What are the components of the ear?

Ear Canal

  • Extends from the outer ear to the middle ear, approximately 1 inch long in adults
  • Divided into two parts:
    • Outer third: cartilaginous portion with hair and ceruminous glands
    • Inner two-thirds: bony portion with thinner, more sensitive epithelium

Inner Ear

  • Located within the petrous part of the temporal bone
  • Consists of two main components:
    1. Bony labyrinth: series of cavities filled with perilymph
    2. Membranous labyrinth: soft tissue structures within the bony labyrinth
  • Major structures:
    • Cochlea: spiral-shaped organ for hearing
    • Vestibule: central part containing the saccule and utricle
    • Semicircular canals: three canals for balance
200

Why is it justified to do antibiotic sensitivity testing?

Guiding appropriate treatment, Combating antimicrobial resistance, Improving antibiotic stewardship, Enhancing patient outcomes, Informing public health measures, Optimizing resource utilization, Supporting personalized medicine. 

200

What is a group of cats called?

A clowder

300

What are the risk factors for AOM?

RF: children 6-36 months, upper respiratory infection, famhx of OM, allergic/seasonal rhinitis, adenoid hypertrophy, GERD, males, caucasian

300

What are the common viruses and tests do you use for viral AOM? 

Viruses: RSV, rhinoviruses, adenoviruses

  1. Pneumatic otoscopy: This is the primary diagnostic tool, with 70-90% sensitivity and specificity for detecting middle ear effusion. It allows visualization of tympanic membrane mobility and bulging.
  2. Tympanometry: An adjunct to pneumatic otoscopy that can help detect middle ear effusion.
  3. Acoustic reflectometry: Another adjunct to pneumatic otoscopy for detecting middle ear effusion.
  4. PCR testing: While not routinely used clinically, PCR can detect viral nucleic acids in middle ear fluid or nasopharyngeal samples, helping identify specific viral pathogens
300

Compare and Contrast Adult ears vs Children's ears.


Bonus: Why is this significant for our case? 

Ear Canal

  • Length: Shorter in children, full adult length typically reached by age 83
  • Shape:
    • Children: More horizontal and straighter
    • Adults: More curved (sigmoid shape)
  • Angle: The lateral portion of the ear canal forms a more acute angle with the tympanic membrane in children (136.57°) compared to adults (172.20°)

Inner Ear

  • Cochlea:
    • Size: Similar in children and adults from birth
    • Orientation: More parallel to the external auditory canal in children
  • Eustachian tube:
    • Children: Shorter, narrower, and more horizontal
    • Adults: Longer, wider, and more angled

Clinical Implications

  • The differences in ear canal anatomy affect the approach angle for procedures and examinations
  • The more horizontal orientation of the Eustachian tube in children makes them more susceptible to middle ear infections and fluid buildup
300

What are preventative measures for AOM? 

Pneumococcal vaccination, Influenza vaccination, Breastfeeding, Avoiding exposure to tobacco smoke, Proper feeding practices, Xylitol use, Tympanostomy tubes, Adenoidectomy 

300

Which team scored the most points ever in a single Super Bowl?

The San Francisco 49ers (55 points in 1990)

400

How does Moraxella catarrhalis evade the immune system in AOM?

Complement Evasion

M. catarrhalis has multiple strategies to resist complement-mediated killing:

  • It activates all three pathways of the human complement system.
  • Major outer membrane proteins (UspAs, OMP E, OMP CD, CopB) and surface structures like lipooligosaccharide (LOS) are involved in complement defense.
  • UspA2 binds terminal components of complement to evade complement-mediated killing via the classical pathway.

Outer Membrane Vesicles (OMVs)

M. catarrhalis produces OMVs that act as decoys to misdirect innate immune cells:

  • OMVs contain virulence factors, periplasmic proteins, and other molecules targeted for export.
  • They play a role in complement evasion and epithelial adhesion.
  • OMVs can favor pathogen coexistence and colonization after interacting with other bacterial species.

Biofilm Formation

  • M. catarrhalis can form biofilms, which contribute to its persistence and recurrence of infections.
  • Biofilms protect the bacteria from host immune responses and antibiotics.

Intracellular Invasion

M. catarrhalis can invade and survive within epithelial cells:

  • This allows the pathogen to escape killing by the host immune system and extracellular antibiotics.
  • Invasion is regulated by the expression of LOS, UspA1, and other outer membrane components.

Interaction with Host Proteins

  • M. catarrhalis binds to cartilage oligomeric matrix protein (COMP), which inhibits bactericidal activity of the complement membrane attack complex.
  • COMP binding also reduces bacterial adhesion and uptake by human lung epithelial cells, protecting M. catarrhalis from intracellular killing.

Antigenic Variation

  • M. catarrhalis uses phase variation to regulate the expression of virulence factors like UspA1 and Hag/MID, allowing it to adapt to different host environments
400

Why do we use Gram stain, catalase, oxidase, nitrate reduction, and butyrate esterase testing for diagnosis?

  1. Gram testing:
    Gram staining of middle ear fluid (MEF) samples can provide rapid and valuable information about the causative organisms in otitis media. It helps differentiate between Gram-positive and Gram-negative bacteria, which is crucial for guiding initial antibiotic therapy. The sensitivity and specificity of Gram staining for detecting bacteria in MEF are high (sensitivity 96%, specificity 100%).
  2. Catalase and oxidase testing:
    These tests are useful for further characterizing bacteria isolated from MEF cultures. 
  3. Nitrate reduction:
    The nitrate reduction test can be helpful in identifying certain bacterial species involved in otitis media. 
  4. Butyrate esterase:
    There is insufficient evidence in the provided search results to justify the use of butyrate esterase testing specifically for otitis media diagnosis
400

What OMT techniques are recommended based off of the physical exam?

  1. Balanced ligamentous tension (BLT): This technique aims to address somatic dysfunction at the OA joint by balancing ligamentous tensions.
  2. Osteopathic cranial manipulative medicine: This approach focuses on treating restrictions in the cranial bones, including the occiput, which articulates with the atlas (C1) at the OA joint.
  3. Myofascial release: This technique can be applied to the head and neck region, including the OA joint area, to address fascial restrictions that may affect ear drainage
400

Drug chart amoxicillin and amox-clav

Amoxicillin: Drug subclass- Aminopenicillin, spectrum: Gram-positive bacteria, some Gram-negative, MOA: Inhibits cell wall synthesis, Interactions: Probenecid, Methotrexate, Oral contraceptives, AE/Contraindications: Rash, Diarrhea, Nausea, Penicillin allergy, ADME: Oral absorption: 75-90%, Protein binding: 17-20%, Renal excretion 

Amox-clav: Drug subclass- Aminopenicillin + Beta-lactamase inhibitor, Spectrum: Broader spectrum including beta-lactamase producing bacteria, MOA: Amoxicillin: Inhibits cell wall synthesis Clavulanate: Inhibits beta-lactamases, Interactions: Probenecid, Methotrexate, Oral contraceptives, Warfarin, Allopurinol, AE/Contraindications: Diarrhea (more common), Rash, Nausea, Liver enzyme elevations, Penicillin allergy, ADME: Oral absorption: 75-90% (amoxicillin), 60-75% (clavulanate), Protein binding: 17-20% (amoxicillin), 22-30% (clavulanate), Renal excretion 

400

What element has the highest atomic number that occurs naturally?

 Uranium 

500

What is the pathophys and pathogen of AOM?

Colonization and Biofilm Formation

  1. M. catarrhalis colonizes the nasopharynx, especially in young children.
  2. It forms biofilms, which contribute to persistence and recurrence of infections.
  3. M. catarrhalis promotes stable polymicrobial biofilms, enhancing survival of other otopathogens like non-typeable Haemophilus influenzae (NTHi).

Migration to Middle Ear

  1. Upper respiratory tract viral infections often precede bacterial OM.
  2. Pathogens migrate from the nasopharynx to the middle ear via the Eustachian tube.
  3. M. catarrhalis possesses virulence factors that facilitate this process.

Inflammatory Response

  1. Once in the middle ear, M. catarrhalis triggers an inflammatory cascade.
  2. This leads to congestion of the Eustachian tube and negative pressure in the middle ear.

Pathogen Interactions

  1. M. catarrhalis often causes mixed infections with other otopathogens.
  2. It enhances survival of NTHi in the presence of Streptococcus pneumoniae in polymicrobial biofilms

Clinical Characteristics

  1. M. catarrhalis typically causes a milder course of OM compared to S. pneumoniae and H. influenzae.
  2. It is associated with a lower rate of spontaneous tympanic membrane perforation.
500

Bug chart for Moraxella Catarrhalis 

Causative Organism

  • Gram-negative, aerobic, oxidase-positive diplococcus
  • Exclusively human commensal and mucosal pathogen

Clinical Features

  • Upper respiratory tract infections in children:
    • Otitis media (15-20% of acute cases)
    • Sinusitis
    • Tracheitis
  • Lower respiratory tract infections in adults with COPD:
    • Bronchitis
    • Pneumonia
  • Rare systemic infections in immunocompromised:
    • Bacteremia
    • Meningitis

Mode of Transmission

  • Person-to-person via respiratory droplets
  • Colonization of nasopharynx, especially in children

Virulence Factors

  • Adhesins for attachment to host cells
  • Outer membrane proteins (UspAs, OMP E, OMP CD, CopB)
  • Lipooligosaccharide (LOS)
  • Biofilm formation
  • Beta-lactamase production

Culture/Diagnosis

  • Growth on blood and chocolate agar
  • "Hockey puck sign": colonies can be slid across agar surface without disruption
  • Gram stain of sputum
  • Oxidase-positive

Prevention/Treatment

  • First-line antibiotic: Amoxiclav
  • Alternative antibiotics: Clarithromycin, doxycycline, ciprofloxacin
  • Most strains resistant to penicillin due to beta-lactamase production
  • Vaccines in development
  • Good hygiene practices, especially in healthcare settings

Epidemiology

  • Common commensal in upper respiratory tract, particularly in children
  • Increasing recognition as a pathogen in recent decades
  • Causes 2-4 million COPD exacerbations annually in the United States

Pathogenesis:

1. Colonization of nasopharynx

  1. Migration to middle ear or lower respiratory tract
  2. Adhesion to epithelial cells and extracellular matrix
  3. Evasion of host immune response:
    • Complement resistance
    • Production of outer membrane vesicles
    • Intracellular invasion
  4. Inflammation and tissue damage
  5. Biofilm formation contributing to persistence
500

Justify use of omm for otitis media at the OA joint.

  1. Anatomical relationships: The OA joint is in close proximity to the upper cervical spine (C1-C3), which has been identified as an area of focus for OMM techniques in treating otitis media. 
  2. Lymphatic drainage: Manipulation of the OA joint can potentially improve lymphatic drainage from the head and neck region. Enhanced lymphatic flow may help reduce congestion and inflammation in the middle ear.
  3. Neurological effects: The OA joint is innervated by the suboccipital nerve (C1), which communicates with other cranial nerves. Manipulation at this level may influence neural pathways that affect eustachian tube function and middle ear physiology.
  4. Biomechanical connections: Restrictions at the OA joint can potentially affect the biomechanics of the temporal and sphenoid bones, which are important in eustachian tube function. Addressing OA dysfunction may indirectly improve eustachian tube drainage.
500

What is myringotomy with tympanostomy tubes?


Bonus: Can you describe the procedure? 

Myringotomy with tympanostomy tubes is a surgical procedure that involves making a small incision in the eardrum (myringotomy) and inserting a tiny tube into the opening. The procedure aims to ventilate the middle ear and prevent fluid accumulation for an extended period. Key aspects of the procedure include:

  1. A small incision is made in the eardrum, typically in the anteroinferior quadrant.
  2. Any accumulated fluid in the middle ear is drained.
  3. A tiny tube, often made of fluoroplastic or silicone, is inserted into the incision.
  4. The tube allows for continuous aeration of the middle ear and helps equalize pressure.

This procedure is commonly performed on children with recurrent ear infections or persistent middle ear fluid, though it can also be done on adults. The tubes usually remain in place for 6 to 18 months before falling out on their own or being removed by a physician 

500

What city in South America is also known as "The Lost City of the Incas?"

Machu Picchu

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