Otitis Media Mary Bennett, Amanda Buisman & Roline Campbell.
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Transcript of Otitis Media Mary Bennett, Amanda Buisman & Roline Campbell.
Otitis Media
Mary Bennett, Amanda Buisman & Roline Campbell
Pertinent AnatomyOssicles
(malleus, incus, stapes)
ORTympanic Membrane
External Ear Canal
ORAuricl
e
Pertinent Anatomy
(Cone of light)
Physiology of the Ear
External Ear
Consists of the pinna (auricle) and the auditory ear
canal
• The pinna functions to both protect the tympanic
membrane, and to collect sound waves.
• The auditory ear canal distributes sounds in the
form of pressure waves to the tympanic
membrane.
Physiology of the EarMiddle Ear
Consists of the tympanic membrane, auditory ossicles
(malleus, incus, stapes) and the eustachian tube.
• The tympanic membrane receives sound waves (in the
form of pressure waves) from the auditory ear canal and
converts the waves into mechanical vibrations by way of
the auditory ossicles. The mechanical vibrations are then
transmitted to the inner ear.
• The eustachian tube links the pharynx to the middle ear
and while it is normally closed, it can let a small amount
of air though to equalize the pressure between the
middle ear and the atmosphere. It also drains mucous
from the middle ear.
Physiology of the EarInner Ear
Consists of the semicircular canals, vestibule, acoustic nerve,
and the cochlea.
• Mechanical vibrations are received from the TM and are
transformed into fluid vibrations, which are then converted
into nerve impulses by nerve endings located in the cochlea.
These impulses are conducted via the auditory nerve to
higher levels and interpreted as sound by the brain.
• The semicircular canals and vestibule function to maintain
balance and equilibrium.
Pathophysiology of Otitis Media (OM)
OM is defined as inflammation in the middle ear
without reference to etiology. OM is one of the most
common reasons for a child to visit the pediatrician.
OM can be classified into four categories;
• Acute Otitis Media (AOM)
• Otitis Media with Effusion (OME)
• Recurrent AOM
• Chronic OME
Pathophysiology of Acute Otitis Media (AOM)
The most important factor in the pathogenesis of
AOM is abnormal function of the eustachian tube.
• Reflux, aspiration, or insufflation of
nasopharyngeal bacteria into the middle ear via
the dysfunctional eustachian tube may lead to
infection.
• Eustachian tube dysfunction occurs due to either
abnormal patency, or obstruction (either
functional or mechanical).
Pathophysiology of Acute Otitis Media (AOM)
Common causative microorganisms for AOM
are:
• Streptococcus pnumoniae (30-50% of
cases)
• Haemophilus influenzae (20-30% of cases)
• Moraxella catarrhalis (7-25% of cases)
Acute Otitis Media (AOM)With and Without Perforation
When AOM is present and the TM is intact,
it is referred to as “AOM without
perforation”.
When AOM is present and the TM is NOT
intact, it is referred to as “AOM with
perforation”.
AOM with PerforationAOM with perforation has two categories;
• AOM complicated by perforation of the tympanic
membrane presenting as otorrhea. (Left)
• AOM in a patient with tympanostomy tubes. (Right)
OM with Effusion (OME)
OME occurs when thick fluid accumulates behind the TM. OME typically occurs
immediately following treatment of AOM due to the resolution of acute
inflammation, allowing visualization of the middle ear fluid behind the TM.
Epidemiology
The overall prevalence of AOM is 15-20%, with
the highest peak at 6-36 months of age.
An additional smaller peak occurs at 4-6 years of
age.
Between 60-80% of infants have had at least
one episode of AOM by one year of age.
AOM is uncommon in older children and
adolescents.
Epidemiology
AOM is more common in boys, and the
prevalence is greatest in Alaskan natives
and Native Americans (Caucasian race is
also considered a risk factor however).
AOM is most common in the winter
months and in early spring, coinciding
with peaks in the incidence of URI’s.
EpidemiologyRisk factors for developing OM;
• Male gender
• Absence of breastfeeding
• White race
• Passive exposure to tobacco smoke
• Daycare attendance
• Low socioeconomic status
• Presence of siblings in the household
• Altered host defenses/underlying conditions
Patient Evaluation-History
Clinical presentation- children with AOM often have a
history of rapid onset of fever and ear pain (usually
within 48 hours). The patient may also have hearing
loss, otorrhea, and irritability. Nonverbal children
present with “ear pulling” and generalized fussiness.
Associated symptoms include URI, cough, diarrhea,
and nonspecific complaints such as decreased
appetite, waking at night, or irritability in infants.
Patient Evaluation- HistoryIt is important in the history to differentiate
nonspecific symptoms of OM from those
indicating a more serious condition such as
meningitis.
For infants or children with a history of
persistent or recurrent OM, it is important to
find out when they had their last documented
infection and what treatment they received.
Patient Evaluation- HistoryHelpful questions to ask when
obtaining the patient’s history;
• Does the infant have fever, ear pain, hearing
loss, or otorrhea?
• Is the infant/child inconsolable or lethargic?
• Has the infant/child had a previous ear
infection? If so, when?
• Did the child complete the course of
prescribed antibiotics?
Helpful Questions• How many ear infections has the child had in
the past year?
• Is the child taking any medication to prevent
recurrent OM?
• Does the child attend daycare?
• Is the child exposed to passive smoke?
• Is the infant breast-fed?
• Does the child appear to hear?
• Is the child’s speech development normal?
Physical Exam Findings
To diagnose OM, the TM must be
visualized. The position, color,
degree of translucency, and mobility
of the TM must be evaluated.
Classically, in AOM the TM is full or
bulging, opaque, and has limited or
no mobility, or is retracted. The light
reflex is usually absent or distorted.
Physical Exam FindingsAssociated physical exam findings may
include;
• posterior auricular and/or cervical
adenopathy
• pain on movement of the pinna
• anterior ear displacement
*The presence of these symptoms may also suggest a more serious condition
such as mastoiditis therefore thorough history taking and visualization of the TM
is essential.
Normal (no AOM present) Exam Findings
Position- process of the malleus should be
visible but not prominent through the
membrane.
Color- pearly gray.
Translucency- middle ear or bony landmarks
should be visible through the TM.
Mobility- normal ear will move with
pneumatic otoscopy.
Physical Exam Findings
Here is a normal TM
Physical Exam Findings
Here is a picture of a typical TM with AOM. The TM is noted to appear erythematous or injected in color, the light reflex is absent, landmarks are poorly visualized, and there is a poor degree oftranslucency.
Physical Exam Findings
Here is an example of AOM with a bulging TM. Note the color, position, transparency, lack of visible landmarks,and distorted light reflex
Physical Exam Findings
Here is a retracted TM
Diagnosis of AOM• Accuracy in diagnosis of utmost
importance• Ensures appropriate treatment for
AOM• Avoids unnecessary use of
antibiotics in OME• Prevents overuse of antibiotics –
considered a major factor in increased drug-resistance
AOM in Infants & Children
• Challenges in establishing a diagnosis:
– Uncooperative
– TM obscured by cerumen
– Symptoms of AOM may overlap with other conditions (URI)
– Symptoms may be subtle or even absent
• Successful diagnosis facilitated by:
– Systematic assessment
– Stringent diagnostic criteria
– Training and experience
AAP & AAFP Diagnostic Criteria Three diagnostic criteria
1. Recent, abrupt onset of ME inflammation & effusion (ear pain, irritability, otorrhea, and/or fever)
2. MEE confirmed by:– bulging TM,– limited or absent mobility (pneumatic otoscopy),– air-fluid level behind TM, or– Otorrhea (with TM not intact)
3. Evidence of ME inflammation - confirmed by:– distinct erythema of TM, or – distinct otalgia interfering with normal sleep or
activity
Diagnostic Techniques• Pneumatic otoscopy
– Assess inflammation
– Assess effusion
– Assess perforation & character of otorrhea
• Tympanometry and/or acoustic reflectometry
– Assess/confirm effusion
• Tympanocentesis (by otolaryngologist)
– Identify infectious organism
– Use in special populations
TympanometryAcoustic
Reflectometry• Analyzes sound reflected off the TM to detect MEE
• No pressure seal required
• Small quantity of cerumen does not affect this test
• Increased use in primary care
• Accurate & objective assessment of effusion
• Requires an air-tight seal & pressurization of the ear canal
• Painful & uncomfortable for children
• Limited use & costly
Pneumatic Otoscopy
• Allows direct visualization of TM & ear structures
to confirm presence of inflammation, effusion and
assess for perforation.
• Important to:
– Remove cerumen obscuring TM
– Ensure adequate lighting
– Appropriately restrain the child to allow examination
& prevent injury
– For pneumatic otoscopy – adequate airtight seal by
choosing correct size and shape speculum.
Assessment of the TM
• Locate border between external ear canal & TM
• Assess:
– Surface
– Opacity
– Color
– Mobility
– Other findings
The Surface of the TM
• Are the landmarks
visible?
• Are the landmarks
obscured or unusually
prominent?
• Where is the cone of
light?
• Is the TM intact?
Retracted & Bulging TMAbnormally retracted TM Bulging TM
Opacity of the TM
Normal Tympanic Membrane- Usually translucent
Scarred Tympanic Membrane
- note loss of translucency at area of scar
Color of the TMExpected Findings
• Normal TM = Pearly grey
• Crying infant = Pink TM
• Classic AOM = red or
infused TM
• Atypical AOM = white or
yellow TM (from purulent
middle ear fluid)
AOM with infused
erythema
Mobility of the TM• Successful pneumatic otoscopy requires airtight seal of external ear canal
• With normal mobility the TM will– move inward when positive pressure is
applied– move outward when negative pressure is
applied• A retracted TM will show – decreased or absent inward deflection– but normal outward deflection with negative
pressure• Crying children have increased middle ear
pressures during exhalation which fleetingly normalize during inspiration
• Severely diminished or absent mobility is indicative of effusion
Normal TM Movement
Decreased TM Movement
Other Findings
Air-fluid level behind the TM
- Indicative of Middle Ear Effusion (MEE)
Cholesteatoma – grey or white mass behind the TM
Blebs / blisters on the surface of the TM – Bullous Myringitis
Cholesteatoma →
↖ Bleb / blister
Clinical Diagnosis of AOM
Requires:
Acute onset of symptoms AND
Middle Ear Effusion AND
Middle Ear Inflammation
OR
Acute purulent otorrhea
via perforated TM or tympanostomy tube
AND otitis externa has been excluded
Differential DiagnosesViral
MyringitisOME AOM
Otalgia Present
Usually absent - some reports "fullness“
Acute pain
InflammationPresent Absent Present
Bulging TM No bulgingNormal position or retracted
Bulging
TM Mobility Normal Decreased Decreased
Diff. Dx
S & S
AOM or OME?
Two year old Ron’s mom reports him rubbing and
slapping at his left ear since early this morning. He
refused breakfast and has been irritable all day.
Pneumatic otoscopy reveals a bulging, yellow
tympanic membrane with marked decrease in
mobility.
Is this AOM or OME?
Summary: MEE• MEE (Middle Ear Effusion) = fluid in
middle ear
• Occurs in both AOM and OME
• OME often precedes development of
AOM
• OME mostly also follows resolution of
AOM
OM with ruptured TMAOM with TM intact
• Acute onset otalgia
• Inflamed TM
• Middle Ear Effusion present (Bulging and decreased mobility)
AOM with ruptured TM
(or with Tympanostomy tube)
• History of acute onset otalgia which improved when ear started draining (relief of pressure when TM ruptured)
• Inflamed TM
• TM ruptured & draining purulent fluid into external ear canal
Treatment of AOM
• Clinical course of 24 – 72 hours with
appropriate antimicrobial Rx
• Slightly slower resolve of acute
symptoms when not treated
• MEE may persist for weeks or months
Clinical Practice Guideline
• AAP and AAFP Clinical Practice Guidelines
(2004) state that the following aspects of
management should be considered:
1. Symptomatic therapy
2. Observation (“Watchful waiting”)
3. Appropriate antimicrobial therapy
1. Symptomatic Therapy - Pain• Acetaminophen
– 10 -15mg/kg PO/PR every 4 – 6 hours as needed
– not to exceed 90mg/kg/day
• Ibuprofen– 5 - 10mg/kg PO/PR every 6 – 8 hours as
needed– not to exceed 40mg/kg/day
• Topical agents– Antipyrine-benzocaine otic drops– 4 – 5 drops into affected ear(s) every 2 hours
as needed– not to be given in case of TM perforation– Aqueous lidocaine ear drops (30 minute
efficacy – needs further evaluation – not currently a recommendation)
Treatment of pain (cont.)
• Complementary treatments
– Herbal extracts:
• Otikon Otic solution
• Compared well to topical anesthetic
• Home remedies
– Distraction
– External application of heat or cold
– Instillation of oil into external auditory canal
– Clinical evidence still lacking
Symptomatic Therapy - Congestion
• Decongestants and antihistamines– Still commonly used in some populations
– No proof of efficacy in treatment of AOM
– Demonstrated:• Increased medication side-effects
• Did not improve healing or reduce complications/surgery
• Prolonged duration of MEE
• AAP recommends OTC cough and cold medications NOT used in infants & children < 2 years (danger of life-threatening side effects!)
2. “Watchful waiting”• Objective is to reduce the unnecessary use of
antibiotics
• Limit development of drug-resistance
• Option only for selected children
• Certain criteria must be met to ensure safety
• “Watchful waiting” is NOT appropriate for any infant < 6 months – Infants < 6 months should be treated with
antibiotics REGARDLESS of the degree of diagnostic certainty.
Considerations for “Watchful Waiting”
• Age of infant/child
• Certainty of diagnosis
• Severity of illness
• Can follow-up be ensured?
• Ability to acquire prescription medications if
needed
• Parents must understand risks and benefits of
“watchful waiting” vs immediate treatment
3. Antimicrobial treatment
• Selection of drugs should be based on: Clinical & microbiologic efficacy Acceptability of the oral preparation
(taste & texture) Absence of side effects and toxicity Convenience of dosing schedule Cost
First-line antimicrobial therapy
Amoxicillin
• Controversy but still recommended as drug of
choice (safe, effective, affordable, narrow spectrum)
• Doubled dose increase concentration in ME
• Then active against most intermediate strains of S.
pneumoniae (including many resistant strains)
• 80 – 90 mg/kg per day (divided in 2 doses)
• Heavier children – max of 3g/day
When is Amoxicillin contra-indicated?
• High risk for AOM caused by an amoxicillin-
resistant otopathogen
– Treated with antibiotics in previous 30 days
(especially beta-lactam antibiotics)
– Concurrent purulent conjunctivitis (non-typable H.
influenzae)
– Receiving amoxicillin chemoprophylaxis for recurrent
AOM or UTI
– Allergy
Alternative 1st Choice treatmentAmoxicillin-clavulanate
• Active against beta-lactamase-producing non-typeable H. influenzae
• Also active against S. pneumoniae• Dosing:
< 3 months: 30mg/kg/day PO divided in 2 daily doses
≥ 3 months & < 40 kg: 90mg/kg/day PO divided in 2 daily doses x 10 days
Children weighing > 40 kg – 250-500mg every 8 hours
Secondary treatment options
• Choice of alternatives depend on type of previous hypersensitivity reaction
HISTORY OF NON-TYPE 1 REACTIONS
Cefdinir • 14 mg/kg/day in 1 or 2 doses (limit total 600mg/day)
Cefpodoxime • 10 mg/kg /day once daily (limit 800 mg/day)
Cefuroxime (cefuroxime axetil suspension)• 30 mg/kg/day in 2 divided doses (limit total 1 g/day)
Cefuroxime tablets• 250 mg every 12 hours
Treating AOM due to Penicillin-resistant S. pneumoniae
• Oral Cephalosporins are not effective against penicillin-
resistant S. pneumonia
• Consider :
Ceftriaxone
• 50mg/kg in single IM dose
• If clinical signs do not improve after 48 hours, a second dose
may be given. In some cases even a third dose may be
necessary.
• Be mindful of the physical discomfort and psychological
distress caused in a young child when following this approach.
Secondary treatment options
HISTORY OF TYPE 1 REACTIONS
Erythromycin plus sulfisoxazole
• 50-150 mg/kg/day in 4 divided doses
• Limit total erythromycin to 2g/day
• Often rejected due to taste and high frequency of dosing
Azithromycin
• Single dose Rx: Give 30mg/kg in one single dose x1 day
• 3-day Rx: Give 20mg/kg/day – one dose daily x3 days
• 5-day Rx: Give 10mg/kg on day 1 & 5mg/kg/day on days
2 – 5
Secondary options cont. HISTORY OF TYPE 1 REACTIONS
Clarithromycin
• 15mg/kg/day divided in 2 doses (limit to
1g/day) OR
• 30-40mg/kg/day divided in 4 doses (limit to
1g/day)
Clindamycin
• 30-40 mg/kg/day divided in 3 – 4 doses
Treatment of AOM in children with Tympanostomy Tubes
• For some children, topical antibiotic therapy may be an alternative to oral therapy.
• Requirements:– Mild to moderate illness– No immune compromise– Must be older than 2 years
• Options:Quinolone otic drops (Ofloxacin /
Ciprofloxacin)• Efficacy has not been studied in children
with AOM & acute perforation• Oral therapy is always preferred
Complications of Otitis MediaRisks for complications associated with otitis
media:
• Increase if an acute episode of otitis media persists longer than 2 weeks.
• Increase if symptoms recur within a 2-3 week period.
• Decrease with early diagnosis and effective antibiotic treatment.
Complications of Otitis MediaIntracranial complications are uncommon in developed
counties but are a concern where access to medical
care is limited. They develop and spread:
• Through vascular channels.
• By direct extension.
• Through preformed pathways such as the round
window.
Extracranial complications are direct sequelae of:
• Localized acute inflammation, or
• Chronic inflammation.
Complications of Otitis Media
• Hearing loss:
Temporary: hearing loss of 25 to 30dB for
several months due to OME; risk of impaired
language development, vestibular, balance,
and motor dysfunctions.
Permanent: damage to the tympanic
membrane or other middle ear structures,
resulting in vertigo or facial weakness.
Complications of Otitis Media
• Adhesive otitis media: abnormal healing in inflamed
middle ear. Irreversible thickening of the mucus
membranes causing impaired movement of the
ossicles and possible conductive hearing loss (e.g.,
tympanosclerosis).
• Chronic suppurative otitis media: chronic otorrhea
through a perforated TM; the cycle of inflammation,
ulceration, infection, and granulation tissue
formation may destroy surrounding bony margins
and ultimately lead to various complications.
Complications of Otitis Media• Postauricular abscess: the most common extracranial complication.
• Tympanic membrane perforation due to increased middle ear
pressure.
• Meningitis: AOM is the most common cause of this intracranial
complication.
• Cholesteatoma: cystlike lesions of the middle ear that may erode
the ossicles, labyrinth, adjacent mastoid bone, and surrounding soft
tissues.
• Mastoiditis: inflammation as an extension of acute or chronic OM,
causing necrosis of the mastoid process and destruction of the bony
intercellular matrix.
Complications of Otitis Media• Facial nerve paresis
• Labyrinthitis: intratemporal complication
• Labyrinthine fistula
• Temporal abscess
• Petrositis: intratemporal complication
• Intracranial abscess
• Otitic hydrocephalus
• Sigmoid sinus thrombosis or thrombophlebitis
• Encephalocele
• CSF leak
Signs of possible impending complication:
• Sagging of the posterior canal wall
• Puckering of the attic or epitympanic recess
• Swelling of the postauricular areas with loss of the skin crease
• Persistent headache and/or fever
• Tinnitus
• Stiff neck
• Visual or other neurologic symptoms
• Severe otalgia
• Vertigo
• Lethargy
• Nausea and vomiting
• Fetid otorrhea
Signs or Symptoms of complication: Intracranial
• Fever associated with a chronic perforation
• Lethargy
• Focal neurologic signs (e.g., ataxia, oculomotor
deficits, seizure)
• Papilledema
• Meningismus
• Altered mental status
• Severe Headaches
Signs or Symptoms of complication:Extracranial
• Fever associated with a chronic
perforation.
• Postauricular edema or erythema.
Patient Education
• Explain the natural history of acute otitis media.
• Explain the benefits of using analgesics to treat ear
pain. Do not use longer than 3 days for pain without
consulting healthcare professional.
• Explain to parents topical analgesics must not be
used if the tympanic membrane ruptures.
• Explain the use of antibiotics in the management of
otitis media and implications of antibiotic-resistant
bacteria in AOM.
Patient Education• Provide parent with extensive information about
antibiotic overuse.
• Explain signs and symptoms of allergic reaction
to antibiotics and to report to healthcare provider
immediately.
• Explain that symptoms should decrease in 24-72
hours with the use of analgesics and/or
antibiotics.
• Explain that persistent otalgia, fever, and other
systemic symptoms past 72 hours should be
reevaluated by healthcare provider.
Patient Education
• Educate regarding the signs and symptoms of
clinical deterioration.
• Educate on preventable risk factors.
• Educate parents and patients regarding the
problem of drug-resistant bacteria and the need to
avoid the use of antibiotics unless absolutely
necessary.
• Explain the entire course of the prescription of
antibiotics must be completed.
Patient Education• Measure body temperature via oral, rectal,
or axillary methods. Transtympanic measurements of temperature in children with middle ear effusions may be inconsistent.
• Heat packs to affected ear may help relieve discomfort.
• Saltwater nasal spray or rinses may decrease congestion.
• Elevating head of crib may facilitate drainage.
Patient Education
• Do not use Q-tips in ears.
• Keep follow-up appointments until the
tympanic membrane is normal. Middle ear
effusion may persist for several weeks,
affecting speech and language development.
• AOM treatment failure requires referral to
otolaryngologist.
Prevention Measures
• Identify and treat underlying conditions that
predispose the child to AOM. This includes:
1. Immune deficiencies: e.g., IgG subclass
deficiency, hypogammaglobulinemia,
granulocyte defects.
2. Anatomic abnormalities: e.g., craniofacial
abnormalities, such as micrognathia, or palatal
clefts.
Prevention Measures
• Breast feed infants: breastfeeding provides for the
transfer of protective maternal antibodies to the
infant; bottle-fed infants have a higher incidence
of AOM than breast-fed infants, probably due to
feeding position during bottle-feeding, which
facilitates the reflux of milk into the middle ear.
• Reduce or eliminate pacifier use, especially after 6
months of age.
Prevention Measures
• Minimal exposure to group settings or daycare
setting with few children.
• Avoid or eliminate bottle-propping.
• Avoid feeding infants in supine position.
• Infection can spread more easily through the
eustachian canal of infants who spend most of
the day in the supine position.
• Avoid exposure to passive tobacco smoke.
Prevention Measures
• Chewing at least 3-5 sticks a day of Xylitol chewing
gum may reduce recurrence rate (if age
appropriate). Xylitol is a sugar found in fruits and
the bark of birch trees that has bacteriostatic
effects against S. pneumonia and interferes with
bacterial adhesion to mucous membranes. Side
effects include excessive gas and diarrhea.
Prevention Measures
• Annual influenza vaccine, especially in high-risk
children who attend day care.
• Early treatment of influenza with the antiviral
oseltamivir may reduce OM.
• Immunization with heptavalent pneumococcal
conjugate vaccine (PCV7 or Prevnar) may reduce the
incidence of AOM caused by S. pneumoniae.
• Consider tympanostomy tube placement for
prevention of recurrent AOM.
References
• American Academy of Pediatrics and American
Academy of Family Physicians (2004). Diagnosis
and management of acute otitis media. Clinical
practice guideline. Retrieved from
http://aappolicy.aappublications.org/cgi/reprint/pedi
atrics;113/5/1451.pdf
• Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B. &
Blosser, C.G. (2009). Pediatric primary care . (4th
ed.). St. Louis, MO: Saunders/Elsevier
References
• Donaldson, J. (2010). Middle ear, acute otitis media,
medical treatment. Retrieved from
http://emedicine.medscape.com/article/859316-overview
• Eaton, D. (2009). Complications of otitis media.
Retrieved from
http://emedicine.medscape.com/article/859316-overview
• Greydanus, D., Feinberg, A., Patel, D., & Homnick, D.
(2008). The pediatric diagnostic examination. NY:
McGraw-Hill.
References• Klein, J. & Pelton, S. (2011). Acute otitis media in
children: Treatment. Retrieved from http://0-
www.uptodate.com.topekalibraries.info/contents/acute-
otitis-media-in-children-treatment?
source=search_result&selectedTitle=1%7E150
• Klein, J. & Pelton, S. (2011). Acute otitis media in
children: Prevention of recurrence. Retrieved from
http://0-www.uptodate.com.topekalibraries.info/contents/
acute-otitis-media-in-children-prevention-of-recurrence?
source=search_result&selectedTitle=1%7E150
References
• Leskinen, K. (2005). Complications of acute otitis
media in children. Current Allergy and Asthma
Reports, 4, 308-312. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/15967073
• Porth, C. & Matfin, G. (2009). Pathophysiology:
Concepts of altered health states. (8th ed.).
Philadelphia, PA: Lippincott Williams &
Wilkins.