Otitis Media, Acute — Considerations for Cochlear Implants — Clinical Pathway: All Settings

Acute Otitis Media Clinical Pathway — All Settings

Considerations for Cochlear Implants

General

Cochlear implants are becoming more common, especially in children < 3 yrs of age to enhance speech and language acquisition.

This device is associated with increased risk for pneumococcal meningitis. Most instances result from a preceding AOM in the ear with a cochlear implant.

This risk has been reduced by:

  • Improved devices and surgical procedure
  • Ensuring age-appropriate vaccination including Pneumococcal and HIB conjugate vaccines
  • Addition of single dose of 23 valent pneumococcal vaccine at 24 mos of age
  • Annual influenza vaccine is also recommended to reduce episodes of AOM

Include the possibility of meningitis on the differential diagnosis: meningitis pathway.

Management of Post-Operative Wound or Suspected Cochlear Implant Infection
  • Infection-related to surgical procedure usually occurs within 30 days of the procedure
  • The majority are superficial, but deep infection to the mastoid, cochlea can occur
  • Consult ENT to assess superficial vs. deep infection
  • Consider CT Head, temporal bones if concerned for deep infection
  • Labs, LP, surgical debridement as clinically indicated
  • Initial Antibiotics: Vancomycin, cefotaxime
  • Review any preceding cultures from the ear to guide therapy
  • Consider ID Consult
Management of AOM in Children with Cochlear Implants
  • AOM after surgery is common
  • Risk for implant-associated infections is highest in the 1st 6 mos following surgery but can also occur after that time frame
  • Assess H&PE for signs/symptoms of meningitis, mastoiditis/cellulitis
  • Check for history of inner ear malformation from previous imaging
  • Review PMH for immunodeficiency/immunosuppression
In Children Whose History and Physical Exam are Consistent with AOM without Complication
  • Immediate empiric antibiotic treatment is indicated
  • Respiratory pathogens predominate: Haemophilus influenzae and Strep pneumoniae
  • If ear has a tympanostomy tube, add an empiric topical antibiotic to the treatments below

Treatment

< 2 mos After Surgery
  • Ceftriaxone
  • ENT Consult
  • Admit or ensure follow-up 24 hrs for reassessment and 2nd dose ceftriaxone
≥ 2 mos After Surgery
No History Inner Ear Malformation
  • Amoxicillin or Augmentin (90 mg/kg amoxicillin)
  • ENT or PCP Follow-up in 2-3 days
  • Strict return precautions
> 2 mos After Surgery
History of Inner Ear Malformation		 Consult ENT