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A 2 year old boy with Acute Otitis Media – Case Presentation

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Acute Otitis Media

A previously healthy 6-year-old female presents to the pediatric clinic for ear pain. Her mother reports that three days ago she developed a sore throat followed by a cough, runny nose, and fatigue. She recorded a temperature of 101.5 F (38.6 C) at home that responded well to antipyretics. Yesterday the child began to develop left ear pain. She had a history of ear infections as a toddler, but none recently. No history of ventilation tubes. The mother reports that siblings at home had similar symptoms without the ear pain that have since resolved. This image of the left ear is obtained with the Wispr digital otoscope.

The child has acute otitis media (AOM).

This is a classic presentation of acute otitis media (AOM) – a prodrome of viral symptoms followed by ear pain. The image obtained is also a textbook characteristic of AOM. The notable features of this presentation include bulging of the eardrum, erythema (redness), and loss of the typical bony associated with the tympanic membrane (eardrum). The dimple seen in the bulging doughnut of AOM is due to the umbo of the malleus .

Compare a normal ear to this ear with AOM.

Treatment of AOM would typically be a course of oral antibiotics.

Here is the video exam of this case:

Complete video of exam

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Chief Complaint

“Increased irritability and right ear pain.”

History of Present Illness

JL is a 22-month-old female who presents to her primary care provider (PCP) with a 2-day history of rhinorrhea and a 1-day history of increased irritability, fever (to 101.5°F per Mom), and right-ear tugging. Mom denies that JL has had any nausea, vomiting, or diarrhea.

Past Medical History

Full-term birth via spontaneous vaginal delivery. Hospitalized at 9 months of age for respiratory syncytial virus–associated bronchiolitis. Two episodes of acute otitis media (AOM), with last episode about 6 months earlier.

Surgical History

Social history.

Lives with mother, father, and her 5-year-old brother who attends kindergarten. JL attends daycare 2 d/wk, and stays at home with maternal grandmother 3 d/wk.

No known drug allergies

Immunizations

Home medications.

Vitamin D drops 600 IU/d

Physical Examination

Vital signs (while crying).

Temp 100.7°F, P 140 bpm, RR 35, BP 100/57 mm Hg, Ht 81 cm, Wt 23.7 kg

Fussy, but consolable by Mom; well-appearing

Normocephalic, atraumatic, moist mucous membranes, normal conjunctiva, clear rhinorrhea, moderate bulging and erythema of right tympanic membrane with middle-ear effusion

Good air movement throughout, clear breath sounds bilaterally

Cardiovascular

Normal rate and rhythm, no murmur, rub or gallop

Soft, non-distended, non-tender, active bowel sounds

Genitourinary

Normal female genitalia, no dysuria or hematuria

Alert and appropriate for age

Extremities

1. Which of the following clinical criteria is not part of the diagnostic evaluation or staging of acute otitis media (AOM) for this patient?

A. Rhinorrhea

D. Contour of the tympanic membrane

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A 2 year old boy with Acute Otitis Media – Case Presentation

Jul 22, 2014

410 likes | 1.74k Views

A 2 year old boy with Acute Otitis Media – Case Presentation. Nilanjana Basu , Homoeopathic Physician Lecturer , Department of Surgery Sameer Rana E.N.T. Specialist , Professor, Department of Surgery Bakson Homoeopathic Medical College, Greater Noida

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NilanjanaBasu, Homoeopathic Physician Lecturer, Department of Surgery • SameerRanaE.N.T. Specialist, Professor, Department of Surgery BaksonHomoeopathic Medical College, Greater Noida Correspondence to : [email protected]

Registration no. 4145/09 • Age/Sex – 2years/Male • Residence – Gamma 1,Greater Noida

Chief Complaints • Recurrent nasal discharge and stuffiness since 1 ½ months • Itching in left ear since 10 days

History of presenting illness • 2 year old baby brought to the E.N.T. clinic on 28.8.09 with recurrent nasal symptom of cold, stuffiness and rhinorrhoea since 11/2months. • His mother complained 2 weeks back of an episode of left earache followed by discharge which was profuse and mucoid. Pain was severe at the middle of the night due to which he couldn’t sleep.

History of hearing loss was not forthcoming. For the above complaints antibiotic and decongestant treatment was given by a local practitioner for 10days. At the time of case taking patient only had nasal complaints and itching in the left ear general irritability.

Past history • Patient had recurrent attacks of Upper respiratory tract infections

Family history • Mother – alive – Susceptibility to cold • Father - alive- Healthy

General physical examination • Mental state & conciousness-Well oriented & fully concious • Built & Nutrition – well built • Facies – normal • Pallor – absent • Icterus – absent

Cyanosis – absent • Oedema – absent • Clubbing – absent • Temperature – normal • Pulse – 100/min • Respiration – 20/min

Examination of Head & Neck • EAR – • Bilaterally pinna normal, excoriation of the skin and external canal on left side. External canal of Right side was normal. Left tympanic membrane congested with a small central perforation. Right tympanic membrane appeared normal. Patient did not respond to Tuning fork test. Facial nerve was normal bilaterally and there was no nystagmus.

NOSE • Bilaterally muco-purulent discharge with pallor and oedema of turbinates. • THROAT – normal • EXAMINATION OF NECK – normal

Otoscopic examination • Left tympanic membrane congested with a small central perforation.

Summary of the case: • A 2 year old boy presented with itching of left ear since 10 days. He had h/o upper respiratory tract infection since 1 ½ months followed by an episode of left earache followed by discharge which was profuse and mucoid 2 weeks ago. Pain was severe at the middle of the night due to which he couldn’t sleep.

On examination the left tympanic membrane was congested with a small central perforation. The right ear was normal.

Diagnosis • Acute Otitis Media of left Ear

Rubric selection The patient was irritable, restless, had itching in left ear at night. The rubrics selected likewise were from Kent Repertory. • Mind, restless, nervousness, night • Mind, irritability • Ear, itching in, left • Generalities, night

Prescription • All the rubrics covered Rhustox, which was prescribed in 0/1 potency thrice a day. • Ear was regularly cleaned.

Follow up • After 7 days the baby’s nasal discharge decreased, irritability, restlessness and itching in ear were relieved. The medicine was continued for another 15 days.

Rhustox 0/2 was prescribed on 20.10.09. The ear was dry but the perforation started healing. The same medicine was continued for 7 more days. On 10.11.09 the ear was examined with an otoscope which revealed that the perforation was healed.

Discussions • The importance of healing this perforation is utmost as the recurrent attacks of cough and cold complicates the perforation and it becomes chronic otitis media with hearing loss and discharging ear.

This age also coincide with the development of speech. If the patient cannot hear there will be improper development of speech.

Rhustox was given on account of the restlessness of the baby at night which was very marked. • Fifty millesimal potency was prescribed as we required frequent repetition of the medicines in ever increasing dose.

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Acute otitis media.

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Last Update: April 15, 2023 .

• Continuing Education Activity

Acute otitis media (AOM) is defined as an infection of the middle ear and is the second most common pediatric diagnosis in the emergency department following upper respiratory infections. Although acute otitis media can occur at any age, it is most commonly seen between the ages of 6 to 24 months. Approximately 80% of all children will experience a case of otitis media during their lifetime, and between 80% and 90% of all children will have otitis media with an effusion before school age. This activity reviews the etiology, epidemiology, evaluation, and management of acute otitis media and highlights the role of the interprofessional team in managing this condition.

• Describe a patient presentation consistent with acute otitis media and the subsequent evaluation that should be performed.
• Explain when imaging studies should be done for a patient with acute otitis media.
• Outline the treatment strategy for otitis media.
• Employ an interprofessional team approach when caring for patients with acute otitis media.
• Introduction

Acute otitis media is defined as an infection of the middle ear space. It is a spectrum of diseases that includes acute otitis media (AOM), chronic suppurative otitis media (CSOM), and otitis media with effusion (OME). Acute otitis media is the second most common pediatric diagnosis in the emergency department, following upper respiratory infections. Although otitis media can occur at any age, it is most commonly seen between the ages of 6 to 24 months. [1]

Infection of the middle ear can be viral, bacterial, or coinfection. The most common bacterial organisms causing otitis media are Streptococcus pneumoniae , followed by non-typeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis . Following the introduction of the conjugate pneumococcal vaccines, the pneumococcal organisms have evolved to non-vaccine serotypes. The most common viral pathogens of otitis media include the respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses. [2] [3] [4]

Otitis media is diagnosed clinically via objective findings on physical exam (otoscopy) combined with the patient's history and presenting signs and symptoms. Several diagnostic tools are available such as a pneumatic otoscope, tympanometry, and acoustic reflectometry, to aid in the diagnosis of otitis media. Pneumatic otoscopy is the most reliable and has a higher sensitivity and specificity as compared to plain otoscopy, though tympanometry and other modalities can facilitate diagnosis if pneumatic otoscopy is unavailable.

Treatment of otitis media with antibiotics is controversial and directly related to the subtype of otitis media in question. Without proper treatment, suppurative fluid from the middle ear can extend to the adjacent anatomical locations and result in complications such as tympanic membrane (TM) perforation, mastoiditis, labyrinthitis, petrositis, meningitis, brain abscess, hearing loss, lateral and cavernous sinus thrombosis, and others. [5] This has led to the development of specific guidelines for the treatment of OM.  In the United States, the mainstay of treatment for an established diagnosis of AOM is high-dose amoxicillin, and this has been found to be most effective in children under two years of age. Treatment in countries like the Netherlands is initially watchful waiting, and if unresolved, antibiotics are warranted [6] . However, the concept of watchful waiting has not gained full acceptance in the United States and other countries due to the risk of prolonged middle ear fluid and its effect on hearing and speech, as well as the risks of complications discussed earlier. Analgesics such as non-steroidal anti-inflammatory medications such as ibuprofen can be used alone or in combination to achieve effective pain control in patients with otitis media.

Otitis media is a multifactorial disease. Infectious, allergic, and environmental factors contribute to otitis media. [7] [8] [9] [10] [11] [12]

These causes and risk factors include:

• Decreased immunity due to human immunodeficiency virus (HIV), diabetes, and other immuno-deficiencies
• Genetic predisposition
• Mucins that include abnormalities of this gene expression, especially upregulation of MUC5B
• Anatomic abnormalities of the palate and tensor veli palatini
• Ciliary dysfunction
• Cochlear implants
• Vitamin A deficiency
• Bacterial pathogens,  Streptococcus pneumoniae , Haemophilus influenza, and Moraxella (Branhamella) catarrhalis  are responsible for more than 95%
• Viral pathogens such as respiratory syncytial virus, influenza virus, parainfluenza virus, rhinovirus, and adenovirus
• Lack of breastfeeding
• Passive smoke exposure
• Daycare attendance
• Lower socioeconomic status
• Family history of recurrent AOM in parents or siblings
• Epidemiology

Otitis media is a global problem and is found to be slightly more common in males than in females. The specific number of cases per year is difficult to determine due to the lack of reporting and different incidences across many different geographical regions. The peak incidence of otitis media occurs between six and twelve months of life and declines after age five. Approximately 80% of all children will experience a case of otitis media during their lifetime, and between 80% and 90% of all children will experience otitis media with an effusion before school age. Otitis media is less common in adults than in children, though it is more common in specific sub-populations such as those with a childhood history of recurrent OM, cleft palate, immunodeficiency or immunocompromised status, and others. [13] [14]

• Pathophysiology

Otitis media begins as an inflammatory process following a viral upper respiratory tract infection involving the mucosa of the nose, nasopharynx, middle ear mucosa, and Eustachian tubes. Due to the constricted anatomical space of the middle ear, the edema caused by the inflammatory process obstructs the narrowest part of the Eustachian tube leading to a decrease in ventilation. This leads to a cascade of events resulting in an increase in negative pressure in the middle ear, increasing exudate from the inflamed mucosa, and buildup of mucosal secretions, which allows for the colonization of bacterial and viral organisms in the middle ear. The growth of these microbes in the middle ear then leads to suppuration and, eventually, frank purulence in the middle ear space. This is demonstrated clinically by a bulging or erythematous tympanic membrane and purulent middle ear fluid. This must be differentiated from chronic serous otitis media (CSOM), which presents with thick, amber-colored fluid in the middle ear space and a retracted tympanic membrane on otoscopic examination. Both will yield decreased TM mobility on tympanometry or pneumatic otoscopy.

Several risk factors can predispose children to develop acute otitis media. The most common risk factor is a preceding upper respiratory tract infection. Other risk factors include male gender, adenoid hypertrophy (obstructing), allergy, daycare attendance, environmental smoke exposure, pacifier use, immunodeficiency, gastroesophageal reflux, parental history of recurrent childhood OM, and other genetic predispositions. [15] [16] [17]

• Histopathology

Histopathology varies according to disease severity. Acute purulent otitis media (APOM) is characterized by edema and hyperemia of the subepithelial space, which is followed by the infiltration of polymorphonuclear (PMN) leukocytes. As the inflammatory process progresses, there is mucosal metaplasia and the formation of granulation tissue. After five days, the epithelium changes from flat cuboidal to pseudostratified columnar with the presence of goblet cells.

In serous acute otitis media (SAOM), inflammation of the middle ear and the eustachian tube has been identified as the major precipitating factor. Venous or lymphatic stasis in the nasopharynx or the eustachian tube plays a vital role in the pathogenesis of AOM. Inflammatory cytokines attract plasma cells, leukocytes, and macrophages to the site of inflammation. The epithelium changes to pseudostratified, columnar, or cuboidal. Hyperplasia of basal cells results in an increased number of goblet cells in the new epithelium. [18]

In practice, biopsy for histology is not performed for OM outside of research settings.

• History and Physical

Although one of the best indicators for otitis media is otalgia, many children with otitis media can present with non-specific signs and symptoms, which can make the diagnosis challenging. These symptoms include pulling or tugging at the ears, irritability, headache, disturbed or restless sleep, poor feeding, anorexia, vomiting, or diarrhea. Approximately two-thirds of the patients present with fever, which is typically low-grade.

The diagnosis of otitis media is primarily based on clinical findings combined with supporting signs and symptoms as described above. No lab test or imaging is needed. According to guidelines set forth by the American Academy of Pediatrics, evidence of moderate to severe bulging of the tympanic membrane or new onset of otorrhea not caused by otitis externa or mild tympanic membrane (TM) bulging with recent onset of ear pain or erythema is required for the diagnosis of acute otitis media. These criteria are intended only to aid primary care clinicians in the diagnosis and proper clinical decision-making but not to replace clinical judgment. [19]

Otoscopic examination should be the first and most convenient way of examining the ear and will yield the diagnosis to the experienced eye. In AOM, the TM may be erythematous or normal, and there may be fluid in the middle ear space. In suppurative OM, there will be obvious purulent fluid visible and a bulging TM. The external ear canal (EAC) may be somewhat edematous, though significant edema should alert the clinician to suspect otitis externa (outer ear infection, AOE), which may be treated differently. In the presence of EAC edema, it is paramount to visualize the TM to ensure it is intact. If there is an intact TM and a painful, erythematous EAC, ototopical drops should be added to treat AOE. This can exist in conjunction with AOM or independent of it, so visualization of the middle ear is paramount. If there is a perforation of the TM, then the EAC edema can be assumed to be reactive, and ototopical medication should be used, but an agent approved for use in the middle ear, such as ofloxacin, must be used, as other agents can be ototoxic. [20] [21] [22]

The diagnosis of otitis media should always begin with a physical exam and the use of an otoscope, ideally a pneumatic otoscope. [23] [24]

Laboratory Studies

Laboratory evaluation is rarely necessary. A full sepsis workup in infants younger than 12 weeks with fever and no obvious source other than associated acute otitis media may be necessary. Laboratory studies may be needed to confirm or exclude possible related systemic or congenital diseases.

Imaging Studies

Imaging studies are not indicated unless intra-temporal or intracranial complications are a concern. [25] [26]

• When an otitis media complication is suspected, computed tomography of the temporal bones may identify mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, meningitis, brain abscess, subdural abscess, ossicular disease, and cholesteatoma.
• Magnetic resonance imaging may identify fluid collections, especially in the middle ear collections.

Tympanocentesis

Tympanocentesis may be used to determine the presence of middle ear fluid, followed by culture to identify pathogens.

Tympanocentesis can improve diagnostic accuracy and guide treatment decisions but is reserved for extreme or refractory cases. [27] [28]

Other Tests

Tympanometry and acoustic reflectometry may also be used to evaluate for middle ear effusion. [29]

• Treatment / Management

Once the diagnosis of acute otitis media is established, the goal of treatment is to control pain and treat the infectious process with antibiotics. Non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen can be used to achieve pain control. There are controversies about prescribing antibiotics in early otitis media, and the guidelines may vary by country, as discussed above. Watchful waiting is practiced in European countries with no reported increased incidence of complications. However, watchful waiting has not gained wide acceptance in the United States. If there is clinical evidence of suppurative AOM, however, oral antibiotics are indicated to treat this bacterial infection, and high-dose amoxicillin or a second-generation cephalosporin are first-line agents. If there is a TM perforation, treatment should proceed with ototopical antibiotics safe for middle-ear use, such as ofloxacin, rather than systemic antibiotics, as this delivers much higher concentrations of antibiotics without any systemic side effects. [23]

When a bacterial etiology is suspected, the antibiotic of choice is high-dose amoxicillin for ten days in both children and adult patients who are not allergic to penicillin. Amoxicillin has good efficacy in the treatment of otitis media due to its high concentration in the middle ear. In cases of penicillin allergy, the American Academy of Pediatrics (AAP) recommends azithromycin as a single dose of 10 mg/kg or clarithromycin (15 mg/kg per day in 2 divided doses). Other options for penicillin-allergic patients are cefdinir (14 mg/kg per day in 1 or 2 doses), cefpodoxime (10 mg/kg per day, once daily), or cefuroxime (30 mg/kg per day in 2 divided doses).

For those patients whose symptoms do not improve after treatment with high-dose amoxicillin, high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses) should be given. In children who are vomiting or if there are situations in which oral antibiotics cannot be administered, ceftriaxone (50 mg/kg per day) for three consecutive days, either intravenously or intramuscularly, is an alternative option. Systemic steroids and antihistamines have not been shown to have any significant benefits. [30] [31] [19] [32] [33] [34]

Patients who have experienced four or more episodes of AOM in the past twelve months should be considered candidates for myringotomy with tube (grommet) placement, according to the American Academy of Pediatrics guidelines. Recurrent infections requiring antibiotics are clinical evidence of Eustachian tube dysfunction, and placement of the tympanostomy tube allows ventilation of the middle ear space and maintenance of normal hearing. Furthermore, should the patient acquire otitis media while a functioning tube is in place, they can be treated with ototopical antibiotic drops rather than systemic antibiotics. [35]

• Differential Diagnosis

The following conditions come under the differential diagnosis of otitis media [36] [37] [38]

• Cholesteatoma
• Fever in the infant and toddler
• Fever without a focus
• Hearing impairment
• Pediatric nasal polyps
• Nasopharyngeal cancer
• Otitis externa
• Human parainfluenza viruses (HPIV) and other parainfluenza viruses
• Passive smoking and lung disease
• Pediatric allergic rhinitis
• Pediatric bacterial meningitis
• Pediatric gastroesophageal reflux
• Pediatric Haemophilus influenzae infection
• Pediatric HIV infection
• Pediatric mastoiditis
• Pediatric pneumococcal infections
• Primary ciliary dyskinesia
• Respiratory syncytial virus infection
• Rhinovirus (RV) infection (common cold)

The prognosis for most of the patients with otitis media is excellent. [39] Mortality from AOM is a rare occurrence in modern times. Due to better access to healthcare in developed countries, early diagnosis and treatment have resulted in a better prognosis for this disease. Effective antibiotic therapy is the mainstay of treatment. Multiple prognostic factors affect the disease course. Children presenting with less than three episodes of AOM are three times more likely to have their symptoms resolved with a single course of antibiotics as compared to children who develop this condition in seasons apart from winter. [40]

Children who develop complications can be difficult to treat and tend to have high rates of recurrence. Intratemporal and intracranial complications, while very rare, have significant mortality rates. [41]

Children with a history of prelingual otitis media are at risk for mild-to-moderate conductive hearing loss. Children with otitis media in the first 24 months of life often have difficulty perceiving strident or high-frequency consonants, such as sibilants.

• Complications

Due to the complex arrangement of structures in and around the middle ear, complications, once developed, are challenging to treat. Complications can be divided into intratemporal and intracranial complications. [41] [42] [43] [42]

The following are the intratemporal complications;

• Hearing loss (conductive and sensorineural)
• TM perforation (acute and chronic)
• Chronic suppurative otitis media (with or without cholesteatoma)
• Tympanosclerosis
• Mastoiditis
• Labyrinthitis
• Facial paralysis
• Cholesterol granuloma
• Infectious eczematoid dermatitis

Additionally, it is important to discuss the effect of OM on hearing, particularly in the 6-24 month age range, as this is an important time for language development, which is related to hearing. The conductive hearing loss resulting from chronic or recurrent OM can adversely affect language development and result in prolonged speech problems requiring speech therapy. This is one reason the American Academy of Pediatrics and the American Academy of Otolaryngology-Head & Neck Surgery recommend aggressive early treatment of recurrent AOM.

The following are the intracranial complications;

• Subdural empyema
• Brain abscess
• Extradural abscess
• Lateral sinus thrombosis
• Otitic hydrocephalus
• Consultations

Patients with uncomplicated AOM are usually treated by their primary care providers. However, primary care physicians may refer the patient to an otolaryngologist for surgical procedures, most likely tympanostomy tubes, in the case of recurrent AOM or CSOM. An audiologist is involved if children present with subjective evidence of hearing loss or failure to meet language development marks. Young children with CSOM may have speech and language delays owing to the hearing loss created by recurrent ear infections, which are managed by a speech therapist. [44]

• Deterrence and Patient Education

Pneumococcal and influenza vaccines prevent upper respiratory tract infections (URTIs) in children. Apart from this, the avoidance of tobacco smoke can decrease the risk of URTI. Tobacco smoke is a respiratory stimulant that increases the risk of pneumonia in children. Infants with otitis media should be breastfed whenever possible, as breast milk contains immunoglobulins that protect infants from foreign pathogens in key phases of early extra-uterine life. [45]

• Enhancing Healthcare Team Outcomes

Acute otitis media can often be managed in the outpatient/clinical setting. However, it can best be served via interprofessional management through an interprofessional team approach, including physicians, family, audiologists, nurses, pharmacists, and/or speech pathologists. Early diagnosis and prompt treatment decrease the risk of complications resulting in better patient outcomes. Nurses instruct the family about medication administration, supportive care, and analgesics. They review follow-up instructions. Pharmacists instruct patients about the potential adverse effects of medication and review for drug interactions.

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Acute Otitis Media on Otoscopy. This otoscopic image shows tympanic membrane erythema and bulging, consistent with acute otitis media. Contributed by Wikimedia Commons, B. Welleschik (CC by 2.0) https://creativecommons.org/licenses/by/2.0/

Acute Otitis Media Pathophysiology. This illustration shows the common etiologies and pathophysiology of acute otitis media. Purchased from Shutterstock

Disclosure: Amina Danishyar declares no relevant financial relationships with ineligible companies.

Disclosure: John Ashurst declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Danishyar A, Ashurst JV. Acute Otitis Media. [Updated 2023 Apr 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Treated with antibiotics 3 weeks ago for AOM. Puffy, fussing with ears, restless sleep, poor appetite, URI symptoms. Temperature 39.4.

Left ear, middle ear effusion, not full, no bulging, no erythema, immobile.

Right ear: initially obstructed by cerumen. After cerumen was removed, right tympanic membrane same as left.

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KATHRYN M. HARMES, MD, R. ALEXANDER BLACKWOOD, MD, PhD, HEATHER L. BURROWS, MD, PhD, JAMES M. COOKE, MD, R. VAN HARRISON, PhD, AND PETER P. PASSAMANI, MD

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2013;88(7):435-440

Related editorials: Should Children with Acute Otitis Media Routinely Be Treated with Antibiotics? Yes: Routine Treatment Makes Sense for Symptomatic, Emotional, and Economic Reasons and No: Most Children Older Than Two Years Do Not Require Antibiotics

A more recent article on otitis media is available.

Author disclosure: No relevant financial affiliations.

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae , and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate, should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist.

Otitis media is among the most common issues faced by physicians caring for children. Approximately 80% of children will have at least one episode of acute otitis media (AOM), and between 80% and 90% will have at least one episode of otitis media with effusion (OME) before school age. 1 , 2 This review of diagnosis and treatment of otitis media is based, in part, on the University of Michigan Health System's clinical care guideline for otitis media. 2

Etiology and Risk Factors

Usually, AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Bacteria can be isolated from middle ear fluid cultures in 50% to 90% of cases of AOM and OME. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most common organisms. 3 , 4 H. influenzae has become the most prevalent organism among children with severe or refractory AOM following the introduction of the pneumococcal conjugate vaccine. 5 – 7 Risk factors for AOM are listed in Table 1 . 8 , 9

Previous diagnostic criteria for AOM were based on symptomatology without otoscopic findings of inflammation. The updated American Academy of Pediatrics guideline endorses more stringent otoscopic criteria for diagnosis. 8 An AOM diagnosis requires moderate to severe bulging of the tympanic membrane ( Figure 1 ) , new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema. AOM should not be diagnosed in children who do not have objective evidence of middle ear effusion. 8 An inaccurate diagnosis can lead to unnecessary treatment with antibiotics and contribute to the development of antibiotic resistance.

OME is defined as middle ear effusion in the absence of acute symptoms. 10 , 11 If OME is suspected and the presence of effusion on otoscopy is not evident by loss of landmarks, pneumatic otoscopy, tympanometry, or both should be used. 11 Pneumatic otoscopy is a useful technique for the diagnosis of AOM and OME 8 – 12 and is 70% to 90% sensitive and specific for determining the presence of middle ear effusion. By comparison, simple otoscopy is 60% to 70% accurate. 10 , 11 Inflammation with bulging of the tympanic membrane on otoscopy is highly predictive of AOM. 7 , 8 , 12 Pneumatic otoscopy is most helpful when cerumen is removed from the external auditory canal.

Tympanometry and acoustic reflectometry are valuable adjuncts to otoscopy or pneumatic otoscopy. 8 , 10 , 11 Tympanometry has a sensitivity and specificity of 70% to 90% for the detection of middle ear fluid, but is dependent on patient cooperation. 13 Combined with normal otoscopy findings, a normal tympanometry result may be helpful to predict absence of middle ear effusion. Acoustic reflectometry has lower sensitivity and specificity in detecting middle ear effusion and must be correlated with the clinical examination. 14 Tympanocentesis is the preferred method for detecting the presence of middle ear effusion and documenting bacterial etiology, 8 but is rarely performed in the primary care setting.

Management of Acute Otitis Media

Treatment of AOM is summarized in Table 2 . 8

Analgesics are recommended for symptoms of ear pain, fever, and irritability. 8 , 15 Analgesics are particularly important at bedtime because disrupted sleep is one of the most common symptoms motivating parents to seek care. 2 Ibuprofen and acetaminophen have been shown to be effective. 16 Ibuprofen is preferred, given its longer duration of action and its lower toxicity in the event of overdose. 2 Topical analgesics, such as benzocaine, can also be helpful. 17

OBSERVATION VS. ANTIBIOTIC THERAPY

Antibiotic-resistant bacteria remain a major public health challenge. A widely endorsed strategy for improving the management of AOM involves deferring antibiotic therapy in patients least likely to benefit from antibiotics. 18 Antibiotics should be routinely prescribed for children with AOM who are six months or older with severe signs or symptoms (i.e., moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or higher), and for children younger than two years with bilateral AOM regardless of additional signs or symptoms. 8

Among children with mild symptoms, observation may be an option in those six to 23 months of age with unilateral AOM, or in those two years or older with bilateral or unilateral AOM. 8 , 10 , 19 A large prospective study of this strategy found that two out of three children will recover without antibiotics. 20 Recently, the American Academy of Family Physicians recommended not prescribing antibiotics for otitis media in children two to 12 years of age with nonsevere symptoms if observation is a reasonable option. 21 , 22 If observation is chosen, a mechanism must be in place to ensure appropriate treatment if symptoms persist for more than 48 to 72 hours. Strategies include a scheduled follow-up visit or providing patients with a backup antibiotic prescription to be filled only if symptoms persist. 8 , 20 , 23

ANTIBIOTIC SELECTION

[ corrected ] Table 3 summarizes the antibiotic options for children with AOM. 8 High-dose amoxicillin should be the initial treatment in the absence of a known allergy. 8 , 10 , 24 The advantages of amoxicillin include low cost, acceptable taste, safety, effectiveness, and a narrow microbiologic spectrum. Children who have taken amoxicillin in the past 30 days, who have conjunctivitis, or who need coverage for β-lactamase–positive organisms should be treated with high-dose amoxicillin/clavulanate (Augmentin). 8

Oral cephalosporins, such as cefuroxime (Ceftin), may be used in children who are allergic to penicillin. Recent research indicates that the degree of cross reactivity between penicillin and second- and third-generation cephalosporins is low (less than 10% to 15%), and avoidance is no longer recommended. 25 Because of their broad-spectrum coverage, third-generation cephalosporins in particular may have an increased risk of selection of resistant bacteria in the community. 26 High-dose azithromycin (Zithromax; 30 mg per kg, single dose) appears to be more effective than the commonly used five-day course, and has a similar cure rate as high-dose amoxicillin/clavulanate. 8 , 27 , 28 However, excessive use of azithromycin is associated with increased resistance, and routine use is not recommended. 8 Trimethoprim/sulfamethoxazole is no longer effective for the treatment of AOM due to evidence of S. pneumoniae resistance. 29

Intramuscular or intravenous ceftriaxone (Rocephin) should be reserved for episodes of treatment failure or when a serious comorbid bacterial infection is suspected. 2 One dose of ceftriaxone may be used in children who cannot tolerate oral antibiotics because it has been shown to have similar effectiveness as high-dose amoxicillin. 30 , 31 A three-day course of ceftriaxone is superior to a one-day course in the treatment of nonresponsive AOM caused by penicillin-resistant S. pneumoniae . 31 Although some children will likely benefit from intramuscular ceftriaxone, overuse of this agent may significantly increase high-level penicillin resistance in the community. 2 High-level penicillin-resistant pneumococci are also resistant to first- and third-generation cephalosporins.

Antibiotic therapy for AOM is often associated with diarrhea. 8 , 10 , 32 Probiotics and yogurts containing active cultures reduce the incidence of diarrhea and should be suggested for children receiving antibiotics for AOM. 32 There is no compelling evidence to support the use of complementary and alternative treatments in AOM. 8

PERSISTENT OR RECURRENT AOM

Children with persistent, significant AOM symptoms despite at least 48 to 72 hours of antibiotic therapy should be reexamined. 8 If a bulging, inflamed tympanic membrane is observed, therapy should be changed to a second-line agent. 2 For children initially on amoxicillin, high-dose amoxicillin/clavulanate is recommended. 8 , 10 , 28

For children with an amoxicillin allergy who do not improve with an oral cephalosporin, intramuscular ceftriaxone, clindamycin, or tympanocentesis may be considered. 4 , 8 If symptoms recur more than one month after the initial diagnosis of AOM, a new and unrelated episode of AOM should be assumed. 10 For children with recurrent AOM (i.e., three or more episodes in six months, or four episodes within 12 months with at least one episode during the preceding six months) with middle ear effusion, tympanostomy tubes may be considered to reduce the need for systemic antibiotics in favor of observation, or topical antibiotics for tube otorrhea. 8 , 10 However, tympanostomy tubes may increase the risk of long-term tympanic membrane abnormalities and reduced hearing compared with medical therapy. 33 Other strategies may help prevent recurrence ( Table 4 ) . 34 – 37

Probiotics, particularly in infants, have been suggested to reduce the incidence of infections during the first year of life. Although available evidence has not demonstrated that probiotics prevent respiratory infections, 38 probiotics do not cause adverse effects and need not be discouraged. Antibiotic prophylaxis is not recommended. 8

Management of OME

Management of OME is summarized in Table 5 . 11 Two rare complications of OME are transient hearing loss potentially associated with language delay, and chronic anatomic injury to the tympanic membrane requiring reconstructive surgery. 11 Children should be screened for speech delay at all visits. If a developmental delay is apparent or middle ear structures appear abnormal, the child should be referred to an otolaryngologist. 11 Antibiotics, decongestants, and nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. 11 , 39

Tympanostomy Tube Placement

Tympanostomy tubes are appropriate for children six months to 12 years of age who have had bilateral OME for three months or longer with documented hearing difficulties, or for children with recurrent AOM who have evidence of middle ear effusion at the time of assessment for tube candidacy. Tubes are not indicated in children with a single episode of OME of less than three months' duration, or in children with recurrent AOM who do not have middle ear effusion in either ear at the time of assessment for tube candidacy. Children with chronic OME who did not receive tubes should be reevaluated every three to six months until the effusion is no longer present, hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected. 40

Children with tympanostomy tubes who present with acute uncomplicated otorrhea should be treated with topical antibiotics and not oral antibiotics. Routine, prophylactic water precautions such as ear plugs, headbands, or avoidance of swimming are not necessary for children with tympanostomy tubes. 40

Special Populations

Infants eight weeks or younger.

Young infants are at increased risk of severe sequelae from suppurative AOM. Middle ear pathogens found in neonates younger than two weeks include group B streptococcus, gram-negative enteric bacteria, and Chlamydia trachomatis . 41 Febrile neonates younger than two weeks with apparent AOM should have a full sepsis workup, which is indicated for any febrile neonate. 41 Empiric amoxicillin is acceptable for infants older than two weeks with upper respiratory tract infection and AOM who are otherwise healthy. 42

There is little published information to guide the management of otitis media in adults. Adults with new-onset unilateral, recurrent AOM (greater than two episodes per year) or persistent OME (greater than six weeks) should receive additional evaluation to rule out a serious underlying condition, such as mechanical obstruction, which in rare cases is caused by nasopharyngeal carcinoma. Isolated AOM or transient OME may be caused by eustachian tube dysfunction from a viral upper respiratory tract infection; however, adults with recurrent AOM or persistent OME should be referred to an otolaryngologist.

Data Sources: We reviewed the updated Agency for Healthcare Research and Quality Evidence Report on the management of acute otitis media, which included a systematic review of the literature through July 2010. We searched Medline for literature published since July 1, 2010, using the keywords human, English language, guidelines, controlled trials, and cohort studies. Searches were performed using the following terms: otitis media with effusion or serous effusion, recurrent otitis media, acute otitis media, otitis media infants 0–4 weeks, otitis media adults, otitis media and screening for speech delay, probiotic bacteria after antibiotics. Search dates: October 2011 and August 14, 2013.

EDITOR'S NOTE: This article is based, in part, on an institution-wide guideline developed at the University of Michigan. As part of the guideline development process, authors of this article, including representatives from primary and specialty care, convened to review current literature and make recommendations for diagnosis and treatment of otitis media and otitis media with effusion in primary care.

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