AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Acute otitis media (AOM) is an infection of the middle ear. AOM accounted for approximately 25 million clinic visits and 20 million antibiotic prescriptions in 1990. However, with the introduction of the Haemophilus influenzae type b vaccine and the pneumococcal vaccine, the incidence has decreased significantly. The estimated direct costs (doctor visits and prescriptions) and indirect costs (time lost from school and work) in 1995 were $1.96 and $1.02 billion, respectively.

Pathophysiology

Children are prone to develop AOM because their eustachian tubes are shorter and more horizontal, have smaller orifices, and have less supporting cartilage compared with those of adults. These factors contribute to eustachian tube dysfunction. Mucosal inflammation and edema due to viral upper respiratory infections (URIs) further impair middle-ear drainage and interfere with host defenses. The cumulative effect predisposes children to the development AOM.

Frequency

United States

Approximately 75% of children experience at least one episode, making AOM the most common childhood infection for which antibiotics are prescribed in the United States.

Mortality/Morbidity

Morbidity of otitis media has decreased with the advent of antibiotics. In Europe, where several nations do not routinely use antibiotics, the disease is usually self-limited.

Race

AOM is more common in white and Native American children than in children of African descent.

Sex

Males are affected more often than females.

Age

AOM usually occurs between 2 months and 12 years of age, with a peak incidence between 6 months and 3 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

Symptoms of acute otitis media (AOM) include otalgia, ear pulling, sensation of a plugged ear, hearing loss, irritability, anorexia, vomiting, diarrhea, and fever (may be more closely related to a coexistent viral URI).

Physical

Evaluation for AOM requires visualization of the entire tympanic membrane (TM) and assessment of its mobility. Obstructing cerumen should be removed with a curette after softening. Pneumatic otoscopy or tympanometry can be used to detect a middle-ear effusion. Conductive hearing loss is consistent with an effusion but does not differentiate AOM from otitis media with effusion (OME). OME may accompany a viral URI or follow resolution of AOM.

• The diagnosis of AOM requires the following:
• • Acute onset of symptoms
  • Presence of a middle-ear effusion
  • Signs of middle-ear inflammation
• Symptoms attributed to AOM should be directly referable to the ear under consideration. Bulging or reduced mobility of the TM or an air-fluid level in the middle ear defines an effusion. An inflamed TM appears yellow or erythematous, and bony landmarks are usually obscured. Note that fever or crying may cause the TMs to appear injected and red in the absence of AOM.

Causes

Nonmodifiable risk factors for AOM include prematurity, a family history of AOM, craniofacial abnormalities, male sex, white or Native American race, cohabitation with other children, and low socioeconomic status. Modifiable risk factors include day care attendance, exposure to tobacco smoke, and bottle-feeding. Clinicians should stress the reduction of modifiable risk factors when discussing the diagnosis of AOM with parents.

• Streptococcus pneumoniae, nontypeable H influenzae, Moraxella catarrhalis, and less commonly Streptococcus pyogenes and Staphylococcus aureus are the responsible bacterial organisms.
• The widespread use of the heptavalent pneumococcal vaccine appears to be reducing the incidence of AOM due to S pneumoniae. S pyogenes, S aureus, gram-negative organisms, and anaerobes account for a minority of cases. Viruses (without bacterial superinfection), including respiratory syncytial virus, rhinovirus, coronavirus, parainfluenza, influenza, adenovirus, and enterovirus, are responsible for many of AOM cases. No pathogen can be identified in 16-25% of middle-ear infections.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

An erythematous TM can also be caused by a viral URI; efforts to remove cerumen; or the child's crying, sneezing, nose blowing, or fever.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Although not usually performed in most clinical settings, tympanocentesis is the criterion standard for diagnosis. If myringotomy is performed or if the TM has perforated, samples may be obtained for culture and sensitivity; however, in most cases the clinician should treat empirically.

Imaging Studies

• Traditionally, AOM is diagnosed by using pneumatic otoscopy. More recently, tympanometry and acoustic reflectometry have been used to detect fluid within the middle ear. These are dependent on user technique and ability to create an adequate seal.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Emergency Department Care

Most children with AOM suffer no adverse sequelae without antibiotics. The number needed to treat (NNT) for 1 child to benefit (resolution of symptoms 1 day sooner on average) from initial antibiotic therapy is between 7 and 20. In the Netherlands and Iceland, standard initial treatment of AOM does not include antibiotics. This policy has decreased the emergence of drug-resistant bacteria, in particular penicillin-resistant S pneumoniae, without increasing complications.

• Initial antibiotics versus observation: Clinical practice guidelines published by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) provide recommendations regarding the choice of initial antibiotics or observation without antibiotics based on the age of the child, diagnostic certainty, and illness severity.¹ Diagnostic certainty is assured by the presence of all 3 aforementioned criteria—acute onset, an effusion, and middle-ear inflammation. Diagnostic uncertainty is defined as the absence of one or more of these criteria. Severe disease is defined as moderate-to-severe otalgia or temperature greater than or equal to 39°C. Nonsevere disease has mild otalgia and temperature less than 39°C.
• • Children younger than 6 months should receive antibiotics for AOM regardless of which diagnostic certainty and disease severity categories define their condition.
  • Children aged 6 months to 2 years should be treated with antibiotics when the diagnosis is certain or if disease is severe. For those with an uncertain diagnosis and nonsevere disease, an observation period of 48-72 hours is acceptable. Antibiotics should be started if symptoms and signs persist or worsen.
  • Children older than 2 years should receive antibiotics for a certain diagnosis and severe disease. Those with an uncertain diagnosis or nonsevere disease can be observed initially without antibiotics.
  • In children older than 6 months, withholding antibiotics for 48 hours is a growing trend in nonsevere cases. One recommended approach is to provide analgesic drops, oral analgesia, and an antibiotic prescription that is only to be filled after 48 hours if no clinical improvement occurs.

Consultations

Otolaryngologist consultation can usually be deferred to the patient's pediatrician. Indications for referral include treatment failure, recurrent or chronic otitis media, TM perforation, and cholesteatoma. Mastoiditis requires admission for intravenous antibiotics and inpatient specialist consultation.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The mainstays of treatment are antibiotics, analgesics, and antipyretics.

Drug Category: Antibiotics

According to the AAP and AAFP clinical practice guideline, first-line therapy for nonsevere AOM is amoxicillin (80-90 mg/kg/d PO divided tid). For severe disease, amoxicillin-clavulanate (90 mg/kg/d PO divided bid, dose based on the amoxicillin component) is recommended. Patients with a previous type I hypersensitivity reaction (urticaria or anaphylaxis) to amoxicillin can receive azithromycin, clarithromycin, erythromycin-sulfisoxazole, trimethoprim-sulfamethoxazole (TMP-SMZ), or clindamycin. Children younger than 6 years and those with severe disease should be treated with a 10-day course of antibiotics. For older children with nonsevere disease, 5-7 days of antibiotics is sufficient. Patients who are unable to tolerate oral antibiotics should receive ceftriaxone (50 mg/kg IV or IM qd) for 3 days. Treatment failure, defined as persistence of signs and symptoms after 48 hours of antibiotic therapy, occurs in 10% of cases. Treatment failure should be addressed with a different antibiotic.

Antibiotic resistance: Currently 50% of H influenzae and 100% of M catarrhalis isolates in the United States produce beta-lactamase. Approximately 15% of S pneumoniae isolates are highly resistant to penicillin and an additional 15% have intermediate resistance. S pneumoniae resistance is due to altered penicillin-binding proteins rather than beta-lactamase production. Amoxicillin at a dose of 80-90 mg/kg/d covers susceptible organisms, intermediate resistant S pneumoniae, most highly resistant S pneumoniae, and most beta-lactamase–producing organisms. This dosing regimen results in bacteriologic cure in approximately 80% of AOM cases.

Drug Category: Analgesics

Otalgia should be addressed whether or not antibiotics are prescribed. Acetaminophen and ibuprofen are effective for mild to moderate pain. Topical benzocaine provides additional analgesia but should not be used if the TM is ruptured. Narcotic analgesics can be added for moderate to severe pain. Decongestants, antihistamines, and steroids have no proven benefit.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• AOM and otitis media with effusion are treated on an outpatient basis. Indications for admission include toxic appearance, refractory vomiting, severe volume depletion, and mastoiditis.

Further Outpatient Care

• The patient should be referred to his or her primary care provider for close follow-up care. Parents should be instructed to return if the child has persistent fever or pain or if the child has worsening signs or symptoms, including more elevated fever and lethargy.
• Recurrent AOM is defined as 3 or more episodes during a 6-month period, with each occurrence starting at least 21 days after the onset of the previous episode. Allergies, immune deficiencies, and craniofacial abnormalities should be ruled out. Daily antibiotic prophylaxis, starting antibiotics at the onset of URIs, and placement of myringotomy tubes are treatment options that decrease AOM recurrence.

Deterrence/Prevention

• Breastfeeding, upright position (versus reclining) during feeding, pneumococcal vaccine (Pneumovax), and influenza vaccination deter AOM.

Complications

• Complications of AOM include conductive hearing loss, TM perforation, cholesteatoma, chronic otitis media, and mastoiditis. Complications of mastoiditis include septic thrombosis of the sigmoid sinus, extradural abscess, subdural empyema, meningitis, and brain abscess.
• Recent studies have failed to demonstrate a reduction in suppurative complications with antibiotic therapy for AOM. Rates of mastoiditis are comparable with and without antibiotics. No cases of bacterial meningitis occurred in a study of 4860 children with AOM who did not receive antibiotics.¹

Patient Education

• For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center . Also, see eMedicine's patient education article Earache.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• For diagnosis
• • Failure to visualize the TM adequately and in its entirety
  • Missed foreign body
  • Diagnosis of otitis media solely based on the visualization of a red membrane with overutilization of antibiotics
• Failure to treat otitis media and its subsequent development of complications
• Failure to treat otitis media with effusion and subsequent hearing deficits, which can lead to delays in language development and behavioral problems
• Diagnosing AOM when a more serious infection is present (eg, meningitis)

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Sean O Henderson, MD, and Peter L Kennedy, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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4. Bosker G. Hot ears in children: safe choices, wise decisions, and effective strategies for optimizing clinical outcomes. Emerg Med Rep. 1997;18(18):175-88.
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6. Finkelstein JA, Stille CJ, Rifas-Shiman SL, Goldmann D. Watchful waiting for acute otitis media: are parents and physicians ready?. Pediatrics. Jun 2005;115(6):1466-73. [Medline].
7. Fischer T, Singer AJ, Lee C, Thode HC Jr. National trends in emergency department antibiotic prescribing for children with acute otitis media, 1996 2005. Acad Emerg Med. Dec 2007;14(12):1172-5. [Medline].
8. Foxlee R, Johansson A, Wejfalk J, et al. Topical analgesia for acute otitis media. Cochrane Database Syst Rev. 2006;3:CD005657. [Medline].
9. Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ. Jul 12 1997;315(7100):98-102. [Medline].
10. Pichichero ME. Preferred antibiotics for treatment of acute otitis media: comparison of practicing pediatricians, general practitioners, and otolaryngologists. Clin Pediatr (Phila). Sep 2005;44(7):575-8. [Medline].
11. Rosenfeld RM, Culpepper L, Doyle KJ, et al. Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg. May 2004;130(5 Suppl):S95-118. [Medline].
12. Spiro DM, Arnold DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr. Feb 2008;20(1):72-8. [Medline].
13. Spiro DM, Tay KY, Arnold DH, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. Sep 13 2006;296(10):1235-41. [Medline].
14. Swanson JA, Hoecker JL. Concise review for primary-care physicians. Mayo Clin Proc. Feb 1996;71(2):179-83. [Medline].
15. Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 6^th ed. 2006.

Article Last Updated: Feb 6, 2008