Basics
Description
- Inflammation of the middle ear
- Most commonly occurs in children 6 " “36 mo
- Rapid onset of local and/or systemic symptoms
- More than 1/3 of children experience >5 episodes by the age of 7 yr
Etiology
- Usually associated with (or as a result of) upper respiratory tract infections
- Viral:
- Parainfluenza
- Respiratory syncytial virus
- Influenza
- Adenovirus
- Rhinovirus
- Bacterial:
- Streptococcus pneumoniae
- Moraxella catarrhalis
- Haemophilus influenzae
- Streptococcus pyogenes
- Mycoplasma pneumoniae
- Associated with blockage of eustachian tube
- Predisposing factors:
- Deficient mucus, cilia, or antibodies
- Intubation, especially nasotracheal
- American Indians, Eskimos
- Down syndrome
- Cleft palate
- Diabetes
- Vitamin A deficiency
- HIV
- Risk factors
- Family history
- Daycare
- Parental smoking
- Pacifier use
- Bottle-feeding
Diagnosis
From the American Academy of Pediatrics 2013 Guidelines: ‚
- Diagnose otitis media (OM) when:
- Moderate to severe bulging of tympanic membrane (TM)
- Mild bulging of TM and recent onset of ear pain (tugging, pulling, rubbing in nonverbal child)
- New otorrhea not due to acute otitis externa
- Should not diagnose if no middle ear effusion (pneumatic otoscopy and/or typanometry)
- Recurrent OM:
- 3 episodes in 6 mo or
- 4 episodes in the last year with 1 in the past 6 mo
Signs and Symptoms
History
- Ear pain (otalgia)
- Irritability
- Rhinitis
- Vomiting, diarrhea
- Poor feeding
- Fever
- Sensation of plugged ear
- Pulling at ear
- Vertigo, tinnitus
- Conjunctivitis
Physical Exam
- TM inflammation, bulging, and limited mobility
- New onset otorrhea without evidence of otitis externa
- Decreased visibility of the landmarks of the middle ear
Essential Workup
- Exclude associated conditions
- Consider full septic workup for sick patients with fever
- Otoscopic exam for appearance and mobility of TM:
- Full visualization essential
- Increased vascularity, erythema, purulence
- Obscured landmarks " ”bony, light reflex
- Pneumatic otoscopy " ”bulging, retracted, decreased mobility
Diagnosis Tests & Interpretation
Lab
Cultures unhelpful unless done by tympanocentesis ‚
Imaging
CT scan if associated mastoiditis is suspected ‚
Diagnostic Procedures/Surgery
- Tympanocentesis " ”indications:
- Severe pain or toxicity
- Failure of antimicrobial therapy
- Suspicion of suppurative complication
- Sick neonate
- Immunocompromised patient
- Tympanometry and acoustic otoscopy may be useful with difficult exams
Differential Diagnosis
- Infection:
- Otitis externa
- Mastoiditis
- Dental abscess
- Allergic rhinitis
- Cholesteatoma
- Peritonsillar abscess
- Sinusitis
- Lymphadenitis
- Parotitis
- Meningitis
- Trauma:
- Perforation of the TM
- Foreign body in ear
- Barotrauma
- Instrumentation
- Serous OM or eustachian tube dysfunction
- Impacted ear cerumen
- Impacted 3rd molar
- Temporomandibular joint dysfunction
Treatment
Ed Treatment/Procedures
- Most mild cases could resolve without antibiotics
- Antibiotics are indicated for:
- All infants <6 mo
- Children <2 yr with bilateral OM
- Bilateral OM in kids <2 yr
- Children >6 mo with severe infection (otalgia for >48 hr or temperature 102.2 ‚ °F or higher)
- Bilateral OM in kids <2 yr
- Children >6 mo with ruptured TM with drainage
- For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2 " “3 days:
- For reliable parents, may provide a prescription for oral antibiotics, which the family can fill if the childs symptoms get worse or persist after 2 days
- Considerations should include recurrent nature of OM, lack of clinical response, and resistance patterns in community
- Parenteral antibiotics are indicated in febrile toxic children <1 yr or with immunocompromise
- Antihistamines, decongestants, and steroids have no proven efficacy
- Antipyretics and analgesics are important (avoid local analgesics in perforated TMs)
Medication
- Antibiotics:
- Amoxicillin: 500 " “875 mg PO q12h (peds: 80 " “90 mg/kg/d PO div. q12h) for 10 days
- Amoxicillin " “clavulanic acid: 500 " “875 mg PO q12h (peds: 90 mg/kg/d PO q12h) for 10 days
- Azithromycin: 10 mg/kg PO day 1, then 5 mg/kg/d PO days 2 " “5
- Cefuroxime: 500 mg PO q12h (peds: 30 mg/kg/d PO div. q12h)
- Analgesia:
- Acetaminophen: 500 mg PO q6h (peds: 15 mg/kg per dose orally/rectally every 4 " “6 hr); not to exceed 4 g/24 h
- Antipyrine/benzocaine (5.4%/1.4% solution): 2 " “4 drops in ear QID PRN
- Ibuprofen: 400 " “600 mg PO q6 " “8h (peds: 10 mg/kg per dose orally every 6 hr)
Follow-Up
Disposition
Admission Criteria
Febrile toxic children who are: ‚
- <1 yr, immunocompromised
- Moderately or severely dehydrated
- Unable to tolerate oral fluids or medications
- Suspected or proven associated significant infection
- Suspected abuse
- Unreliable caretaker
Discharge Criteria
Children without any of the aforementioned criteria ‚
Follow-Up Recommendations
- Follow-up in 10 " “14 days to ensure resolution
- Indications for earlier follow-up:
- Child does not get better in 24 " “48 hr
- Any progression of signs or symptoms
- New problems develop, including a rash
- Any concerns arise
Complications
- Recurrent OM:
- 3 episodes within 6 mo or
- 4 episodes in 1 yr with the last within 6 mo
- Perforated TM
- Serous OM
- Hearing loss (conductive and sensorineural)
- Facial nerve injury
- Mastoiditis
- Cholesteatoma
- Meningitis
- Subdural empyema
- Labyrinthitis
- Epidural abscess
- Venous sinus thrombosis
Pearls and Pitfalls
For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2 " “3 days. ‚
Additional Reading
- American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451 " “1465.
- Coker ‚ TR, Chan ‚ LS, Newberry ‚ SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: A systematic review. JAMA. 2010;304:2161 " “2169.
- Fischer ‚ T, Singer ‚ AJ, Lee ‚ C, et al. National trends in emergency department antibiotic prescribing for children with acute otitis media, 1996 " “2005. Acad Emerg Med. 2007;14:1172 " “1175.
- Greenberg ‚ D, Hoffman ‚ S, Leibovitz ‚ E, et al. Acute otitis media in children: Association with day care centers " “antibacterial resistance, treatment, and prevention. Paediatr Drugs. 2008;10:75 " “83.
- Gunasekera ‚ H, Morris ‚ PS, McIntyre ‚ P, et al. Management of children with otitis media: A summary of evidence from recent systematic reviews. J Paediatr Child Health. 2009;45:554 " “562.
- Lieberthal ‚ AS, Carroll ‚ AE, Chonmaitree ‚ T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964 " “e999.
- Powers ‚ JH. Diagnosis and treatment of acute otitis media: Evaluating the evidence. Infect Dis Clin North Am. 2007;21:409 " “426.
- Spiro ‚ DM, Arnold ‚ DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr. 2008;20:72 " “78.
Codes
ICD9
- 381.4 Nonsuppurative otitis media, not specified as acute or chronic
- 381.60 Obstruction of Eustachian tube, unspecified
- 382.9 Unspecified otitis media
ICD10
- H65.90 Unspecified nonsuppurative otitis media, unspecified ear
- H66.90 Otitis media, unspecified, unspecified ear
- H68.109 Unspecified obstruction of Eustachian tube, unspecified ear
- H65.91 Unspecified nonsuppurative otitis media, right ear
- H65.92 Unspecified nonsuppurative otitis media, left ear
- H65.93 Unspecified nonsuppurative otitis media, bilateral
- H65.9 Unspecified nonsuppurative otitis media
- H66.91 Otitis media, unspecified, right ear
- H66.92 Otitis media, unspecified, left ear
- H66.93 Otitis media, unspecified, bilateral
- H66.9 Otitis media, unspecified
SNOMED
- 65363002 otitis media (disorder)
- 80327007 Serous otitis media (disorder)
- 48145001 obstruction of Eustachian tube (disorder)
- 194287004 Recurrent acute otitis media