Basics
Description
Otitis media is a general term for middle ear inflammation with or without symptoms. It can be acute or chronic. ‚
- 2 specific diagnoses
- Otitis media with effusion, middle ear effusion (MEE)
- Acute otitis media (AOM)
- Uncomplicated/nonsevere
- Severe
- Recurrent
Epidemiology
- Most common condition for which antibacterial agents are prescribed for children in the United States
- Peak incidence between 6 and 12 months of age
- By age 3 years, 50 " “85% of children have had AOM.
Risk Factors
- Age <2 years
- Gender: male > female
- Family history of AOM
- Anatomic differences, craniofacial abnormalities
- Environmental tobacco smoke exposure
- Exposure to large numbers of other children
General Prevention
- Breastfeeding for at least 3 " “6 months
- Decreased pacifier use after 6 months
- Vaccines
- Pneumococcal conjugate vaccine
- Influenza vaccine
- Reduction in secondhand smoke
- Reduction of day care crowding
Pathophysiology
- Eustachian tube dysfunction leads to MEE. If effusion is not cleared by the mucociliary system, bacteria and viruses have a good environment for growth.
- Severe eustachian tube dysfunction occurs during 66% of upper respiratory infections (URIs) in school-aged children and in 75% of URIs in day care " “aged children.
Etiology
- Nontypeable Haemophilus influenzae: 35 " “50%
- Streptococcus pneumoniae: 25 " “40%
- Moraxella catarrhalis: 5 " “10%
- Viruses: 40 " “75%
- High rate of coinfection with bacteria
- Without bacterial coinfection: 5 " “22%
- Group A Streptococcus (3%)
- Staphylococcus aureus (2%)
- Gram-negative organisms such as Pseudomonas aeruginosa: 1 " “2%
- More common in neonatal AOM
Diagnosis
History
- Recent abrupt onset of signs and symptoms of middle ear inflammation and MEE
- Ear pain for <48 hours
- New-onset otorrhea not caused by acute otitis externa
- Fever
- Irritability
- Past medical history, including underlying disorders (e.g., cleft palate, Down syndrome), immune deficiency, and previous history of otitis media
- Recent treatment with antibiotics
- Exposure to large numbers of children (school, child care, large family)
Physical Exam
- Look for other causes of fever and irritability in children: URIs, pharyngitis, lymphadenitis, meningitis, urinary tract infection, and bone and joint infections.
- Physical exam is best done with pneumatic otoscopy:
- The patient should be adequately restrained if uncooperative.
- Cerumen should be removed if view of tympanic membrane (TM) is inadequate.
- Visualize TM at rest and with gentle positive and negative pressure via pneumatic otoscopy.
- The presence of an MEE is determined by the characteristics of the TM:
- Contour: normal, retracted, full, or bulging; associated bulla(e)
- Color: gray, pink, yellow, white, or red; hemorrhagic
- Translucency: translucent or opaque
- Mobility: normal, decreased, or absent
- Middle ear inflammation is indicated by the following:
- Erythema of the TM
- Otalgia
- MEE is indicated by the following:
- Bulging of the TM
- Limited or absent mobility of the TM
- Air " “fluid level behind the TM
- Otorrhea
- A diagnosis of AOM is suggested if an MEE is present along with ear pain, fever, erythema, fullness, or bulging of TM.
- The concomitant presence of conjunctivitis (otitis media " “conjunctivitis syndrome) suggests the presence of H. influenzae or a virus as a causative organism.
- AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show MEE.
Diagnostic Tests & Interpretation
Diagnostic Procedures/Other
- Tympanometry
- Easily performed by office personnel
- Provides information on middle ear pressure and TM compliance
- Sensitive in detecting MEE but poor positive predictive value
- Tympanocentesis
- For episodes of AOM that are resistant to antibiotic therapy, tympanocentesis and culture and sensitivity of the middle ear fluid may help guide antibiotic therapy.
- Tympanocentesis or myringotomy may also be required as part of the treatment of suppurative complications.
Differential Diagnosis
- MEE: TM may appear dull with a diffuse light reflex, fluid bubbles may be visible, and mobility may be decreased.
- Otitis externa
- Auricular lesions like a furuncle or laceration
- Other causes of fever, including viral URIs, pharyngitis, pneumonia, meningitis, UTIs, and bone and joint infections
- Pharyngitis and dental pain may be mistaken for otalgia.
Treatment
Medication
Note: AOM management should include pain evaluation and treatment. ‚
- Antibiotic therapy for AOM in children ≥6 months of age with severe signs or symptoms (moderate or severe otalgia or otalgia of 48 hours or temperature ≥39 ‚ °C [102.2 ‚ °F])
- Antibiotic therapy for bilateral AOM in children 6 " “23 months of age without severe signs or symptoms
- Antibiotic therapy or observation with close follow-up if joint decision-making with caregiver for unilateral AOM in children 6 " “23 months of age without severe signs or symptoms
- Observation and follow-up and antibiotic therapy if child worsens or fails to improve in 48 " “72 hours
- Initial treatment
- Amoxicillin (80 " “90 mg/kg/24 h PO divided b.i.d.)
- When child has not received amoxicillin in past 30 days
- Does not have concurrent purulent conjunctivitis
- Not allergic to penicillin
- Antibiotic treatment after 48 " “72 hours of no improvement
- Amoxicillin-clavulanate (90 mg/kg/24 h amoxicillin and 12.8 mg/kg/24 h clavulanate PO divided b.i.d.)
- Has received amoxicillin in the last 30 days
- Concurrent purulent conjunctivitis
- History of recurrent AOM unresponsive to amoxicillin
- Initial oral antibiotic treatment if penicillin allergy
- Cefdinir (14 mg/kg/24 h QD or divided b.i.d.)
- Cefuroxime (30 mg/kg/24 h divided b.i.d.)
- Cefpodoxime (10 mg/kg/24 h divided b.i.d.)
- Ceftriaxone (50 mg IM or IV per day for 1 or 3 days)
- Treatment after 48 " “72 hours of no improvement
- Ceftriaxone (50 mg IM or IV per day for 1 or 3 days)
- Clindamycin (30 " “40 mg/kg/24 h PO divided t.i.d.), with or without 3rd-generation cephalosporin
Additional Treatment
General Measures
- Do not use prophylactic antibiotics to reduce frequency of episodes of AOM in children with recurrent AOM.
- Adjunctive therapy
- Fever relief with acetaminophen or ibuprofen
- Pain may be treated with acetaminophen, ibuprofen, or topical anesthetic drops.
Issues for Referral
- Consider otolaryngology referral:
- Tympanostomy tubes for recurrent AOM if
- 3 episodes in 6 months
- 4 episodes in 1 year with 1 episode in the preceding 6 months
- Persistent and/or recurrent otitis with abnormal hearing and/or speech
Ongoing Care
Follow-up Recommendations
- Expect symptomatic improvement within 48 " “72 hours of treatment; may need to switch antibiotic and/or evaluate for complications
- Follow-up exam should be scheduled 3 " “4 weeks after completion of antibiotic therapy to ensure resolution of AOM.
- If effusion is present, follow up monthly. For persistent effusions of >3 months ' duration, a hearing evaluation is recommended.
Prognosis
- Symptoms of acute infection (fever and otalgia) are relieved within 48 " “72 hours in most patients.
- Treatment failures are more likely with increased severity of disease and younger age.
- Development of another infection within 30 days usually represents a recurrence caused by a different organism rather than a relapse.
- Recurrences are frequent and more common in younger children and if initial episode is severe.
- 30 " “70% of treated children will have an effusion at 2 weeks.
- MEE may persist for weeks to months.
Complications
- Hearing loss
- Acute conductive hearing loss is common and usually resolves as the effusion resolves.
- Fluid of long-standing duration may lead to permanent conductive hearing loss.
- Sensorineural hearing loss may result from spread of infection into the labyrinth.
- TM perforation
- Chronic suppurative otitis media
- Tympanosclerosis
- Cholesteatoma
- Acute mastoiditis
- Petrositis
- Labyrinthitis
- Facial nerve paralysis
- Bacterial meningitis
- Epidural abscess
- Subdural empyema
- Brain abscess
- Lateral sinus thrombosis
Additional Reading
- 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(19):2161 " “2169. ‚ [View Abstract]
- Gould ‚ JM, Matz ‚ PS. Otitis media. Pediatr Rev. 2010;31(3):102 " “116. ‚ [View Abstract]
- Hoberman ‚ A, Paradise ‚ JL, Rockette ‚ HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011;364(2):105 " “115. ‚ [View Abstract]
- Lieberthal ‚ AS, Carroll ‚ AE, Chonmaitree ‚ T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964 " “e999. ‚ [View Abstract]
- Spiro ‚ DM, Tay ‚ KY, Arnold ‚ DH, et al. Wait-and-see prescription for the treatment of acute otitis media. JAMA. 2006;296(10):1235 " “1241. ‚ [View Abstract]
- Takata ‚ GS, Chan ‚ LS, Morphew ‚ T, et al. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics. 2003;112(6, Pt 1):1379 " “1387. ‚ [View Abstract]
Codes
ICD09
- 382.9 Unspecified otitis media
- 381.00 Acute nonsuppurative otitis media, unspecified
- 381.3 Other and unspecified chronic nonsuppurative otitis media
- 381.4 Nonsuppurative otitis media, not specified as acute or chronic
- 380.10 Infective otitis externa, unspecified
ICD10
- H66.90 Otitis media, unspecified, unspecified ear
- H65.199 Other acute nonsuppurative otitis media, unspecified ear
- H65.499 Other chronic nonsuppurative otitis media, unspecified ear
- H65.197 Other acute nonsuppurative otitis media recurrent, unsp ear
- H65.491 Other chronic nonsuppurative otitis media, right ear
- H65.492 Other chronic nonsuppurative otitis media, left ear
- H65.194 Oth acute nonsuppurative otitis media, recurrent, right ear
- H65.192 Other acute nonsuppurative otitis media, left ear
- H65.195 Other acute nonsuppurative otitis media, recurrent, left ear
- H65.196 Oth acute nonsuppurative otitis media, recurrent, bilateral
- H60.93 Unspecified otitis externa, bilateral
- H66.91 Otitis media, unspecified, right ear
- H65.193 Other acute nonsuppurative otitis media, bilateral
- H60.92 Unspecified otitis externa, left ear
- H60.91 Unspecified otitis externa, right ear
- H66.92 Otitis media, unspecified, left ear
- H60.90 Unspecified otitis externa, unspecified ear
- H65.493 Other chronic nonsuppurative otitis media, bilateral
- H65.191 Other acute nonsuppurative otitis media, right ear
SNOMED
- 65363002 otitis media (disorder)
- 3110003 Acute otitis media (disorder)
- 21186006 Chronic otitis media (disorder)
- 194287004 Recurrent acute otitis media
- 232254004 Chronic non-suppurative otitis media (disorder)
FAQ
- Q: When should children with AOM be treated?
- A: Antibiotic therapy for AOM in children ≥ 6 months of age with severe signs or symptoms. Antibiotic therapy for bilateral AOM in children 6 " “23 months of age without severe signs or symptoms
- Q: What is the antibiotic of choice for initial therapy of AOM?
- A: The initial therapy is amoxicillin. The antibiotic treatment after 48 " “72 hours of no improvement is amoxicillin-clavulanate.
- Q: What can be done to prevent the development of AOM in an individual child?
- A: Pneumococcal conjugate vaccine.
Annual influenza vaccine.
Encourage breastfeeding for at least 6 months.
Encourage avoidance of tobacco smoke exposure.