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Otitis Media, Pediatric

Basics

Description

- 2 specific diagnoses - Otitis media with effusion, middle ear effusion (MEE) - Acute otitis media (AOM) - Uncomplicated/nonsevere - Severe - Recurrent

- 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

- Tympanometry - Easily performed by office personnel - Provides information on middle ear pressure and TM compliance - Sensitive in detecting MEE but poor positive predictive value

- 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)

Otitis media is a general term for middle ear inflammation with or without symptoms. It can be acute or chronic. ‚

  • 2 specific diagnosesOtitis media with effusion, middle ear effusion (MEE)Acute otitis media (AOM)Uncomplicated/nonsevereSevereRecurrent

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
  • VaccinesPneumococcal conjugate vaccineInfluenza 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 bacteriaWithout 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; hemorrhagicTranslucency: translucent or opaqueMobility: normal, decreased, or absent
  • Middle ear inflammation is indicated by the following:Erythema of the TMOtalgia
  • MEE is indicated by the following:Bulging of the TMLimited or absent mobility of the TMAir " “fluid level behind the TMOtorrhea
  • 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

  • TympanometryEasily performed by office personnelProvides information on middle ear pressure and TM complianceSensitive in detecting MEE but poor positive predictive value
  • TympanocentesisFor 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 symptomsObservation and follow-up and antibiotic therapy if child worsens or fails to improve in 48 " “72 hours
  • Initial treatmentAmoxicillin (80 " “90 mg/kg/24 h PO divided b.i.d.)When child has not received amoxicillin in past 30 daysDoes not have concurrent purulent conjunctivitisNot allergic to penicillin
  • Antibiotic treatment after 48 " “72 hours of no improvementAmoxicillin-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 daysConcurrent purulent conjunctivitisHistory of recurrent AOM unresponsive to amoxicillin
  • Initial oral antibiotic treatment if penicillin allergyCefdinir (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 improvementCeftriaxone (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 therapyFever relief with acetaminophen or ibuprofenPain may be treated with acetaminophen, ibuprofen, or topical anesthetic drops.

Issues for Referral

  • Consider otolaryngology referral:Tympanostomy tubes for recurrent AOM if3 episodes in 6 months4 episodes in 1 year with 1 episode in the preceding 6 monthsPersistent 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 lossAcute 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.