para />
á
PHYSICAL EXAM
- Infectious AOM:
- Fever (not required for diagnosis)
- Decreased eardrum mobility (with pneumatic otoscopy)
- Moderate to severe bulging of tympanic membrane
- Otorrhea
- Redness alone is not a reliable sign.
- OME:
- Eardrum often dull but not bulging
- Decreased eardrum mobility (pneumatic otoscopy)
- Presence of air-fluid level
- Weber test is positive to affected ear for an ear with effusion.
DIFFERENTIAL DIAGNOSIS
- Tympanosclerosis
- Trauma
- Referred pain from the jaw, teeth, or throat
- TMJ in adults
- Otitis externa
- Otitis-conjunctivitis syndrome
- Temporal arteritis in adults
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
WBC count may be higher in bacterial AOM than in sterile AOM, but this is almost never useful. á
Diagnostic Procedures/Other
- To document the presence of middle ear fluid, pneumatic otoscopy can be supplemented with tympanometry and acoustic reflex measurement.
- Hearing testing is recommended when hearing loss persists for ≥3 months or at any time suspecting language delay, significant hearing loss, or learning problems.
- Language testing should be performed for children with hearing loss.
- Tympanocentesis for microbiologic diagnosis is recommended for treatment failures; may be followed by myringotomy.
TREATMENT
- Significant disagreement exists about the usefulness of antibiotic treatment for this often self-resolving condition. Studies suggest that ~15 children need to be treated with antibiotics to prevent one case of persisting AOM pain at 1 to 2 weeks; the number needed to treat to cause harm (primarily diarrhea) is 8 to 10 (2)[B].
- If antibiotics are not used, 81% of patients >2 years of age are better in 1 week versus 94% if antibiotics are used.
- Delay of antibiotics found a modest increase in mastoiditis from 2/100,000 to 4/100,000.
- American Academy of Pediatrics/American Academy of Family Physicians (AAP/AAFP) guidelines recommend the following for observation versus antibacterial therapy, although these guidelines are not rigorously evidence based (2)[B]:
- <6 months of age: No recommendation (2004 guidelines suggest treatment with antibiotic therapy to any child diagnosed with otitis media < 6 months of age)
- >6 months: Antibacterial therapy is recommended when the diagnosis with severe otitis media (i.e., moderate to severe otalgia or fever ≥39 ░C in the previous 24 hours) or otorrhea or bilateral otitis media between 6 months and 2 years of age
- Observation is an option with nonsevere otitis media.
- OME: Watchful waiting for 3 months per AAP/AFPP guidelines for those not at risk (see "Complications"Ł). Of these cases, 25-90% will recover spontaneously over this period. No benefit of antihistamines, decongestants, or antibiotics or systemic steroids (4)[A].
GENERAL MEASURES
- Assess pain.
- Although unusual in adults, the treatment is the same.
- Acetaminophen, ibuprofen, benzocaine drops (additional but brief benefit over acetaminophen)
MEDICATION
First Line
- AOM: AAP/AAFP consensus guideline recommends amoxicillin, 80 to 90 mg/kg/day in 2 divided doses; (5)[A] OR
- Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate in 2 divided doses; recommended in children who have taken amoxicillin in the previous 30 days and those with concurrent conjunctivitis or history of AOM unresponsive to amoxicillin
- Treatment duration: 10-day course for children <2 years; 7-day course for children 2 to 5 years; 5- to 7-day course for children 6 years and older
- If penicillin allergic:
- Non-type 1 hypersensitivity reaction: cefdinir, 14 mg/kg/day in 1 to 2 doses; cefpodoxime, 10 mg/kg/day BID; or cefuroxime 30 mg/kg/day BID
- Type 1 hypersensitivity to penicillin: azithromycin (10 mg/kg/day [max dose 500 mg/day] as a single dose on day 1 and 5 mg/kg/day [max dose 250 mg/day] for days 2 to 5)
- A single dose of parenteral ceftriaxone (50 mg/kg) is as effective as a full course of antibiotics in uncomplicated AOM.
- A single dose of azithromycin has been approved by the FDA, but studies did not include otitis-prone children or have criteria for AOM diagnosis.
- Consider treatment of children between ages 6 months and 2 years with antibiotics to reduce duration of symptoms (6)[A].
- OME: See "General Measures"Ł; no benefit to treatment. Medications promote transitory resolution in 10-15%, but the effect is short-lived.
Second Line
- Alternative antibiotics are indicated for the following AOM patients:
- Persistent symptoms after 48 to 72 hours of amoxicillin
- AOM within 1 month of amoxicillin therapy
- Severe earache
- Age <6 months with high fever
- Immunocompromised
- Amoxicillin-clavulanate, 90 mg/kg to 6.4 mg/kg/day, divided BID
- Ceftriaxone, 50 mg/kg IM or IV q24h for 3 consecutive days can be reserved for those who are too sick to take oral medications or who unsuccessfully took amoxicillin-clavulanate. Neither erythromycin-sulfisoxazole nor trimethoprim-sulfamethoxazole should be used as a 2nd-line agent in treatment failures.
- Recurrent AOM: Antibiotic prophylaxis for recurrent AOM (>3 distinct, well-documented episodes in 6 months) is not recommended.
SURGERY/OTHER PROCEDURES
- Recurrent AOM: Consider referral for surgery if ≥3 episodes of well-documented AOM within 6 months, ≥4 episodes within 12 months with ≥ 1 episode in previous 6 months, or AOM episodes occur while on chemoprophylaxis.
- Tympanostomy tubes may be effective in selective patients, particularly children age <2 years with recurrent AOM (7)[A].
- Adenoidectomy has limited or no effect.
- Adenotonsillectomy reduced the rate of AOM by 0.7 episode per child only in the 1st year after surgery and had a 15% complications rate.
- OME: Referral for surgery for tympanostomy should be individualized. It can be considered if >4 to 6 months of bilateral OME and/or >6 months of unilateral OME and/or hearing loss >25 dB or for high-risk individuals at any time.
- Tympanostomy tubes may reduce recurrence of AOM minimally, but it does not lower the risk of hearing loss (8)[A].
- Adenoidectomy is indicated in specific cases; tonsillectomy or myringotomy is never indicated.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- It is unclear whether alternative and homeopathic therapies are effective for AOM, including mixed evidence about the effectiveness of zinc supplementation of reducing AOM.
- Xylitol, probiotics, herbal ear drops, and homeopathic interventions may be beneficial in reducing pain duration, antibiotic use, and bacterial resistance.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Outpatient, except if surgery is indicated, or for AOM in febrile infants age <2 months or children requiring ceftriaxone who also require monitoring for 24 hours á
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patients with otitis media who do not respond within 48 to 72 hours should be reevaluated: á
- If therapy was delayed and diagnosis is confirmed, start therapy with high-dose amoxicillin.
- If therapy was initiated, consider changing the antibiotic; options are limited because macrolides have limited benefit against Haemophilus influenzae over amoxicillin, and most oral cephalosporins have no improved outcomes.
Patient Monitoring
- AOM: Up to 40% may have persistent middle ear effusion at 1 month, with 10-25% at 3 months.
- OME: Repeat otoscopic or tympanometric exams at 3 months, as indicated, as long as OME persists or sooner if there are red flags (see earlier discussion).
PROGNOSIS
- See "General Measures."Ł
- Recurrent AOM and OME: Usually subsides in school-aged children; few have complications.
COMPLICATIONS
- AOM: Serious complications are rare: tympanic membrane perforation/otorrhea, acute mastoiditis, facial nerve paralysis, otitic hydrocephalus, meningitis, hearing impairment.
- OME: Speech and language disabilities may occur. Hearing loss is not caused by OME, but in children who are at risk for speech, language, or learning problems (e.g., autism spectrum, syndromes, craniofacial disorders, developmental delay, and children already with speech/language delay), it could lead to further problems because they are less tolerant of a hearing impairment.
- Recurrent AOM and OME: atrophy and scarring of eardrum, chronic perforation and otorrhea, cholesteatoma, permanent hearing loss, chronic mastoiditis, other intracranial suppurative complications
REFERENCES
11 Rettig áE, Tunkel áDE. Contemporary concepts in the management of acute otitis media in children. Otolaryngol Clin North Am. 2014;47(5):651-672.22 Harmes áKN, Blackwood áRA, Burrows áHL, et al. Otitis media: diagnosis and treatment. Am Fam Physician. 2013;88 (7): 435-440.33 Marchioso áP, Consonni áD, Baggi áE, et al. Vitamin D supplementation reduces the risk of acute otitis media in otitis-prone children. Pediatr Infect Dis J. 2013;32(10):1055-1060.44 Coleman áC, Moore áM. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev. 2008;(3):CD001727.55 Thanaviratananich áS, Laopaiboon áM, Vatanasapt áP. Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media. Cochrane Database Syst Rev. 2008;(4):CD004975.66 Hoberman áA, Paradise áJL, Rockette áHE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011;364(2):105-115.77 Kujala áT, Alho áOP, Luotonen áJ, et al. Tympanostomy with and without adenoidectomy for the prevention of recurrences of acute otitis media: a randomized controlled trial. Pediatr Infect Dis J. 2012;31(6):565-569.88 Lous áJ, Burton áMJ, Felding áJU, et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2005;(1):CD001801.
ADDITIONAL READING
- Lieberthal áAS, Carroll áAE, Chonmaitree áT, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999.
SEE ALSO
Algorithm: Ear Pain á
CODES
ICD10
- H66.90 Otitis media, unspecified, unspecified ear
- H66.40 Suppurative otitis media, unspecified, unspecified ear
- H65.199 Other acute nonsuppurative otitis media, unspecified ear
- H66.3X9 Other chronic suppurative otitis media, unspecified ear
- H66.012 Acute suppr otitis media w spon rupt ear drum, left ear
- H66.3X3 Other chronic suppurative otitis media, bilateral
- H66.013 Acute suppr otitis media w spon rupt ear drum, bilateral
- H66.93 Otitis media, unspecified, bilateral
- H66.3X1 Other chronic suppurative otitis media, right ear
- H66.014 Acute suppr otitis media w spon rupt ear drum, recur, r ear
- H65.93 Unspecified nonsuppurative otitis media, bilateral
- H66.015 Acute suppr otitis media w spon rupt ear drum, recur, l ear
- H66.016 Acute suppr otitis media w spon rupt ear drum, recurrent, bi
- H66.42 Suppurative otitis media, unspecified, left ear
- H65.92 Unspecified nonsuppurative otitis media, left ear
- H66.43 Suppurative otitis media, unspecified, bilateral
- H66.3X2 Other chronic suppurative otitis media, left ear
- H65.91 Unspecified nonsuppurative otitis media, right ear
- H66.006 Acute suppr otitis media w/o spon rupt ear drum, recur, bi
- H66.011 Acute suppr otitis media w spon rupt ear drum, right ear
- H66.91 Otitis media, unspecified, right ear
- H66.019 Acute suppr otitis media w spon rupt ear drum, unsp ear
- H66.41 Suppurative otitis media, unspecified, right ear
- H66.92 Otitis media, unspecified, left ear
- H66.009 Acute suppr otitis media w/o spon rupt ear drum, unsp ear
- H66.005 Ac suppr otitis media w/o spon rupt ear drum, recur, l ear
- H66.007 Ac suppr otitis media w/o spon rupt ear drum,recur, unsp ear
- H66.017 Ac suppr otitis media w spon rupt ear drum, recur, unsp ear
ICD9
- 382.9 Unspecified otitis media
- 381.01 Acute serous otitis media
- 381.00 Acute nonsuppurative otitis media, unspecified
- 382.3 Unspecified chronic suppurative otitis media
- 381.3 Other and unspecified chronic nonsuppurative otitis media
- 382.00 Acute suppurative otitis media without spontaneous rupture of eardrum
- 381.10 Chronic serous otitis media, simple or unspecified
- 381.4 Nonsuppurative otitis media, not specified as acute or chronic
SNOMED
- 65363002 otitis media (disorder)
- 194281003 Acute suppurative otitis media
- 275481002 Non-suppurative otitis media (disorder)
- 21186006 Chronic otitis media (disorder)
- 1091131000119107 Chronic otitis media of right ear (disorder)
- 1092191000119104 Serous otitis media of right ear (disorder)
- 1089581000119103 Serous otitis media of left ear (disorder)
- 43561008 Chronic exudative otitis media
- 1088521000119106 Chronic otitis media of left ear (disorder)
- 1089341000119100 Otitis media of left ear (disorder)
- 359609001 Acute secretory otitis media
- 1091951000119104 Otitis media of right ear (disorder)
- 194240006 Acute serous otitis media
- 81564005 Chronic serous otitis media
CLINICAL PEARLS
- Pneumatic otoscopy is the single most specific and clinically useful test for diagnosis.
- Consider a delay of antibiotics for 24 to 48 hours in uncomplicated presentations (>2 years of age) who do not have severe illness or otorrhea.
- First-line treatment is amoxicillin, 80 to 90 mg/kg/day for 10 days for children age <2 years; consider a 5- to 7-day course in >2 years of age.
- Erythema and effusion can persist for weeks.
- Antibiotics, antihistamines, and steroids are not indicated for OME.
- OME rarely develops in adults. Persistent unilateral effusion should be investigated to rule out neoplasm, particularly if there is a cranial nerve palsy.