Diseases » Middle ear infection

Otitis Media

Otitis Media: Excerpt from The 5-Minute Pediatric Consult

William R. Graessle, MD

Otitis Media - BASICS

Otitis Media - description

Otitis media refers to inflammation of the middle ear. A distinction is usually made between otitis media with effusion (OME) and acute otitis media (AOM). AOM implies that infection is present.

Otitis Media - general prevention

• Preventing exposure to environmental tobacco smoke can decrease the risk of otitis media.
• Decreasing exposure to multiple respiratory pathogens by delaying entrance to group child care or choosing settings with fewer numbers of children may be helpful.
• Vaccines: In addition to preventing invasive disease, conjugated pneumococcal vaccine significantly reduces the risk of AOM.

Otitis Media - epidemiology

• More common in fall and winter, and less common in spring and summer
• Inverse relationship with breastfeeding duration

Otitis Media - incidence

Increased incidence in those <2 years of age, with the peak incidence between 6 and 12 months of age

Otitis Media - risk factors

• Exposure to environmental tobacco smoke is an independent risk factor.
• Risk increased with exposure to large numbers of children (e.g., day care). Additive factors include number of hours spent in child care, younger age at day care entry, and type of child care setting (center vs. family day care).

Otitis Media - genetics

Genetic predisposition appears to play a role.

Otitis Media - pathophysiology

• Dysfunction of the eustachian tube is the most important factor:
  • The eustachian tube in younger children is shorter, and more compliant, and more horizontal than in older children and adults.
  • Children with craniofacial anomalies have an increased risk of eustachian tube dysfunction and subsequent otitis media.
• Viral upper respiratory infection often precedes or coincides with AOM. Viral infections may lead to development of AOM by several mechanisms:
  • Inducing inflammation in the nasopharynx and eustachian tube
  • Enhancing nasopharyngeal bacterial colonization
  • Impairing host immune system and increasing susceptibility to secondary bacterial infection

Otitis Media - etiology

• Streptococcus pneumoniae—up to 40%
• Nontypeable Haemophilus influenzae—25–30%
• Moraxella catarrhalis—10–20%
• Other organisms include group A streptococcus, Staphylococcus aureus, and Gram-negative organisms, such as Pseudomonas species. Respiratory viruses are often noted as part of AOM, but are the sole pathogen in <10% of cases.

Otitis Media - DIAGNOSIS

Otitis Media - signs & symptoms

• Ear pain
• Fever
• Irritability

Otitis Media - history

• History of current episode with presence of ear pain, fever, and associated symptoms
• 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, day care, large family)

Otitis Media - physical exam

• Look for other causes of fever and irritability in children: Upper respiratory infections, pharyngitis, lymphadenitis, meningitis, urinary tract infection, and bone and joint infections.
• Physical examination of the ear is best done with pneumatic otoscopy:
  • The patient should be adequately restrained if uncooperative.
  • Cerumen in the canal should be removed if view of the tympanic membrane is inadequate.
  • The tympanic membrane is visualized at rest, and with gentle positive and negative pressure via pneumatic otoscopy.
• The presence of a middle ear effusion is determined by the characteristics of the tympanic membrane:
  • Contour: Normal, retracted, full, or bulging
  • Color: Gray, pink, yellow, white, or red
  • Translucency: Translucent or opaque
  • Mobility: Normal, decreased, or absent
• The presence of a middle ear effusion is suggested by abnormal color, opacification, decreased mobility, visible or air-fluid levels or air bubbles within fluid.
• A diagnosis of AOM is suggested if a middle ear effusion is present along with ear pain, fever, erythema, fullness, or bulging of tympanic membrane.
• The concomitant presence of conjunctivitis (otitis media–conjunctivitis syndrome) suggests the presence of H. influenzae or a virus as a causative organism.

Otitis Media - tests

Otitis Media - diag proced-surgery

• Tympanometry:
  • Easily performed by office personnel
  • Provides information on middle ear pressure and tympanic membrane compliance
  • Sensitive in detecting middle ear effusion, 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.

Otitis Media - differencial diagnosis

• OME: Tympanic membrane 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 upper respiratory infections, pharyngitis, pneumonia, meningitis, urinary tract infections, and bone and joint infections
• Pharyngitis and dental pain may be mistaken for otalgia.

Otitis Media - TREATMENT

Otitis Media - general measures

• Antibiotics (see “Medication”)
• Adjunctive therapy:
  • Fever relief may be provided with acetaminophen or other antipyretic.
  • Pain may be treated with acetaminophen, ibuprofen, or topical anesthetic drops.

Otitis Media - medication

Note: Because many patients who have physical findings consistent with diagnosis of AOM may recover without treatment, some experts recommend treating pain and fever 48–72 hours before starting antibiotics, especially in older patients.

Otitis Media - first line

• Amoxicillin (80–90 mg/kg/d divided b.i.d.) is the drug of choice for most episodes of AOM. The higher doses are recommended because of increased pneumococcal resistance, and should be used in children <2 years of age, with recent beta-lactam use, exposure to day care, and exposure to older siblings.
• Recommended duration of therapy is 10 days, but a 5–7-day course as well as lower dosing of amoxicillin may be considered for uncomplicated and isolated cases of AOM in children >2 years.
• Azithromycin may be used in patients who are allergic to penicillin (type I hypersensitivity). For patients who do not have type I reactions, a cephalosporin may be used.

Otitis Media - second line

• Failure of antibiotic therapy may be related to bacterial resistance or a viral etiology. The choice of a 2nd-line antibiotic depends on suspected mechanism of resistance. H. influenzae and M. catarrhalis produce β-lactamase. S. pneumoniae alters penicillin-binding proteins. Failure caused by a resistant pathogen is more likely for S. pneumoniae than for H. influenzae or M. catarrhalis.
• In cases where resistant S. pneumoniae is likely, treatment with higher doses of amoxicillin (80–90 mg/kg/d) is recommended if not done initially.
• Amoxicillin–clavulanate, cefuroxime axetil, and IM ceftriaxone are also effective against resistant strains.
• The macrolides and trimethoprim–sulfa do not provide reliable coverage for resistant S. pneumoniae.
• Amoxicillin–clavulanate or a second-generation cephalosporin may be used if H. influenzae (i.e., otitis media–conjunctivitis syndrome) or M. catarrhalis is suspected.
• IM ceftriaxone:
  • Not recommended for routine treatment of AOM
  • May be considered when oral therapy is impossible or when appropriate 1st- and 2nd-line therapies for S. pneumoniae have already failed
  • When used for treatment of resistant organisms, ceftriaxone 50 mg/kg IM should be given every 1–3 days for 3 doses, or as a single dose according to some studies.

Otitis Media - FOLLOW UP

• Expect symptomatic improvement within 48–72 hours of treatment. May need to switch antibiotic therapy and/or re-evaluate for complications.
• Tympanic membrane may appear abnormal for some time after treatment. In infants or young children, initial follow-up exam should be scheduled 3–4 weeks after completion of antibiotic therapy. If effusion is present, follow monthly. For persistent effusions of >3 months’ duration, a hearing evaluation is recommended.

Otitis Media - disposition

Otitis Media - issues for referral

Consider otolaryngology referral:

• Persistent otitis media not responding to antibiotic therapy. Tympanocentesis may be helpful.
• Recurrent otitis media with more than four episodes during a respiratory season, especially if earlier in the season. Prior to ENT referral, some clinicians recommend prophylactic antibiotic therapy with once-daily amoxicillin (20 mg/kg/d); however, this practice has gone out of favor and is rarely used.
• Persistent and/or recurrent otitis with abnormal hearing and/or speech

Otitis Media - 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.
• Middle ear effusion may persist for weeks to months.

Otitis Media - complications

• Suppurative complications of AOM are much less common with current antibiotic therapy. The recent increase in resistant organisms could lead to a resurgence of suppurative 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.
• Tympanic membrane 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

Otitis Media - bibliography

1. AAP Subcommittee on Management of Acute Otitis Media. Clinical practice guideline. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451–1465.
2. Barnett ED. Antibiotic resistance and choice of antimicrobial agents for acute otitis media. Pediatr Ann. 2003;31:794–799.
3. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J. 2000;19:S37–S46.
4. Harrison CJ. Changes in treatment strategies for acute otitis media after full implementation of the pneumococcal seven valent conjugate vaccine. Pediatr Infect Dis J. 2003;22(suppl):S120–S130.
5. Spiro DM, Tay KY, Arnold DH, et al. Wait-and-see prescription for the treatment of acute otitis media. JAMA. 2006;296:1235–1241.
6. 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(pt 1):1379–1387.
7. Weber SM, Grundfast KM. Modern management of acute otitis media. Pediatr Clin North Am. 2003;50:399–411.

Otitis Media - CODES

Otitis Media - icd9

382.9 Otitis media

Otitis Media - FAQ

• Q: When should children with otitis media be treated?
• A: The presence of a middle ear effusion may occur commonly with an upper respiratory infection. The presence of AOM, as described above, usually warrants treatment with antibiotics, especially in children <2 years, those who are prone to infection, and those with AOM during the winter season. Because a number of cases of otitis media resolve spontaneously, treatment with antibiotics may be deferred for 48–72 hours while treating pain.
• Q: What is the current strategy for dealing with resistant S. pneumoniae?
• A: S. pneumoniae develops resistance by alteration of penicillin-binding proteins. H. influenzae and M. catarrhalis produce β-lactamase. A previous strategy to deal with these resistant organisms was to use antibiotics resistant to β-lactamase, such as 2nd-generation cephalosporins. This strategy is not effective for resistant strains of pneumococcus. The most effective strategy is to increase the dose of amoxicillin, bringing the concentration of antibiotic in the middle ear fluid above the minimum inhibitory concentration (MIC). Due to increasing rates of resistance, these higher doses of amoxicillin, 80–90 mg/kg/d, are now recommended as initial therapy for most children.
• Q: What can be done to prevent the development of AOM in an individual child?
• A: A number of factors appear to put children at risk for AOM, including genetic, immune, and environmental factors and exposure to viral upper respiratory infections. Breastfeeding during the 1st year of life decreases the risk of AOM and is recommended. Eliminating exposure to environmental tobacco smoke may also be helpful. Development of upper respiratory infections at an early age is probably the most important factor in the development of otitis media. Limiting the exposure to large numbers of children by delayed entry to child care or by choosing a setting with smaller numbers of children should decrease a child’s risk of otitis media. Administering influenza and pneumococcal vaccines may also be helpful.

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Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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