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GENERAL PRINCIPLES
Definition
Acute otitis media (AOM) is an acute suppurative infection of the middle ear, often occurring in the setting of an upper respiratory infection. AOM may occur in adults, although more frequently develops in children. Generally short-lived, AOM in a healthy child has a self-limited course and only in some cases needs antibiotic therapy.1
Anatomy and Pathophysiology
The much higher propensity of children for AOM is in part due to the less steeply angled, shorter eustachian tube, which allows reflux of organisms and debris from the nasopharynx into the middle ear. With congestion of the tube from an upper respiratory infection, secretions can accumulate and bacterial pathogens can multiply, leading to inflammation and clinical symptoms.1
Epidemiology
AOM is the most common bacterial infection of children, with 5 million cases diagnosed per year. An estimated 30 million clinic visits for AOM are made each year.1 It is also the most common reason for antibiotic use in children, and is the reason for 50% of antibiotics prescribed to preschool-age children.2 However, office visits for AOM decreased in number between 1995–1996 and 2004–2005, with a resulting decrease in antibiotic prescriptions.
Risk may be reduced by breastfeeding for at least 6 months, ceasing pacifier use after 6 months of age, avoidance of “bottle-propping,” and elimination of secondhand smoke exposure.2 Other risk factors that are not modifiable include genetic predisposition, male gender, premature birth, Native American or Inuit ethnicity, family history, the presence of siblings in the home, and low socioeconomic status.2
Administration of influenza and pneumococcal vaccines may be of some benefit for reduction of the incidence of AOM and are recommended.2
Etiology
Streptococcus pneumoniae, non-typable Haemophilus influenzae, and Moraxella catarrhalis are the most commonly found pathogens found on culture of middle ear fluid obtained by tympanocentesis.2,3
S. pneumoniae has been found in middle ear fluid in 25% to 50% of children with AOM, H. influenzae has been found in 15% to 30%, and M. catarrhalis has been found in 3% to 20%.2
The microbiology of AOM may be changing due to the administration of the pneumococcal conjugate vaccine to infants, with an increase in H. influenzae.2
Viruses, including respiratory syncytial virus, rhinovirus, coronavirus, parainfluenza, adenovirus, and enterovirus, have been found in respiratory secretions and/or middle ear effusion (MEE) in 40% to 75% of AOM cases and in 5% to 22% of MEE without bacteria.4 Viruses may be the causative pathogen when antibiotic treatment is ineffective. However, viruses are the only pathogen in AOM in only 10% of cases.2
In 16% to 25% of cases of AOM, no organism can be found in middle ear fluid.2
DIAGNOSIS
AOM must be carefully distinguished from otitis media with effusion (OME) to avoid over diagnosis and inappropriate antibiotic use. Although OME may precede AOM, or occur as a consequence of eustachian tube dysfunction, OME does not necessitate antibiotics.
Elements of the definition of AOM are all of the following: recent, usually abrupt, onset of signs and symptoms of middle ear inflammation and MEE. Changes from the 2004 guideline include the description of more specific otoscopic findings. The diagnosis of AOM should be made in children with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to another cause, such as otitis externa. It can also be made in the presence of a mildly bulging TM plus either less than 48 hours of ear pain or intense erythema of the TM.5 Children without MEE should not be diagnosed with AOM.
1. The presence of MEE is indicated by any of the following:
a. Bulging of the TM
b. Limited or absent mobility of the TM
c. Air-fluid level behind the TM
d. Otorrhea
Clinical Presentation
Signs and symptoms of AOM are nonspecific and may vary with age group. Cough, nasal discharge, and other upper respiratory symptoms are common and nonspecific. Fever, vomiting, otalgia, otorrhea, and hearing loss are variably present, with ear pain present only in 50% to 60% of children with AOM.5
Infants may present with irritability, fever, pulling on the ear, or anorexia. Clinical history alone is poorly predictive of the presence of AOM.1
Physical Examination
The position of the TM is key for differentiating AOM from OME; a red TM alone is inadequate for diagnosis. Importantly, AOM must be distinguished from OME.5
• Pneumatic otoscopy. Evaluation of the TM for position, color, translucency, and mobility provides predictive information. In one Finnish study, a cloudy-appearing, bulging TM with impaired mobility was the strongest predictor of AOM, with impaired mobility having the highest sensitivity and specificity. Cloudiness was the next best, with bulging of the membrane having high specificity but lower sensitivity.6 It has also been reported that a bulging TM is highly associated with the presence of a bacterial pathogen, another indicator of the importance of this physical finding.7
• Care must be taken to ensure an adequate examination. Important factors include adequate illumination, a functioning bulb, and obtaining a tight seal with the external auditory canal. A crying child’s TM may appear pink or red, impairing the examination. Excess cerumen in the canal can also impair the examination and should be removed.1
• Tympanometry. It is an adjunctive diagnostic technique to determine the pressure of the middle ear space. In one study, the sensitivity and specificity of a flat tympanogram for the presence of an MEE were 90% and 86%, respectively.8 A seal must be made with the external canal for an accurate reading.
• Acoustic reflectometry. A seal does not need to be made, an advantage over tympanometery. Like tympanometry, acoustic reflectometry relies on measuring sound waves returning from the TM to measure the middle ear pressure.8
• Tympanocentesis. It is the gold standard for diagnosis of an MEE. Culture of fluid may be done to direct antibiotic use. This is not routinely used, but is an excellent diagnostic tool used by a specialist for refractory or recurrent AOM.8
Differential Diagnosis
• OME
• Eustachian tube dysfunction
• Otitis externa
• Temporomandibular junction pain
• Dental pain
• Pharyngitis
• Upper respiratory infection
TREATMENT
Medications
Pain may be significant with AOM, persisting even after treatment; as antibiotics do not provide symptomatic relief in the first 24 hours, it is important to use analgesics as necessary. Antipyretics, including acetaminophen and ibuprofen, are the mainstays of pain control in AOM, and should be given for fever and pain as necessary. Home remedies, such as oil drops in the ear canal, or the external application of heat or cold, have not been directly evaluated and may have limited effectiveness but are unlikely to cause harm. Topical agents such as benzocaine drops are beneficial in patients over 5 years of age, but short-acting.5
There are no data supporting the use of decongestants and antihistamines for AOM; children treated with these medications have an increased risk of medication side effects.6
Observation Versus Antibiotic Use
The decision to observe a patient without prescribing antibiotics is directed by the patient’s age and the severity of symptoms. A major change from the 2004 guideline includes the elimination of a caveat allowing observation in the case of uncertain diagnosis; greater emphasis is now placed on accurate diagnosis and complete visualization of the TM. Initial treatment can consist of observation in children aged 24 months or older with bilateral AOM with non-severe symptoms (mild otalgia for less than 48 hours, temperature less than 102.2°F).5 A system must be established to follow up and begin antibiotic therapy in the case of worsening symptoms or lack of improvement within 48 to 72 hours of diagnosis. Additionally, for children aged 6 months to 2 years, initial observation may be offered for children with unilateral AOM with mild symptoms. Symptomatic treatment with antipyretics/analgesics is still indicated with the decision to observe. In the first 24 hours of observation, the patient should experience a stabilization of symptoms, possibly after a period of worsening. By 72 hours if no improvement is noted, antibiotics are indicated.2,5
If antibiotic use is indicated, amoxicillin at high dose (80 to 90 mg/kg/day) is recommended for most children. If amoxicillin has been given in the past 30 days, there is a history of recurrent AOM unresponsive to amoxicillin, or the child has concurrent purulent conjunctivitis, an antibiotic with additional β-lactamase coverage should be used (e.g., amoxicillin–clavulanate 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate).5 If antibiotics are given, within 48 to 72 hours the child’s symptoms, including fever, irritability, and discomfort, should improve. If the patient is not improved, either the causative bacteria is resistant to the therapy or an additional viral infection may be present.
• Amoxicillin allergy
• Cefdinir: 14 mg/kg/day in one to two doses
• Cefpodoxime: 10 mg/kg/day in one dose
• Cefuroxime: 30 mg/kg/day in two doses
• Ceftriaxone: (50 mg IM or IV per day for 1 or 3 days)
• Alternative treatment5
• In case of failure of initial antibiotic: amoxicillin–clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in two doses), or clindamycin 30 to 40 mg/kg/day in three doses (concurrent prescription for third-generation cephalosporin should be given in case of failure of second antibiotic), or parenteral treatment with ceftriaxone.
• Substantial resistance exists to erythromycin–sulfisoxazole, azithromycin, and sulfamethoxazole–trimethaprim, a change from the 2004 guideline.
• If patient does not tolerate oral medication, a single dose of parenteral ceftriaxone (50 mg per kg) may be used, although a 3-day course is more effective.
• Duration of therapy
• A 10-day course of therapy is recommended for children under age 2 years, whereas children 2 to 5 years of age may be prescribed a 7-day course. For children 6 years and older with mild to moderate symptoms, 5 to 7 days of antibiotic therapy is sufficient.5
Referral
For refractory or recurrent AOM, a referral to an otolaryngologist may be warranted for tympanocentesis and placement of tympanostomy tubes. Tympanostomy tubes may be offered for recurrent AOM (defined as three episodes in 6 months or four episodes in 1 year, with one episode in the preceding 6 months).5
Complications
Complications of AOM are rare, even without antibiotics or with delaying antibiotics, but include acute mastoiditis, intracranial abscess, bacterial meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, and carotid artery thrombosis.7 A more common complication is perforation of the TM, resulting in purulent otorrhea. Infrequently, chronic suppurative otitis media may develop.7 Complications of chronic or recurrent otitis may include school absenteeism, decreased hearing, and speech delay. MEE may persist for weeks after resolution of AOM, leading to transient hearing loss, which should be monitored if it occurs.2
Prognosis
Prognosis is excellent; most children with AOM recover without sequelae.
REFERENCES
1. Rothman R, Owens T, Simel D. Does this child have acute otitis media? JAMA 2003;290:1633–1640.
2. American Academy of Pediatrics and American Academy of Family Physicians, Sub-committee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451–1465.
3. Berman S. Otitis media in children. N Engl J Med 1995;332:1560–1565.
4. Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med 1999;340:260–264.
5. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964–e999.
6. Karma PH, Penttila MA, Sipila MM, et al. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. The value of otoscopic findings. Int J Pediatr Otorhinolaryngol 1989;12(1):37–49.
7. McCormick DP, Lim-Melia E, Saeed K, et al. Otitis media: can clinical findings predict bacterial or viral etiology? Pediatr Infect Dis J 2000;19(3):256–258.
8. Pichichero M. Acute otitis media: part I. Improving diagnostic accuracy. Am Fam Physician 2000;61(7):2051–2056.
9. Flynn CA, Griffin GH, Schultz JK. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev 2004;3:CD001727.
10. Klein JO, Pelton S. Epidemiology, pathogenesis, clinical manifestations, and complications of acute otitis media (online). http://www.uptodate.com.
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GENERAL PRINCIPLES
Chronic otitis media (COM) encompasses a broad area of ear disease that is discussed as three main clinical entities: otitis media with effusion (OME), chronic suppurative otitis media (CSOM), and COM. OME is defined as the presence of fluid in the middle ear without signs or symptoms of infection. Controversy exists regarding the diagnosis and treatment of OME. OME has been studied by several evidence-based panels since the 1990s that have developed objective treatment recommendations.1,2 Much of the discussion on OME is based on these panels’ recommendations for ages 2 to 12. CSOM is defined as chronic (6-week) otorrhea through a tympanic membrane (TM) that is not intact. COM is defined as a perforation lasting longer than 1 month without drainage.
OTITIS MEDIA WITH EFFUSION
Clinical Presentation
In children and adults, the presentation is similar; commonly there are no complaints. The diagnosis is made on a screening examination or follow-up for acute otitis media (AOM). If symptoms are present, they include behavioral changes, parental or patient complaints of diminished hearing, or a fullness or discomfort in one or both ears. Historically, the most common cause of OME is a prior ear infection.
Risk Factors
Risk factors of OME include recurrent AOM, group childcare, passive smoke exposure, absence of breastfeeding as an infant, craniofacial abnormalities, and possibly allergies.
Clinical Examination
The diagnosis of OME is primarily clinical. There are few useful tests and no laboratory studies that aid in the diagnosis. It is important to document whether the effusion is unilateral or bilateral.
Physical Examination
By definition, a middle ear effusion is present, and there is no evidence for acute infection. The external auditory canal should appear normal. The TM may appear normal or thickened. A middle ear effusion may be noted as an air–fluid level, bubbles, or serous or serosanguinous fluid in the middle ear. If fever, a bulging erythematous eardrum, or drainage is present, the diagnosis of OME cannot be made.
Additional Tests
• Pneumatic otoscopy. Pneumatic otoscopy should be used as the primary diagnostic method, as a TM that appears normal may have fluid behind it.1 For pneumatic otoscopy to be accurate, a complete seal must be obtained in the ear canal. When slight positive and negative pressure is applied to the TM, it should move briskly back and forth. An effusion inhibits this movement.
• Tympanometry. If following clinical examination and pneumatic otoscopy the clinician is unsure about the diagnosis, tympanometry provides a useful adjunct and is accurate for infants 4 months and older. An effusion produces a flat, type B tympanogram.
Treatment
Treatment for adults and children is primarily medical but varies depending on the examination and underlying illnesses.
• Children at risk. Children at risk, those with sensory, physical, cognitive, or behavioral issues, should be considered for earlier evaluation. These children may be less tolerant of hearing loss. A hearing and, if necessary, speech and language assessment should be performed.
• Normal child with OME for less than 3 months:
• Watchful waiting. In a variety of studies, the spontaneous resolution of OME ranges from 75% to 90% over 3 months. Given that approximately two thirds of all children improve without any treatment and with no risk to the child, watchful waiting is the recommended treatment course. Interval visits are optional after the initial diagnosis. At 3 months, the child should be reassessed for resolution by pneumatic otoscopy and/or tympanometry.
• Antibiotics. In the past, antibiotics have been an option for treatment during the first 3 months. Given the increasing difficulties and risks with resistant organisms, watchful waiting is now the preferred course.
• Antihistamines and decongestants. These are ineffective and have no role.1
• Steroids. Steroids are not recommended because they show no benefit, especially in this early period.3
• Risk factor reduction. In all patients, there are several modifiable risk factors that contribute to OME. The child should not be exposed to any secondary smoke. Any smoking by family members or relatives should be done outside of the home or car, not in a different room. Group childcare is a risk factor that rarely can be modified.
• OME for 3 months or more in normal children
• Hearing evaluation. At 3 months, all children with bilateral effusions should receive a hearing evaluation. If the hearing loss is 20 decibels (dB) or greater, the patient should have language testing.
• Watchful waiting. Children at low risk who pass their hearing test may be reassessed at 3- to 6-month intervals. Asymptomatic OME tends to resolve spontaneously. If on reassessment the OME is present and the hearing evaluation is >39 dB, then surgery is recommended. From 21 to 39 dB of hearing loss, a comprehensive audiologic evaluation is indicated. Treatment options depend upon the child’s situation and parental preference. If the hearing loss is <21 dB, a repeat test should be done in 3 to 6 months.
• Antibiotics. Antibiotics have no benefit beyond 1 month. For parents averse to surgery, a single course may be tried. A 10- to 14-day course of amoxicillin or trimethoprim–sulfamethoxazole would be first-line treatment, with amoxicillin doses at 40 to 80 mg/kg/day in three divided does. Repeat courses are not recommended.1
• Surgery. Candidates for surgery have OME for 4 months or longer with persistent hearing loss, recurrent or persistent OME in children at risk (regardless of hearing status), or OME with structural damage to the TM or middle ear. Tympanostomy tubes are the recommended surgical option. If repeat tube placement is needed, adenoidectomy is recommended. Myringotomy or tonsillectomy provides no benefit over watchful waiting. Of note, although studies show a quicker resolution of the effusion, an intermediate endpoint, no study has demonstrated an improvement in language or school performance.4
• Patient education. Resources include patient handouts at http://familydoctor.org/330.xml, http://www.cdc.gov/drugresistance/community/files/GetSmart_OME.pdf, and for ear tubes http://www.entnet.org/healthinfo/ears/Ear-Tubes.cfm.
CHRONIC SUPPURATIVE OTITIS MEDIA AND CHRONIC OTITIS MEDIA
Clinical Presentation
CSOM often presents with drainage from an ear. Usually the individual feels fine or otherwise appears healthy. The patient may complain of otalgia, state that he or she is “out of sorts,” or complain of hearing loss or difficulty hearing from the affected ear. COM is usually painless.
Risk Factors
Risk factors include recurrent AOM, immune impairment (e.g., from diabetes or chronic illness), allergies, craniofacial abnormalities, and certain subpopulations, including Eskimos and Native Americans. The use of tympanostomy tubes results in an approximately 1.6% to 3.0% incidence of chronic otorrhea.
Physical Examination
Clear otorrhea is unusual, and a cerebrospinal fluid leak should be considered. Especially in children, one needs to rule out a foreign body with secondary otitis externa as the cause of otorrhea. In adults as well, a careful examination and possibly a therapeutic trial must be done to rule out otitis externa as the cause of otorrhea. Once the external auditory canal has been cleaned, the TM should be examined. Often a large central perforation is seen, with an abnormal middle ear noted. Marginal perforations are more often associated with cholesteatomas and other severe complications. If a cholesteatoma is noted, the patient should be referred to an otolaryngologist. CSOM with cholesteatoma is primarily a surgical disease.
Laboratory Studies
If possible, cultures should be obtained. Material from the middle ear is most helpful. Drainage from the external auditory canal is acceptable, but the canal should be sterilized and the culture obtained from newly accumulated fluid. Culture should include both aerobes and anaerobes.
• Tympanometry. If a perforation is suspected but not seen, a tympanogram will show a large canal volume but flat tracing or will fail to make a seal.
• Audiologic evaluation. Because many patients complain of hearing abnormalities, it is helpful to document this finding so as to follow it during treatment. A conductive hearing loss of more than 30 dB is suggestive of disruption of the ossicular chain.
• Imaging studies. The diagnosis of CSOM and COM is primarily clinical. If a cholesteatoma is suspected, if the diagnosis is uncertain, or if intracranial extension is suspected, computed tomography or magnetic resonance imaging should be performed.5
• Immediate referral. Patients with a facial palsy, labyrinthitis, or suspected intracranial suppuration should be referred immediately.
Treatment
Chronic Suppurative Otitis Media
Initial management is medical and involves removing the debris. If the practitioner does not have an operating microscope or suction, treatment may be better referred to an otolaryngologist. Following removal of debris, the preferred treatment in children and adults with topical fluoroquinolones is recommended.6 The long-term goal is a dry ear and involves aural toilet.7 In a patient with systemic signs and symptoms with concern for invasive disease, systemic antibiotics are indicated.
• Aggressive medical management. For CSOM refractory to topical treatment and aural toilet consideration of a fungal infection, referral to an otolaryngologist should be considered.
• Surgery. If aggressive medical management fails, tympanomastoid surgery should be considered as the next step.
Chronic Otitis Media
A dry, uninfected middle ear does not require acute treatment other than being kept dry. Definitive repair is done electively in adults or at age 9 to 12 years in children.
Patient Education
Resources include http://www.nlm.nih.gov/medlineplus/ency/article/007010.htm for OME and http://www.nlm.nih.gov/medlineplus/ency/article/003042.htm (accessed on 15 March, 2014) for the acute draining ear.
REFERENCES
1. American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004;113:1412–1429. http://pediatrics.aappublications.org/content/113/5/1412.full.html. Accessed March 15, 2014.
2. National Institute for Health and Clinical Excellence. Surgical management of otitis media with effusion in children. 2008. http://publications.nice.org.uk/surgical-management-of-otitis-media-with-effusion-in-children-cg60. Accessed March 15, 2014.
3. Mandel EM, Casselbrant ML, Rockette HE, et al. Systemic steroid for chronic otitis media with effusion in children. Pediatrics 2002;110:1071–1080.
4. Roberts JE, Rosenfeld RM, Zeisel SA. Otitis media and speech and language: a meta-analysis of prospective studies. Pediatrics 2004;113:e238–e248.
5. Kimmelman CP. Office management of the draining ear. Otolaryngol Clin North Am 1992;25:739.
6. Hannley MT, Denneny JC IIIrd, Holzer SS. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg 2000;122:934.
7. Acuin, J. Chronic suppurative otitis media. Burden of illness and management options. World Health Organization. http://www.who.int/pbd/publications/Chronicsuppurativeotitis_media.pdf. Accessed March 15, 2014.
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