Otitis Media – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Inflammation of the middle earAcute otitis media (AOM): Inflammation of the middle ear often following a viral upper respiratory infection (URI): Rapid onset; cause may be infectious, either viral (AOM-v) or bacterial (AOM-b), but there is also a sterile etiology (AOM-s)Recurrent AOM: =3 episodes in 6 months or =4 episodes in 1 yearOtitis media with effusion (OME): Persistent middle ear fluid that is associated with AOM but can arise without prior AOMChronic otitis media with or without cholesteatomaSystem(s) affected: Nervous; ENTSynonym(s): Secretory or serous otitis media

Epidemiology

Incidence

AOM: Predominant age: 6–24 months; declines >7 years; rare in adultsPredominant sex: Male > FemaleBy age 7 years, 93% of children have had =1 episodes of AOM; 39% have had =6.Placement of tympanostomy tubes is 2nd only to circumcision as the most frequent surgical procedure in infants.Increased incidence in the fall and winterOME: 90% of children aged 6 months–4 years have at least 1 episode.

Prevalence

Most common infection for which antibacterial agents are prescribed in the USDiagnosed 5 million times per year in the US

Risk Factors

Premature birthBottle-feeding while supineRoutine daycare attendanceFrequent pacifier use after 6 months of ageSmoking in householdMale genderNative American/Inuit ethnicityLow socioeconomic statusFamily history of recurrent otitisAOM before age 1 is a risk for recurrent AOM.Presence of siblings in the householdUnderlying ENT disease (e.g., cleft palate, Down syndrome, allergic rhinitis)

Genetics

Strong genetic component in twin studies for recurrent and prolonged AOMMay be influenced by skull configuration or immunologic defects

General Prevention

PCV-7 immunization reduces number of cases of AOM by about 6–28% (however, evidence shows that this is offset by an increase in AOM caused by other bacteria) (1)[C].Influenza vaccine reduces AOM by about 30% in children older than age 2 (by preventing influenza).Breastfeeding for =6 months is protective.Avoiding supine bottle-feeding, passive smoke, and pacifiers >6 months may be helpful.Secondary prevention: Adenoidectomy and adenotonsillectomy for recurrent AOM has limited short-term efficacy for children older than 3 years of age and is associated with its own adverse risks.

Etiology

AOM-b (bacterial): Usually, a preceding viral URI produces eustachian tube dysfunction: S. pneumoniae: 20–35%H. influenzae: 20–30%.M. (B.) catarrhalis: 15%Group A streptococci: 3%S. aureus: 12% produce ß-lactamases that hydrolyze amoxicillin and some cephalosporins.AOM-v (viral): 15–44% of AOM infections are caused primarily by viruses (e.g., respiratory syncytial virus, parainfluenza, influenza, enteroviruses, adenovirus, human metapneumovirus, and parechovirus).AOM-s (sterile/nonpathogens): 25–30%OME: Eustachian tube dysfunctionAllergic causes are rarely substantiated.

Commonly Associated Conditions

Diagnosis

AOM: Acute history, signs, and symptoms of middle ear inflammation and effusion: Earache (LR = 3–7.3)Preceding or accompanying URI symptomsDecreased hearingInfectious AOM: Fever (although it is debatable whether OM itself causes fever or fever is due to accompanying viral illness)Decreased eardrum mobility (with pneumatic otoscopy) (LR = 51)Eardrum bulging (LR = 51), cloudy (LR = 34), distinctly red (LR = 8.4). Presence of air–fluid level behind the tympanic membrane [B].Redness alone is not a reliable sign.Otorrhea if eardrum is perforatedAOM in infants and toddlers: May cause few symptoms in the 1st few months of lifeIrritability may be the only symptom.OME: Usually asymptomaticDecreased hearingEardrum often dull but not bulgingDecreased eardrum mobility (pneumatic otoscopy)Presence of air–fluid levelWeber test is positive for an ear with effusion.

Diagnostic Tests & Interpretation

Lab

Initial lab tests

WBC count may be higher in bacterial AOM than in sterile AOM, but is almost never useful.

Diagnostic Procedures/Surgery

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 language delay, significant hearing loss, or learning problems are suspected.Language testing should be performed for children with hearing loss.Tympanocentesis for microbiologic diagnosis is recommended for treatment failures; may be followed by myringotomy.

Differential Diagnosis

TympanosclerosisRedness because of cryingTraumaAOM vs OMEAOM-b vs AOM-v vs AOM-sReferred pain from the jaw, teeth, or throatOtitis externa

Treatment

Medication

First Line

AOM: AAP-AAFP Consensus Guideline recommends amoxicillin 80–90 mg/kg/d; children >2 years old with no complications, 5- to 7-day course [A]; 10-day course for children <2 years old. It is unclear if daily or b.i.d. dosing is as effective as t.i.d. or q.i.d. dosing (2)[A].If penicillin-allergic:Non–type 1 hypersensitivity reaction: Cefdinir 14 mg/kg/d, cefpodoxime 10 mg/kg/d, or cefuroxime 30 mg/kg b.i.d.Type 1 hypersensitivity to penicillin: Azithromycin (10 mg/kg/d [maximum dose 500 mg/d] as a single dose on day 1 and 5 mg/kg/d [maximum dose 250 mg/d] for days 2–5)Other alternatives: Clarithromycin 15 mg/kg/d (b.i.d. dose), erythromycin-sulfisoxazole (50 mg/kg/d), or sulfamethoxazole–trimethoprim (6–10 mg/kg/d based on trimethoprim)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 FDA, but studies did not include otitis-prone children or have criteria for AOM diagnosis [B].OME: See General Measures; no benefit to treatment. Medications promote transitory resolution in 10–15%, but effect is short lived.

Second Line

Alternative antibiotics are indicated for the following AOM patients: Persistent symptoms after 48–72 h of amoxicillinAOM within 1 month of amoxicillin therapySevere earacheAge <6 months with high feverImmunocompromised: Amoxicillin-clavulanate 90 mg/kg–6.4 mg/kg/d, b.i.d.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 fail amoxicillin-clavunate. 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) with amoxicillin 20 mg/kg/d for 3 months resulted in a benefit of ~1 fewer episode per child per year. The risks of increased resistance and side effects are not thought to be worth it.

Additional Treatment

General Measures

Assess pain.Acetaminophen, ibuprofen, benzocaine drops (additional but brief benefit over acetaminophen)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 1 case of persisting AOM pain at 1–2 weeks (NNT = ~15); the NNT to cause harm (primarily diarrhea) is 8–10.81% of patients over 2 years of age are better in 1 week vs 94% if antibiotics are used.Delay of antibiotics found a modest increase in mastoiditis from 2/100,000 to 4/100,000.The AAP/AAFP guideline committee recommends the following for observation vs antibacterial therapy, although these guidelines are not rigorously evidence-based: <6 months of age: Antibacterial therapy should be administered to any child, regardless of the degree of diagnostic certainty.Children >6 months: Antibacterial therapy is recommended when the diagnosis of AOM is certain and the illness is severe (i.e., moderate-to-severe otalgia or fever =39°C in the previous 24 h).Observation is an option when the diagnosis is certain, but illness is not severe, and in patients with an uncertain diagnosis.OME: Watchful waiting for 3 months per AAP/AFPP guidelines for those not at risk (see Complications). 25–90% will recover spontaneously over this period: No benefit of antihistamines or decongestants (3)[A] or antibiotics or systemic steroids

Complementary and 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.

Surgery/Other Procedures

Recurrent AOM: Consider referral for surgery if =3 episodes of well-documented AOM within 6 months, =4 episodes within 12 months, or AOM episodes that occur while on chemoprophylaxis.Tympanostomy tubes may be effective in selective patients.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 >4–6 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 risk of hearing loss (4)[A].Adenoidectomy is indicated in specific cases; tonsillectomy or myringotomy is never indicated (5)[A].

In-Patient Considerations

Initial Stabilization

Outpatient treatment except when surgery is indicated or for AOM in febrile infants <2 months old or children requiring ceftriaxone who also require monitoring for 24 h

Ongoing Care

Follow-Up Recommendations

Patients with otitis media who do not respond within 48–72 h should be re-evaluated:

If therapy was delayed and diagnosis is confirmed, start therapy with high-dose amoxicillin.If therapy was initiated, consider changing antibiotic; options are limited because macrolides have limited benefit against H. influenza 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 red flags (see above).

Prognosis

See Treatment under General Measures.Recurrent AOM and OME: Usually subsides in school-age children; few have complications.

Complications

AOM: Serious complications are rare: Tympanic membrane perforation/otorrheaAcute mastoiditisFacial nerve paralysisOtitic hydrocephalusMeningitisHearing impairmentOME: 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 hearing impairment.Recurrent AOM and OME: Atrophy and scarring of eardrumChronic perforation and otorrheaCholesteatomaPermanent hearing lossChronic mastoiditisOther intracranial suppurative complications

References

1. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med. 2001;344:403–9.

2. Thanaviratananich S, Laopaiboon M, Vatanasapt P. 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;CD004975.

3. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev. 2008;CD001727.

4. Lous J, Burton MJ, Felding JU, et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev.2005;CD001801.

5. 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;113:1412–29.

Additional Reading

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004; 113:1451–65.

Gould JM, Matz PS et al. Otitis media. Pediatr Rev. 2010;31:102–16.

Shaikh N, Hoberman A, Kaleida PH, et al. Videos in clinical medicine. Diagnosing otitis media–otoscopy and cerumen removal. N Engl J Med. 2010;362:e62.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Ear pain

Codes

ICD9

381.00 Acute nonsuppurative otitis media, unspecified381.3 Other and unspecified chronic nonsuppurative otitis media381.10 Chronic serous otitis media, simple or unspecified381.4 Nonsuppurative otitis media, not specified as acute or chronic382.00 Acute suppurative otitis media without spontaneous rupture of eardrum382.3 Unspecified chronic suppurative otitis media382.9 Unspecified otitis media381.01 Acute serous otitis media

Snomed

65363002 otitis media (disorder)81564005 chronic serous otitis media (disorder)43561008 chronic exudative otitis media (disorder)194281003 acute suppurative otitis media (disorder)359609001 acute nonsuppurative otitis media (disorder)194240006 acute non-suppurative otitis media – serous (disorder)

Clinical Pearls

Pneumatic otoscopy is single most specific and clinically useful test for diagnosis.Consider a delay of antibiotics for 24–48 hours in uncomplicated children >2 years old.1st-line treatment is amoxicillin 80–90 mg/kg/d for 10 days for children <2 years old; consider 5- to 7-day course in children >2 years old.Erythema and effusion can persist for weeks.Antibiotics, antihistamines, and steroids are not indicated for OME.