AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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Background

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) define acute otitis media as an infection of the middle ear with acute onset, presence of middle ear effusion (MEE), and signs of middle ear inflammation. Acute otitis media most commonly occurs in children and is the most frequent specific diagnosis in children who are febrile. Physicians, including those in the ED, often overdiagnose acute otitis media.

Bulging of the tympanic membrane is the highest predictive value when evaluating the presence of MEE. Other findings that indicate the presence of MEE include limited mobility of the tympanic membrane with pneumatic otoscopy and fluid visualized behind the tympanic membrane or in the ear canal (with perforation).

Distinguishing between acute otitis media and otitis media with effusion (OME) is important. OME is more common than acute otitis media. When OME is mistaken for acute otitis media, antibiotics may be prescribed unnecessarily. OME is fluid in the middle ear without signs or symptoms of infection. OME is usually caused when the eustachian tube is blocked and fluid becomes trapped in the middle ear. Signs and symptoms of acute otitis media occur when fluid in the middle ear becomes infected.

Recurrent otitis media is defined as 3 episodes of acute otitis media within 6 months or 4 or more episodes within 1 year.

Pathophysiology

Acute otitis media usually arises as a complication of a preceding viral upper respiratory infection (URI). The secretions and inflammation cause a relative occlusion of the eustachian tubes. Normally, the middle ear mucosa absorbs air in the middle ear. If air is not replaced because of relative obstruction of the eustachian tube, a negative pressure is generated and causes a serous effusion. This effusion of the middle ear provides a fertile media for microbial growth, and, with the URI, introduction of upper airway viruses and/or bacteria into the middle ear may occur. If growth is rapid, the patient will have a middle ear infection. If the infection and the resultant inflammatory reaction persist, perforation of the tympanic membrane or extension into the adjacent mastoid air cells may be present.

Frequency

United States

Otitis media is common, with 50% of children having an episode before their first birthday and 80% of children having one by their third birthday. An estimated $3-4 billion are spent each year on care of patients with acute otitis media and related complications.

Mortality/Morbidity

• Mortality is rare in countries where treatment of complications is available, and it is not frequent in countries where treatment is not available.
• Morbidity may be significant for infants in whom persistent MEE develops. MEE leads to hearing deficits and speech delay. Most spontaneous perforations eventually heal, but some persist. Frequent recurrences of acute otitis media are relatively common.  
• Otitis is not considered a major source of bacteremia or meningeal seeding, but local brain abscess has been documented, demonstrating that it is possible for acute otitis media to extend.

Race

Otitis media is more frequent in certain racial groups (eg, Inuit and American Indians) than in others.

• Other factors in the environment (eg, crowding, daycare setting, nutrition) may be more important than race, but they have not been fully delineated.
• Otitis media is less common in groups with high rates of breastfeeding than in groups with low rates of breastfeeding.

Sex

Boys are affected more commonly than girls, but no specific causative factors have been found. Male sex is a minor determinant of infection.

Age

• Ear infection occurs in all age groups, but it is considerably more common in children, particularly those aged 6 months to 3 years, than in adults. This age distribution is presumably due to immunologic factors (eg, lack of pneumococcal antibodies) and anatomic factors (eg, a low angle of the eustachian tube with relation to the nasopharynx).
• Children with significant predisposing factors (eg, cleft palate) acquire infections so frequently that some authors advocate the routine placement of polyethylene tubes in their tympanic membranes to maintain aeration of the middle ear.

CLINICAL

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History

Patients who can communicate usually describe feelings of pain or discomfort in the affected ear. However, most cases occur in children who are unable to communicate specific complaints.

• Acute otitis media
• • Earache
  • Fever (not required for the diagnosis)
  • Accompanying or precedent URI symptoms (very common)
  • Decreased hearing
• Acute otitis media in infants
• • Infants may be asymptomatic.
  • Irritability may be the only symptom.
• Serous OME
  
  
  • Patients are usually asymptomatic.
  • Decreased hearing may be demonstrated on audiometry.

Physical

If the canal is clean and if the patient is cooperative, physical examination is easy. If the canal is occluded with cerumen or debris, if the canal is anatomically small, or if the patient is unable to cooperate, examination may be difficult.

• Inflammation of the tympanic membrane and diminished movement of the membrane with insufflation or decreased visibility of the landmarks of the middle ear are the hallmarks of otitis media.
• • Injection of the membrane is common in crying infants, and it may mislead the casual observer to believe the patient has acute otitis media. Therefore, pneumatic otoscopy is helpful in examining any patient with an injected tympanic membrane.
  • A history suggestive of acute otitis media and an ear canal full of purulent exudate is usually considered sufficient to diagnosis acute otitis media with perforation.
  • Acute otitis media should be painless. If pain is present, suspect that a foreign body in the ear canal is causing the infection or that the patient has otitis externa.
• Remove cerumen and other debris from the canal, as necessary, to allow clear visualization of the entire tympanic membrane.
• • Removal may be difficult if the patient is uncooperative.
  • Irrigation may be useful, as it may soften and dislodge cerumen so that it can be removed more easily.
  • Soft plastic curettes are preferred to metal ones, but a firm tool may be necessary to remove a hard block of cerumen.
  • Patients may require a referral if sufficient time and resources are not available for the proper and safe removal of cerumen.
  • Care should be taken to avoid perforation of the tympanic membrane.
• The association between bacterial conjunctivitis and otitis media is well described.
• • Any patient with purulent conjunctival exudate should receive thorough examination of the tympanic membranes.
  • Sinusitis and purulent rhinitis frequently accompany otitis in children and infants.

Causes

Anatomic and immunologic factors in the presence of acute infection are the main causes of acute otitis media.

• Pneumococcus species, Haemophilus influenzae (untypeable), and Moraxella species are the bacteria most commonly involved in otitis media.
• Less common causes are other bacteria, Mycoplasma species, and viruses.
• Sterile effusions occur in approximately 20% of cases studied.
• Risk factors for otitis media have been identified and can generally be divided into those associated with the host and those associated with the environment.
  
  
  • Host risk factors include age, prematurity, race, allergy, craniofacial abnormalities, gastroesophageal reflux, presence of adenoids, and genetic predisposition.
  • Environmental risk factors include upper airway infections, seasonality, daycare, family size, exposure to passive smoking, breastfeeding, socioeconomic level, and use of pacifiers.
  • Upper airway infections may lead to AOM.
  • Incidence is increased in the autumn and winter months.
  • Daycare center attendance increases risk of development of AOM.
  • Bottle-feeding increases the incidence compared with breastfeeding.
  • Pacifier use increases risk for AOM.
  • Smoking in the household clearly increases the incidence of all forms of respiratory problems in childhood.
  • A family history of middle ear disease increases the incidence.
  • Siblings with recurrent AOM is a risk factor.
  • Helicobacter pylori has recently been studied and found in middle ear, tonsillar, and adenoid tissues in patients with OME, indicating a possible role in pathogenesis of OME.
  • Acute otitis media in the first year of life is a risk factor for recurrent acute otitis media.

DIFFERENTIALS

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Other Problems to be Considered

Coexistent conjunctivitis
Acute hearing loss
Tympanosclerosis
Erythema caused by crying
Pain referred from the teeth or jaw
Bullous myringitis
Parotitis (ie, mumps)
Cavernous sinus thrombosis

WORKUP

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Lab Studies

• No definitive laboratory examination exists; however, the WBC count may be elevated in association with any infection.
• Blood cultures are positive in only about 3% of febrile patients with acute otitis media and are not routinely recommended.

Imaging Studies

• Imaging studies are not valuable for diagnosis of acute otitis media.
• Radiography and/or CT scanning of the mastoid air cells may be helpful in select cases of suspected mastoiditis.

Other Tests

• Tympanometry is easy to perform on any ear. Even when the tympanic membrane cannot be visualized, the results indicate the presence or absence of MEE.
• • The findings cannot be used to differentiate between acute otitis media and chronic serous OME.
  • Tympanometry cannot be recommended as a routine screening test for acute otitis media. However, in a patient in whom examination is difficult, normal tympanometric results may help rule out acute otitis media.
• Hearing tests are not helpful in diagnosing acute otitis media.
• Nasopharyngoscopy may reveal anatomic factors involved in acute otitis media and show purulent matter at the nasal opening of the eustachian tube, but the findings are of no acute diagnostic value.

Procedures

• Tympanocentesis with a needle and syringe may be appropriate to delineate the etiology of an acute otitis media in an immunocompromised patient or in patients with persistent fever in the face of antibiotic therapy.
  
  
  • If acute otitis media is present in infants younger than 2-3 months, some authors recommend tympanocentesis.
  • This procedure often is performed by the ear, nose, and throat (ENT) consultant.
• Myringotomy is indicated only for patients with intractable pain.

TREATMENT

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Emergency Department Care

• According to AAP and AAFP guidelines for the treatment of acute otitis media, an observation period may be recommended depending on the patient's age, the diagnostic certainty, and the severity of illness.
• • Diagnostic certainty is based on all 3 of the following criteria: acute onset, MEE, and middle ear inflammation.
  • Severe illness is defined as moderate-to-severe otalgia or temperature greater than 39°C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39°C.
• The following recommendations were made:
• • Infants younger than 6 months should receive antibiotics.
  • Children aged 6 months to 2 years should receive antibiotics if the diagnosis is certain. If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere, and antibiotic therapy can be considered for severe illness.
  • Children aged 2 years and older should receive antibiotics if the diagnosis is certain and if the illness is severe. An observation period is an option when the diagnosis is uncertain or when it is certain and nonsevere.
• The observation option is a 48- to 72-hour period of symptomatic treatment with analgesics and without antibiotics, followed by reexamination.
• For an observation option to be considered, the parent must be able to communicate with the physician and have access to follow-up care whenever problems ensue or symptoms worsen.
• Pain management is an important part of treating acute otitis media, especially in the first 24 hours. Appropriate analgesics should be offered.
• A recent study by Spiro et al evaluated a "wait-and-see prescription" for antibiotics in AOM. It was conducted in an emergency department, and parents were asked to not fill the prescription unless the child either did not improve or worsened in 48 hours. The results showed a substantial reduction in the use of antibiotics in children with AOM in the "wait-and-see prescription" group (62% vs 13%; P<.001).¹
• Recent studies have also shown that, despite adequate access to clinical guidelines, the prescribing rates for antibiotics in AOM in some emergency departments remain high. 

Consultations

• In general, patients with acute otitis media seen in the ED should be referred to a primary care physician for follow-up care.
• Patients discharged with a full course of therapy should be reexamined 4-6 weeks after their initial presentation for evidence of middle ear aeration.
• Patients whose symptoms (eg, pain, fever) do not resolve within 48 hours of treatment should be reevaluated. Most treatment failures are due to compliance problems or anatomic factors rather than antibiotic resistance.

MEDICATION

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In the United States, antibiotic therapy is usually prescribed for patients with any hint of acute otitis media. In other parts of the world, many patients are monitored for evidence of spontaneous clearing or onset of complications instead of routine antibiotic use. Studies have shown that antibiotics provide little benefit beyond placebo in mild cases of acute otitis media. Antipyretics and analgesics may be necessary and should be prescribed liberally. Steroids, decongestants, and antihistamines are not effective in the treatment of acute otitis media, and they may cause complications.

Drug Category: Antibiotics

Empiric coverage for Streptococcus pneumoniae, H influenzae, and Moraxella species may be provided to children; adults have H influenzae infection less frequently than children. Controlled studies of effective antibiotics in the United States have demonstrated 90-95% efficacy. Studies in other parts of the world demonstrate about 80% resolution with observation alone. The AAP and AAFP recommend the use of high doses and short courses of amoxicillin.

If antibiotic therapy is chosen, amoxicillin 80-90 mg/kg/d is the antibiotic of choice. The length of treatment is 10 days for younger children and patients with severe illness, and a 5- to 7-day course is recommended for children older than 6 years. If additional beta-lactamase–positive H influenzae and/or Moraxella catarrhalis coverage is desired, high-dose amoxicillin and clavulanate potassium is recommended.

If the patient is allergic to amoxicillin, alternatives are cefdinir, cefpodoxime, or cefuroxime if the allergic reaction is not a type 1 hypersensitivity. Patients with type 1 hypersensitivity should be given azithromycin or clarithromycin. Other alternatives are clindamycin and ceftriaxone given intravenously or intramuscularly. Ceftriaxone 50 mg/kg/d is recommended for children who are unable to take oral antibiotics and for patients with compliance problems.

In patients whose condition fails to improve after initial antibiotic therapy, a 3-day course of ceftriaxone offers outcomes better than those of a 1-day course.

Drug Category: Analgesics

Relief of pain is one of the prime functions of effective treatment. Oral analgesics or topical medications may be required for relief of pain. Appropriate doses of acetaminophen or ibuprofen are available in tablet or liquid form. Codeine may be used as an ancillary agent; however, it may provoke emesis or constipation.

FOLLOW-UP

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Further Outpatient Care

• Most cases of otitis media are self-limited. The incidence of complications is high enough that all patients should be encouraged to have a follow-up visit with their regular physician or clinic approximately 14-21 days after the initial visit.
• Patients with persistent pain or fever should be reexamined within 48 hours.
• If an observation period is chosen, failure to improve within 48-72 hours should prompt initiation of antibiotic therapy.
• If antibiotics were started initially and if the patient's condition fails to improve, the antibiotic should be changed, and compliance must be emphasized.
• Infants with frequent recurrences may benefit from daily antibiotic prophylaxis with sulfamethoxazole or amoxicillin for a period of several months.
• An osteopathic manipulation technique (ie, Galbreath technique) has been described. It may help some patients open their eustachian tubes and treat or prevent middle ear fluid accumulation. No blinded studies of this technique have been performed.

Deterrence/Prevention

• Breastfeeding decreases the incidence of acute otitis media.
• Cigarette smoking in the household should be eliminated.
• In adults and older children, regular exercises to increase upper airway pressure and to force inflation of the middle ear may be useful (see the reference to the Galbreath technique above). Blowing up balloons is effective in some small children.

Complications

• Serous OME is the most common complication.
  
  
  • It may cause mild discomfort in some patients; however, if it is bilateral, hearing loss with resultant speech delay may occur in infants.
  • Treatment of this condition is not the responsibility of an ED physician. The patient should be referred.
• Mastoiditis used to be a common complication, but now with antibiotic treatment, it is rare. Patients with any mastoid tenderness or edema accompanying otitis should be treated aggressively in consultation with an ENT specialist.
• Perforation of the tympanic membrane is a frequent but usually not serious complication. Treatment is not changed from that described above, but follow-up care is more important. With proper treatment, most perforations heal within a couple of weeks, with no residual complications.
• Intracranial complications, such as epidural abscess or cavernous sinus thrombosis, are rare and should be treated with admission to a critical care unit. They usually present primarily rather than as a late complication of treated otitis.

Prognosis

• The prognosis of patients with acute otitis media is excellent. However, patients and/or their parents still should be encouraged to finish the prescribed medication and to keep their follow-up appointments.
• Symptoms usually improve within 24 hours and almost always within 48-72 hours.

Patient Education

• Parent education by the physician is the most important factor contributing to the proper use of medications and follow-up care.
• • Failure to finish a course of antibiotic therapy usually occurs because the prescribing physician fails to explain the importance of the medication and the need to finish the entire course of therapy.
  • Therefore, the physician must discuss the process and the specific treatment plan with the patient and/or the parents.
• For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Earache.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Diagnosis and treatment of otitis media are rare causes of legal problems. However, failure to diagnose meningitis in a sick child with associated otitis can lead to inadequate treatment of the meningitis and significant legal problems for the provider.
• Do not allow the presence of acute otitis media to deter further diagnostic workup if the patient appears significantly ill.
• Failure to recognize contiguous spread to mastoid air cells is a pitfall.

MULTIMEDIA

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Media file 1:  Drawing of a normal right tympanic membrane. Note the outward curvature of the pars tens (*) of the eardrum. The tympanic annulus is indicated anteriorly (a), inferiorly (i), and posteriorly (P). M = long process of the malleus; I = incus; L = lateral (short) process of the malleus.
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Media type:  Illustration

Media file 2:  Tympanic membrane of a person with 12 hours of ear pain, slight tympanic membrane bulge, and slight meniscus of purulent effusion at bottom of tympanic membrane. Reproduced with permission from Isaacson G: The natural history of a treated episode of acute otitis media. Pediatrics. 1996; 98(5): 968-7. See also Image 3.
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Media type:  Photo

Media file 3:  Days after onset of symptoms, vessels continue across pars tensa, and a fluid layer of pus is noted. Reproduced with permission from Isaacson G: The natural history of a treated episode of acute otitis media. Pediatrics. 1996; 98(5): 968-7. See also Image 2.
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Media type:  Photo

Media file 4:  Tympanic membrane.
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Media type:  Image

REFERENCES

Section 11 of 11

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1. Spiro DM, Tay KY, Arnold DH, Dziura JD, Baker MD, Shapiro ED. Wait-and-See Prescription for the Treatment of Acute Otitis Media. JAMA. Sep 2006;296:1235-1241. [Medline].
2. American Academy of Pediatrics. Diagnosis and management of acute otitis media. Pediatrics. May 2004;113(5):1451-65. [Medline].
3. Barnett ED, Teele DW, Klein JO, Cabral HJ, Kharasch SJ. Comparison of ceftriaxone and trimethoprim-sulfamethoxazole for acute otitis media. Greater Boston Otitis Media Study Group. Pediatrics. Jan 1997;99(1):23-8. [Medline].
4. Berman S, Byrns PJ, Bondy J, Lezotte D. Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric medicaid population. Pediatrics. Oct 1997;100(4):585-92. [Medline].
5. Canafax DM, Yuan Z, Chonmaitree T, Deka K, Russlie HQ, Giebink GS. Amoxicillin middle ear fluid penetration and pharmacokinetics in children with acute otitis media. Pediatr Infect Dis J. Feb 1998;17(2):149-56. [Medline].
6. Cantor RM. Otitis externa and otitis media. A new look at old problems. Emerg Med Clin North Am. May 1995;13(2):445-55. [Medline].
7. Cohen R, Levy C, Boucherat M, Langue J, de La Rocque F. A multicenter, randomized, double-blind trial of 5 versus 10 days of antibiotic therapy for acute otitis media in young children. J Pediatr. Nov 1998;133(5):634-9. [Medline].
8. Heikkinen T, Chonmaitree T. Viral-Bacterial Synergy in Otitis Media: Implications for Management. Curr Infect Dis Rep. Apr 2000;2(2):154-159. [Medline].
9. Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med. Jan 28 1999;340(4):260-4. [Medline].
10. Howie VM. Otitis media. Pediatr Rev. Aug 1993;14(8):320-3. [Medline].
11. Isaacson G. The natural history of a treated episode of acute otitis media. Pediatrics. Nov 1996;98(5):968-71. [Medline].
12. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics. Apr 1991;87(4):466-74. [Medline].
13. Lubianca Neto JF, Hemb L, Silva DB. Systematic literature review of modifiable risk factors for recurrent acute otitis media in childhood. J Pediatr. Mar-Apr 2006;82:87-96. [Medline].
14. Lund WS. A review of 50 cases of intracranial complications from otogenic infection between 1961 and 1977. Clin Otolaryngol. Nov 1978;3(4):495-501. [Medline].
15. Mandel EM, Casselbrant ML, Rockette HE, Bluestone CD, Kurs-Lasky M. Efficacy of 20- versus 10-day antimicrobial treatment for acute otitis media. Pediatrics. Jul 1995;96(1 Pt 1):5-13. [Medline].
16. Pratt-Harrington D. Galbreath technique: a manipulative treatment for otitis media revisited. J Am Osteopath Assoc. Oct 2000;100(10):635-9. [Medline].
17. Rosenfeld RM. An evidence-based approach to treating otitis media. Pediatr Clin North Am. Dec 1996;43(6):1165-81. [Medline].
18. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr. Mar 1994;124(3):355-67. [Medline].
19. Schutzman SA, Petrycki S, Fleisher GR. Bacteremia with otitis media. Pediatrics. Jan 1991;87(1):48-53. [Medline].
20. Steinmann K, Babl FE. Antibiotic prescribing rates for acute otitis media in a paediatric emergency department. J Paediatr Child Health. 2006;42:204-5. [Medline].
21. Yilmaz T, Ceylan M, Akyon Y, Ozcakyr O, Gursel B. Helicobacter pylori: A possible association with otitis media with effusion. Otolaryngol Head Neck Surg. May 2006;134:772-777. [Medline].

Article Last Updated: Jul 17, 2007