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Otitis media
OVERVIEW: Inflammation of the middle ear
• Acute otitis media (AOM): Usually a bacterial infection accompanied by viral upper respiratory infection; rapid onset of signs and symptoms
• Recurrent AOM: 3 or more AOM in 6 months, or 4 or more AOM in 1 year
• Otitis media with effusion (OME): Persistent inflammation manifested as asymptomatic middle ear fluid that follows AOM or arises without prior AOM
• Chronic otitis media with or without cholesteatoma
System(s) affected: Nervous
Genetics: May be influenced by skull configuration or immunological defects
Incidence/Prevalence in USA: (Incidence) By age 7 years 93% of children have 1 or more AOM; 39% have 6 or more AOM; after AOM 10 to 20% still have OME 3 months later
Predominant age: Peak incidence age 6-18 months; declines after age 7 years; rare in adults
Predominant sex: Male > Female (for AOM and recurrent AOM)
SIGNS AND SYMPTOMS: • AOM:
• Earache
• Fever, although more often afebrile
• Accompanying URI symptoms
• Decreased hearing
• Otorrhea if eardrum perforated
• Eardrum mobility decreased (as observed by pneumatic otoscopy)
• Eardrum bulging, opaque, often yellowish or inflamed. Redness alone is not a reliable sign.
• AOM in infants:
• May cause no symptoms in the first few months of life
• Irritability is sometimes the only indication of earache
• Eardrum bulging, opaque, often yellowish or inflamed. Redness alone not a reliable sign.
• OME:
• Usually asymptomatic
• Decreased hearing probably universal, but not always measurable, and rarely appreciated by parents
• Eardrum often dull, but not bulging
• Eardrum mobility decreased (as observed by pneumatic otoscopy)
CAUSES: • AOM: A preceding viral upper respiratory infection produces eustachian tube dysfunction that is thought to promote bacterial infection via eustachian tube. Bacteriology:
• Pneumococci: 30-35%
• Haemophilus influenzae: 20-25%; 40% of these produce beta-lactamases that hydrolyze amoxicillin and some cephalosporins
• Moraxella (Branhamella) catarrhalis: 10-15%; 90% of these produce beta-lactamases that hydrolyze amoxicillin and some cephalosporins
• Group A streptococci: 3%
• Staphylococcus aureus: 1-2%
• Sterile/non-pathogens: 25-30%
• OME:
• 20-40% silent bacterial infection
• Eustachian tube dysfunction thought important
• Allergic causes rarely substantiated
RISK FACTORS: • Day care
• Formula feeding
• Smoking in household
• Male gender
• Family history of middle ear disease
• AOM in 1st year of life is a risk factor for recurrent AOM
• Sibling history of otitis media
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: • Tympanosclerosis
• Redness due to crying
• Earache with a normal ear exam may be caused by referred pain from the jaw or teeth
LABORATORY: WBC higher in bacterial AOM than in sterile AOM
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: N/A
SPECIAL TESTS: • To document the presence of middle ear fluid - tympanometry, acoustic reflex measurement or acoustic reflectometry
• Hearing testing helpful to assess the need for early surgical intervention in OME
• Nasopharyngoscopy
IMAGING: N/A
DIAGNOSTIC PROCEDURES: Tympanocentesis for microbiologic diagnosis recommended for treatment failures, may be followed by myringotomy
TREATMENT APPROPRIATE HEALTH CARE: Outpatient except when surgery is indicated
GENERAL MEASURES: • AOM: Outpatient except for febrile infants < 2 months
• May use watchful waiting approach, treating symptoms without antibiotics for first 2-3 days. If symptoms persist, then amoxicillin is first line treatment.
SURGICAL MEASURES:
• OME: Referral for surgery if: > 4-6 months bilateral OME, and/or > 6 months unilateral OME, and/or hearing loss > 25 decibels
• Recurrent AOM: Referral for surgery if > 2 or 3 AOM while on chemoprophylaxis. Tympanostomy tubes and adenoidectomy effective surgical procedures for OME and recurrent AOM, but not in all cases.
ACTIVITY: No restrictions
DIET: No special diet
PATIENT EDUCATION: N/A
MEDICATIONS DRUG(S) OF CHOICE: • AOM: Amoxicillin 40-45 mg/kg bid >age 2 years, 5-7 day course with no complications; probably the most effective of penicillins/cephalosporins against relatively resistant (but not highly resistant) pneumococci
• Recurrent AOM: Amoxicillin 20 mg/kg daily for 3-6 months or until summer
• OME: Antihistamines and decongestants ineffective, indications for steroids not defined, amoxicillin promotes resolution in 10-15% but effect is usually transitory - not recommended.
• Note: if patient not toxic appearing, may choose to treat with antipyrine-benzocaine (Auralgan) drops and acetaminophen (Tylenol) as long as close follow up available - see evidence based web site. Spontaneous clinical resolution is 81%.
Contraindications: Allergy to penicillins
Precautions: Refer to manufacturer's profile of each drug
Significant possible interactions: Refer to manufacturer's profile of each drug
ALTERNATIVE DRUGS: • Alternative drugs are indicated for the following AOM patients:
• Patients with penicillin allergy
• Persistent symptoms after 48-72 hrs of amoxicillin
• AOM within 1 month of amoxicillin therapy
• AOM with severe earache
• Infants less than 6 months with high fever
• Immunocompromised hosts
• AOM due to Chlamydia trachomatis will respond to macrolides and sulfonamides
• AOM due to Mycoplasma pneumoniae will respond to macrolides
• AOM: Alternative drugs (treat for 10 days):
• Amoxicillin-clavulanate (Augmentin) 40 mg/kg/day of amoxicillin component tid - effective against resistant H. influenzae and M. catarrhalis, amoxicillin component effective against relatively resistant pneumococci
• Cefaclor (Ceclor) 40 mg/kg/day bid or tid is less effective than other alternatives
• Cefixime (Suprax) 8 mg/kg/day bid or single daily dose - effective against resistant H. influenzae and M. catarrhalis less effective than amoxicillin for pneumococci
• Cefpodoxime (Vantin) 10 mg/kg/day bid - less effective in vivo against H. influenzae than other drugs
• Ceftriaxone (Rocephin) 50 mg/kg IM single dose - effective against major pathogens, but expensive and painful so reserved for sick infants
• Clarithromycin (Biaxin) 15 mg/kg/day divided bid - not effective in vivo against H. influenzae
• Trimethoprim-sulfamethoxazole (Septra, Bactrim) 8 mg TMP/kg/day divided bid: up to 30% of pneumococci are resistant
• Erythromycin-sulfisoxazole (Pediazole) 40 mg erythromycin component/kg/day divided qid - some strains of pneumococci are resistant
• Recurrent AOM:
• Sulfisoxazole 75 mg/kg single daily dose for penicillin allergic patients
• Analgesics and antipyretics as needed
FOLLOW UP PATIENT MONITORING: • AOM: Otoscopic examination 4 weeks after diagnosis
• OME: Monthly otoscopic or tympanometric exams as long as OME persists
PREVENTION/AVOIDANCE: • Breast-feeding decreases incidence of AOM
• Eliminate cigarette smoking in the household
POSSIBLE COMPLICATIONS: • AOM: Perforation/otorrhea, acute mastoiditis, facial nerve paralysis, otitic hydrocephalus, meningitis
• OME: Hearing loss. Extent and significance of impaired speech and language is controversial.
• Recurrent AOM and OME: Atrophy and scarring of eardrum, chronic perforation and otorrhea, cholesteatoma, permanent hearing loss, chronic mastoiditis, brain abscess and other intracranial suppurative complications
EXPECTED COURSE AND PROGNOSIS: • AOM: Symptoms usually improve in 48-72 hrs; OME following AOM resolved in 90% by 3 months
• OME: Approximately 50% resolve after 8 weeks of observation
• Recurrent AOM and OME: Usually subside in school age children; only a small percentage have complications
MISCELLANEOUS ASSOCIATED CONDITIONS: • Upper respiratory infection
• Bacteremia
• Meningitis
• Allergies
AGE-RELATED FACTORS:
Pediatric: Primarily a pediatric disease
Geriatric: N/A
Others: N/A
PREGNANCY: N/A
SYNONYMS: • Secretory otitis media
• Serous otitis media
ICD-9-CM: 382.0 Acute otitis media
381.0 Acute suppurative otitis media
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