Acute Otitis Media

AOM is common in children of all ages. Parents will generally bring their child to the office with a complaint of pain, pulling on the ear, fever, and/or ear drainage. Before examining a child for AOM or OME, the physician must be comfortable with otoscopy of the normal ear and TM. The most common TM landmarks visible on a normal examination include the umbo and handle of the malleus, the shadow of the incus, and the cone of light reflex (Figure 31-3). On pneumatic otoscopy, the physician should appreciate the back-and-forth motion of the normal TM with gentle squeezing and releasing of the bulb.

Figure 31-3 Right tympanic membrane.

A physical examination is required to determine the presence of a middle ear effusion (MEE). On inspection of the TM, it may be bulging, or an air-fluid level or bubble will be visible. The normal landmarks may be obscured and the light-reflex absent or distorted. The movement of the TM will be decreased or absent. Sometimes purulent material will be seen behind the TM (Figure 31-4). In the case of a perforated TM, the perforation itself may be visible or the canal may be filled with debris, fluid, or exudate. Erythema of the TM alone is nondiagnostic because the TM may be red in many other conditions, including AOE and OME and during a child’s crying. In children, lack of cooperation often impedes a complete examination. Treatment recommendations for a nondiagnostic, uncertain examination are discussed further below.

Figure 31-4 Acute otitis media.

Otitis Media with Effusion

In some cases of OME, a child may present with mild ear pain, but often, OME is seen on a routine well-child examination or on examination for follow-up of AOM. Generally, this condition is asymptomatic, but effects of persistent effusion such as hearing loss, speech/language delay, behavioral difficulties, or difficulty sleeping may be noticed and reported by parents.

On examination, as in AOM, an air-fluid level or fluid bubble may be seen. Generally, the fluid visualized is clear. There is no distinct erythema to the TM. There will be decreased movement of the TM with pneumatic otoscopy.

The differential diagnosis of ear pain is broad, but when considering otitis media as a diagnosis, some common conditions that should be considered in children include AOE, mastoiditis, sinusitis, pharyngitis, foreign body, and dental caries.

Acute Otitis Media Treatment

The goals of treatment for AOM include relieving pain, eradicating infection, and preventing complications. Pain should be evaluated and treated in all patients either with an NSAID or acetaminophen. Topical anesthetic otic drops such as benzocaine may provide additional, brief pain relief.

In recent years, there has been a shift in the treatment recommendations for AOM from universal antibiotic use to include the option of observation before requiring antibiotics. Clinical research has shown that most children older than 2 years of age have spontaneous resolution of AOM without antibiotic therapy. There also appears to be no increased risk for complications such as mastoiditis with watchful waiting of older children. Importantly, the observation option helps to limit further emergence of resistant bacteria. The decision to observe or treat should be based on the child’s age, diagnostic certainty, and disease severity (Table 31-1). The treatment guidelines proposed by the New York Regional Otitis Project, the AAP, and the American Academy of Family Physicians recommend treatment differences based on age because severe complications are most common in infants and the youngest children.

Table 31-1 Criteria for Initial Antibiotic Treatment versus Observation in Children with Acute Otitis Media

* Observation option is appropriate only when follow-up can be ensured within 48 to 72 hours and antibiotics started if symptoms persist or worsen. Nonsevere illness is defined as only mild otalgia and fever below 39°C. A history of acute symptom onset, middle ear effusion, and signs of middle ear inflammation make a certain diagnosis.

Modified Rosenfeld R: Observation option toolkit for acute otitis media. Int J Pediatr Otorhinolaryngol 58(1):1-8, 2001; New York Regional Otitis Project: Observation Option Toolkit for Acute Otitis Media. State of New York, Department of Health, Publication #4894, March 2002; and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 113(5):1451-1465, 2004.

In choosing antimicrobial therapy for AOM, amoxicillin is the antibiotic of choice even though a large percentage of S. pneumoniae are resistant. The mechanism of resistance is via a penicillin-binding protein that may be overcome by “high-dose” amoxicillin at 80 to 90 mg/kg/d in two divided doses. Even though half of all H. influenzae and all of M. catarrhalis are β-lactamase positive, more of these infections clear spontaneously than infections with S. pneumoniae. In patients with severe illness or recurrent AOM, a broader antibiotic should be used such as amoxicillin–clavulanate, a third-generation cephalosporin, or azithromycin in a penicillin-allergic patient. The length of treatment has traditionally been 10 days, but newer studies conclude that 5 days of treatment may be sufficient for older children. Intramuscular ceftriaxone may also be used if the patient cannot tolerate oral antibiotics or has failed initial treatment.

If a perforation of the TM exists or a draining tympanostomy tube is present, only a topical antimicrobial agent is necessary. Possible choices include ofloxacin or ciprofloxacin with dexamethasone. Decongestants, antihistamines, and oral steroids have not shown any clinical benefit and should not be recommended for AOM treatment.

Referral to an otolaryngologist should be considered if the child has had AOM four times in 6 months or six times in 1 year, there is worsening of symptoms despite antibiotic therapy, or there is any complication of AOM. Tympanostomy tubes may be considered for recurrent AOM because they have been shown to decrease the number of episodes of AOM per year.

Otitis Media with Effusion Treatment

The management of children with OME has trended toward “watchful waiting.” Antibiotic therapy is not effective for long-term treatment of OME. Furthermore, most cases (75%-90%) of OME resolve spontaneously within 3 months. In a healthy child with persistent OME and normal hearing and language testing results, the period of watchful waiting may continue with primary care visits every 3 months to follow the effusion and assess for developmental difficulties.

Referral to an otolaryngologist should occur when OME is associated with hearing or language delay or there are physical changes to the TM such as retraction pockets. The primary surgery is tympanostomy tube placement, although adenoidectomy with myringotomy may be considered for children older than age 4 years as a second surgery. Data regarding beneficial outcomes for tympanostomy tube placement to treat OME are lacking but have shown that tube presence does decrease effusions and raise hearing levels. It has been clearly shown, though, that using early tympanostomy tubes to treat OME does not improve long-term developmental outcomes at 6 years and 9 to 11 years.

A link between allergic rhinitis and OME makes physiologic sense but has not proven true in research studies. As with AOM, antihistamines and decongestants have not shown benefit in treating or preventing OME and may cause harm in children; these agents should not be prescribed for children with OME.