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acute otitis media (AOM)

Etiology: 1) eustachian tube dysfunction a) developmental changes in the eustachian tube - persistent collapse due to abnormal eustachian tube compliance - delayed innervation of the tensor veli palatini muscle which opens & closes the eustachian tube b) infection from the nasopharynx ascending through the eustachian tube 2) infection a) acute otitis media generally occurs 5-7 days after an upper respiratory tract infection b) viral role suspected, but not proven - influenza vaccination prevents ~50% of acute otitis media in healthy children [27] c) bacteria - Streptococcus pneumoniae (46%) - Haemophilus influenzae (34%) - Moraxella catarrhalis - Streptococcus pyogenes - anaerobes - enteric gram-negative bacilli 3) in adults, occurs in association with: a) severe diabetes mellitus b) cystic fibrosis c) common variable immunodeficency [28] Risk factors: 1) bottle feeding, especially supine 2) upper respiratory tract infection 3) genetic factors 4) parental smoking 5) allergies 6) craniofacial anomalies, for example cleft palate 7) previous episode of otitis media Epidemiology: 1) peak incidence between ages 6 months to 24 months - 50% of infants [24] 2) occurs more frequently in males 3) Native Americans at higher risk Pathology: - middle ear inflammation - middle ear effusion Clinical manifestations: 1) earache 2) ear-pulling 3) diminished hearing 4) fever 5) loss of appetite 6) irritability 7) vomiting 8) vertigo 9) tinnitus 10) otorrhea is a sign of tympanic membrane perforation 11) otoscopy: tympanic membrane [22] a) erythema b) bulging c) limited mobility 12) children may have one or more signs suggestive of complex partial seizures [12] Laboratory: - complete blood count & blood culture if indicated Differential diagnosis: 1) myringitis - red tympanic membrane without exudate 2) referred pain from a) pharyngitis b) tonsillitis c) temporomandibular joint (TMJ) syndrome 3) teething Complications: 1) mastoiditis 2) meningitis 3) brain abscess 4) middle ear effusion can cause conductive hearing loss [21] 5) tympanic membrane perforation [2] 6) upper respiratory tract infections more common among infants with acute otitis media [24] Management: 1) systemic antibiotics a) 48 hour 'wait & see' prior to antibiotics appropriate [15] - observation recommended for uncomplicated acute otitis media [2] b) indications: [6,9,10] - all infants < 6 months of age [9] - < 2 years of age with - signs of middle-ear effusion [9] - signs & symptoms of middle ear inflammation [9] - children > 2 years of age with [9] - signs of middle-ear effusion [21] - signs & symptoms of middle ear inflammation - severe ear pain &/or fever > 102 degrees F - consider watchful waiting for children with mild to moderate symptoms & unilateral disease [19] - treatment of children < 3 years of age with Augmentin superior to watchful waiting [17] - antibiotic use increases risk of recurrence [16] - benefit of antibiotics in adults is unclear [2] - most cases in adults resolve spontaneously [2] c) agents - amoxicillin 250 mg TID; 40 mg/kg/day divided TID (1st line) - penicillin or amoxicillin as effective & associated with fewer adverse events than amoxicillin clavulanate or cephalosporins in children [26] - Augmentin (1st line) - 250 mg TID; 40 mg/kg/day divided TID - 90 mg/kg/day divided BID [3] - recurrent or persistent or - antibiotics within 3 months & attends day care or < 3 years of age - 10 days of therapy better than 5 days in children 6 months-2 years of age [25] - Cefaclor 250 mg TID; 40 mg/kg/day divided TID - Cefuroxime axetil (Ceftin) - 125 mg BID, children under 2 years - 250 mg BID, children over 2 years - Bactrim, 8 mg/kg/day trimethoprim, 40 mg/kg/day sulfamethoxazole divided BID - Pediazole: erythromycin 50 mg/kg/day & sulfisoxazole 150 mg/kg/day divided QID - Cefixime (Suprax) 8 mg/kg/day QD - Cefprozil (Cefzil) 30 mg/kg/day divided BID - azithromycin (Zithromax) [4] - 10 mg/kg QD for 3 days - 30 mg/kg once d) duration of therapy [6] - 10 days if < 2 years of age [25] - 5 days may be effective is > 2 years of age e) number needed to treat (NNT) - 20 to reduce pain at 2-7 days [23] - 33 to reduce 1 tympanic membrane rupture - 11 to prevent contralateral acute otitis media f) number needed to harm - 14 to precipitate 1 case of diarrhea [23] 2) topical antibiotics (in children with tympanostomy tube) - Ciprodex otic 4 drops BID for 7 days superior to ofloxacin otic 5 drops BID for 10 days 3) symptomatic relief a) anhydrous glycerol eardrops b) acetaminophen 4) systemic decongestants & expectorants 5) antihistamines not recommended for treatment of acute otitis media because they decrease ciliary action needed for clearance of middle ear secretions through the eustachian tube 6) Surgery a) tympanocentesis b) myringotomy c) adenoidectomy NOT helpful [8,13] 7) patient education [14] a) avoid second hand smoke b) avoid barotrauma, i.e. flying, scuba diving c) avoid feeding infants in supine position d) 80% of patients get better without antibiotics [6] e) exposure to other children during treatment may increase risk of treatment failure [25] 8) follow-up in 4-6 weeks 9) prophylaxis - influenza vaccination prevents ~50% of acute otitis media in healthy children [27] - amoxicillin 20 mg/kg/day QD or BID during winter months for patients with 3 episodes in 6 months or 4 episodes in 1 year [14]

Related

chronic otitis media middle ear effusion (otitis media with effusion)

General

otitis media

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 78-79
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2022 - Coco A, Vernacchio L, Horst M, Anderson A. Management of acute otitis media after publication of the 2004 AAP and AAFP clinical practice guideline. Pediatrics. 2010 Feb;125(2):214-20 PMID: 20100746
  3. Prescriber's Letter 8(11):63 2001
  4. Prescriber's Letter 9(2):8 2002
  5. Journal Watch 22(16):130, 2002 - Turner D et al Acute otitis media in infants younger than two months of age: microbiology, clinical presentation and therapeutic approach. Pediatr Infect Dis J 21:669, 2002 PMID: 12237601
  6. Prescriber's Letter 10(7):38 2003
  7. Journal Watch 24(4):35, 2004 - Roland PS et al Topical ciprofloxacin/dexamethasone otic suspension is superior to ofloxacin otic solution in the treatment of children with acute otitis media with otorrhea through tympanostomy tubes. Pediatrics 113:e40, 2004 PMID: 14702493 http://pediatrics.aappublications.org/cgi/content/full/113/1/e40
  8. Journal Watch 24(8):65, 2004 Koivunen P et al Adenoidectomy versus chemoprophylaxis and placebo for recurrent acute otitis media in children aged under 2 years: randomised controlled trial. BMJ 328:487, 2004 PMID: 14769785 http://bmj.bmjjournals.com/cgi/content/full/328/7438/487
  9. Journal Watch 24(11):92, 2004 American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004 May;113(5):1451-65. PMID: 15121972 http://pediatrics.aappublications.org/cgi/content/full/113/5/1451 (Guideline withdrawn 02/2009)
  10. Journal Watch 25(14):109, 2005 McCormick DP, Chonmaitree T, Pittman C, Saeed K, Friedman NR, Uchida T, Baldwin CD. Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics. 2005 Jun;115(6):1455-65. PMID: 15930204
  11. Guidelines for the Treatment of Otitis Media Prescriber's Letter 11(5):29 2004 Detail-Document#: 200505 (subscription needed) http://www.prescribersletter.com
  12. Journal Watch 25(16):132, 2005 Soman TB, Krishnamoorthy KS. Paroxysmal non-epileptic events resembling seizures in children with otitis media. Clin Pediatr (Phila). 2005 Jun;44(5):437-41. PMID: 15965551
  13. Journal Watch 25(16):132, 2005 Hammaren-Malmi S, Saxen H, Tarkkanen J, Mattila PS. Adenoidectomy does not significantly reduce the incidence of otitis media in conjunction with the insertion of tympanostomy tubes in children who are younger than 4 years: a randomized trial. Pediatrics. 2005 Jul;116(1):185-9. PMID: 15995051
  14. Merestein D et al, An assessment of the shared-decision model in parents of children with acute otitis media. Pediatrics 2005; 116:1267 PMID: 16322146
  15. Spiro DM et al, Wait-and-see prescription for the treatment of acute otitis media: A randomized controlled trial. JAMA 2006, 296:1235 http://jama.amsa-assn.org/cgi/content/full/296/10/1235 - Little P Delayed prescribing - A sensible approach to the management of acute otitis media. JAMA 2006, 296:1290 http://jama.amsa-assn.org/cgi/content/full/296/10/1235
  16. Bezakova N et al Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: Survey of trial participants. BMJ 2009 Jun 30; 338:b2525. PMID: 19567910
  17. Hoberman A et al Treatment of Acute Otitis Media in Children under 2 Years of Age N Engl J Med 2011; 364:105-115January 13, 2011 PMID: 21226576 http://www.nejm.org/doi/full/10.1056/NEJMoa0912254 - Tahtinen PA et al A Placebo-Controlled Trial of Antimicrobial Treatment for Acute Otitis Media N Engl J Med 2011; 364:116-126January 13, 2011 PMID: 21226577 http://www.nejm.org/doi/full/10.1056/NEJMoa1007174 - Klein JO Is Acute Otitis Media a Treatable Disease? N Engl J Med 2011; 364:168-169January 13, 2011 PMID: 21226583 http://www.nejm.org/doi/full/10.1056/NEJMe1009121
  18. Lieberthal AS et al for the American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. Feb 25, 2013 PMID: 23439909 http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.full.pdf+html
  19. Hersh AL et al Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics. Pediatrics. Nov 8, 2013 PMID: 24249823 http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-3260.full.pdf+html
  20. Powers JH. Diagnosis and treatment of acute otitis media: evaluating the evidence. Infect Dis Clin North Am. 2007 Jun;21(2):409-26 PMID: 17561076
  21. Tapiainen T et al. Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: A placebo- controlled trial. JAMA Pediatr 2014 May 5 PMID: 24797294 http://archpedi.jamanetwork.com/article.aspx?articleid=1867334
  22. Shaikh N et al. Videos in clinical medicine. Diagnosing otitis media-- otoscopy and cerumen removal. N Engl J Med 2010 May 21; 362:e62 PMID: 20484393
  23. The NNT: Antibiotics for Acute Otitis Media http://www.thennt.com/nnt/antibiotics-for-otitis-media/ - Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013 Jan 31;1:CD000219. PMID: 23440776
  24. Adler C, Sadoughi S, Sofair S Upper Respiratory Infection, Acute Otitis Media Common in Infancy Physician's First Watch, March 28, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Chonmaitree T, Trujillo R, Jennings K et al Acute Otitis Media and Other Complications of Viral Respiratory Infection. Pediatrics Mar 2016, DOI: 10.1542/peds.2015-3555 http://pediatrics.aappublications.org/content/early/recent
  25. Hoberman A, Paradise JL, Rockette HE et al Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med 2016; 375:2446-2456. December 22, 2016 PMID: 28002709 http://www.nejm.org/doi/full/10.1056/NEJMoa1606043
  26. Gerber JS, Ross RK, Bryan M et al Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA. 2017;318(23):2325-2336 PMID: 29260224 https://jamanetwork.com/journals/jama/article-abstract/2666503
  27. Manzoli L, Schioppa F, Boccia A, Villari P. The efficacy of influenza vaccine for healthy children: a meta-analysis evaluating potential sources of variation in efficacy estimates including study quality. Pediatr Infect Dis J. 2007 Feb;26(2):97-106. PMID: 17259870
  28. NEJM Knowledge+