Acute Otitis Media

Acute otitis media (AOM) is one of the most common infectious diseases of childhood. The peak incidence is between age 6-18 months. An estimated 60% of children are diagnosed with AOM by the time they are one year old. Exclusive breastfeeding is a protective factor.

In young children, the eustachian tube is shorter, floppier, straighter, and more horizontal than in older children. These anatomical differences mean that when a viral process increases mucus production in the nasopharynx and creates inflammation, fluid can accumulate more easily behind the tympanic membrane (TM). Bacteria within the nasopharynx can reflux into the middle-ear space and progress to AOM. As children grow older, the eustachian tube becomes more slanted and drainage is more effective.

• Otitis media specifies inflammation of the mucoperiosteal lining of the middle ear.

• Acute otitis media (AOM) describes the rapid onset of signs and symptoms of infection within the middle ear.

• Otitis media with effusion indicates inflammation in the middle ear where fluid has collected. Persistent effusion can lead to hearing loss and speech delay in children.

Risk Factors

Risk factors that predispose to the development of AOM include the following:

• young age (<18 months)

• exposure to secondhand smoke

• preterm birth

• day care attendance

• congenital facial or nasal abnormalities

• siblings in the home

• supine feeding position

• allergic rhinitis

• male sex

Etiology

Both bacteria and viruses have been implicated in AOM, and frequently both can be isolated from middle-ear fluid. The most commonly isolated bacterial pathogens include Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis. Widespread use of pneumococcal conjugate vaccines (PCVs) has significantly reduced the overall incidence of AOM and the proportion of AOM attributable to S. pneumoniae, specifically PCV serotypes.

Examination of the Tympanic Membrane

Accurate diagnosis of AOM in infants and young children can be challenging. Experts agree that pneumatic otoscopy is the best tool to diagnose AOM and differentiate it from other conditions. A normal tympanic membrane should be translucent and mobile, with several recognizable landmarks. These landmarks include the manubrium of the malleus and the pars flaccida.

In AOM, the TM appears bulging and opaque, and has limited mobility. The TM can also appear red or yellow. If pressure behind the TM builds up, the TM can perforate and otorrhea may occur.

(Source: The Diagnosis and Management of Acute Otitis Media. Pediatrics 2013.)

Management

• Previously healthy children aged 2 years and older with AOM who are afebrile and do not have ear pain can be observed with close follow-up, and acetaminophen and ibuprofen can be used for management of otalgia.

• Infants younger than 6 months who are diagnosed with AOM should be examined for serious bacterial infection and receive antibiotics.

• Children older than 6 months with ear pain or fever (>39 °C or 102.2 °F) and visible changes consistent with AOM should receive antibiotics. Children younger than 2 years with bilateral AOM should also receive antibiotics regardless of symptoms. Because antibiotics may not have an immediate effect on pain, over-the-counter analgesics, including acetaminophen and ibuprofen, should be given for relief.

Antibiotic Treatment

High-dose amoxicillin is the first-line antibiotic treatment for AOM. Amoxicillin is inexpensive, safe, and a narrow-spectrum antibiotic that covers the main pathogens associated with AOM. Treatment with narrow-spectrum antibiotics for this common childhood infection is a key component of antibiotic stewardship, along with attention to treatment duration (≤10 days). A shorter antibiotic course (7 days) may be equally effective in children older than 2 years.

Amoxicillin-clavulanate should be prescribed for AOM in the following patients:

• children who do not respond to narrow-spectrum antibiotics (in an effort to cover beta-lactamase-producing organisms such as H. influenzae and M. catarrhalis)

• children who have received amoxicillin in the preceding 30 days (due to concerns for antibiotic resistance)

• children who have concurrent conjunctivitis (suggestive of H. influenzae)

Cephalosporins are an alternative initial antibiotic for AOM, depending on the child’s exposure and allergy history. Children who are allergic to penicillin should be treated with a cephalosporin. However, U.S. surveillance data suggest that S. pneumoniae may be more susceptible to amoxicillin than to cefuroxime.

Macrolides should be avoided due to the increased resistance to these drugs in S. pneumoniae.

Treatment duration: Although data are limited regarding the optimal duration of therapy for AOM, a 10-day course of antibiotics is recommended in children younger than 2 years. A shorter, 7-day course of antibiotics appears to be as effective as a 10-day course in children ages 2 to 5 years with mild or moderate AOM. Older children without severe symptoms can be treated with a 7-day course.

Delayed treatment of AOM can be considered in children aged 6 months to 2 years who have unilateral AOM without otorrhea and in children older than 2 years who have bilateral or unilateral AOM without otorrhea.

Recurrent Acute Otitis Media

Recurrent AOM is defined as three episodes in 6 months or at least four episodes in 12 months with a least one episode within the preceding 6 months. Recurrent AOM is often an indication for tympanostomy-tube placement. In a recent randomized controlled trial, rates of recurrent AOM did not differ significantly during a 2-year follow-up period between children aged 6 to 35 months who received tympanostomy tubes and those who received medical management with antibiotics.

Follow-Up

Although some pediatricians provide a follow-up visit at 10-14 days after treatment of infection, limited scientific evidence supports this practice. Most children (60%-70%) have persistent middle-ear effusion 2 weeks after resolution of AOM that generally resolves several months after antibiotic treatment.