Otitis Media
Brenda Liz Natal, MD, Clinical Assistant Instructor and Staff Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate, Brooklyn
Jennifer H Chao, MD, FAAP, Clinical Assistant Professor of Pediatric Emergency Medicine, University Hospital of Brooklyn; Attending Physician, Pediatric Emergency Department, Kings County Hospital, Brooklyn
Updated: Nov 2, 2009
Introduction
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. Clinicians often overdiagnose acute otitis media.
Distinguishing between acute otitis media (AOM) and otitis media with effusion (OME) is important. Otitis media with effusion is more common than acute otitis media. When otitis media with effusion is mistaken for acute otitis media, antibiotics may be prescribed unnecessarily. Otitis media with effusion is fluid in the middle ear without signs or symptoms of infection. Otitis media with effusion 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 acute otitis media is defined as 3 episodes 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 obstruction of the eustachian tubes. Normally, the middle ear mucosa absorbs air in the middle ear. If this air is not replaced because of obstruction of the eustachian tube, a negative pressure is generated, which pulls interstitial fluid into the tube and creates a serous effusion. This effusion of the middle ear provides a fertile media for microbial growth. If growth is rapid, a middle ear infection develops.
Frequency
United States
Acute otitis media is the most frequent diagnosis made by pediatricians, second only to the common cold. Two thirds of all American children have had at least one episode of AOM prior to 1 year of age, and 80% have had one by 3 years of age.1 Despite advances in pubic health and medical care, middle ear infections are still prevalent around the world, and the incidence in the United States has actually increased over the past 10-20 years. AOM is the most common indication for antimicrobial therapy in children in the United States.2,3
In 2006, 9 million children aged 0-17 years were reported to have an ear infection or AOM.4 Of those, 8 million children reported visiting a physician or obtaining a prescription drug to treat the condition.4 As such, the diagnosis and management of AOM has a significant impact on the health of children, the direct cost of health care, and the overall use of antibacterial agents.
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 middle ear effusion (MEE) develops. Chronic MEE may lead to hearing deficits and speech delay.
After an episode of acute otitis media (AOM), as many as 45% of children have persistent effusion at 1 month, but this number decreases to 10% after 3 months.
Most spontaneous perforations eventually heal, but some persist. Cholesteatoma formation with destruction of the ossicles is a serious but infrequent complication.
Frequent recurrences of AOM are relatively common.
AOM is not considered a major source of bacteremia or meningeal seeding, but local brain abscess and mastoiditis are potential sequela, demonstrating that it is possible for AOM to extend.
Race
Otitis media is more frequent in certain racial groups (eg, Inuit and American Indians); this is likely due to anatomic differences in the eustachian tube.
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 infections occur in all age groups, but they are considerably more common in children, particularly those between ages 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, Down syndrome) 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
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. History alone is a poor predictor of acute otitis media, especially in young children.
Accompanying or precedent upper respiratory infection (URI) symptoms (very common)
Earache/fullness
Decreased hearing
Fever (not required for the diagnosis)
Otorrhea
Infants may be asymptomatic or irritable.
Infants may present with pulling/tugging of the ear.
Physical
If the ear canal is clean and if the patient is cooperative, physical examination is generally easy. If the ear 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.
Remove cerumen and other debris from the ear canal, as necessary, to allow clear visualization of the entire tympanic membrane.
Irrigation is useful, as it may soften and dislodge cerumen or any foreign bodies so that they may be removed more easily.
A curette or suction may also be used.
Patients may require referral to an otolaryngologist 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 or injury to the canal.
Visualization of the tympanic membrane with identification of a middle ear effusion (MEE) and inflammatory changes is necessary to establish the diagnosis of acute otitis media (AOM).
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.
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 Media file 3.
Bulging of the tympanic membrane is the most sensitive sign 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. If difficult to determine, acoustic reflectometry or tympanometry may be helpful.
Injection of the tympanic membrane is common in crying infants and with fever, this must be distinguished from the injection due to inflammation associated with AOM.
A history suggestive of AOM and an ear canal full of purulent exudate is generally considered sufficient to diagnosis AOM with perforation.
Blisters on the tympanic membrane may be present (bullous myringitis).
Movement of the tragus should be painless in AOM. If pain is present, suspect that a foreign body is in the ear canal or that the patient has otitis externa.
The association between bacterial conjunctivitis and AOM is well described, thus any patient with purulent conjunctival exudate should receive thorough examination of the tympanic membranes.
Sinusitis and purulent rhinitis frequently accompany AOM in children and infants.
Causes
Anatomic and immunologic factors in the presence of acute URI are the main causes of acute otitis media (AOM).
Pneumococcus species, Haemophilus influenzae (untypeable), and Moraxella species are the bacteria most commonly involved in AOM.
Various viruses, of which the most frequent are Rhinovirus and respiratory syncytial virus (RSV), are often involved in AOM.
Bullous myringitis was initially believed to be associated with Mycoplasma pneumoniae but now is described as merely an acute otitis media with blisters within the substance of the eardrum.
Sterile effusions occur in approximately 20% of cases studied.
Risk factors for acute 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:
Age
Race
History of seasonal allergies
Craniofacial abnormalities
Gastroesophageal reflux
Presence of adenoids
Genetic predisposition
Environmental risk factors:
Frequent upper airway infections
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.
Helicobacter pylori has recently been studied and found in middle ear, tonsillar, and adenoid tissues in patients with otitis media with effusion (OME), indicating a possible role in pathogenesis of OME.5
Differential Diagnoses
Bell Palsy
Mastoiditis
Dental pain
Middle Ear, Otitis Media With Effusion
Dysbarism
Otitis Externa
Foreign Bodies, Ear
Pharyngitis
Herpes Zoster Oticus
Sinusitis
Labyrinthitis
Upper Respiratory Tract Infection
Other Problems to Be Considered
Coexistent conjunctivitis
Acute hearing loss
Tympanosclerosis
Erythema caused by crying
Pain referred from the teeth or jaw
Cavernous sinus thrombosis
Cholesteatoma
Workup
Laboratory Studies
No definitive laboratory examination exists for acute otitis media.
In the event that a tympanocentesis is performed, a sample of the effusion should be sent for culture and sensitivity.
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
Insufflation, tympanometry, and acoustic reflexometry are helpful to identify the presence or absence of middle ear effusion (MEE).
Of these, insufflation is the only one commonly used in the ED setting.
Tympanometry and acoustic reflexometry 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, myringotomy, or both may be appropriate to delineate the etiology of acute otitis media in an immunocompromised patient, a patient with mastoiditis, a patient with persistent fever in the face of antibiotic therapy, or a patient with intractable pain.
If acute otitis media is present in infants younger than 2-3 months, some authors recommend tympanocentesis.
These procedures often are performed by the ear, nose, and throat (ENT) consultant.
Treatment
Emergency Department Care
According to American Academy of Pediatrics (AAP) and American Academy of Family Physicians (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. 6
Diagnostic certainty is based on all 3 of the following criteria: acute onset, middle ear effusion (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.
Diagnosis: The definition of acute otitis media (AOM) is relatively uniform; however, the diagnosis is not always as clear. It is this uncertainty in diagnosis which may lead to overdiagnosis and unnecessary antibiotic use or to underdiagnosis and an increase in complications.
Overdiagnosis of acute otitis media is frequently a result of all of the following:
Difficulty in differentiating AOM from otitis media with effusion (OME)
Difficulty in confirming middle ear effusion
Poor compliance with guidelines for diagnosis (Diagnosis of AOM meets all 3 of the criteria: rapid onset, presence of MEE, and signs and symptoms of middle ear inflammation.)
Several studies have demonstrated the difficulty and inconsistency with which practitioners diagnose acute otitis media.7,8 In a study of inter-rater agreement of AOM in children, Blomgren et al noted a substantial discrepancy concerning practitioner impressions of the tympanic membrane. The clinicians agreed only on 64% of the diagnoses of AOM. The use of a pneumatic otoscopy and tympanometry reduces the number of acute otitis media diagnoses by greater than 30%, suggesting that acute otitis media is misdiagnosed often.9
Treatment recommendations are as follows:
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.
For an observation option to be considered, the parent or caregiver must be able to communicate with the clinician and have access to follow-up care whenever problems ensue or symptoms worsen.
Pain management is an important part of treating AOM. Appropriate analgesics should be offered.
If prescribed antibiotics, children younger than 2 years old and those aged 2-5 years with severe disease should receive 10-days of therapy. For those who are 6 years old and older with mild to moderate disease, 5-7 days is appropriate.
Studies in the ED setting have shown that the observation option is both feasible and well accepted.10,11
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.12
Criteria for Initial Antibacterial Agent Treatment or Observation in Children With Acute Otitis Media2
Age Certain Diagnosis Uncertain Diagnosis
<6 mo Antibacterial therapy Antibacterial therapy
6 mo?2 y Antibacterial therapy Antibacterial therapy if severe illness; observation option* if nonsevere illness
>2 y Antibacterial therapy if severe illness; observation option* if nonsevere illness Observation option*
*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Nonsevere illness is mild otalgia and fever less than 39?C in the past 24 hours. Severe illness is moderate-to-severe otalgia or fever greater than or equal to 39?C. A certain diagnosis of acute otitis media meets all 3 criteria: (1) rapid onset, (2) signs of middle ear effusion (MEE), and (3) signs and symptoms of middle-ear inflammation. 2
Consultations
In general, patients with acute otitis media seen in the ED should be referred to a primary care provider for follow-up care.
Patients discharged with or without antibiotic 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 48-72 hours of treatment should be reevaluated.
Patients with persistent symptoms or recurrent acute otitis media (AOM) should be referred to an otorhinolaryngologist for evaluation and possible tympanocentesis.
Medication
Studies have shown that antibiotics provide little benefit beyond placebo in mild cases of acute otitis media (AOM).
Infants with frequent recurrences may be considered for daily antibiotic prophylaxis with sulfamethoxazole or amoxicillin for a period of several months. However, the decrease in frequency of recurrent episodes is small to none.13,14
The potential consequences of excessive antibiotic use are also well known, and newer recommendations are that antibiotic prophylaxis for AOM should be avoided whenever possible.
The management of AOM should always include assessment of pain and fever. Antipyretics and analgesics may be necessary and should be prescribed liberally. Steroids, decongestants, and antihistamines are not effective in the treatment of AOM, and they may cause complications.
Several complimentary and/or alternative medicine (CAM) therapies, such as homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements, have been used by parents/caregivers for the treatment of AOM. The preferred therapy is largely dependent on cultural background and/or practices. Data supporting complimentary and alternative therapies are limited and controversial. Currently, there are no recommendations for the use of CAM for the treatment of AOM.2
If antibiotic therapy is chosen, the AAP and FAAP recommend that 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, otherwise, a 5- to 7-day course is appropriate.
Routine use of the conjugated heptavalent pneumococcal vaccine (PCV 7) in children younger than 2 years may have changed the microbiology of AOM in vaccinees, by increasing the proportion of gram-negative bacteria as a cause; in which case, an antibiotic with beta-lactamase activity may be preferable. Currently though, the recommendations for antibiotics remain unchanged.15
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.
When prescribing antibiotics to the pediatric population, one also has to consider the probability of noncompliance to therapy. In this age group, the palatability of a drug may influence adherence to treatment. If prescribing cephalosporins, consider the use of cefdinir (Omnicef) as it has a more accepted taste when compared with the other recommended cephalosporins (eg, cefuroxime).16
Topical quinolones are the preferred agents for the treatment of AOM in children with tympanostomy tubes (AOMT) and/or perforations. The treatment options for AOMT, as discussed in a clinical review by Schmelzle et al include systemic or topical antibiotics. Topical treatment with fluoroquinolones is superior than systemic antibiotics and results in less antibiotic resistance and fewer adverse effects (ototoxicity) than other treatments.17
Topical aminoglycosides should be avoided and not used to treat the draining ear because of potential ototoxicity.17
Addition of dexamethasone to a topical antibiotic may decrease the length of time necessary for middle ear drainage when compared with a topical antibiotic alone. The evidence for superior outcomes with the addition of steroids is lacking strength, and the addition of the steroids to the management exacerbates overall treatment costs; and this may lead to nonadherence to treatment.17
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Cefdinir (Omnicef)
Used to treat acute bacterial otitis media. Classified as a third-generation cephalosporin and inhibits mucopeptide synthesis in the bacterial cell wall. Typically bactericidal, depending on organism susceptibility, dose, and serum or tissue concentrations.
Dosing
Adult
300 mg PO q12h for 5-10 d
Alternative: 600 mg PO qd for 10 d
Pediatric
<6 months: Not established
6 months to 13 years: 7 mg/kg PO q12h or 14 mg/kg PO qd; not to exceed 600 mg/d
>13 years: Administer as in adults
Interactions
May increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dosage by 1/2 if creatinine clearance is 10-30 mL/min, and by 3/4 if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Ofloxacin (Floxin)
Inhibits bacterial growth by inhibiting DNA gyrase.
Dosing
Adult
5-10 gtt in affected ear bid
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Failure to respond after treating for 2-3 d may indicate presence of resistant organism or another causative agent
Amoxicillin (Amoxil, Biomox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Inexpensive and effective, even in populations with certain highly resistant bacteria.
Dosing
Adult
250-500 mg PO q8h
Pediatric
80-90 mg/kg/d PO divided q8h for 10 d in younger children and in patients with severe disease
Interactions
Reduces efficacy of oral contraceptives
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; use in Ebstein-Barr viral mononucleosis increases risk of severe rash
Amoxicillin and clavulanate potassium (Augmentin)
Drug combination treats bacteria resistant to beta-lactam antibiotics. For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin and clavulanate ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Dosing
Adult
500-875 mg PO q12h PO or 250-500 mg PO q8h
Pediatric
90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h
Interactions
Coadministration with warfarin or heparin increases risk of bleeding
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, perform cultures to confirm eradication of streptococci
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.
Benzocaine (Americaine, Cylex)
Inhibits neuronal membrane depolarization, blocking nerve impulses. Drops may be used as local anesthetic, with some benefit.
Dosing
Adult
2-3 gtt q4-6h prn
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not intended for use when infection present
Acetaminophen (Tylenol, Tempra, Panadol)
Used worldwide for antipyretic effects and mild analgesic effects. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or with oral anticoagulation. May be used with ibuprofen for additive effects.
Dosing
Adult
650 mg PO q4-6h; not to exceed 4 g/d
Pediatric
15-20 mg/kg/dose q4-6h; not to exceed 2.6 g/d
Interactions
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Contraindications
Documented hypersensitivity; G-6-PD deficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism at various doses; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen contained in many OTC products, and combined use of acetaminophen products may result in cumulative doses exceeding recommended maximum
Ibuprofen (Motrin, Ibuprin, Advil)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Approved for use in children. Available as inexpensive liquid form, allowing for effective dosing in infants.
Dosing
Adult
400-800 mg PO q6-8h for pain or fever; not to exceed 3.2 g/d
Pediatric
10 mg/kg PO (100 mg/5 mL) q6h for pain or fever
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; closely monitor PT (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
At therapeutic doses, can cause renal failure and/or gastric upset (more common in elderly persons but also described in children); caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Follow-up
Further Outpatient Care
Most cases of otitis media are self-limited. If the signs and symptoms are resolved, patients should follow up with their primary care provider in 4-6 weeks to evaluate for persistent otitis media with effusion (OME).
Patients with persistent pain or fever should be reexamined within 72 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.
Deterrence/Prevention
Primary prevention of acute otitis media (AOM) should be tailored to reducing risk factors.
Decrease number of upper respiratory infection by altering childcare center attendance patterns.
Encourage breastfeeding at least for the first 6 months as it decreases the incidence of AOM.
Avoid supine bottle feeding "bottle popping."
Eliminate pacifier use in the second 6 months of life.
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. An osteopathic manipulation technique (ie, Galbreath technique18 ) 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.
Similarly, blowing up balloons is effective in some small children.
Complications
Serous otitis media with effusion (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 the ED. The patient should be referred.
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.
Mastoiditis
There has been concern that lower rates of prescribing antibiotics for AOM may be associated with increased rates of mastoiditis or other rare complications. However, according to a retrospective cohort study in the United Kingdom, where observation is routinely practiced, most children with mastoiditis have no recent history of AOM. Furthermore, the incidence of mastoiditis remained stable between 1990 and 2006, despite a 50% decrease in prescribing antibiotics for AOM during this period.19
The Agency for Health Care Research and Quality evidence report on AOM concluded that mastoiditis is not increased with an initial observation, provided that the children are followed closely and antibacterial therapy is initiated in those who do not improve.2
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.
Cholesteatoma (secondary acquired): This is an epithelial growth that occurs behind the eardrum and is a serious possible sequela of injury to the tympanic membrane.
This injury can be a perforation (mostly, a posterior marginal perforation) resulting as a complication from chronic otitis media or trauma, or it may be due to surgical manipulation of the drum.
The hallmark symptom of a cholesteatoma is painless otorrhea, either unremitting or frequently recurrent.
Overtime, the cholesteatoma increases in size and destroys the delicate middle ear bones. The resulting ossicular problems due to fixation, discontinuity, or absorption can cause a further conductive hearing loss.
Cholesteatoma may also grow to involve the facial nerve causing facial paralysis. In some instances, they can expand up into the brain.
Cholesteatoma is a serious condition and, when diagnosed, requires prompt treatment.
Computed tomography (CT scan) may be helpful in defining the extent of the disease and can act as a roadmap for surgery.
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 72 hours.
Patient Education
Parent education 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 clinician fails to explain the importance of the medication and the need to finish the entire course of therapy.
Therefore, the process and the specific treatment plan must be discussed 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
Medicolegal Pitfalls
Diagnosis and treatment of acute otitis media (AOM) are rare causes of legal problems. However, failure to diagnose meningitis or other invasive disease in a child with associated AOM can lead to inadequate treatment and significant legal problems for the provider.
Do not allow the presence of AOM to deter further diagnostic workup if the patient appears significantly ill.
Failure to recognize contiguous spread to mastoid air cells (mastoiditis) is a pitfall.
http://emedicine.medscape.com/article/764006-print
Brenda Liz Natal, MD, Clinical Assistant Instructor and Staff Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate, Brooklyn
Jennifer H Chao, MD, FAAP, Clinical Assistant Professor of Pediatric Emergency Medicine, University Hospital of Brooklyn; Attending Physician, Pediatric Emergency Department, Kings County Hospital, Brooklyn
Updated: Nov 2, 2009
Introduction
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. Clinicians often overdiagnose acute otitis media.
Distinguishing between acute otitis media (AOM) and otitis media with effusion (OME) is important. Otitis media with effusion is more common than acute otitis media. When otitis media with effusion is mistaken for acute otitis media, antibiotics may be prescribed unnecessarily. Otitis media with effusion is fluid in the middle ear without signs or symptoms of infection. Otitis media with effusion 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 acute otitis media is defined as 3 episodes 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 obstruction of the eustachian tubes. Normally, the middle ear mucosa absorbs air in the middle ear. If this air is not replaced because of obstruction of the eustachian tube, a negative pressure is generated, which pulls interstitial fluid into the tube and creates a serous effusion. This effusion of the middle ear provides a fertile media for microbial growth. If growth is rapid, a middle ear infection develops.
Frequency
United States
Acute otitis media is the most frequent diagnosis made by pediatricians, second only to the common cold. Two thirds of all American children have had at least one episode of AOM prior to 1 year of age, and 80% have had one by 3 years of age.1 Despite advances in pubic health and medical care, middle ear infections are still prevalent around the world, and the incidence in the United States has actually increased over the past 10-20 years. AOM is the most common indication for antimicrobial therapy in children in the United States.2,3
In 2006, 9 million children aged 0-17 years were reported to have an ear infection or AOM.4 Of those, 8 million children reported visiting a physician or obtaining a prescription drug to treat the condition.4 As such, the diagnosis and management of AOM has a significant impact on the health of children, the direct cost of health care, and the overall use of antibacterial agents.
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 middle ear effusion (MEE) develops. Chronic MEE may lead to hearing deficits and speech delay.
After an episode of acute otitis media (AOM), as many as 45% of children have persistent effusion at 1 month, but this number decreases to 10% after 3 months.
Most spontaneous perforations eventually heal, but some persist. Cholesteatoma formation with destruction of the ossicles is a serious but infrequent complication.
Frequent recurrences of AOM are relatively common.
AOM is not considered a major source of bacteremia or meningeal seeding, but local brain abscess and mastoiditis are potential sequela, demonstrating that it is possible for AOM to extend.
Race
Otitis media is more frequent in certain racial groups (eg, Inuit and American Indians); this is likely due to anatomic differences in the eustachian tube.
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 infections occur in all age groups, but they are considerably more common in children, particularly those between ages 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, Down syndrome) 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
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. History alone is a poor predictor of acute otitis media, especially in young children.
Accompanying or precedent upper respiratory infection (URI) symptoms (very common)
Earache/fullness
Decreased hearing
Fever (not required for the diagnosis)
Otorrhea
Infants may be asymptomatic or irritable.
Infants may present with pulling/tugging of the ear.
Physical
If the ear canal is clean and if the patient is cooperative, physical examination is generally easy. If the ear 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.
Remove cerumen and other debris from the ear canal, as necessary, to allow clear visualization of the entire tympanic membrane.
Irrigation is useful, as it may soften and dislodge cerumen or any foreign bodies so that they may be removed more easily.
A curette or suction may also be used.
Patients may require referral to an otolaryngologist 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 or injury to the canal.
Visualization of the tympanic membrane with identification of a middle ear effusion (MEE) and inflammatory changes is necessary to establish the diagnosis of acute otitis media (AOM).
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.
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 Media file 3.
Bulging of the tympanic membrane is the most sensitive sign 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. If difficult to determine, acoustic reflectometry or tympanometry may be helpful.
Injection of the tympanic membrane is common in crying infants and with fever, this must be distinguished from the injection due to inflammation associated with AOM.
A history suggestive of AOM and an ear canal full of purulent exudate is generally considered sufficient to diagnosis AOM with perforation.
Blisters on the tympanic membrane may be present (bullous myringitis).
Movement of the tragus should be painless in AOM. If pain is present, suspect that a foreign body is in the ear canal or that the patient has otitis externa.
The association between bacterial conjunctivitis and AOM is well described, thus any patient with purulent conjunctival exudate should receive thorough examination of the tympanic membranes.
Sinusitis and purulent rhinitis frequently accompany AOM in children and infants.
Causes
Anatomic and immunologic factors in the presence of acute URI are the main causes of acute otitis media (AOM).
Pneumococcus species, Haemophilus influenzae (untypeable), and Moraxella species are the bacteria most commonly involved in AOM.
Various viruses, of which the most frequent are Rhinovirus and respiratory syncytial virus (RSV), are often involved in AOM.
Bullous myringitis was initially believed to be associated with Mycoplasma pneumoniae but now is described as merely an acute otitis media with blisters within the substance of the eardrum.
Sterile effusions occur in approximately 20% of cases studied.
Risk factors for acute 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:
Age
Race
History of seasonal allergies
Craniofacial abnormalities
Gastroesophageal reflux
Presence of adenoids
Genetic predisposition
Environmental risk factors:
Frequent upper airway infections
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.
Helicobacter pylori has recently been studied and found in middle ear, tonsillar, and adenoid tissues in patients with otitis media with effusion (OME), indicating a possible role in pathogenesis of OME.5
Differential Diagnoses
Bell Palsy
Mastoiditis
Dental pain
Middle Ear, Otitis Media With Effusion
Dysbarism
Otitis Externa
Foreign Bodies, Ear
Pharyngitis
Herpes Zoster Oticus
Sinusitis
Labyrinthitis
Upper Respiratory Tract Infection
Other Problems to Be Considered
Coexistent conjunctivitis
Acute hearing loss
Tympanosclerosis
Erythema caused by crying
Pain referred from the teeth or jaw
Cavernous sinus thrombosis
Cholesteatoma
Workup
Laboratory Studies
No definitive laboratory examination exists for acute otitis media.
In the event that a tympanocentesis is performed, a sample of the effusion should be sent for culture and sensitivity.
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
Insufflation, tympanometry, and acoustic reflexometry are helpful to identify the presence or absence of middle ear effusion (MEE).
Of these, insufflation is the only one commonly used in the ED setting.
Tympanometry and acoustic reflexometry 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, myringotomy, or both may be appropriate to delineate the etiology of acute otitis media in an immunocompromised patient, a patient with mastoiditis, a patient with persistent fever in the face of antibiotic therapy, or a patient with intractable pain.
If acute otitis media is present in infants younger than 2-3 months, some authors recommend tympanocentesis.
These procedures often are performed by the ear, nose, and throat (ENT) consultant.
Treatment
Emergency Department Care
According to American Academy of Pediatrics (AAP) and American Academy of Family Physicians (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. 6
Diagnostic certainty is based on all 3 of the following criteria: acute onset, middle ear effusion (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.
Diagnosis: The definition of acute otitis media (AOM) is relatively uniform; however, the diagnosis is not always as clear. It is this uncertainty in diagnosis which may lead to overdiagnosis and unnecessary antibiotic use or to underdiagnosis and an increase in complications.
Overdiagnosis of acute otitis media is frequently a result of all of the following:
Difficulty in differentiating AOM from otitis media with effusion (OME)
Difficulty in confirming middle ear effusion
Poor compliance with guidelines for diagnosis (Diagnosis of AOM meets all 3 of the criteria: rapid onset, presence of MEE, and signs and symptoms of middle ear inflammation.)
Several studies have demonstrated the difficulty and inconsistency with which practitioners diagnose acute otitis media.7,8 In a study of inter-rater agreement of AOM in children, Blomgren et al noted a substantial discrepancy concerning practitioner impressions of the tympanic membrane. The clinicians agreed only on 64% of the diagnoses of AOM. The use of a pneumatic otoscopy and tympanometry reduces the number of acute otitis media diagnoses by greater than 30%, suggesting that acute otitis media is misdiagnosed often.9
Treatment recommendations are as follows:
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.
For an observation option to be considered, the parent or caregiver must be able to communicate with the clinician and have access to follow-up care whenever problems ensue or symptoms worsen.
Pain management is an important part of treating AOM. Appropriate analgesics should be offered.
If prescribed antibiotics, children younger than 2 years old and those aged 2-5 years with severe disease should receive 10-days of therapy. For those who are 6 years old and older with mild to moderate disease, 5-7 days is appropriate.
Studies in the ED setting have shown that the observation option is both feasible and well accepted.10,11
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.12
Criteria for Initial Antibacterial Agent Treatment or Observation in Children With Acute Otitis Media2
Age Certain Diagnosis Uncertain Diagnosis
<6 mo Antibacterial therapy Antibacterial therapy
6 mo?2 y Antibacterial therapy Antibacterial therapy if severe illness; observation option* if nonsevere illness
>2 y Antibacterial therapy if severe illness; observation option* if nonsevere illness Observation option*
*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Nonsevere illness is mild otalgia and fever less than 39?C in the past 24 hours. Severe illness is moderate-to-severe otalgia or fever greater than or equal to 39?C. A certain diagnosis of acute otitis media meets all 3 criteria: (1) rapid onset, (2) signs of middle ear effusion (MEE), and (3) signs and symptoms of middle-ear inflammation. 2
Consultations
In general, patients with acute otitis media seen in the ED should be referred to a primary care provider for follow-up care.
Patients discharged with or without antibiotic 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 48-72 hours of treatment should be reevaluated.
Patients with persistent symptoms or recurrent acute otitis media (AOM) should be referred to an otorhinolaryngologist for evaluation and possible tympanocentesis.
Medication
Studies have shown that antibiotics provide little benefit beyond placebo in mild cases of acute otitis media (AOM).
Infants with frequent recurrences may be considered for daily antibiotic prophylaxis with sulfamethoxazole or amoxicillin for a period of several months. However, the decrease in frequency of recurrent episodes is small to none.13,14
The potential consequences of excessive antibiotic use are also well known, and newer recommendations are that antibiotic prophylaxis for AOM should be avoided whenever possible.
The management of AOM should always include assessment of pain and fever. Antipyretics and analgesics may be necessary and should be prescribed liberally. Steroids, decongestants, and antihistamines are not effective in the treatment of AOM, and they may cause complications.
Several complimentary and/or alternative medicine (CAM) therapies, such as homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements, have been used by parents/caregivers for the treatment of AOM. The preferred therapy is largely dependent on cultural background and/or practices. Data supporting complimentary and alternative therapies are limited and controversial. Currently, there are no recommendations for the use of CAM for the treatment of AOM.2
If antibiotic therapy is chosen, the AAP and FAAP recommend that 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, otherwise, a 5- to 7-day course is appropriate.
Routine use of the conjugated heptavalent pneumococcal vaccine (PCV 7) in children younger than 2 years may have changed the microbiology of AOM in vaccinees, by increasing the proportion of gram-negative bacteria as a cause; in which case, an antibiotic with beta-lactamase activity may be preferable. Currently though, the recommendations for antibiotics remain unchanged.15
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.
When prescribing antibiotics to the pediatric population, one also has to consider the probability of noncompliance to therapy. In this age group, the palatability of a drug may influence adherence to treatment. If prescribing cephalosporins, consider the use of cefdinir (Omnicef) as it has a more accepted taste when compared with the other recommended cephalosporins (eg, cefuroxime).16
Topical quinolones are the preferred agents for the treatment of AOM in children with tympanostomy tubes (AOMT) and/or perforations. The treatment options for AOMT, as discussed in a clinical review by Schmelzle et al include systemic or topical antibiotics. Topical treatment with fluoroquinolones is superior than systemic antibiotics and results in less antibiotic resistance and fewer adverse effects (ototoxicity) than other treatments.17
Topical aminoglycosides should be avoided and not used to treat the draining ear because of potential ototoxicity.17
Addition of dexamethasone to a topical antibiotic may decrease the length of time necessary for middle ear drainage when compared with a topical antibiotic alone. The evidence for superior outcomes with the addition of steroids is lacking strength, and the addition of the steroids to the management exacerbates overall treatment costs; and this may lead to nonadherence to treatment.17
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Cefdinir (Omnicef)
Used to treat acute bacterial otitis media. Classified as a third-generation cephalosporin and inhibits mucopeptide synthesis in the bacterial cell wall. Typically bactericidal, depending on organism susceptibility, dose, and serum or tissue concentrations.
Dosing
Adult
300 mg PO q12h for 5-10 d
Alternative: 600 mg PO qd for 10 d
Pediatric
<6 months: Not established
6 months to 13 years: 7 mg/kg PO q12h or 14 mg/kg PO qd; not to exceed 600 mg/d
>13 years: Administer as in adults
Interactions
May increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dosage by 1/2 if creatinine clearance is 10-30 mL/min, and by 3/4 if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Ofloxacin (Floxin)
Inhibits bacterial growth by inhibiting DNA gyrase.
Dosing
Adult
5-10 gtt in affected ear bid
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Failure to respond after treating for 2-3 d may indicate presence of resistant organism or another causative agent
Amoxicillin (Amoxil, Biomox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Inexpensive and effective, even in populations with certain highly resistant bacteria.
Dosing
Adult
250-500 mg PO q8h
Pediatric
80-90 mg/kg/d PO divided q8h for 10 d in younger children and in patients with severe disease
Interactions
Reduces efficacy of oral contraceptives
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; use in Ebstein-Barr viral mononucleosis increases risk of severe rash
Amoxicillin and clavulanate potassium (Augmentin)
Drug combination treats bacteria resistant to beta-lactam antibiotics. For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin and clavulanate ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Dosing
Adult
500-875 mg PO q12h PO or 250-500 mg PO q8h
Pediatric
90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h
Interactions
Coadministration with warfarin or heparin increases risk of bleeding
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, perform cultures to confirm eradication of streptococci
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.
Benzocaine (Americaine, Cylex)
Inhibits neuronal membrane depolarization, blocking nerve impulses. Drops may be used as local anesthetic, with some benefit.
Dosing
Adult
2-3 gtt q4-6h prn
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not intended for use when infection present
Acetaminophen (Tylenol, Tempra, Panadol)
Used worldwide for antipyretic effects and mild analgesic effects. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or with oral anticoagulation. May be used with ibuprofen for additive effects.
Dosing
Adult
650 mg PO q4-6h; not to exceed 4 g/d
Pediatric
15-20 mg/kg/dose q4-6h; not to exceed 2.6 g/d
Interactions
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Contraindications
Documented hypersensitivity; G-6-PD deficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism at various doses; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen contained in many OTC products, and combined use of acetaminophen products may result in cumulative doses exceeding recommended maximum
Ibuprofen (Motrin, Ibuprin, Advil)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Approved for use in children. Available as inexpensive liquid form, allowing for effective dosing in infants.
Dosing
Adult
400-800 mg PO q6-8h for pain or fever; not to exceed 3.2 g/d
Pediatric
10 mg/kg PO (100 mg/5 mL) q6h for pain or fever
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; closely monitor PT (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
At therapeutic doses, can cause renal failure and/or gastric upset (more common in elderly persons but also described in children); caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Follow-up
Further Outpatient Care
Most cases of otitis media are self-limited. If the signs and symptoms are resolved, patients should follow up with their primary care provider in 4-6 weeks to evaluate for persistent otitis media with effusion (OME).
Patients with persistent pain or fever should be reexamined within 72 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.
Deterrence/Prevention
Primary prevention of acute otitis media (AOM) should be tailored to reducing risk factors.
Decrease number of upper respiratory infection by altering childcare center attendance patterns.
Encourage breastfeeding at least for the first 6 months as it decreases the incidence of AOM.
Avoid supine bottle feeding "bottle popping."
Eliminate pacifier use in the second 6 months of life.
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. An osteopathic manipulation technique (ie, Galbreath technique18 ) 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.
Similarly, blowing up balloons is effective in some small children.
Complications
Serous otitis media with effusion (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 the ED. The patient should be referred.
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.
Mastoiditis
There has been concern that lower rates of prescribing antibiotics for AOM may be associated with increased rates of mastoiditis or other rare complications. However, according to a retrospective cohort study in the United Kingdom, where observation is routinely practiced, most children with mastoiditis have no recent history of AOM. Furthermore, the incidence of mastoiditis remained stable between 1990 and 2006, despite a 50% decrease in prescribing antibiotics for AOM during this period.19
The Agency for Health Care Research and Quality evidence report on AOM concluded that mastoiditis is not increased with an initial observation, provided that the children are followed closely and antibacterial therapy is initiated in those who do not improve.2
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.
Cholesteatoma (secondary acquired): This is an epithelial growth that occurs behind the eardrum and is a serious possible sequela of injury to the tympanic membrane.
This injury can be a perforation (mostly, a posterior marginal perforation) resulting as a complication from chronic otitis media or trauma, or it may be due to surgical manipulation of the drum.
The hallmark symptom of a cholesteatoma is painless otorrhea, either unremitting or frequently recurrent.
Overtime, the cholesteatoma increases in size and destroys the delicate middle ear bones. The resulting ossicular problems due to fixation, discontinuity, or absorption can cause a further conductive hearing loss.
Cholesteatoma may also grow to involve the facial nerve causing facial paralysis. In some instances, they can expand up into the brain.
Cholesteatoma is a serious condition and, when diagnosed, requires prompt treatment.
Computed tomography (CT scan) may be helpful in defining the extent of the disease and can act as a roadmap for surgery.
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 72 hours.
Patient Education
Parent education 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 clinician fails to explain the importance of the medication and the need to finish the entire course of therapy.
Therefore, the process and the specific treatment plan must be discussed 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
Medicolegal Pitfalls
Diagnosis and treatment of acute otitis media (AOM) are rare causes of legal problems. However, failure to diagnose meningitis or other invasive disease in a child with associated AOM can lead to inadequate treatment and significant legal problems for the provider.
Do not allow the presence of AOM to deter further diagnostic workup if the patient appears significantly ill.
Failure to recognize contiguous spread to mastoid air cells (mastoiditis) is a pitfall.
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