Dr. Joel Schwab

Acute otitis media (AOM) is defined as an inflammatory process of the middle ear associated with an effusion.  It is the most common indication for antibiotic therapy in infants and children and almost all children will have one episode by 7 years of age. AOM is an unusual finding in older children and adults. The highest incidence is between 6-13 months of age during the winter season. AOM represents one of the most frequent reasons  for visits to the pediatrician and an estimated expenditure of 3-4 billion dollars/year in the United States. In the past 20 years, there has been three times the number of visits to pediatrician's offices for ear infections. The placement of ventilating tubes into the middle ear is the second most frequently performed surgical procedure in the United States behind circumcision. 
The introduction of Prevnar has resulted in a decrease incidence of AOM

Risk factors

1. Attendance at daycare because of increased exposure to viral illnesses, allergens, and many children.
2. Exposure to smoke and allergens
3. First episode before 6 months of age -may be related to anatomical abnormalities or minor immunologic deficiency. The infant may not have developed protection against common pathogens.
4. Family history
5. not having been breast fed- three months of nursing needed to be protective
6. Anatomical variations- cleft palate, Eustachian tube abnormalities, nasopharyngeal tumors, Down Syndrome
7. Altered immune system- HIV, immune suppression secondary to drugs, IgA deficiency, Kartagener's syndrome 
8. Native Americans and Eskimos 
9. Males 
10. Whites> Blacks
11. Allergic rhinitis
12. Bottle propping

1. Normal Eustachian tube functions
1. Equalize pressure between the middle ear and atmosphere-middle ear pressure slightly negative normally
2. protect the middle ear from nasopharyngeal secretions and sounds
3. drainage of secretions from the middle ear into the nasopharynx.
2. Eustachian tube obstruction leads to negative pressure within the middle ear and transudation of capillary fluid into the space.  Obstruction may be due to intrinsic narrowing most commonly with inflammation secondary to infection or allergy. There may be functional obstruction because in infants the supporting structures of the Eustachian tube are not well developed. Extrinsic obstruction may be due to tumors or enlarged lymphoid tissue. Increased negative pressure within the middle ear may lead to "sucking" of pathogens into the space. 
3. Eustachian tube in infants is shorter and at a greater angle than in older children
4. Supportive structures of the Eustachian tube may be underdeveloped and this allows for obstruction and inability of the tube to close at rest.
5. Viral infections, especially RSV and Influenza, may increase the vulnerability to AOM due to obstruction secondary to inflammatory changes.

1. Streptococcus pneumoniae-35-40%- The least likely to resolve spontaneously. The highest incidence of antibiotic resistance is in daycare attendees and those with prior exposure to antibiotics within the last 1-3 months.
2. non-typable Hemophilus influenza- 20-25% - may be associated with conjunctivitis-often beta lactamase producers. Frequently will resolve without antibiotic treatment.
3. Moraxella catarrhalis- 5-20% High rate of spontaneous cure. Usually beta lactamase resistant
4. Group A beta hemolytic strep- Streptococcus pyogenes- 2-3%
5. Staphylococcus aureus and Mycoplasma are unusual pathogens. 
6. Viral- <10%. The incidence may be higher if PCR were done on all specimens.  Often associated with bacterial infections. The presence of viruses may promote bacterial suprainfection, impair Eustachian tube function, and destroy normal epithelial cell barriers. 
7. Sterile middle ear fluid may result from prior antibiotic treatment, Mycoplasma or Chlamydia infections, anaerobes and improper collection of specimens. Also, there may be inflammatory products present such as cytokines and leukotrienes causing the changes in the middle ear space. 
8. Nasopharyngeal cultures are not indicated. They are and not specific for middle ear pathogens.
9. Newborns- increased incidence of Group B strep and gram negative organisms.

1. Often there is a history of a preceding URI.  There may be fever, irritability, ear pulling,, vomiting, diarrhea, and pain on swallowing. 
2. The older child will complain of ear pain and the younger child may awake at night with some discomfort.
3. Otorrhea- spontaneous rupture of the tympanic membrane
4. Decreased hearing
5. Vertigo, nystagmus, tinnitus, and facial paralysis are unusual presenting symptoms.
6. Eye drainage- infections secondary to H. influenza non-typable are often associated with conjunctivitis

1. Over diagnosis secondary to relying on redness, not using pneumatic otoscope, relying on past history, parental pressure, and rechecking too soon after treatment.
2. Pneumatic otoscopic examination is the most reliable tool to diagnose AOM. It is 95% sensitive and 80% specific. Must establish a tight seal and remove cerumen. Need to evaluate color, mobility, and translucency. 
3. Assessment may be hindered by the presence of cerumen, a poor light source, failure to establish a tight seal, mistaking the canal wall for the drum, and narrow canals
4. Redness of the tympanic membrane may be associated with URIs, crying, sneezing, and following cerumen removal.
5. Tympanometry- Useful for teaching and confirming presence of fluid that you diagnose with pneumatic otoscope. Better negative predicative value. 50% of abnormal tympanograms will have normal ears. Majority of normal tympanograms will have normal ears.
6. Tympanocentesis- 
7.      a. useful to relieve pain 
8.      b. in infants, immunodeficient children, and treatment failures a means to obtain organism for culture and sensitivity.

1. Greater than 60% will resolve spontaneously within 10 days but there is no clinical means to distinguish those that need to be treated. In patients older than 6 months without severe symptoms, observation for 48-72 hours is an option.  Relief of pain symptoms should be instituted.  If ymptoms are not better, antibiotics should be started.
2. Amoxicillin is still the first drug of choice and the initial dosage should be 80 to 90 mg./kg/day.  Amoxicillin has excellent middle ear penetration and even with some penicillin resistance, levels may be high enough to kill many bacteria. It is 85-94% effective, tastes good, is inexpensive, has a narrow spectrum of activity, and has a good safety record. 
3.  If the child is not clinically improved on antibioitcs within 48 to 72, recheck the child because there may be a poor response to Amoxicillin.  This occurs in 10% of cases and more frequently when viruses are present  Alternative treatment should be effective against drug resistant Streptococcal pneumonia and beta-lactamase producing organisms. This would include amoxicillin-clavulanate (Augmentin), PO cefuroxime (Ceftin) Cefpodoxime (Vantin) , Cefuxime (Supra), or IM ceftriaxone. The effectiveness of the newer Macrolides for treatment failures has not been established.
4. If there is no response after initiating second line antibiotics, 3 daily IM injections of Ceftriaxone or Clindamycin po have been tried.  It is important to remember that Clindmycin is not effective against beta lactamase producing organisms. Tympanocentesis should be considered to recover an organism. 
5. There is an increased incidence of drug resistance in daycare attendees, recent users of antibiotics, and patients on prophylactic antibiotics. Often penicillin resistant pneumococci will also be resistant to trimethoprim/sulfisoxazole, erythromycin, and cephalosporins.
6. Antibiotic choice must take in consideration cost, compliance and convenience of dosing schedule, taste, and bacterial resistance in the community or region. 
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9. Symptomatic otitis media greater than 2 weeks after completion of therapy should be considered to be a new pathogen and Amoxacillin may be started. 
10. Duration of treatment is variable and data not conclusive whether 5, 7, or 10 days is necessary.
11. Rechecking schedule is also very variable. Effusion may be present in 60% at 2 weeks, 50% at 4 weeks, 20% at 8 weeks and 15% at 90 days. Children who are asymptomatic should be checked in 3-6 weeks and try to coordinate with their regular scheduled appointments. Should recheck earlier if the child has had frequent recurrences and has recently been treated with an antibiotic.
12. Adjunctive therapy- "Caine" drops, analgesics, heating pad, warm oil. Most studies have shown that antihistamines and decongestants do not facilitate cure nor decrease the incidence of developing OME. 
13. Instructions to parents
1. when to follow-up,
2. directions on how to give the medicine including the importance to complete the entire prescription, 
3. Tell parents that the medicine will not help URI symptoms, 
4. signs that the medicine is not working and any complications that they should notify you about. 
5. Tell the family that pain may persist for up to 24 hours after starting treatment.
14. Influenza vaccine- if infant had many bouts the previous year, may consider vaccine to decrease the incidence of viral illness.
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16. Xylitol, a sugar substitute, has been shown to inhibit the growth of pneumococcus. Study of 5 year olds who chewed gum containing xylitol, had a decreased incidence of AOM.
17. Prophylaxis- use of prophylactic antibiotics may decrease the frequency of AOM. Data for appropriate dosage and timing is not available. Studies have demonstrated that prophylaxis is a good as ventilating tubes in preventing AOM. May induce increase of resistant organisms and some studies have shown no benefit. Amoxicillin and sulfasoxazole recommended if you choose to use prophylaxis.
18. If the child presents with otorrhea, treatment is the same as AOM without perforation, but need to reassure parents that resolution doesn't differ and there are no long term complications. 
19. Studies have shown that parental satisfaction is not dependent on getting a prescription for antibiotics

1. Hearing Loss- usually conductive and temporary. There have been rare cases of sensorineural hearing loss. If have adhesion of drum, tympanosclerosis, or ossicle changes, may have permanent loss of hearing. 
2. Perforation- May be associated with AOM. Use same antibiotics as without perforation. Some recommend antibiotic/corticosteroid drops to prevent external otitis. Perforations usually heal by themselves. If there is a chronic perforation, may need surgical repair but this is uncommon.
3. Cholesteotoma- presence of keratinized material in the middle ear. There is an odorous chronic drainage. There may be bony destruction and invasion of the cranium.
4. Mastoiditis- With most cases of AOM, there will be inflammation of the mastoid air cell. This will resolve with treatment of the AOM. May develop periostitis of the mastoid and have the ear pushed out and redness and tenderness over the mastoid. Myringotomy and IV antibiotics usually necessary. If an abscess develops in the subperiostal tissue, surgery may be required. 
5. Intracranial abscesses
6. Sinus thrombosis
7. Facial nerve paralysis 

1. Definition- The presence of fluid in the middle ear without signs or symptoms of infection. In some instances, aspiration may yield the presence of bacteria. 
2. Because of association with hearing loss and concern of this relationship to learning, speech, and other developmental abnormalities, physicians are anxious to treat OME. 
3. Diagnosis-
1. may be incidental finding 
2. seen following treatment of AOM
3. present with decreased hearing, "discomfort", or behavioral changes. 
4. Pneumatic otoscope is recommended for assessing the middle ear. Examination will have decreased mobility of TM, yellow-orange fluid, may have air fluid level, and drum may appear thickened. Hearing evaluation may be used in diagnostic evaluation.
4. Natural history- most of the cases of OME will resolve spontaneously 
5. Complications 
6.      a. high frequnecy hearing loss
7.      b. decreasd expressive language skills
8.      c. decreased attention span
9.      d. difficulty discriminating sounds
10. Symptoms of hearing deficit may include slow development of speech, inattentiveness, less responsiveness, television is loud, telephone hearing diminished,
11. Therapeutic Interventions 1-3 year olds -US Agency on Health Care Policy and Research
1. Observation with interval rechecks of the status of the effusion
2. Treatment with antibiotics. Studies have shown a slight advantage in resolution of the fluid with antibiotic treatment.
3. Environmental risk factor control counseling
4. After 6 weeks, hearing evaluation is an option. 
5. After 3 months of effusion, hearing test should be performed and if there is significant (>20 decibel) bilateral hearing loss, antibiotic treatment or bilateral myringotomy tubes are options and environmental control counseling should be performed.( smoking, daycare attendance) Also evaluate speech and language development.
6. At 4-6 months, if there is significant bilateral hearing loss, bilateral myringotomy tube placement should be performed.
12. There is no role in the treatment of OME for Antihistamines/decongestants, adenoidectomy, nor tonsillectomy. The use of steroids in combination with antibiotics has been shown to be successful in eliminating fluid in various clinical trials and additional studies are being performed presently.
13. Adenoidectomy may be beneficial in older children with OME

1. Acute otitis media: management and surveillance in an era of pneumococcal resistance- a report from the Drug resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatric Infectious Disease Journal. January 1999.
2. Berman, Stephen. Otitis Media in Children. NEJM June 8, 1995.
3. Bluestone CD and Klein JO. Consultation with the Specialist: Chronic Suppurative Otitis Media. Pediatrics in Review. 1999; 20:277-279.
4. Daly KA, Hunter LL and Giebink GS. Chronic Otitis Media with Effusion. Pediatrics in Review. 1999; 20:85-94.
5. Dowell SF et al. Otitis Media - Principles of Judicious Use of Antimicrobial Agents. Pediatrics. 1998; 101(1 Suppl.):165-171.
6. Hendley J. Owen. Otitis Media NEJM Vol 347, No. 15 pg1169 October 10,2002
7. The Treatment and Prevention of Recurrent Otitis Media Journal of Clinical Prevention May 2003
8. American Academy of Pediatrics Diagnosis and Management of Acute Otitis Media. Pediatrics May 2004
9. Paradise J. et al. Otitis Media and Tympanostomy Tube Inseition during the first 3 Years of Life: Developmental outcomes at 4 years of Age. Pediatrics 112(2) 265-277 2003
10. American Academy of Pediatrics Clinical Practice Guidelines. Otitis Media with Effusion.  Pediatrics May 2004
11. Paradise J. et al. Developmental Outcomes after Early or Delayed Insertion of Tympanostomy Tubes.  NEJM 353;6 August 11, 2005
    
12. Paradise J. and Bluestone C. Tympanostomy Tubes: A Contemporary Guide to Judicious Use. Pediatrics in Review February 2005
13. Stenstrom R et al. Hearing Thresholds and Tympanic Membrane Sequelae in Children Managed Medically or Surgically for Otitis Media With Effusiion. Arch Pediatr Adolesc Med Dec 2005
14. BermanS. Long-term Sequelae of Ventilating Tubes Arch Pediatr Adolesc Med Dec 2005
15. Paradise J. et al.  Tympanosotomy Tubes and Developmental Outcome 9-11 Years Later.  NEJM Jan 18, 2007
16. Roberts J. etal. Otitis Media in Early Childhood and Its Relationship to Later Verbal and Academic Performance.  Pediatarics Sept 1986
17. Rover M. et al. Antibiotics for Acute Otitis Media: Meta-analysis .  Lancet October 2006
18. Feldman H. and Paradise J.  OME and Child Development. Rethinking Management.  Contemporary Pediatrics.  May 2009