Otitis Media Virgil M. Howie Pediatrics in Review 1993;14;320 DOI: 10.1542/pir.

14-8-320

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/14/8/320

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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ARTiCLE

Otitis
Virgil
FOCUS
1.

Media
M. Howie,
QUESTiONS

MD*
fully the landmarks (eg, both ends

How can a firm diagnosis of otitis media with effusion be made? 2. How well do technical procedures support the diagnosis of titis o media? 3. What factors predispose to frequent or recurrent otitis media in children? 4. How is the occurrence of otitis media related to viral infections? 5 How Is therapy of otitis media tailored by Identification of the responsible pathogen?

the malleolus) and their mobility with the pneumatic otoscope. The practicing clinician wants to know whether an upper respiratory infection, oniginally viral in most cases, has become

of be cultured from any perforation or from the lumen of any patent, draining tympanostomy tubes. AseudoP monas infection often complicates

chronic
on other

OME

with

a ventilation
This organism

tube
is

perforation.

Definitions
When the diagnosis of otitis media has been made on the basis of skilled clinical observation and the tympanic membrane is intact, it is practical to assume that an effusion is present. However, this can be confirmed only by recovery of fluid from the middle ear on tympanocentesis on myringotomy. Several methods will confirm the diagnosis of effusion with the indicated accuracy, as generally reported in the literature (Table 1).

complicated by a bacterial infection warranting antibiotic therapy. Factors pnedisposing to OME indude prior OME, propped bottle feedings, exposure to infectious groups (eg, in day care settings), parental smoking, winter season, pnesence of siblings, and family history of frequent OME. Cleft palate and respiratory allergy also are believed to predispose to middle ear disease.

eradicated cleansing ear with

Burow

most effectively by daily of the external and middle suction or by irrigation with
solution and the instillation of

ophthalmic grade that are effective

Ian strain Most of these

antibiotic solutions against the particuof Pseudomonas isolated.

locally instilled anti-

Chronic

Otitis

Media

Acute

through a perand aeration of the middle ear should Mastoiditis may be performed. This procedure will otitis media with effusion (OME) is present as edema and tenderness over identify the offending organism and equating an injected on red ear- the mastoid bone or occult fever in a its sensitivity pattern, so therapy can drum with OME. Acute otitis media patient who has OME resistant to be individualized. In skilled hands, may present with an injected drum, therapy. Labyninthitis is extremely tympanocentesis essentially is combut the critical factor is not drum rare and is manifested by vertigo. If plication-free, with no persistent pencolor but the presence of fluid in the no physical signs of these three con- forations or middle ear damage. middle ear cavity. The drum freditions are found in a carefully examquently is suffused and red when an med patient who has chronic infant or toddler is crying from either perforation and drainage, additional fear or pain during the otoscopic ex- information may be obtained by conTabi I. Accuracy of Tests amination. A bulging eardrum, on sulting with an otolaryngologist or To Confirm Effusion the other hand, usually is regarded as radiologist. The radiologist may be defining acute otitis media (also able to identify an otherwise hidden Tympanocentesis yielding fluid called suppunative or purulent otitis cholesteatoma or occult mastoiditis. middle ear contents: 100% media) with or without symptoms Mastoiditis usually responds to pro(pain, sleeplessness, fever, irritabilAcoustic reflectivity >5 in child longed therapy with an appropriate ity) of systemic illness. 5 mo12y: 96% antibiotic, but may require surgery. Experienced clinicians try to avoid Cholesteatoma requires surgery. The Flat or Jengen type B tympanogram: the red ear error with either tym- persistent perforation of chronic otitis 90% panometry or acoustic reflectivity media requires tympanoplasty after Skilled pneumatic otoscopy: 60% (Table 1) on by careful removal of all the child has matured sufficiently to external ear contents to visualize have adequate resistance to recurrent 90% A common error in the diagnosis

Otitis

Media

Otitis media with persistent perfonation always has occurred more often OME and are seriously ill or immuin medically underserved populations nocompromised on who have an unthan in populations having good ac- satisfactory response to antibiotic cess to care, but it also occurs in rare therapy yields information helpful to instances as a complication of ventithe choice of specific therapy. When lation tube insertion. Rare complicaOME is symptomatic (ie, pain, sleeptions of chronic otitis media include lessness, high fever) after 2 to 3 days mastoiditis, labyninthitis, and cholesof antibiotic therapy, tympanocenteatoma. Cholesteatoma is manifested tesis of the intact drum for culture

biotics should be discontinued after 3 days have passed without middle ear drainage because they would be toxic to the cochlea if instilled in the absence of middle ear inflammation. Tympanocentesis for culture of the middle ear fluid in patients who have

by chronic discharge of sistent perforation.

F
I

OME.
#{149}PrJft!or of Pediatrics, Deportment of Pediatrics, The University of Texas Medical Branch at Galveston, Galveston, 7X.

If therapy with the first antibiotic agent chosen does not stop drainage in 3 to 4 days, draining fluid should

Nonpneumatic otoscopy, audiograms, the report of otalgia, and other methoLc provide useful information but are not diagnostic of otitis media with effusion (OME).

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r
Incidence and Prevalence mal models of otitis media have been developed, and studies involving The axiom that you find what you both viruses and bacteria are helping look for applies to OME. The mcito elucidate the transmission and dence of otitis media appears to inpathogenesis of acute and recurrent crease with the intensity with which It is widely accepted that any the problem is studied and the num- OME. factors in the infants or childs heben of observations made. A study of nedity, early environment, on later the incidence of OME in 173 infants environment that increase the chance included monitoring by tympanomeof contracting entenic or respiratory try on acoustic reflectometry by also increases his on trained technicians, who made an av- viral infections hen risk for all types of OME. erage of 45 house calls during these One prospective study in a nursery infants first 3 years of life. Only in for African-American children 1 child of the 173 followed was no school in North Carolina has shown a clear evidence of middle ear effusion association between viral respiratory found during this period. The percentage of the first 3 years of life spent with OME among these children varied from 0 to 83%, despite the ready availability of physicians, antibiotics, and continued free monitoning of middle ear status at home visits. Most other reported series in this and other countries have estimated the incidence and prevalence of OME primarily from observations in medical settings. In the Scandinavian countries, selected populations were invited for special testing (usually tympanometry) at different consecutive ages so that a cross-section of the same populations at different ages and in different seasons could be viewed. Since the percentage of the surveyed populations responding to these invitations was very high, these estimates of the cross-sectional mcidence and prevalence of OME most likely are reasonably accurate for the countries studied. However, the mcidence and prevalence of OME cannot be generalized from one society to another because of differences in childrearing practices (eg, breastfeeding, day cane, exposure to crowds, parental smoking). In this article, I will address primarily the management and clinical aspects of OME as it occurs in the North American communities with which I am familiar. recently

INFECTIOUS

DISEASE

OUtis

Media

discovered silent OME are asymptomatic) usually involves the systemic administration of an antibiotic. Therapy with antihistamines and decongestants has been shown to be ineffective and sometimes harmful in the management of acute OME. The predominant bacterial pathogens causing

(50% of cases

OME in this country

Streptococcus

continue

to be

pneumoniae (30% to 40%), nontypable Haemophilus in/luenzae (25% to 45%), Moraxella catarrhalis (5% to 20%), and S py-

ogenes

(2%

to 3%);

less

Staphylococcus

aureus and

frequently, gram-neg-

Tympanocentesis of the intact drum for culture and aeration of the middle ear should be performed when symptomatic OME (ie,
pain, sleeplessness, antibiotic therapy. high fever) continues after 2 to 3 days of

and entenic infections and subsequent ative entenic pathogens are involved. episodes of otitis media. The investiRecent studies of acute otitis methat about 40% of gators recorded in detail how the in- dia have shown cidence of OME surged with subjects have an acute viral illness at the same time as the acute OME is increases in the prevalence of viral infection each year. Another group of discovered. The respiratory syncytial virus is most common, although investigators followed in a medical setting a fairly large cohort of white other respiratory and entenic viruses children through the second grade in also are found. school in the Boston area. These inNearly 100% of the Moraxella and about 20% of the Haemophilus onvestigators estimated the number of ganisms isolated by tympanocentesis days spent with OME in these chilare beta-lactamase producers and, dren during the first 3 years of life based on the number of episodes ob- therefore, resistant to beta-lactamserved during medical office visits. containing amoxicillin and ampicilWhen children with less than 30 days lin. In 1992 and 1993, investigators in Virginia, Washington, DC, Kenof OME were compared with those having more than 1 10 days, a signifi- tucky, and Texas reported isolation cant difference in IQ scores, as obof pneumococci from ears with acute tamed by the WISC-R test adminisotitis media that exhibited moderateto-marked penicillin resistance. Some tered at the second-grade level, was found. Another investigator followed of these practitioner-investigators neca group of infants prospectively ommended new combinations of antithrough the first 2 years of life in biotics to address this new developCleveland and reported that the oti- ment. The aminopenicillins tis-pnone infant was very likely to (ampicillin and amoxicillin) always have had bilateral OME at the second have been associated with early andmonth check-up. This association be- frequent relapses, and I do not necPathogenesis tween early onset and more frequent ommend them as first-line therapy in disease has been reported by other the first 24 months of life. SulfonRecent refinements in the detection investigators. The peak prevalence of amides given along with erythromyof viral infections by antigen detecOME is from 6 to 18 months of age. cm or penicillin G or V are less tion, antibody response, and viral nelapsogenic and, thus, are preferisolation, in combination with new able. Scandinavian experience has epidemiologic studies, have led to never favored the aminopenicillins. the recognition that viruses are inManagement In comparing the frequency of otitis volved in about 40% of cases of (eg, 5 or more attacks) in acute otitis media. A number of ani- Management of either acute OME on proneness
Pediatrics in Review VoL 14 No. 8 August 1993 321

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INFECTIOUS DISEASE Otitis Media

patients treated with ampicillin corn- more of the principal pathogens follow-up of antibiotic-treated OME pared with those treated with mixshould be used only when the partic- will show that 20% to 40% of infants tunes, we found a 30% incidence in ular pathogen involved in the ear at and toddlers have persistent middle the former and 6% incidence in the the time is known to be sensitive to ear fluid for periods varying from 6 latter. that antibiotic, as demonstrated by to 12 weeks. Patients should be folTable 2 contains a list of antibiottympanocentesis, culture, and sensilowed until the middle ear is normal ics recently marketed for OME in the tivity testing. Most frequently, we and contains air. OME is accomUSA, with their relative effectiveness will have available antibiotics that panied by up to a 40- to 50-dB against the three most common path- are only 80% effective, and the anti- decrease in hearing acuity (averaging ogens. These culture results came biotics that meet this requirement 25 dB). from tympanocenteses at 2 to 4 days change through time. The medical community varies as on-therapy during antibiotic trials In a paper demonstrating the Pol- to how aggressively and with what over the past 6 years. In 1985, we lyanna effect, one investigator has therapy this condition should be reported similar studies on antibiotics shown that less vigorous evaluation treated. It is fairly well established currently used, but marketed earlier. methods than on-therapy culture (eg, that breast feeding of infants deWe believe that the only way to es- clinical response) are unable to show creases and that attendance at nursery tablish antibiotic efficacy is through significant differences between most schools increases the occurrence of the use of on-therapy cultures of antibiotics without huge numbers of the otitis-pnone condition. However, samples from the diseased site. It is subjects. Antibiotics are evaluated some authorities believe that no penapparent from Table 2 that most of best by their in vivo effectiveness in manent disability comes from months the failures of individual antimicroeliminating organisms judged to be or years of OME and that aggressive bial drugs on therapy are associated pathogenic in causing otitis media. It therapy (such as corticosteroid with only one of the principal patho- would appear that even correction of administration on placement of ventigens. the failure of aminopenicillins against latory tubes) should be reserved for Each antibiotic has its own profile beta-lactamase producers (by addition the worst cases. Others, including of efficacy. Remembering that 50% of clavulanic acid) was followed by myself, believe that diminished hearof H influenzae strains will disappear the development of another form of ing and persistent OME should not after tympanocentesis alone, it is ap- resistance, which appeared in the H be tolerated at any age; we advocate parent that cefprozil, clanithromycin, influenzae organisms we isolated be- the placement of pressure equalizaand amoxicillin (against beta lactatween 1989 and 1991. tion (PE) tubes when OME has permase-positive strains) lack efficacy sisted for 6 to 12 weeks despite two against this organism in children who courses of appropriate antibiotic thenand Prevention have otitis media. In addition, cefix- Management apy. The occurrence of three epiof the Otitis-prone Condition ime failed to eradicate pneumococci sodes of OME in 6 months on four in 12 of 45 patients. My recommenDespite symptomatic control of acute episodes in 12 months also should dation is that antibiotic therapy that infections and production of sterility lead to the placement of PE tubes, misses less than 10% of the known in middle ear fluid, a significant preferably under local anesthesia with number of children, especially inprincipal pathogens is most desirable. appropriate sedation in the outpatient Any antibiotic that misses 30% or fants, remain otitis-prone. Careful setting. Hearing tests in the presence

STREPTOCOCCUS PNEUMONIAE

HAEMOPHILUS INFLUENZAE NUMBER TREATED NUMBER CULTUREPOSITIVEt 5(+)

MOR4Y.ELLA CATARRHALIS NUMBER NUMBER CULTURE-

KNOWN PAThOGEN PERCENT FAILURES

YEARS
ANTIBIOTIC* Amoxicillin** Amoxicillin! clavulanate Cefixime Cefpodoxime Cefpnozil Cefuroxime Clanithromycin Ceftniaxone
*
1

NUMBER STUDIED TREATED

NUMBER CULTUREPOSITIVEt

TREATED

POSITIVEt

1985-1987 1988-1989 1989-1991 1985-1987 1988-1991 1987-1988 1987-1988 1990-1991 1991-1993

administered usually had
were

18 15 27 45 24 13 11 12 24
10 days, except at 2 to 4 days
(-)

1 1 1 12 4 1 0 0 0
ceftriaxone,

8(+) 13(-) 15 28 61 22 14
5

12(+)
St l8 28 15 4 3
5

3(+)
0
2t

18%
3% 18% 14% 15% 32%
5%

15 30
than

0 0 10 4 1 8 1 12 0

20
SO mg/kg of therapy. on day

3 6 1 0 1 3
0 only.

41% 4%

Antibiotics

were
cultures

On-therapy
indicates

p.o. for taken

or nolater

which was given IM 9 days after start

(+)
**

heto-kctamase

positive

Only

amoxiciilin

in vivo growth

indicates heto-kctamase negative (failures)related to heta-lactamase production.

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INFECTIOUS
Otitis
of fluid are expected to show a mod- or who are allergic to one of the enate hearing loss. PE tubes improve other drugs. hearing immediately, and the imTraditionally, adenoidectomy has provement lasts until the tube is ex- been advocated to help prevent recurtnuded on until the next ear infection rent acute otitis media; this has been occurs. Management is designed to shown to be effective in olden age keep the middle ear air-filled with groups, but not in the 6- to 18normal hearing. In 90% of patients month-old infants and toddlers in receiving tubes, ear infections occur whom the incidence of OME is highmuch less frequently following tube est. With general anesthesia and hosplacement than before. Functioning pitalization, this procedure entails PE tubes bypass the eustachian tube greaten risk and expense. Tonsillecto provide middle ear ventilation, but tomy has not been shown to be of do not change the susceptibility to in- any benefit in controlling OME. For fectious agents. When infection oc- procedures that are beyond his on her curs, the etiology is easy to ascertain skills (eg, PE tube insertion, tympaby culturing the fluid draining from noplasty, on adenoidectomy when apthe tubes. pnopniate), the primary care physician can refer the patient to an otolaryngologist. Diagnostic tympanocentesis for identification of resistent pathoSurgical Management gens on relief of severe pain should Prior to the advent of antibiotics, be among the pediatricians skills. myningotomy frequently was used to alleviate pain and drain the middle Prognosis ear cavity when it was filled with With persistent, conscientious pnipurulent material. Effective antibiotic mary medical cane, the outlook for therapy can sterilize the middle ear infants and children who have OME cavity, but middle ear effusion may very good. There are persist in the absence of a middle ear is generally very few persistent perforations, and pathogen. In the 1950s, one investithe incidences of mastoiditis and chogaton reintroduced the insertion of lesteatoma are much lower than prior ventilation tubes through the tymto the modern era. It is hoped that panic membrane to reestablish the with the advent of effective vaccines eardrum as a drum (membrane with against respiratory syncytial virus and air on both sides). When antibiotics some of the other respiratory and enhave not been successful in eliminatthe precursor ing the effusion in OME, the persist- tenic viral pathogens, that commonly lead ent ventilation of the middle ear with viral infections With the various types of Armstrong tubes to OME will be eliminated. has been practiced widely. Their in- better conjugated vaccines against the bacterial invaders, these sertion can be performed as an outpa- common also may be controlled, and the tient procedure with local iontoscourge of recurrent OME may be phonesis anesthesia by using relegated to history, along with poxylocaine and epinephnine after apliomyelitis, measles, mumps, rubella, propriate sedation. We favor this diphtheria, and pertussis. mode of treatment in conjunction with the administration of prophylactic doses of sulfonamide in patients SUGGESTED READING younger than 2 years of age on 20 American Speech-Language-Hearing mg/kg of erythnomycin or amoxicillin Association. Guidelines for screening for in patients who are 2 years on olden hearing impairments and middle ear

DISEASE Media

disorders. ASHA. 1990;32(suppl 2):17-24 Arola M, Ruuskanen 0, Ziegler T, et al. Clinical role of respiratory virus infection acute otitis media. Pediatrics. 1990;86:848855

in

Arola M, Ziegler T, Ruuskanen 0. Respiratory virus infection as a cause of prolonged symptoms in acute otitis media. I Pediatr. 1990116:697-701 Bluestone CD. Modern management of otitis media. Pediatr Clin North Am. 1989;36: 1371-1378 Carlin SA, Marchant CD, Shurin PA, Johnson CE, Super DM, Rehmus JM. Host factors and early therapeutic response in acute otitis media. J Pediatr. 1991;118:178-183 Chonmaitree T, Owen Mi, Howie VM. Respiratory viruses interfere with bacteriologic response to antibiotic in children with acute otitis media. J Infect Dis. 1990;162:546-549 Chonmaitree 1, Owen MJ, Patel JA, Hedgpeth D, Horlick D, Howie VM. Effect of viral respiratory tract infection on outcome of acute otitis media. J Pediatr. 1992;120:856862 Henderson GW, Giebink GS. Otitis media among children in day care: Epidemiology and pathogenesis. Rev Infect Dis. 1986;8: 533-538 Howie VM, Dillard R, Laurence B. In vivo sensitivity test in otitis media: Efficacy of antibiotics. Pediatrics. 1985;75:8-13 Lampe RM, Schwartz RH. Diagnostic value of acoustic reflectometry in children with acute otitis media. Pediatr Infect Dis J. 1989;7: 59-61 Marchant CD, Carlin SA, Johnson CE, Shurin PA. Measuring the comparative efficacy of antibacterial agents for acute otitis media: The pollyanna phenomenon. I Pediatr. 1992;120:72-77 Marchant CD, Shurin PA, Turczyk VA, Wasikowski DE, Tutihasi MA, Kinney SE. Course and outcome of otitis media in early infancy: A prospective study. J Pediatr. 1984; 104:826-831 Paradise JL. Long-term effects of short-term hearing loss-menace or myth?Pediatrics. 1983;71 :647-648 Paradise JL, Rogers KD. On otitis media, child development, and tympanostomy tubes: New answers or old questions? Pediatrics. 1986;77:88-92 Sade J, Luntz M. Adenoidectomy in otitis media. A review. Ann Owl Rhino! Larayngol. 1991;100:226-231 Teele DW, Klein JO, Chase C, Menyuk P. Rosner BA. Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. Greater Boston Otitis Media Study Group. J Infect Dis. 1990;162:685-694

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Otitis Media Virgil M. Howie Pediatrics in Review 1993;14;320 DOI: 10.1542/pir.14-8-320

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