Otitis Media

ETIOLOGY
• Otitis media is suppurative infection of the middle ear cavity.
• Bacteria gain access to the middle ear when the normal
patency of the eustachian tube is blocked by infection,
pharyngitis, or hypertrophied adenoids.
• Air trapped in the middle ear is resorbed, creating negative
pressure in this cavity and facilitating reflux of
nasopharyngeal bacteria.
• Obstructed flow of secretions from the middle ear to the
pharynx combined with bacterial reflux leads to infected
middle ear effusion.
• The common bacterial pathogens are S. pneumoniae,
nontypable H. influenzae, M. catarrhalis, and, less frequently,
group A streptococcus.
• S. pneumoniae that is relatively resistant to penicillin
(minimal inhibitory concentration 0.1 to 1 μg/mL) or
highly resistant to penicillin (minimal inhibitory
concentration >2 μg/mL) is isolated with increasing
frequency from young children, particularly from
children who attend daycare or who have received
antibiotics recently.
• Viruses, including rhinoviruses and RSV, are recovered
alone or as copathogens in 20% to 25% of patients.
EPIDEMIOLOGY
• Diseases of the middle ear account for approximately one third of
office visits to pediatricians.
• The peak incidence of acute otitis media is in the second 6 months of
life.
• By the first birthday, 62% of children experience at least one episode.
• Few first episodes occur after 18 months of age.
• Otitis media is more common in boys and in patients of lower
socioeconomic status.
• There is increased incidence of otitis media among Native Americans
and Alaskan Natives and in certain high-risk populations, such as
children with HIV, cleft palate, and trisomy 21.
• In most of the U.S., otitis media is a seasonal disease with a distinct
peak in January and February, which corresponds to the rhinovirus,
RSV, and influenza seasons. It is less common from July to September.
• The major risk factors for acute otitis media are:
 young age,
 bottle-feeding as opposed to breastfeeding,
 drinking a bottle in bed,
 parental history of ear infection,
 the presence of a sibling in the home (especially a sibling
with a history of ear infection),
 sharing a room with a sibling,
 passive exposure to tobacco smoke from parental smoking,
 and increased exposure to infectious agents (daycare).
• As defined by the presence of six or more
acute otitis media episodes in the first 6 years
of life, at least 12% of children in the general
population have recurrent otitis media and
would be considered otitisprone. Craniofacial
anomalies and immunodeficiencies often are
associated with recurrent otitis media; most
children with recurrent acute otitis media are
otherwise healthy.
CLINICAL MANIFESTATIONS
 In infants, the most frequent symptoms of acute otitis media are
nonspecific and include:
 fever,
 irritability,
 and poor feeding.
 In older children and adolescents, acute otitis media usually is
associated with:
 fever
 and otalgia (acute ear pain).
 Acute otitis media also may present with otorrhea, or ear drainage,
after spontaneous rupture of the tympanic membrane.
 Signs of a common cold, which predisposes to acute otitis media,
are often present.
LABORATORY AND IMAGING STUDIES
• Routine laboratory studies, including complete blood count
and ESR, are not useful in the evaluation of otitis media.
• Tympanometry provides objective acoustic measurements
of the tympanic membrane-middle ear system by reflection
or absorption of sound energy from the external ear duct
as pressure in the duct is varied (just as in pneumatic
otoscopy).
• Measurements of the resulting tympanogram correlate
well with the presence or absence of middle ear effusion.
• Instruments using acoustic reflectometry are available for office
and home use. Use of reflectometry as a screening test for
acute otitis media should be followed by examination with
pneumatic otoscopy when abnormal reflectometry is identified.
• Bacteria recovered from the nasopharynx do not correlate with
bacteria isolated by tympanocentesis.
• Tympanocentesis and culture of the middle ear exudate is not
always necessary, but is required for accurate identification of
bacterial pathogens present in the middle ear and may be
useful in neonates, immunocompromised patients, and
patients not responding to therapy.
DIFFERENTIAL DIAGNOSIS
• Examination of the ears is essential for diagnosis and
should be part of the physical examination of any child
with fever.
• The hallmark of otitis media is the presence of effusion in the middle
ear cavity.
• The presence of an effusion does not define its nature or
potentially infectious etiology, but does define the need
for appropriate diagnosis and therapy.
• Pneumatic otoscopy, using a pneumatic attachment to a
hermetically sealed otoscope, allows evaluation of
ventilation of the middle ear and is a standard for clinical
diagnosis.
• The tympanic membrane of the normal, air-filled middle ear
has much greater compliance than if the middle ear is fluid-
filled.
• With acute otitis media, the tympanic membrane is
characterized by hyperemia, or red color rather than the
normal pearly gray color, but it can be pink, white, or yellow
with a full to bulging position and with poor mobility to
negative and positive pressure.
• The light reflex is lost, and the middle ear structures are
obscured and difficult to distinguish.
• A hole in the tympanic membrane or purulent drainage
confirms perforation.
• Occasionally, bullae are present on the lateral aspect of the
tympanic membrane, which characteristically are associated
with severe ear pain.
• The major difficulty is differentiation of acute
otitis media from otitis media with effusion,
which also is referred to as chronic otitis media.
 Acute otitis media is accompanied by signs of
acute illness, such as fever, pain, and upper
respiratory tract inflammation.
 Otitis media with effusion is the presence of
effusion without any of the other signs and
symptoms.
TREATMENT
• Recommendations for treatment are based on
certainty of diagnosis and severity of illness.
• The recommended first-line therapy for most children with
acute otitis media is amoxicillin (80 to 90 mg/kg/day in two
divided doses).
• Failure of initial therapy with amoxicillin at 3 days
suggests infection with β-lacta-mase-producing H.
influenzae or M. catarrhalis or relatively or highly
resistant S. pneumoniae.
• Recommended next-step treatments include high-dose
amoxicillin-clavulanate (amoxicillin 80 to 90 mg/kg/day),
cefuroxime axetil, cefdinir, or ceftriaxone (50 mg/kg
intramuscularly in one to three daily doses).
• IM ceftriaxone is especially appropriate for children younger
than 3 years old with vomiting that precludes oral
treatment.
• Tympanocentesis may be required for patients
who are difficult to treat or who do not respond
to therapy, but this is not a routine procedure in
most pediatric offices.
• Acetaminophen and ibuprofen are recommended for fever.
• Decongestants or antihistamines are not effective
alone or when combined with antibiotics
COMPLICATIONS

• The complications of otitis media are:

 chronic effusion,
 hearing loss,
 cholesteatoma (masslike keratinized epithelial growth),
 petrositis,
 intracranial extension (brain abscess, subdural empyema, or
venous thrombosis),
 and mastoiditis.
Acute mastoiditis
• is a suppurative complication of otitis media with inflammation
and potential destruction of the mastoid airspaces.
• The disease progresses from a periostitis to an osteitis with
mastoid abscess formation.
• Posterior auricular tenderness and swelling and erythema, in
addition to the signs of otitis media, are present.
• The pinna is displaced downward and outward.
• Radiographs or CT scan of the mastoid reveals clouding of the air
cells, demineralization, or bone destruction.
• The bacteria that cause acute otitis media also are those
responsible for acute mastoiditis.
• Treatment includes systemic antibiotics and drainage if the
disease has progressed to abscess formation.
PROGNOSIS
• Otitis media with effusion is the most frequent sequela of acute otitis media
and occurs most frequently in the first 2 years of life.
• Persistent middle ear effusion may last for many weeks or months in some
children.
• The condition should be sought at all well-child examinations of young
children.
• Conductive hearing loss should be assumed to be present with persistent
middle ear effusion; the loss is mild to moderate and often is transient or
fluctuating.
• Glue ear is used to describe the presence of a viscous, gluelike effusion that is
produced when the chronically inflamed middle ear mucosa produces an
excess of mucus that, because of absence of the normal clearance of the
middle ear cavity, is retained for prolonged periods.
• Normal tympanograms after 1 month of
treatment obviate the need for further follow-
up. In children at developmental risk or with
frequent episodes of recurrent acute otitis
media, 3 months of persistent effusion with
significant bilateral hearing loss is a
reasonable indicator of need for intervention
with insertion of pressure equalization tubes.
PREVENTION
• Parents should be encouraged to continue exclusive
breastfeeding as long as possible and should be cautioned
about the risks of "bottle-propping" and of children taking
a bottle to bed. The home should be a smoke-free
environment. Children identified at high-risk for recurrent
acute otitis media are candidates for prolonged courses of
antimicrobial prophylaxis, which can reduce recurrences
significantly. Amoxicillin (20 to 30 mg/kg/day) or
sulfisoxazole (50 mg/kg/day) given once daily at bedtime
for 3 to 6 months or longer is used for prophylaxis.
• Pneumococcal vaccine and influenza vaccine
may reduce marginally the incidence of otitis
media. The conjugate S. pneumoniae vaccine
seems to reduce pneumococcal otitis media
caused by vaccine serotypes by half, all
pneumococcal otitis media by one third, and
all otitis media by 6%. Annual immunization
against influenza virus may be helpful in high-
risk children.