A 15-month-old boy is brought by both parents to his pediatrician with a 2-day history of fever, irritability, and frequent tugging of his left ear. This was preceded by a 1-week history of nasal congestion, cough, and rhinorrhea. On otoscopy, his left tympanic membrane (TM) appears erythematous, cloudy, bulging, and exudative (Figure 22-1). His left TM fails to move on pneumatic otoscopy. The physician diagnoses acute otitis media and decides with the parents to prescribe a 10-day course of amoxicillin; the child recovers uneventfully.
Acute otitis media in the left ear of a 15-month-old patient with marked erythema and bulging of the tympanic membrane. The malleus and light reflex are not visible. (Used with permission from William Clark, MD.)
In follow-up 2 months later, the child appears healthy and is meeting all his developmental milestones. On otoscopic examination, air–fluid levels are seen in the right ear (Figure 22-2). The physician explains the diagnosis of otitis media with effusion to the parents and arranges follow-up. Three months later the effusion is completely resolved.
Otitis media with effusion (OME) in the right ear. Note multiple air–fluid levels in this slightly retracted, translucent, nonerythematous tympanic membrane. (Used with permission from Frank Miller, MD.)
Acute otitis media (AOM) is the most common diagnosis for acute office visits for children.1 AOM is characterized by middle-ear effusion in a patient with signs and symptoms of acute illness (e.g., fever, irritability, otalgia). Otitis media with effusion (OME) is a disorder characterized by fluid in the middle ear in a patient without signs and symptoms of acute ear infection; it is also very common in childhood.
AOM accounted for $5 billion of the total national health expenditure in 2000; more than 40 percent was incurred for children between 1 and 3 years of age.1
It is estimated that 60 percent to 80 percent of children in the US develop AOM by 1 year of age and that 80 percent to 90 percent develop AOM by 2 to 3 years of age.2,3
The highest incidence occurs between 6 and 24 months of age.2,3
AOM is the most common reason for outpatient antibiotic treatment in the US.4 A national survey in 1992 revealed that 30 percent of all antibiotics prescribed for children younger than age 18 years was for treatment of AOM.5
OME is diagnosed in 2.2 million children yearly in the US.6
Approximately 90 percent of children (80% of individual ears) have OME at some time before school age, most often between ages 6 months and 4 years.6
The combined direct and indirect health care costs of OME amount to $4 billion annually.6
Etiology and Pathophysiology
AOM is often preceded by upper respiratory symptoms such as cough and rhinorrhea.
Pathogenesis of AOM includes:7
Eustachian tube dysfunction (usually a result of an upper respiratory infection) and subsequent tube obstruction.
Increased negative pressure in the middle ear.
Accumulation of middle-ear fluid.
Suppuration (that leads to clinical signs of AOM).
Most common pathogens in the US and United Kingdom are:8,9
Viruses account for 16 percent of cases. Respiratory syncytial viruses, rhinoviruses, influenza viruses, and adenoviruses have been the most common isolated viruses.10
OME most commonly follows AOM; it may also occur spontaneously.
Fluid limits sound conduction through the ossicles and results in decreased hearing.
Reasons for the persistence of fluid in otitis media remain unclear, although potential etiologies include allergies, biofilm, and physiologic features.
“Glue ear” refers to extremely viscous mucoid material within the middle ear and is a distinct subtype of OME.
The most important risk factors for AOM include young age and attendance at a child care center.
Other risk factors include:11
History of enlarged adenoids, tonsillitis, or asthma.
Multiple previous episodes.
History of ear infections in parents or siblings.
Use of a soother or pacifier.
Second-hand smoke is a risk factor when parents smoke at home.
Risk factors for OME include age 6 years or younger, large number of siblings, low socioeconomic group, frequent upper respiratory tract infection, tobacco exposure, daycare attendance, and bottle feeding.12
To diagnose AOM, the clinician should confirm a bulging TM using otoscopy, verify the acuteness of symptoms, and identify objective signs of middle-ear effusion (MEE) using pneumatic otoscopy and/or tympanometry.6,13 SOR C
Elements of the definition of AOM are:6,13
Signs or symptoms of middle-ear inflammation as indicated by:
Moderate to severe bulging of the TM or new otorrhea not attributable to acute otitis externa.
Mild bulging of the TM and recent onset (≤48 hours) of ear pain or intense erythema of the TM (Figure 22-1) in contrast to the normal TM (Figure 22-5).
The presence of MEE. Although MEE is often presumed by bulging of the TM (Figure 22-1) or air–fluid level behind the TM (Figure 22-2), guidelines stress the use of objective measures of confirming MEE such as:
Limited or absent mobility of the TM established by pneumatic otoscopy—The TM does not move during air insufflation; often initially seen as retraction of the TM (Figures 22-3 and 22-4).
Tympanometry demonstrating reduced or flat waveforms.
Otitis media with effusion in the left ear showing retraction of the tympanic membrane (TM) and straightening of the handle of the malleus as the retraction pulls the bone upward. (Used with permission from Glen Medellin, MD.)
Early acute otitis media at the stage of eustachian tube obstruction. Note the slight retraction of the tympanic membrane (TM), the more horizontal position of the malleus, and the prominence of the lateral process. (Used with permission from William Clark, MD.)
The most common symptom, present in more than half of patients, is mild hearing loss. This is usually identified when parents express concern regarding their child’s behavior, performance at school, or language development.12
Absence of signs and symptoms of acute illness assists in differentiating OME from AOM.
Common otoscopic findings include:
Air–fluid level or bubble (Figure 22-2).
Cloudy TM (Figures 22-4 and 22-6) in contrast to the normal TM (Figure 22-5).
Redness of the TM is present in approximately 5 percent of ears with OME.
Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME.14 SOR A
Impaired mobility of the TM is the hallmark of MEE.
According to a metaanalysis, impaired mobility on pneumatic otoscopy has a pooled sensitivity of 94 percent and specificity of 80 percent, and positive likelihood ratio of 4.7 and negative likelihood ratio of 0.075.14
Acute otitis media, stage of suppuration. Note presence of purulent exudate behind the tympanic membrane (TM), the outward bulging of the TM, prominence of the posterosuperior portion of the drum, and generalized TM edema. The white area is tympanosclerosis from a previous infection. (Used with permission from William Clark, MD.)
A. Normal right tympanic membrane with comparison using. B. Normal bony landmarks of the inner ear. The ossicles were removed in this dissection. (Used with permission from William Clark, MD.)
Laboratory Tests and Imaging
Because AOM and OME are clinical diagnoses, diagnostic testing has a limited role. When clinical presentation and physical examination (including otoscopy) do not establish the diagnosis, the following can be used as adjunctive techniques:
Tympanometry—This procedure records compliance of the TM by measuring reflected sound. AOM and OME will plot as a reduced or flat waveform. This technique requires patient cooperation but provides more objective data.
Acoustic reflectometry—This procedure, very similar to tympanometry, measures sound reflectivity from the middle ear. With this test, the clinician is able to distinguish air- or fluid-filled space without requiring an airtight seal of the ear canal.
Middle ear aspiration—For patients with AOM, aspiration may be warranted if patient is toxic, immunocompromised, or has failed prior courses of antibiotics.
The key differentiating feature between AOM and OME is the absence of signs and symptoms of acute illness in OME (e.g., fever, irritability, otalgia). Otoscopic findings may be similar. Other clinical entities that can be confused with AOM and OME include:
Otitis externa—Otitis externa presents with otalgia, otorrhea and mild hearing loss, all of which can be present in AOM. Tragal pain on physical exam and signs of external canal inflammation on otoscopic exam differentiate it from AOM. Careful ear irrigation if tolerated may be helpful to visualize the TM to differentiate otitis externa from AOM (see Chapter 21, Otitis Externa).
Otitic barotrauma—This often presents with severe otalgia. Key historical features include recent air travel, scuba diving, or ear trauma, preceded by an upper respiratory infection.
Cholesteatoma—Unlike AOM, this is a clinically silent disease in its initial stages. Presence of white keratin debris in the middle ear cavity (on otoscopy) is diagnostic (Figures 22-7 and 22-8).
Foreign body—A foreign body may present with otalgia. Otoscopy reveals presence of foreign body (see Chapter 24, Ear—Foreign Body).
Bullous myringitis—Bullous myringitis is often associated with viral or mycoplasma infection as well as usual AOM pathogens; in approximately 1/3 of patients, there is a component of sensorineural hearing loss. Otoscopy shows serous-filled bulla on the surface of the TM (Figure 22-9). Patients present with severe otalgia.
Chronic suppurative otitis media (CSOM)—Otoscopy shows TM perforation and otorrhea; history reveals a chronically draining ear and recurrent middle-ear infections with or without hearing loss.
Referred otalgia—This is rare in children and in cases of bilateral otalgia. Should be considered in cases of otalgia that do not fit clinical features of AOM. Referred pain is usually from other head and neck structures (e.g., teeth, jaw, cervical spine, lymph and salivary glands, nose and sinuses, tonsils, tongue, pharynx, meninges).
Mastoiditis—Mastoiditis can be differentiated from simple AOM by the presence of increasing pain, erythema, and tenderness over mastoid bone in a patient with AOM who has not been treated with antibiotics or recurrence of mastoid pain and tenderness in patients treated with antibiotics. Recurrence or persistence of fever as well as progressive otorrhea are other historical clues. The mastoid swelling can cause the pinna to protrude further than normal (Figure 22-10).
Traumatic perforation of the TM (Figure 22-11)—A hole in the TM is seen without purulent drainage.
Cholesteatoma. (Used with permission from Vladimir Zlinsky, MD, in Roy F. Sullivan, PhD. Audiology Forum: Video Otoscopy, www.rcsullivan.com.)
Primary acquired cholesteatoma with debris removed from the attic retraction pocket. (Used with permission from William Clark, MD.)
Bullous myringitis can be differentiated from otitis media with effusion by identifying serous-filled bulla on the surface of the tympanic membrane (TM). (Used with permission from Vladimir Zlinsky, MD, in Roy F. Sullivan, PhD. Audiology Forum: Video Otoscopy, www.rcsullivan.com.)
A. Mastoiditis in a young boy with recurrent otitis media. Note the erythema and swelling behind the ear. The ear is sticking out more than the other side. B. Surgical drainage was performed. (Used with permission from William Clark, MD.)
Traumatic perforation of the left tympanic membrane. (Used with permission from William Clark, MD.)
Management of OME primarily consists of watchful waiting. Most cases resolve spontaneously within 3 months; only 5 percent to 10 percent last 1 year or longer. Treatment depends on duration and associated conditions. The following options should be considered:
Document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME.6 SOR C
Distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk.6 SOR C Risk factors for developmental difficulties include:
Permanent hearing loss independent of OME.
Suspected or diagnosed speech and language delay or disorder.
Autism-spectrum disorder and other pervasive developmental disorders.
Syndromes (e.g., Down syndrome) or craniofacial disorders that include cognitive, speech, and language delays.
Blindness or uncorrectable visual impairment.
Cleft palate with or without associated syndrome.
Manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown).6 SOR B
Hearing testing is recommended when OME persists for 3 months or longer or at any time if language delay, learning problems, or significant hearing loss is suspected in a child with OME.6 SOR B
Autoinflation methods that attempt reopening the eustachian tube by increasing intranasal pressure may have some short-term benefits for restoring hearing in patients with OME. These methods include forced exhalation through closed nose and mouth (which may be impractical for young children), inflatable intranasal balloon, or an anesthetic mask. Acute side effects are rare and the cost is not prohibitive; however, long-term adverse effects are unknown.12 SOR B
Oral acetaminophen (paracetamol) and ibuprofen can reduce earache when given with antibiotics.16 Anesthetic ear drops (e.g., amethocaine, benzocaine, or lidocaine) can be effective in reducing pain among children ages 3 to 18 years with AOM when used with oral analgesics.17 SOR B
Antibiotics seem to be most beneficial in children ages 6 to 23 months with bilateral AOM, otorrhea, or severe signs and symptoms (e.g., moderate to severe otalgia, persistent otalgia greater than 48 hours, temperature 39 °C [102.2 °F] or higher). For most other children with mild, unilateral disease, an observational policy based on shared decision-making seems justified.13,15,18 SOR B
Antibiotics can lead to more rapid reduction in symptoms of AOM, but increase the risk of adverse effects, including diarrhea, vomiting, and rash.16 SOR B
Antibiotics seem to reduce pain at 2 to 7 days, and may prevent development of contralateral AOM, but increase the risks of adverse effects compared with placebo.14
There is insufficient effectiveness data regarding which antibiotic regimen is better than another.14,16
Antibiotics found to be effective in AOM include amoxicillin, amoxicillin-clavulanic acid, and cephalosporins. Amoxicillin is a good first-line treatment because it is inexpensive and children tolerate the bubblegum taste well.13
For children who have been treated with amoxicillin within the past 30 days, or with superimposed conjunctivitis suggestive of H. influenzae, or who previously failed amoxicillin in the setting of recurrent AOM, adding beta-lactamase coverage is recommended (e.g., amoxicillin-clavulanate). Alternative treatment for non-anaphylactic penicillin-allergic patients include 2nd-generation (e.g., cefuroxime) and 3rd generation cephalosporins (e.g., cefdinir, cefpodoxime, or ceftriaxone).13
Longer (8- to 10-day) courses of antibiotics reduce short-term treatment failure but have no long-term benefits compared with shorter regimens (5-day courses).16,19
An observational approach substantially reduces unnecessary use of antibiotics in children with AOM and may be an alternative to routine use of antimicrobials for treatment of such children.20
Immediate antibiotic treatment (i.e., given at initial consultation) may reduce the duration of symptoms of AOM, but increases the risk of vomiting, diarrhea, and rash compared with delayed treatment (i.e., given after 72 hours).16 SOR B
Treatment of AOM with decongestants and antihistamines is not recommended.21 SOR B
Antihistamines and decongestants are not effective for OME.6 Furthermore, they may cause harm in children younger than 5 years.22 SOR A
Antimicrobials, oral corticosteroids, and intranasal steroids are not recommended for OME.6,23 SOR A
Complementary and Alternative Therapy
Refer to a specialist (otolaryngologist, audiologist, or speech-language pathologist) if there is:6 SOR C
Tympanostomy tubes (or grommets) for children with recurrent AOM (3 or more episodes of AOM in 6 months, or 4 or more AOM in 1 year) diminish AOM recurrences for up to six months. Because long-term effectiveness is uncertain, clinicians should weigh this immediate benefit alongside potential adverse outcomes from the surgery.25 SOR B
Insertion of tympanostomy tubes in young children with persistent middle-ear infection does not improve cognitive development, language acquisition, or speech development compared with waiting 6 to 9 months for the effusion to resolve before placing the tubes.26 Moreover, delayed insertion of tubes helps children avoid getting tubes altogether and does not result in worse developmental outcomes.27 SOR A
When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure; adenoidectomy should not be performed unless a distinct indication exists (e.g., nasal obstruction or chronic adenoiditis).6 SOR B
Repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME.6 SOR B
At best, the previously licensed PCV7 was only marginally effective in preventing AOM as an infant vaccine. However, this 6 percent to 7 percent reduction in incidence of AOM was justifiable from a public health perspective considering the significant disease burden. The PCV7 vaccine was not effective in preventing AOM in older children with prior history of AOM.28 SOR A
There are insufficient data to determine the effectiveness of the currently licensed 13-valent pneumococcal vaccine (PCV13) given its recent licensure and use.
Influenza vaccination may decrease the incidence of AOM but rigorous systematic reviews are needed to evaluate the magnitude of this effect.13 SOR B
For at-risk children, long-term oral antibiotics administered for at least 6 weeks reduces the incidence of AOM while on therapy from 3 to 1.5 episodes per year. This benefit needs to be balanced against the potential side effects and the risks of antibiotic resistance.16,29 SOR A This practice is no longer considered routine.
Xylitol chewing gum, lozenge or syrup prophylactically given 3 to 5 times daily among healthy children at daycare centers can prevent AOM recurrence by 25 percent. However, the safety of giving a gum or lozenge to a young child, coupled with the compliance issues raised by its frequent administration, renders it an unrealistic preventive option.30 SOR B
Exclusive breastfeeding for at least 6 months appears to diminish occurrence of AOM, hence should be encouraged.13 SOR B
Tympanostomy tubes lead to short-term reduction in the number of episodes of AOM but increase the risk of complications (i.e., tympanosclerosis; Figures 22-12 and 22-13).16 SOR B
A. Left tympanic membrane (TM) of a 9-year-old girl with recurrent acute otitis media and chronic TM retractions prior to polyethylene (PE) tube placement. The circular area near the center of the TM is caused by the TM being retracted against the promontory of the medial wall of the middle ear. B. A fluoroplastic polyethylene (PE) tube is placed in the anterior-inferior quadrant of the TM of a 9-year-old girl with recurrent acute otitis media. It is black because it is impregnated with silver oxide to retard the growth of bacterial microfilms. (Used with permission from William Clark, MD.)
Tympanosclerosis as the result of previous recurrent episodes of otitis media and polyethylene (PE) tube placement. (Used with permission from Glen Medellin, MD.)
Without antibiotics, AOM resolves within 24 hours in approximately 60 percent of children and within 3 days in approximately 80 percent of children. Rate of suppurative complications if antibiotics are withheld is 0.13 percent.31
Most cases of OME resolve spontaneously within 3 months; only 5 percent to 10 percent last 1 year or longer. However, effusion will recur in 30 percent to 40 percent of patients.6
If a patient with AOM fails to respond to the initial management option within 48 to 72 hours, the clinician should reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in a patient initially managed with observation, the clinician should begin antibiotics. If the patient was initially managed with antibiotics, the clinician should change antibiotics.6 SOR B
Potentially serious complications of AOM, such as mastoiditis or facial nerve involvement, require urgent referral.
There is no consensus in the medical community regarding timing of posttreatment follow-up of AOM or who should receive follow-up. There is some evidence that parents can be reliable predictors in the resolution or persistence of AOM following antibiotic treatment.32
Children with persistent OME who are not thought to be at significant risk should be reexamined at 3- to 6-month intervals until the effusion is gone, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected.6 SOR B
Patient education should focus on identification, prevention, and control of risk factors.
Parents should be made aware of the high rates of spontaneous resolution of AOM and potential adverse effects of antibiotics. Providing a prescription for an antibiotic at the initial visit but advising delay of initiation of medication (i.e., observational approach for up to 48 hours) is an alternative to immediate treatment and is associated with lower antibiotic use.20
Patients should be informed that the natural history of OME is spontaneous resolution.
Periodic follow-up to monitor resolution of MEE is extremely important.
If MEE is persistent and signs and symptoms of hearing loss, language difficulties, and learning problems arise, additional treatment may be considered.
Clinical Practice Guideline: The diagnosis and management of acute otitis media from the American Academy of Pediatrics. Pediatrics. 2013;131;e964-e99.
Guideline: diagnosis and management of acute otitis media. Clinical Practice Guideline by the American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Pediatrics. 2004;113:1451-1465.
British Columbia Guidelines for AOM—http://www.bcguidelines.ca/pdf/otitaom.pdf.
Guideline: otitis media with effusion. Clinical Practice Guideline by the American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Pediatrics. 2004;113:1412-1429.
British Columbia Guidelines for OME—http://www.bcguidelines.ca/pdf/otitome.pdf.
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