Mary Bennett, Amanda Buisman & Roline Campbell

Mary Bennett, Amanda Buisman & Roline Campbell
Otitis Media Mary Bennett, Amanda Buisman & Roline Campbell

Pertinent Anatomy OR Auricle External Ear Canal OR Tympanic Membrane
Ossicles (malleus, incus, stapes) OR Auricle External Ear Canal OR Tympanic Membrane

Pertinent Anatomy (Cone of light)

Consists of the pinna (auricle) and the auditory ear canal
Physiology of the Ear External Ear Consists of the pinna (auricle) and the auditory ear canal The pinna functions to both protect the tympanic membrane, and to collect sound waves. The auditory ear canal distributes sounds in the form of pressure waves to the tympanic membrane.

Physiology of the Ear Middle Ear
Consists of the tympanic membrane, auditory ossicles (malleus, incus, stapes) and the eustachian tube. The tympanic membrane receives sound waves (in the form of pressure waves) from the auditory ear canal and converts the waves into mechanical vibrations by way of the auditory ossicles. The mechanical vibrations are then transmitted to the inner ear. The eustachian tube links the pharynx to the middle ear and while it is normally closed, it can let a small amount of air though to equalize the pressure between the middle ear and the atmosphere. It also drains mucous from the middle ear.

Physiology of the Ear Inner Ear
Consists of the semicircular canals, vestibule, acoustic nerve, and the cochlea. Mechanical vibrations are received from the TM and are transformed into fluid vibrations, which are then converted into nerve impulses by nerve endings located in the cochlea. These impulses are conducted via the auditory nerve to higher levels and interpreted as sound by the brain. The semicircular canals and vestibule function to maintain balance and equilibrium.

Pathophysiology of Otitis Media (OM)
OM is defined as inflammation in the middle ear without reference to etiology. OM is one of the most common reasons for a child to visit the pediatrician. OM can be classified into four categories; Acute Otitis Media (AOM) Otitis Media with Effusion (OME) Recurrent AOM Chronic OME

Pathophysiology of Acute Otitis Media (AOM)
The most important factor in the pathogenesis of AOM is abnormal function of the eustachian tube. Reflux, aspiration, or insufflation of nasopharyngeal bacteria into the middle ear via the dysfunctional eustachian tube may lead to infection. Eustachian tube dysfunction occurs due to either abnormal patency, or obstruction (either functional or mechanical).

Pathophysiology of Acute Otitis Media (AOM)
Common causative microorganisms for AOM are: Streptococcus pnumoniae (30-50% of cases) Haemophilus influenzae (20-30% of cases) Moraxella catarrhalis (7-25% of cases)

Acute Otitis Media (AOM) With and Without Perforation
When AOM is present and the TM is intact, it is referred to as “AOM without perforation”. When AOM is present and the TM is NOT intact, it is referred to as “AOM with perforation”.

AOM with perforation has two categories;
AOM complicated by perforation of the tympanic membrane presenting as otorrhea. (Left) AOM in a patient with tympanostomy tubes. (Right)

OM with Effusion (OME) OME occurs when thick fluid accumulates behind the TM. OME typically occurs immediately following treatment of AOM due to the resolution of acute inflammation, allowing visualization of the middle ear fluid behind the TM.

Epidemiology The overall prevalence of AOM is 15-20%, with the highest peak at 6-36 months of age. An additional smaller peak occurs at 4-6 years of age. Between 60-80% of infants have had at least one episode of AOM by one year of age. AOM is uncommon in older children and adolescents.

Epidemiology AOM is more common in boys, and the prevalence is greatest in Alaskan natives and Native Americans (Caucasian race is also considered a risk factor however). AOM is most common in the winter months and in early spring, coinciding with peaks in the incidence of URI’s.

Epidemiology Risk factors for developing OM; Male gender
Absence of breastfeeding White race Passive exposure to tobacco smoke Daycare attendance Low socioeconomic status Presence of siblings in the household Altered host defenses/underlying conditions

Patient Evaluation-History
Clinical presentation- children with AOM often have a history of rapid onset of fever and ear pain (usually within 48 hours). The patient may also have hearing loss, otorrhea, and irritability. Nonverbal children present with “ear pulling” and generalized fussiness. Associated symptoms include URI, cough, diarrhea, and nonspecific complaints such as decreased appetite, waking at night, or irritability in infants.

Patient Evaluation- History
It is important in the history to differentiate nonspecific symptoms of OM from those indicating a more serious condition such as meningitis. For infants or children with a history of persistent or recurrent OM, it is important to find out when they had their last documented infection and what treatment they received.

Patient Evaluation- History
Helpful questions to ask when obtaining the patient’s history; Does the infant have fever, ear pain, hearing loss, or otorrhea? Is the infant/child inconsolable or lethargic? Has the infant/child had a previous ear infection? If so, when? Did the child complete the course of prescribed antibiotics?

Helpful Questions How many ear infections has the child had in the past year? Is the child taking any medication to prevent recurrent OM? Does the child attend daycare? Is the child exposed to passive smoke? Is the infant breast-fed? Does the child appear to hear? Is the child’s speech development normal?

Physical Exam Findings
To diagnose OM, the TM must be visualized. The position, color, degree of translucency, and mobility of the TM must be evaluated. Classically, in AOM the TM is full or bulging, opaque, and has limited or no mobility, or is retracted. The light reflex is usually absent or distorted.

Associated physical exam findings may include; posterior auricular and/or cervical adenopathy pain on movement of the pinna anterior ear displacement *The presence of these symptoms may also suggest a more serious condition such as mastoiditis therefore thorough history taking and visualization of the TM is essential.

Normal (no AOM present) Exam Findings
Position- process of the malleus should be visible but not prominent through the membrane. Color- pearly gray. Translucency- middle ear or bony landmarks should be visible through the TM. Mobility- normal ear will move with pneumatic otoscopy.

Here is a normal TM

Here is a picture of a typical TM with AOM. The TM is noted to appear erythematous or injected in color, the light reflex is absent, landmarks are poorly visualized, and there is a poor degree of translucency.

Here is an example of AOM with a bulging TM. Note the color, position, transparency, lack of visible landmarks, and distorted light reflex

Here is a retracted TM

Diagnosis of AOM Accuracy in diagnosis of utmost importance
Ensures appropriate treatment for AOM Avoids unnecessary use of antibiotics in OME Prevents overuse of antibiotics – considered a major factor in increased drug-resistance Acute otitis media (AOM), also called suppurative otitis media, is one of the most frequent diagnoses for children seeking acute medical care. It accounts for a large proportion of pediatric antibiotic prescriptions and is associated with considerable medical expenditures. The importance of accurate diagnosis of AOM cannot be overstated. Accurate diagnosis ensures appropriate treatment for children with AOM, who require antibiotic therapy, and avoidance of antibiotics in children with Otitis Media with Effusion (OME), in whom antibiotics are unnecessary. Accurate diagnosis also prevents overuse of antibiotics, which is a major contributor in the development of drug resistant organisms.

AOM in Infants & Children
Challenges in establishing a diagnosis: Uncooperative TM obscured by cerumen Symptoms of AOM may overlap with other conditions (URI) Symptoms may be subtle or even absent Successful diagnosis facilitated by: Systematic assessment Stringent diagnostic criteria Training and experience Establishing the diagnosis of AOM in infants and young children can be challenging. The child may not cooperate with the examination, and the tympanic membrane may be obscured by cerumen. Symptoms of AOM may also overlap with those of upper respiratory tract infection (URI), or in some cases, symptoms of true AOM may be subtle or absent. The diagnosis of AOM is facilitated by systematic assessment of the tympanic membrane using a pneumatic otoscope and adherence to stringent diagnostic criteria. Pneumatic otoscopy skills, including the accurate interpretation of findings, can be improved through training and honed with frequent practice.

AAP & AAFP Diagnostic Criteria
Three diagnostic criteria 1. Recent, abrupt onset of ME inflammation & effusion (ear pain, irritability, otorrhea, and/or fever) 2. MEE confirmed by: bulging TM, limited or absent mobility (pneumatic otoscopy), air-fluid level behind TM, or Otorrhea (with TM not intact) 3. Evidence of ME inflammation - confirmed by: distinct erythema of TM, or distinct otalgia interfering with normal sleep or activity The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) established Clinical Practice Guidelines (2004) which require the presence of the following three diagnostic criteria to definitively diagnose AOM: 1. Recent, abrupt onset of signs & symptoms of middle ear inflammation & effusion (manifested as ear pain, irritability, otorrhea, and/or fever) 2. A Middle ear effusion (MEE) must be present. This is confirmed by a bulging TM; limited or absent mobility of the TM observed during pneumatic otoscopy; a visible air-fluid level behind TM or otorrhea. 3. Signs and symptoms of middle ear inflammation must be present. Distinct erythema of TM or distinct otalgia (ear pain) interfering with normal sleep or activity, confirms the presence of ME inflammation.

Diagnostic Techniques
Pneumatic otoscopy Assess inflammation Assess effusion Assess perforation & character of otorrhea Tympanometry and/or acoustic reflectometry Assess/confirm effusion Tympanocentesis (by otolaryngologist) Identify infectious organism Use in special populations Pneumatic otoscopy is the diagnostic technique most frequently used in the assessment of otalgia (ear pain) and is of vital importance to the primary care provider. It allows for visualization of the TM and it’s landmarks to assess inflammation, effusion, perforation, and the character of otorrhea, if present. Tympanometry and/or acoustic reflectometry can be used as supplemental techniques to diagnose the presence of middle ear effusion (MEE). Tympanocentesis is rarely done in older infants and children but may be helpful in the diagnosis and treatment of infants aged 2 months or less. For this procedure, infants should always be referred to an otolaryngologist. The goal of tympanocentesis is mainly to identify the infecting organism and is especially useful when: a. The patient is in a toxic state, b. The patient is immuno-compromised, c. A resistant infection is suspected,or d. When the patient is experiencing acute pain from bullous myringitis

Acoustic Reflectometry
Tympanometry Acoustic Reflectometry Analyzes sound reflected off the TM to detect MEE No pressure seal required Small quantity of cerumen does not affect this test Increased use in primary care Accurate & objective assessment of effusion Requires an air-tight seal & pressurization of the ear canal Painful & uncomfortable for children Limited use & costly Acoustic reflectometry is a tool that performs an analysis of sound reflected off the tympanic membrane in an effort to predict the presence of middle ear effusion in OME. It essentially is an auditory impedance testing device where sound is presented in the external auditory canal and a sensitive microphone measures the quantum of sound bounced back by the tympanic membrane. The more the sound reflected back, more is the likelihood of fluid in the middle ear. As there is no pressure seal required in the external auditory canal, the instrument is very well accepted by the children. The presence of small quantity of wax in the external canal too does not effect results. The tool is not widely used and may find an increasing role in diagnosis in the future.

Pneumatic Otoscopy Allows direct visualization of TM & ear structures to confirm presence of inflammation, effusion and assess for perforation. Important to: Remove cerumen obscuring TM Ensure adequate lighting Appropriately restrain the child to allow examination & prevent injury For pneumatic otoscopy – adequate airtight seal by choosing correct size and shape speculum. Visualization of the TM with identification of an MEE and inflammatory changes is necessary to establish the diagnosis of AOM with certainty. To visualize the tympanic membrane adequately it is essential to: a. remove any cerumen that is obscuring the TM, b. use a good light source to provide adequate lighting. c. appropriately restrain the child to permit adequate examination and prevent injury. For pneumatic otoscopy, a speculum of proper shape and diameter must be selected to permit a seal in the external auditory canal.

Assessment of the TM Locate border between external ear canal & TM
Surface Opacity Color Mobility Other findings Assessment of the TM should be a systematic process and with regular practice should eventually only take a few moments. To ensure that you are looking at the right structure, locate the border between the walls of the external ear canal and the TM itself. Then assess the surface of the TM, the opacity, color, mobility and any other findings.

The Surface of the TM Are the landmarks visible?
Are the landmarks obscured or unusually prominent? Where is the cone of light? Is the TM intact? The SURFACE of the TM can be divided into 4 unequal quadrants. It’s structures include the bony landmarks of the umbo and the malleus. The cone-shaped light reflex, usually found in the antero-inferior quadrant, is a vital point of reference. You may want to ask * Is the membrane retracted or bulging? Remember if the bony landmarks are obscured, it’s usually due to a bulging TM. When the bony landmarks appear unusually prominent, the TM is most likely retracted. * Is the cone of light in its expected position, absent or displaced? * Is the TM intact or perforated?

Abnormally retracted TM
Retracted & Bulging TM Abnormally retracted TM Bulging TM Abnormally Retracted TM: Image of bulging TM: Retrieved from

note loss of translucency
Opacity of the TM The OPACITY of the TM. * A normal TM is usually translucent. * A dull TM can be associated with acute infection or chronic scarring. Normal Tympanic Membrane - Usually translucent Scarred Tympanic Membrane note loss of translucency at area of scar

Color of the TM AOM with infused erythema Expected Findings
Normal TM = Pearly grey Crying infant = Pink TM Classic AOM = red or infused TM Atypical AOM = white or yellow TM (from purulent middle ear fluid) The COLOR of the TM. A normal TM can be pearly grey but also may be slightly pink (often pink after a child/infant has been crying) Classic AOM presents with a red (infused) TM but atypical presentations of a white or yellow TM have also been reported (Greydanus, 2008 p. 176)

Mobility of the TM Successful pneumatic otoscopy requires airtight seal of external ear canal With normal mobility the TM will move inward when positive pressure is applied move outward when negative pressure is applied A retracted TM will show decreased or absent inward deflection but normal outward deflection with negative pressure Crying children have increased middle ear pressures during exhalation which fleetingly normalize during inspiration Severely diminished or absent mobility is indicative of effusion The MOBILITY of the TM With a good seal, pneumatic otoscopy can elicit equal positive and negative deflections of the normal TM. Decreased mobility results from a middle ear effusion (MEE) or if the membrane is retracted at the baseline. A retracted TM without effusion will show movement during negative pressure from the insufflator (suction). Middle ear pressure is often increased in crying children (rendering TM mobility decreased). Overcome this by quickly pumping the insufflator during the inhalation phase of crying – mobility should then be observed if no effusion is present.

Normal TM Movement Follow this link to watch a short video clip illustrating a TM with normal mobility:

Decreased TM Movement Follow this link to watch a short video clip illustrating a TM with decreased/limited mobility:

- Indicative of Middle Ear Effusion (MEE)
Other Findings Cholesteatoma → ↖ Bleb / blister OTHER FINDINGS Look for air-fluid level or bubbles behind the TM (indicating effusion) Cholesteatoma appear as a grey or white mass behind the TM. Blebs on the surface of the TM indicate Bullous myringitis Purulent drainage from a ruptured TM Air-fluid level behind the TM - Indicative of Middle Ear Effusion (MEE) Cholesteatoma – grey or white mass behind the TM Blebs / blisters on the surface of the TM – Bullous Myringitis

Clinical Diagnosis of AOM
Requires: Acute onset of symptoms AND Middle Ear Effusion AND Middle Ear Inflammation OR Acute purulent otorrhea via perforated TM or tympanostomy tube AND otitis externa has been excluded The clinical diagnosis of AOM requires Middle ear effusion AND acute signs of middle ear inflammation. A diagnosis of AOM also can be established if there is acute purulent otorrhea and otitis externa has been excluded MEE can be confirmed by one or both of the following findings on otoscopy Bubbles or an air-fluid level Two or more of the following: Abnormal color (white, yellow, amber, or blue) Opacity (involving part or all of the tympanic membrane) not due to scarring Impairment of mobility MEE also can be confirmed by myringotomy/tympanocentesis, but this procedure is rarely performed in the primary care setting.

Differential Diagnoses
Viral Myringitis OME AOM Otalgia Present Usually absent - some reports "fullness“ Acute pain Inflammation Absent Bulging TM No bulging Normal position or retracted Bulging TM Mobility Normal Decreased Diff. Dx S & S Otitis media with Effusion and viral myringitis may be mistaken for AOM. A systematic comparison of signs and symptoms will aide in eliminating differential diagnoses. Remember that MEE (middle ear effusion = bulging + decreased mobility) is necessary to diagnose AOM but by itself it is not sufficient to diagnose AOM; there also must be evidence of acute inflammation. If a child has MEE but no evidence of acute inflammation, he or she has OME. Marked redness of the tympanic membrane is another sign of acute inflammation. However, marked redness of the tympanic membrane without bulging is unusual in AOM. (A different probable cause of the redness should then be considered – such as vigorous crying). A distinctly red tympanic membrane in the absence of bulging or impaired mobility has a predictive value of only 15 percent for AOM.

AOM or OME? Two year old Ron’s mom reports him rubbing and slapping at his left ear since early this morning. He refused breakfast and has been irritable all day. Pneumatic otoscopy reveals a bulging, yellow tympanic membrane with marked decrease in mobility. Is this AOM or OME? Non-otoscopic symptoms that may satisfy the criteria for acute inflammation include ear pain or unaccustomed tugging or rubbing of the ear but by itself these symptoms do not satisfy the diagnostic criteria for AOM. Non-otoscopic symptoms MUST be accompanied by abnormal otoscopic findings to make a diagnosis of AOM. The absence of redness (inflammation) of the TM in this case may cast some doubt on the diagnosis of AOM but remember that the color of the middle ear fluid (in this case probably a very purulent yellow) may alter the appearance of the TM. Ron indeed has AOM.

Summary: MEE MEE (Middle Ear Effusion) = fluid in middle ear
Occurs in both AOM and OME OME often precedes development of AOM OME mostly also follows resolution of AOM Middle ear effusion — Middle ear effusion (MEE) refers to fluid in the middle ear cavity. MEE occurs in both otitis media with effusion and AOM. Acute otitis media — AOM refers to acute bacterial infection of middle ear fluid. Otitis media with effusion (OME) refers to middle ear fluid that is not infected. OME is also called serous, secretory, or nonsuppurative otitis media. OME frequently precedes the development of AOM or follows its resolution. The distinction between OME and AOM may be difficult, since they are part of a continuous spectrum.

(or with Tympanostomy tube)
OM with ruptured TM AOM with TM intact AOM with ruptured TM (or with Tympanostomy tube) Acute onset otalgia Inflamed TM Middle Ear Effusion present (Bulging and decreased mobility) History of acute onset otalgia which improved when ear started draining (relief of pressure when TM ruptured) Inflamed TM TM ruptured & draining purulent fluid into external ear canal With a ruptured TM or when the child already has tympanostomy tubes in place, the presence of middle ear effusion (MEE) may also be demonstrated by the presence of purulent fluid in the external auditory canal. With purulent fluid, AOM is diagnosed when Otitis externa can be eliminated as a differential diagnosis. With tympanostomy tubes in place, a non-purulent drainage may be present in the absence of infection. This is a normal finding.

Treatment of AOM Clinical course of 24 – 72 hours with appropriate antimicrobial Rx Slightly slower resolve of acute symptoms when not treated MEE may persist for weeks or months The systemic and local signs and symptoms of AOM usually resolve within 24 to 72 hours with appropriate antimicrobial therapy, and somewhat more slowly in children who are not treated. Middle ear effusion (MEE) may persist after the resolution of acute symptoms – even for as long as weeks to months after the onset of AOM. This is most likely due to the persistent existence of biofilm on the mucosa of the middle ear.

Clinical Practice Guideline
AAP and AAFP Clinical Practice Guidelines (2004) state that the following aspects of management should be considered: 1. Symptomatic therapy 2. Observation (“Watchful waiting”) 3. Appropriate antimicrobial therapy Guidelines issued in 2004 by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) state that the management of AOM should include: Symptomatic therapy Considering careful observation vs immediate antimicrobial treatment (also referred to as “watchful waiting”), and Appropriate antimicrobial therapy in certain cases or when deemed necessary. :

1. Symptomatic Therapy - Pain
Acetaminophen 10 -15mg/kg PO/PR every 4 – 6 hours as needed not to exceed 90mg/kg/day Ibuprofen 5 - 10mg/kg PO/PR every 6 – 8 hours as needed not to exceed 40mg/kg/day Topical agents Antipyrine-benzocaine otic drops 4 – 5 drops into affected ear(s) every 2 hours as needed not to be given in case of TM perforation Aqueous lidocaine ear drops (30 minute efficacy – needs further evaluation – not currently a recommendation) The effective treatment of acute pain is central to the successful management of AOM. Treatment options include: Acetaminophen 10-15mg/kg orally or rectally every 4-6 hours as needed but do not exceed 90mg/kg/day Ibuprofen 5-10mg/kg orally or rectally every 6-8 hours as needed but do not exceed 40mg/kg/day. The topical analgesic combination of antipyrine-benzocaine-glycerin (marketed as Auralgan) demonstrated promising effects as an adjunct therapy for pain relief. These otic drops may be instilled into the affected ear(s) as often as every 2 hours but cannot be used in case of TM perforation. The use of aqueous lidocaine ear drops has also been investigated. Although further evaluation and dose-specifications are needed, patients who used lidocaine reported noticeable pain relief in the first 30 minutes.

Treatment of pain (cont.)
Complementary treatments Herbal extracts: Otikon Otic solution Compared well to topical anesthetic Home remedies Distraction External application of heat or cold Instillation of oil into external auditory canal Clinical evidence still lacking Despite the lack of controlled trials regarding the efficacy of complementary treatments and home remedies, primary care providers need to be aware of the options in order to advise patients regarding their appropriate use. In initial trials, the herbal extract Otikon Otic solution compared well to topical anesthetics for its analgesic properties. Home remedies such as distraction, external application of heat or cold, and oil instilled into the external auditory canal have been proposed, but controlled trials addressing their effectiveness are still lacking.

Symptomatic Therapy - Congestion
Decongestants and antihistamines Still commonly used in some populations No proof of efficacy in treatment of AOM Demonstrated: Increased medication side-effects Did not improve healing or reduce complications/surgery Prolonged duration of MEE AAP recommends OTC cough and cold medications NOT used in infants & children < 2 years (danger of life-threatening side effects!) Controversy exist regarding the use of decongestants to relieve nasal congestion or antihistamines to minimize nasal allergy symptoms. Despite its popularity among patients, the efficacy of antihistamines and decongestants in treating AOM has not been proven. Systematic review findings concluded that decongestants and antihistamines alone or in combination: a. were associated with increased medication side effects, b. did not improve healing, c. did not prevent surgery or other complications in AOM, and d. in some cases, prolonged the duration of Middle ear effusion (MEE) Additionally, the American Academy of Pediatrics (AAP) recommends that over-the-counter cough and cold medications should not be given to infants and children younger than two years of age, due to the risk of life-threatening side effects.

2. “Watchful waiting” Objective is to reduce the unnecessary use of antibiotics Limit development of drug-resistance Option only for selected children Certain criteria must be met to ensure safety “Watchful waiting” is NOT appropriate for any infant < 6 months Infants < 6 months should be treated with antibiotics REGARDLESS of the degree of diagnostic certainty. The American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) recommended in their Clinical Practice Guideline (2004) to consider a period of observation without the use of antibacterial therapy (often referred to as “Watchful waiting”) in order to reduce the unnecessary use of antibiotics and hopefully limit the development of drug resistant micro-organisms. This option however, is only appropriate for select children and where certain criteria can be met. The AAP/AAFP guideline committee states that watchful waiting is not appropriate for infants younger than 6 months and that, for this age group, antibacterial therapy should be administered, regardless of the degree of diagnostic certainty.

Considerations for “Watchful Waiting”
Age of infant/child Certainty of diagnosis Severity of illness Can follow-up be ensured? Ability to acquire prescription medications if needed Parents must understand risks and benefits of “watchful waiting” vs immediate treatment When considering an approach of “watchful waiting” the following factors should be reviewed and discussed with the parents or caregivers. The age of the infant / child. As already stated, infants younger than 6 months should receive antimicrobial treatment without delay. The certainty of the diagnosis of AOM. If all other differential diagnoses cannot be definitively ruled out, a period of watchful waiting may accommodate certain diagnosis or allow for spontaneous resolve of the problem. The severity of the illness should also be considered. Where symptoms lack severity, watchful waiting may once again, allow for spontaneous resolve of the problem. To ensure the safety of children, providers should ascertain if timely follow-up can be ensured and if parents/caregivers will at a later time be able to acquire prescription medications. Parents must also understand the risks and benefits of watchful waiting and must understand the importance of timely follow-up.

The AAP & AAFP recommendations for observation versus antibiotics are summarized in this table.
Note that for infants < 6 months antibacterial therapy is always indicated – regardless of certainty of diagnosis. For children ages six months to two years, antibacterial therapy is recommended when the diagnosis of AOM is certain or if the diagnosis is uncertain, but illness is severe. Severe illness is described as moderate to severe otalgia or fever ≥39ºC in the previous 24 hours. In this age group, observation is an option only for children in whom the diagnosis is not certain and illness is not severe. 3. For children older than two years, antibacterial therapy is recommended if the diagnosis is certain and illness is severe. * Observation is an option when the diagnosis is certain but illness is not severe, and in patients with an uncertain diagnosis. 4. Other resources (Klein, J.O. & Pelton, S., 2011) suggest that for children older than two years with bilateral disease or with otorrhea, management with antimicrobial therapy should not be delayed. As stated already, observation is appropriate only when follow-up (within 72 hours) can be ensured. Antibiotics should be prescribed when the patient does not improve with observation after 48 to 72 hours or earlier if symptoms worsen. Table copied from: Klein, J. & Pelton, S. (2011). Acute otitis media in children: Treatment. Retrieved from

3. Antimicrobial treatment
Selection of drugs should be based on: Clinical & microbiologic efficacy Acceptability of the oral preparation (taste & texture) Absence of side effects and toxicity Convenience of dosing schedule Cost Once the decision is made to treat with antimicrobial agents, the following aspects should be considered when selection a drug: 3. Absence of side effects and toxicity 2. Acceptability of the oral preparation – in other words the taste and texture 1. Clinical and microbiologic efficacy 5. Cost 4. Convenience of the dosing schedule, and

First-line antimicrobial therapy
Amoxicillin Controversy but still recommended as drug of choice (safe, effective, affordable, narrow spectrum) Doubled dose increase concentration in ME Then active against most intermediate strains of S. pneumoniae (including many resistant strains) 80 – 90 mg/kg per day (divided in 2 doses) Heavier children – max of 3g/day Despite many controversies, a review of literature early in 2011 concludes that AMOXICILLIN remains the drug of choice because it is effective, safe, relatively inexpensive, and has a narrow microbiologic spectrum. Doubling the dose from 40 to 80 mg/kg per day divided into two doses increases the concentration of amoxicillin in the middle ear and this increased concentrations provide activity against most intermediate strains of S. pneumoniae, including many of the resistant strains. The AAP/AAFP guideline recommends a dose of 80 to 90 mg/kg per day. For heavier children, a maximum dose of 3 g/day is recommended, although diarrhea is a potential adverse effect at this higher dose. S. pneumoniae which are highly resistant to penicillin will most likely not respond to this regimen but it is expected that more than 80 percent of children with pneumococcal AOM would respond to high-dose amoxicillin treatment.

When is Amoxicillin contra-indicated?
High risk for AOM caused by an amoxicillin-resistant otopathogen Treated with antibiotics in previous 30 days (especially beta-lactam antibiotics) Concurrent purulent conjunctivitis (non-typable H. influenzae) Receiving amoxicillin chemoprophylaxis for recurrent AOM or UTI Allergy These include: Amoxicillin should not be used as first-line therapy in children who are at high risk for AOM caused by an amoxicillin-resistant otopathogen. a. Children who were treated with antibiotics in the previous 30 days particularly beta-lactam antibiotics b. Children with concurrent purulent conjunctivitis (usually caused by nontypeable H. influenzae, which is frequently resistant to beta-lactam antibiotics) c. Children receiving amoxicillin for chemoprophylaxis of recurrent AOM or urinary tract infection. d. Known allergy to penicillins

Alternative 1st Choice treatment
Amoxicillin-clavulanate Active against beta-lactamase-producing non-typeable H. influenzae Also active against S. pneumoniae Dosing: < 3 months: 30mg/kg/day PO divided in 2 daily doses ≥ 3 months & < 40 kg: 90mg/kg/day PO divided in 2 daily doses x 10 days Children weighing > 40 kg – mg every 8 hours Children in the above categories should start therapy with an agent such as amoxicillin-clavulanate which is active against beta-lactamase-producing nontypeable H. influenzae, as well as S. pneumoniae The recommended dosing is: For infants < 3 months mg/kg/day PO divided in 2 daily doses For infants and children 3 months and older but weighing less than 40 kg -- 90mg/kg/day PO divided in 2 daily doses x 10 days For children weighing more than 40 kg mg every 8 hours or 875mg every 12 hours (adult dosing recommendations)

Secondary treatment options
Choice of alternatives depend on type of previous hypersensitivity reaction HISTORY OF NON-TYPE 1 REACTIONS Cefdinir 14 mg/kg/day in 1 or 2 doses (limit total 600mg/day) Cefpodoxime 10 mg/kg /day once daily (limit 800 mg/day) Cefuroxime (cefuroxime axetil suspension) 30 mg/kg/day in 2 divided doses (limit total 1 g/day) Cefuroxime tablets 250 mg every 12 hours Secondary treatment options. Acceptable alternatives to penicillin in patients with allergy to penicillin depend upon the type of the previous hypersensitivity reaction. In patients who report penicillin allergy but who did NOT experience a type 1 hypersensitivity reaction (urticaria or anaphylaxis), one of the following is recommended: a. Cefdinir (14 mg/kg per day in 1 or 2 doses; maximum dose 600 mg/day) b. Cefpodoxime (10 mg/kg per day once daily; maximum dose 800 mg/day) c. Cefuroxime (cefuroxime axetil suspension: 30 mg/kg per day in two divided doses, maximum dose 1 g/day OR cefuroxime tablets: 250 mg every 12 hours However, these oral agents do not achieve sufficient concentration in the middle ear to eradicate penicillin-resistant S. pneumoniae.

Treating AOM due to Penicillin-resistant S. pneumoniae
Oral Cephalosporins are not effective against penicillin-resistant S. pneumonia Consider : Ceftriaxone 50mg/kg in single IM dose If clinical signs do not improve after 48 hours, a second dose may be given. In some cases even a third dose may be necessary. Be mindful of the physical discomfort and psychological distress caused in a young child when following this approach. The oral cephalosporins discussed on the previous slide do not achieve sufficient concentration in the middle ear to eradicate penicillin-resistant S. pneumoniae. To treat AOM due to resistant S. pneumonia a single intramuscular dose of ceftriaxone (50 mg/kg) provides high concentrations in the middle ear for more than 48 hours. This treatment may thus be considered an alternative for children with AOM and history of non-type 1 penicillin allergy. If clinical signs improve within 48 hours following administration of ceftriaxone, no further therapy is necessary but if clinical signs persist, a second dose is administered and, if necessary, a third dose. Keep in mind though the discomfort and psychological distress caused in a young child when following this approach.

Secondary treatment options
HISTORY OF TYPE 1 REACTIONS Erythromycin plus sulfisoxazole mg/kg/day in 4 divided doses Limit total erythromycin to 2g/day Often rejected due to taste and high frequency of dosing Azithromycin Single dose Rx: Give 30mg/kg in one single dose x1 day 3-day Rx: Give 20mg/kg/day – one dose daily x3 days 5-day Rx: Give 10mg/kg on day 1 & 5mg/kg/day on days 2 – 5 Secondary treatments in patient with a history of Type 1 allergic reactions include Macrolide antibiotics. However, macrolide resistance is common among isolates of S. pneumoniae, and macrolides generally are not effective for eradication of H. influenzae. Available macrolide drugs approved for AOM include erythromycin plus sulfisoxazole Recommended dose of 50 to 150 mg/kg per day of the erythromycin component divided into 4 doses; maximum dose 2g erythromycin (or 6 g sulfisoxazole/day) may be the most effective of these regimens but is rejected often by patients based upon taste and frequency of dosing Five days of azithromycin (10 mg/kg per day [maximum dose 500 mg/day] as a single dose on day one and 5 mg/kg per day [maximum dose 250 mg/day] for days two through five)

Secondary options cont.
HISTORY OF TYPE 1 REACTIONS Clarithromycin 15mg/kg/day divided in 2 doses (limit to 1g/day) OR 30-40mg/kg/day divided in 4 doses (limit to 1g/day) Clindamycin 30-40 mg/kg/day divided in 3 – 4 doses Clarithromycin (15 mg/kg per day divided into 2 doses; maximum dose 1 g/day) can be used, but resistant pneumococcal isolates cannot be overcome by increasing the dose of macrolides, unlike the scenario with beta-lactam drugs. Another source recommends a dose of mg/kg/day divided in 4 doses which provides a much higher total daily dose (be careful to not exceed 1gram/day) – however the 4 times daily dosing schedule makes it hard for patients and their caregivers to be compliant.

Treatment of AOM in children with Tympanostomy Tubes
For some children, topical antibiotic therapy may be an alternative to oral therapy. Requirements: Mild to moderate illness No immune compromise Must be older than 2 years Options: Quinolone otic drops (Ofloxacin / Ciprofloxacin) Efficacy has not been studied in children with AOM & acute perforation Oral therapy is always preferred When the perforation occurs in the setting of AOM, topical therapy may be an alternative to oral therapy for the well-appearing, immunocompetent child who is older than two years. However, oral therapy is preferred. Topical therapy with quinolone otic drops (ofloxacin or ciprofloxacin) is equivalent to oral therapy for treatment of otorrhea in children with tympanostomy tubes or chronic suppurative otitis media, but has not been studied in children with AOM and acute perforation. Remember, in case of ruptured TM or in children with Tympanostomy tubes, the use of topical analgesic drops is CONTRA-INDICATED!!

Complications of Otitis Media
Risks for complications associated with otitis media: Increase if an acute episode of otitis media persists longer than 2 weeks. Increase if symptoms recur within a 2-3 week period. Decrease with early diagnosis and effective antibiotic treatment.

Intracranial complications are uncommon in developed counties but are a concern where access to medical care is limited. They develop and spread: Through vascular channels. By direct extension. Through preformed pathways such as the round window. Extracranial complications are direct sequelae of: Localized acute inflammation, or Chronic inflammation.

Hearing loss: Temporary: hearing loss of 25 to 30dB for several months due to OME; risk of impaired language development, vestibular, balance, and motor dysfunctions. Permanent: damage to the tympanic membrane or other middle ear structures, resulting in vertigo or facial weakness.

Adhesive otitis media: abnormal healing in inflamed middle ear. Irreversible thickening of the mucus membranes causing impaired movement of the ossicles and possible conductive hearing loss (e.g., tympanosclerosis). Chronic suppurative otitis media: chronic otorrhea through a perforated TM; the cycle of inflammation, ulceration, infection, and granulation tissue formation may destroy surrounding bony margins and ultimately lead to various complications.

Postauricular abscess: the most common extracranial complication. Tympanic membrane perforation due to increased middle ear pressure. Meningitis: AOM is the most common cause of this intracranial complication. Cholesteatoma: cystlike lesions of the middle ear that may erode the ossicles, labyrinth, adjacent mastoid bone, and surrounding soft tissues. Mastoiditis: inflammation as an extension of acute or chronic OM, causing necrosis of the mastoid process and destruction of the bony intercellular matrix.

Facial nerve paresis Labyrinthitis: intratemporal complication Labyrinthine fistula Temporal abscess Petrositis: intratemporal complication Intracranial abscess Otitic hydrocephalus Sigmoid sinus thrombosis or thrombophlebitis Encephalocele CSF leak

Signs of possible impending complication:
Sagging of the posterior canal wall Puckering of the attic or epitympanic recess Swelling of the postauricular areas with loss of the skin crease Persistent headache and/or fever Tinnitus Stiff neck Visual or other neurologic symptoms Severe otalgia Vertigo Lethargy Nausea and vomiting Fetid otorrhea

Signs or Symptoms of complication: Intracranial
Fever associated with a chronic perforation Lethargy Focal neurologic signs (e.g., ataxia, oculomotor deficits, seizure) Papilledema Meningismus Altered mental status Severe Headaches

Signs or Symptoms of complication: Extracranial
Fever associated with a chronic perforation. Postauricular edema or erythema.

Patient Education Explain the natural history of acute otitis media.
Explain the benefits of using analgesics to treat ear pain. Do not use longer than 3 days for pain without consulting healthcare professional. Explain to parents topical analgesics must not be used if the tympanic membrane ruptures. Explain the use of antibiotics in the management of otitis media and implications of antibiotic-resistant bacteria in AOM.

Patient Education Provide parent with extensive information about antibiotic overuse. Explain signs and symptoms of allergic reaction to antibiotics and to report to healthcare provider immediately. Explain that symptoms should decrease in hours with the use of analgesics and/or antibiotics. Explain that persistent otalgia, fever, and other systemic symptoms past 72 hours should be reevaluated by healthcare provider.

Patient Education Educate regarding the signs and symptoms of clinical deterioration. Educate on preventable risk factors. Educate parents and patients regarding the problem of drug-resistant bacteria and the need to avoid the use of antibiotics unless absolutely necessary. Explain the entire course of the prescription of antibiotics must be completed.

Patient Education Measure body temperature via oral, rectal, or axillary methods. Transtympanic measurements of temperature in children with middle ear effusions may be inconsistent. Heat packs to affected ear may help relieve discomfort. Saltwater nasal spray or rinses may decrease congestion. Elevating head of crib may facilitate drainage.

Patient Education Do not use Q-tips in ears.
Keep follow-up appointments until the tympanic membrane is normal. Middle ear effusion may persist for several weeks, affecting speech and language development. AOM treatment failure requires referral to otolaryngologist.

Prevention Measures Identify and treat underlying conditions that predispose the child to AOM. This includes: 1. Immune deficiencies: e.g., IgG subclass deficiency, hypogammaglobulinemia, granulocyte defects. 2. Anatomic abnormalities: e.g., craniofacial abnormalities, such as micrognathia, or palatal clefts.

Prevention Measures Breast feed infants: breastfeeding provides for the transfer of protective maternal antibodies to the infant; bottle-fed infants have a higher incidence of AOM than breast-fed infants, probably due to feeding position during bottle-feeding, which facilitates the reflux of milk into the middle ear. Reduce or eliminate pacifier use, especially after 6 months of age.

Prevention Measures Minimal exposure to group settings or daycare setting with few children. Avoid or eliminate bottle-propping. Avoid feeding infants in supine position. Infection can spread more easily through the eustachian canal of infants who spend most of the day in the supine position. Avoid exposure to passive tobacco smoke.

Prevention Measures Chewing at least 3-5 sticks a day of Xylitol chewing gum may reduce recurrence rate (if age appropriate). Xylitol is a sugar found in fruits and the bark of birch trees that has bacteriostatic effects against S. pneumonia and interferes with bacterial adhesion to mucous membranes. Side effects include excessive gas and diarrhea.

Prevention Measures Annual influenza vaccine, especially in high-risk children who attend day care. Early treatment of influenza with the antiviral oseltamivir may reduce OM. Immunization with heptavalent pneumococcal conjugate vaccine (PCV7 or Prevnar) may reduce the incidence of AOM caused by S. pneumoniae. Consider tympanostomy tube placement for prevention of recurrent AOM.

References American Academy of Pediatrics and American Academy of Family Physicians (2004). Diagnosis and management of acute otitis media. Clinical practice guideline. Retrieved from Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B. & Blosser, C.G. (2009). Pediatric primary care . (4th ed.). St. Louis, MO: Saunders/Elsevier

References Donaldson, J. (2010). Middle ear, acute otitis media, medical treatment. Retrieved from Eaton, D. (2009). Complications of otitis media. Retrieved from Greydanus, D., Feinberg, A., Patel, D., & Homnick, D. (2008). The pediatric diagnostic examination. NY: McGraw-Hill.

References Klein, J. & Pelton, S. (2011). Acute otitis media in children: Treatment. Retrieved from Klein, J. & Pelton, S. (2011). Acute otitis media in children: Prevention of recurrence. Retrieved from

References Leskinen, K. (2005). Complications of acute otitis media in children. Current Allergy and Asthma Reports, 4, Retrieved from Porth, C. & Matfin, G. (2009). Pathophysiology: Concepts of altered health states. (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Mary Bennett, Amanda Buisman & Roline Campbell

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