Ottis media
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Here is a thorough overview of Otitis Media drawn from the medical textbook library:
Otitis Media
Definition and Types
Otitis media (OM) is inflammation or infection of the middle ear. There are three main clinical forms:
| Type | Key Feature |
|---|---|
| Acute Otitis Media (AOM) | Rapid-onset infection with middle ear effusion + signs of inflammation |
| Otitis Media with Effusion (OME) | Fluid in the middle ear WITHOUT signs/symptoms of acute infection ("glue ear") |
| Chronic Suppurative Otitis Media (CSOM) | Persistent otorrhea through a perforated tympanic membrane (TM) |
Epidemiology
- By age 7, 93% of children have had at least one episode of AOM; 75% have recurrent infections.
- Peak incidence is 6-24 months of age.
- ~80% of children will have at least one OME episode before school age.
- Annual cost in the US: ~$2.88 billion.
Pathophysiology
The primary driver is Eustachian tube dysfunction. Abnormal tubal compliance and delayed innervation of the tensor veli palatini muscle leads to tube collapse, impaired drainage, negative middle ear pressure, and fluid accumulation. Nasopharyngeal organisms then colonize this trapped fluid.
Causative Organisms
| Organism | Frequency |
|---|---|
| Streptococcus pneumoniae | 25%-40% |
| Haemophilus influenzae | 10%-30% |
| Moraxella catarrhalis | 2%-15% |
Viral upper respiratory infections commonly precede AOM and contribute to Eustachian tube dysfunction.
Risk Factors
- Male gender
- Daycare attendance
- Parental smoking
- Bottle feeding in the supine position
- Use of a pacifier
- Craniofacial abnormalities (e.g., cleft palate)
- Genetic and ethnic factors (e.g., Inuit, Native American)
- Prior AOM episode (especially in the preceding 3 months)
- Allergy
(Textbook of Family Medicine 9e)
Diagnosis
AOM is confirmed when all three of the following are present:
- Acute onset of symptoms (ear pain, irritability, tugging the ear in an infant)
- Middle ear effusion (MEE) - visualized as:
- Air-fluid level behind TM
- Bulging TM
- Absent TM movement on pneumatic otoscopy
- Flat tympanogram
- Signs of middle ear inflammation:
- TM erythema (moderate to severe)
- Otalgia
- Fever
Note: Redness of the TM alone without MEE is myringitis/tympanitis, NOT AOM. Ear pain with a normal, flaccid TM points to other causes (dental abscess, TMJ disorder, sinusitis, etc.).
Bullous myringitis (fluid-filled bullae on the TM) can occur in AOM - treatment is the same as non-bullous AOM.
Treatment
Watchful Waiting vs. Antibiotics
The decision depends on age, severity, and laterality:
- < 6 months: Always treat with antibiotics.
- 6 months - 2 years:
- Bilateral AOM or severe symptoms → antibiotics
- Unilateral, non-severe → observation is an option
- > 2 years:
- Non-severe → observation is acceptable if follow-up is reliable
- Severe (moderate/severe otalgia, fever > 39°C) → antibiotics
Most cases of AOM resolve spontaneously; observation for 2-3 days is a valid strategy in appropriately selected patients.
Antibiotic Regimens
| Patient Category | Antibiotic | Dose / Duration |
|---|---|---|
| Low-risk (>6 yr, no recent antibiotics, afebrile, not in daycare) | Amoxicillin | 40-50 mg/kg/day divided, 5 days |
| High-risk (<2 yr, daycare, recent antibiotics, otorrhea, fever >38°C) | Amoxicillin | 80-90 mg/kg/day divided, 10 days |
| Treatment failure (symptoms persist after 3 days) | Amoxicillin-clavulanate (Augmentin) | 80-90 mg/kg/day, 7-10 days |
| Cefuroxime axetil | 20-30 mg/kg/day bid, 7-10 days | |
| Ceftriaxone IM | 50 mg/kg x 1-3 days | |
| Penicillin-allergy | Cefuroxime axetil | 30 mg/kg/day |
(Textbook of Family Medicine 9e, pp. 404-405)
Pain management: Antibiotics do NOT improve pain in the first 24 hours. Use acetaminophen or ibuprofen for analgesia regardless of antibiotic decision.
Tympanostomy Tubes
- Patients with tubes presenting with acute otorrhea: treat with ototopical fluoroquinolone drops (e.g., ofloxacin, ciprofloxacin).
- Aminoglycoside drops are contraindicated when TM is not intact (ototoxic).
Complications
- Mastoiditis - the most common suppurative complication; rare in the modern antibiotic era.
- TM perforation - typically small and heals spontaneously.
- Hearing loss (conductive) from persistent MEE.
- Intracranial complications (rare): meningitis, epidural abscess, brain abscess.
Recurrent AOM
Defined as:
- 3+ episodes in 6 months, or
- 4+ episodes in 12 months with at least one in the last 6 months.
Warrants consideration of tympanostomy tube placement and ENT referral.
Key Distinctions
| Feature | AOM | OME |
|---|---|---|
| Onset | Acute | Insidious |
| Ear pain | Yes (often severe) | Minimal/absent |
| Fever | Common | Absent |
| TM appearance | Bulging, erythematous | Retracted, dull, amber |
| Treatment | Antibiotics ± watchful waiting | Watchful waiting; tubes if persistent |
Sources: Textbook of Family Medicine 9e (p. 403-413); Rosen's Emergency Medicine (p. 514-532)
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