Otitis media

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Otitis Media

Otitis media (OM) is inflammation of the middle ear, most common in children under 2 years. It encompasses several forms - acute (AOM), with effusion (OME, "glue ear"), and chronic suppurative (CSOM). It is the most common reason children visit a physician's office in the United States, with an estimated annual cost of $2.88 billion.

Classification

Type	Description
Acute Otitis Media (AOM)	Rapid-onset middle ear infection with signs of inflammation
Otitis Media with Effusion (OME)	Persistent middle ear fluid WITHOUT signs of acute inflammation ("glue ear")
Recurrent AOM	≥3 episodes in 6 months, or ≥4 in 12 months
Chronic Suppurative OM (CSOM)	Persistent discharge through a perforated TM for >6-12 weeks
Bullous Myringitis	AOM variant with blisters on the TM; treatment is identical to AOM

Epidemiology & Risk Factors

Peak incidence: 6-24 months of age; 93% of children have had at least one AOM episode by age 7
90% of children will have OME before school age

Risk factors for AOM:

Male gender
Daycare attendance / exposure to URIs
Bottle feeding (especially supine position)
Parental smoking (secondhand smoke)
Pacifier use
Craniofacial abnormalities (e.g., cleft palate)
Genetic and ethnic factors (higher in Inuit, Native American populations)
Previous AOM episode (especially within 3 months)
Textbook of Family Medicine 9e, p. 404

Pathophysiology

The primary mechanism is eustachian tube dysfunction. Abnormal tubal compliance and delayed innervation of the tensor veli palatini muscle cause the tube to collapse. This leads to:

Negative middle ear pressure
Fluid accumulation (effusion)
Bacterial and/or viral colonization from the nasopharynx

A viral upper respiratory infection typically precedes an episode of AOM.

Most common bacteria:

Organism	Frequency
Streptococcus pneumoniae	25%-40%
Haemophilus influenzae	10%-30%
Moraxella catarrhalis	2%-15%

Rosen's Emergency Medicine, p. 514; Textbook of Family Medicine 9e

Clinical Features

Symptoms:

Otalgia (ear pain; tugging/rubbing the ear in pre-verbal children)
Fever
Otorrhea (if TM has perforated)
Hearing loss (conductive)
Irritability, poor feeding (infants)
Tinnitus, vertigo, vomiting (less common)

Signs (otoscopic examination):

Moderate-to-severe bulging of the tympanic membrane (TM) - most specific
Erythema of the TM
Air-fluid levels behind the TM
Absence of TM mobility on pneumatic otoscopy
Flat tympanogram (Type B)

Important distinction: Erythema of the TM without middle ear effusion = myringitis/tympanitis (not AOM). Ear pain with a normal, flaccid TM suggests other causes (referred otalgia from dental disease, TMJ, cervical arthritis, etc.)

Diagnosis

Diagnosis of AOM requires all three:

Acute onset of symptoms
Middle ear effusion (MEE) - evidenced by bulging TM, air-fluid level, reduced TM mobility, flat tympanogram
Signs of middle ear inflammation - otalgia, TM erythema, or fever

Rosen's Emergency Medicine; Textbook of Family Medicine 9e (Lieberthal et al., 2013 criteria)

OME is diagnosed by:

Fluid visible behind TM WITHOUT erythema, pain, or fever
Flat (Type B) or hypercompliant (Type C) tympanogram
Conductive hearing loss (10-20 dB typical)

Management

AOM - Observation vs. Antibiotics

Not all AOM needs immediate antibiotics. The "watch and wait" strategy is evidence-based for selected patients:

Immediate antibiotics are indicated when:

Age < 6 months
Bilateral AOM in children < 24 months
AOM with TM perforation/otorrhea
Severe symptoms: ear pain ≥48 hours, or fever > 39°C (102.2°F)
Recurrent AOM (episode within 2-4 weeks)
Craniofacial abnormalities or immunocompromise
Tympanostomy tubes in place

Observation (48-72 hours) is acceptable when:

Age 6-23 months with unilateral AOM, mild symptoms (pain < 48 h, temp < 39°C)
Age ≥24 months with unilateral or bilateral AOM, mild symptoms
Reliable follow-up is available
Rosen's Emergency Medicine, Tables 121-4 & 121-5

Antibiotic Choice (AOM)

Scenario	Drug	Dose
First-line	Amoxicillin	High-dose: 80-90 mg/kg/day in 2 divided doses
Low-risk (>6 yr, no recent antibiotics, afebrile)	Amoxicillin	40-50 mg/kg/day for 5 days
High-risk (<2 yr, daycare, recent antibiotics, fever >38°C)	Amoxicillin	80-90 mg/kg/day for 10 days
Treatment failure (symptoms persist at 72 hours)	Amoxicillin-clavulanate	80-90 mg/kg/day for 7-10 days
Can't tolerate oral / vomiting	Ceftriaxone IM	50 mg/kg for 1-3 days
Penicillin allergy	Cefuroxime axetil OR cefpodoxime	20-30 mg/kg/day

Macrolides (azithromycin) are not recommended because H. influenzae - the dominant organism in this age group - is intrinsically resistant.

Middle ear fluid becomes sterile 3-6 days after starting appropriate antibiotics.

Textbook of Family Medicine 9e, Table 18-6; Rosen's Emergency Medicine, Table 121-5

Pain Management

Antibiotics alone do NOT improve pain in the first 24 hours. Analgesics (acetaminophen or ibuprofen) should be used alongside or instead of antibiotics for symptom relief.

Otitis Media with Effusion (OME)

80-90% of OME resolves spontaneously within 3 months; 95% within 1 year
Treatment:

Duration	Action
< 6 weeks	Observation ± hearing test
3 months	Comprehensive hearing evaluation; refer if ≥20 dB loss
4-6 months (with hearing loss)	Referral for PE (polyethylene) tube placement

A 40 dB bilateral hearing loss mandates referral for tympanostomy tube evaluation
High-risk groups for OME complications: Down syndrome, cleft palate, autism, developmental delays, permanent hearing loss
Textbook of Family Medicine 9e, Table 18-7; Rosen's Emergency Medicine

Recurrent AOM

Defined as: 3 or more episodes within 6 months, or 4 or more within 12 months with complete resolution between episodes.

Management options:

Tympanostomy tube (PE tube) insertion - reduces episodes; also recommended for OME with bilateral hearing loss
Adenoidectomy (in children with nasal symptoms)
No role for prophylactic antibiotics (conflicting evidence)

Complications

Suppurative (Infectious)

Complication	Notes
Mastoiditis	Most common suppurative complication; rare in antibiotic era
Meningitis	Via direct extension or hematogenous spread
Brain abscess
Lateral sinus thrombosis
Labyrinthitis	Sensorineural hearing loss, vertigo
Facial nerve palsy
Bezold's abscess	Abscess tracking beneath sternocleidomastoid

Non-Suppurative

Complication	Notes
Conductive hearing loss	Most common overall; due to effusion or TM/ossicular damage
Tympanosclerosis	White chalky plaques on TM; seen in ~23% after tympanostomy tubes
Cholesteatoma	Epithelial ingrowth; can erode ossicles and bone
Adhesive otitis media	TM retraction and scarring
Speech/language delay	From chronic hearing loss in developing children

Rosen's Emergency Medicine; Cummings Otolaryngology

Special Situations

AOM with tympanostomy tubes: Treat with ototopical fluoroquinolone drops (e.g., ofloxacin/ciprofloxacin-dexamethasone). Do NOT use aminoglycoside drops with a non-intact TM (ototoxic).

AOM with perforation: Treat the same as AOM without perforation. Small perforations typically heal spontaneously.

Prevention

Pneumococcal conjugate vaccine (PCV13/PCV15) - reduces AOM caused by vaccine serotypes
Influenza vaccine - shown to reduce AOM episodes
Breastfeeding for ≥6 months
Avoiding supine bottle feeding
Smoke-free environment
Limiting daycare exposure in early infancy

Key Clinical Pearls

Bulging TM is the most specific sign - more important than erythema alone
Erythema alone without effusion = myringitis, not AOM
Always treat pain separately - antibiotics don't relieve pain in the first 24 hours
High-dose amoxicillin (80-90 mg/kg/day) is key to overcoming penicillin-resistant S. pneumoniae
Macrolides are poor choices for AOM due to H. influenzae resistance
OME does not need antibiotics - observation is appropriate for ≤3 months
Mastoiditis is the most common suppurative complication

Sources:

[Textbook of Family Medicine 9e](Lieberthal et al. 2013 AAP guidelines incorporated), pp. 403-411
Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapter 121
Tintinalli's Emergency Medicine: A Comprehensive Study, Chapter 121
Cummings Otolaryngology Head and Neck Surgery

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