Otitis Media

Classification

Epidemiology

• The most common infection for which children visit a physician
• By age 7 years, 93% of children have had at least one AOM episode; 75% have recurrent infections
• Peak incidence: 6-24 months of age
• Annual cost of AOM in the United States: ~$2.88 billion
• • Textbook of Family Medicine 9e

Pathophysiology

1. ET inflammation (usually following a viral URI) leads to negative middle ear pressure
2. Abnormal tubal compliance + delayed innervation of the tensor veli palatini muscle causes ET collapse
3. Nasopharyngeal secretions and bacteria are aspirated into the middle ear
4. Fluid accumulates, creating an ideal environment for bacterial proliferation

Microbiology

• In CSOM: S. pneumoniae, H. influenzae, S. aureus, Pseudomonas spp., and anaerobes
• Viruses and anaerobes also contribute to AOM
• • Textbook of Family Medicine 9e; Rosen's Emergency Medicine

Risk Factors for AOM

• Male gender
• Bottle feeding (especially supine)
• Daycare attendance / exposure to URIs (winter season)
• Parental smoking
• Use of a pacifier
• Allergy
• Craniofacial abnormalities (e.g., cleft palate)
• Ethnic factors (Inuit, Native American)
• Previous AOM episode (especially within 3 months)
• Genetic factors
• • Textbook of Family Medicine 9e

Diagnosis

Acute Otitis Media

1. Acute onset of symptoms
2. Middle ear effusion (MEE) - confirmed by:
   • Direct visualization of air-fluid level or bulging TM
   • Lack of TM movement on pneumatic otoscopy
   • Flat tympanogram
3. Signs of middle ear inflammation:
   • Moderate-to-severe TM bulging (most specific sign)
   • New-onset otorrhoea not due to otitis externa
   • Ear pain (otalgia), TM erythema

Key: Erythema of TM alone (without effusion) = myringitis/tympanitis - NOT AOM. A normal, flaccid TM with ear pain points to other causes (dental, TMJ, cervical, pharyngeal).

Common Signs and Symptoms

• Otalgia (ear pulling in infants)
• Fever
• Diminished hearing
• Irritability, loss of appetite
• Tinnitus, vertigo, vomiting

Otitis Media with Effusion (OME)

• Fluid in middle ear without signs of acute infection
• Often asymptomatic or presents with conductive hearing loss
• Diagnosed by tympanometry (type B curve) or pneumatic otoscopy

Management

AOM - Antibiotic Decision Framework

• Severe illness = moderate-to-severe otalgia + fever >39°C (102.2°F)
• Observation period: 2-3 days before antibiotic prescription in selected patients
• Observation is not validated in adult patients - Rosen's Emergency Medicine

Antibiotic Therapy

• Increasing penicillin resistance in S. pneumoniae drives the high-dose amoxicillin recommendation
• Pain management: Antibiotics alone do NOT provide pain relief in the first 24 hours - use acetaminophen or ibuprofen concurrently
• • Textbook of Family Medicine 9e; Rosen's Emergency Medicine

AOM with Tympanostomy Tubes

• Increased otorrhoea through a tube: treat with ototopical fluoroquinolone drops (e.g., ofloxacin or ciprofloxacin/dexamethasone) - NOT systemic antibiotics
• Avoid aminoglycoside drops if TM is not intact (ototoxicity risk)

OME Management

• Most cases resolve spontaneously within 3 months - watchful waiting is appropriate
• Indications for intervention: persistent bilateral OME >3 months + hearing loss, speech delay, or developmental concerns
• Tympanostomy tube (grommet) insertion is the surgical treatment of choice
• Adenoidectomy may be considered for children >4 years with recurrent OME

CSOM Management

1. Culture and sensitivity of discharge (including fungal if OE suspected)
2. Ototopical antibiotics - quinolone drops are preferred (safe for middle ear); aminoglycosides carry ototoxicity risk
3. A Cochrane review confirms ototopicals are superior to oral antibiotics for CSOM
4. Aural toilet: acetic acid solution (1:1 distilled water + white vinegar) to clear debris
5. Systemic antibiotics for severe cases or when copious drainage limits topical therapy
6. Surgery: tympanoplasty (TM repair) if perforation persists after resolution; tympanomastoidectomy if medical therapy fails
7. Adenoidectomy if chronic adenoiditis is a contributing nidus

• • Textbook of Family Medicine 9e

Complications

Intratemporal

Intracranial

Differential Diagnosis of Otalgia

• Abscessed teeth
• Dental malocclusion / TMJ disorders
• Cervical arthritis
• Sinus infection
• Sore throat / pharyngitis
• Nasopharyngeal carcinoma (referred pain)

Prevention

• Pneumococcal conjugate vaccine (PCV13/PCV15) - reduces AOM episodes due to S. pneumoniae
• Influenza vaccine - reduces viral triggers
• Breastfeeding (reduces risk vs. bottle feeding)
• Avoidance of passive smoke exposure
• Limiting pacifier use after 6 months

Recent Evidence (2024-2026)

• A 2025 Cochrane review on systemic antibiotics for CSOM (PMID 40484405) supports the preference for topical over systemic antibiotics in chronic disease.
• A 2025 Cochrane review found that decongestants and antihistamines are not recommended for AOM in children (PMID 41307300), consistent with current guidelines.
• A 2024 systematic review and meta-analysis in Laryngoscope reported significant quality of life improvement after surgery (tympanostomy tube insertion) for pediatric OM (PMID 38666491).

• Bulging TM is more specific for AOM than erythema alone
• Always address pain - antibiotics take >24h to work
• In children >2 with mild unilateral AOM, watchful waiting for 48-72h is guideline-supported
• Recurrent AOM (≥3 episodes/6 months) warrants ENT referral and consideration of tympanostomy tubes
• CSOM with new facial palsy, vertigo, or severe headache = emergency - rule out intracranial complication