Otitis Media

Definition and Types

Otitis media (OM) is inflammation and/or infection of the middle ear. It is broadly classified into:

Acute Otitis Media (AOM) - rapid onset infection with signs of inflammation
Otitis Media with Effusion (OME) - fluid in the middle ear without acute infection ("glue ear")
Chronic Suppurative Otitis Media (CSOM) - persistent perforation with recurrent or continuous discharge

Epidemiology

AOM is the most common infection for which children are seen in a physician's office. By age 7, 93% of children have had at least one episode, and 75% have had recurrent infections. Peak incidence is between 6 and 24 months of age.

Pathophysiology

The primary mechanism is Eustachian tube dysfunction - abnormal tubal compliance and delayed innervation of the tensor veli palatini muscle leads to tube collapse. This results in:

Negative middle ear pressure
Accumulation of fluid/effusion
Secondary bacterial colonization from the nasopharynx

A viral upper respiratory infection (URI) typically precedes AOM.

Common Pathogens

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

Viruses and anaerobes also contribute.

Risk Factors

Age < 2 years
Daycare attendance / exposure to URIs
Parental smoking
Bottle feeding in supine position
Male gender
Pacifier use
Craniofacial abnormalities (e.g., cleft palate)
Ethnic factors (Inuit, Native American)
Previous AOM episode (especially in prior 3 months)
Genetic predisposition

Diagnosis

Diagnosis of AOM requires both of:

Middle ear effusion (MEE) - confirmed by direct visualization of air-fluid level, bulging TM, reduced TM mobility on pneumatic otoscopy, or flat tympanogram
Signs of inflammation - at least one of:
- Acute onset otalgia (ear tugging/rubbing in nonverbal child)
- Moderate-to-severe bulging of the TM
- New-onset otorrhea not due to otitis externa
- Intense erythema of TM

Note: Erythema of the TM alone without effusion = myringitis (not AOM). Ear pain with a normal, flaccid TM suggests other causes (dental abscess, TMJ disorder, cervical arthritis, sore throat, sinusitis).

Bullous myringitis (blisters/bullae on TM) is a subset of AOM - treatment is the same as non-bullous AOM.

Signs and Symptoms

Otalgia (ear pain)
Fever
Otorrhea
Diminished hearing
Irritability, loss of appetite (in infants)
Tinnitus, vertigo, vomiting (less common)

Treatment

1. Observation vs. Immediate Antibiotics

Most AOM resolves spontaneously. A 2-3 day watchful waiting approach is appropriate in selected pediatric patients:

Age	Bilateral AOM	Unilateral AOM
< 6 months	Antibiotics	Antibiotics
6 months - 2 years	Antibiotics	Antibiotics if severe; observation if mild
> 2 years	Antibiotics if severe; observation if mild	Observation acceptable if mild

Severe = moderate-to-severe otalgia + fever > 39°C (102.2°F). Observation is NOT validated in adults.

2. Antibiotic Therapy

First-line: Amoxicillin

Patient Risk	Dose	Duration
Low-risk (>6 yr, no recent antibiotics, no otorrhea, temp <38°C)	40-50 mg/kg/day divided	5 days
High-risk (<2 yr, daycare, recent antibiotics, otorrhea, fever >38°C)	80-90 mg/kg/day divided	10 days

Treatment failure (symptoms persist after 3 days):

Amoxicillin-clavulanate (Augmentin): 80-90 mg/kg/day for 7-10 days
Cefuroxime axetil: 20-30 mg/kg/day for 7-10 days
Ceftriaxone IM: 50 mg/kg for 1-3 days

Penicillin-allergic patients:

Cefuroxime axetil or cefpodoxime (if no severe allergy)
Ceftriaxone IM

3. Pain Management

Antibiotics do not relieve pain in the first 24 hours. Use:

Acetaminophen or ibuprofen (OTC analgesics)
Topical analgesic ear drops (benzocaine) can be used if TM is intact

4. Special Situations

AOM with acute perforation/otorrhea - treat same as AOM without perforation; perforations typically heal spontaneously
Tympanostomy tubes with increased otorrhea - treat with ototopical fluoroquinolone drops (not systemic antibiotics)

Complications

Complication	Notes
Mastoiditis	Most common suppurative complication; rare in modern era
Meningitis	Spread via bony erosion or preformed pathways
Lateral sinus thrombosis	Rare, serious
Brain abscess	Rare
Labyrinthitis	Sensorineural hearing loss
TM perforation	Usually heals spontaneously
Cholesteatoma	From chronic disease/OME

Recurrent AOM / Prevention

Recurrent AOM (3 episodes in 6 months or 4 in 12 months) warrants consideration of tympanostomy tube insertion
Pneumococcal vaccine (PCV) has reduced AOM incidence
Avoid smoking exposure, pacifier use after 6 months, and bottle propping
Breastfeeding is protective

Recent Evidence (2025-2026)

A 2026 systematic review (PMID 41764103) found that shorter antibiotic courses (5 days) may be as effective as longer courses (10 days) in older children with AOM, but shorter courses are less effective in children under 2 years.

A 2025 Cochrane review (PMID 41307300) on decongestants and antihistamines for AOM in children confirmed that these agents are not recommended - no clinically meaningful benefit and potential for harm.

A 2026 meta-analysis (PMID 42359822) highlighted RSV as an important precursor to AOM in children under 5, reinforcing the role of viral respiratory infections in AOM pathogenesis.

Sources: Rosen's Emergency Medicine, 10e; Textbook of Family Medicine, 9e; The Harriet Lane Handbook, 23e

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