Otitis media
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Otitis Media
Definition and Classification
Otitis media (OM) refers to inflammation of the middle ear. It is classified into three main types:
| Type | Description |
|---|---|
| Acute Otitis Media (AOM) | Acute-onset infection with middle ear effusion and signs of inflammation |
| Otitis Media with Effusion (OME) | "Glue ear" - middle ear fluid without signs of acute infection |
| Chronic Suppurative Otitis Media (CSOM) | Persistent purulent otorrhea through a perforated tympanic membrane |
Epidemiology
AOM is the most common infection for which children visit a physician. By age 7, ~93% of children have had at least one episode, and 75% have had recurrent infections. The peak incidence is between 6 and 24 months of age. Annual cost in the US is estimated at $2.88 billion. - Textbook of Family Medicine 9e
Pathophysiology
The primary mechanism is Eustachian tube (ET) dysfunction. Abnormal tubal compliance, combined with delayed innervation of the tensor veli palatini muscle, leads to ET collapse. This creates negative middle ear pressure, impairs mucociliary clearance, and allows nasopharyngeal bacteria to colonize the middle ear. A viral upper respiratory infection (URI) typically precedes an episode. - Textbook of Family Medicine 9e
Role of GERD: Pepsin/pepsinogen has been detected in middle ear effusions at concentrations higher than in serum. Acid reflux reduces ciliary motility and increases ET opening/closing pressures. However, no causal relationship has been definitively established, and antireflux therapy is not currently supported for OM. - Scott-Brown's Otorhinolaryngology Vol 2
Microbiology
The three most common bacteria:
- Streptococcus pneumoniae - 25-40% of cases
- Haemophilus influenzae - 10-30% of cases
- Moraxella catarrhalis - 2-15% of cases
Viruses and anaerobes may also contribute. - Textbook of Family Medicine 9e, ROSEN's Emergency Medicine
Risk Factors
- Male gender
- Age < 2 years
- Bottle feeding (especially supine)
- Daycare attendance / exposure to URIs
- Parental smoking
- Pacifier use
- Genetic and ethnic factors (Inuit, Native American populations)
- Craniofacial abnormalities (e.g., cleft palate)
- Allergy
- Previous episode of AOM within the last 3 months
Textbook of Family Medicine 9e
Diagnosis
AOM diagnostic criteria (all three required):
- Acute onset of symptoms (ear pain, tugging/holding ear in non-verbal child)
- Middle ear effusion (MEE) - confirmed by bulging TM, air-fluid level, absent TM mobility on pneumatic otoscopy, or flat tympanogram
- Signs of middle ear inflammation - TM erythema, moderate-to-severe TM bulging, new otorrhea not from otitis externa
Note: Erythema of the TM alone without MEE is myringitis/tympanitis - a separate diagnosis. Ear pain with a normal, flaccid TM points toward other causes (dental abscess, TMJ disorder, cervical arthritis, sinus infection, pharyngitis, nasopharyngeal carcinoma). - Textbook of Family Medicine 9e
Bullous myringitis: Bullae on the TM are seen in some AOM cases - treatment does not differ from non-bullous AOM. - ROSEN's Emergency Medicine
Management
Analgesia (First 24 Hours)
Antibiotics alone do NOT reduce pain in the first 24 hours. Acetaminophen or ibuprofen should be used immediately for pain relief. - ROSEN's Emergency Medicine
Watchful Waiting ("Wait-and-See")
Most cases of AOM resolve spontaneously. Observation for 2-3 days may be offered (with a safety-net prescription) in appropriately selected children. Observation is not validated in adults. - ROSEN's Emergency Medicine
Antibiotic Treatment
| Patient Group | Antibiotic | Dose / Duration |
|---|---|---|
| Low-risk (>6 yr, no abx in past 3 mo, no otorrhea, not in daycare, temp <38°C) | Amoxicillin | 40-50 mg/kg/day divided doses x 5 days |
| High-risk (<2 yr, daycare, abx in past 3 mo, otorrhea, temp >38°C) | Amoxicillin | 80-90 mg/kg/day divided doses x 10 days |
| Treatment failure (symptoms persist >72 hours) | Amoxicillin-clavulanate | 80-90 mg/kg/day x 7-10 days |
| Penicillin allergy | Cefuroxime axetil, cefpodoxime, or ceftriaxone IM | See dosing table |
- High-dose amoxicillin (80-90 mg/kg/day) overcomes penicillin-resistant S. pneumoniae (resistance via altered penicillin-binding proteins, NOT beta-lactamase).
- Macrolides are not recommended in children because H. influenzae dominates and is resistant.
- Middle ear fluid sterilizes 3-6 days after starting treatment.
- If amoxicillin-clavulanate fails, IM ceftriaxone x 3 days is the next step.
Textbook of Family Medicine 9e
AOM with Perforation
Treat the same as AOM without perforation - perforations are typically small and resolve spontaneously. - ROSEN's Emergency Medicine
Tympanostomy Tube Otorrhea
If a patient with tympanostomy tubes develops increased otorrhea, treat with ototopical fluoroquinolone drops (not oral antibiotics). - ROSEN's Emergency Medicine
Otitis Media with Effusion (OME)
OME is middle ear fluid without signs of acute infection. It commonly follows AOM or can arise independently. Management is generally watchful waiting for 3 months. If persistent, tympanostomy tube insertion is the primary surgical intervention. Associated hearing loss should be monitored, as it can impair speech and language development.
Chronic Suppurative Otitis Media (CSOM)
Persistent purulent otorrhea through a perforated TM or tympanostomy tube. May result from AOM, chronic ET dysfunction, trauma, or cholesteatoma.
- Symptoms: Otorrhea, hearing loss, tinnitus
- Red flags warranting urgent ENT referral: increasing pain, vertigo, facial palsy
- Imaging: CT for bony erosion; MRI if CNS involvement suspected
- Treatment:
- Culture and sensitivity-guided antibiotics
- Ototopical quinolones - superior to oral antibiotics (Cochrane review evidence)
- Topical aminoglycosides carry ototoxicity risk - avoid if TM not intact
- Systemic antibiotics for severe cases
- Aural toilet with dilute acetic acid solution
- Surgery: Tympanoplasty for persistent perforation; tympanomastoidectomy for refractory cases
Textbook of Family Medicine 9e
Complications
Although uncommon in the antibiotic era, OM complications can be serious:
Intratemporal:
- Acute mastoiditis - most common suppurative complication; fever, post-auricular tenderness/erythema/edema; clinical (not purely radiologic) diagnosis
- Facial nerve paralysis - from inflammation along the nerve's middle ear course
- Labyrinthitis / sensorineural hearing loss
- Tympanic membrane perforation, retraction, tympanosclerosis
- Petrositis, labyrinthine fistula
Intracranial:
- Brain abscess
- Epidural abscess
- Meningitis
- Lateral sinus thrombosis
- Subdural empyema
- Otitic hydrocephalus
Textbook of Family Medicine 9e, ROSEN's Emergency Medicine
Hearing Loss in OM
- SNHL is rarely associated with acute OM
- Patients with long-standing chronic OM commonly develop mixed hearing loss (conductive + sensorineural)
- Whether the sensorineural component is from the infection itself vs. ototoxic topical antibiotics or surgery remains controversial - Cummings Otolaryngology
Recent Evidence (2025-2026)
- A 2025 Cochrane systematic review (PMID 41307300) found decongestants and antihistamines are not effective for AOM in children.
- A 2026 systematic review (PMID 41764103) examined shorter vs. longer antibiotic courses in pediatric AOM - supports the trend toward shorter courses in low-risk children.
- A 2026 meta-analysis (PMID 42359822) confirms RSV as a significant pathogen associated with AOM in children under 5 - relevant as RSV vaccines are now becoming available.
Sources: ROSEN's Emergency Medicine, Textbook of Family Medicine 9e, Cummings Otolaryngology Head and Neck Surgery, Scott-Brown's Otorhinolaryngology Vol 2
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