Some viral infections predispose, eg, RSV, influenza, and adeno (Nejm 1982;306:1377).

Serous OM often follows infectious resolution and correlates w socioeconomic status; smoking effect

Sx:Pain, severe and deep, unbothered by external ear manipulation, may improve suddenly w spontaneous drainage; sense of fullness; diminished hearing acuity

Si:Decreased hearing; inflamed drum often bulging; loss of light reflex, poor air movement and pain w pneumatic otoscopy

Acute usually improves within 48 h of starting antibiotics, and clears in <2 wk.

Serous OM is persistent OM w effusion which lasts >3 mo w hearing loss

• Ossicle necrosis esp of incus
• Chronic otitis with granulomas and polyps
• Mastoiditis leading to "erect ear" si, loss of post-auricular crease
• Meningitis and encephalitis
• Lateral sinus thrombosis with undulating fever and rigors, rx by tying jugular vein to stop spread
• Facial nerve paralysis, in chronic OM rx with surgical decompression
• Labyrinthitis, extension of infection through windows leading to vertigo, rx by destroying labyrinth
• Lateral semicircular canal involvement causes vertigo
• Chronic serous otitis
• Hearing acuity decrease with chronic involvement, but no diminished intellectual/verbal abilities if delay tubes (Nejm 1985;312:1529)

Lab:Parents unreliable as diagnosticians (Peds 2010;125:e1154)

Tympanometry (Fig 4.1) to evaluate middle ear effusions (Nejm 1982;307:1074); not helpful <age 6 mo

Figure 4.1 Tympanogram Interpretation.

Reproduced with permission from Micro Audiometrics Corp.

Xray:CT of mastoids show haziness early, sclerosis and erosion later

Rx:Prevent w

• Pneumococcal vaccine conjugated at age 2, 4, 6, and 12 mo, decr overall incid by 6%, vaccine type pneumococcal episodes by 20% (NNT-2 = 5) (Nejm 2001;344:403)
• Prophylactic antibiotics, rarely used now: sulfisoxazole, or amoxicillin, or Tm/S all at half rx doses as single hs dose × 3 mo or with URIs (Med Let 1983;25:102); as good as tubes
• Influenza vaccines do not decr incidence (Jama 2003;290:1608)

of acute OM (see management flow chart—Nejm 1995;332:1560): antibiotics, 1st, amoxicillin 40 mg/kg/d, or 60-90 mg/kg/d if pcn-resistant pneumococcus possible; 2nd, amoxicillin/clavulinic acid (Augmentin); 3rd, Tm/S (8/40 kg/24 h) in 2 doses; 4th, erythromycin + sulfa (Pediazole); 5th, cefaclor, et al. Or, if won't take po, ceftriaxone 50 mg/kg im up to 1 gm × 1, may dilute w lidocaine to decr pain (Rx Let 1998;5:10). 5 d rx may be enough over age 2 yr. Could give rx and tell to fill if not better on Tylenol in 48 h since only <1/7 cases, over age 2 yr and otherwise low risk, will need antibiotics and benefit at 2 wk no different than placebo (Jama 2006;296:1235; BMJ 2000;320:350); an especially good strategy if TM not bulging since most of these are viral (Nejm 2002;347:1169)

of serous OM: antibiotics may help clear (~1/3 over 1 mo after 2 wk rx), but many will clear spontaneously (Nejm 1987;316:432); steroids × 7-14 d with antibiotics (Arch Otolaryngol Head Neck Surg 1991;117:984)

Decongestants and antihistamines no help in acute or serous (BMJ 1983;287:654; Nejm 1983;308:297) though many practitioners still feel they help

Surgical: tubes help hearing acuity, but not verbal/intellectual losses (Nejm 2005;353:576; 2001;344:1179; 1985;312:1529) or long-term outcomes (Paradis Nejm 2007;356:248); polyp and granulation tissue removal; prosthetic replacement for ossicle necrosis. Mastoiditis can be rx’d with simple mastoidectomy, mastoid tympanoplasty, or radical mastoidectomy if advanced. Adenoidectomy may help serous OM esp w tubes (Nejm 2001;344:1188; 1987;317:1444; Jama 1999;282:945 vs 987)