Otitis Media

AUTHOR: Katherine Elizabeth McGraw, MD

Definition

Acute otitis media (AOM) is defined by infected middle ear fluid resulting in moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. Table 1 summarizes otitis media definitions and terminology. Care should be taken to differentiate AOM from serous otitis media, which involves noninfected middle ear fluid that does not result in bulging of the TM. Serous otitis media does not require antibiotic treatment.¹^,²

TABLE 1 Otitis Media Definitions and Terminology

Preferred Term	Definition	Comment
Otitis media (OM)	Inflammation of the middle ear without reference to etiology or pathogenesis	Nonspecific umbrella term for any condition associated with middle ear inflammation
Acute otitis media (AOM)	Rapid onset of signs and symptoms of inflammation in the middle ear	Diagnosed when there is moderate to severe bulging of the ear drum; mild bulging of the ear drum and recent (<48 h) onset of ear pain or intense erythema of the ear drum; or acute ear discharge unrelated to otitis externa (inflammation of the external ear canal)∗
Recurrent AOM (rAOM)	≥3 well-documented and separate AOM episodes in the preceding 6 mo or ≥4 episodes in the preceding 12 mo with >1 episode in the past 6 mo	Children without persistent MEE tend to have a good prognosis and often improve spontaneously; children with persistent MEE have a poorer prognosis and might benefit from ventilation tubes
Otitis media with effusion (OME)	Fluid in the middle ear without signs or symptoms of acute ear infection	Diagnosed by one or more of the following: Reduced ear drum mobility on pneumatic otoscopy, reduced ear drum mobility on tympanometry, opaque ear drum or a visible air-fluid interface behind the ear drum on otoscopy
Chronic OME	OME persisting for ≥3 mo from date of onset (if known) or from date of diagnosis (if onset is unknown)	Chronic OME has much lower rates of spontaneous resolution compared to OME of new onset or following an episode of AOM
Chronic suppurative otitis media (CSOM)	Chronic inflammation of the middle ear and mastoid mucosa with a nonintact ear drum (perforation or ventilation tube) and persistent ear discharge	No consensus on duration of ear discharge needed for diagnosis, with recommendations ranging from 2 wk to at least 3 mo
Middle ear effusion (MEE)	Fluid in the middle ear from any cause	MEE is present with both OME and AOM and might persist for weeks or months after the signs and symptoms of AOM resolve

^∗The degree of bulging does not reflect AOM severity. Severe AOM is defined as having moderate-to-severe ear pain, ear pain for at least 48 h, or temperature 39° C or higher.

From Flint PW et al: Cummings otolaryngology, head and neck surgery, ed 7, Philadelphia, 2021, Elsevier.

Synonyms

Acute suppurative otitis media

Purulent otitis media

Acute otitis media

AOM

ICD-10CM CODES
H65.3		Chronic mucoid otitis media
H66.0		Acute suppurative otitis media
H66.4		Suppurative otitis media, unspecified
H66.9		Otitis media, unspecified
H66.1		Chronic tubotympanic suppurative otitis media
H66.2		Chronic atticoantral suppurative otitis media

Epidemiology & Demographics

Incidence (In U.S.)

Affects patients of all ages but is largely a disease of infants and young children
Affects approximately 80% of all children by age 5 yr
Occurs three or more times in one third of all children by age 3 yr
Costs associated with otitis media exceed $5 billion, with 40% of the costs occurring from patients ages 1 to 3 yr
One of the most common indications for antibiotic prescription among children

Peak Incidence

AOM occurs at all ages but is most prevalent between 6 and 24 mo of age.
A second peak in incidence occurs between 4 and 6 yr of age.
AOM is most frequent in the fall, winter, and early spring (coincident with peak respiratory virus prevalence in the community).
Incidence of infection declines with age; AOM is seen infrequently in adults.

Risk Factors

Daycare attendance
Limited or no breastfeeding
Tobacco smoke exposure
Pacifier use
Craniofacial anomalies
Immune globulin G (IgG) or subclass deficiencies

Physical Findings & Clinical Presentation ³

Moderate to severe bulging of the TM.
Fluid in the middle ear along with signs and symptoms of local inflammation.
1. Erythema with diminished light reflex (Fig. E1)
As infection progresses, middle ear exudation occurs (exudative phase); the exudate rapidly changes from serous to purulent (suppurative phase).
Retraction and poor mobility of the TM ensues, and the TM begins to bulge.
At any time during the suppurative phase, the TM may rupture, releasing the middle ear contents (otorrhea).
Erythema of the TM without other abnormalities is not a diagnostic criterion for acute otitis media (AOM) because it may occur with any inflammation of the upper respiratory tract, crying, or nose blowing.
Symptoms ¹:
1. Rapid- or recent-onset otalgia, ranging from slight discomfort to severe, is the most common presenting symptom.
2. Hearing loss while middle ear fluid is present.
3. Otorrhea (if TM has ruptured).
4. Systemic symptoms such as fever, listlessness, irritability, decreased appetite, vomiting, and diarrhea are common. Although vertigo, facial swelling, nystagmus, tinnitus, lethargy, and facial nerve palsies can occur as rare complications of AOM; these symptoms should prompt consideration of an alternate diagnosis.
5. Table 2 summarizes symptom scoring systems designed to aid in diagnosis.
After an episode of AOM:
1. Persistence of effusion for weeks or months (called secretory, serous, or nonsuppurative otitis media)
2. Fever and otalgia usually absent
3. Hearing loss possible (10 to 50 dB, with predominant involvement of the low frequencies)
4. Manifestations of the sequelae and complications of otitis media are summarized in Table E3

TABLE 2 Acute Otitis Media Symptom Scoring Systems Designed to Aid in Diagnosis

3-Item Otitis Media Score (OM-3)	Ear Treatment Group Symptom Questionnaire (ETG-5)	Acute Otitis Media Faces Scale (AOM-FS)	Otoscopic Severity Scale (OS-8)	Acute Otitis Media Severity of Symptom Scale (AOM-SOS)	Otitis Media Clinical Severity Index (OM-CSI) 30-Point Scale ^a	Otitis Media Clinical Severity Index (OM-CSI) 10-Point Scale ^a
Physical suffering	Ear pain	Seven facial expressions ranging from no problem to extreme problem	Eight categories of TM inflammation ^b	Ear pain	Ear pain	Ear pain
Emotional distress	Fever			Ear tugging	Fever	Fever
Limitation of activities	Irritability			Irritability	Irritability	Irritability
	Appetite			Decreased play	Fever at examination	Fever at examination
	Sleep quality			Decreased appetite	TM erythema	TM erythema
				Difficulty sleeping	TM mobility	TM mobility
				Fever	TM position	TM position
					Effusion color	Effusion color
					Otorrhea	Otorrhea

TM, Tympanic membrane.

^aThe 30-point scale used a 2- to 5-point Likert scale and the 10-point scale used a 2- to 3-point Likert scale.

^b0 = normal; 1 = erythema only; 2 = erythema, air-fluid level, clear fluid; 3 = erythema, complete effusion, no opacification; 4 = erythema, opacification with air-fluid level or air bubbles, no bulging; 5 = erythema, complete effusion, opacification, no bulging; 6 = erythema, bulging rounded doughnut appearance of the tympanic membrane; 7 = erythema, bulging, complete effusion and opacification with bulla formation.

From Cherry JD et al: Feigin and Cherry’s pediatric infectious diseases, ed 8, Philadelphia, 2019, Elsevier.

Figure E1 Transition from Normal to Otitis Media with Effusion (Ome) to Acute Otitis Media

A, Normal tympanic membrane with pearly gray, translucent appearance. B, OME with air bubbles. C and D, OME fully filled with effusion; note retracted and translucent tympanic membrane with prominent head of the malleus. E, Slight bulging with semiopaque white tympanic membrane. F, Bulging semiopaque tympanic membrane. G, Markedly bulging, donut appearance, opaque, white tympanic membrane. H and I, Severe bulging with bullae formation.

Courtesy Dr. Hoberman, University of Pittsburgh. In Cherry JD et al: Feigin and Cherry’s pediatric infectious diseases, ed 8, Philadelphia, 2019, Elsevier.

TABLE E3 Manifestations of the Sequelae and Complications of Otitis Media

Complication		Clinical Features
Acute
Perforation with otorrhea		Immobile tympanic membrane secondary to visible perforation, exudate in ear canal
Acute mastoiditis with periostitis		Tenderness and erythema over mastoid process, no destruction of bony trabeculae
Acute mastoid osteitis		Destruction of bony trabeculae; tenderness and erythema over mastoid process coupled with outward displacement of pinna
Petrositis		Infection of perilabyrinthine cells; may present with otitis, paralysis of lateral rectus, and ipsilateral orbital or facial pain (Gradenigo syndrome)
Facial nerve palsy		Peripheral cranial nerve VII paralysis
Labyrinthitis		Vertigo, fever, ear pain, nystagmus, hearing loss, tinnitus, nausea and vomiting
Lateral sinus thrombosis		Headache, fever, seizures, altered states of consciousness, septic emboli
Meningitis		Fever, headache, nuchal rigidity, seizures, altered states of consciousness
Intracranial empyema or brain abscess		Fever, headache, seizures, altered states of consciousness, focal neurologic examination findings
Nonacute
Chronic perforation		Immobile tympanic membrane secondary to perforation
Otitis media with effusion (OME)		Immobile, opaque tympanic membrane
Adhesive otitis		Irreversible conductive hearing loss secondary to chronic OME
Tympanosclerosis		Thickened white plaques may cause conductive hearing loss
Chronic suppurative otitis media		Following acute otitis media with perforation, secondary infection with Staphylococcus aureus, Pseudomonas aeruginosa, or anaerobes develops, causing chronic otorrhea
Cholesteatoma		White, pearl-like, destructive tumor with otorrhea arising near or within tympanic membrane; may be secondary to chronic negative middle ear pressure
Otitic hydrocephalus		Increased intracranial pressure secondary to AOM; signs and symptoms include severe headaches, blurred vision, nausea, vomiting, papilledema, diplopia (abducens paralysis)

AOM, Acute otitis media.

From Kliegman RM: Nelson textbook of pediatrics, ed 21, Philadelphia, 2020, Elsevier.

Etiology

Most common etiology is a viral upper respiratory tract infection, which causes inflammation and dysfunction of the eustachian tube and transient aspiration of nasopharyngeal secretions into the middle ear (Fig. 2). Bacterial colonization from the nasopharynx in conjunction with eustachian tube dysfunction leads to infection.
May occasionally develop as a result of hematogenous spread or by direct invasion from the nasopharynx.
Conjugated pneumococcal vaccination of children has resulted in decreases in Streptococcus pneumoniae causing AOM.
Most common bacterial pathogens ⁴^,⁵:
1. Haemophilus influenzae is now the most common causative pathogen of AOM in children.
2. S. pneumoniae causes up to half of cases and is the least likely of the major pathogens to resolve without treatment.
3. Moraxella catarrhalis.
Of increasing importance, infection caused by penicillin-nonsusceptible S. pneumoniae (MIC >0.1 mg/ml), ranging from 8% to 34%. About 50% of PNSSP isolates are penicillin-intermediate (MIC 0.1 to 2.0 mg/ml).
Group A streptococci is associated with higher rates of TM perforation than AOM caused by other pathogens.
Viral pathogens:
1. Respiratory syncytial virus (RSV)
2. Rhinovirus
3. Adenovirus
4. Influenza
Others:
1. Mycoplasma pneumoniae
2. Chlamydia trachomatis
3. Streptococcus pyogenes (Latin America)

Figure 2 Pathogenesis of virus-induced acute otitis media.

URI, Upper respiratory infection.

From Cherry JD et al: Feigin and Cherry’s pediatric infectious diseases, ed 8, Philadelphia, 2019, Elsevier.

Diagnosis ⬆ ⬇

Differential Diagnosis

Otitis externa
Otitis media with effusion (OME): An algorithm for distinguishing between acute otitis media and otitis media with effusion is illustrated in Fig. 3
Referred pain from mouth, nasopharynx, or throat
Section II describes the differential diagnosis of earache

Figure 3 Algorithm for Distinguishing Between Acute Otitis Media and Otitis Media with Effusion

TM, tympanic membrane.

From Kliegman RM: Nelson textbook of pediatrics, ed 21, Philadelphia, 2020, Elsevier.

Workup (TABLE 4

Thorough otoscopic examination. AOM is a visual diagnosis based on viewing the tympanic membrane. Adequate visualization of the tympanic membrane may require removal of cerumen and debris from the external ear canal.

Tympanometry
1. Measures compliance of the tympanic membrane and middle ear pressure
2. Detects the presence of fluid, but cannot determine whether the fluid is infected
Acoustic reflectometry
1. Measures sound waves reflected from the middle ear
2. Is useful in infants >3 mo
3. Increased reflected sound correlated with the presence of effusion, but cannot determine whether the fluid is infected

TABLE 4 Diagnostic Modalities for Otitis Media

Modality	Description	Comment
Signs and symptoms (obtained by history)	Includes ear-specific symptoms (ear pain, hearing loss), nonspecific symptoms (nausea, irritability, sleep disturbance, anorexia), and signs (fever, vomiting)	The hallmark of AOM and OME are ear pain and hearing loss, respectively, but signs and symptoms alone have poor diagnostic accuracy
Symptom severity scales	Parent-reported measures of AOM severity using categoric responses or a faces scale	Not useful for AOM diagnosis, but can be used to rate severity, follow the course of disease, and assess outcomes
Otoscopy	Visual examination of the ear canal and tympanic membrane with an otoscope	Bulging tympanic membrane is characteristic of AOM; opaque or cloudy tympanic membrane is characteristic of OME
Pneumatic otoscopy	Examination of the middle ear using an otoscope to create an air-tight (hermetic) seal in the ear canal and then gently squeezing (or releasing) the attached rubber bulb to change the pressure in the ear canal and observe the tympanic membrane	A normal tympanic membrane moves briskly with applied pressure, but the movement is minimal or sluggish when there is fluid in the middle ear; no motion is observed if tympanic membrane is not intact
Otomicroscopy	Examination of the ear canal and tympanic membrane using the binocular, otologic microscope to obtain a magnified view with good depth perception	Primary use is to assess tympanic membrane abnormalities (atrophy, sclerosis, retraction pockets) and to help distinguish surface findings from middle ear pathology
Tympanometry	An objective measure of middle ear function that requires an air-tight seal in the ear canal. Tympanometry provides a graph showing how energy admitted to the ear canal is reflected back to an internal microphone while the canal pressure is varied from negative to positive (pressure admittance function) and can be performed with a portable (handheld) unit or a desktop machine	If the middle ear is filled with fluid, tympanic membrane vibration is impaired and the result is a flat, or nearly flat, tracing. If the middle ear is filled with air but at a higher or lower pressure than the surrounding atmosphere, the peak on the graph will be shifted in position based on the pressure (to the left if negative, to the right if positive)
Acoustic reflectometry	Uses a transducer and microphone at the entrance of the ear canal, without an air-tight seal, to measure how much sound is reflected off the tympanic membrane	Higher reflectivity levels indicate a greater probability of effusion, but unlike tympanometry it only assesses the probability of effusion and cannot measure middle ear function
Computed tomography	An imaging procedure, using ionizing radiation, to create a detailed scan of the temporal bone	Useful in surgical planning for CSOM but not useful for primary diagnosis of AOM, OME, or CSOM

AOM, Acute otitis media; CSOM, chronic suppurative otitis media; OME, otitis media with effusion.

From Flint PW et al: Cummings otolaryngology, head and neck surgery, ed 7, Philadelphia, 2021, Elsevier.

Laboratory Tests

Tympanocentesis.
1. Not necessary in most cases because the microbiology of middle ear effusions has been shown to be extremely consistent
2. May be indicated in:
  1. Patients who do not respond to treatment in 72 hr or those who experience multiple treatment failures
  2. Immunocompromised patients
Cultures of the nasopharynx are not helpful.
Blood counts (generally unnecessary) usually reveal leukocytosis with polymorphonuclear elevation.
Plain mastoid radiographs (generally unnecessary) reveal haziness in the periantral cells that may extend to entire mastoid.
CT or MRI may be indicated if serious complications are suspected (meningitis, brain abscess, severe mastoiditis).

Treatment ⬆ ⬇

Acute General Rx

Hydration, avoidance of irritants (e.g., tobacco smoke, air pollution, bottle feeding), nasal decongestants, cool mist humidifier, and oral ibuprofen or acetaminophen. Topical procaine or lidocaine preparations (if available) are an alternative to oral analgesics for children ≥2 yr but should not be used in children with tympanic membrane perforation.³
Antibiotics: See section on ‘Complementary & Alternative Medicine Therapies’.

Surgical Rx

There is no evidence to support the routine use of myringotomy, but in severe cases it provides prompt pain relief and accelerates resolution of infection.
Purulent secretions retained in the middle ear can lead to increased pressure that may lead to spread of infection to contiguous areas. Myringotomy to decompress the middle ear is sometimes necessary to avoid complications such as mastoiditis, facial nerve paralysis, labyrinthitis, meningitis, and brain abscess.

Chronic Rx

Among children 6 to 35 mo of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-yr period is not significantly lower with tympanostomy-tube placement than with medical management, however myringotomy and tympanostomy tube placement for persistent or recurrent middle ear effusion unresponsive to medical therapy can be considered if fluid has persisted for ≥3 mo if bilateral or ≥6 mo if unilateral.
Adenoidectomy, with or without tonsillectomy, often is advocated for treatment of recurrent otitis media, although evidence for this procedure is controversial.
Long-term complications include tympanic membrane perforations, cholesteatoma, tympanosclerosis, ossicular necrosis, toxic or suppurative labyrinthitis, hearing loss, and intracranial suppuration.

Disposition

Patients can be treated at home as outpatients with the rare exception of patients with evidence of local suppurative complications (e.g., meningitis, acute mastoiditis, brain abscess, cavernous sinus, or lateral sinus thrombosis).

Complementary & Alternative Medicine Therapies ⁶

Xylitol and vitamin intake may help prevent further otitis media.⁷
Biologically based therapies such as botanical extracts can be used if there is no perforation (all prepared in an olive oil base) and can be a reasonable complement during observation period or with the wait-and-see approach.
1. Calendula
2. Hypericum perforatum homeopathic preparation-can help with pain ⁷
3. Lavendar
4. Vitamin E oil
Manipulative methods have also been used by those properly trained in osteopathic manipulation and chiropractic techniques. Osteopathy requires weekly treatment for 3 wk and is an adjunct to other treatment modalities. Chiropractic techniques: Little is published and there are currently no randomized controlled trials on PubMed.
Chinese medicine has shown promising results but demands further research.⁷

Antimicrobials:

Note: Most uncomplicated cases of AOM resolve spontaneously, without complications. Studies have demonstrated limited therapeutic benefit from antibiotic therapy. Watchful waiting is appropriate for children who look well, can be comforted with supportive care, and are old enough to easily evaluate. Children <24 mo with bilateral AOM should receive antibiotic therapy. Children with severe signs or symptoms (moderate or severe otalgia or otalgia for ≥48 h or temperature ≥39° C) should also receive antibiotic therapy. Fig. E4 illustrates an algorithm for management of acute otitis media in pediatric populations.

Figure E4 Congenital chronic otitis media with cholesteatoma.

AOM, Acute otitis media; IM, intramuscular; IV, intravenous; MEE, middle-ear effusion.

From Chole RA, Sudhoff HH: Chronic otitis media, mastoiditis, and petrositis. In Flint PW, Haughey BH, Lund VJ et al [eds]: Cummings otolaryngology-head and neck surgery, ed 5, Philadelphia, 2010, Elsevier, Fig 139-6. In Kliegman RM: Nelson textbook of pediatrics, ed 21, Philadelphia, 2020, Elsevier.

When opting to use antibiotic therapy ²^,⁴^,^8-10:

Amoxicillin has been used for years as first line treatment of AOM but because of increased prevalence of AOM caused by beta-lactamase strains of H. influenzae and M. catarrhalis some expert clinicians now recommend amoxicillin-clavulanate for initial treatment.
Treatment failure is defined by lack of clinical improvement of signs or symptoms after 3 days (72 h or greater) of therapy.
With treatment failure (if using amoxicillin), in the absence of an identified etiologic pathogen, therapy should be redirected to cover:
1. Drug-resistant S. pneumoniae
2. β-lactamase-producing strains of H. influenzae and M. catarrhalis
Agents fulfilling these criteria include amoxicillin/clavulanate, second-generation (e.g., cefuroxime axetil, cefaclor) or third-generation (e.g., oral cefdinir or cefpodoxime or IM ceftriaxone) cephalosporins. Cefaclor, cefixime, loracarbef, and ceftibuten should be avoided given their limited activity against pneumococci.
Cross-resistance between TMP/SX and macrolides and the β-lactams exists; therefore patients who do not respond to amoxicillin are more likely to have infections resistant to TMP/SMX and macrolides.
Fluoroquinolones are not indicated as first- or second-line therapy for AOM and should be avoided in young children due to risks of musculoskeletal effects and limited dosing guidance and limited availability of oral suspension compounds or compounding pharmacies.
Treatment should be modified according to cultures and sensitivities when available.
Treatment course is 10 days for children <2 yr and those with severe symptoms, 7 days for children age 2 to 5 yr, and 5 to 7 days for children ≥6 yr.
Follow-up should be tailored to clinical improvement and concern for neurocognitive developmental delays in at-risk children. Standard follow-up of all cases is no longer recommended.
Antibiotic prophylaxis to reduce the frequency of AOM episodes in children with recurrent AOM is not recommended.
Table E5 summarizes suggested antibiotics for treatment of otitis media and for patients who have failed first-line antibiotic treatment.

TABLE E5 Suggested Antibiotics for Treatment of Otitis Media and for Patients Who Have Failed First-Line Antibiotic Treatment

Initial Immediate or Delayed Antibiotic Treatment		Antibiotic Treatment After 48-72 h of Failure of Initial Antibiotic Treatment
Recommended First-Line Treatment	Alternative Treatment (If Penicillin Allergy or Suspicion of Beta Lactamase-Producing Organisms)	Recommended Treatment	Alternative Treatment
Amoxicillin (Pathogens include Pneumococcus, H. influenzae nontype B, Moraxella)	Cefdinir	Amoxicillin-clavulanate	Ceftriaxone
Or	Or	Or	Failure of second antibiotic
Amoxicillin-clavulanate Ceftriaxone IM/IV for 1-3 days	Cefpodoxime Ceftriaxone Levofloxacin	Ceftriaxone	Azithromycin Tympanocentesis ∗
Antibiotic Dosage
Amoxicillin 90 mg/kg/day bid for 10 days Amoxicillin-clavulanate (ratio 14:1) 90 mg/kg/day of amoxicillin component bid for 10 days Ceftriaxone 50 mg/kg/day daily IM, IV for 1-3 days Cefdinir 14 mg/kg/day daily for 10 days Cefpodoxime 10 mg/kg/day bid for 10 days Levofloxacin 20 mg/kg/day bid if ≤5 yr for 10 days; 10 mg/kg/day bid if >5 yr for 10 days Azithromycin 10 mg/kg/day on day 1 daily then 5 mg/kg/day days 2-5 daily or 10 mg/kg/day for 3 days daily or 20 mg/kg once

IM, Intramuscular; IV, intravenous; bid, twice daily.

Note: Effusions may persist for 8 wk or longer in many cases of adequately treated otitis media.

^∗Tympanocentesis for those who fail second-line therapy.

From Kliegman RM: Nelson textbook of pediatrics, ed 21, Philadelphia, 2020, Elsevier.

Referral

To otorhinolaryngologist in cases of:
1. Medical treatment failure
2. An uncertain diagnosis; adults with one or more episodes of AOM should be referred for evaluation to rule out an underlying process (e.g., malignancy)
3. Any of the above-mentioned acute and chronic complications

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Basic Information ⬇

Diagnosis ⬆ ⬇

Treatment ⬆ ⬇

Pearls & Considerations ⬆ ⬇

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