DESCRIPTION

• Inflammation of the middle ear
• Most commonly occurs in children 6–36 mo
• Rapid onset of local and/or systemic symptoms
• More than 1/3 of children experience > 5 episodes by the age of 7 yr

ETIOLOGY

• Usually associated with (or as a result of) upper respiratory tract infections
• Viral:
  • Parainfluenza
  • Respiratory syncytial virus
  • Influenza
  • Adenovirus
  • Rhinovirus
• Bacterial:
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
  • Haemophilus influenzae
  • Streptococcus pyogenes
  • Mycoplasma pneumoniae
• Associated with blockage of eustachian tube
• Predisposing factors:
  • Deficient mucus, cilia, or antibodies
  • Intubation, especially nasotracheal
  • American Indians, Eskimos
  • Down syndrome
  • Cleft palate
  • Diabetes
  • Vitamin A deficiency
  • HIV
• Risk factors
  • Family history
  • Daycare
  • Parental smoking
  • Pacifier use
  • Bottle-feeding

[Outline]

• DESCRIPTION
• ETIOLOGY

From the American Academy of Pediatrics 2013 Guidelines:

• Diagnose otitis media (OM) when:
  • Moderate to severe bulging of tympanic membrane (TM)
  • Mild bulging of TM and recent onset of ear pain (tugging, pulling, rubbing in nonverbal child)
  • New otorrhea not due to acute otitis externa
• Should not diagnose if no middle ear effusion (pneumatic otoscopy and/or typanometry)
• Recurrent OM:
  • 3 episodes in 6 mo or
  • 4 episodes in the last year with 1 in the past 6 mo

SIGNS AND SYMPTOMS

History

• Ear pain (otalgia)
• Irritability
• Rhinitis
• Vomiting, diarrhea
• Poor feeding
• Fever
• Sensation of plugged ear
• Pulling at ear
• Vertigo, tinnitus
• Conjunctivitis

Physical Exam

• TM inflammation, bulging, and limited mobility
• New onset otorrhea without evidence of otitis externa
• Decreased visibility of the landmarks of the middle ear

ESSENTIAL WORKUP

• Exclude associated conditions
• Consider full septic workup for sick patients with fever
• Otoscopic exam for appearance and mobility of TM:
  • Full visualization essential
  • Increased vascularity, erythema, purulence
  • Obscured landmarks—bony, light reflex
  • Pneumatic otoscopy—bulging, retracted, decreased mobility

DIAGNOSIS TESTS & INTERPRETATION

Lab

Cultures unhelpful unless done by tympanocentesis

Imaging

CT scan if associated mastoiditis is suspected

Diagnostic Procedures/Surgery

• Tympanocentesis—indications:
  • Severe pain or toxicity
  • Failure of antimicrobial therapy
  • Suspicion of suppurative complication
  • Sick neonate
  • Immunocompromised patient
• Tympanometry and acoustic otoscopy may be useful with difficult exams

DIFFERENTIAL DIAGNOSIS

• Infection:
  • Otitis externa
  • Mastoiditis
  • Dental abscess
  • Allergic rhinitis
  • Cholesteatoma
  • Peritonsillar abscess
  • Sinusitis
  • Lymphadenitis
  • Parotitis
  • Meningitis
• Trauma:
  • Perforation of the TM
  • Foreign body in ear
  • Barotrauma
  • Instrumentation
• Serous OM or eustachian tube dysfunction
• Impacted ear cerumen
• Impacted 3rd molar
• Temporomandibular joint dysfunction

[Outline]

• INFORMATION
• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

ED TREATMENT/PROCEDURES

• Most mild cases could resolve without antibiotics
• Antibiotics are indicated for:
  • All infants < 6 mo
  • Children < 2 yr with bilateral OM
  • Bilateral OM in kids < 2 yr
  • Children > 6 mo with severe infection (otalgia for > 48 hr or temperature 102.2°F or higher)
  • Bilateral OM in kids < 2 yr
  • Children > 6 mo with ruptured TM with drainage
• For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2–3 days:
  • For reliable parents, may provide a prescription for oral antibiotics, which the family can fill if the child's symptoms get worse or persist after 2 days
• Considerations should include recurrent nature of OM, lack of clinical response, and resistance patterns in community
• Parenteral antibiotics are indicated in febrile toxic children < 1 yr or with immunocompromise
• Antihistamines, decongestants, and steroids have no proven efficacy
• Antipyretics and analgesics are important (avoid local analgesics in perforated TMs)

MEDICATION

• Antibiotics:
  • Amoxicillin: 500–875 mg PO q12h (peds: 80–90 mg/kg/d PO div. q12h) for 10 days
  • Amoxicillin–clavulanic acid: 500–875 mg PO q12h (peds: 90 mg/kg/d PO q12h) for 10 days
  • Azithromycin: 10 mg/kg PO day 1, then 5 mg/kg/d PO days 2–5
  • Cefuroxime: 500 mg PO q12h (peds: 30 mg/kg/d PO div. q12h)
• Analgesia:
  • Acetaminophen: 500 mg PO q6h (peds: 15 mg/kg per dose orally/rectally every 4–6 hr); not to exceed 4 g/24 h
  • Antipyrine/benzocaine (5.4%/1.4% solution): 2–4 drops in ear QID PRN
  • Ibuprofen: 400–600 mg PO q6–8h (peds: 10 mg/kg per dose orally every 6 hr)

[Outline]

• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

Febrile toxic children who are:

• < 1 yr, immunocompromised
• Moderately or severely dehydrated
• Unable to tolerate oral fluids or medications
• Suspected or proven associated significant infection
• Suspected abuse
• Unreliable caretaker

Discharge Criteria

Children without any of the aforementioned criteria

FOLLOW-UP RECOMMENDATIONS

• Follow-up in 10–14 days to ensure resolution
• Indications for earlier follow-up:
  • Child does not get better in 24–48 hr
  • Any progression of signs or symptoms
  • New problems develop, including a rash
  • Any concerns arise

COMPLICATIONS

• Recurrent OM:
  • 3 episodes within 6 mo or
  • 4 episodes in 1 yr with the last within 6 mo
• Perforated TM
• Serous OM
• Hearing loss (conductive and sensorineural)
• Facial nerve injury
• Mastoiditis
• Cholesteatoma
• Meningitis
• Subdural empyema
• Labyrinthitis
• Epidural abscess
• Venous sinus thrombosis

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS
• COMPLICATIONS

For otherwise normal healthy patients ≥6 mo with mild symptoms and/or uncertain diagnosis, consider no antibiotics and repeat evaluation in 2–3 days.

ICD9

• 381.4 Nonsuppurative otitis media, not specified as acute or chronic
• 381.60 Obstruction of Eustachian tube, unspecified
• 382.9 Unspecified otitis media

ICD10

• H65.90 Unspecified nonsuppurative otitis media, unspecified ear
• H66.90 Otitis media, unspecified, unspecified ear
• H68.109 Unspecified obstruction of Eustachian tube, unspecified ear

[Outline]

• ICD9
• ICD10

• American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451–1465.
• Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: A systematic review. JAMA. 2010;304:2161–2169.
• Fischer T, Singer AJ, Lee C, et al. National trends in emergency department antibiotic prescribing for children with acute otitis media, 1996–2005. Acad Emerg Med. 2007;14:1172–1175.
• Greenberg D, Hoffman S, Leibovitz E, et al. Acute otitis media in children: Association with day care centers–antibacterial resistance, treatment, and prevention. Paediatr Drugs. 2008;10:75–83.
• Gunasekera H, Morris PS, McIntyre P, et al. Management of children with otitis media: A summary of evidence from recent systematic reviews. J Paediatr Child Health. 2009;45:554–562.
• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964–e999.
• Powers JH. Diagnosis and treatment of acute otitis media: Evaluating the evidence. Infect Dis Clin North Am. 2007;21:409–426.
• Spiro DM, Arnold DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr. 2008;20:72–78.

Assaad J. Sayah