A. Introduction

1. Most common primary diagnosis in pediatrics
   1. Typically in children younger than 15 years old; peak onset before age 1 year
   2. More than 50% of children have repeat episodes of otitis media by age 3 years
   3. Nearly 40% of older children have at least 6 episodes
   4. Genetic component: increased concordance in monozygotic versus dizygotic twins [3]
   5. Increased risk in patients with Down Syndrome and cleft palate
   6. Usually self limited but can progress to severe mastoid infection
   7. Increased risk with parental smoking, family history, day care outside home
2. Classification
   1. Acute otitis media - inflammation of middle ear, pain, fever
   2. Otitis media with effusion - asymptomatic middle ear effusion (or "plugged ear")
   3. Recurrent Acute Otitis Media - three new episodes within 6 month period
   4. Otitis Media with Residual Effusion - concern about hearing loss
3. Acute Otitis Media (AOM)
   1. Acute onset of pain, usually with fever, constitutional symptoms
   2. Anorexia, nausea, vomiting, irritability may occur
   3. Decreased mobility of red/yellow tympanic membrane
   4. Viral effusions usually do not cause bulging tympanic membrane
   5. Bacterial effusions typically cause bulging tympanic membrane with pus behind it
4. Otitis Media with Effusion (OME)
   1. OME is middle ear effusion without acute symptoms; may be acute or chronic
   2. Chronic otitis media includes presence of fluid in middle ear for >3 months
   3. Minimal or no constitutional symptoms
   4. Only ~1/3 of cases have positive cultures for bacteria
   5. >75% of effusions are positive for DNA from the three most common organisms
   6. DNA is detected with very sensitive polymerase chain reaction (PCR)
   7. Most common organisms (below) are similar for otitis, chronic bronchitis, and sinusitis
   8. EarCheck Middle Ear Monitor® market to detect middle ear effusion in children []
   9. EarCheck does detect effusion, but cannot distinguish sterile for infected effusion
5. Sequellae of Middle Ear Effusion [6]
   1. Recurrent effusions especially concerning
   2. OME with fluid present for >3 months particularly concerning
   3. Reduction in hearing can lead to long term sequellae
   4. Delays in speech and language development
   5. Developmental delays more broadly
   6. If hearing loss >20dB sensorineural, then language disabilities can occur
6. Mastoiditis
   1. Usually associated with acute supperative otitis media
   2. Initial symptoms are middle ear problems, with hearing loss, ear pain, fever
   3. Progressing to swelling, redness, tenderness over mastoid bone (post-auricular)
   4. Radiographs of the mastoid bone may show loss of sharpness
   5. Often toxic appearing
7. Heptavalent pneumococcal vaccine now approved for prevention of otitis media [14]

B. Organisms

1. Most otitis media is due to viral pathogens
   1. Viral agents detected by polymerase chain reaction in acute otitis media in children [4]
   2. Viruses were present in ~40% of middle ear fluid or nasal wash
   3. Repiratory syncytial virus (RSV) was the most common virus found
   4. Parainfluenza viruses and influenza viruses were next most common
   5. Enteroviruses and adnoviruses were rarely found in middle ear fluid
2. Bacterial pathogens are found in a minority of cases
3. With purulent acute otitis media, common organisms include:
   1. Streptococcus pneumoniae
   2. H. influenza (non-typable)
   3. M. catarrhalis
   4. S. pyogenes
   5. S. aureus is less common
4. Recurrent Otitis Media
   1. Role of organisms including anaerobes is unclear
   2. Chronic inflammation with effusion may be underlying problem
   3. Vaccination with influenza vaccine may be helpful [1]
   4. Associated with genetically determined immunoglobulin markers
5. OME [5]
   1. Alloiococcus otitis, a gram positive organism, found in 50% of patients
   2. Proprionobacterium detected in 25% of patients
   3. Coreynebacterial species detected in several patients
6. Very Unusual
   1. Mycoplasma pneumoniae - bullous myringitis (middle ear bullae)
   2. Chlamydia trachomatis - acute respiratory infections and otitis in children <6 months
   3. Diphtherioid infection - C. diphtheriae otitis
   4. Tuberculosis
   5. Enteric organisms

C. Symptoms of AOM

1. Pain in ear, not on outside (unless otitis externa also present)
2. Opaque Tympanic membrane, without motion on otoscopy (may be bulging)
3. Ruptured Tympanic Membrane
4. Fever
5. Concern for meningitis, especially with headache
6. Serous effusions can occur which are often culture negative
7. Mastoiditis may occur

D. Treatment [1,2]

1. ~80% of cases will resolve without antibiotics
   1. Absence of bulging tympanic membrane reduces need for immediate antibiotics
   2. In acute otitis media with otorrhea, antibiotics primarily benefit children <2 years old [15]
   3. Recurrent acute otitis media should also be treated with oral analgesics with drops initially
   4. Clear data indicate that wait-and-see antibiotics (after 48 hours of analgesics alone) are safe with similar outcomes (mainly in age >2 years) [8]
   5. Otic analgesics + acetaminophen (Tylenol®) or ibuprofen (Advil®, others) are used
   6. Otic analgesic such as benzocaine / antipyrene
   7. Ibuprofen dose 10mg/kg q4-6 hours as needed for pain
2. Antibiotics
   1. Immediate antibiotics may be most helpful in children <2 years old with acute otitis [15]
   2. Antibiotics are generally instituted after 48-72 hours if no symptomatic improvement [8]
   3. Although most organisms are "resistant" to amoxicillin, it remains effective
   4. Dose is 80-100-mg/kg qd for 7 days (divided into three doses)
   5. Many alternatives are available
   6. For penicillin allergies, cefuroxime, azithromycin, or parenteral ceftriaxone may be used
3. Second Choice Antibiotics
   1. Oral TMP/SMX (Bactrim®, Septra®) is the least expensive
   2. However, there is always a concern for sulfa allergy
   3. Amoxicillin-Clavulanate (Augmentin®) is reserved for resistant bacterial otitis
   4. Cefuroxime (Ceftin®), cefixime (Suprax®), cefpodoxime proxetil, cefprozil
   5. Ofloxacin (Floxin® otic) bid drops for tympanostomy tubes or perforation
   6. Oral azithromycin (Zithromax®) for 5 days is also effective [7]
   7. Ceftriaxone (Rocephin®) parenteral dose is 50mg/kg IM or IV for 3 days
4. Decongestants as for sinusitis
5. Chronic Otitis Media with Effusion
   1. Anti-histamine combined with decongestants are usually recommended
   2. Overall, results are not very good
   3. Bacteria may be present and may require antibiotic treatment [3]
   4. A two-week trial of Augmentin® may be considered for these patients
   5. Influenza vaccine recommended [2]
6. Tympanostomy Tubes [9,10,11,12]
   1. Usually placed for recurrent otitis media or middle ear effusion
   2. Reduces AOM events in patients with recurrent attacks
   3. Previously believed to prevent effects of chronic effusion on speech, language, or other areas of development; this has been disproven in otherwise healthy children [12]
   4. No developmental benefit of early versus delayed (9 months) placement of tympanostomy tubes in infants at up to age 3 years [9,10]
   5. No developmental benefit of early versus delayed placement of tympanostomy tubes in children up to age 3 years of age by the time they reach 6 years of age [11]
   6. No developmental benefit of early versus delayed placement of tympanostomy tubes in children up to age 3 years of age by the time they reach 9-11 years of age [12]
   7. Routine tympanostomy tube placement is no longer recommended [12]
   8. Performing adenoidectomy ± tonsillectomy at time of initial tube insertion reduces the likelihood of subsequent hospitalizations and effusion related complications [3]
   9. Long term consequences (tympanosclerosis, retraction reduced mobility) unknown

E. Recurrence

1. Should rule out mastoiditis in recurrent infection
2. Resistant and anaerobic organisms may be involved
3. Multiple drainages may be required
4. Resolving acute otitis media may progress to serous otitis media
   1. Opaque tympanic membrane
   2. May persist from weeks to months
   3. Treat with antibiotics, anti-histamines, decongestants as for chronic sinusitis
   4. Persistent otitis may be treated with myringotomy and tympanostamy tubes
5. Persistent Otitis Media
   1. Adenoidectomy and adenotonsillectomy have been recommended treatments
   2. In children with tympanostomies and removal, adenoidectomy showed some benefit
   3. In children without tympanostomy treatment, these operations are of limited benefit [11]
   4. Tonsillectomy without adenoidectomy is not beneficial
6. Heptavalent (but not 23-valent), pneumococcal vaccine reduces AOM >50% [13,16]

References

1. Rovers MM, Schilder AGM, Zielhuis GA, Rosenfeld RM. 2004. Lancet. 363(9407):465
2. Hendley JO. 2002. NEJM. 347(15):1169
3. Casselbrant ML, Mandel EM, Fall PA, et al. 1999. JAMA. 282(22):2125
4. Heikkinin T, Thint M, Chonmaitree T. 1999. NEJM. 340(4):260
5. Beswick AJ, Lawley B, Fraise AP, et al. 1999. Lancet. 354(9176):386
6. Perrin JM. 2001. NEJM. 344(16):1241
7. Kozyrskj AL, Hildes-Ripstein E, Longstaffe SEA, et al. 1998. JAMA. 279(21):1736
8. Spiro DM, Tay KY, Arnold DH, et al. 2006. JAMA. 296(10):1235
9. Paradise JL, Bluestone CD, Colborn DK, et al. 1999. JAMA. 282(10):945
10. Paradise JL, Feldman HM, Campbell TF, et al. 2001. NEJM. 344(16):1179
11. Paradise JL, Campbell TF, Dollaghan CA, et al. 2005. NEJM. 353(6):576
12. Paradise JL, Feldman HM, Campbell TF, et al. 2007. NEJM. 356(3):248
13. Giebink GS. 2001. NEJM. 345(16):1177
14. Pneumococcal vaccine for Otitis Media. 2003. Med Let. 45(1153):27
15. Rovers MM, Glasziou P, Appelman CL, et al. 2006. Lancet. 368(9545):1429
16. Eskola J, Kilpi T, Palmu A, et al. 2001. NEJM. 344(6):403
17. EarCheck Middle Ear Monitor. 2008. Med Let. 50(1290):55