OVERVIEW: What every practitioner needs to know
Are you sure your patient has otitis media? What should you expect to find?
Acute otitis media (AOM) is diagnosed based on three criteria:
Onset of acute illness including nonspecific signs of illness (fever, irritability, headache, anorexia, vomiting, and diarrhea) and specific signs (ear pain, otorrhea, hearing impairment, tinnitus, and nystagmus)
Fluid in the middle ear defined by bulging of the tympanic membrane, decreased mobility of the tympanic membrane or observation of an air fluid level
Inflammation of the tympanic membrane
If appropriately treated with an antibiotic, sterile middle ear fluid may persist for weeks to months after each episode of AOM and is part of the initial disease and not a new episode of AOM.
Observation of inflammation of the tympanic membrane and identification of middle ear effusion are the keys to diagnosis of AOM.
How did the patient develop otitis media? What was the primary source from which the infection spread?
AOM occurs as a result of the following sequence: congestion of the mucosa of the upper respiratory tract usually due to a viral infection; swelling of the mucosa of the Eustachian tube (which connects the posterior nasopharynx with the middle ear space); obstruction of the tube at its narrowest section, the isthmus; accumulation secretions that are constantly formed by the middle ear mucosa behind the Eustachian tube obstruction; and, if viral or bacterial pathogens are present, inflammation of the middle ear mucosa and tympanic membrane and development of purulent middle ear fluid.
AOM occurs at all ages but attack rates are highest during the first 3years of life. By 3 years of age, a majority of children have had at least one episode of AOM. The age of the first episode of AOM signals a child who is likely to be susceptible to recurrent AOM. Children who are breast fed have fewer episodes of AOM than those who are bottle fed. Although AOM is infrequent in adults, the microbiology and treatment are the same. Males are more frequently affected than females. Severe and recurrent disease has been identified in certain racial and ethnic groups including Native Americans, Alaskan and Canadian Eskimos, and Australian aboriginal populations. The severity of disease in these groups may be due to climate extremes, a genetic susceptibility, or the consequences of poverty including crowding, poor hygiene, and decreased access to medical care.
Which individuals are at greater risk of developing otitis media?
Anatomic or physiologic defects including cleft palate or other craniofacial abnormalities are associated with recurrent episodes of AOM. Children with immunodeficiencies such as chronic granulomatous disease or human immunodeficiency virus (HIV) infection may have recurrent and severe AOM as the initial or frequent sign of the underlying pathology. A genetic predisposition to severe and recurrent AOM has been identified in children born into families with siblings and parents who have a history of middle ear disease. In addition, certain racial and ethnic groups have are particularly affected by middle ear disease and its complications (see above). Infants in group day care are exposed to peers who come to the program with contributions of respiratory infections from each household; the result is up to eight episodes of respiratory infections—including AOM—per year for each of the first 3 years of life.
Anatomic, physiologic, and immunologic defects are associated with recurrent AOM. Among healthy children, genetic susceptibility and environmental exposure to respiratory agents are the key risk factors for severe and recurrent AOM.
Beware: there are other diseases that can mimic disease otitis media:
Otalgia or ear pain can be caused by otitis externa, a foreign body in the external ear canal or referred pain from dental disease. Middle ear effusion may result from barotrauma or allergy and be accompanied by hearing impairment.
What laboratory studies should you order and what should you expect to find?
Results consistent with the diagnosis
Accurate clinicial diagnosis is sufficient for diagnosis of AOM. Other laboratory tests such as white blood cell (WBC) count are neither sensitive nor specific for diagnosis of AOM. If the patient is systemically ill, cultures of blood should be considered. If there is purulent drainage in the external canal, careful cleansing of the canal and culture of the pus as it emerges from the tympanic membrane perforation provides specific information about the pathogen associated with the episode of AOM.
Results that confirm the diagnosis
Other fluid cultures, polymerase chain reaction (PCR) assays, etc.
What imaging studies will be helpful in making or excluding the diagnosis of otitis media?
Imaging studies of patients with AOM are warranted only if there is concern for complications of the middle ear disease such as mastoiditis, petrositis, labyrinthitis, or brain abscess or meningitis.
What consult service or services would be helpful for making the diagnosis and assisting with treatment?
The patient with severe or recurrent disease may require consultation with an otolaryngologist. In selected children or adults, placement of tympanostomy tubes may be of value in reducing the incidence of disease and decreasing time of middle ear effusion. In a rare circumstance, severe and recurrent AOM may identify a congenital or acquired immune deficiency. Other signs of recurrent infection are usually present in such patients which prompt consultation with an immunologist.
If you decide the patient has otitis media, what therapies should you initiate immediately?
The decision to treat AOM with an antimicrobial drug is based on the age of the patient and the certainty of diagnosis. All patients with AOM do not benefit from antimicrobial agents since many episodes of AOM are due to viral agents and some episodes of bacterial AOM respond without use of antimicrobial drugs. Infants aged less than 2 years with a certain diagnosis of AOM should be treated. Some children aged more than 2 years with an uncertain diagnosis of AOM or mild disease can be managed with observation and without antimicrobial drugs. If the disease persists or becomes more severe antimicrobial agents can then be provided.
Seventeen antimicrobial drugs (16 oral and one parenteral preparation, ceftriaxone) have been approved for treatment of AOM. In addition, two otic preparations (ofloxacin otic and ciprofloxacin—dexamethasone otic) also are available for treatmet of AOM with otorrhea in children with tympanostomy tubes in place or tympanic membrane perforation.
Key principles of therapy
1. Anti-infective agents
The microbiology of AOM has been so consistent in identifying the pneumococcus and Haemophilus influenzae as the usual agents of AOM that choice of antimicrobial drugs can be based on the assumption of providing coverage for those two agents. Amoxicillin is the drug of choice for initial therapy of AOM. If the patient has severe otalgia or a temperature greater than 39°C, amoxicillin-clavulanate should be considered to cover β-lactamase producing H. influenzae.
If I am not sure what pathogen is causing the infection, what anti-infective should I order?
Treatment options for otitis media are summarized in Table I.
|Temperature >39°C or severe otalgia||Antibiotic||Dose|
|No||Amoxicillin||90mg/kg/day in three doses; adult dose = 750mg to 1.5g in three doses per day|
|Yes||Amoxicillin-clavulanateCeftriaxone||Amoxicillin dose listed above50mg/kg/day for one to three days; adult dose = 1g/day|
|Alternative for patients with penicillin allergyNon-type 1||CefdinirCefuroxime||14mg/kg/day in one to two doses; adult dose = 600mg/day in one to two doses30mg/kg/day in two doses; adult dose = 0.5-1g/day in two doses|
|Type 1||AzithromycinClarithromycin||30mg/kg in one dose ; or 10/mg//kg/day x 3 days or 10 mg/kg on day one and 5 mg/kg/day on days 2-5 adult dose = 1.5-2g 15mg/kg/day in two doses; adult dose = 0.5-1.0g/day|
*Other oral drugs approved for the treatment of AOM in the United State are cefaclor, cefixime, cefpodoxime, cefprozil, ceftibuten, loracarbef, erythromycin plus sulfisoxazole, and trimethoprim-sulfamethoxazole.
2. Next list other key therapeutic modalities.
Pain management should be considered for cases of AOM with moderate to severe otalgia. For moderate pain acetaminophen or ibuprofen should be considered. For severe pain codeine or an analog may be necessary. In some cases the expansion of the middle ear abscess results in spontaneous perforation of the tympanic membrane with immediate relief of pain. The same result may be accomplished for patients with; severe pain and an intact tympanic membrane by use of incision and drainage (myringotomy) of the middle ear pus. Antihistamines may be considered in the patient who has seasonal allergies but does not alter the course of AOM. Similarly, nasal and oral decongestants may provide symptomatic relief but do not alter the course of middle ear disease.
What complications could arise as a consequence of otitis media?
Suppurative complications of AOM are now rare in developed countries but continue to a concern in children and adults living in developing regions with limited access to medical care. Complications and sequelae of AOM may result from extension of the middle ear abscess into adjacent areas including the mastoid, the inner ear, the petrous bone and the brain. Complications may be categorized as intratemporal or intracranial. Intratemporal complications include: hearing loss, vestibular, balance and motor dysfunction; acute and chronic perforation of the tympanic membrane; mastoiditis (see separate section); petrositis, labyrinthitis, facial paralysis; cholesteatoma; and tympanosclerosis. Intracranial complications include meningitis, extradural abscess, subdural empyema, brain abscess, and lateral sinus thrombosis.
Conductive hearing loss is present in most cases of AOM due to the presence of the middle ear fluid. With successful management of AOM, hearing is restored with the return of an aerated middle ear space. Audiograms of patients with middle ear fluid reveal a conductive loss between 20 and 30dB—equivalent to putting plugs in the external canal. Since some children have recurrent episodes of AOM with prolonged time spent with middle ear effusion, there is concern that prolonged time spent with hearing loss in infancy may lead to delay in speech and language and lower scores on tests of cognitive abilities.
What should you tell the family about the patient's prognosis?
The vast majority of patients with AOM respond with appropriate management.
Suppurative complications (see above) are rare but parents and physicians should be alert for the possibility of spread of the disease to contiguous areas.
What pathogens are responsible for this disease?
The microbiologic causes of AOM have been documented by appropriate cultures of middle-ear fluids obtained by needle aspiration. Many bacteriologic studies of AOM have been performed and the results are consistent in demonstrating the importance of Streptococcus pneumoniae and non-typable H. influenzae and a minor role for Moraxella catarrhalis. Respiratory viruses, alone or combined with bacterial pathogens, have been identified in approximately one fifth of episodes of AOM. The introduction of conjugate pneumococcal vaccines has reduced the proportion of AOM due to the pneumococcus and increased episodes due to non-typable H. influenzae.
Group A Streptococcus was an important cause of severe AOM during the preantibiotic years but now is an infrequent cause of AOM. Other infrequent causes of AOM include Staphylococcus aureus, gram-negative bacilli, Mycoplasma pneumoniae, and Chlamydia trachomatis. In developing regions tuberculous otitis and otogenenous tetanus are possible causes of chronic otitis media.
How can otitis media be prevented?
Preventing new episodes of AOM in patients who are otitis-prone may be achieved by four general approaches:
empowering patients to reduce risk factors
Empowering patients to recognize risk features for AOM is important. Breastfeeding of infants reduces many respiratory and gastrointestinal infections and has been documented to reduce the incidence of AOM. The home and workplace should be a smoke-free environment. Removal of the patient from environments that increase exposure to respiratory agents reduces the incidence of AOM. In children, group day care is responsible for frequent exposure to virus and bacterial pathogens. Placement of the child in home or small group day care reduces the opportunities for exposure to pathogens.
Chemoprophylaxis has been effective in reducing the incidence of AOM. The rationale for chemoprophylaxis to prevent AOM is that a modified dose of antimicrobial agents administered during a prolonged period will decrease the rate or intensity of upper respiratory tract colonization by bacterial pathogens. Patients who have had three episodes of AOM in 6 months or four episodes in 12 months should be considered for prophylaxis. Amoxicillin has been the preferred agent in on half of the therapeutic dose administered once a day (45mg/kg for children or 750mg for adults). The regimen is administered during the winter and spring when respiratory tract infections are most frequent.
The 7 serotype conjugate pneumococcal vaccine (PCV 7) introduced in the United States in 2000 was effective in reducing the incidence of vaccine-serotype AOM but had no effect on nonvaccine serotypes. The 13 serotype vaccine was introduced in 2010 and its efficacy in prevention of pneumococcal AOM is still to be determined. Influenza virus vaccines are effective in reducing AOM during periods of epidemic influenzal disease.
Myringotomy with tympanostomy tube insertion is effective in reducing the incidence of AOM. The procedure results in an aerated middle ear and restoration of hearing in children who have prolonged time spent with middle ear effusion. In recent years this surgical procedure has been second only to circumcision as the most frequently performed surgical procedure in children.
WHAT'S THE EVIDENCE for specific management and treatment recommendations?
“Diagnosis and management of acute otitis media”. Pediatrics. vol. 113. 2004. pp. 1451-1465.
vam Buchem, FL, Peeters, MF, van’t Hof, MA. “Acute otitis media; a new treatment strategy”. Br Med J. vol. 290. 1985. pp. 1033-37.
Hoberman, A, Paradise, JL, Rockette, HE. “Treatment of acute otitis media in children under 2 years of age”. N Engl J Med. vol. 364. 2011. pp. 105-15.
Tahtinin, PA, Laine, MK, Hovinen, P. “A placeblo controlled trial of antimicrobial treatment for acute otitis media”. N Engl J Med. vol. 364. 2011. pp. 116-126.
Klein, JO. “Is acute otitits media a treatable disease?”. N Engl J Med. vol. 364. 2011. pp. 168-9.
Tahtinin, PA, Laine, MK, Ruuskanen, O, Ruohola, A. “Delayed versus immediate antimicrobial treatment for acute otitis media”. Pediatr Infec Dis J. vol. 31. 2012. pp. 1227-1232.
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- OVERVIEW: What every practitioner needs to know
- Are you sure your patient has otitis media? What should you expect to find?
- How did the patient develop otitis media? What was the primary source from which the infection spread?
- Which individuals are at greater risk of developing otitis media?
- Beware: there are other diseases that can mimic disease otitis media:
- What laboratory studies should you order and what should you expect to find?
- What imaging studies will be helpful in making or excluding the diagnosis of otitis media?
- What consult service or services would be helpful for making the diagnosis and assisting with treatment?
- If I am not sure what pathogen is causing the infection, what anti-infective should I order?
- What complications could arise as a consequence of otitis media?
- What should you tell the family about the patient's prognosis?
- What pathogens are responsible for this disease?
- How can otitis media be prevented?
- WHAT'S THE EVIDENCE for specific management and treatment recommendations?