Otitis Media: Diagnosis and Handling

A more than recent article on otitis media is available.

This is a corrected version of the article that appeared in impress.

KATHRYN M. HARMES, Dr.; R. ALEXANDER BLACKWOOD, Medico, PhD; HEATHER 50. BURROWS, Physician, PhD; JAMES One thousand. COOKE, Dr.; R. VAN HARRISON, PhD; and PETER P. PASSAMANI, MD

Am Fam Dr.. 2013 Oct 1;88(7):435-440.

Related editorials: Should Children with Acute Otitis Media Routinely Be Treated with Antibiotics? Yes: Routine Treatment Makes Sense for Symptomatic, Emotional, and Economical Reasons and No: Most Children Older Than Two Years Do Not Crave Antibiotics

Patient data: A handout on otitis media is available at https://familydoctor.org/familydoctor/en/diseases-conditions/ear-infections/handling.html.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz.

Author disclosure: No relevant financial affiliations.

Article Sections

  • Abstract
  • Etiology and Risk Factors
  • Diagnosis
  • Management of Acute Otitis Media
  • Management of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical bear witness of middle ear inflammation, and symptoms such every bit pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most mutual organisms isolated from eye ear fluid. Management of acute otitis media should brainstorm with acceptable analgesia. Antibody therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80 to 90 mg per kg per day) is the antibody of selection for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibody therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate, should be used if advisable. Otitis media with effusion is defined equally middle ear effusion in the absenteeism of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of eye ear fluid and are not recommended. Children with testify of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist.

Otitis media is among the virtually common problems faced by physicians caring for children. Approximately fourscore% of children will take at least i episode of acute otitis media (AOM), and between 80% and ninety% will have at least one episode of otitis media with effusion (OME) before school historic period.1,2 This review of diagnosis and treatment of otitis media is based, in part, on the Academy of Michigan Health Arrangement's clinical intendance guideline for otitis media.2

SORT: Key RECOMMENDATIONS FOR Do

Clinical recommendation Evidence rating References

An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea non acquired by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

8

Middle ear effusion can be detected with the combined utilize of otoscopy, pneumatic otoscopy, and tympanometry.

C

ix

Adequate analgesia is recommended for all children with AOM.

C

8, fifteen

Deferring antibiotic therapy for lower-risk children with AOM should be considered.

C

xix, 20, 23

High-dose amoxicillin (80 to xc mg per kg per day in two divided doses) is the first option for initial antibiotic therapy in children with AOM.

C

8, 10

Children with centre ear effusion and anatomic impairment or prove of hearing loss or linguistic communication delay should be referred to an otolaryngologist.

C

xi

Etiology and Risk Factors

  • Abstract
  • Etiology and Take chances Factors
  • Diagnosis
  • Management of Acute Otitis Media
  • Direction of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

Unremarkably, AOM is a complexity of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Bacteria tin can be isolated from eye ear fluid cultures in 50% to 90% of cases of AOM and OME. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most mutual organisms.3,4 H. influenzae has go the nearly prevalent organism among children with severe or refractory AOM following the introduction of the pneumococcal cohabit vaccine.5–seven  Hazard factors for AOM are listed in Table 1.viii,9

Tabular array 1.

Adventure Factors for Acute Otitis Media

Age (younger)

Allergies

Craniofacial abnormalities

Exposure to environmental smoke or other respiratory irritants

Exposure to group day care

Family unit history of recurrent astute otitis media

Gastroesophageal reflux

Immunodeficiency

No breastfeeding

Pacifier employ

Upper respiratory tract infections

Diagnosis

  • Abstruse
  • Etiology and Risk Factors
  • Diagnosis
  • Direction of Acute Otitis Media
  • Management of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

Previous diagnostic criteria for AOM were based on symptomatology without otoscopic findings of inflammation. The updated American University of Pediatrics guideline endorses more stringent otoscopic criteria for diagnosis.eight An AOM diagnosis requires moderate to severe bulging of the tympanic membrane (Figure one), new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema. AOM should non be diagnosed in children who do not have objective evidence of middle ear effusion.8 An inaccurate diagnosis tin can lead to unnecessary treatment with antibiotics and contribute to the development of antibiotic resistance.

Figure 1.

Otoscopic view of astute otitis media. Erythema and bulging of the tympanic membrane with loss of normal landmarks are noted.

OME is divers as middle ear effusion in the absence of acute symptoms.ten,11 If OME is suspected and the presence of effusion on otoscopy is not evident past loss of landmarks, pneumatic otoscopy, tympanometry, or both should be used.eleven Pneumatic otoscopy is a useful technique for the diagnosis of AOM and OME8–12 and is 70% to xc% sensitive and specific for determining the presence of center ear effusion. Past comparison, simple otoscopy is 60% to 70% authentic.10,xi Inflammation with bulging of the tympanic membrane on otoscopy is highly predictive of AOM.7,8,12 Pneumatic otoscopy is near helpful when cerumen is removed from the external auditory canal.

Tympanometry and acoustic reflectometry are valuable adjuncts to otoscopy or pneumatic otoscopy.8,ten,11 Tympanometry has a sensitivity and specificity of 70% to xc% for the detection of middle ear fluid, just is dependent on patient cooperation.13 Combined with normal otoscopy findings, a normal tympanometry upshot may be helpful to predict absence of center ear effusion. Acoustic reflectometry has lower sensitivity and specificity in detecting center ear effusion and must be correlated with the clinical exam.14 Tympanocentesis is the preferred method for detecting the presence of centre ear effusion and documenting bacterial etiology,8 merely is rarely performed in the primary intendance setting.

Management of Acute Otitis Media

  • Abstract
  • Etiology and Risk Factors
  • Diagnosis
  • Management of Acute Otitis Media
  • Management of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

Treatment of AOM is summarized in Table ii.8

Table two.

Treatment Strategy for Acute Otitis Media

Initial presentation

Diagnosis established by physical examination findings and presence of symptoms

Treat pain

Children six months or older with otorrhea or severe signs or symptoms (moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or college): antibiotic therapy for 10 days

Children half-dozen to 23 months of age with bilateral acute otitis media without severe signs or symptoms: antibiotic therapy for x days

Children half-dozen to 23 months of historic period with unilateral acute otitis media without severe signs or symptoms: observation or antibody therapy for x days

Children 2 years or older without severe signs or symptoms: observation or antibiotic therapy for five to seven days

Persistent symptoms (48 to 72 hours)

Repeat ear test for signs of otitis media

If otitis media is nowadays, initiate or change antibiotic therapy

If symptoms persist despite appropriate antibiotic therapy, consider intramuscular ceftriaxone (Rocephin), clindamycin, or tympanocentesis

ANALGESICS

Analgesics are recommended for symptoms of ear pain, fever, and irritability.eight,15 Analgesics are particularly important at bedtime because disrupted sleep is one of the most common symptoms motivating parents to seek care.two Ibuprofen and acetaminophen have been shown to exist effective.16 Ibuprofen is preferred, given its longer elapsing of activity and its lower toxicity in the effect of overdose.2 Topical analgesics, such every bit benzocaine, can also be helpful.17

OBSERVATION VS. ANTIBIOTIC THERAPY

Antibody-resistant bacteria remain a major public health claiming. A widely endorsed strategy for improving the direction of AOM involves deferring antibiotic therapy in patients to the lowest degree probable to benefit from antibiotics.18 Antibiotics should be routinely prescribed for children with AOM who are six months or older with severe signs or symptoms (i.e., moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or college), and for children younger than two years with bilateral AOM regardless of additional signs or symptoms.8

Amid children with mild symptoms, ascertainment may exist an option in those half-dozen to 23 months of age with unilateral AOM, or in those two years or older with bilateral or unilateral AOM.8,10,nineteen A large prospective study of this strategy establish that ii out of three children will recover without antibiotics.twenty Recently, the American Academy of Family Physicians recommended not prescribing antibiotics for otitis media in children two to 12 years of age with nonsevere symptoms if observation is a reasonable option.21,22 If observation is chosen, a machinery must be in place to ensure appropriate handling if symptoms persist for more than than 48 to 72 hours. Strategies include a scheduled follow-up visit or providing patients with a backup antibiotic prescription to be filled only if symptoms persist.eight,20,23

Antibody Pick

[ corrected] Table 3 summarizes the antibody options for children with AOM.8 Loftier-dose amoxicillin should be the initial handling in the absenteeism of a known allergy.eight,10,24 The advantages of amoxicillin include low price, acceptable gustation, prophylactic, effectiveness, and a narrow microbiologic spectrum. Children who have taken amoxicillin in the by thirty days, who have conjunctivitis, or who need coverage for β-lactamase–positive organisms should exist treated with high-dose amoxicillin/clavulanate (Augmentin).8

Table 3.

Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Therapy

Initial immediate or delayed antibiotic treatment Antibiotic treatment after 48–72 h of failure of initial antibiotic treatment
Recommended commencement-line treatment Alternative handling (if penicillin allergy) Recommended first-line treatment Culling treatment

Amoxicillin (80 to 90 mg/kg per day in 2 divided doses)

Or

Amoxicillin-clavulanate* (xc mg/kg per solar day of amoxicillin, with six.4 mg/kg per twenty-four hour period of clavulanate [amoxicillin to clavulanate ratio, fourteen:ane] in ii divided doses)

Cefdinir (14 mg/kg per twenty-four hour period in 1 or 2 doses)

Cefuroxime (30 mg/kg per mean solar day in 2 divided doses)

Cefpodoxime (10 mg/kg per twenty-four hour period in 2 divided doses)

Ceftriaxone (50 mg/kg IM or 4 per day for 1 or 3 days, non to exceed i g per twenty-four hour period)

Amoxicillin-clavulanate* (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per 24-hour interval of clavulanate in 2 divided doses)

Or

Ceftriaxone (fifty mg/kg IM or Iv per day for 1 or iii days, not to exceed one g per twenty-four hour period)

Ceftriaxone, 3 d clindamycin (xxx–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin

Failure of second antibody

Clindamycin (xxx–40 mg/kg per twenty-four hour period in iii divided doses) plus third-generation cephalosporin

Tympanocentesis†

Consult specialist†

Oral cephalosporins, such as cefuroxime (Ceftin), may exist used in children who are allergic to penicillin. Recent research indicates that the degree of cross reactivity between penicillin and second- and tertiary-generation cephalosporins is low (less than 10% to 15%), and avoidance is no longer recommended.25 Because of their broad-spectrum coverage, 3rd-generation cephalosporins in item may have an increased risk of selection of resistant bacteria in the customs.26 High-dose azithromycin (Zithromax; 30 mg per kg, single dose) appears to exist more effective than the commonly used five-24-hour interval class, and has a similar cure rate every bit high-dose amoxicillin/clavulanate.8,27,28 Yet, excessive use of azithromycin is associated with increased resistance, and routine use is not recommended.8 Trimethoprim/sulfamethoxazole is no longer effective for the treatment of AOM due to testify of South. pneumoniae resistance.29

Intramuscular or intravenous ceftriaxone (Rocephin) should exist reserved for episodes of treatment failure or when a serious comorbid bacterial infection is suspected.2 One dose of ceftriaxone may be used in children who cannot tolerate oral antibiotics because information technology has been shown to take similar effectiveness as loftier-dose amoxicillin.thirty,31 A three-day form of ceftriaxone is superior to a i-day course in the treatment of nonresponsive AOM caused by penicillin-resistant S. pneumoniae.31 Although some children volition probable benefit from intramuscular ceftriaxone, overuse of this amanuensis may significantly increase loftier-level penicillin resistance in the customs.two High-level penicillin-resistant pneumococci are as well resistant to offset- and third-generation cephalosporins.

Antibiotic therapy for AOM is often associated with diarrhea.viii,ten,32 Probiotics and yogurts containing active cultures reduce the incidence of diarrhea and should be suggested for children receiving antibiotics for AOM.32 There is no compelling evidence to support the use of complementary and alternative treatments in AOM.8

PERSISTENT OR RECURRENT AOM

Children with persistent, meaning AOM symptoms despite at least 48 to 72 hours of antibiotic therapy should be reexamined.8 If a bulging, inflamed tympanic membrane is observed, therapy should be changed to a 2d-line amanuensis.2 For children initially on amoxicillin, high-dose amoxicillin/clavulanate is recommended.8,10,28

For children with an amoxicillin allergy who do not improve with an oral cephalosporin, intramuscular ceftriaxone, clindamycin, or tympanocentesis may exist considered.4,8 If symptoms recur more than than ane month afterward the initial diagnosis of AOM, a new and unrelated episode of AOM should be assumed.ten For children with recurrent AOM (i.e., three or more episodes in half-dozen months, or four episodes within 12 months with at to the lowest degree one episode during the preceding six months) with middle ear effusion, tympanostomy tubes may exist considered to reduce the need for systemic antibiotics in favor of observation, or topical antibiotics for tube otorrhea.8,10 Nonetheless, tympanostomy tubes may increment the risk of long-term tympanic membrane abnormalities and reduced hearing compared with medical therapy.33  Other strategies may assistance prevent recurrence (Table four).34–37

Table four.

Strategies for Preventing Recurrent Otitis Media

Check for undiagnosed allergies leading to chronic rhinorrhea

Eliminate bottle propping and pacifiers34

Eliminate exposure to passive smoke35

Routinely immunize with the pneumococcal conjugate and influenza vaccines36

Use xylitol mucilage in advisable children (ii pieces, five times a day afterward meals and chewed for at least five minutes)37

Probiotics, particularly in infants, have been suggested to reduce the incidence of infections during the showtime twelvemonth of life. Although available prove has not demonstrated that probiotics prevent respiratory infections,38 probiotics exercise not cause adverse effects and demand not be discouraged. Antibody prophylaxis is non recommended.8

Direction of OME

  • Abstract
  • Etiology and Risk Factors
  • Diagnosis
  • Management of Acute Otitis Media
  • Management of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

Management of OME is summarized in Tabular array 5.xi Two rare complications of OME are transient hearing loss potentially associated with language delay, and chronic anatomic injury to the tympanic membrane requiring reconstructive surgery.11 Children should be screened for spoken language filibuster at all visits. If a developmental delay is apparent or centre ear structures appear abnormal, the child should exist referred to an otolaryngologist.xi Antibiotics, decongestants, and nasal steroids do non hasten the clearance of middle ear fluid and are not recommended.11,39

Tabular array 5.

Diagnosis and Treatment of Otitis Media with Effusion

Evaluate tympanic membranes at every well-child and sick visit if feasible; perform pneumatic otoscopy or tympanometry when possible (consider removing cerumen)

If transient effusion is likely, reevaluate at three-month intervals, including screening for language delay; if there is no anatomic damage or evidence of developmental or behavioral complications, go on to find at 3- to six-month intervals; if complications are suspected, refer to an otolaryngologist

For effusion that appears to be associated with anatomic damage, such as adhesive otitis media or retraction pockets, reevaluate in four to six weeks; if abnormality persists, refer to an otolaryngologist

Antibiotics, decongestants, and nasal steroids are not indicated

Tympanostomy Tube Placement

  • Abstract
  • Etiology and Chance Factors
  • Diagnosis
  • Management of Acute Otitis Media
  • Management of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

Tympanostomy tubes are appropriate for children six months to 12 years of age who have had bilateral OME for three months or longer with documented hearing difficulties, or for children with recurrent AOM who have evidence of middle ear effusion at the fourth dimension of assessment for tube candidacy. Tubes are not indicated in children with a single episode of OME of less than 3 months' duration, or in children with recurrent AOM who practise non accept centre ear effusion in either ear at the fourth dimension of assessment for tube candidacy. Children with chronic OME who did not receive tubes should exist reevaluated every three to six months until the effusion is no longer present, hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected.40

Children with tympanostomy tubes who nowadays with acute uncomplicated otorrhea should be treated with topical antibiotics and not oral antibiotics. Routine, rubber h2o precautions such as ear plugs, headbands, or avoidance of pond are not necessary for children with tympanostomy tubes.forty

Special Populations

  • Abstract
  • Etiology and Hazard Factors
  • Diagnosis
  • Direction of Astute Otitis Media
  • Management of OME
  • Tympanostomy Tube Placement
  • Special Populations
  • References

INFANTS 8 WEEKS OR YOUNGER

Immature infants are at increased take chances of severe sequelae from suppurative AOM. Middle ear pathogens plant in neonates younger than two weeks include group B streptococcus, gram-negative enteric leaner, and Chlamydia trachomatis.41 Febrile neonates younger than two weeks with credible AOM should have a total sepsis workup, which is indicated for any febrile neonate.41 Empiric amoxicillin is acceptable for infants older than two weeks with upper respiratory tract infection and AOM who are otherwise salubrious.42

ADULTS

There is footling published information to guide the management of otitis media in adults. Adults with new-onset unilateral, recurrent AOM (greater than two episodes per year) or persistent OME (greater than six weeks) should receive boosted evaluation to rule out a serious underlying condition, such as mechanical obstruction, which in rare cases is caused by nasopharyngeal carcinoma. Isolated AOM or transient OME may be acquired past eustachian tube dysfunction from a viral upper respiratory tract infection; withal, adults with recurrent AOM or persistent OME should exist referred to an otolaryngologist.

Data Sources: We reviewed the updated Agency for Healthcare Research and Quality Evidence Report on the management of acute otitis media, which included a systematic review of the literature through July 2010. We searched Medline for literature published since July 1, 2010, using the keywords human, English, guidelines, controlled trials, and cohort studies. Searches were performed using the following terms: otitis media with effusion or serous effusion, recurrent otitis media, astute otitis media, otitis media infants 0–4 weeks, otitis media adults, otitis media and screening for speech delay, probiotic bacteria later antibiotics. Search dates: October 2011 and August 14, 2013.

EDITOR'Southward NOTE: This article is based, in part, on an institution-wide guideline adult at the University of Michigan. As office of the guideline development process, authors of this article, including representatives from chief and specialty care, convened to review current literature and make recommendations for diagnosis and treatment of otitis media and otitis media with effusion in master care.

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The Authors

show all writer info

KATHRYN M. HARMES, MD, is medical director of Dexter Health Center in Ann Arbor, Mich. She is a clinical lecturer in the Section of Family unit Medicine at the Academy of Michigan Medical School in Ann Arbor....

R. ALEXANDER BLACKWOOD, Doctor, PhD, is an associate professor in the Department of Pediatrics at the Academy of Michigan Medical Schoolhouse.

HEATHER Fifty. BURROWS, MD, PhD, is a clinical banana professor in the Department of Pediatrics and is associate director of education in the Sectionalisation of Full general Pediatrics at the University of Michigan Medical Schoolhouse.

JAMES M. COOKE, MD, is an banana professor in the Department of Family Medicine and is the director of the Family Medicine Residency Programme at the University of Michigan Medical School.

R. VAN HARRISON, PhD, is a professor in the Section of Medical Educational activity at the Academy of Michigan Medical School.

PETER P. PASSAMANI, Doctor, is an banana professor in the Department of Pediatric Otolaryngology at the University of Michigan Medical School.

Author disclosure: No relevant financial affiliations.

Address correspondence to Kathryn Grand. Harmes, MD, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 (e-mail: jordankm@umich.edu). Reprints are non available from the authors.

REFERENCES

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35. Etzel RA, Pattishall EN, Haley NJ, et al. Passive smoking and middle ear effusion among children in mean solar day intendance. Pediatrics. 1992;90(two pt 1):228–232.

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37. Azarpazhooh A, Limeback H, Lawrence HP, et al. Xylitol for preventing acute otitis media in children upwardly to 12 years of age. Cochrane Database Syst Rev. 2011(xi):CD007095.

38. Weichert S, Schroten H, Adam R. The role of prebiotics and probiotics in prevention and treatment of childhood infectious diseases. Pediatr Infect Dis J. 2012;31(viii):859–862.

39. Gluth MB, McDonald DR, Weaver AL, et al. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 2011;137(5):449–455.

40. Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical practice guideline: tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013;149(1 suppl):S1–S35.

41. Nozicka CA, Hanly JG, Beste DJ, et al. Otitis media in infants anile 0–8 weeks: frequency of associated serious bacterial disease. Pediatr Emerg Care. 1999;15(iv):252–254.

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