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Otitis Media

BASICS

Description

  • Inflammation of the middle ear, usually with fluid collection
    • Acute otitis media (AOM): Rapid onset; infectious (viral/bacterial) or sterile
    • Recurrent AOM: ≥3 episodes in 6 months or ≥4 in a year (with ≥1 in last 6 months)
    • Otitis media with effusion (OME): Middle ear fluid without infection signs/symptoms
    • Chronic suppurative otitis media (CSOM): Chronic/recurrent infection without intact tympanic membrane; may have cholesteatoma

EPIDEMIOLOGY

  • AOM: Most common age 6–24 months; rare in adults
  • By age 3: 50–85% of children have had ≥1 AOM; 24% have ≥3 episodes
  • OME: 90% of children have had at least one episode by age 4

ETIOLOGY & PATHOPHYSIOLOGY

  • AOM-bacterial: Preceding viral URI → eustachian tube dysfunction → reduced clearance
    • Main pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis (80% of cases)
    • Others: S. pyogenes, Mycoplasma, Chlamydia, anaerobes
  • AOM-viral: 15–44% (rhinovirus, RSV, influenza, etc.)
  • OME: Eustachian tube dysfunction; allergic causes less substantiated
  • Genetics: Immunologic defects, genetic syndromes (Down syndrome) increase risk

RISK FACTORS

  • Early onset (<1 year)
  • Bottle feeding supine; pacifier use >6 months
  • Daycare, family history, smoke exposure
  • Lack of breastfeeding (first 6 months)
  • Low SES, atopy (eczema, asthma)
  • ENT abnormalities (cleft palate)

GENERAL PREVENTION

  • Vaccines: PCV-7/13 and influenza
  • Breastfeeding ≥6 months is protective
  • Avoid supine bottlefeeding, pacifiers, smoke exposure

DIAGNOSIS

History

  • AOM: Otalgia, URI symptoms, decreased hearing
    • In infants: Irritability may be sole finding
  • OME: Usually asymptomatic, decreased hearing, ± tinnitus/fullness

Physical Exam

  • AOM: Fever (not required), decreased eardrum mobility (pneumatic otoscopy), bulging/red/yellow/cloudy TM, otorrhea
  • OME: Dull TM, air-fluid level, decreased mobility, Weber lateralizes to affected ear

Differential Diagnosis

  • Tympanosclerosis, trauma, otitis externa, temporal arteritis (adults)

Diagnostic Tests

  • Clinical diagnosis (MEE + signs of inflammation)
  • Otoscopy: Confirms MEE
  • Pneumatic otoscopy: Most specific/clinically useful
  • Tympanometry: If uncertain
  • Hearing test: If hearing loss persists ≥3 months, or if language delay suspected
  • Tympanocentesis: If toxic, immunocompromised, or failed previous antibiotics

TREATMENT

General Measures

  • Pain control: Acetaminophen, ibuprofen, topical agents (>2y, no TM perforation)
  • Observation: >6 months with mild AOM; antibiotics if not improved/worsening in 24–48h
  • OME: Watchful waiting 3 months before ENT referral

Medication

First Line - <6 months: Amoxicillin if >2 weeks old - >6 months: Treat with antibiotics if severe AOM (moderate/severe otalgia >48h, fever ≥39°C), otorrhea, or bilateral AOM in 6–23 months - Observation option if nonsevere and >6 months, but antibiotics recommended if high risk/treatment failure - Amoxicillin: 90 mg/kg/day in 2 divided doses (max 3g/day) - 10 days if <2y, 5–7 days if ≥2y - Penicillin allergic: - Cefdinir, Cefpodoxime, Cefuroxime, Ceftriaxone, or Azithromycin (see original for dosages) - OME: No benefit from antibiotics, decongestants, antihistamines, or steroids

Second Line - Persistent symptoms, prior amoxicillin in last month, severe illness: Amoxicillin-clavulanate 90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate - Ceftriaxone for severe/unresponsive cases or unable to tolerate oral meds

NOT recommended: Erythromycin, TMP-SMX as second-line agents; antibiotic prophylaxis for recurrent AOM

REFERRAL/SURGERY

  • Audiogram if hearing loss persists >2 weeks after AOM resolves
  • ENT referral if ≥2 episodes in 6 months (rule out malignancy), recurrent COM (consider tubes)
  • Tympanostomy tubes: For recurrent AOM (<2y with recurrences), OME >4–6 months bilateral or >6 months unilateral, or hearing loss >25 dB

ADMISSION

  • Only for infants <2 months with AOM + fever, or those needing IV ceftriaxone and monitoring

ONGOING CARE

  • Reevaluate if no improvement in 48–72h
  • OME/COM: Otoscopic/tympanometric follow-up at 3 months or as needed

PROGNOSIS

  • Most AOM resolves without antibiotics
  • OME/COM: Repeat exams; consider hearing/language concerns

COMPLICATIONS

  • AOM: TM perforation, mastoiditis, facial nerve palsy, meningitis, labyrinthitis, hearing loss, cholesteatoma
  • COM: Speech/language delay, chronic perforation, cholesteatoma, permanent hearing loss

ICD-10 Codes

  • H65: Nonsuppurative otitis media
  • H65.0: Acute serous otitis media
  • H65.00: Acute serous otitis media, unspecified ear

Clinical Pearls

  • Pneumatic otoscopy: Most specific/clinically useful diagnostic tool
  • Delay antibiotics 24–48h in >6 months, nonsevere, no otorrhea
  • Amoxicillin (80–90 mg/kg/day) is first-line for 10 days (<2y), 5–7 days (≥2y)
  • Erythema and effusion may persist weeks after infection
  • Antibiotics/antihistamines/steroids NOT for chronic OME
  • Persistent unilateral OME in adults: Rule out neoplasm, especially with cranial nerve palsy