Overview/Definition
Definition:
Acute otitis media (AOM) is bacterial or viral infection of the middle ear space, characterized by rapid onset of ear pain, fever, and signs of middle ear inflammation
Chronic otitis media involves persistent infection >3 months.
Epidemiology:
Most common bacterial infection in children
Peak incidence 6-24 months in India
80% children have at least one episode by age 3 years
Higher incidence in males, urban areas, and during winter months.
Age Distribution:
Peak incidence 6-24 months due to immature immune system and eustachian tube anatomy
Second peak at 4-6 years when children start school
Rare in newborns due to protective maternal antibodies.
Clinical Significance:
Leading cause of antibiotic prescriptions in children
Potential complications include hearing loss, mastoiditis, brain abscess
Recurrent episodes may affect speech and language development.
Age-Specific Considerations
Newborn:
Rare occurrence, usually associated with congenital anomalies or NICU stay
Presents with nonspecific symptoms: irritability, feeding difficulties, fever
Higher risk of complications
Requires immediate antibiotic treatment.
Infant:
Peak incidence group
Diagnosis challenging due to communication limitations
Pulling at ears, irritability, sleep disturbance common
Shorter eustachian tubes predispose to infection
Immediate antibiotics often recommended.
Child:
Can verbalize ear pain, making diagnosis easier
School attendance affected
Watchful waiting appropriate in some cases
Tympanic membrane visualization easier
Consider underlying conditions like adenoid hypertrophy.
Adolescent:
Less common but may be more severe
Often associated with upper respiratory infections, allergic rhinitis
Better able to cooperate with examination and treatment
Complications rare but more serious when present.
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Clinical Presentation
Symptoms:
Sudden onset severe ear pain, fever (>38.5°C), irritability, sleep disturbance
Hearing loss, sensation of fullness in ear
In infants: excessive crying, pulling at ears, feeding difficulties, diarrhea, vomiting.
Physical Signs:
Red, bulging, opaque tympanic membrane with loss of landmarks
Reduced mobility on pneumatic otoscopy
Purulent discharge if tympanic membrane ruptures
Fever, cervical lymphadenopathy, upper respiratory symptoms.
Severity Assessment:
Mild: Minimal otalgia, no systemic symptoms, slightly red TM
Moderate: Moderate pain, fever, bulging TM, some hearing loss
Severe: Severe pain, high fever, bulging/perforated TM, systemic toxicity.
Differential Diagnosis:
Otitis externa, temporomandibular joint dysfunction, dental pain, mastoiditis, lymphadenitis
Distinguish from otitis media with effusion (no acute symptoms)
Consider viral causes in mild cases.
Diagnostic Approach
History Taking:
Onset and duration of symptoms, fever pattern, upper respiratory symptoms, previous episodes, risk factors (daycare, siblings, smoke exposure), immunization status, recent antibiotic use, hearing concerns.
Investigations:
Clinical diagnosis based on otoscopy
Pneumatic otoscopy to assess TM mobility
Tympanometry if available
Tympanocentesis rarely needed except in severe cases, immunocompromised patients, or treatment failures.
Normal Values:
Normal TM: Translucent, gray color, visible landmarks (malleus, incus), mobile on pneumatic otoscopy
Normal hearing thresholds: <20 dB at all frequencies
Body temperature <38°C (100.4°F).
Interpretation:
AOM diagnosis requires: Acute onset symptoms + Middle ear inflammation (red, bulging TM) + Middle ear effusion (reduced mobility)
Otitis media with effusion lacks acute inflammatory signs.
Management/Treatment
Acute Management:
Pain management with acetaminophen/ibuprofen
Antibiotic decision based on age, severity, and risk factors
Immediate antibiotics for: <6 months age, severe symptoms, bilateral AOM <2 years, immunocompromised patients.
Chronic Management:
Watchful waiting (48-72 hours) appropriate for: >6 months age, unilateral mild-moderate AOM, reliable follow-up available
If no improvement, start antibiotics
Address predisposing factors (allergies, adenoids).
Lifestyle Modifications:
Avoid supine bottle feeding, reduce pacifier use after 6 months, eliminate smoke exposure, promote breastfeeding
Manage allergic rhinitis, consider pneumococcal and influenza vaccines.
Follow Up:
Recheck in 48-72 hours if watchful waiting chosen
Follow-up in 2-3 weeks to ensure resolution
Hearing assessment if recurrent episodes
Consider ENT referral for persistent effusion or complications.
Age-Specific Dosing
Medications:
First-line: Amoxicillin 80-90 mg/kg/day divided BID for 5-7 days (10 days if <2 years)
Second-line: Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component divided BID
Ceftriaxone 50 mg/kg IM/IV daily for 3 days if severe.
Formulations:
Amoxicillin: 125 mg/5mL, 250 mg/5mL suspensions, 250/500 mg tablets
Amoxicillin-clavulanate: 200/28.5 mg/5mL, 400/57 mg/5mL suspensions
Pain relief: Acetaminophen 10-15 mg/kg every 4-6 hours.
Safety Considerations:
Penicillin allergy: Use macrolides (azithromycin, clarithromycin) or cephalexin if mild allergy
Avoid amoxicillin-clavulanate in severe penicillin allergy
Monitor for antibiotic-associated diarrhea, rash.
Monitoring:
Clinical improvement expected within 48-72 hours of antibiotic initiation
Monitor for complications: persistent fever, severe headache, neck stiffness, worsening ear pain, hearing loss, facial weakness.
Prevention & Follow-up
Prevention Strategies:
Pneumococcal and Haemophilus influenzae type b vaccination, annual influenza vaccine, breastfeeding promotion, reduction of environmental risk factors (smoke exposure, daycare infections).
Vaccination Considerations:
PCV13 vaccination reduces pneumococcal AOM by 6-7%
Hib vaccine virtually eliminates H
influenzae type b AOM
Influenza vaccine reduces viral causes and secondary bacterial infections.
Follow Up Schedule:
Acute: 48-72 hours if watchful waiting, 3-5 days if on antibiotics
Post-treatment: 2-3 weeks to ensure resolution
Recurrent AOM: Consider prophylaxis or tympanostomy tubes if ≥3 episodes in 6 months.
Monitoring Parameters:
Resolution of symptoms (pain, fever), tympanic membrane appearance, hearing assessment
For recurrent cases: Frequency of episodes, hearing thresholds, speech/language development, quality of life impact.
Complications
Acute Complications:
Mastoiditis (most common serious complication), tympanic membrane perforation with hearing loss, facial nerve palsy, lateral sinus thrombosis, meningitis, brain abscess
Recurrent AOM leading to chronic suppurative otitis media.
Chronic Complications:
Chronic otitis media with effusion, permanent hearing loss, speech and language delays, learning difficulties, chronic perforation, cholesteatoma formation, ossicular chain damage.
Warning Signs:
Persistent high fever >48 hours on antibiotics, severe headache, neck stiffness, altered mental status, facial weakness, severe postauricular pain/swelling, purulent discharge from ear canal.
Emergency Referral:
Signs of mastoiditis, meningitis, or intracranial complications
Severe systemic toxicity, immunocompromised patients with complications, failed outpatient management, need for tympanocentesis or IV antibiotics.
Parent Education Points
Counseling Points:
Most AOM cases resolve without antibiotics
Immediate antibiotics not always necessary for mild cases
Pain management is important regardless of antibiotic use
Prevention strategies can reduce recurrence.
Home Care:
Pain relief with acetaminophen or ibuprofen, warm compresses to affected ear
Keep ear dry, avoid swimming
Complete antibiotic course if prescribed
Watch for improvement within 48-72 hours.
Medication Administration:
Give antibiotics with food to reduce stomach upset
Use measuring device provided with liquid medications
Complete full course even if child feels better
Space doses evenly throughout the day.
When To Seek Help:
Worsening symptoms after 48-72 hours of treatment, high fever persisting beyond 3 days, severe headache, neck stiffness, facial weakness, severe ear drainage, hearing concerns, or behavioral changes.