Otitis Media: Diagnosis and Treatment

A more recent article on otitis media is available.

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

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

Am Fam Doctor. 2013 Oct one;88(7):435-440.

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

Patient information: 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). Come across the CME Quiz.

Author disclosure: No relevant financial affiliations.

Article Sections

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

Acute otitis media is diagnosed in patients with astute onset, presence of middle ear effusion, physical show of eye ear inflammation, and symptoms such every bit pain, irritability, or fever. Astute otitis media is normally 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 middle ear fluid. Management of astute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (fourscore to xc mg per kg per twenty-four hours) is the antibiotic 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 equally amoxicillin/clavulanate, should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in the absence of astute symptoms. Antibiotics, decongestants, or nasal steroids do non hasten the clearance of eye ear fluid and are not recommended. Children with prove of anatomic impairment, hearing loss, or linguistic communication delay should be referred to an otolaryngologist.

Otitis media is amidst the nigh common problems faced by physicians caring for children. Approximately eighty% of children will have at to the lowest degree one episode of astute otitis media (AOM), and betwixt eighty% and 90% will have at least one episode of otitis media with effusion (OME) before schoolhouse age.1,2 This review of diagnosis and treatment of otitis media is based, in part, on the University of Michigan Health Organisation'southward clinical care guideline for otitis media.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused past otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

viii

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

C

9

Acceptable analgesia is recommended for all children with AOM.

C

8, 15

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

C

xix, 20, 23

Loftier-dose amoxicillin (80 to xc mg per kg per mean solar day in two divided doses) is the first choice for initial antibody therapy in children with AOM.

C

8, 10

Children with heart ear effusion and anatomic impairment or evidence of hearing loss or language delay should be referred to an otolaryngologist.

C

11

Etiology and Risk Factors

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

Commonly, AOM is a complexity of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Leaner tin can be isolated from middle ear fluid cultures in 50% to 90% of cases of AOM and OME. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most common organisms.iii,4 H. influenzae has become the most prevalent organism amid children with severe or refractory AOM post-obit the introduction of the pneumococcal conjugate vaccine.5–7  Risk factors for AOM are listed in Tabular array 1.8,9

Table 1.

Hazard Factors for Acute Otitis Media

Age (younger)

Allergies

Craniofacial abnormalities

Exposure to environmental fume or other respiratory irritants

Exposure to grouping twenty-four hours care

Family history of recurrent acute otitis media

Gastroesophageal reflux

Immunodeficiency

No breastfeeding

Pacifier utilise

Upper respiratory tract infections

Diagnosis

  • Abstract
  • Etiology and Take a chance 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 Academy of Pediatrics guideline endorses more stringent otoscopic criteria for diagnosis.viii An AOM diagnosis requires moderate to severe bulging of the tympanic membrane (Figure 1), new onset of otorrhea non 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 not exist diagnosed in children who do not accept objective evidence of center ear effusion.8 An inaccurate diagnosis tin can atomic number 82 to unnecessary treatment with antibiotics and contribute to the development of antibiotic resistance.

Effigy 1.

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

OME is defined as middle ear effusion in the absence of acute symptoms.10,xi If OME is suspected and the presence of effusion on otoscopy is not evident by loss of landmarks, pneumatic otoscopy, tympanometry, or both should exist used.xi Pneumatic otoscopy is a useful technique for the diagnosis of AOM and OME8–12 and is lxx% to 90% sensitive and specific for determining the presence of middle ear effusion. By comparison, elementary otoscopy is 60% to lxx% accurate.10,11 Inflammation with bulging of the tympanic membrane on otoscopy is highly predictive of AOM.7,8,12 Pneumatic otoscopy is most helpful when cerumen is removed from the external auditory culvert.

Tympanometry and acoustic reflectometry are valuable adjuncts to otoscopy or pneumatic otoscopy.eight,10,11 Tympanometry has a sensitivity and specificity of 70% to 90% for the detection of middle ear fluid, but is dependent on patient cooperation.13 Combined with normal otoscopy findings, a normal tympanometry result may exist helpful to predict absenteeism of eye ear effusion. Acoustic reflectometry has lower sensitivity and specificity in detecting centre ear effusion and must be correlated with the clinical test.14 Tympanocentesis is the preferred method for detecting the presence of eye ear effusion and documenting bacterial etiology,eight but is rarely performed in the principal care setting.

Direction of Astute Otitis Media

  • Abstruse
  • 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 Tabular array 2.viii

Table 2.

Handling Strategy for Astute Otitis Media

Initial presentation

Diagnosis established by concrete examination findings and presence of symptoms

Treat hurting

Children half dozen months or older with otorrhea or severe signs or symptoms (moderate or astringent otalgia, otalgia for at least 48 hours, or temperature of 102.two°F [39°C] or higher): antibiotic therapy for 10 days

Children six to 23 months of historic period with bilateral acute otitis media without severe signs or symptoms: antibiotic therapy for x days

Children six to 23 months of historic period with unilateral acute otitis media without severe signs or symptoms: observation or antibody therapy for 10 days

Children ii years or older without severe signs or symptoms: ascertainment or antibiotic therapy for v to seven days

Persistent symptoms (48 to 72 hours)

Repeat ear exam for signs of otitis media

If otitis media is nowadays, initiate or change antibiotic therapy

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

ANALGESICS

Analgesics are recommended for symptoms of ear pain, fever, and irritability.viii,xv Analgesics are particularly important at bedtime considering disrupted slumber is i of the most mutual symptoms motivating parents to seek intendance.two Ibuprofen and acetaminophen have been shown to be effective.16 Ibuprofen is preferred, given its longer duration of action and its lower toxicity in the issue of overdose.2 Topical analgesics, such as benzocaine, can also be helpful.17

OBSERVATION VS. ANTIBIOTIC THERAPY

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

Among children with mild symptoms, observation may be an choice in those six to 23 months of age with unilateral AOM, or in those two years or older with bilateral or unilateral AOM.8,ten,19 A large prospective study of this strategy found that two out of three children will recover without antibiotics.20 Recently, the American Academy of Family unit 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 called, a mechanism must exist in place to ensure appropriate treatment if symptoms persist for more 48 to 72 hours. Strategies include a scheduled follow-up visit or providing patients with a backup antibody prescription to be filled just if symptoms persist.eight,20,23

ANTIBIOTIC SELECTION

[ corrected] Table three summarizes the antibiotic options for children with AOM.8 Loftier-dose amoxicillin should be the initial handling in the absence of a known allergy.eight,10,24 The advantages of amoxicillin include low toll, acceptable sense of taste, safe, effectiveness, and a narrow microbiologic spectrum. Children who have taken amoxicillin in the past 30 days, who have conjunctivitis, or who need coverage for β-lactamase–positive organisms should be treated with high-dose amoxicillin/clavulanate (Augmentin).viii

Table 3.

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

Initial firsthand or delayed antibiotic treatment Antibody treatment later on 48–72 h of failure of initial antibiotic treatment
Recommended first-line treatment Culling handling (if penicillin allergy) Recommended offset-line handling Alternative treatment

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

Or

Amoxicillin-clavulanate* (ninety mg/kg per day of amoxicillin, with vi.4 mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, xiv:1] in 2 divided doses)

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

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

Cefpodoxime (10 mg/kg per day in 2 divided doses)

Ceftriaxone (l mg/kg IM or IV per twenty-four hour period for 1 or iii days, not to exceed 1 chiliad per day)

Amoxicillin-clavulanate* (ninety mg/kg per 24-hour interval of amoxicillin, with six.iv mg/kg per day of clavulanate in 2 divided doses)

Or

Ceftriaxone (50 mg/kg IM or Four per mean solar day for ane or 3 days, non to exceed 1 thou per day)

Ceftriaxone, 3 d clindamycin (30–xl mg/kg per twenty-four hour period in iii divided doses), with or without third-generation cephalosporin

Failure of second antibiotic

Clindamycin (30–40 mg/kg per day in 3 divided doses) plus tertiary-generation cephalosporin

Tympanocentesis†

Consult specialist†

Oral cephalosporins, such every bit cefuroxime (Ceftin), may be used in children who are allergic to penicillin. Recent research indicates that the caste of cross reactivity between penicillin and 2nd- and tertiary-generation cephalosporins is low (less than 10% to 15%), and avoidance is no longer recommended.25 Because of their broad-spectrum coverage, third-generation cephalosporins in particular may have an increased risk of selection of resistant leaner in the community.26 Loftier-dose azithromycin (Zithromax; 30 mg per kg, single dose) appears to be more effective than the normally used five-day course, and has a similar cure rate as loftier-dose amoxicillin/clavulanate.viii,27,28 Still, excessive use of azithromycin is associated with increased resistance, and routine use is not recommended.8 Trimethoprim/sulfamethoxazole is no longer effective for the handling of AOM due to prove of S. pneumoniae resistance.29

Intramuscular or intravenous ceftriaxone (Rocephin) should be reserved for episodes of treatment failure or when a serious comorbid bacterial infection is suspected.2 I dose of ceftriaxone may exist used in children who cannot tolerate oral antibiotics because information technology has been shown to accept similar effectiveness every bit high-dose amoxicillin.30,31 A three-twenty-four hour period class of ceftriaxone is superior to a 1-day course in the treatment of nonresponsive AOM caused by penicillin-resistant Southward. pneumoniae.31 Although some children will likely benefit from intramuscular ceftriaxone, overuse of this amanuensis may significantly increment high-level penicillin resistance in the community.2 High-level penicillin-resistant pneumococci are likewise resistant to beginning- and third-generation cephalosporins.

Antibody therapy for AOM is often associated with diarrhea.8,10,32 Probiotics and yogurts containing agile cultures reduce the incidence of diarrhea and should be suggested for children receiving antibiotics for AOM.32 There is no compelling evidence to back up 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 antibody therapy should be reexamined.8 If a bulging, inflamed tympanic membrane is observed, therapy should be changed to a second-line agent.ii For children initially on amoxicillin, high-dose amoxicillin/clavulanate is recommended.8,10,28

For children with an amoxicillin allergy who exercise not amend with an oral cephalosporin, intramuscular ceftriaxone, clindamycin, or tympanocentesis may be considered.4,8 If symptoms recur more than one month after the initial diagnosis of AOM, a new and unrelated episode of AOM should be assumed.10 For children with recurrent AOM (i.e., three or more episodes in vi months, or four episodes within 12 months with at least one episode during the preceding six months) with eye ear effusion, tympanostomy tubes may be considered to reduce the need for systemic antibiotics in favor of ascertainment, or topical antibiotics for tube otorrhea.8,10 Nevertheless, tympanostomy tubes may increment the risk of long-term tympanic membrane abnormalities and reduced hearing compared with medical therapy.33  Other strategies may assist forbid recurrence (Table 4).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 cohabit and flu vaccines36

Use xylitol glue in appropriate children (two pieces, five times a day later on meals and chewed for at least five minutes)37

Probiotics, specially in infants, have been suggested to reduce the incidence of infections during the first year of life. Although available evidence has non demonstrated that probiotics forbid respiratory infections,38 probiotics practice not cause agin furnishings and need not exist discouraged. Antibody prophylaxis is not recommended.8

Management of OME

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

Management of OME is summarized in Table 5.eleven 2 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 voice communication delay at all visits. If a developmental filibuster is apparent or middle ear structures appear aberrant, the kid should be referred to an otolaryngologist.11 Antibiotics, decongestants, and nasal steroids do not hasten the clearance of middle ear fluid and are not recommended.xi,39

Table 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 probable, reevaluate at three-month intervals, including screening for language delay; if at that place is no anatomic damage or evidence of developmental or behavioral complications, continue to notice at three- to half dozen-month intervals; if complications are suspected, refer to an otolaryngologist

For effusion that appears to be associated with anatomic harm, 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 Risk Factors
  • Diagnosis
  • Management of Astute Otitis Media
  • Direction 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 3 months or longer with documented hearing difficulties, or for children with recurrent AOM who have testify of center 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 three months' elapsing, or in children with recurrent AOM who practise non take eye ear effusion in either ear at the fourth dimension of cess for tube candidacy. Children with chronic OME who did not receive tubes should exist reevaluated every iii 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.twoscore

Children with tympanostomy tubes who present with acute uncomplicated otorrhea should be treated with topical antibiotics and not oral antibiotics. Routine, prophylactic water precautions such as ear plugs, headbands, or avoidance of swimming are not necessary for children with tympanostomy tubes.xl

Special Populations

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

INFANTS EIGHT WEEKS OR YOUNGER

Young infants are at increased hazard of astringent sequelae from suppurative AOM. Heart ear pathogens found in neonates younger than ii weeks include group B streptococcus, gram-negative enteric bacteria, and Chlamydia trachomatis.41 Delirious neonates younger than two weeks with apparent AOM should accept a full 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 good for you.42

ADULTS

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

Data Sources: Nosotros reviewed the updated Bureau for Healthcare Inquiry and Quality Show 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 ane, 2010, using the keywords human, English language, guidelines, controlled trials, and accomplice studies. Searches were performed using the following terms: otitis media with effusion or serous effusion, recurrent otitis media, acute otitis media, otitis media infants 0–four weeks, otitis media adults, otitis media and screening for voice communication delay, probiotic leaner afterwards antibiotics. Search dates: October 2011 and August 14, 2013.

EDITOR'S Notation: This article is based, in function, on an institution-broad guideline adult at the Academy of Michigan. Equally part of the guideline evolution process, authors of this article, including representatives from primary and specialty care, convened to review current literature and make recommendations for diagnosis and handling of otitis media and otitis media with effusion in primary intendance.

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The Authors

prove all author info

KATHRYN M. HARMES, Md, is medical manager of Dexter Wellness Center in Ann Arbor, Mich. She is a clinical lecturer in the Department of Family unit Medicine at the University of Michigan Medical School in Ann Arbor....

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

HEATHER L. BURROWS, Md, PhD, is a clinical banana professor in the Department of Pediatrics and is associate director of education in the Partitioning 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 unit Medicine Residency Program at the University of Michigan Medical School.

R. VAN HARRISON, PhD, is a professor in the Department of Medical Instruction at the University of Michigan Medical School.

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

Author disclosure: No relevant financial affiliations.

Accost correspondence to Kathryn Grand. Harmes, Doctor, Academy of Michigan Health System, 1500 E. Medical Eye Dr., Ann Arbor, MI 48109 (e-postal service: jordankm@umich.edu). Reprints are not bachelor from the authors.

REFERENCES

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

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37. Azarpazhooh A, Limeback H, Lawrence HP, et al. Xylitol for preventing astute otitis media in children up to 12 years of age. Cochrane Database Syst Rev. 2011(11):CD007095.

38. Weichert S, Schroten H, Adam R. The office of prebiotics and probiotics in prevention and treatment of babyhood infectious diseases. Pediatr Infect Dis J. 2012;31(8):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 Cervix Surg. 2011;137(five):449–455.

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

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