Otitis Media: Diagnosis and Handling

A more recent article on otitis media is bachelor.

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

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

Am Fam Physician. 2013 Oct 1;88(7):435-440.

Related editorials: Should Children with Acute Otitis Media Routinely Exist Treated with Antibiotics? Yes: Routine Handling Makes Sense for Symptomatic, Emotional, and Economic Reasons and No: Nigh Children Older Than Ii Years Do Not Crave Antibiotics

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

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

Author disclosure: No relevant financial affiliations.

Commodity Sections

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

Astute otitis media is diagnosed in patients with acute onset, presence of centre ear effusion, physical bear witness of eye ear inflammation, and symptoms such every bit hurting, 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 near mutual organisms isolated from heart ear fluid. Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with balmy symptoms. High-dose amoxicillin (fourscore to 90 mg per kg per day) is the antibiotic of pick for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be reexamined, and a 2d-line agent, such as amoxicillin/clavulanate, should be used if advisable. Otitis media with effusion is divers as middle ear effusion in the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids practise not hasten the clearance of heart ear fluid and are non recommended. Children with testify of anatomic impairment, hearing loss, or language delay should be referred to an otolaryngologist.

Otitis media is among the almost common issues faced by physicians caring for children. Approximately eighty% of children volition have at least one episode of acute otitis media (AOM), and between fourscore% and ninety% will have at to the lowest degree i 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 Wellness System's 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 by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

viii

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

C

9

Adequate analgesia is recommended for all children with AOM.

C

8, 15

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

C

19, 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

viii, 10

Children with eye ear effusion and anatomic damage or bear witness of hearing loss or linguistic communication filibuster should be referred to an otolaryngologist.

C

11

Etiology and Risk Factors

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

Usually, AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Bacteria can be isolated from heart ear fluid cultures in 50% to 90% of cases of AOM and OME. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the near mutual organisms.3,four H. influenzae has become the almost prevalent organism among children with astringent or refractory AOM following the introduction of the pneumococcal conjugate vaccine.5–seven  Gamble factors for AOM are listed in Tabular array ane.8,9

Tabular array 1.

Risk Factors for Acute Otitis Media

Age (younger)

Allergies

Craniofacial abnormalities

Exposure to environmental smoke or other respiratory irritants

Exposure to grouping twenty-four hour period intendance

Family history of recurrent acute otitis media

Gastroesophageal reflux

Immunodeficiency

No breastfeeding

Pacifier utilize

Upper respiratory tract infections

Diagnosis

  • Abstruse
  • Etiology and Risk Factors
  • Diagnosis
  • Management 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 jutting of the tympanic membrane (Effigy 1), new onset of otorrhea not acquired by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear hurting (less than 48 hours) or erythema. AOM should not be diagnosed in children who practise not have objective prove of middle ear effusion.8 An inaccurate diagnosis can pb to unnecessary treatment with antibiotics and contribute to the development of antibiotic resistance.

Figure 1.

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

OME is defined as middle ear effusion in the absence of astute symptoms.10,xi 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.11 Pneumatic otoscopy is a useful technique for the diagnosis of AOM and OME8–12 and is 70% to 90% sensitive and specific for determining the presence of middle ear effusion. By comparing, simple otoscopy is 60% to 70% authentic.x,xi Inflammation with bulging of the tympanic membrane on otoscopy is highly predictive of AOM.7,8,12 Pneumatic otoscopy is about helpful when cerumen is removed from the external auditory culvert.

Tympanometry and acoustic reflectometry are valuable adjuncts to otoscopy or pneumatic otoscopy.viii,10,xi 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 outcome may be helpful to predict absence of middle ear effusion. Acoustic reflectometry has lower sensitivity and specificity in detecting heart ear effusion and must exist correlated with the clinical examination.fourteen Tympanocentesis is the preferred method for detecting the presence of middle ear effusion and documenting bacterial etiology,8 but is rarely performed in the main care setting.

Management of Astute Otitis Media

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

Handling of AOM is summarized in Tabular array 2.8

Table 2.

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 astringent signs or symptoms (moderate or severe otalgia, otalgia for at to the lowest degree 48 hours, or temperature of 102.2°F [39°C] or higher): antibiotic therapy for 10 days

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

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

Children 2 years or older without severe signs or symptoms: ascertainment or antibiotic therapy for v to vii days

Persistent symptoms (48 to 72 hours)

Echo ear test for signs of otitis media

If otitis media is present, initiate or modify antibody therapy

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

ANALGESICS

Analgesics are recommended for symptoms of ear hurting, fever, and irritability.8,15 Analgesics are especially of import at bedtime considering disrupted slumber is one of the most common symptoms motivating parents to seek care.2 Ibuprofen and acetaminophen have been shown to exist effective.16 Ibuprofen is preferred, given its longer duration of action and its lower toxicity in the consequence of overdose.2 Topical analgesics, such every bit benzocaine, can also be helpful.17

Ascertainment 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 exist routinely prescribed for children with AOM who are six months or older with astringent signs or symptoms (i.e., moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or higher), and for children younger than two years with bilateral AOM regardless of boosted signs or symptoms.8

Among children with balmy symptoms, observation may be an option in those six to 23 months of age with unilateral AOM, or in those ii years or older with bilateral or unilateral AOM.eight,10,19 A large prospective study of this strategy found that two out of three children volition 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 historic period with nonsevere symptoms if ascertainment is a reasonable option.21,22 If ascertainment is chosen, a mechanism must be in place to ensure appropriate handling if symptoms persist for more than 48 to 72 hours. Strategies include a scheduled follow-up visit or providing patients with a backup antibody prescription to exist filled just if symptoms persist.8,20,23

ANTIBIOTIC SELECTION

[ corrected] Table iii summarizes the antibiotic options for children with AOM.viii High-dose amoxicillin should be the initial treatment in the absence of a known allergy.8,ten,24 The advantages of amoxicillin include low price, acceptable taste, safety, 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).8

Tabular array three.

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

Initial immediate or delayed antibody handling Antibiotic treatment later 48–72 h of failure of initial antibody treatment
Recommended offset-line treatment Alternative treatment (if penicillin allergy) Recommended first-line treatment Alternative treatment

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

Or

Amoxicillin-clavulanate* (ninety mg/kg per solar day of amoxicillin, with 6.iv mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, fourteen:1] in 2 divided doses)

Cefdinir (xiv mg/kg per solar day in 1 or 2 doses)

Cefuroxime (30 mg/kg per twenty-four hours in 2 divided doses)

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

Ceftriaxone (l mg/kg IM or IV per day for 1 or iii days, not to exceed 1 g per day)

Amoxicillin-clavulanate* (90 mg/kg per twenty-four hours of amoxicillin, with vi.four mg/kg per 24-hour interval of clavulanate in ii divided doses)

Or

Ceftriaxone (50 mg/kg IM or IV per day for 1 or 3 days, not to exceed i yard per 24-hour interval)

Ceftriaxone, iii d clindamycin (30–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin

Failure of second antibiotic

Clindamycin (xxx–twoscore mg/kg per 24-hour interval in three divided doses) plus third-generation cephalosporin

Tympanocentesis†

Consult specialist†

Oral cephalosporins, such as cefuroxime (Ceftin), may be used in children who are allergic to penicillin. Contempo research indicates that the degree of cross reactivity between penicillin and 2d- and third-generation cephalosporins is low (less than 10% to fifteen%), and abstention is no longer recommended.25 Because of their broad-spectrum coverage, 3rd-generation cephalosporins in detail may have an increased take chances of selection of resistant leaner in the community.26 High-dose azithromycin (Zithromax; xxx mg per kg, single dose) appears to be more effective than the commonly used v-twenty-four hour period course, and has a similar cure rate every bit loftier-dose amoxicillin/clavulanate.viii,27,28 However, excessive utilise of azithromycin is associated with increased resistance, and routine use is non recommended.eight Trimethoprim/sulfamethoxazole is no longer effective for the treatment of AOM due to evidence of S. pneumoniae resistance.29

Intramuscular or intravenous ceftriaxone (Rocephin) should be reserved for episodes of handling failure or when a serious comorbid bacterial infection is suspected.2 Ane dose of ceftriaxone may be used in children who cannot tolerate oral antibiotics because information technology has been shown to have similar effectiveness as high-dose amoxicillin.30,31 A iii-day grade of ceftriaxone is superior to a ane-day course in the treatment of nonresponsive AOM acquired by penicillin-resistant Southward. pneumoniae.31 Although some children will likely benefit from intramuscular ceftriaxone, overuse of this agent may significantly increase high-level penicillin resistance in the community.2 High-level penicillin-resistant pneumococci are too resistant to first- and third-generation cephalosporins.

Antibiotic therapy for AOM is often associated with diarrhea.viii,10,32 Probiotics and yogurts containing active cultures reduce the incidence of diarrhea and should be suggested for children receiving antibiotics for AOM.32 At that place is no compelling evidence to back up the employ of complementary and alternative treatments in AOM.eight

PERSISTENT OR RECURRENT AOM

Children with persistent, significant AOM symptoms despite at least 48 to 72 hours of antibody therapy should be reexamined.eight If a bulging, inflamed tympanic membrane is observed, therapy should be inverse to a 2nd-line agent.two For children initially on amoxicillin, loftier-dose amoxicillin/clavulanate is recommended.8,10,28

For children with an amoxicillin allergy who exercise non improve with an oral cephalosporin, intramuscular ceftriaxone, clindamycin, or tympanocentesis may be considered.four,8 If symptoms recur more than one calendar 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., iii or more than episodes in six months, or four episodes within 12 months with at least 1 episode during the preceding vi months) with center 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 Withal, tympanostomy tubes may increase the risk of long-term tympanic membrane abnormalities and reduced hearing compared with medical therapy.33  Other strategies may assist prevent recurrence (Table 4).34–37

Table 4.

Strategies for Preventing Recurrent Otitis Media

Check for undiagnosed allergies leading to chronic rhinorrhea

Eliminate canteen propping and pacifiers34

Eliminate exposure to passive smoke35

Routinely immunize with the pneumococcal conjugate and influenza vaccines36

Use xylitol gum in appropriate children (ii pieces, five times a mean solar day later meals and chewed for at least five minutes)37

Probiotics, particularly in infants, accept been suggested to reduce the incidence of infections during the offset yr of life. Although available bear witness has not demonstrated that probiotics prevent respiratory infections,38 probiotics do not crusade adverse furnishings and need not be discouraged. Antibiotic prophylaxis is not recommended.8

Management of OME

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

Management of OME is summarized in Table v.11 Two rare complications of OME are transient hearing loss potentially associated with linguistic communication delay, and chronic anatomic injury to the tympanic membrane requiring reconstructive surgery.11 Children should be screened for voice communication filibuster at all visits. If a developmental delay is credible or middle ear structures appear abnormal, the child should be referred to an otolaryngologist.11 Antibiotics, decongestants, and nasal steroids do not hasten the clearance of eye 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 likely, reevaluate at three-month intervals, including screening for language delay; if there is no anatomic damage or prove of developmental or behavioral complications, continue to observe at three- to six-month intervals; if complications are suspected, refer to an otolaryngologist

For effusion that appears to exist associated with anatomic impairment, such as agglutinative otitis media or retraction pockets, reevaluate in four to six weeks; if aberration persists, refer to an otolaryngologist

Antibiotics, decongestants, and nasal steroids are not indicated

Tympanostomy Tube Placement

  • Abstract
  • Etiology and Risk 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 historic period who have had bilateral OME for three months or longer with documented hearing difficulties, or for children with recurrent AOM who have prove of middle ear effusion at the time 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 not have middle ear effusion in either ear at the time of assessment for tube candidacy. Children with chronic OME who did not receive tubes should be reevaluated every three to six months until the effusion is no longer nowadays, hearing loss is detected, or structural abnormalities of the tympanic membrane or centre 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, safe h2o precautions such every bit ear plugs, headbands, or avoidance of swimming are non necessary for children with tympanostomy tubes.40

Special Populations

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

INFANTS Viii WEEKS OR YOUNGER

Young infants are at increased risk of severe sequelae from suppurative AOM. Center ear pathogens constitute in neonates younger than two weeks include group B streptococcus, gram-negative enteric bacteria, and Chlamydia trachomatis.41 Febrile neonates younger than ii weeks with apparent AOM should have a full sepsis workup, which is indicated for whatever delirious neonate.41 Empiric amoxicillin is acceptable for infants older than two weeks with upper respiratory tract infection and AOM who are otherwise healthy.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 additional evaluation to rule out a serious underlying status, such as mechanical obstruction, which in rare cases is caused by nasopharyngeal carcinoma. Isolated AOM or transient OME may be caused by eustachian tube dysfunction from a viral upper respiratory tract infection; notwithstanding, 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 one, 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 0–4 weeks, otitis media adults, otitis media and screening for spoken communication delay, probiotic leaner after antibiotics. Search dates: Oct 2011 and August 14, 2013.

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

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The Authors

bear witness all author info

KATHRYN K. HARMES, Dr., is medical manager of Dexter Wellness Centre in Ann Arbor, Mich. She is a clinical lecturer in the Section of Family unit Medicine at the University of Michigan Medical School in Ann Arbor....

R. ALEXANDER BLACKWOOD, Physician, PhD, is an acquaintance professor in the Department of Pediatrics at the Academy of Michigan Medical School.

HEATHER L. BURROWS, Medico, PhD, is a clinical assistant professor in the Section of Pediatrics and is associate director of teaching in the Division of General Pediatrics at the University of Michigan Medical Schoolhouse.

JAMES M. COOKE, Dr., is an banana professor in the Department of Family Medicine and is the manager 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 Pedagogy at the Academy of Michigan Medical School.

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

Author disclosure: No relevant fiscal affiliations.

Address correspondence to Kathryn M. Harmes, MD, University of Michigan Health System, 1500 E. Medical Heart Dr., Ann Arbor, MI 48109 (e-mail: jordankm@umich.edu). Reprints are not 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 day care. Pediatrics. 1992;xc(two pt 1):228–232.

36. Fire-eater B, Black SB, Shinefield HR, et al. Affect of the pneumococcal conjugate vaccine on otitis media [published correction appears in Pediatr Infect Dis J. 2003;22(2):163]. Pediatr Infect Dis J. 2003;22(one):10–sixteen.

37. Azarpazhooh A, Limeback H, Lawrence HP, et al. Xylitol for preventing acute otitis media in children up to 12 years of historic period. Cochrane Database Syst Rev. 2011(eleven):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(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 Caput Neck Surg. 2011;137(5):449–455.

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

41. Nozicka CA, Hanly JG, Beste DJ, et al. Otitis media in infants aged 0–8 weeks: frequency of associated serious bacterial disease. Pediatr Emerg Care. 1999;15(4):252–254.

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