Overview
Definition:
Acute otitis media (AOM) is a common childhood illness characterized by inflammation of the middle ear, typically accompanied by a rapid onset of signs and symptoms of middle ear effusion and inflammation
It is often associated with a viral upper respiratory infection.
Epidemiology:
AOM is the most common bacterial infection diagnosed in young children in developed countries, with a peak incidence between 6 and 20 months of age
Recurrent AOM affects up to one-third of children by age 3
In India, AOM remains a significant cause of pediatric morbidity.
Clinical Significance:
AOM is a leading reason for antibiotic prescriptions in children, contributing to antibiotic resistance
Differentiating between AOM cases that can be managed with watchful waiting and those requiring immediate antibiotics is crucial for optimizing patient outcomes and promoting judicious antibiotic use.
Clinical Presentation
Symptoms:
Ear pain (otalgia), often worse when lying down
Fever
Irritability or fussiness, particularly in infants
Difficulty sleeping
Decreased appetite
Tugging or pulling at the ear (in infants)
Fluid draining from the ear (otorrhea) if the tympanic membrane has perforated.
Signs:
Bulging tympanic membrane
Loss of normal tympanic membrane landmarks (e.g., malleus)
Middle ear effusion (dullness or absence of light reflex, poor mobility on pneumatic otoscopy)
Erythema (redness) of the tympanic membrane
Fever (temperature >38°C or 100.4°F).
Diagnostic Criteria:
The American Academy of Pediatrics (AAP) guidelines define AOM as: 1
Recent onset of symptoms
2
Signs and symptoms of middle ear effusion (e.g., bulging TM, limited mobility)
3
Signs and symptoms of middle ear inflammation (e.g., erythema of TM, ear pain).
Diagnostic Approach
History Taking:
Key questions include onset and duration of symptoms, presence of ear pain or fever, any recent upper respiratory infection, previous episodes of AOM, antibiotic allergies, and vaccination status
Red flags include persistent high fever, severe pain unresponsive to analgesics, signs of complications, or symptoms in immunocompromised children.
Physical Examination:
A thorough otoscopic examination is paramount
Assess the tympanic membrane for color, transparency, mobility (using pneumatic otoscopy), and landmarks
Examine the nasopharynx and oropharynx for signs of infection
Auscultate the lungs to rule out pneumonia.
Investigations:
For typical AOM, investigations are generally not required
Tympanometry can be useful in assessing middle ear effusion and tympanic membrane mobility, especially in older children or when diagnosis is uncertain
Pneumatic otoscopy is the most important bedside tool
Bacterial culture is rarely indicated unless there are complications or recurrent treatment failures.
Differential Diagnosis:
Otitis externa (swimmer's ear)
Otitis media with effusion (OME) without signs of acute inflammation
Foreign body in the ear canal
Cerumen impaction
Mastoiditis (a complication)
Dental pain referred to the ear.
Management
Initial Management:
Pain and fever management is crucial
Acetaminophen or ibuprofen are recommended
Advise parents on watchful waiting parameters and when to seek further medical attention.
Medical Management:
Decision between watchful waiting and immediate antibiotics is based on age, severity of symptoms, and laterality (unilateral vs
bilateral)
For children < 6 months: immediate antibiotics
For children 6 months to 2 years with severe symptoms (moderate-severe otalgia, otalgia > 48 hours, temp > 39°C): immediate antibiotics
For children > 2 years with severe symptoms: immediate antibiotics
For children 6 months to 2 years with non-severe symptoms: shared decision-making, can offer watchful waiting
For children > 2 years with non-severe symptoms: shared decision-making, can offer watchful waiting
First-line antibiotic: Amoxicillin (80-90 mg/kg/day in 2 divided doses) for 5-7 days for children aged 2 years or older
For children < 2 years or severe symptoms, 10 days is recommended
Alternatives include Amoxicillin-clavulanate if recent amoxicillin use or persistent symptoms
Macrolides or clindamycin for penicillin allergy.
Surgical Management:
Tympanostomy tubes (grommets) are indicated for recurrent AOM (e.g., 3 or more episodes in 6 months, or 4 or more in 12 months) or persistent middle ear effusion with hearing loss.
Supportive Care:
Encourage fluid intake
Monitor for worsening symptoms or signs of complications
Educate parents on proper ear hygiene and signs of recurrence.
Complications
Early Complications:
Tympanic membrane perforation with otorrhea
Facial nerve palsy
Mastoiditis (serious infection of the mastoid bone)
Labyrinthitis or vestibular dysfunction
Petrositis.
Late Complications:
Hearing loss (conductive, due to effusion
sensorineural, less common)
Tympanosclerosis (scarring of TM)
Cholesteatoma (abnormal skin growth in middle ear)
Chronic suppurative otitis media.
Prevention Strategies:
Pneumococcal and influenza vaccinations
Exclusive breastfeeding for the first 6 months
Avoiding exposure to secondhand smoke
Limiting pacifier use after infancy
Good hand hygiene.
Prognosis
Factors Affecting Prognosis:
Prompt and appropriate antibiotic treatment (if indicated)
Absence of complications
Younger age and presence of risk factors (e.g., daycare attendance) may be associated with higher recurrence rates.
Outcomes:
Most children recover fully from AOM without long-term sequelae with appropriate management
Hearing typically returns to normal after resolution of effusion
Recurrent episodes can impact speech and language development if untreated
Successful management of AOM is associated with excellent long-term outcomes.
Follow Up:
Children treated with antibiotics should be re-evaluated if symptoms do not improve within 48-72 hours
Follow-up audiometry may be indicated for children with recurrent AOM or persistent effusion for more than 3 months to assess for hearing loss.
Key Points
Exam Focus:
Distinguish between AOM and OME
Recall AAP guidelines for antibiotic prescribing
Understand indications for watchful waiting
Know first-line antibiotics, dosages, and durations for different age groups
Recognize complications of AOM.
Clinical Pearls:
Pneumatic otoscopy is your best friend for assessing TM mobility
Always consider pain control as a primary management step
Empower parents with clear instructions for watchful waiting
Antibiotic stewardship is key – not all AOM needs immediate antibiotics.
Common Mistakes:
Over-prescribing antibiotics for viral URIs mistaken as AOM
Failure to assess TM mobility properly
Inadequate pain management
Not recognizing signs of complications like mastoiditis
Incorrect antibiotic dosing or duration.