Acute otitis media

Next to the common cold, acute otitis media is the most frequently diagnosed illness in children in the US.

Most common illness requiring a visit to a physician in the developed world.

The most common childhood infection for which antibiotics are prescribed in the United States.

Acute otitis media is an infection of the middle ear. 

More than 80% of children experience at least one episode of otitis media by age 3 years.

Common cause of primary otalgia is otitis media, meaning an infection behind the eardrum.

The peak age for children to get acute otitis media is ages 6–24 months. 

83% of children had at least one episode of acute otitis media by 3 years of age.

Worldwide, there are 709 millions cases of acute otitis media every year.[36] Hearing loss globally due to ear infection is estimated to be 30 people in every 10,000.

While acute otitis media is also most common in these first 3 years of life, though older children may also experience it.

The most common associated bacteria for otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Otitis media often occurs with or following colds.

The diagnosis of otitis media is made by the combination of symptoms and examination of the tympanic membrane for redness, bulging, and/or a middle ear effusion.

Complications of otitis media include: hearing loss, facial nerve paralysis, or extension of infection to surrounding anatomic structures.

The most common bacterial organisms are due to Streptococcus and H influenzae.

Acute otitis media is the leading indication for anti-microbial treatment in children.

In 2006 an average expenditure for a child with a OAM was $350 totaling $2.8 billion (Soni A).

Affects approximately 80% of children and contributing to approximately $4 billion in annual health care costs in the United States alone.

Wait and see approach is effective emergency department management.

Watchful waiting is based on relatively high rates of spontaneous improvement in children with acute otitis media.

Wait and see approach reduces antibiotic use to 38% vs. 87% without a difference in fever, otalgia or unscheduled medical visits.

Watchful waiting is recommended for children six months to 23 months of age in whom illness is not severe , with mild otalgia and temperature less than 39° and in whom the diagnosis of AOM is uncertain.

Of 100 children with average risk AOM approximately 80% would likely get better within three days without antibiotics (Rosenfeld RM et al).

If 100 children with average risk AOM were treated with immediate ampicillin/amoxicillin an additional 12 children would likely improve, but 3-10 would develop a rash and 5-10 would develop diarrhea.

Meta-analyses suggest that for on child to have relief of symptoms, 7-17 children must be treated with antimicrobial agents.

Wait and see studies indicate as many as 15 children need to be treated with antibiotics for 1 child to benefit.

Analgesics are prescribed and if symptoms do not resolve within 48-72 hours antibiotics are utilized.

Immediate anabiotics for acute otitis media are recommended for patients younger than six months of age, those six months of age or older who have acute otitis media with severe symptoms of temperature 39°C is or greater, moderate to severe otalgia, or otalgia that has lasted longer than 48 hours, children younger than two years of age with acute otitis media in both ears or with disease in one ear and severe symptoms, or any child with ottorhea not associated with otitis externa.

A clinical diagnosis with three components: acute signs of infection, evidence of middle ear inflammation and effusion.

A red, immobile or a bulging tympanic membrane predicts for AOM but accuracy has not been established.

With introduction of heptavalent pneumococcal conjugate vaccine (PCV7), AOM micribiology studies reveal streptococcal pneumoniae is becoming less prevalent and H influenza is becoming more so, As our non-vaccine streptococcal pneumonia serotypes.

Wait and see studies exclude patients whom clinical examiners consider toxic, therefore studies should not be extrapolated to very sick children.

Amoxicillin and amoxicillin/clavulanate the drugs of choice for the empiric treatment of uncomplicated acute otitis media.

No antibiotic is superior to any other antibiotic over amoxicillin.

In a randomized double-blind trial of children 6 to 35 months of age with AOM received amoxicillin-clavulanate or placebo for seven days: treatment failure occurred in 18.6% of the children on the antibiotic compared with 44.9% of the children who received placebo (Tahtinen PA et al).

In a study randomizing 291 children age 6-23 months, with acute otitis media diagnosed with stringent criteria to receive amoxicillin-clavulanate or placebo for 10 days: among children treated with amoxicillin-clavulanate 35% had resolution of symptoms by day one, 61% by day four and 80% by day seven, compared to the placebo patients 28%, 54%, and 74%, respectively (Hoberman A et al).

In the above study treatment with amoxicillin-clavulanate for 10 days among children ages 6-23 months there was reduced time to resolution of symptoms and reduced overall symptom burden, decreased rate of middle ear effusion, and a decrease in the rate of persistent signs of infection on otoscopic exam (Hoberman A et al).

Commonly involved bacterial infections include Streptococcus pneumonia, Hemophilus influenzae, and Moraxella catarrhalis.

Tympanocentesis may be indicated with acute severe otalgia in the presence of a bulging tympanic membrane in children younger than 4 years, in a febrile toxic-appearing child, when suppurative complications exist, during the presence of an immunocompromised state or the identification of an unusual pathogen in a neonate. The

Complications are rare and include perforation of the tympanic membrane, mastoiditis, labyrinthitis, subperiosteal abscess, facial nerve palsy, subdural abscess, epidural abscess, brain abscess, meningitis and sinus thrombophlebitis.

Overuse of antibiotics increases bacterial resistance, and associated with high costs, risk of rashes, diarrhea, and less commonly severe allergic reactions or C.difficile  infection.

Four bouts of infection in 6 months or six episodes in 1 year are indications for tympanostomy placement, with reduction in incidence of such infections.

Recurrent acute otitis media is defined as at least three episodes in six months, or at least four episodes in 12 months with at least one episode within the preceding months.

Recurrent otitis media is the principal indication for  tympanostomy tube placement, the most frequently performed operation in children after the newborn period.