Acute otitis media

Background

• Peak incidence: 6-18 months of age

Etiology

• Viral (70% of cases)
• Bacterial
  • S. pneumo (50%)
  • Nontypable H. flu (30%)
  • Moraxella (30%)

Clinical Features

A bulging tympanic membrane which is typical in a case of acute otitis media

• Acute onset (<48hr) AND
• Middle ear effusion AND
• Signs of middle ear inflammation
  • Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level
  • Middle Ear inflammation: erythema of TM or otalgia

Differential Diagnosis

Ear Diagnoses

• External
  • Auricular hematoma
  • Cholesteatoma
  • Contact dermatitis
  • Ear foreign body
  • Herpes zoster oticus (Ramsay Hunt syndrome)
  • Malignant otitis externa
  • Mastoiditis
  • Otitis externa
  • Otomycosis
  • Tympanic membrane rupture
• Internal
  • Acute otitis media
  • Bullous myringitis
  • Chronic otitis media
  • Mastoiditis
  • Otic barotrauma
• Inner/vestibular
  • Labyrinthitis
  • Meniere's disease
  • Sudden sensorineural hearing loss

Less common

• Oral cavity disease (referred pain)
• Cholesteatoma
• PTA
• Brain abscess
• Lemierre's Syndrome
• Herpes zoster oticus

Pediatric fever

• Upper respiratory infection (URI)
• UTI
• Sepsis
• Meningitis
• Febrile seizure
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV

Evaluation

• Typically clinical

Management

Analgesia

• Acetaminophen/ibuprofen and topical benzocaine (unless perforated TM)

2013 AAP Decision to Treat Guidelines

Age	Otorrhea	Severe Symptoms (unilateral or bilateral)	Bilateral without Otorrhea	Unilateral without Otorrhea
6mo-2y	Antibiotics	Antibiotics	Antibiotics	Antibiotics
2=≥2y	Antibiotics	Antibiotics	Antibiotics or observation period	Antibiotics or observation period

Also Consider In:

• Age <6mo
• Ill-appearing
• Recurrent acute otitis media (within 2-4wk)
• Concurrent antibiotic treatment
• Other bacterial infections
• Immunocompromised
• Craniofacial abnormalities

Wait-and-see antibiotic prescription (WASP)

• Rather that routine perscription is an option to avoid over use if the patient does not meet any of the prescription criteria
• If symptoms worsen or persist for 48-72 then caretaker fill the prescription
• Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group

Antibiotics Options

• Consider treating for a standard of 10 days as opposed to a shorter duration of 5 days to reduce treatment failure in young children
  • Treatment failure for 10 day at 16% and for 5 day at 34% for amoxicillin-clavulanate
  • RTC of 520 children aged 6-23 months

Initial Treatment

1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses 7-10 days

Treatment during prior Month

1. Can use Amoxicillin as same dosing as initial treatment
2. Cefdinir 14mg/kg/day BID x7-10 days
3. Cefpodoxime 10mg/kg PO daily x7-10 days
4. Cefuroxime 15mg/kg PO BID x7-10 days
5. Cefprozil 15mg/kg PO BID x7-10 days

Treatment Failure

defined as treatment during the prior 7-10 days

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day
   • Clavulanate increases vomiting/diarrhea
2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
   • Use if cannot tolerate PO

Penicillin Allergy

1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
2. Clarithromycin 7.5mg/kg PO BID x 10 days
3. Clindamycin 10mg/kg PO three times daily
   • Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use

Disposition

• Outpatient management

Complications

• Mastoiditis
• Meningitis
• Brain Abscess
• Lateral Sinus Thrombosis

See Also

• Ear diagnoses

References

Authors

Daniel Ostermayer, Ross Donaldson, Jordan Swartz, Yos Yachivev, Kevin Lu, Jonathan Osgood, Claire, Neil Young