Acute Otitis Media

Article Author:
Amina Danishyar
Article Editor:
John Ashurst
Updated:
2/25/2020 12:55:18 PM
PubMed Link:
Acute Otitis Media

Introduction

Otitis media is defined as an infection of the middle ear fluid. It is a spectrum of diseases that include acute otitis media (AOM), chronic suppurative otitis media (CSOM), and otitis media with effusion (OME). Acute otitis media is the second most common pediatric diagnosis in the emergency department following upper respiratory infections. Although otitis media can occur at any age, it is most commonly seen between the ages of 6 to 24 months.[1]

Infection of the middle ear can be due to viral, bacterial or coinfection with both. The most common bacterial organisms causing otitis media are Streptococcus pneumoniae, followed by non-typeable Haemophilus influenzae (NTHi), and Moraxella catarrhalis. Following the introduction of the conjugate pneumococcal vaccines, the pneumococcal organisms have evolved to non-vaccine serotypes. The most common viral pathogens of otitis media include the respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses.[2][3][4]

Otitis media is diagnosed clinically considering objective findings on physical exam combined with presenting signs and symptoms. Several diagnostic tools are available such as a pneumatic otoscope, tympanometry, and acoustic reflectometry to aid in the diagnosis of otitis media. Pneumatic otoscopy is the most reliable and has a higher sensitivity and specificity as compared to otoscope, tympanometry and other modalities.

Treatment of otitis media with antibiotics is controversial. Without proper treatment, suppurative fluid from the middle ear can extend to the adjacent anatomical locations and result in complications such as tympanic membrane (TM) perforation, mastoiditis, labyrinthitis, petrositis, meningitis, brain abscess, hearing loss, lateral and cavernous sinus thrombosis, and others.[5] Due to the controversy surrounding treatment and the risks of complications, there are guidelines in place for the treatment of OM.  In the United States, the mainstay of treatment of an established diagnosis of otitis media is high dose amoxicillin and has been found to be most beneficial in children under two years of age. Treatment in countries like the Netherlands is initially watchful waiting, and if unresolved, antibiotics are warranted[6]. However, the concept of watchful waiting has not gained full acceptance in the United States. Analgesics such as non-steroidal drugs and acetaminophen can be used alone or in combination to achieve effective pain control in patients with otitis media.

Etiology

Otitis media is a multifactorial disease. Infectious, allergic, and environmental factors contribute to otitis media.[7][8][9][10][11][12]

The causes include:

  • Decreased immunity due to human immunodeficiency virus (HIV), diabetes, and other immuno-deficiencies
  • Genetic predisposition
  • Mucins which include abnormalities of this gene expression, especially upregulation of MUC5B
  • Anatomic abnormalities of the palate and tensor veli palatini
  • Ciliary dysfunction
  • Cochlear implants
  • Vitamin A deficiency
  • Bacterial pathogens, Streptococcus pneumoniae, Haemophilus influenza, and Moraxella (Branhamella) catarrhalis, are responsible for more than 95%
  • Viral pathogens such as respiratory syncytial virus, influenza virus, parainfluenza virus, rhinovirus, and adenovirus
  • Allergies
  • Lack of breastfeeding
  • Passive smoke exposure
  • Daycare attendance
  • Lower socioeconomic status

Epidemiology

Otitis media is a global problem and is found to be slightly more common in males than in females. The specific number of cases per year is difficult to determine due to the lack of reporting and different incidence across many different geographical regions. The peak incidence of otitis media occurs between six and twelve months of life and declines after age five. Approximately 80% of all children will experience a case of otitis media during their lifetime, and between 80% and 90% of all children will have otitis media with an effusion before school age. Otitis media is less common in adults than in children, unless it occurs in immunocompromised adults.[13][14]

Pathophysiology

Otitis media initially starts as an inflammatory process following a viral upper respiratory tract infection involving the mucosa of the nose, nasopharynx, and Eustachian tube. Due to narrow anatomical space, the edema caused by the inflammatory process obstructs the narrowest part of the Eustachian tube leading to a decrease in ventilation. This leads to a cascade of events such as an increase in negative pressure in the middle ear and buildup of mucosal secretions allowing for the colonization of bacterial and viral organisms in the middle ear. The growth of these microbes in the middle ear then leads to suppuration. This is demonstrated as the clinical signs of acute otitis media such as bulging or erythematous tympanic membrane and middle ear fluid. 

Several risk factors play a role in causing Eustachian tube dysfunction predisposing children to otitis media. The most common risk factor is a preceding upper respiratory tract infection. Other risk factors include male gender, adenoid hypertrophy (obstructing), allergy, daycare attendance, environmental smoke exposure, pacifier use, immunodeficiency, gastroesophageal reflux, and genetic predisposition.[15][16][17]

Traditionally it was believed that breastfeeding is protective; however, recent studies in Denmark did not support such benefit as increased breastfeeding in a population did not change the incident of otitis media.[14]

Histopathology

Histopathology varies according to disease severity. Acute purulent otitis media (APOM) is characterized by edema and hyperemia of the subepithelial space, which is followed by the infiltration of polymorphonuclear (PMN) leukocytes. As the inflammatory process progresses, there is mucosal metaplasia and formation of granulation tissue. After five days, the epithelium changes from flat cuboidal to pseudostratified columnar with the presence of goblet cells.

In serous acute otitis media (SAOM), inflammation of the middle ear and the eustachian tube has been identified as the major precipitating factor. Venous or lymphatic stasis in the nasopharynx or the eustachian tube plays a vital role in the pathogenesis of AOM. Inflammatory cytokines attract plasma cells, leukocytes, and macrophages to the site of inflammation. The epithelium changes to pseudostratified, columnar, or cuboidal. Hyperplasia of basal cells results in an increased number of goblet cells in the new epithelium.[18]

History and Physical

Although one of the best indicators for otitis media is otalgia, many children with otitis media can present with non-specific signs and symptoms, which can make the diagnosis challenging. These symptoms include irritability, headache, disturbed or restless sleep, poor feeding, anorexia, vomiting, or diarrhea. Approximately two-thirds of the patients present with fever, which is typically low grade.

The diagnosis of otitis media is primarily based on clinical findings combined with supporting signs and symptoms as described above. No lab test or imaging is needed. According to guidelines set forth by American Academy of Pediatrics, evidence of moderate to severe bulging of the tympanic membrane, or new onset of otorrhea not caused by otitis externa or mild tympanic membrane (TM) bulging with recent onset of ear pain or erythema is required for the diagnosis of acute otitis media. These criteria are intended only to aid primary care clinicians in the diagnosis and proper clinical decision making but not to replace clinical judgment.[19]

Any of the diagnostic tools, such as an otoscope, pneumatic otoscope, tympanometry, and acoustic reflectometry, can be used for visual examination of the middle ear. Otoscope examination is usually the first and more convenient way of examining the ear canal for erythema or loss of landmarks indicating middle ear effusion. However, the preferred method of detecting middle ear effusion and obtaining a culture sample for bacterial etiology is tympanocentesis, but it is rarely used in a primary care setting.[20][21][22]

Evaluation

The diagnosis of otitis media should always begin with a physical exam and the use of a pneumatic otoscope.[23][24]

Laboratory Studies

Laboratory evaluation is rarely necessary. A full sepsis workup in infants younger than 12 weeks with fever and associated acute otitis media is often necessary. Laboratory studies may be needed to confirm or exclude possible related systemic or congenital diseases.

Imaging Studies

Imaging studies are not indicated unless intra-temporal or intracranial complications are a concern.[25][26]

  • When an otitis media complication is suspected, computed tomography of the temporal bones may identify mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, meningitis, brain abscess, subdural abscess, ossicular disease, and cholesteatoma.
  • Magnetic resonance imaging may identify fluid collections, especially in the middle ear collections.

Tympanocentesis

Tympanocentesis may be used to determine the presence of middle ear fluid, followed by culture to identify pathogens.

Tympanocentesis can improve diagnostic accuracy and guide treatment decisions.[27][28]

Neonates or children who appear toxic or those that are at higher risk should undergo early tympanocentesis with culturing.

Other Tests

Tympanometry and acoustic reflectometry may also be used to evaluate for middle ear effusion.[29]

Treatment / Management

When the diagnosis of otitis media is established, the goal of the treatment is to control pain and to target the infectious process with antibiotics. Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can be used in combination or alone to achieve pain control as they are superior to placebo. There are controversies about prescribing antibiotics in early otitis media. Watchful waiting is practiced in European countries with no increased incidence of complications. However, watchful waiting has not gained wide acceptance in the United States. Reportedly, the presence of concomitant viral infection and bacterial infection decreased the efficacy of the antibiotic treatment due to increased inflammation and decreased antibiotic penetration of the middle ear. Hence, watchful waiting in the initial stages of otitis media is recommended.

When a bacterial etiology is suspected, the antibiotic of choice is for ten days in both children and adult patients who are not allergic to penicillin. Amoxicillin has good efficacy in the treatment of otitis media due to its high concentration in the middle ear. In cases of penicillin allergy, the American Academy of Pediatrics (AAP) recommends azithromycin as a single dose of 10 mg/kg or clarithromycin (15 mg/kg per day in 2 divided doses). Other options for penicillin-allergic patients are cefdinir (14 mg/kg per day in 1 or 2 doses), cefpodoxime (10 mg/kg per day, once daily), or cefuroxime (30 mg/kg per day in 2 divided doses).

Those patients whose symptoms do not improve after treatment with high dose amoxicillin, high-dose amoxicillin-clavulanate (90 mg/kg per day of amoxicillin component, with 6.4 mg/kg per day of clavulanate in 2 divided doses) should be given. In children who are vomiting or if there are situations in which oral antibiotics cannot be administered, ceftriaxone (50 mg/kg per day) for three consecutive days either intravenously or intramuscularly is an alternative option. Systemic steroids and antihistamine have not been shown to have any significant benefit.[30][31][19][32][33][34]

Differential Diagnosis

The following conditions come under the differential diagnosis of otitis media[35][36][37]

  • Acute Sinusitis
  • Bacteremia
  • Cholesteatoma
  • Fever in the Infant and Toddler
  • Fever Without a Focus
  • Hearing Impairment
  • Pediatric Nasal Polyps
  • Nasopharyngeal Cancer
  • Otitis Externa
  • Human Parainfluenza Viruses (HPIV) and Other Parainfluenza Viruses
  • Passive Smoking and Lung Disease
  • Pediatric Allergic Rhinitis
  • Pediatric Bacterial Meningitis
  • Pediatric Cleft Lip and Palate
  • Pediatric Gastroenteritis
  • Pediatric Gastroesophageal Reflux
  • Pediatric Haemophilus Influenzae Infection
  • Pediatric Head Trauma
  • Pediatric HIV Infection
  • Pediatric Mastoiditis
  • Pediatric Otosclerosis
  • Pediatric Pharyngitis
  • Pediatric Pneumococcal Infections
  • Primary Ciliary Dyskinesia
  • Respiratory Syncytial Virus Infection
  • Rhinovirus (RV) Infection (Common Cold)

Prognosis

The prognosis for most of the patients with otitis media is excellent.[38] Mortality from AOM is a rare occurrence in modern times. Due to better access to healthcare in developed countries, early diagnosis and treatment have resulted in a better prognosis of this disease. Effective antibiotic therapy is the mainstay of treatment. Multiple prognostic factors affect the disease course. Children presenting with less than three episodes of AOM are three times more likely to have their symptoms resolved with a single course of antibiotics as compared to children who develop this condition in seasons apart from winter.[39]

Children who develop complications are difficult to treat and have high rates of recurrence. Intratemporal and intracranial complications have significant mortality rates.[40]

Complications

Due to the complex arrangement of structures in and around the middle ear, complications once developed are challenging to treat. Complications can be divided into intratemporal and intracranial complications.[40][41][42][41]

The following are the intratemporal complications;

  • Hearing loss (conductive and sensorineural)
  • TM perforation (acute and chronic)
  • Chronic suppurative Otitis Media (with or without cholesteatoma)
  • Cholesteatoma
  • Tympanosclerosis
  • Mastoiditis
  • Petrositis
  • Labyrinthitis
  • Facial paralysis
  • Cholesterol granuloma
  • Infectious eczematoid dermatitis

The following are the intracranial complications;

  • Meningitis
  • Subdural empyema
  • Brain abscess
  • Extradural abscess
  • Lateral sinus thrombosis
  • Otitic hydrocephalus

Consultations

Patients most likely present in the emergency department due to the severity of the symptoms of acute otitis media. Patients with uncomplicated AOM are usually treated by their primary care physicians. However, primary care physicians may refer the patient to an otolaryngologist for surgical procedures, mostly tympanocentesis. Patients with chronic or recurrent otitis media may require surgical interventions. An audiologist is involved if children present with subjective evidence of hearing loss. Young children with CSOM may have speech and language delays, which are managed by a speech therapist.[43]

Deterrence and Patient Education

Pneumococcal and influenza vaccines prevent upper respiratory tract infections (URTIs) in children. Apart from this avoidance of tobacco smoke decreases the risk of URTI. Tobacco smoke is a respiratory stimulant that increases the risk of pneumonia in children. Infants with otitis media should be breastfed as breast milk contain immunoglobulins that prevent infants against foreign pathogens.[44]

Patients who develop intratemporal or intracranial complications need inpatient care. After discharge regular follow-ups are advised to prevent a recurrence. Hearing tests should be done at each follow-up visit to asses hearing loss if any.

Enhancing Healthcare Team Outcomes

Acute otitis media needs multidisciplinary management through an interprofessional team approach. Early diagnosis and prompt treatment decrease the risk of complications resulting in better patient outcomes.


References

[1] Meherali S,Campbell A,Hartling L,Scott S, Understanding Parents' Experiences and Information Needs on Pediatric Acute Otitis Media: A Qualitative Study. Journal of patient experience. 2019 Mar     [PubMed PMID: 31236452]
[2] Ubukata K,Morozumi M,Sakuma M,Takata M,Mokuno E,Tajima T,Iwata S, Etiology of Acute Otitis Media and Characterization of Pneumococcal Isolates After Introduction of 13-Valent Pneumococcal Conjugate Vaccine in Japanese Children. The Pediatric infectious disease journal. 2018 Jun     [PubMed PMID: 29474258]
[3] Ubukata K,Morozumi M,Sakuma M,Adachi Y,Mokuno E,Tajima T,Iwata S, Genetic characteristics and antibiotic resistance of Haemophilus influenzae isolates from pediatric patients with acute otitis media after introduction of 13-valent pneumococcal conjugate vaccine in Japan. Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy. 2019 Sep     [PubMed PMID: 30987951]
[4]     [PubMed PMID: 28514373]
[5]     [PubMed PMID: 28864559]
[6]     [PubMed PMID: 14687684]
[7]     [PubMed PMID: 25434680]
[8]     [PubMed PMID: 27780081]
[9]     [PubMed PMID: 29557599]
[10]     [PubMed PMID: 9577522]
[11]     [PubMed PMID: 21893640]
[12]     [PubMed PMID: 28483256]
[13]     [PubMed PMID: 27457584]
[14]     [PubMed PMID: 27604644]
[15]     [PubMed PMID: 9042072]
[16]     [PubMed PMID: 6681641]
[17]     [PubMed PMID: 4019946]
[18]     [PubMed PMID: 6978445]
[19]     [PubMed PMID: 25395494]
[20]     [PubMed PMID: 31876601]
[21]     [PubMed PMID: 32007567]
[22]     [PubMed PMID: 25475135]
[23]     [PubMed PMID: 31876600]
[24]     [PubMed PMID: 31505007]
[25]     [PubMed PMID: 15632907]
[26]     [PubMed PMID: 25447953]
[27] Vayalumkal J,Kellner JD, Tympanocentesis for the management of acute otitis media in children: a survey of Canadian pediatricians and family physicians. Archives of pediatrics & adolescent medicine. 2004 Oct     [PubMed PMID: 15466683]
[28] Schaad UB, Predictive value of double tympanocentesis in acute otitis media. Pharmacotherapy. 2005 Dec     [PubMed PMID: 16305279]
[29] Lampe RM,Weir MR,Spier J,Rhodes MF, Acoustic reflectometry in the detection of middle ear effusion. Pediatrics. 1985 Jul     [PubMed PMID: 4040237]
[30]     [PubMed PMID: 25213276]
[31]     [PubMed PMID: 23439909]
[32]     [PubMed PMID: 31876602]
[33]     [PubMed PMID: 30311779]
[34]     [PubMed PMID: 30335043]
[35]     [PubMed PMID: 31750180]
[36]     [PubMed PMID: 30952780]
[37]     [PubMed PMID: 28903516]
[38]     [PubMed PMID: 23435311]
[39]     [PubMed PMID: 28790141]
[40]     [PubMed PMID: 19887978]
[41]     [PubMed PMID: 31914264]
[42]     [PubMed PMID: 31324458]
[43]     [PubMed PMID: 31129994]
[44]     [PubMed PMID: 31975608]