Overview and Risk Factors
Acute otitis media (AOM) is an inflammatory process of the middle ear. The condition may occur at any age, but mainly affects children and peaks between 6 months and 2 years of age. An estimated 30% of all antibiotics prescribed for children in the United States are prescribed for AOM.1 Common specific symptoms include pain, otorrhea, and temporary hearing loss; vertigo occasionally occurs. Nonspecific findings are more common in young children and include fever, irritability, reduced activity or expressivity, vomiting, diarrhea, and anorexia. Incidence of AOM has been rising in the last 25 to 30 years.2
An upper respiratory infection often precedes acute otitis media, and resultant congestion can obstruct the eustachian tube, creating an accumulation of middle-ear secretions and a potential breeding ground for infections. Spread of infection from the inner ear may result in mastoiditis, meningitis, carotid artery thrombosis, and disease of other contiguous structures. Allergies can contribute to eustachian tube dysfunction and predispose to chronic otitis media.
Risk Factors
Indigenous North American populations have a greater incidence of aggressive AOM. Bottle feeding may also increase risk. Breastfeeding for at least 3 months appears to be protective against AOM.2
Risk factors include:
- Male gender.
- Age <10 years.
- Pacifier use.2
- Day care attendance.
- Exposure to tobacco smoke and air pollution.
- Hereditary factors.
- Low socioeconomic status.
- Fall and winter months.
Diagnosis and Treatment
Diagnosis
Diagnosis requires a consistent acute history, otalgia or erythema and opacity of the tympanic membrane, and a middle-ear effusion. Effusion can be demonstrated by a bulging and immobile tympanic membrane (or one with decreased mobility as demonstrated with pneumatic otoscopy), an air-fluid level, or otorrhea.3
An erythematous tympanic membrane should not be presumed to be due to AOM. Only 15% of such cases are caused by AOM.4
To ensure a correct diagnosis, immobility of the tympanic membrane should be demonstrated. Tympanometry may substitute for pneumatic otoscopy when the presence of middle-ear effusion is uncertain.
Bacterial culture of a middle ear aspirate is only indicated in the case of immunosuppression, severe illness (with AOM as the likely source), or refractory AOM.
Treatment
Suggestions in the Nutritional Considerations below should be considered early in the treatment of AOM; they reduce the need for other treatments, which can often be difficult and taxing.
Decongestants and antihistamines have no proven benefit in AOM.
Several possible treatment options are available for otalgia.
NSAIDs and acetaminophen may improve symptoms, although objective findings are not necessarily apparent.5
Benzocaine/antipyrine (Auralgan) otic solution and Otikon Otic (an herbal preparation including garlic) may also improve the condition.6,7
The American Academy of Family Physicians (AAFP) makes the following recommendations regarding use of antibiotics for AOM3:
- All patients under 6 months of age should receive antibiotics, even if the diagnosis of AOM is uncertain.
- Patients aged 6 months to 2 years should receive antibiotics if the diagnosis is clear. If the diagnosis is uncertain, antibiotics should be given if otalgia is moderate to severe, or a temperature is greater than or equal to 39°C. Otherwise, observation may be considered.
- Patients older than 2 years with a definite diagnosis of AOM should start an antibiotic if otalgia is moderate to severe, or if they have a temperature greater than or equal to 39°C. Otherwise, observation may be considered.
- Observation should only be used if rapid initiation of antibiotics and follow-up can be guaranteed. Antibiotics should be started if no improvement occurs in 2 to 3 days.
- Amoxicillin, 80 to 90 mg/kg divided into 2 doses, is the first-line therapy, and 5 to 7 days is usually adequate.3
- For penicillin-allergic patients, cephalosporins may be used, provided patients did not develop hives or anaphylaxis with penicillin. Macrolides or trimethoprim-sulfamethoxazole may also be used, but bacteria are often resistant to these medications.
Recurrent ear infections may warrant additional treatments, such as prophylactic antibiotics, tympanostomy, and adenoidectomy.
Tympanostomy is indicated for severe or recurrent otitis media, or persistent, serous effusion.
Adenoidectomy (with or without tonsillectomy) may benefit those who have recurrent AOM despite tympanostomy. Adenoidectomy may also reduce future AOM episodes when it occurs concomitantly with tympanostomy.8
Nutritional Considerations
Although most AOM follows viral infection, food and other environmental allergies can result in chronic otitis media in 35% to 40% of cases.9 Diets that eliminate foods suspected of causing allergy have resulted in improvement in 86% of affected children, and most relapse when the offending foods are reintroduced.10 These occurrences may be related to immunoglobulin G (IgG)-food antigen complexes, particularly those of cow's milk protein.11 Children with otitis media have some evidence of poor antioxidant status,12,13 and poorer zinc and iron status than healthy controls,14 indicating a need for improved diets.
Orders
Consider an elimination diet. For guidelines, see Anaphylaxis and Food Allergy.
What to Tell the Family
Acute otitis media may be prevented in some cases by breast-feeding, avoiding crowded environments (such as day care), preventing exposure to tobacco smoke and food allergens, refraining from use of a pacifier, and providing a diet with adequate micronutrients to support immune function. Antibiotic therapy is not always necessary and is contingent on signs and symptoms of bacterial infection. Repeated episodes of infection may require surgery.
References
1. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA. 1998;279:875-877.
2. Uhari M, Mantysaari K, Niemela M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis. 1996;22:1079-1083.
3. American Academy of Family Physicians and American Academy of Pediatrics. Clinical Practice Guideline. Diagnosis and Management of Acute Otitis Media. 2004. Available at: www.aafp.org/PreBuilt/final_aom.pdf
Accessed June 15, 2005.
4. Pelton SI. Otoscopy for the diagnosis of otitis media. Pediatr Infect Dis J. 1998;17:540-543.
5. Bertin L, Pons G, d'Athis P, et al. A randomized, double-blind, multicenter controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol. 1996;10:387-392.
6. Hoberman A, Paradise JL, Reynolds EA, Urkin J. Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med. 1997;151:675-678.
7. Sarrell EM, Mandelberg A, Cohen HA. Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media. Arch Pediatr Adolesc Med. 2001;155:796-799.
8. Coyte PC, Croxford R, McIsaac W, et al. The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes. N Engl J Med. 2001;344:1188-1195.
9. Bernstein JM. The role of IgE-mediated hypersensitivity in the development of otitis media with effusion: a review. Otolaryngol Head Neck Surg. 1993;109(pt 2):611-620.
10. Nsouli TM, Nsouli SM, Linde RE, O'Mara F, Scanlon RT, Bellanti JA. Role of food allergy in serous otitis media. Ann Allergy. 1994;73:215-219.
11. James JM. Respiratory manifestations of food allergy. Pediatrics. 2003;111(pt 3):1625-1630.
12. Cemek M, Dede S, Bayiroglu F, Caksen H, Cemek F, Yuca K. Oxidant and antioxidant levels in children with acute otitis media and tonsillitis: A comparative study. Int J Pediatr Otorhinolaryngol. 2005;69:823-827.
13. Yariktas M, Doner F, Dogru H, Yasan H, Delibas N. The role of free oxygen radicals on the development of otitis media with effusion. Int J Pediatr Otorhinolaryngol. 2004;68:889-894.
14. Bondestam M, Foucard T, Gebre-Medhin M. Subclinical trace element deficiency in children with undue susceptibility to infections. Acta Paediatr Scand. 1985;74:515-520.
