Otitis media is the second-most common diagnosis after upper respiratory tract infection and is the most common cause of antibiotic prescriptions in young children. If untreated, otitis media can cause severe complications, such as mastoiditis and loss of hearing.
“Acute Otitis Media,” by Drs Paul and Frohna in the March issue of Pediatrics in Review, reviews the current education gap, clinical presentation, epidemiology, pathophysiology, diagnosis, management, and treatment of acute otitis media, and offers some key takeaways.
The risk factors for acute otitis media (AOM) include genetic predisposition, exposure to cigarette smoking, day care attendance, and ciliary dysfunction; incidence among males is slightly higher than females. Studies show the pneumococcal vaccine has decreased the incidence of AOM, and masking and social distancing during the COVID pandemic also were credited for a decrease in AOM incidence during that period.
AOM can be caused by both bacteria and viruses. The most common bacterial causes are Streptococcus pneumoniae, non-typeable Hemophilus influenzae, and Moraxella catarrhalis. Viral causes of AOM include respiratory syncytial virus, coronaviruses, and human metapneumovirus. Coinfection is common in 66% of cases.
A dysfunctional eustachian tube due to the horizontal position of the tube in children less than 2 years of age predisposes them to repeated exposure to pathogens in the middle ear by decreased clearing of secretions. Diagnosis is by otoscopy, preferably pneumatic otoscopy, to confirm immobility of the tympanic membrane (TM). The key characteristics to look for during examination are position, color, bony landmarks, translucency of the TM, and any discharge. Impaired mobility of the TM is diagnostic of middle ear effusion either from AOM or serous otitis media (SOM). Bulging TM, per the 2013 American Academy of Pediatrics guideline, is required for the diagnosis of AOM. Lack of a bulging TM in the presence of an immobile TM is more likely to be associated with SOM, especially if there are no symptoms of pain. Patients with SOM should be followed till resolution, as very rarely cholesteatoma can have a similar presentation.
Children older than 3 years of age, well appearing, non-toxic, with fever less than 38.5°C, and mild otalgia can be managed with close follow-up for monitoring of any symptoms that worsen in 48–72 hours. Pain can be managed with over-the-counter ibuprofen and acetaminophen. In children between 6 and 24 months, antibiotics are recommended if the child has fever greater than 39°C and severe otalgia. The first line of antibiotic treatment is amoxicillin. However, if the patient has concomitant conjunctivitis (suspicious for H. influenza), amoxicillin-clavulanic acid is recommended. Finally, referral to an otolaryngologist is needed for multiple infections in a year.
