Acute Otitis Media

Acute otitis media (AOM) is the inflammation of the middle ear secondary to viral or bacterial infection. This disease is more prevalent in young children, especially those with risk factors. It is diagnosed based on the clinical presentation, history, physical exam including otoscopy, and appropriate testing when necessary.

The disorder stems from the following process: infectious.

Presentation

AOM occurs most predominantly between the ages of 3 to 18 months as it commonly affects children 2 years or younger [1]. Moreover, some children are prone to developing recurrent episodes.

Neonates with AOM present with irritability and/or trouble with feeding. Older children with this condition typically have fever, ear pain with ear tugging, conductive hearing loss, and possibly an upper respiratory tract infection (URTI). Other possible symptoms include nausea, emesis, diarrhea, and signs related to URTI. Note that hearing loss is common in both children and adults with AOM as well as otitis media with effusion (OME). Hearing does eventually recover [2].

In cases with tympanic membrane perforation, exudative discharge leaks out for a day or two and the pain quickly subsides.

Risk factors

It is important to consider the risk factors when evaluating the patient. These include prematurity, low birth weight, immunosuppression, allergies, exposure to tobacco and environmental pollutants, colder climates, low socioeconomic status, positive family history, and certain racial backgrounds (such as Native Americans). Children with craniofacial defects and neuromuscular disease may be predisposed as well. Finally, pacifier and bottle use, prone sleeping position, and daycare attendance are other contributing factors.

Physical exam

Notable findings suggestive of inflammation on pneumatic otoscopy include an erythematous tympanic membrane, purulent or serosanguinous effusion in the middle ear, and decreased mobility of the tympanic membrane. Bulging of the membrane is also observed.

Ears
Otalgia
  • Often the otalgia settles when perforation occurs.[gloshospitals.nhs.uk]
  • In adolescents and adults, otalgia is a more common presenting symptom than in children under the age of 2. [ 1 ] Indeed, in adults, otalgia may occur without fever or hearing loss and may be the only presenting feature.[patient.info]
  • The patient has reduction in otalgia, fever subsides.[drtbalu.com]
  • Diagnostic criteria for AOM AOM is characterized by acute onset of symptoms (eg, otalgia or suspected otalgia) with middle ear fluid and significant inflammation of the middle ear.[cps.ca]
Hearing Problem
  • Fluid buildup in the middle ear also blocks sound, which can lead to temporary hearing problems .[kidshealth.org]
  • Long-term problems related to ear infections — persistent fluids in the middle ear, persistent infections or frequent infections — can cause hearing problems and other serious complications.[mayoclinic.org]
  • Three main signs of an acute middle ear infection include sudden onset of the illness with severe earache, possibly fever , hearing problems and general weakness, a red eardrum, and an eardrum that bulges outward, does not move freely and is not transparent[informedhealth.org]
  • The patient should be re-evaluated at two weeks for hearing problem and response.[jpgmonline.com]
  • In otitis media with effusion antibiotics may help if the fluid is still present after a few months and is causing hearing problems in both ears.[emedexpert.com]
Ear Discharge
  • Medscape Education Clinical Briefs , January 2010 A 14-Year-Old Girl With Purulent Ear Discharge and Double Vision A 14-year-old girl presents to the ED with a 2-week history of ear pain and discharge.[medscape.org]
  • Ear discharge occurs after the tympanic membrane is perforated.[jpgmonline.com]
  • discharge”, “rhinitis”, and “vomiting”.[bmcpediatr.biomedcentral.com]
  • discharge associated with grommets (ventilation tubes)Cochrane Database Syst Rev20062CD001933 DoharJGilesWRolandPBikhaziNCarrollSMoeRTopical ciprofloxacin/dexamethasone superior to oral amoxicillin/clavulanic acid in otitis media with otorrhea through[cfp.ca]
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  • neurologic
    Dizziness
    • Other symptoms include trouble hearing, fever, fluid drainage from ears, dizziness and congestion.[clinicaladvisor.com]
    • […] local policy Combination antibiotic and steroid ear drops Good analgesia IV fluids if the patient is vomiting or dehydrated Artificial tears and eye lubrication if there is facial palsy Short term vestibular sedative eg prochlorperazine if there is dizziness[entsho.com]
    • A feeling of fullness in the ear A popping feeling when swallowing Dizziness A feeling of motion in the ear Ringing in the ears Your child may turn up the volume on the TV or radio or sit very close to it.[nationwidechildrens.org]
    • A child with a ruptured eardrum might feel dizzy or nauseated, and have ringing or buzzing in the ear.[kidshealth.org]
    Vertigo
    • There are many causes and types of balance disorders including benign positional vertigo, labyrinthitis, vestibular neuritis, and Ménière’s disease.[otonomy.com]
    • Bacterial labyrinthitis/vestibulitis – Vertigo (room spinning), nausea, vomiting and imbalance, increasing in intensity.[entsho.com]
    • Otorrhea: spontaneous rupture of the tympanic membrane Decreased hearing Vertigo, nystagmus, tinnitus, and facial paralysis are unusual presenting symptoms.[pedclerk.bsd.uchicago.edu]
    Febrile Convulsions
    • Febrile convulsions are commonly related to AOM.[rch.org.au]
    • In a small child with a high temperature there is a risk of febrile convulsions .[patient.info]
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  • Entire body system
    Fever
    • The child may cry a lot, have an earache, run a fever and be unable to sleep.[informedhealth.org]
    • Take over-the-counter medicines such as ibuprofen or acetaminophen for pain or fever.[nlm.nih.gov]
    • It is important to visit the doctor if your child has any pain or fever, and is fretful.[ensg.co.nz]
    • Acute otitis media starts suddenly with fever, pain and irritability.[nationwidechildrens.org]
    • Physical Exam A fever is a telling sign of AOM, but not as much as tympanometry.[sharinginhealth.ca]
    Recent Upper Respiratory Infection
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  • Workup

    To establish the diagnosis, the clinician will evaluate the patient's clinical manifestations, history, and risk factors. Also crucial is the physical exam including otoscopy. Testing may be warranted in some cases as explained below.

    According to clinical practice guidelines set forth by the American Academy of Pediatrics and the American Academy of Family Physicians [3], diagnostic criteria include the presence of tympanic membrane bulging, recent onset of otorrhea (in the absence of external otitis media), middle ear effusion, and ear pain or tugging.

    Procedure

    Tympanocentesis is performed through piercing of the tympanic membrane and aspiration of the contents. This procedure is indicated in infants less than 6 weeks of age since AOM in this age group may be attributed to unusual organisms. Additionally, patients with failed treatment or signs indicative of sepsis should undergo this procedure. Finally, some patients will need a culture to determine the appropriate management, especially with the emergence of antibacterial resistance hindering treatment [4].

    Imaging

    Computed tomography (CT) or magnetic resonance imaging (MRI) are obtained if complications are suspected.

    Laboratory

    Serum
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  • Treatment

    Prognosis

    Complications

    Fever
    • The child may cry a lot, have an earache, run a fever and be unable to sleep.[informedhealth.org]
    • Take over-the-counter medicines such as ibuprofen or acetaminophen for pain or fever.[nlm.nih.gov]
    • It is important to visit the doctor if your child has any pain or fever, and is fretful.[ensg.co.nz]
    • Acute otitis media starts suddenly with fever, pain and irritability.[nationwidechildrens.org]
    • Physical Exam A fever is a telling sign of AOM, but not as much as tympanometry.[sharinginhealth.ca]
    Febrile Convulsions
    • Febrile convulsions are commonly related to AOM.[rch.org.au]
    • In a small child with a high temperature there is a risk of febrile convulsions .[patient.info]
    Otitis Media
    • - Acute otitis media , Acute otitis media , Acute otitis media (disorder) , otitis; media, acute , Acute otitis media, NOS Czech Akutní otitis media NOS , Akutní otitis media Hungarian acut otitis media , acut otitis media k.m.n.[fpnotebook.com]
    • Synonyms Acute otitis media Acute otitis media (middle ear infection) Acute persistent otitis media Chronic otitis media Chronic otitis media after insertion of tympanic ventilation tube Influenza a with otitis media Otitis media Otitis media (middle[icd10data.com]
    • Acute otitis media Acute otitis media, myringitis bullosa Chronic otitis media (otitis media chronica mesotympanalis) Otitis media chronica mesotympanalis Otitis media chronica mesotympanalis Otitis media chronica mesotympanalis Prevention [ edit ] AOM[en.wikipedia.org]
    Bacterial Meningitis
    • meningitis , brain abscess , or dural sinus thrombosis . [58] It is estimated that each year 21,000 people die due to complications of otitis media. [12] Membrane rupture [ edit ] In severe or untreated cases, the tympanic membrane may perforate , allowing[en.wikipedia.org]
    Meningitis
    • Check for signs of meningitis.[entsho.com]
    • Assessment Note: A child with otitis media can also have serious bacterial infection such as septicaemia or meningitis.[rch.org.au]
    • This vaccine is routinely given to infants and toddlers to prevent meningitis , pneumonia, and blood infections.[webmd.com]
    • If the bacteria spread, they can cause meningitis.[informedhealth.org]
    Serous Otitis Media
    • The epidemiology, pathogenesis, diagnosis, complications, and prevention of AOM are discussed separately, as is otitis media with effusion (serous otitis media).[uptodate.com]
    • Serous otitis media ("glue ear") Serous middle ear effusion commonly persists for several weeks or even months following an episode of AOM.[rch.org.au]
    • If fluid builds up in the ear, the infection is called serous otitis media.[medbroadcast.com]
    • […] common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniae , Haemophilus influenzae , Moraxella catarrhalis , [15] and Staphylococcus aureus . [23] Otitis media with effusion [ edit ] Otitis media with effusion (OME), also known as serous[en.wikipedia.org]
    Tympanic Membrane Perforation
    • Additionally, no differences in the number of children with abnormal tympanometry findings at four weeks, tympanic membrane perforations and AOM recurrence were observed between groups.[cochrane.org]
    • Additionally, no difference in tympanic membrane perforations and AOM recurrence was observed.[onlinelibrary.wiley.com]
    • Complications [ 1 , 2 , 9 ] As with children, common complications include Tympanic membrane perforation.[patient.info]
    • Prolonged duration of otitis media is associated with ossicular complications and, together with persistent tympanic membrane perforation, contributes to the severity of the disease and hearing loss.[en.wikipedia.org]
    Mastoiditis
    • mastoiditis Patient Data Age: 6 Gender: Male CT Limited non-contrast CT through the petrous temporal bones Loading Stack - 0 images remaining Fluid in the middle ear cleft on the right as well as the mastoid antrum and mastoid air cells.[radiopaedia.org]
    • These patients have also coexistant mastoid tenderness due to mastoiditis.[drtbalu.com]
    • Mastoiditis – Infection spreading from the middle ear to form an abscess in the mastoid air spaces of the temporal bone.[entsho.com]
    • - otitis externa - cervical lymphadenitis Inflammation of the mucoperiosteal lining of the middle ear cleft (Eustachian tube, tympanic cavity, mastoid antrum and mastoid air cell).[quizlet.com]
    • Mastoiditis is acute inflammation of the mastoid periosteum and air cells occurring when AOM infection spreads out from the middle ear.[patient.info]
    Suppurative Labyrinthitis
    • Suppurative complications such as mastoiditis, suppurative labyrinthitis or intracranial infection (meningitis, extradural or subdural abscess, brain abscess) are very uncommon in our population.[rch.org.au]

    Etiology

    Causes

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Other symptoms

    Otitis Externa
    • Acute Otitis Externa Acute otitis externa (AOE), also known as swimmer’s ear, is a common condition involving infection and inflammation of the ear canal typically caused by bacterial infection.[otonomy.com]
    • The assessment also rules out mastoiditis, cholesteotoma, otitis externa and otitis media with effusion.[npstudent.com]
    • externa OME diagnosis is based on a middle ear effusion w/o middle ear inflammation Definitions Observation May observe 48-72 hours if 6 months and not severe.[chop.edu]
    • They include: Cerumen impaction (compressed earwax) Otitis externa: Inflammation of the external auditory canal, also called “swimmer's ear.” Cholesteatoma: A mass of horn shaped squamous cell epithelium and cholesterol in the middle ear, usually resulting[entnet.org]
    • When doctors refer to an ear infection, they usually mean otitis media rather than swimmer's ear (or otitis externa ).[kidshealth.org]

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    References

    1. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics. 1997; 99(3):318-33.
    2. McDonald S, Langton Hewer CD, et al. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database of Systemic Reviews. 2008; (4):CD004741.
    3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013; 131(3):e964-99.
    4. Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. The Pediatric Infectious Disease Journal. 1997; 16(4):449-56.

    • Antibiotics for acute otitis media: a meta-analysis with individual patient data - MM Rovers, P Glasziou, CL Appelman, P Burke - The Lancet, 2006 - thelancet.com
    • Beta‐lactamase‐producing bacteria in head and neck infection - I Brook - The Laryngoscope, 2009 - Wiley Online Library
    • Acute mastoiditis in children: a 12-year retrospective study - EH Harley, T Sdralis, RG Berkowitz - Otolaryngology-Head and Neck , 1997 - Elsevier
    • Acute otitis media and respiratory virus infections. - O Ruuskanen, M Arola, A Putto-Laurila - The Pediatric , 1989 - ukpmc.ac.uk
    • Capsular polysaccharide antigens by latex agglutination, counterimmunoelectrophoresis, and radioimmunoassay in middle ear exudates in acute otitis media. - MK Leinonen - Journal of clinical microbiology, 1980 - Am Soc Microbiol
    • Erythromycin Estolate, Triple Sulfonamide, Ampicillin, Erythromycin Estolate-Triple Sulfonamide, and Placebo in 280 Patients with Acute Otitis Media Under Two and - VM Howie, JH Ploussard - Clinical pediatrics, 1972 - cpj.sagepub.com
    • Acute otitis media: management and surveillance in an era of pneumococcal resistance-a report from the Drug-resistant Streptococcus pneumoniae Therapeutic - SF Dowell, JC Butler, GS Giebink - The Pediatric , 1999 - journals.lww.com
    • A new treatment for chronic secretory otitis media - BW Armstrong - Archives of Otolaryngology—Head & Neck Surgery, 1954 - Am Med Assoc
    • BENIGN PAROXYSMAL VERTIGO OF CHILDHOOD A VARIETY OF VESTIBULAR NEURONITIS - LS Basser - Brain, 1964 - Oxford Univ Press
    • Acute mastoiditis--the antibiotic era: a multicenter study. - M Luntz, A Brodsky, S Nusem, J Kronenberg - International journal of , 2001 - ukpmc.ac.uk
    • Acute Bacterial Meningitis with Absent or Minimal Cerebrospinal Fluid Abnormalities A Report of Three Cases - CM Moore, M Ross - Clinical Pediatrics, 1973 - cpj.sagepub.com
    • Acute otitis media - P O'Neill - BMJ, 1999 - bmj.com
    • Comparative study of the efficacy and safety of azithromycin compared with amoxicillin/clavulanic acid in the treatment of paediatric patients with otitis media - N Principi - European Journal of Clinical Microbiology & Infectious , 1995 - Springer
    • Bacterial meningitis—a review of selected aspects - MN Swartz, PR Dodge - New England Journal of Medicine, 1965 - Mass Medical Soc
    • Bacterial Meningoencephalomyelitis in Dogs: A Retrospective Study of 23 Cases (1990‐1999) - ST Radaelli, SR Platt - Journal of veterinary internal medicine, 2002 - Wiley Online Library
    • A randomized, double‐blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children - L Bertin, G Pons, P d'Athis, JF Duhamel - Fundamental & , 2009 - Wiley Online Library
    • The round window membrane permeability barrier evoked by streptolysin O: possible etiologic role in development of sensorineural hearing loss in acute otitis media. - F Engel, R Blatz, J Kellner, M Palmer - Infection and , 1995 - Am Soc Microbiol
    • Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media - SL Block - The Pediatric infectious disease journal, 1997 - journals.lww.com
    • A multicenter, open label, double tympanocentesis study of high dose cefdinir in children with acute otitis media at high risk of persistent or recurrent infection - A Arguedas, R Dagan, E Leibovitz - The Pediatric , 2006 - journals.lww.com
    • A comparative study of azithromycin and amoxycillin in paediatric patients with acute otitis media - E Mobs, A Rodriguez-Solares - Journal of , 1993 - Br Soc Antimicrob Chemo
    • AVIATION DEAFNESS--ACUTE AND CHRONIC - PA Campbell, J Hargreaves - Archives of Otolaryngology—Head & , 1940 - Am Med Assoc
    • Acute otitis media in pediatrics: are there rational issues for empiric therapy? - A Boccazzi, P Careddu - The Pediatric infectious disease journal, 1997 - journals.lww.com
    • A longitudinal study of respiratory viruses and bacteria in the etiology of acute otitis media with effusion - FW Henderson, AM Collier, MA Sanyal - England Journal of , 1982 - Mass Medical Soc
    • Acute Otitis Media Toward a More Precise Definition - RH Schwartz, SE Stool, WJ Rodriguez - Clinical , 1981 - cpj.sagepub.com

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