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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.


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.

Fever
  • Hearing symptoms were common (67%) but fever (32%) and retroauricular symptoms were uncommon in AOM. Fever (44%) and mastoid tenderness (65%) were common in AM. Patients with LM underwent the most mastoidectomies (54%).[ncbi.nlm.nih.gov]
  • We present a 3-year-old girl who suffered from acute otitis media for already 2 weeks and presented with fever, abducens nerve palsy of her left eye and vomiting.[ncbi.nlm.nih.gov]
  • The 2 patients with complete paralysis required mastoidectomy to control otorrhea and fever after initial myringotomy and antibiotics. Both patients had a prolonged recovery requiring 3 and 7 months for complete recovery.[ncbi.nlm.nih.gov]
  • Review after 48 hours 17. 48 hours review • Earache fever persists: change to higher antibiotic. • If T.M. is bulging perform myringotomy.[slideshare.net]
  • Neonates without AOM admitted during the same period for neonatal fever workup were included as controls. Information regarding rAOM and possible risk factors were collected through a phone interview with the parents.[ncbi.nlm.nih.gov]
Malaise
  • Malaise. Irritability, crying, poor feeding, restlessness. Fever. Coryza/rhinorrhoea. Vomiting. Signs Examination may reveal: High temperature (febrile convulsions may be associated with the temperature rise in AOM).[patient.info]
Recent Upper Respiratory Infection
  • History of a recent upper respiratory infection is common. Treatment Since AOM is usually self-limiting and resolves in 1 to 2 weeks without antibiotics, the best approach is to watch and wait.[medical-dictionary.thefreedictionary.com]
Severe Abdominal Pain
  • A female aged 9 years with a recent episode of acute otitis media (AOM) presented to her primary care physician with complaints of severe abdominal pain with right lower quadrant rebound tenderness, suggestive of an acute surgical abdomen.[ncbi.nlm.nih.gov]
Joint Effusion
  • His blood inflammatory markers were raised and magnetic resonance imaging (MRI) showed significant left temporomandibular joint effusion and partial attenuation of the left mastoid.[ncbi.nlm.nih.gov]
Miosis
  • A seventeen-year-old girl presented with acute otitis media, unilateral miosis and ptosis (partial Horner's syndrome) and tenderness of the ipsilateral jugular vein. A culture of the otorrhoea showed Staphylococcus aureus and Streptococcus pyogenes.[ncbi.nlm.nih.gov]
Ptosis
  • A seventeen-year-old girl presented with acute otitis media, unilateral miosis and ptosis (partial Horner's syndrome) and tenderness of the ipsilateral jugular vein. A culture of the otorrhoea showed Staphylococcus aureus and Streptococcus pyogenes.[ncbi.nlm.nih.gov]
Otalgia
  • The diagnosis is based on acute onset of symptoms such as otalgia and fever, middle ear inflammation such as erythema of the tympanic membrane, and middle ear effusion.[ncbi.nlm.nih.gov]
  • KEYWORDS: Acute otitis media; Attitude; Otalgia; Pediatrician; Treatment; Turkey[ncbi.nlm.nih.gov]
  • Early symptoms included otalgia, progressive sensorineural hearing loss, and tinnitus with inflammation of the tympanic membrane. During the second week a conductive component emerged resulting in a 60-dB mixed loss in the 2- to 4-kHz region.[ncbi.nlm.nih.gov]
  • The following pre-defined secondary outcomes were not reported: change in symptom scores for otalgia or otorrhoea, alteration in the frequency of otalgia or otorrhoea, and number of days at nursery or school lost secondary to acute otitis media.The second[ncbi.nlm.nih.gov]
  • Fever was the most common presenting sign/symptom, observed in 8 patients, followed by otalgia, neck stiffness, headache, and confusion. An opaque and bulging tympanic membrane was observed in 8 patients.[ncbi.nlm.nih.gov]
Ear Discharge
  • Streptococcus pneumoniae and Haemophilus influenzae were cultured from the purulent ear discharge. The final diagnosis was locked-in syndrome consecutive to inflammatory changes compressing the basilar artery.[ncbi.nlm.nih.gov]
  • Perforation of the tympanic membrane can occur, with associated purulent ear discharge. Investigations Investigations are rarely required in the evaluation of AOM.[gponline.com]
  • Aural toilet for ear discharge 6. Hot fomentation for severe earache 7. Review after 48 hours 17. 48 hours review • Earache fever persists: change to higher antibiotic. • If T.M. is bulging perform myringotomy.[slideshare.net]
Hearing Problem
  • RESULTS: Recurrent acute otitis media subjects reported hearing problems comparable to those of the controls. Pure tone audiometry, at 125-8000 Hz, did not differ between groups.[ncbi.nlm.nih.gov]
  • Otorrhea (83%), tympanic membrane perforation (57%), and hearing problems (83%) were common in S. pyogenes infections. Patients with S. pneumoniae had longer lengths of hospitalization than those with other bacterial infections (7 vs. 4 days).[ncbi.nlm.nih.gov]
  • Three main signs of an acute middle ear infection include sudden onset of the illness with severe earache, fever, hearing problems and general weakness, a red eardrum, and an eardrum that bulges outward, does not move freely and is not transparent, which[informedhealth.org]
  • Fluid buildup in the middle ear also blocks sound, which can lead to temporary hearing problems.[kidshealth.org]
  • Fluid buildup in the middle ear also blocks sound, which can lead to temporary hearing problems .[kidshealth.org]
Erythematous Tympanic Membrane
  • 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.[symptoma.com]
  • Normal Tympanic Membrane Pink Tympanic Membrane, often seen with fever or upper respiratory tract infections Bulging and erythematous Tympanic Membrane in AOM Otitis Media with Effusion "glue ear" Middle ear effusion Loss of TM landmarks, particularly[rch.org.au]
  • Erythematous tympanic membranes may be due to viral infection, crying, or efforts to remove cerumen. Fever or irritability may or may not be present.[coreem.net]
  • Otoscopic examination can show a bulging, erythematous tympanic membrane (TM) with indistinct landmarks and displacement of the light reflex. Air insufflation (pneumatic otoscopy) shows poor mobility of the TM.[merckmanuals.com]
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]
  • Clinical course and diagnosis The symptoms of otitis media are earache, discharge from the ear, hearing loss, ear popping, ear fullness, dizziness, and fever.[ncbi.nlm.nih.gov]
  • Hold the bottle in your hand to warm it – cold ear drops can make you feel dizzy. Lie on your side with the affected ear facing up to put the drops in. Gently pull and push your ear to work the drops in.[nhs.uk]
  • Infants will not suck because it causes pain Vomiting Diarrhea Signs and symptoms of chronic otitis media with effusion If your child is old enough to tell you, he may complain of: A feeling of fullness in the ears A popping feeling when swallowing Dizziness[nationwidechildrens.org]
Vertigo
  • […] 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/vertigo[entsho.com]
  • Facial paralysis or vertigo suggests local extension to the fallopian canal or labyrinth.[merckmanuals.com]
Febrile Convulsions
  • In a small child with a high temperature there is a risk of febrile convulsions. This is discussed more fully in its own article. Rare complications include Petrositis.[patient.info]
Slurred Speech
  • She was transferred to the local children's hospital for workup of appendicitis, during which she began exhibiting ataxia and slurred speech. Further evaluation revealed mastoiditis, venous sinus thrombosis and subdural empyema.[ncbi.nlm.nih.gov]
Ataxia
  • She was transferred to the local children's hospital for workup of appendicitis, during which she began exhibiting ataxia and slurred speech. Further evaluation revealed mastoiditis, venous sinus thrombosis and subdural empyema.[ncbi.nlm.nih.gov]

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.

Treatment

  • Our primary outcome was time until treatment failure. RESULTS: Treatment failure occurred in 31.7% of all children.[ncbi.nlm.nih.gov]
  • […] no treatment and all active treatments in recurrent acute otitis media.[ncbi.nlm.nih.gov]
  • Cases were regarded as persistent SOM when a tympanogram was type B or C2 four weeks after treatment was initiated.[ncbi.nlm.nih.gov]
  • This information can be used when weighing the pros and cons of various AOM treatment options.[ncbi.nlm.nih.gov]
  • The objective of this study was to review treatment strategies and extent of recovery in adult patients with the aim of defining a standard treatment protocol for this rare pathologic condition. Retrospective chart review.[ncbi.nlm.nih.gov]

Prognosis

  • Physicians should understand the etiology, pathophysiology, treatment options, and prognosis of facial palsy in association with otitis media.[ncbi.nlm.nih.gov]
  • Patients who have a bad prognosis in electrophysiological tests also have indication of surgery 3.[scielo.br]
  • With appropriate treatment Acute Ear Infection has excellent prognosis.[dovemed.com]
  • […] activity or sleep) Reference: (1) MeReC Bulletin 2006;17(3):9-11. (2) Subcommittee on management of acute otitis media.Pediatrics 2004;113:1451-1465 Links: aetiology incidence infective organisms pathology clinical features management complications prognosis[gpnotebook.co.uk]

Etiology

  • This study estimated the baseline etiology, distribution, and antibiotic susceptibility of bacterial serotypes that causes AOM in children aged[ncbi.nlm.nih.gov]
  • Multibacterial etiology was seen in 34 (38%) samples, and M. catarrhalis was detected in most (85%) of those cases. Fifteen signals for M. catarrhalis were strong, suggesting a highly probable etiological role of the pathogen.[ncbi.nlm.nih.gov]
  • Physicians should understand the etiology, pathophysiology, treatment options, and prognosis of facial palsy in association with otitis media.[ncbi.nlm.nih.gov]
  • We present three new cases of facial palsy in children with acute otitis media and discuss the etiological mechanisms and different approaches to the treatment; a flow chart for facial paralysis in acute otitis media is also presented.[ncbi.nlm.nih.gov]
  • The etiological mechanisms behind and the different approaches to the treatment of facial palsy in children with acute otitis media are discussed.[ncbi.nlm.nih.gov]

Epidemiology

  • Investigating serotype epidemiology, vaccine serotypes decreased significantly after the conjugate vaccine introductions with the exception of serotype 3.[ncbi.nlm.nih.gov]
  • OBJECTIVES: To study the epidemiology of acute otitis media (AOM), especially the otitis-prone condition, during the pneumococcal conjugate vaccines 7 and 13 era.[ncbi.nlm.nih.gov]
  • BACKGROUND: Although acute otitis media (AOM) remains a major public health problem worldwide and brings economic burden on health care system and caregivers, little information is available about its epidemiology in Eastern Europe.[ncbi.nlm.nih.gov]
  • Our objective is to review the latest data on epidemiology, presenting symptoms, diagnosis, and treatment of CVST.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To review in depth the epidemiology, pathophysiology, clinical manifestations, diagnosis, complications and particularly treatment of acute otitis media in children.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Physicians should understand the etiology, pathophysiology, treatment options, and prognosis of facial palsy in association with otitis media.[ncbi.nlm.nih.gov]
  • Our understanding of the pathophysiology of ascariasis in the eustachian tube and middle ear is discussed.[ncbi.nlm.nih.gov]
  • To describe a case of lateral sinus insufficiency, presumably occurring just prior to lateral sinus thrombosis (LST), and to discuss the importance of early surgical intervention and the pathophysiology of full-blown LST.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To review in depth the epidemiology, pathophysiology, clinical manifestations, diagnosis, complications and particularly treatment of acute otitis media in children.[ncbi.nlm.nih.gov]
  • The pathophysiology and treatment of facial nerve paralysis associated with acute otitis media are still under debate.[ncbi.nlm.nih.gov]

Prevention

  • There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: This is the first report of recurrent AOM prevention by herbal medication. JTT appears to effectively prevent recurrent AOM in children.[ncbi.nlm.nih.gov]
  • Taking into consideration past studies, PCV7 may play a role in preventing the aggravation of AOM in 1-year-olds. When evaluating the effectiveness of PCVs, measures to evaluate severity may be as important as evaluating disease prevention.[ncbi.nlm.nih.gov]
  • AOM prevention strategies in day care facilities should therefore focus in particular on the youngest age groups.[ncbi.nlm.nih.gov]
  • There remains a need to develop improved vaccines for prevention of NTHi disease, which could be achieved by combining protein D with other antigens.[ncbi.nlm.nih.gov]

Patient Information

References

Article

  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.

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Last updated: 2019-07-11 21:27