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Otitis Media
Paul George, MD, MHPE
image BASICS
  • Inflammation of the middle ear; usually accompanied by fluid collection
  • Acute otitis media (AOM): inflammation of the middle ear. Rapid onset; cause may be infectious, either viral (AOM-v) or bacterial (AOM-b), but there is also a sterile etiology (AOM-s).
  • Recurrent AOM: ≥3 episodes in 6 months or ≥4 episodes in 1 year with ≥ 1 in the past 6 months
  • Otitis media with effusion (OME): fluid in the middle ear without signs or symptoms of infection
  • Chronic otitis media with or without cholesteatoma
  • System(s) affected: nervous, ENT
  • Synonym(s): secretory or serous otitis media
  • AOM
    • Predominant age: 6 to 24 months; declines >7 years; rare in adults
    • Predominant gender: male > female
    • By age 7 years, 93% of children have had ≥1 episodes of AOM; 39% have had ≥6.
    • Placement of tympanostomy tubes is second only to circumcision as the most frequent surgical procedure in infants.
    • Increased incidence in the fall and winter
  • OME
    • By age 4 years, 90% of children have had at least one episode.
  • Most common infection for which antibacterial agents are prescribed in the United States
  • Diagnosed 5 million times per year in the United States
  • AOM-b (bacterial): usually, a preceding viral upper respiratory infection (URI) produces eustachian tube dysfunction
    • Streptococcus pneumoniae: 20-35%, Haemophilus influenzae: 20-30%, Moraxella (B.) catarrhalis: 15%, group A streptococci: 3%, Staphylococcus aureus: 12% produce &bgr;-lactamases that hydrolyze amoxicillin and some cephalosporins.
  • AOM-v (viral): 15-44% of AOM infections are caused primarily by viruses (e.g., respiratory syncytial virus, parainfluenza, influenza, enteroviruses, adenovirus, human metapneumovirus, and parechovirus).
  • AOM-s (sterile/nonpathogens): 25-30%
  • OME: Eustachian tube dysfunction; allergic causes are rarely substantiated.
  • Strong genetic component in twin studies for recurrent and prolonged AOM
  • May be influenced by skull configuration or immunologic defects
  • Age
  • Bottlefeeding while supine
  • Routine daycare attendance
  • Frequent pacifier use after 6 months of age
  • Environmental smoke exposure
  • Male gender
  • Absence of breastfeeding
  • Low socioeconomic status
  • Family history of recurrent otitis
  • AOM before age 1 year is a risk for recurrent AOM
  • Presence of siblings in the household
  • Underlying ENT disease (e.g., cleft palate, Down syndrome, allergic rhinitis)
  • Pneumococcal vaccine (PCV)-7 immunization reduces the number of cases of AOM by about 6-28% (however, evidence shows that this is offset by an increase in AOM caused by other bacteria). The effect of the introduction of the PCV-13 vaccine on the incidence of AOM has yet to be studied (1,2)[B].
  • Influenza vaccine reduces AOM.
  • Breastfeeding for ≥6 months is protective.
  • Avoiding supine bottlefeeding, passive smoke, and pacifiers >6 months may be helpful.
  • Secondary prevention: Adenoidectomy and adenotonsillectomy for recurrent AOM has limited short-term efficacy and is associated with its own adverse risks.
  • Vitamin D supplementation (1,000 U/day to maintain vitamin D levels >30) may be helpful in reducing recurrent AOM (3)[B].
  • Infectious AOM:
    • Fever (not required for diagnosis)
    • Decreased eardrum mobility (with pneumatic otoscopy)
    • Moderate to severe bulging of tympanic membrane
    • Otorrhea
    • Redness alone is not a reliable sign.
  • OME:
    • Eardrum often dull but not bulging
    • Decreased eardrum mobility (pneumatic otoscopy)
    • Presence of air-fluid level
    • Weber test is positive to affected ear for an ear with effusion.
  • Tympanosclerosis
  • Trauma
  • Referred pain from the jaw, teeth, or throat
  • TMJ in adults
  • Otitis externa
  • Otitis-conjunctivitis syndrome
  • Temporal arteritis in adults
Initial Tests (lab, imaging)
WBC count may be higher in bacterial AOM than in sterile AOM, but this is almost never useful.
Diagnostic Procedures/Other
  • To document the presence of middle ear fluid, pneumatic otoscopy can be supplemented with tympanometry and acoustic reflex measurement.
  • Hearing testing is recommended when hearing loss persists for ≥3 months or at any time suspecting language delay, significant hearing loss, or learning problems.
  • Language testing should be performed for children with hearing loss.
  • Tympanocentesis for microbiologic diagnosis is recommended for treatment failures; may be followed by myringotomy.
  • Significant disagreement exists about the usefulness of antibiotic treatment for this often self-resolving condition. Studies suggest that ˜15 children need to be treated with antibiotics to prevent one case of persisting AOM pain at 1 to 2 weeks; the number needed to treat to cause harm (primarily diarrhea) is 8 to 10 (2)[B].
  • If antibiotics are not used, 81% of patients >2 years of age are better in 1 week versus 94% if antibiotics are used.
  • Delay of antibiotics found a modest increase in mastoiditis from 2/100,000 to 4/100,000.
  • American Academy of Pediatrics/American Academy of Family Physicians (AAP/AAFP) guidelines recommend the following for observation versus antibacterial therapy, although these guidelines are not rigorously evidence-based (2)[B]:
    • <6 months of age: No recommendation (2004 guidelines suggest treatment with antibiotic therapy to any child diagnosed with otitis media < 6 months of age)
    • >6 months: Antibacterial therapy is recommended when the diagnosis with severe otitis media (i.e., moderate to severe otalgia or fever ≥39°C in the previous 24 hours) or otorrhea or bilateral otitis media between 6 months and 2 years of age
    • Observation is an option with nonsevere otitis media.
  • OME: Watchful waiting for 3 months per AAP/AFPP guidelines for those not at risk (see “Complications”). Of these cases, 25-90% will recover spontaneously over this period. No benefit of antihistamines, decongestants, or antibiotics or systemic steroids (4)[A].

  • Assess pain.
  • Although unusual in adults, the treatment is the same.
  • Acetaminophen, ibuprofen, benzocaine drops (additional but brief benefit over acetaminophen)
First Line
  • AOM: AAP/AAFP consensus guideline recommends amoxicillin, 80 to 90 mg/kg/day in 2 divided doses; (5)[A] OR
  • Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate in 2 divided doses; recommended in children who have taken amoxicillin in the previous 30 days and those with concurrent conjunctivitis or history of AOM unresponsive to amoxicillin
  • Treatment duration: 10-day course for children <2 years; 7-day course for children 2 to 5 years; 5- to 7-day course for children 6 years and older
  • If penicillin allergic:
    • Non-type 1 hypersensitivity reaction: cefdinir, 14 mg/kg/day in 1 to 2 doses; cefpodoxime, 10 mg/kg/day BID; or cefuroxime 30 mg/kg/day BID
    • Type 1 hypersensitivity to penicillin: azithromycin (10 mg/kg/day [max dose 500 mg/day] as a single dose on day 1 and 5 mg/kg/day [max dose 250 mg/day] for days 2 to 5)
  • A single dose of parenteral ceftriaxone (50 mg/kg) is as effective as a full course of antibiotics in uncomplicated AOM.
  • A single dose of azithromycin has been approved by the FDA, but studies did not include otitis-prone children or have criteria for AOM diagnosis.
  • Consider treatment of children between ages 6 months and 2 years with antibiotics to reduce duration of symptoms (6)[A].
  • OME: See “General Measures”; no benefit to treatment. Medications promote transitory resolution in 10-15%, but the effect is short-lived.
Second Line
  • Alternative antibiotics are indicated for the following AOM patients:
    • Persistent symptoms after 48 to 72 hours of amoxicillin
    • AOM within 1 month of amoxicillin therapy
    • Severe earache
    • Age <6 months with high fever
    • Immunocompromised
      • Amoxicillin-clavulanate, 90 mg/kg to 6.4 mg/kg/day, divided BID
      • Ceftriaxone, 50 mg/kg IM or IV q24h for 3 consecutive days can be reserved for those who are too sick to take oral medications or who unsuccessfully took amoxicillin-clavulanate. Neither erythromycin-sulfisoxazole nor trimethoprimsulfamethoxazole should be used as a 2nd-line agent in treatment failures.
  • Recurrent AOM: Antibiotic prophylaxis for recurrent AOM (>3 distinct, well-documented episodes in 6 months) is not recommended.
  • Recurrent AOM: Consider referral for surgery if ≥3 episodes of well-documented AOM within 6 months, ≥4 episodes within 12 months with ≥1 episode in previous 6 months, or AOM episodes occur while on chemoprophylaxis.
  • Tympanostomy tubes may be effective in selective patients, particularly children age <2 years with recurrent AOM (7)[A].
  • Adenoidectomy has limited or no effect.
  • Adenotonsillectomy reduced the rate of AOM by 0.7 episode per child only in the 1st year after surgery and had a 15% complications rate.
  • OME: Referral for surgery for tympanostomy should be individualized. It can be considered if >4 to 6 months of bilateral OME and/or >6 months of unilateral OME and/or hearing loss >25 dB or for high-risk individuals at any time.
  • Tympanostomy tubes may reduce recurrence of AOM minimally, but it does not lower the risk of hearing loss (8)[A].
  • Adenoidectomy is indicated in specific cases; tonsillectomy or myringotomy is never indicated.
  • It is unclear whether alternative and homeopathic therapies are effective for AOM, including mixed evidence about the effectiveness of zinc supplementation of reducing AOM.
  • Xylitol, probiotics, herbal ear drops, and homeopathic interventions may be beneficial in reducing pain duration, antibiotic use, and bacterial resistance.
Admission Criteria/Initial Stabilization
Outpatient, except if surgery is indicated, or for AOM in febrile infants age <2 months or children requiring ceftriaxone who also require monitoring for 24 hours
Patients with otitis media who do not respond within 48 to 72 hours should be reevaluated:
  • If therapy was delayed and diagnosis is confirmed, start therapy with high-dose amoxicillin.
  • If therapy was initiated, consider changing the antibiotic; options are limited because macrolides have limited benefit against Haemophilus influenzae over amoxicillin, and most oral cephalosporins have no improved outcomes.
Patient Monitoring
  • AOM: Up to 40% may have persistent middle ear effusion at 1 month, with 10-25% at 3 months.
  • OME: Repeat otoscopic or tympanometric exams at 3 months, as indicated, as long as OME persists or sooner if there are red flags (see earlier discussion).
  • See “General Measures.”
  • Recurrent AOM and OME: Usually subsides in school-aged children; few have complications.
  • AOM: Serious complications are rare: tympanic membrane perforation/otorrhea, acute mastoiditis, facial nerve paralysis, otitic hydrocephalus, meningitis, hearing impairment.
  • OME: Speech and language disabilities may occur. Hearing loss is not caused by OME, but in children who are at risk for speech, language, or learning problems (e.g., autism spectrum, syndromes, craniofacial disorders, developmental delay, and children already with speech/language delay), it could lead to further problems because they are less tolerant of a hearing impairment.
  • Recurrent AOM and OME: atrophy and scarring of eardrum, chronic perforation and otorrhea, cholesteatoma, permanent hearing loss, chronic mastoiditis, other intracranial suppurative complications
1. Rettig E, Tunkel DE. Contemporary concepts in the management of acute otitis media in children. Otolaryngol Clin North Am. 2014;47(5):651-672.
2. Harmes KN, Blackwood RA, Burrows HL, et al. Otitis media: diagnosis and treatment. Am Fam Physician. 2013;88 (7):435-440.
3. Marchioso P, Consonni D, Baggi E, et al. Vitamin D supplementation reduces the risk of acute otitis media in otitis-prone children. Pediatr Infect Dis J. 2013;32(10):1055-1060.
4. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev. 2008;(3):CD001727.
5. Thanaviratananich S, Laopaiboon M, Vatanasapt P. Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media. Cochrane Database Syst Rev. 2008;(4):CD004975.
6. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011;364(2):105-115.
7. Kujala T, Alho OP, Luotonen J, et al. Tympanostomy with and without adenoidectomy for the prevention of recurrences of acute otitis media: a randomized controlled trial. Pediatr Infect Dis J. 2012;31(6):565-569.
8. Lous J, Burton MJ, Felding JU, et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2005;(1):CD001801.
Additional Reading
Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999.
See Also
Algorithm: Ear Pain
  • H66.90 Otitis media, unspecified, unspecified ear
  • H66.40 Suppurative otitis media, unspecified, unspecified ear
  • H65.199 Other acute nonsuppurative otitis media, unspecified ear
Clinical Pearls
  • Pneumatic otoscopy is the single most specific and clinically useful test for diagnosis.
  • Consider a delay of antibiotics for 24 to 48 hours in uncomplicated presentations (>2 years of age) who do not have severe illness or otorrhea.
  • First-line treatment is amoxicillin, 80 to 90 mg/kg/day for 10 days for children age <2 years; consider a 5- to 7-day course in >2 years of age.
  • Erythema and effusion can persist for weeks.
  • Antibiotics, antihistamines, and steroids are not indicated for OME.
  • OME rarely develops in adults. Persistent unilateral effusion should be investigated to rule out neoplasm, particularly if there is a cranial nerve palsy.