Otitis media (OM) is the second most common disease of childhood, after upper respiratory infection (URI). OM is also the most common cause of childhood visits to a physician’s office.
It is an inflammatory condition of the middle ear that results from dysfunction of the eustachian tube in association with local infection. This definition is followed by otitis media risk factors that help in predisposing the disease.
When a local infection like upper respiratory infections or chronic rhinosinusitis occurs, tissues of the eustachian tube swell, so fluid is trapped in it. The fluid may be infected by pathogens causing acute otitis media (AOM) in which ear infection pushes the eardrum causing the signs and symptoms of acute otitis media (e.g. red, sore, thickened, bulging, immobile eardrum, and pain). But if the fluid was not infected, this would result in otitis media with effusion (OME), in which fluid is in the middle ear without signs or symptoms of infection.
Acute otitis media is caused mainly by viruses. Among the most common bacteria that cause AOM there are: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
Management of acute otitis media
- Symptomatic treatment using analgesics and antipyretics.
- Observation versus antibiotic use. This is should be determined according to “Criteria for Initial Antibacterial Treatment” table on the right of the map.
- Follow-up after at least 3 months.
- Management of recurrent AOM.
If antibiotic therapy is chosen for managing AOM, then the antibiotic of choice is amoxicillin because it has the best pharmacodynamic profile (time above the minimum inhibitory concentration [MIC90] in the middle ear fluid for more than 40% of the dosing interval), it is of narrow-spectrum for avoiding microbial resistance, and because it is of low cost and high safety.
If the symptoms persist or worsen 48-72 hours after the administration of amoxicillin or observation, or exposure to antibiotics within 30 days, then there is a need to use an agent that acts against β-lactamase-producing H. influenzae, M. catarrhalis and/or drug resistant S. pneumoniae. So, another course of high-dose amoxicillin and clavulanate potassium or azithromycin would be required.
Consider patients who are allergic to penicillin (suitable options are stated in the map).
Ceftriaxone injection (50 mg/kg/d), a 1-day course could be used in certain cases (stated in the map).
According to University of Michigan Health System guidelines,
Otitis media with effusion (OME) should be managed by:
- Clinical reevaluation at 3 month intervals.
- Referral to otolaryngology for persistent abnormal findings or complications like: hearing loss or language delay. Children with an asymptomatic middle ear effusion (no developmental or behavioral problems) can be followed without referral.
- Parental education regarding approaches to maximizing language.
Diagnosis of Otitis Media
It is important to distinguish between AOM and OME cases for making therapeutic decisions and to avoid unnecessary prescription of antibiotics in OME cases. Thus, diagnostic certainty for AOM is based on all 3 of the following criteria (as stated by the American Academy of Pediatrics and American Academy of Family Physicians): acute onset, middle ear effusion (MEE), and middle ear inflammation. On the other hand, OME is fluid in the middle ear without signs or symptoms of infection.
Download the map
The otitis media concept map is a part of the larger map of Upper Respiratory Tract Infections.