Otitis Media

Acute Otitis Media

The most common infection for which children are seen in a physician's office is acute otitis media (AOM). The annual cost of AOM in the United States is an estimated $5 billion (Bondy et al., 2000). By age 7 years, 93% of children have had at least one episode of AOM, and 75% have had recurrent infections. AOM can occur at any age, but the highest incidence is between 6 and 24 months in the United States.

The primary cause of bacterial colonization of the middle ear is eustachian tube dysfunction. Abnormal tubal compliance in addition to delayed innervation of the tensor veli palatini muscle leads to collapse of the eustachian tube. Aerobic and anaerobic organisms, as well as viruses, can contribute to middle ear infection (Heikkinen et al., 1999). The three most common bacteria involved in AOM are S. pneumoniae (25%-40% of cases), H. influenzae (10%-30%), and Moraxella catarrhalis (2%-15%) (Klein, 2004). Risk factors most often associated with AOM are child care outside the home and parental smoking. Box 19-3 lists the common risk factors for AOM. A viral upper respiratory infection usually precedes an episode of AOM.

Three criteria are necessary to confirm the diagnosis of AOM: acute onset, presence of middle ear effusion, and signs or symptoms of middle ear inflammation (American Academy of Pediatrics [AAP], 2004; Level of evidence [Grade] B). Middle ear effusion can be diagnosed by direct visualization of air-fluid levels behind the tympanic membrane, a bulging drum, lack of movement on pneumatic otoscopy, or a flat tympanogram readout that indicates no tympanic membrane movement and therefore the presence of middle ear effusion. Redness of the tympanic membrane, pain, and fever are the most common signs and symptoms of middle ear inflammation (see eBox 19-4 online). Erythema of the tympanic membrane without middle ear effusion is myrin-gitis or tympanitis and is a separate diagnosis from AOM. Ear pain in the presence of a normal-appearing, flaccid tympanic membrane indicates causes other than AOM (Box 19-4).

The standard of care for the treatment of AOM in children older than 2 years is not to treat with antibiotics at the first visit, but to treat the pain and either observe the patient or prescribe an antimicrobial agent depending on certain criteria. The decision either to begin antibiotics or to observe the patient without them is based on the certainty of diagnosis, severity of symptoms, and age of the patient (AAP, 2004). (Table 19-2).

When all three criteria for the diagnosis of AOM are met (acute onset, middle ear effusion, and inflammation), the diagnosis is certain, and antibiotic therapy is indicated for any child 2 years old or younger (AAP, 2004; Grade A). For children older than 2 years, observation is an option if the illness is not severe and the parents can be relied on to report the patient's status and can obtain medication if necessary. Severe illness is defined as moderate to severe otalgia and fever higher than 39° C. (102.2° F.) When two or fewer diagnostic criteria are present, diagnosis is considered uncertain, and observation is allowed for children 6 months and older with nonsevere illness.

Box 19-3 Common Risk Factors for Acute Otitis Media (AOM)

Male gender

Bottle-feeding, especially in the supine position

Exposure to upper respiratory tract infections (e.g., daycare setting, winter season)

Genetic factors

Ethnic factors (e.g., Inuit or Native American)

Parental smoking

Allergy

Craniofacial abnormalities (e.g., cleft palate)

Previous episode of AOM, particularly during the preceding 3 months) Use of a pacifier

From O'Handley JG. Controversies in the management of otitis media. Prim Care Rep 1 999;5:43.

Box 19-4 Causes of Otalgia Other than Acute Otitis Media

Abscessed teeth Cervical arthritis Dental malocclusion Nasopharyngeal carcinoma Sinus infection Sore throat

Temporomandibular joint disorders

Table 19-2 Treatment of Acute Otitis Media

Features

Treatment

Low-Risk Patients 1

Older than 6 years, no antimicrobial therapy within past 3 months, no otorrhea, not in daycare, and temperature <38° C (<100.5° F)

Amoxicillin: 40-50 mg/kg/day in divided doses for 5 days

High-Risk Patients 1

Younger than 2 years, in daycare, treated with antimicrobials within past 3 months, otorrhea, or temperature >38° C (>100.5° F)

Amoxicillin: 80-90 mg/kg/day in divided doses for 10 days

Treatment Failure

Signs and symptoms persisting after 3 days

Amoxicillin-clavulanic acid (Augmentin): 80-90 mg/kg/day for 10 days Cefuroxime axetil (Ceftin): 20-30 mg/kg/day bid for 10 days Ceftriaxone (Rocephin): 50 mg/kg intramuscularly for 1 dose

Penicillin-Allergic Patient

Any

Cefuroxime axetil: <2 years, 125 mg bid; >2 years, 250 mg bid TMP-SMX (Bactrim, Septra): 8 mg/kg TMP, 40 mg/kg SMX, per 24 hours in 2 doses

Cefprozil (Cefzil): 30 mg/kg/day in 2 doses Cefaclor (Ceclor): 40 mg/kg/day in 3 doses Cefixime (Suprax): 8 mg/kg/day as a single dose

TMP-SMX, Trimethoprim-sulfamethoxazole; bid, twice daily.

Resistance of Streptococcus pneumoniae to penicillin is an increasing problem and ranges from 15% to 50% depending on the area. The mechanism of resistance is based on an alteration of penicillin-binding proteins rather than the production of beta-lactamase, as occurs with H. influenzae and M. catarrhalis. Resistance rates are higher in children than in adults, especially if the children are in daycare or have received antimicrobial therapy in the previous 3 months (Dowell and Schwartz, 1997).

The dose to treat AOM is 80 to 90 mg/kg/day in two divided doses (AAP, 2004). This allows the drug to overcome resistance in the causative organism (Dowell et al., 1999). For patients with a penicillin allergy, alternative medications include cefdinir, cefpodoxime, or cefuroxime. A meta-analysis found that first-generation cephalosporins have cross-allergy with penicillin, although the cross-allergy with second- and third-generation cephalosporins is negligible (Pichichero and Casey, 2007). Macrolides are not recommended for AOM in children because H. influenzae is the dominant organism causing AOM in this age group. Middle ear fluid becomes sterile 3 to 6 days after starting treatment (Carlin et al., 1991), so duration of therapy for uncomplicated AOM is 5 to 7 days, except for the child with an episode of AOM in the past 30 days, for whom a 10-day course of therapy is recommended (Pichichero and Brixner, 2006).

If the initial antibiotic fails to resolve symptoms in 72 hours (pain, fever, redness and bulging of the tympanic membrane, otorrhea), high-dose amoxicillin-clavulanic acid is recommended. Alternatives in penicillin-allergic patients include the antibiotics cited earlier. Patients who do not respond to amoxicillin-clavulanic acid therapy should be treated with intramuscular ceftriaxone for 3 days. This antibiotic in a single dose can also be used initially if the child is vomiting or unable to keep down oral medication. Doses of antimicrobials are given in Table 19-2.

Influenza vaccine has been shown to decrease the number of cases of AOM in immunized patients compared to controls and is recommended for all children age 6 to 24 months.

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