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Source: Frei C, Frei B, Zhanel G. Upper Respiratory Tract Infections. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed July 14, 2012.

  • Acute onset of inflammation of middle ear
    • Three subtypes differentiated by onset, signs and symptoms of infection, and presence of fluid in middle ear:
      • Acute otitis media
      • Otitis media with effusion
      • Chronic otitis media

  • Viral pathogens cause 40–75% of cases.
  • Bacterial causes:
    • Streptococcus pneumoniae 20–50%
      • 1–50% of isolates not susceptible to penicillin.
      • Up to 50% possess high-level penicillin resistance.
      • Incidence may be declining due to use of pneumococcal conjugate vaccine.
    • Haemophilus influenzae 15–30%
      • Half of isolates from upper respiratory tract produce β-lactamases.
    • Moraxella catarrhalis 3–20%
      • 100% ofisolates from upper respiratory tract produce β-lactamases.

  • Usually follows viral upper respiratory tract infection that causes eustachian tube dysfunction and mucosal swelling in middle ear.

  • Most common in infants and children following cold symptoms of runny nose, nasal congestion, or cough.

  • Seven-valent pneumococcal conjugate vaccine
    • Reduced occurrence by 6–7% during infancy
    • Did not benefit older children with history of acute otitis media.
  • Surgical insertion of tympanostomy tubes (T tubes) to prevent recurrent otitis media

  • Viral respiratory tract infection
  • Nasotracheal intubation

  • Rapid onset of signs and symptoms of inflammation in middle ear that manifests clinically as one or more of the following:
    • Otalgia (denoted by pulling of ear in some infants)
    • Hearing loss
    • Fever
    • Irritability
  • If effusion (accumulation of liquid in middle ear cavity) present, signs and symptoms of acute infection are absent.

Signs and Symptoms

  • Otalgia in >75% of cases
    • Infants may pull on ear(s).
  • Hearing loss
  • Fever in <25% of cases.
    • More common in younger children,
  • Irritability
  • Discolored, thickened, bulging eardrum
  • Immobile eardrum
    • Bilateral in 50% of cases.

Means of Confirmation and Diagnosis

  • Clinical diagnosis
  • Requires 3 criteria be met:
    • Acute onset of signs and symptoms
    • Middle ear effusion, indicated by:
      • Bulging of tympanic membrane
      • Limited or absent mobility of tympanic membrane
      • Air–fluid level behind tympanic membrane
      • Otorrhea
    • Middle ear inflammation

Laboratory Tests

  • Draining or aspirated fluid:
    • Gram stain
    • Culture
    • Sensitivity

Diagnostic Procedures

  • Tympanocentesis—optional

Differential Diagnosis

  • Differentiate among subtypes of otitis media.
    • Antibiotics less effective if otitis media with effusion or chronic otitis media.
  • Treat pain.
  • Consider if brief observation period warranted or if disease severity or patient characteristics require immediate antibiotic therapy.

  • Pain
    • Oral analgesics such as acetaminophen or ibuprofen
    • Eardrops with local anesthetic in addition to oral analgesics
  • Decongestants or antihistamines provide minimal benefit.

  • Consider antimicrobial therapy
    • High percentage of children will be cured with symptomatic treatment alone.
    • Consider delayed antibiotic treatment (48–72 hours):
      • In children 6 months to 2 years of age ...

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