Otitis Media, Acute

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. http://accesspharmacy.com/content.aspx?aid=8001906. 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

• Otitis externa
• Eustachian tube dysfunction
• Mastoiditis

• Pain management
• Prudent antibiotic use
• Secondary disease prevention

• 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 if symptoms not severe and diagnosis uncertain
    • In children ...