Acute otitis media

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Author: V. Dimov, M.D.

The diagnosis of acute otitis media (AOM) requires:

- middle ear effusion and inflammation - bulging of tympanic membrane (TM) - the single most important criteria
- otorrhea may be present
- limited or absent mobility of TM
- air-fluid levels may be present

Questions to ask:

- is pain intermittent or constant?
- does pain wake child at night?
- does pain interfere with normal activities?
- history of tympanocentesis?

Diagnostic tools - tympanometry, acoustic reflectometry and pneumatic otoscopy.

Many symptoms of AOM overlap with simple OM with effusion (OME). However, bulging TM or otorrhea clearly indicate AOM.

Diagnosis of AOM can be made on clinical grounds alone - otorrhea or bulging opacified and discolored TM.

Management of pain in AOM - NSAIDs are better than acetaminophen (Tylenol) because they control the inflammation (Tylenol does not).

Benzocaine drops provide only very temporary relief. Myringotomy provides instant relief of bulging TM.

Microbiology of AOM:

- Streptococcus pneumoniae, 50%-35% - the incidence is decreasing due to immunization
- nontypeable Haemophilus influenzae, 40%-55% - incidence is increasing
- Moraxella catarrhalis, 5%-10%
- viruses alone, 5%-10%

Amoxicillin alone does not work for nontypeable Haemophilus influenzae and Moraxella catarrhalis - you have to use Augmentin.

Antibiotics

Resistance of S. pneumoniae to beta-lactam agents due to penicillin–binding protein is a growing issue. The resistance can be overcome by high serum levels in 80% of patients.

50% of H. influenzae and 95% of M. catarrhalis isolates are beta-lactamase positive and will not respond to penicillin V or amoxicillin.

Suggested antibiotics

For nonsevere illness, amoxicillin, 80 to 90 mg/kg per day in 2 divided doses for 5 to 10 days

For severe illness or symptoms for longer than 48 hr, use amoxicillin-clavulanate 80 to 90 mg/kg per day; or cefdinir, cefuroxime, or cefpodoxime. Cefdinir has advantage of pleasant taste - tastes like strawberry.

One alternative for noncompliant patients who may be lost to follow-up is a single shot of ceftriaxone 50 mg/kg intramuscularly (IM).

Antibiotic choice for penicillin-allergic patients

If there is history of non-IgE-mediated to penicillin and nonsevere reaction, use cephalosporin.

If there is history of severe IgE-mediated reaction to penicillin, cephaloridine, cephalothin, or cefoxitin should be used with caution.

Indications for IM ceftriaxone as therapy for AOM:

- vomiting, inability to tolerate oral medication
- noncompliance due to refusal of medication or unreliable caregiver

If there is a failure to respond to primary treatment within 48 to 72 hr, consider the possibility of wrong diagnosis or wrong antibiotic.

Switch to amoxicillin-clavulanate (90 mg/kg per day), cefdinir, cefuroxime or cefpodoxime, or IM ceftriaxone (50 mg/kg) for 1 to 3 days (one dose is often enough).

In recurrent AOM consider the following:

- breastfeeding rather than bottle feeding
- reduce group day care attendance - smaller centers preferable
- stop passive tobacco smoke exposure
- look for allergic rhinitis or immuno deficiency

Updates from the NEJM, 01/2011

What is the most effective treatment for acute otitis media?

Amoxicillin-clavulanate (Augmentin) has been shown to be the most effective treatment for acute otitis media.

Among children who received amoxicillin-clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7.

What adverse effects were significantly more common among children with acute otitis media who received antibiotic treatment?

Dermatitis in the diaper area and diarrhea occurred commonly, and often together, among children receiving antimicrobial agents.

References

Upper respiratory tract bacterial infections. S. Michael Marcy, MD. Volume 55, Issue 18, September 21, 2009.

Secondhand Smoke Increases Ear Infection Risk in Children http://goo.gl/7Y850

A child with an earache - what to do? BMJ http://goo.gl/1ctzu

Related reading

Children chewing xylitol gum were 25% less likely to develop acute ear infections. NYTimes, 2011.

Published: 05/31/2010
Updated: 04/12/2011