Acute Otitis Media: Update on Diagnosis and Treatment
Primary Care Update
Brief Summaries for Clinical Practice
Among American children, acute otitis media (AOM) is the most common bacterial infection treated with antibiotics.1 Rising rates of antibacterial resistance have focused attention on the need to prescribe these agents judiciously.
Recently, the American Academy of Pediatrics (AAP) updated its 2004 recommendations1 on the diagnosis and management of uncomplicated AOM in children aged 6 months to 12 years.2 These guidelines apply only to otherwise healthy children who have no underlying conditions that may alter the natural course of AOM, such as cleft palate, Down syndrome, immunodeficiencies, or the presence of tympanostomy tubes or cochlear implants. Also excluded are children who have otitis media with effusion (OME). Highlights of the updated guidelines are presented here.
DIAGNOSIS
The updated guidelines use more stringent criteria for making the diagnosis of AOM; specifically, the emphasis is on otoscopic diagnostic criteria as the basis for management decisions.
The diagnosis of AOM rests on the following criteria:
•Moderate to severe bulging of the tympanic membrane or new onset of otorrhea not caused by acute otitis externa.
•Mild bulging of the tympanic membrane and recent (less than 48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the tympanic membrane.
History. Children with AOM generally present with a history of rapid onset of symptoms, including otalgia, irritability (in an infant or toddler), otorrhea, and/or fever. However, these symptoms—except for otorrhea—are nonspecific and often overlap with the symptoms of an uncomplicated upper respiratory tract viral infection. Other symptoms of an upper respiratory tract viral infection, such as cough and nasal discharge or stuffiness, often precede or accompany AOM and are also nonspecific. Thus, clinical history alone is a weak indicator of AOM, especially in younger children.
Otoscopic findings. Identification of a middle-ear effusion (MEE) and inflammatory changes in the tympanic membrane is essential for making the diagnosis. Children who do not have an MEE should not receive a diagnosis of AOM. The tympanic membrane findings are usually detected by pneumatic otoscopy, although pneumatic otoscopy can be supplemented with tympanometry. MEE can also be demonstrated directly by tympanocentesis or by the presence of fluid in the external auditory canal as a result of tympanic membrane perforation. Otoscopic findings that signal an MEE and inflammation have been well defined. Fullness or bulging of the tympanic membrane has the highest predictive value for an MEE (Figure).
Figure – A bulging tympanic membrane with impaired mobility is diagnostic of acute
otitis media. (Courtesy of Carlos Armengol, MD, and Meg G. Keeley, MD.)
Reduced or absent mobility of the tympanic membrane also suggests the presence of fluid in the middle ear. Opacification or cloudiness of the tympanic membrane that results from edema rather than from scarring is also consistent with an MEE. The strongest predictor of AOM is bulging of the membrane coupled with erythema and limited or absent mobility.
Uncertainty about the diagnosis of AOM is usually attributable to an inability to confirm the presence of MEE. Contributing factors include the inability to sufficiently clear the external auditory canal of cerumen, a narrow ear canal, or inability to maintain an adequate seal for successful pneumatic otoscopy or tympanometry.
A key challenge is to distinguish AOM from OME, which does not benefit from antibiotic therapy. OME is relatively asymptomatic, and pneumatic otoscopy often reveals a retracted or concave tympanic membrane.
TREATMENT
Pain management. If otalgia is present, take steps to reduce the pain and discomfort—especially during the first 24 hours of the illness—regardless of whether an antibiotic is prescribed. Acetaminophen or ibuprofen is most often used in this setting.
Treatment recommendations. The updated AAP guidelines place greater emphasis on making a certain diagnosis of AOM before proceeding with treatment. The decision to observe or prescribe an antibiotic is based on the child’s age and the severity of the illness.
Antibiotic therapy is recommended in the following scenarios:
•Bilateral or unilateral AOM in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher).
•Bilateral AOM in children 6 months through 23 months of age who do not have severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]).
In the following settings, either antibiotic therapy or observation with close follow-up is an option:
•Unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]).
•Bilateral or unilateral AOM in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]).
If observation is selected, it is important to make sure that the parent or caregiver is able to both successfully monitor the child’s condition and contact you in the event that the child’s symptoms worsen or do not begin to improve after 48 hours. If a patient fails to exhibit signs of recovery within 48 to 72 hours of the onset of symptoms, start antibiotic therapy.
Initial selection of an antibiotic. If the decision is made to prescribe an antibiotic, high-dose amoxicillin is recommended because it has been shown to be most effective in treating AOM in randomized clinical trials. Prescribe an antibiotic with additional ß-lactamase coverage if the child has received amoxicillin in the last 30 days or has concurrent purulent conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin. Alternative initial antibiotics include cefdinir, cefuroxime, cefpodoxime, and ceftriaxone.
A clinical response should occur within 48 to 72 hours. If the caregiver reports that the child’s symptoms have worsened or failed to respond to the initial antibiotic during that time frame, reassess the patient and determine whether a change in therapy is needed.
Duration of therapy. The optimal duration of therapy for patients with AOM has not been determined with certainty in clinical trials. However, the consensus is that for younger children and for those with severe disease, a 10-day course is appropriate. For children 6 years and older who have mild to moderate disease, a 5- to 7-day course is recommended.
RECURRENT AOM
Recurrent AOM, which was not addressed in the 2004 AAP guidelines, has been defined as the occurrence of 3 or more episodes of AOM in a 6-month period or the occurrence of 4 or more episodes of AOM in a 12-month period that includes at least 1 episode in the preceding 6 months.3 Among the risk factors for recurrent AOM are cold weather, male gender, and passive exposure to tobacco smoke.
Antibiotic prophylaxis is not recommended to reduce the frequency of episodes. However, tympanostomy tubes are an option because they have been shown to improve quality of life for children with recurrent AOM.
PREVENTION OF AOM
A number of steps can be taken to lower the risk of AOM. Infants who are breast-fed exclusively for at least the first 6 months of life are at lower risk for early episodes of AOM. Avoidance of exposure to tobacco smoke may also reduce the incidence of AOM.
Immunizations can help prevent AOM. Recommend pneumococcal conjugate vaccine and annual influenza vaccine for all children according to the schedule of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, the AAP, and the American Academy of Family Physicians.
REFERENCES:
1. Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451-1465.
2. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964 -e999. (doi: 10.1542/peds.2012-3488)
3. Shekelle PG, Takata G, Newberry SJ, et al. Management of Acute Otitis Media: Update.
Evidence Report/Technology Assessment No. 198. Rockville, MD: Agency for Healthcare Research and Quality; 2010.