Acute Otitis Media

There remains a gap in the implementation of the appropriate diagnostic criteria and management of acute otitis media.After completing this article, readers should be able to:List the diagnostic criteria for acute otitis media.Discuss the therapeutic management of acute otitis media.Describe the components of the pediatric otoscopic exam needed for the management of acute otitis media.Describe the important role of the parent/caregiver in the diagnosis and the management of acute otitis media.Acute otitis media (AOM) is the most common cause for antimicrobial treatment in young children, accounting for 56% of antimicrobial prescriptions for children aged 3 to 36 months and 40% of antimicrobial prescriptions for children aged 3 to 6 years.1,2 It is the second most common diagnosis after upper respiratory infection in children. The epidemiology of AOM has international and regional variances and has been impacted by both pneumococcal vaccines and the COVID-19 pandemic.3,4 Approximately 50% of children will have 1 episode of AOM by age 2 years, and by age 3 years, 80% will have had at least 1 episode.5Health disparities have been noted in children with AOM.6 Children who are socially disadvantaged are less likely to receive treatment and more likely to experience complications of misdiagnosed and mismanaged episodes of AOM. Frequent ear infections have been associated with living below the poverty level. In under-resourced countries, chronic supportive otitis media is a leading cause of hearing loss.7The most specific symptom of AOM is acute otalgia. This acute otalgia can manifest in many ways, from the acute onset of ear pain in the school-aged child to nighttime awakening, fussiness, and decreased appetite in younger children. While the acute otalgia is usually constant, it often appears to be worse in the evening. Fever can be associated with AOM but is not a consistent finding associated with AOM. Finally, recent or concurrent upper respiratory infection symptoms such as nasal congestion will often accompany the key symptoms of AOM.8The peak incidence of AOM is between age 6 to 12 months. It is multifactorial in terms of risk factors, with males being at a slightly higher risk than females. Genetic predisposition, passive smoke exposure, conditions associated with decreased immunity, ciliary dysfunction, cochlear implants, daycare attendance, and family history of recurrent AOM in parents or siblings are other risk factors associated with AOM.2AOM can be caused by viruses, bacteria, or a combination of both. Bacterial causes include the most common bacteria that occupy the upper respiratory tract: Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella catarrhalis. Since the implementation of conjugate pneumococcal vaccines, AOM is more commonly caused by nonvaccine serotypes. In terms of viral causes of AOM, the most common viral pathogens of otitis media include respiratory syncytial virus, adenovirus, influenza viruses, coronaviruses, human metapneumovirus, and picornaviruses. Infection with both viruses and bacteria is quite common, with one study documenting 66% coinfection rates.9Many practicing clinicians likely noticed a significant decrease in the incidence of AOM during the COVID-19 pandemic. Several studies documented this decrease, along with a decrease in the use of antibiotics and emergency department visits for AOM.10,11 This decrease has largely been attributed to the social distancing and mask use that was in place during the pandemic. The incidence of other viral respiratory infections was also decreased during this time. The presence of SARS-CoV2 in patients with AOM has also been documented, suggesting that the 2 conditions can coexist.12AOM results from the acute inflammation of fluid in the middle ear space, which is dense with bacterial otopathogens. Many factors contribute to the acute inflammatory cycle, including bacterial persistence, viral infections, allergic rhinitis, recent or current upper respiratory infection, and anatomic variation and abnormalities, which set up the genesis of AOM.7 The eustachian tube is particularly essential in protecting the middle ear space from bacterial pathogens and viruses. A properly functioning eustachian tube is essential to the drainage of secretions. The eustachian tube also serves to equalize pressures. In young children under 2 years of age, the eustachian tube is less effective in these functions because it sits in a more horizontal position, leading to a slower drainage of secretions and allowing for more transmission of pathogens into the middle ear space.The diagnosis of AOM rests on the visualization of the tympanic membrane and clinician competence in performing the overall ear exam.13 Therefore, it is important to understand the diagnostic criteria and to be proficient in performing the pediatric ear exam. The accurate diagnosis of AOM facilitates the appropriate usage of antimicrobial therapy for AOM. This also helps to mitigate the unnecessary use of antibiotics, thereby decreasing the overuse of antibiotics in general. Rising health care costs, increasing antibiotic resistance, and the possible need for surgical referrals for recurrent AOM stress the critical importance of an accurate diagnosis of AOM.Understanding the anatomy of the middle ear is essential to making an accurate diagnosis of AOM. The middle ear is the area between the tympanic membrane (which separates the external and middle ear spaces) and the oval/round windows (which mark the beginning of the inner ear). The eustachian tube connects the upper respiratory tract to the middle ear and is more horizontal in infants and children. Several resources are available that physicians can use to explain to parents how AOM may arise in their child.14When examining a normal tympanic membrane (TM), the membrane appears translucent, and the malleus is often seen through the TM in the anterior-superior quadrant (Figure 1). On the other hand, in cases of AOM, the diagnosis is dependent on a bulging TM (Figures 2 and 3). There is often decreased mobility of the TM, and the color is often erythematous with purulent and turbid fluid behind the membrane, suggestive of a bacterial infection.Training in pediatric otoscopy involves learning how to perform a proper ear exam in a child, which includes the use of appropriate techniques for holding and distracting a child, performing pneumatic otoscopy, and removing cerumen. A checklist (Table 1) containing the essential components of a pediatric ear exam has been shown to be helpful in teaching settings.15,16 It is important to remain proficient in pneumatic otoscopy and cerumen removal because it has been shown that these skills can decline over time.17The examiner should perform a deliberate, stepwise exam. When performing the otoscopy exam, it is important to first determine the overall status of the patient, especially with regards to age, development status, and the severity of their illness. This will guide the examiner’s approach to the ear exam. Using an appropriate otoscope that provides adequate illumination and resolution to visualize the TM will allow the examiner to make a diagnosis of AOM. It is also important to use an otoscope that allows for the pneumatic otoscopy. Appropriately sized scope tips should be used based on the size of the child and the presence of any craniofacial anomalies. In addition, other developmental needs of the child should be considered; for instance, some children may be afraid of the light from the otoscope, thinking that it may be hot or too bright for their eyes.Next, the examiner should attend to the positioning of the patient. The school-aged child is likely to be on the examining table, and an otoscopy exam can generally be done with appropriate distraction and gentleness without the aid of a parent or caregiver. The younger child should be on the lap of the parent/caregiver or on the examining table with parent/caregiver assistance. Generally, infants younger than 9 months should be on the examining table in a supine position for a safe exam. An effective otoscopy exam does not necessarily require a lot of time. A “few golden minutes” should suffice in the absence of cerumen; during this time, the child is held in a comforting position that allows the examiner to perform a double-handed exam in which the nondominant hand is used to steady the head, and the dominant hand manipulates the otoscope to visualize the TM.Once the examiner can see the anatomy, the examiner should take note of various characteristics of the TM, including the position of the TM, the color, presence of the bony landmarks, translucency of the TM, and any discharge.18Pneumatic otoscopy is an integral component of the overall pediatric ear exam. It allows for the visualization of the movement of the TM based on pressure changes. It is helpful in determining the presence of effusion in the middle ear space. Performing pneumonic otoscopy requires the examiner to be adept at the basic otoscopy skills described above. It involves attaching a bulb to the otoscope and then applying positive pressure (deflation of the bulb) and negative pressure (inflation of the bulb).Many TM conditions can be associated with abnormal responses to positive and negative pressures. Most often, the reason for impaired mobility of the TM is due to effusion in the middle ear space. As AOM involves the accumulation of fluid in the middle space, impaired movement of the TM as determined by pneumatic otoscopy is associated with AOM. Still, pneumatic otoscopy does not differentiate between serous and purulent effusion. Importantly, it can also be the first step in the evaluation for other more concerning etiologies such as cholesteatoma. A child with impaired mobility of the TM as determined by pneumatic otoscopy should be followed closely.The 2013 American Academy of Pediatrics (AAP) guideline provides a framework for the diagnosis of AOM.8 It is important to recognize that the bulging of the TM is required in each of these criteria in order to make the diagnosis of AOM. Below are excerpts from the AAP guideline regarding the diagnosis of AOM. “Statement 1A: Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the TM or new onset of otorrhea not due to acute otitis externa. Evidence Quality: Grade B. Strength: Recommendation.”“Statement 1B: Clinicians should diagnose AOM in children who present with mild bulging of the TM 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 TM. Evidence Quality: Grade C. Strength: Recommendation.”Conditions such as otitis media with effusion (OME) (Figure 4), pharyngitis, and viral upper respiratory infection can mimic some of the symptoms of AOM. However, the acute onset of moderate to severe otalgia is not common with these other conditions. OME is often associated with abnormal findings of the TM such as air-fluid levels or a prominent short process of the malleus, mild otalgia, and often a sensation of ear fullness or popping when swallowing (Figure 3). With OME, there is no bulging of the TM or other associated findings of acute inflammation of the middle ear effusions such as a purulent color of the TM. The management of OME is supportive and requires no medications. Still, OME must be followed up until resolution. It is important to document resolution of any abnormal TM finding so as to not overlook chronic OME or other conditions that might present initially in a similar manner such as a cholesteatoma. Of note, despite the distortion of the TM, OME does not represent an acute virulent bacterial infection of the middle ear fluid. Therefore, OME does not necessitate the use of antibiotics.Chronic OME is defined as the persistence of middle ear effusion for more than 3 months. Evaluation by an otolaryngologist is recommended for children with unresolved OME and atypical symptoms accompanying OME such as concern for worsening hearing. Thus, is it important to be able to differentiate between the tympanic findings of OME and AOM, stressing again the importance of competency in the examination of the middle ear.13,19The management and therapies discussed here will be broad based and follow evidence-based criteria. Pediatricians should consider the AAP guideline, studies published following the AAP guideline and the prevalence of pathogens in their community, and should adhere to a strict evidence-based approach in the treatment of their patient.8 It is vital that pediatricians continuously update their knowledge and skills regarding diagnostic criteria, epidemiology, and management plans. Online resources such a peer-reviewed pediatric website offer the pediatrician access to rapid PubMed searches regarding current evidence-based therapeutic regimens.18,20 It is important to reference only peer-reviewed online resources.Some patients with AOM can be safely managed without antimicrobial therapy. The natural history of the condition is such that the pain and discomfort will resolve after the first few days, and the use of antibiotics may result in 1 less day of symptoms. Safety-net antibiotic prescriptions and other similar protocols21,22 have been described, including in the AAP guideline, as a nonantimicrobial management protocol. Criteria for such management usually include older children with non-severe AOM (mild otalgia for less than 48 hours and temperature of less than 38.5°C), no other bacterial infection, and nontoxic status. These children can be followed closely without the use of antimicrobial therapy. Close follow-up is needed, and antibiotics should be started if signs and symptoms worsen or do not improve over 48 to 72 hours. Current studies following publication of the AAP guideline do not support safety-net antibiotic prescriptions and other similar non-antibiotic treatment plans in an evidence-based manner for children younger than 2 years. Studies have shown that withholding antibiotics in children younger than 3 years can result in unfavorable outcomes.23 Also, it is possible that many of the cases of AOM that resolved without antibiotics may have a viral etiology or may not actually have been AOM and rather were OME. This again calls for the need to be competent in the diagnosis of AOM and adhere to the diagnostic gold standard.When managing patients with AOM, a key consideration is the control of pain, recognizing that the acute otalgia of AOM may resolve only after the first 48 hours of antimicrobial therapy. Appropriate nonprescription analgesic medication is the foundation of management of AOM in children. Oral acetaminophen or ibuprofen can be used to treat the otalgia. Aspirin should never be given for pain management. There is no evidence that pain caused by AOM is improved by alternating acetaminophen and ibuprofen in children,24 and this regimen can lead to medication dosing errors. Otic drops for pain can be considered only after a patient has been examined and appropriately diagnosed. Otic drops are contraindicated in some conditions, including the presence or uncertainly of a ruptured TM.Shared decision-making with families is appropriate in almost all cases of AOM. Indeed, educating the parent/caregiver about the diagnosis of AOM and the indications for antimicrobial treatment optimizes the overall management of AOM in the pediatric patient. Table 2 shows a script of talking points that can be used as a guide in the discussion and communication of managing AOM with a parent or caregiver. Additional resources including visual aids appropriate for parents are also available to help support parent/caregiver education about this condition.14,20,25The AAP guideline recommends antibiotic therapy for bilateral AOM in children aged 6 to 23 months even if they do not have severe signs or symptoms;8 more recently, Wald has urged a similar approach (either treatment or close observation) to unilateral or bilateral AOM in younger children.26 Clinicians will usually prescribe antibiotic therapy for children with severe signs or symptoms of AOM such as a temperature above 39°C, moderate to severe otalgia, or otalgia for at least 48 hours. The current AAP guideline recommends amoxicillin as first line of therapy for children who do not have an allergy to penicillin, have not been on penicillin in the past 30 days, and do not have purulent bilateral conjunctivitis.It is recommended that antibiotics with beta-lactamase coverage for AOM should be prescribed if the patient has received amoxicillin in the past 30 days, has concurrent purulent conjunctivitis (suggesting H influenzae infection), and has a history of recurrent AOM unresponsive to amoxicillin of if one suspects H influenzae as the cause of AOM. Attention should be paid to local prevalence microbiology data as well.8,19Since the AAP guideline in 2013, well-regarded studies have emerged with recommended management regimens that differ from the guideline. Especially due to the impact of pneumococcal vaccines, there have been significant changes in the prevalence of microorganisms for AOM,27 thus affecting the antimicrobial management of AOM in the pediatric patient. For instance, in 1999, S pneumoniae accounted for 40% to 45% of AOM, with H influenza (25% to 30%), Moraxella catarrhalis (15% to 20%), and Strep pyogenes (3% to 5%) following. In 2017, the pattern was S pneumoniae (15% to 25%), H influenza (50% to 60%), M catarrhalis (12% to 15%), and S pyogenes (3% to 5%). Overall, there has been a decrease in penicillin-resistant S pneumonia. Given these changes since the AAP guideline, Wald recommends a regimen with “regular dose amoxicillin-clavulanate as the preferred treatment (45 mg/kg/day in 2 divided doses of 400 mg/57 mg) for children with AOM” for 10 days to treat H influenzae and penicillin-sensitive S pneumoniae as initial therapy.27 Pediatric clinicians should continue to monitor changes in microbial prevalence and resistance patterns to continue practicing in an evidence-based manner.The AAP guideline recommends the traditional 10 days of antimicrobial treatment. Since the publication of the guideline, various studies have suggested that a 5- or 7-day course may be just as effective as the traditional 10-day However, that a of treatment with amoxicillin-clavulanate children aged 6 to 23 months with AOM was less the AAP guideline of 10 days of especially for younger children, most to the current AAP guideline, the child has an to penicillin, a course of of amoxicillin for 10 days is In the of a 1 allergic a such as is recommended as are not in the treatment of AOM due to of antimicrobial treatment should be based on evidence-based and resistance with the of a pediatric as the patient does not to amoxicillin in a an such as should be prescribed to treat such as non-typeable H studies of the and of specific in respiratory infections the use of in this should be Most the patient who does not in a manner needs to be followed to care is and the parent/caregiver needs to be as to indications for including acute changes in and antibiotics for to AOM is not in pediatric to a pediatric otolaryngologist should be considered when AOM is not to antibiotics therapies in a in children with complications of AOM such as in children with conditions that place at risk for more and for patients with recurrent AOM as 3 episodes in 6 months or episodes in 1 with 1 episode in the 6 younger than with AOM should be considered higher risk for atypical and severe at this age from other age and should be with AOM should be considered for a In these with a pediatric can be diagnosis and management of AOM is important because if it is more complications can In some the infection can to the and cause which can be and require surgical treatment. less common, is AOM can also cause the to leading to drainage of fluid from the In AOM can lead to hearing which can have on a development and to should recognize the risk factors of AOM. in the first 6 months of has been shown to be In to stressing the of pediatricians should the influenza along with the of the pneumococcal as for diagnostic criteria for AOM require the presence of a bulging there can also be decreased mobility of the TM, with an erythematous color evidence of turbid middle ear fluid. The presence of and an erythematous TM is not diagnostic of AOM.8 of management of AOM in children includes pain management and other supportive therapy. In some a approach in which the patient is managed without antibiotics and the are with a for antibiotics and criteria for use may be of treatment in patients not allergic to penicillin is a 10-day course of to of of antimicrobial treatment should be based on evidence-based and resistance with the of a pediatric as of in the pediatric ear exam, which includes the visualization of the TM, pneumatic otoscopy, and cerumen is critical to the appropriate diagnosis of of the parents or in decision-making is important for patients with AOM. including the use of and indications for follow-up should be discussed with the parents and of