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Epidemiology

Acute otitis media (AOM) is the most frequent diagnosis in ill children and the most common reason for antibiotic prescriptions (which is debatable).  Children < 2 years-old are at the highest risk, with nearly 80% of children in the US having at least one documented episode of AOM annually.  Incidence has been declining in the US since 2009 with the widespread use of the 13-valent pneumococcal vaccine.

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Risk Factors

• Age
  • < 2yrs with peak range from 6-18 months
• Family History
• Day Care
• Lack of Breastfeeding
• Tobacco smoke
• Pacifier use
• Season

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Pathogenesis

The development of AOM follows a predictable series of events:

1. Antecedent event
   1. URI
2. Inflammatory edema of mucous membranes of URT
   1. Obstructs the narrowest portion of the Eustachian tube (isthmus)
      1. Results in negative middle ear pressure
         1. Causes fluid accumulation and effusion
3. Pathogens now have a medium to grow and cause suppuration and bulging of TM
4. Effusion may persists for weeks to months after sterilization with antibiotics

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Microbiology

• Bacteria
  • 3 bugs account for most cases of bacterial AOM
    • pneumoniae – 50%
    • influenza
    • catarrhalis
  • Viruses
    • RSV
    • Human metapneumovirus
    • Influenza
• It is worth noting that up to 2/3^rd have combined bacterial and viral isolates

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Signs and Symptoms

• Otalgia (most common and best predictor)
• Fever
• Irritability
• Poor feeding
• Vomiting

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Physical Exam

The diagnosis of AOM requires:

• Any of the above signs or symptoms; and
• Bulging of the TM, presence of middle ear effusion with inflammation, or TM hypomobility on pneumatic otoscopy

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Acute Management

Analgesia

• Systemic
  • Ibuprofen – 10mg/kg every 4-6hr (max 40mg/kg/day)
  • Acetaminophen – 10-15mg/kg every 4-6hr (max 75mg/kg/day)
• Topical
  • Lidocaine

Antibiotics vs Observation

Antimicrobial Therapy

• No recent beta-lactam use, no history of recurrent AOM, no concomitant conjunctivitis
  • Amoxicillin 90mg/kg/day divided into 2 doses/day x 5-7 days
• Recent beta-lactam use, history of recurrent AOM, concomitant conjunctivitis
  • Amoxicillin-clavulanate 90mg/kg/day divided into 2 doses/day x 10 days
• Pencillin allergy
  • Non-type I hypersensitivity reaction
    • Cefdinir 14mg/kg/day 1-2 doses/day x 10 days
    • Ceftriaxone 50mg/kg IM daily x 1-3 days
  • Type-1 hypersensitivity reaction
    • Azithromycin 10mg/kg on day 1 and 5mg/kg on days 2-5
    • Clarithromycin 15mg/kg divided into 2 days/day

 

Oral therapy is preferred if perforation is present.

 

If a child has acute onset of otorrhea with known tympanostomy tubes in place:

• Uncomplicated
  • Ciprofloxacin-dexamethasone 4gtts twice daily x 7 days
  • Ofloxacin 5gtts twice daily x 10 days
• Complicated or ill-appearing
  • Amoxicillin 90mg/kg/day divided into 2 doses x 10 days
  • Amoxicillin-clavulanate 90mg/kg/day divided into 2 doses x 10 days

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Treatment Failure

This is defined as lack of improvement by 72 hours in patients treated with antibiotics.

• If initial therapy was amoxicillin, then change to amoxicillin-clavulanate
• If initial therapy was amoxicillin-clavulanate, then change to cephalosporin
• If patient has type-1 hypersensitivity to PCN, then options include:
  • Tympanocentesis for culture and sensitivity and pain relief
  • Levofloxacin 10mg/kg every 12 hours (6m-5yr) or daily x 10 days (≥ 5yr)

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Recurrent AOM

This defined as development of AOM after successful treatment and treatment depends on the timeframe:

• ≤ 15 days
  • Ceftriaxone 50mg/kg daily for 3 days
  • Levofloxacin 10mg/kg every 12 hours (6m-5yr) or daily x 10 days (≥ 5yr)
• > 15 days
  • Amoxicillin-clavulanate 90mg/kg/day divided into 2 doses/day x 10 days
• Prophylaxis
  • Amoxicillin 40mg/kg/day during fall, winter, and early spring
  • No longer than 6 months

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Tympanostomy Tube Placement Indications

• ≥ 3 distinct and documented episodes within 6 months; or
• ≥ 4 distinct and documented episodes within 12 months;
• Other factors include:
  • Multiple drug allergies in recurrent AOM
  • Breakthrough episodes on prophylaxis therapy

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References

1. Lieberthal AS, Carroll AE, Chonmaitree T. The diagnosis and management of acute otitis media. Pediatrics. 2013; 131(3):e964-99. [pubmed]
2. Todberg T, Koch A, Andersson M, Olsen SF, Lous J, Homøe P. Incidence of otitis media in a contemporary Danish National Birth Cohort. PloS one. 2014; 9(12):e111732. [pubmed]
3. Marom T, Tan A, Wilkinson GS, Pierson KS, Freeman JL, Chonmaitree T. Trends in otitis media-related health care use in the United States, 2001-2011. JAMA pediatrics. 2014; 168(1):68-75. [pubmed]
4. Uhari M, Mäntysaari K, Niemelä M. A meta-analytic review of the risk factors for acute otitis media. Clinical Infectious Diseases. 1996; 22(6):1079-83. [pubmed]
5. Rovers MM, Schilder AG, Zielhuis GA, Rosenfeld RM. Otitis media. Lancet. 2004; 363(9407):465-73. [pubmed]
6. Coker TR, Chan LS, Newberry SJ. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA. 2010; 304(19):2161-9. [pubmed]
7. Chonmaitree T. Acute otitis media is not a pure bacterial disease. Clinical infectious diseases. 2006; 43(11):1423-5. [pubmed]
8. Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. The Pediatric Infectious Disease Journal. 2010; 29(4):304-9. [pubmed]
9. Kontiokari T, Koivunen P, Niemelä M, Pokka T, Uhari M. Symptoms of acute otitis media.. The Pediatric infectious disease journal. 1998; 17(8):676-9. [pubmed]
10. Niemela M, Uhari M, Jounio-Ervasti K, Luotonen J, Alho OP, Vierimaa E. Lack of specific symptomatology in children with acute otitis media.. The Pediatric infectious disease journal. 1994; 13(9):765-8. [pubmed]
11. Rosa-Olivares J, Porro A, Rodriguez-Varela M, Riefkohl G, Niroomand-Rad I. Otitis Media: To Treat, To Refer, To Do Nothing: A Review for the Practitioner.. Pediatrics in review. 2015; 36(11):480-6; quiz 487-8. [pubmed]
12. Lieberthal AS, Carroll AE, Chonmaitree T. The diagnosis and management of acute otitis media.. Pediatrics. 2013; 131(3):e964-99. [pubmed]
13. Arguedas A, Dagan R, Pichichero M. An open-label, double tympanocentesis study of levofloxacin therapy in children with, or at high risk for, recurrent or persistent acute otitis media.. The Pediatric infectious disease journal. 2006; 25(12):1102-9. [pubmed]