Acute Otitis Media
a Structured Approach
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Background: Two-thirds of all children have an episode of acute otitis media (AOM) before their third birthday. Antibiotic treatment is often given immediately, even though adequate scientific evidence for this practice is lacking.
Methods: This review is based on a selective literature search including previously published evidence-based recommendations, particularly those of the current American guidelines.
Results: A purulent tympanic effusion, possibly associated with inflammation of the tympanic membrane, is indicative of AOM. Only some patients with AOM need immediate antibiotic treatment: children with severe otalgia and/or fever of 39.0°C or above, infants under 6 months of age, and children with certain specific risk factors, including immune deficiency and Down syndrome. In other cases, symptomatic treatment is appropriate. Antibiotic therapy (preferably with amoxicillin) should be initiated only if the symptoms and signs do not improve within two to three days.
Conclusion: As the currently available data are not fully consistent, there is still a need for controlled trials with well-defined endpoints to determine the relative benefits of immediate antibiotic treatment versus two to three days of watchful waiting.
Acute otitis media (AOM) is one of the most commonly occurring inflammatory diseases of infancy and childhood and the third most frequent reason for prescription of antibiotics in this age group (1).
The introduction of antibiotics in the first half of the 20th century was followed by a dramatic decrease in occurrence of the previously severe complications of this disease (e1). Up to the 1980s no-one doubted the necessity of immediate antibiotic treatment as soon as AOM was diagnosed (e2). In 1981, motivated by the increasingly evident resistance to antibiotics, van Buchem et al. were the first to demonstrate that children over the age of 2 years with uncomplicated AOM could tenably be managed by observation with purely symptomatic treatment (2). Although this paradigm shift has become embodied in various countries’ guidelines (3, 4, e3–e5) in the intervening years, some studies have questioned this practice (5, 6).
An S2 guideline for the treatment of AOM is currently being prepared under the aegis of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery. The German College of General Practitioners and Family Physicians issued an S3 guideline on “Earache” that was initially valid until December 2011 and is currently under revision (e6).
After studying this article, the reader should be in a position to:
- Accurately diagnose AOM
- Differentiate uncomplicated AOM from cases where complications may arise
- Initiate and monitor appropriate treatment of AOM.
“Acute otitis media” is the general term embracing all inflammatory diseases of the middle ear with particular involvement of the tympanic cavity. In Germany, acute purulent otitis media is distinguished from viral otitis media; this differs from the nomenclature in the English-speaking countries, where “otitis media” includes otitis media with (serous or mucous) tympanic effusion (e7).
The incidence of AOM is highest in the first 2 years of life and decreases to 2% by the age of 8 years (7). More than two thirds of children have suffered at least one attack of AOM by their third birthday, and around half have experienced three or more episodes (8).
Some of these patients develop tympanic effusion, which may result in middle ear hearing impairment persisting into later childhood (e8).
In Germany, the mean 12-month prevalence of AOM in children and adolescents between 0 and 17 years of age was 11% during the observation period 2003 to 2006 (e9).
An increase in the prevalence of AOM up to the mid-1990s was followed by a reduction of around 19%. Besides the introduction of vaccination against pneumococcal infection and influenza, this decrease has been attributed to the establishment of less ambiguous diagnostic criteria, the recommendation of an attitude of watchful observation together with the growing acceptance of this policy by parents (9), and decreasing exposure to cigarette smoke (10).
Depending on the method used and how stringently the diagnostic criteria are applied, bacteria can be demonstrated in 70% to as many as 90% of patients with AOM (e10).
In almost all cases, AOM is preceded by viral infection of the upper respiratory tract. The most frequent pathogen is respiratory syncytial virus. Other commonly occurring viruses are influenza and parainfluenza viruses, rhinoviruses, adenoviruses, and enteroviruses.
The most frequently occurring bacterial pathogens are Streptococcus pneumoniae and Haemophilus influenzae, followed by Moraxella catarrhalis. Streptococcus pyogenes and Staphylococcus aureus are found in smaller numbers of cases (e11). Prior to introduction of the heptavalent pneumococcal conjugate vaccine (PCV-7) the majority of cases of bacterial AOM were caused by pneumococci, but the bacterial spectrum changed thereafter. Studies in the USA showed a relative reduction in pneumococcal AOM from 33–48% to 23–31%, while the proportion of H. influenzae infections rose from 41–43% to 56–57% (11, e12). It is unknown whether the same is true for Germany. However, this shift may possibly be reversed by an increase in serotypes not contained in PCV-7. The consequences of the introduction of tridecavalent pneumococcal conjugate vaccine (PCV-13), which could potentially reduce the incidence of AOM caused by resistant pneumococcal serotypes, remain to be seen (12). Because influenza viruses are among the viruses most commonly demonstrated in middle ear fluid from patients with AOM and are also known to be precursors of pneumococcal infections, it may seem self-evident that influenza vaccination will reduce the incidence and severity of both viral and bacterial AOM, but to date only partial proof of this has been provided. A recent meta-analysis has shown that nasal administration of live attenuated influenza vaccine (LAIV) to children aged between 6 and 71 months lowers the incidence of AOM by 12.4% (13). However, these findings do not currently justify an obligatory recommendation to administer LAIV.
AOM often occurs in patients with an upper respiratory tract infection. In isolation, symptoms such as earache and, in infants, compulsive grasping of the ear are not specific (11). Only 10% of children with compulsive ear grasping have AOM (14). Fever, general malaise, and, in smaller children, diarrhea and vomiting are variable symptoms (e13).
In adolescents and adults, earache, headache, and impairment of hearing are usually less ambiguous. If there is spontaneous perforation of the tympanic membrane, the earache disappears abruptly.
Examination of the tympanic membrane by otomicroscopy or otoscopy is the keystone of correct diagnosis.
While previously inflammatory changes of the tympanic membrane and simultaneous demonstration of an inflammatory effusion led to the diagnosis of AOM, the new guidelines of the American Academy of Pediatrics (AAP) recommend that the following criteria be met (3):
- Demonstration of moderate to severe bulging of the tympanic membrane or newly occurring otorrhea not caused by acute otitis externa.
- Demonstration of mild bulging of the tympanic membrane with occurrence of earache or pronounced reddening of the tympanic membrane in the previous 48 h.
Absence of fluid accumulation in the tympanic cavity is considered to exclude the presence of AOM.
The first of the two AAP recommendations for diagnosis is controversial. If severe bulging of the tympanic membrane suffices as sole criterion for AOM, differentiation from simple tympanic effusion becomes difficult. The transparency of the tympanic membrane should also be a criterion.
A history of acute occurrence of clinical symptoms such as earache, otorrhea, and/or fever supports the diagnosis of AOM but is not specific in isolation; it has a merely moderate predictive relationship with correct diagnosis (sensitivity 54%, specificity 82%) (11).
Reddening of the tympanic membrane as sole symptom is also insufficient for diagnosis of AOM, because its positive predictive value is only 7% (e14). In the early stage of AOM, with reddening and vascular injection of the membrane and before development of a purulent effusion, differentiation between purulent and nonpurulent (viral) otitis media is impossible. Diagnosis of purulent AOM is not justified until the appearance of the scaly, yellowish bulging of the membrane with vascular injection and in some cases pulsation of the membrane and flattening of the appearance of the manubrium mallei (Figure 1).
Particularly in infants and young children, assessment of the tympanic membrane may be hampered by lack of cooperation, the narrowness of the external auditory meatus, and increased amounts of cerumen. In such cases the diagnosis is not completely certain. Pneumatic otoscopy to confirm the restricted mobility of the tympanic membrane can be helpful, but may well also present problems in small children. Other potential diagnostic procedures are tympanometry and acoustic reflectometry—neither of which, however, can distinguish AOM from tympanic effusion. Therefore, both of these examinations can be used only to supplement insufficiently evaluable otomicroscopy/otoscopy, not to replace it (e15, e16).
Exclusion of an otogenic complication requires inspection and palpation of the mastoid together with assessment of the function of the facial nerve by means of specific grimaces. Older children, adolescents, and adults should undergo audiological examination by means of the Weber/Rinne tuning fork test to exclude toxic involvement of the inner ear.
If an otogenic complication is suspected, further diagnostic procedures are indicated. These include:
- Detailed cochleovestibular diagnosis
- Swab analysis
- Skull MRI or petrosal CT
- Laboratory testing.
Not only do purulent and viral AOM have to be differentiated, AOM also has to be distinguished from myringitis in association with an inflammation of the external auditory meatus and from acute exacerbation of chronic otitis media. The most commonly occurring differential diagnosis is serous/mucous tympanic effusion, which usually does not involve pain, reddening of the tympanic membrane, or a purulent exudate in the tympanic cavity. Clinically, however, differentiation may be problematic in the early stages of AOM or in the recovery phase.
The following recommendations relate to uncomplicated AOM with no signs of systemic disease in an otherwise healthy patient (Figure 2). In addition to otogenic complications, conditions that may complicate the natural course of AOM include cleft lip and palate, genetic aberrations as in Down syndrome, immune deficiencies, and the presence of a cochlear implant. Furthermore, patients who suffer recurrence of AOM within 30 days must be considered separately owing to the lower likelihood of spontaneous healing and the higher incidence of otogenic complications.
The level of evidence (I to IV) and the grade of recommendation (A to C, good clinical practice [GCP]) are given in parentheses.
Earache is often the most bothersome early symptom and must be treated immediately and adequately, independent of any subsequent causal treatment (3). Acetaminophen (paracetamol) and ibuprofen are considered the standard analgesics in AOM (15) (IIa, A). Administration of topical local anesthetics is not recommended (e17) (IV).
Owing to the limited data there are no universally valid recommendations for complementary or alternative procedures in the treatment of AOM.
Historically, the immediate administration of antibiotics to patients with AOM was considered the principal reason for the sharp decline in acute mastoiditis from the 1950s onward (17). However, this initial assumption turned out not to be true for uncomplicated AOM. The rate of mastoiditis in older children who were given antibiotics straightaway did not differ significantly from that in those who were monitored and only treated with antibiotics if they did not improve (0.59% versus 0.17%) (e19). International studies comparing countries with different policies for treatment of AOM also showed no significant variance in the incidence of acute mastoiditis (18).
Taken together, these studies seem to show that in children over 1 year of age the risk of acute mastoiditis following uncomplicated AOM is not increased by an initial period of observation, provided the patients are clinically examined at short intervals and antibiotic treatment is initiated in the absence of improvement. There is also no evidence that the incidence of meningitis in connection with AOM can be reduced by early administration of antibiotics (19, 20).
Since the mid-1980s it has been shown that differences in cure rates between immediate administration of antibiotics and an initial phase of observation with adequate analgesia (watchful waiting) are also only marginally significant (19, 21, 22) (Ia).
Spontaneous amelioration of the symptoms of AOM occurs in about 60% of patients within the first 24 h, in around 80 to 85% within 2 to 3 days, and in 90% of cases after 4 to 7 days. Owing to the latency of the antimicrobial effect, immediate antibiotic treatment offers no advantage over placebo in the first 24 h. Four percent of patients benefit from antibiotics after 2 to 3 days, 9% after 4 to 7 days (e20). There is also no evidence for more rapid improvement in hearing due to immediate antibiotic treatment (23). However, immediate administration of antibiotics increases the likelihood of diarrhea by 5 to 14% (20, 21, 24) and the probability of skin rashes by 3 to 6% (5, 25). The slight therapeutic benefit of immediate antibiotic treatment should be weighed against the considerable spontaneous remission and the potential adverse effects of antibiotics, together with the possible facilitation of resistance to antibiotics and the medicoeconomic aspects.
The factors “age” and “severity of symptoms” play an essential part in the decision between watchful waiting and immediate antibiotic treatment. The failure rate of an initial phase of watchful waiting is almost twice as high in children under 2 years as in children over that age. Patients whose symptoms are classed as severe also have a significantly higher failure rate than those with only mild symptoms (14% versus 4%) (e21).
Therefore, depending on the patient’s age and the severity of the symptoms, a large proportion of patients with uncomplicated AOM can initially be treated purely symptomatically, provided they undergo clinical examination and otomicroscopy/otoscopy after 2 to 3 days (Ia, A).
The appropriate treatment must nevertheless be determined on an individual basis. The decision relies essentially on the clinical experience of the treating physician in assessing the severity of the patient’s symptoms.
The following are considered to indicate immediate administration of antibiotics:
- Age <6 months (Ia, A)
- Age <2 years with bilateral AOM, even in the case of only mild earache and temperature <39.0 °C (Ia, A)
- AOM with moderate to severe earache or temperature ≥ 39.0 °C (Ib, A)
- Persistent purulent otorrhea (Ia, A) (26)
- Risk factors (e.g., otogenic complication, immunodeficiency, severe underlying diseases, Down syndrome, cleft lip and palate, presence of cochlear implant, influenza) (III, B)
- Monitoring within the first 3 days not assured (Ib, A).
The recommendation criteria for antibiotic administration at the time of diagnosis are outlined in the Table.
If the initial management—whether observation or immediate antimicrobial treatment—does not result in amelioration of the symptoms within 48 to 72 h, alternative differential diagnoses must be excluded. If the diagnosis of AOM is confirmed in a patient initially treated by watchful waiting, antibiotic treatment should be started. If an antibiotic has already been given, it should be switched for a different antimicrobial substance. In patients who respond to antibiotic treatment the symptoms generally begin to lessen after 24 h. Any fever should have disappeared by 48 to 72 h after commencement of antibiotic administration.
The antibiotic of choice is amoxicillin, 50 (–60) mg/kg BW/day, divided into three doses (Box 1) (3). The advantages of amoxicillin are its high efficacy rate, high degree of safety, narrow microbiological spectrum, relatively low rate of adverse effects, and low cost (e22). In children, water-soluble dehydrated juice preparations should be used because of their higher resorption rate and thus bioavailability and their lower rate of gastrointestinal complications.
If the patient has been treated with amoxicillin in the previous 30 days or has a history of recurring episodes of AOM that have not responded to amoxicillin, in cases of suspected infection with a β-lactamase–positive pathogen, and possibly in the presence of accompanying purulent conjunctivitis, primary administration of amoxicillin + clavulanic acid is recommended (Box 1) (3, e23).
Cefuroxime and cefpodoxime can be considered as alternatives in patients who are allergic to penicillins (14). In the event that oral intake is not feasible, a single dose of ceftriaxone i.v. or i.m. can be administered as adequate initial treatment (e24).
In the case of a true penicillin allergy, i.e., if the patient has had an unambiguous anaphylactic reaction to penicillin, erythromycin, clarythromycin, and azithromycin should be considered, bearing in mind the limited effect of macrolides against H. influenzae and S. pneumoniae (27).
Patients with a cochlear implant who develop AOM within 2 months of implantation should be given parenteral ceftriaxone. If AOM occurs more than 3 months after implantation, empirical treatment with amoxicillin or amoxicillin + clavulanic acid is recommended (28).
With regard to the duration of antibiotic treatment, the recommendations are as follows: children under 2 years old or with severe AOM should be treated for 10 days, children aged 2 to 6 years for 7 days, and children aged 7 years and above for 5 to 7 days (3, 29).
If the first-line antibiotic treatment fails, the following recommendations apply:
- The second-line antibiotic after failure of amoxicillin is amoxicillin + clavulanic acid.
- Failure of first- or second-line amoxicillin + clavulanic acid should be followed by paracentesis and microbiological testing. Alternatively, a 3-day course of parenteral ceftriaxone can be considered (3, e23) (Box 2).
If the above-mentioned escalation of antibiotic treatment still fails to ameliorate the symptoms, paracentesis and swabbing are indicated to identify the pathogen and thus establish the appropriate antibiotic.
Otogenic complications of AOM such as the development of acute mastoiditis, sinus thrombosis, otogenic meningitis, labyrinthitis, facial palsy, cerebral abscess, or Gradenigo syndrome generally necessitate, in addition to adequate antibiotic treatment, surgical intervention in the form of mastoidectomy with additional paracentesis and, if required, insertion of tympanic tubes to improve the circulation of air in the middle ear. Depending on the individual situation, further measures may be necessary (Box 3).
Recurring AOM is considered to be present when the patient has had at least three episodes of AOM in the previous 6 months or at least four episodes in the previous 12 months. Besides the exclusion of allergies and immune defects, patients with recurring AOM should have their vaccination status with regard to pneumococci checked, because vaccination can reduce the number of infections by 10 to 25% (e25).
The insertion of tympanic tubes, alone or in combination with adenotomy, can reduce the rate of recurrences by 1.5 events in 6 months (number needed to treat [NNT] = 2–5) (30, 31). Adenotomy alone does not lead to a reduction in the frequency of recurrent episodes of AOM (32).
Apart from the above-mentioned follow-up after 2 to 3 days, it should be borne in mind that remission of the tympanic effusion is often a protracted affair. Tympanic effusion is still evident in 60 to 70% of children after 2 weeks, in 40% after 4 weeks, and in up to 25% as long as 3 months after onset of AOM. This must be monitored and treated as required in order to avoid delays in speech development. In the short term, decongestant nose drops can be given, the active Valsalva maneuver employed, or the tube opened passively by means of a Politzer balloon or a special nasal balloon. If the tympanic effusion persists for over 3 months, earlier in more severe cases, paracentesis is indicated, possibly accompanied by insertion of tympanic tubes together with adenotomy (e7).
Some factors that contribute to early or recurring AOM are not amenable to influence: these include genetic predisposition, premature birth, male sex, some ethnicities, number of siblings, and low socioeconomic status (34). The following measures, however, reduce the risk of AOM:
- Breastfeeding for the first 6 months (35)
- Avoidance of exposure to tobacco smoke (10, 35, e26)
- Adequate vaccination against pneumococci and influenza (36–38).
Other measures that may exert a protective effect include:
- Dispensing with a pacifier (39)
- Reduction of the rate of upper respiratory tract infections by lowering kindergarten group size (e27)
- Use of xylitol chewing gum or xylitol lozenges several times a day during the time of year when common colds are prevalent (40)
- Insertion of tympanic tubes, in combination with adenotomy if required.
The criteria that have to be fulfilled before a diagnosis of AOM can be assigned are demonstration of a purulent tympanic effusion and, if applicable, demonstration of inflammatory changes of the tympanic membrane.
Uncomplicated AOM must be distinguished from AOM with complicating factors or the danger of otogenic complications.
In selected patients, depending on age, severity of symptoms, and accompanying diseases, management of uncomplicated AOM can begin with 2 to 3 days of symptomatic treatment and observation, followed by clinical examination.
If there is no remission of the symptoms, antibiotic treatment with amoxicillin should be initiated.
Conflict of interest statement
Prof. Berner has received lecture fees from Glaxo Smith Kline (Impfakademie), InfectoPharm, the Falk Foundation, and Milupa.
Dr. Thomas, Prof. Zahnert, and Prof. Dazert declare that no conflict of interest exists.
Manuscript received on 3 May 2013, revised version accepted on
5 November 2013.
Translated from the original German by David Roseveare.
Dr. med. Jan Peter Thomas
Klinik für Hals-, Nasen- und Ohrenheilkunde
Kopf- und Halschirurgie der Ruhr-Universität Bochum
St. Elisabeth Hospital, Bleichstr. 15, 44787 Bochum, Germany
@For e-references please refer to:
Thomas, M.D.; Prof. Dazert
Department of Child and Adolescent Medicine, Technical University of Dresden (Carl Gustav Carus University Hospital Dresden): Prof. Berner
Department of Otorhinolaryngology, Technical University of Dresden (Carl Gustav Carus University Hospital Dresden): Prof. Zahnert
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