- Epidemiology: 33% of all pediatric office visits; by 3 yo, 80% have ≥ 1 AOM
- Pathophysiology: URI or inflammation → Eustachian tube dysfunction or occlusion → effusion → infection
- Etiologic agents: Respiratory viruses >> Haemophilus influenzae (Post PCV7 52%, Pre PCV7 15-30%) > Pneumococcus spp. (Post PCV7 34%, Pre PCV7 25-50%) > Moraxella spp. (Pre PCV7 3%–20%) > GABHS > other (Pediatrics 2004;113:1451)
- Diagnosis
- History: Fever (especially increasing fever curve), URI, ear pain or fullness, hearing loss, vomiting, ear drainage or diarrhea.
- Physical exam: Bulging tympanic membrane (TM), purulent material, air-fluid level, ↓ or no movement of TM, otorrhea, ± redness, ± bullae.
- Best predictors are position (ie, bulging), mobility of TM (↓ or no movement of TM), and color (PIDJ 1998;17(6):540). Consider tympanocentesis and bacterial culture for children with recurrent or chronic disease.
- History: Fever (especially increasing fever curve), URI, ear pain or fullness, hearing loss, vomiting, ear drainage or diarrhea.
- Treatment
- Pain and fever control are the most important interventions.
- Within 24 hours, 61% of patients have resolution of symptoms without antibiotics.
- Antibiotics (see table below) often do not change the duration of illness of AOM.
- Pain and fever control are the most important interventions.
Age | Diagnosis of AOM is Certain | Diagnosis of AOM is Uncertain |
|---|---|---|
<6 mo | Start antibiotic treatment | Start antibiotic treatment |
6–24 mo | Start antibiotic treatment | Observe with follow-up assured if the patient’s condition is non-severe (temperature <39°C [102.2°F] and mild otalgia); Start antibiotics if the patient’s condition is severe (moderate to severe otalgia and temperature >39°C) |
≥24 mo | Observe with follow-up assured if the patient’s condition is non-severe (temperature <39°C [102.2°F] and mild otalgia); Start antibiotics if the patient’s condition is severe (moderate to severe otalgia and temperature >39°C) | Observe with follow-up assured |
Temperature >39°C (102.2°F) | Initial antibiotic choice | Treatment failure at 48–72 h after initial management |
|---|---|---|
No | Amoxicillin, 80–90 mg/kg/day (If penicillin allergic: Non–type I: cefdinir, cefuroxime, or cefpodoxime; type I: azithromycin, clarithromycin) | Amoxicillin–clavulanate, 90 mg/kg/day of amoxicillin with 6.4 mg/kg/ day of clavulanate (If penicillin allergic: Non–type I: ceftriaxone for 3 days; type I: clindamycin) |
Yes | Amoxicillin–clavulanate, 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (If penicillin allergic, ceftriaxone for 3 days) | Ceftriaxone for 3 days (If penicillin allergic, tympanocentesis, clindamycin) |
- Single high-dose azithromycin (30 mg/kg/dose) is equal to amoxicillin in efficacy (PIDJ 2005;24:153).
- Add topical agents as well for AOM with perforation or if the patient has tympanostomy tubes (eg, Ciprofloxacin; Ofloxacin).
- Surgical treatment: Consider ENT referral if the patient has >3 episodes in 6 mo or >4 episodes in 1 yr.
- Complications: Labyrinthitis, mastoiditis, intracranial extension, conductive hearing loss.
- Epidemiology: Highest incidence <2 yo; 80% of <10 yo have had one episode of ome
- Pathophysiology: Eustachian tube dysfunction: Resolution of AOM → OME (45% at 1 mo after and 10% at 3 mo after AOM); GER; anatomic (children with cleft palate)
- Etiologic agents: Viruses > H. influenzae > Moraxella spp., bottle feeding, feeding supine, daycare attendance, allergies, smoke exposure
- Diagnosis
- Often OME is subjectively asymptomatic → no intervention required if no hearing loss; when symptomatic:
- History: ↓ hearing, ear fullness, pressure, pain (rare), recent travel, diving, allergies (environmental)
- Physical exam: Air fluid level, TM retraction or bulging, serous middle ear fluid, ↓ TM mobility, ± large tonsils, signs of atopy.
- Tests: Hearing test if speech or language delay present
- History: ↓ hearing, ear fullness, pressure, pain (rare), recent travel, diving, allergies (environmental)
- Often OME is subjectively asymptomatic → no intervention required if no hearing loss; when symptomatic:
- Treatment
- Most spontaneously resolve → avoid smoke exposure; ↓ bottle feeding, daycare, and allergens.
- More aggressive therapy if the child has a speech or language delay, PDD, craniofacial abnormality (eg, Down syndrome, cleft palate), visual impairment, or developmental delay
- Antimicrobial agents: Consider amoxicillin, amoxicillin + clavulanate, trimethoprim–sulfamethoxazole, or erythromycin for 2 to 5 wk.
- Tympanostomy tube: OME and >40-dB hearing loss → definite indication; OME and 21- to 40-dB hearing loss; or persistent effusion >3 mo → relative indications.
- Steroids, antihistamines, decongestants, and mucolytics are not effective.
- Antimicrobial agents: Consider amoxicillin, amoxicillin + clavulanate, trimethoprim–sulfamethoxazole, or erythromycin for 2 to 5 wk.
- Most spontaneously resolve → avoid smoke exposure; ↓ bottle feeding, daycare, and allergens.
- Definition: Suppurative infection of the mastoid air cells.
- Pathophysiology: Because the middle ear cavity is contiguous with the mastoid, all middle ear infections cause some degree of mastoid inflammation. However, when inflammation leads to occlusion of mastoid aditus → ↑ pressure → relative hypoxia and acidosis → bony erosion into surrounding structures → potential for intra- or extracranial spread of infection.
Diagnosis | Diagnosis | Etiologic Agents | Treatment* |
|---|---|---|---|
Acute mastoiditis | Fever (often <2 yrs of age), recent AOM with temporary improvement followed by clinical decline Exam: Postauricular swelling, erythema ± fluctuance, TM suggestive of infection, pinna anteriorly displaced Test: CT temporal bone with contrast | Pneumococcus spp. (serotype 19A is associated with high rates of β-lactam resistance) > GABHS > Staphylococcus aureus > others | ENT consultation;† Start, vancomycin/ clindamycin (oxacillin/nafcillin depending on local prevalence of MRSA) and cefotaxime |
Chronic mastoiditis | Usually with persistent ear drainage ± fever ± postauricular swelling Test: CT temporal bone with contrast | S. aureus, Pseudomonas spp., other GNRs, mycobacteria, fungal; 80% of chronic cases demonstrate co-infection with anaerobes | Would also include ticarcillin–clavulanate + gentamicin and topical ear drops (Ciprofloxacin or Cortisporin) |
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