A 15-month-old boy is brought by both parents to his pediatrician with a 2-day history of fever, irritability, and frequent tugging of his left ear. This was preceded by a 1-week history of nasal congestion, cough, and rhinorrhea. On otoscopy, his left tympanic membrane (TM) appears erythematous, cloudy, bulging, and exudative (Figure 22-1). His left TM fails to move on pneumatic otoscopy. The physician diagnoses acute otitis media and decides with the parents to prescribe a 10-day course of amoxicillin; the child recovers uneventfully.

In follow-up 2 months later, the child appears healthy and is meeting all his developmental milestones. On otoscopic examination, air–fluid levels are seen in the right ear (Figure 22-2). The physician explains the diagnosis of otitis media with effusion to the parents and arranges follow-up. Three months later the effusion is completely resolved.

Acute otitis media (AOM) is the most common diagnosis for acute office visits for children.¹ AOM is characterized by middle-ear effusion in a patient with signs and symptoms of acute illness (e.g., fever, irritability, otalgia). Otitis media with effusion (OME) is a disorder characterized by fluid in the middle ear in a patient without signs and symptoms of acute ear infection; it is also very common in childhood.

• AOM accounted for $5 billion of the total national health expenditure in 2000; more than 40 percent was incurred for children between 1 and 3 years of age.¹

• It is estimated that 60 percent to 80 percent of children in the US develop AOM by 1 year of age and that 80 percent to 90 percent develop AOM by 2 to 3 years of age.^2,3

• The highest incidence occurs between 6 and 24 months of age.^2,3

• AOM is the most common reason for outpatient antibiotic treatment in the US.⁴ A national survey in 1992 revealed that 30 percent of all antibiotics prescribed for children younger than age 18 years was for treatment of AOM.⁵

• OME is diagnosed in 2.2 million children yearly in the US.⁶

• Approximately 90 percent of children (80% of individual ears) have OME at some time before school age, most often between ages 6 months and 4 years.⁶

• The combined direct and indirect health care costs of OME amount to $4 billion annually.⁶

AOM is often preceded by upper respiratory symptoms such as cough and rhinorrhea.

• Pathogenesis of AOM includes:⁷

  • Eustachian tube dysfunction (usually a result of an upper respiratory infection) and subsequent tube obstruction.

  • Increased negative pressure in the middle ear.

  • Accumulation of middle-ear fluid.

  • Microbial growth.

  • Suppuration (that leads to clinical signs of AOM).

• Most common pathogens in the US and United Kingdom are:^8,9

  • Strains of Streptococcus pneumoniae not in the heptavalent pneumococcal vaccine (PCV7) (after introduction of PCV7 vaccine in 2000).

  • Nonencapsulated (nontypeable) Haemophilus influenzae (NTHi).

  • Moraxella catarrhalis.

  • Staphylococcus aureus.

• Viruses account for 16 percent of cases. Respiratory syncytial viruses, rhinoviruses, influenza viruses, and adenoviruses have been the most common isolated viruses.¹⁰

OME most commonly follows AOM; it may also occur spontaneously.

• Fluid limits sound conduction through the ossicles and results in decreased hearing.

• Reasons for the persistence of fluid in otitis media remain unclear, although potential etiologies include allergies, biofilm, and physiologic features.

• “Glue ear” refers to extremely viscous mucoid material within the middle ear and is a distinct subtype of OME.

• The most important risk factors for AOM include young age and attendance at a child care center.

• Other risk factors include:¹¹

  • White race.

  • Male gender.

  • History of enlarged adenoids, tonsillitis, or asthma.

  • Multiple previous episodes.

  • Bottle feeding.

  • History of ear infections in parents or siblings.

  • Use of a soother or pacifier.

• Second-hand smoke is a risk factor when parents smoke at home.

• Risk factors for OME include age 6 years or younger, large number of siblings, low socioeconomic group, frequent upper respiratory tract infection, tobacco exposure, daycare attendance, and bottle feeding.¹²

Clinical Features of AOM

• To diagnose AOM, the clinician should confirm a bulging TM using otoscopy, verify the acuteness of symptoms, and identify objective signs of middle-ear effusion (MEE) using pneumatic otoscopy and/or tympanometry.^6,13 SOR C

• Elements of the definition of AOM are:^6,13

  • Signs or symptoms of middle-ear inflammation as indicated by:

    • Moderate to severe bulging of the TM or new otorrhea not attributable to acute otitis externa.

    • Mild bulging of the TM and recent onset (≤48 hours) of ear pain or intense erythema of the TM (Figure 22-1) in contrast to the normal TM (Figure 22-5).

  • The presence of MEE. Although MEE is often presumed by bulging of the TM (Figure 22-1) or air–fluid level behind the TM (Figure 22-2), guidelines stress the use of objective measures of confirming MEE such as:

  • Limited or absent mobility of the TM established by pneumatic otoscopy—The TM does not move during air insufflation; often initially seen as retraction of the TM (Figures 22-3 and 22-4).

  • Tympanometry demonstrating reduced or flat waveforms.

Clinical Features of OME

• The most common symptom, present in more than half of patients, is mild hearing loss. This is usually identified when parents express concern regarding their child’s behavior, performance at school, or language development.¹²

• Absence of signs and symptoms of acute illness assists in differentiating OME from AOM.

• Common otoscopic findings include:

  • Air–fluid level or bubble (Figure 22-2).

  • Cloudy TM (Figures 22-4 and 22-6) in contrast to the normal TM (Figure 22-5).

  • Redness of the TM is present in approximately 5 percent of ears with OME.

• Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME.¹⁴ SOR A

  • Impaired mobility of the TM is the hallmark of MEE.

  • According to a metaanalysis, impaired mobility on pneumatic otoscopy has a pooled sensitivity of 94 percent and specificity of 80 percent, and positive likelihood ratio of 4.7 and negative likelihood ratio of 0.075.¹⁴

Laboratory Tests and Imaging