least 1 episode of acute otitis media is seen in 94% of children before
age 2. Attendance in a day-care setting is among the major risk
factors. Middle ear fluid may be sterile or may grow viruses and/or
bacteria. Accurate diagnosis and distinction from otitis media with
effusion is essential for proper management, but physicians often have
difficulty in making the correct diagnosis. Since overuse of
antibacterial agents contributes to an increase in bacterial
resistance, physicians should consider delaying treatment for 2 to 3
days, during which therapy is aimed at controlling pain. High-dose
amoxicillin is the preferred antibacterial agent in a young child with
a purulent middle ear effusion, but amoxicillin-clavulanate, cefuroxime
axetil, and ceftriaxone are options when resistant bacteria are
Acute otitis media (AOM) is a
common clinical problem facing all providers who care for children. Ear
infections account for $3 billion in health care expenditures annually.
In the United States, about 24 million prescriptions for antibacterial
agents are written annually for AOM. The number of cases of diagnosed
AOM continues to rise. In 1975, AOM was diagnosed during 9.9 million
health care visits, and in 1990, it was diagnosed at 24.5 million
visits. Increased bacterial resistance to antibacterial
agents combined with increased use of these drugs to treat AOM has
generated discussions in the pediatric community focused on determining
the best way to manage this common condition that plagues children,
parents, and physicians. In this article, we present 20 pearls we have
found helpful in understanding, diagnosing, treating, and preventing
Fluid Accumulation Breeds Bacteria
pathophysiology of AOM is impaired mucociliary clearance of fluid from
the middle ear resulting from eustachian tube dysfunction. The middle
ear becomes a fluid-filled closed space that provides a wonderful
medium for growth of bacteria that may be present. When bacteria are
isolated from middle ear effusions, the question becomes, "Is the
middle ear infected or are bacteria merely proliferating in the trapped
fluid?" Children are at higher risk for eustachian tube dysfunction
because their eustachian tubes are shorter, more horizontal, and more
prone to obstruction by adenoid tissue than those in adults.
Otitis Media is Seasonal and is Often Associated with Viral URIs
average 3 to 8 viral upper respiratory tract infections (URIs) each
year, predominantly in the winter months. URIs can cause inflammatory
edema of the eustachian tubes with resultant dysfunction leading to AOM.
Aspirated middle ear fluid (MEF) from children with viral URIs may
contain bacteria alone, virus alone, or bacteria and viruses, or it may
AOM is Almost Universal
Before the age of 2
years, 94% of children will have had at least 1 episode of otitis
media. The peak age for otitis media is between 6 and 13 months. The occurrence of AOM decreases with age, and by 6 years of age, AOM is relatively uncommon in healthy children.
Age, Day Care Top List of Risk Factors
factors for AOM include attendance at day care, exposure to secondhand
smoke, not being breast-fed, craniofacial abnormalities, and having
biologic siblings or parents with a history of problems with AOM.
However, the greatest risk factors are being younger than 2 years and
attending day care.
Viral, Bacterial, or Both?
In a study that looked for both bacterial and viral causes of AOM, Chonmaitree et al
found 93 (34%) of 271 children to have bacterial pathogens in their MEF
and no evidence of a viral infection. Forty-three children (16%) had
bacteria in their MEF and evidence of viral infection (virus isolated
from a nasal wash or serologic evidence). Fifty children (18%) had both
bacteria and viruses isolated from their MEF, and 16 children (6%) had
only virus isolated from their MEF. Sixty-nine children (25%) had no
pathogens in their MEF, but 15 of these children had other evidence of
a viral infection. When bacteria are isolated from the
MEF, the usual pathogens are Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis. The most common viruses found in
the middle ear include respiratory syncytial virus, influenza virus,
parainfluenza virus, rhinovirus, and adenovirus.
Accurate Diagnosis is Imperative
is important to distinguish between AOM and otitis media with effusion
(OME). Essential tools for the physical diagnosis of otitis media are
otoscopy and pneumatic insufflation. Position, color, translucency, and
mobility of the eardrum are 4 components that should be adequately
assessed in each patient (Figures 1, 2, and 3). Tympanometry and
acoustic reflectometry are additional resources that can help assess
whether an effusion is present in the middle ear, but they do not
provide information about whether the fluid is infected.
Normal appearance of the tympanic membrane. (Figures 1, 2, and 3
courtesy of Janet Griffin, MD, Children's Hospital Medical Center of
Figure 2. Acute otitis media with effusion. The tympanic membrane is injected but landmarks are still clearly visualized.
Figure 3. Acute otitis media. The tympanic membrane is bulging and hyperemic, and yellow purulent fluid is seen in the middle ear space.
Diagnosis Can be Challenging
pediatricians surveyed indicated that 30% of the time they are
uncertain about their diagnosis. Evaluating the tympanic membrane of a
fighting child with cerumen in the external auditory canal is always a
challenge. Pichichero and Poole8 examined the accuracy of the diagnosis
of AOM by pediatricians compared with otolaryngologists. They found
that pediatricians correctly diagnosed AOM 50% of the time and
otolaryngologists were correct 73% of the time. Although both groups
were able to recognize abnormal tympanic membranes, pediatricians
called OME or a retracted tympanic membrane AOM 27% of the time on
Effusions are Common after AOM
percent of children will have an effusion that persists for a month
after an episode of AOM, but 90% of the effusions will resolve without
treatment within 3 months.[9,10]
Resistance, Resistance, Resistance!
resistance to antibacterial agents is increasing, and concern about
this problem is impacting the treatment of AOM. A major cause of
increased resistance is the ongoing inappropriate use of antibacterial
agents. In some regions, the rate of penicillin resistance exceeded 50%
for S pneumoniae (Figure 4) and 30% for H influenzae.[11,12]
It is imperative that physicians improve their ability to diagnose AOM
and thereby increase their confidence in not using antimicrobial agents
when they are not called for. By using antibacterial agents more
judiciously and appropriately, we should see a decrease in resistance.
Figure 4. Penicillin-resistant pneumococcal infections in the United States, 1979 - 1999.
Earache: Bacteria Do Not Cause Pain
inability to effectively drain the eustachian tube results in increased
pressure in the middle ear. Pressure in the middle ear causes the pain.
Pain control for any type of AOM is imperative and includes analgesics,
topical analgesic eardrops, cold or hot packs, and positioning the
child to keep the head propped up.[13,14]
OME: No Treatment Needed
usually resolves spontaneously. Treatment with myringotomy and
tympanostomy tube placement may be necessary if the effusion is present
for more than 3 months, if OME is chronic (present 6 months out of the
previous 12 months), or if OME is associated with hearing loss.
Delaying Treatment is an Option
of studies comparing antibacterial therapy with placebo consistently
finds that about 80% of episodes of AOM will resolve in 2 to 7 days
without antibacterial therapy, compared with slightly more than 90% if
antibacterial agents are used.[15,16] Furthermore, no antibacterial agent has been shown to be superior to amoxicillin.
Initial treatment of a patient with fluid in the middle ear, but not
pus, who has symptoms and signs such as ear pain, erythema of the
tympanic membrane, and fever, and accompanying symptoms of URI should
be pain control for 2 to 3 days with a contingency plan. The plan may
include office recheck in 48 to 72 hours or a prescription to use if
symptoms persist for more than 2 to 3 days (Table). Children younger than 2 years should be rechecked in 24 hours. This approach has been used in the Netherlands since 1990.
Delaying Treatment Does Not Substantially Increase Complications
the United States, where 96% of patients with AOM are treated with
antibacterial agents, the incidence of mastoiditis is 2 per 100,000. In
the Netherlands, Norway, and Denmark, where the rates of treatment with
antibacterial agents are 31%, 67%, and 76%, respectively, the incidence
of mastoiditis is 4 per 100,000.
Start with Amoxicillin
the young child with a purulent middle ear effusion, treatment is
high-dose amoxicillin (80 to 100 mg/kg/d) for 7 days. If a child fails
to respond to this treatment within 3 days, alternative therapy for
resistant bacteria should be started with high-dose
amoxicillin-clavulanate (80 to 100 mg/kg/d of the amoxicillin
component) for 7 days. Treatment with cefuroxime axetil (30 mg/kg twice
a day) for 7 days or ceftriaxone (50 mg/kg IM once a day) for 3 days is
the next step.[11,18]
Patients, Parents, and Antibacterial Agents
studies have shown that contrary to popular belief, patient and
parental satisfaction is not dependent on the prescription of
antibacterial agents.[19,20] Studies have shown that parents
and patients want reliable information and good communication, not
antibacterial agents. Patients and parents were satisfied with
caregivers who explained the illness, gave reasons for a specific
treatment, suggested symptomatic control measures and, most important,
provided a contingency plan should the patient's condition worsen.
Providing parents with literature that explains the increasing
bacterial resistance and inappropriate use of antibacterial drugs was
also found to be beneficial in decreasing the expectations of the
parents to receive antibacterial agents. Information for parents, patients, and physicians is available at the CDC Web site (www.cdc. gov/drugresistance/community/tools.htm).
Vaccination May Help
Prevention of infections with respiratory pathogens, such as influenza virus, lowers the incidence of AOM. Clements and associates
suggest that giving influenza vaccine to children older than 6 months
should significantly cut down on winter respiratory disease, thus
decreasing the likelihood of otitis media. The 7-valent conjugate
pneumococcal vaccine has been successful in decreasing the incidence of
AOM in Finland.
Hand Washing and other Factors
washing remains one of the most important methods of decreasing
person-to-person transmission of bacteria and viruses. Other factors
that may potentially decrease the risk of AOM include breast-feeding
for at least 3 months, limiting day-care exposure, and eliminating
secondhand smoke exposure.
American Academy of Pediatrics (AAP) Committee on Infectious Diseases
is likely to review current recommendations for the management of
children with AOM with an eye toward decreasing antibacterial therapy
for this diagnosis. Stay tuned to the AAP news.
for physicians, residents, patients, and parents is an ongoing process
and is essential. In a survey of accredited pediatric residency program
directors, only 59% of the respondents had some formal otitis media
curriculum. Instructional videos, seminars with
interactive simulation to teach otoscopy, and formal lecture series for
residency programs are examples of ways to help retrain physicians and
teach residents the importance of accuracy in the diagnosis of AOM.
Principles to Keep in Mind
in the diagnosis of AOM is paramount. Observation and symptomatic
treatment is an option for some patients, but the recognition and
treatment of pain is essential for all patients. Amoxicillin is the
drug of choice to treat AOM. If the patient does not respond to the
initial treatment in 48 to 72 hours, be prepared with a backup plan.
Emphasize preventive measures for the child who has recurrent episodes
Immediate treatment with high-dose amoxicillin (80 to 100 mg/kg/d orally) for 7 days
Otitis media without bulging tympanic membrane
Delayed-treatment option (see pearls on Delaying treatment)
Recurrent acute otitis media
Delayed-treatment option (see pearls on Delaying treatment); immunization with influenza vaccine
Modified from Hendley JO. N Engl J Med. 2002.
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otitis media diagnoses: extrapolations from a pediatric medicaid
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for otitis media: United States, 1975-2000. Hyattsville, Md: National
Center for Health Statistics. Data From Vital and Health Statistics of
the Centers for Disease Control; 1992;214:1-18.
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media and its complications. In: Behrman RE, Kliegman RM, Jenson HB,
eds. Nelson Textbook of Pediatrics. Philadelphia: WB Saunders Co;
Block SL, Harrison CJ, Hedrick J, et al.
Restricted use of antibiotic prophylaxis for recurrent acute otitis
media in the era of penicillin non-susceptible Streptococcus
pneumoniae. Int J Pediatr Otorhinolaryngol. 2001;61:47-60.
LC, Faden H, Wasielewski R, et al. Exclusive breastfeeding protects
against bacterial colonization and day care exposure to otitis media.
Pediatrics. 1997;100:E7. Available at: http://www.pediatrics.org/cgi/content/full/100/4/e7. Accessed March 31, 2003.
T, Owen MJ, Patel JA, et al. Effect of viral respiratory tract
infection on outcome of acute otitis media. J Pediatr. 1992;120:856-862.
Heikkinen T. Role of viruses in pathogenesis of acute otitis media. Pediatr Infect Dis J. 2000;19:S17-S23.
ME, Poole MD. Assessing diagnostic accuracy and tympanocentesis skills
in the management of otitis media. Arch Pediatr Adolesc Med.
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DeRosa J, Grundfast KM. Surgical management of otitis media. Pediatr Ann. 2002;31:814-820.
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cold-adapted, trivalent, intransal influenza virus vaccine in children.
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Sidebar: Editorial Comment
Scott and Powell have written a wonderful article providing 20 clinical
pearls on acute otitis media (AOM). One particular area that deserves
comment relates to the delayed-treatment, or "observation," option
instead of antibiotics. The proponents of the observation option point
to concerns about rising bacterial resistance, injudicious antibiotic
use, the occurrence of viruses as a cause of AOM, a high spontaneous
resolution rate (often cited to be 80% to 90%) for AOM, and the lack of
a substantial increase in complications when such a strategy is applied
(as occurs in the Netherlands). The opponents of the observation option
point out that AOM is caused by bacterial pathogens in more than 70% of
cases; that antibiotic treatment improves symptom resolution and
shortens the duration of middle ear effusion; that planning a follow-up
visit within 24 hours in children younger than 2 years and within 48 to
72 hours in children older than 2 years is impractical; that the risk
of complications, even if small, is a high price to pay; and that
exposure to malpractice litigation is a real concern. In my view, the
center of the controversy is the issue of accurate diagnosis.
Scott and Powell state, "Accurate diagnosis and distinction [between
acute otitis media and] otitis media with effusion is essential for
proper management, but physicians often have difficulty in making the
correct diagnosis." We recently examined the accuracy of the diagnosis
of AOM by pediatricians attending a continuing medical education (CME)
course (Outcomes Management Education Workshops; www.OMEW.com). The
pediatricians were shown video of 9 pneumatic otoscopy examinations.
All cerumen had been removed from the external auditory canal. The
pediatricians were comfortably seated in a classroom setting and were
afforded as much time as they needed to reach their best diagnosis
based on the visual findings. The pediatricians made the correct
diagnosis 50% of the time, while otolaryngologists were correct 73% of
In other publications, we have reported that nurse practitioners achieve the correct diagnosis 42% of the time and pediatric residents in training 41% of the time.
Is this representative? Thousands of pediatricians and hundreds of
otolaryngologists, nurse practitioners, and pediatric residents were
included in the database. Clinicians who attend CME courses generally
are motivated to learn, to keep up, and to acquire new skills. One
wonders how the practitioner too busy to find the time for CME and too
confident to consider the possibility that his or her diagnostic acumen
may be lacking would perform on this CME test.
incorrectly diagnose AOM 50% of the time and otolaryngologists about
25% of the time, then how often do the general practitioners in the
Netherlands misdiagnose AOM? One study suggests the misdiagnosis rate
may be as high as 85%. How often did the investigators
who generated the data for the clinical trials included in the
meta-analysis that yielded a spontaneous cure rate of 80% for AOM
actually misdiagnose AOM? How many of these patients really had otitis
media with effusion (and not AOM), which indeed will improve as well
with observation as with antibiotic therapy?
We are moving toward
a new definition of AOM that requires that the patient have a bulging
tympanic membrane. When the tympanic membrane is bulging, bacteria are
isolated more than 90% of the time and antibiotics are
recommended by all authorities and all guidelines. How many of the
investigations without tympanocentesis that evaluated amoxicillin
versus the more potent broader-spectrum agents included bulging as a
required sign for the diagnosis of AOM?
Based on these concerns, I and others
believe that the data are so fundamentally flawed for
non-tympanocentesis trials of nonantibiotic treatment and comparative
trials of amoxicillin versus broader-spectrum antibiotic treatment that
we are left with more questions than answers. While we are waiting for
those answers, I favor continued use of antibiotics for appropriately
and accurately diagnosed AOM. If the patient has a bulging tympanic
membrane, then a prescription of an appropriately selected antibiotic
Michael E. Pichichero, MD Professor of Microbiology and Immunology, Pediatrics and Medicine University of Rochester School of Medicine and Dentistry Rochester, NY
ME, Poole MD. Assessing diagnostic accuracy and tympanocentesis skills
in the management of otitis media. Arch Pediatr Adolesc Med.
Sorrento A, Pichichero ME. Assessing
diagnostic accuracy and tympanocentesis skills by nurse practitioners
in management of otitis media. J Am Acad Nurse Pract. 2001;13:524-529.
ME. Diagnostic accuracy, tympanocentesis training performance, and
antibiotic selection by pediatric residents in management of otitis
media. Pediatrics. 2002;110:1064-1070.
Laurin L, Prellner K,
Kamme C. Phenoxymethylpenicillin and therapeutic failure in acute
otitis media. Scand J Infect Dis. 1985;17:367-370.
RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial
drugs for acute otitis media: metaanalysis of 5400 children from
thirty-three randomized trials. J Pediatr. 1994;124:355-367.
E, Greenberg D, Piglansky L, et al. Recurrent acute otitis media
occurring within one month from completion of antibiotic therapy:
relationship to the original pathogen. Pediatr Infect Dis J.
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