Acute otitis media

Last updated: March 23, 2022

Summarytoggle arrow icon

Acute otitis media (AOM) is a painful infection of the middle ear that most commonly results from a bacterial superinfection with Streptococcus pneumoniae, Haemophilus influenza, or Moraxella catarrhalis following a viral upper respiratory tract infection. AOM is a common infection in children under the age of 2 years and is characterized by an acute onset of symptoms (e.g., otalgia, fever, anorexia) with signs of middle ear inflammation (e.g., bulging tympanic membrane, erythema). Mild unilateral infections can be managed without antibiotics, as they are often self-limiting. Infections in children under 6 months, bilateral AOM, or severe symptoms are usually treated with oral antibiotics. Most children will experience at least one episode before the age of five; in children with recurrent AOM that causes frequent symptoms, myringotomy and insertion of tympanostomy tubes may be considered. The most common complication is acute mastoiditis, but facial palsy, labyrinthitis, and in rare cases, even intracranial abscesses may also occur.

References:[5][6]

Epidemiological data refers to the US, unless otherwise specified.

References:[5][6]

Common pathogens [2]

Risk factors [1][8]

  • Passive cigarette smoke
  • Children who attend daycare centers
  • Formula feeding/bottle-feeding [9]
  • Pacifier use
  • Children who have more than one sibling or live in a crowded space
  • Male sex
  • Family or personal history of AOM
  • Anatomic abnormalities
  • Feeding in a supine position [10]

Older children and adults will most frequently report ear pain; in infants and nonverbal children symptoms can be nonspecific, and may be easily confused with other conditions.

General symptoms [8]

Typical presentation in infants [1][8]

Examination findings [8]

Otoscopy

Tuning fork test

AOM is primarily a clinical diagnosis based on characteristic symptoms and otoscopic findings. Other causes of otalgia and hearing loss should be excluded (see “Differential diagnoses”). Pneumatic otoscopy or tympanometry should be used to confirm the presence of an effusion. [2]

Diagnostic criteria for AOM in children [2][8]

The diagnosis of AOM can be made if any of the following features are present: [2]

Laboratory studies

Not routinely indicated; consider in severe infection or diagnostic uncertainty.

Imaging [16]

  • Rarely required unless there is clinical uncertainty and/or concerns of complications
  • Suspected intracranial complications: MRI brain and temporal bone
  • Suspected extracranial complications, e.g., mastoiditis: high-resolution CT temporal bone

Evaluation for effusion

  • Pneumatic otoscopy [17]
    • Description
      • A pneumatic bulb is attached to the otoscope to allow assessment of tympanic membrane mobility.
      • A seal is formed in the ear canal by the tip of the speculum, and air is forced in by pressing the bulb.
    • Indications: clinical uncertainty for AOM and to confirm the presence of middle ear effusion
    • Characteristic finding: hypomobility of the tympanic membrane [18]
  • Tympanometry [19]
    • Description: a probe is inserted into the ear to generate sound waves and measure pressure in the ear canal
    • Indications: confirmation of middle ear effusion [2][19]
    • Characteristic findings

The differential diagnoses listed here are not exhaustive.

Approach [2][8]

Conservative management

Uncomplicated AOM is self-limiting in most children (∼ 80%). [1][8]

Many patients with AOM can be treated conservatively. [8]

Antibiotic treatment

Systemic antibiotic therapy in AOM is recommended to relieve symptoms and reduce the risk of complications in young infants and patients with severe infections. [2]

  • Topical antibiotics are typically reserved for patients with AOM and tympanostomy tubes (see “Special situations”) or those with chronic suppurative otitis media. [24]
  • Treatment failure is common (due to drug resistance and viral coinfection); If initial treatment is unsuccessful, consider tympanocentesis to help guide further therapy.
  • Typical duration of first-line therapy [22]
    • Children < 2 years OR any child with severe symptoms: 10 days
    • Children ≥ 2 years AND no severe symptoms: 5–7 days

Topical antibiotics are generally ineffective in treating AOM unless tympanostomy tubes are present.

Indications

  • Children [2][8]
    • Age ≤ 6 months
    • Age < 2 years with bilateral AOM [1][2][22]
    • Any age with:
  • Adults: Antibiotics (e.g., amoxicillin) are typically given to prevent complications. [1][8][22][23]

Children with cochlear implants who develop AOM should always be treated with antibiotics.

Regimens

Amoxicillin is the first-line agent in antibiotic-naive patients. A macrolide can be given if the patient is severely allergic to penicillin.

Empiric antibiotic therapy for acute otitis media [2][26]
No antibiotic use in previous 30 days Antibiotic use in previous 30 days Penicillin allergy
Initial treatment
Treatment failure

H.influenzae and S.pneumoniae show limited sensitivity towards macrolides and trimethoprim/sulfamethoxazole; these antibiotics should only be used for patients with a proven history of type I hypersensitivity to penicillin. [8]

Surgical procedures

Special situations

Otitis media can spread to affect other local structures (e.g., mastoiditis, labyrinthitis, facial nerve palsy, perforated tympanic membrane) or the intracranial cavity (e.g., meningitis, cerebral venous thrombosis. otogenic abscess).

Risk factors for complications

Complications are rare and are usually only seen in the following cases:

Mastoiditis [8]

Background

  • Definition: inflammation of the mastoid air cells
  • Epidemiology: : most commonly occurs in children < 2 years [33]
  • Pathophysiology: infection spreads from the middle ear cavity into the mastoid, which is a closed bony compartment → collection of pus under tension and hyperemic resorption of the bony walls → destruction of the air cells (coalescent mastoiditis) → mastoid becomes a pus-filled cavity (empyema mastoid)

Clinical features

  • Signs and symptoms
    • Recurrence of otalgia and fever after initial improvement
    • Symptoms persist for > 2 weeks
    • Tender and edematous mastoid
    • Ear displaced laterally and forward
    • Obliteration of the retroauricular sulcus in advanced stages
    • In chronic mastoiditis, there may be persistent otorrhea.
  • Otoscopy findings: May be normal

Suspect mastoiditis in patients with recent or persistent otitis media and erythema, swelling, and/or pain behind the ear or protrusion of the pinna! [34]

Diagnostics [8][34][35]

Mastoiditis is primarily a clinical diagnosis.

  • Indications for imaging
    • Symptoms that do not improve after 48 hours of treatment.
    • Suspected intracranial complication
    • Planned surgical interventions
  • CT scan of the temporal bone: Initial imaging study (if indicated)
  • MRI brain and temporal bone [36] Consider as initial modality in children due to lack of ionizing radiation [35][36]
    • More sensitive for intracranial infectious complications
    • Characteristic findings include increased fluid signal intensity in mastoid air cells.
  • X-ray of the mastoid [37][38]
    • Early stage: The air cells appear cloudy and indistinct.
    • Advanced stage: A cavity can be seen in the mastoid.

Management

Complications

Untreated, the pus may perforate through the bony walls and cause the following abscesses:

  • Postauricular abscess
  • Bezold abscess
  • Zygomatic abscess
    • Infection spreads to the zygomatic air cells (located at the zygomatic root)
    • Causes swelling in front of and above the auricle
  • Brain abscess

Bacterial labyrinthitis

Peripheral facial palsy [42]

Otogenic abscess

Other intracranial complications

We list the most important complications. The selection is not exhaustive.

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