Contemporary Concepts in Management of Acute Otitis Media in Children

Key points

Introduction and definitions

Acute otitis media (AOM) is a common disorder of early childhood, and among the most common reasons for referral of a young child to the otolaryngologist. Although the majority of children with AOM are managed by primary care providers without the need for specialty consultation, children with recurrent episodes, severe symptoms, or complications of AOM can require prompt otolaryngologic evaluation and surgical treatment. Although AOM affects many children, and tympanostomy tube placement is

Epidemiology

AOM is a common disease in children. In the United States, 8.8 million children (11.8%) under the age of 18 were reported to have ear infections in 2006, with an estimated total treatment cost of $2.8 billion.⁵ Antibiotics are prescribed for AOM more frequently than for any other illness of childhood.⁶ The epidemiology of AOM has evolved over the past decade, with a decrease in clinician visits for suspected AOM by 33% from 1995–1996 to 2005–2006.⁶ The reasons for the decrease in clinician

Pathophysiology and microbiology

AOM is often, although not always, preceded by a viral upper respiratory tract infection.¹¹ Inflammation leads to edema in the nasal cavities and nasopharynx, causing functional obstruction of the Eustachian tube and the development of negative pressure in the middle ear from a lack of equilibration. Microbe-containing secretions from the upper airway mucosa move into the middle ear owing to the pressure differential, where they become trapped. Bacterial replication and infection may ensue.12,

Diagnosis

Because there is no gold standard for the diagnosis of AOM, short of tympanocentesis and culture of middle ear fluid, there is controversy about the best clinical means to accurately diagnose acute middle ear infection. Diagnostic accuracy is challenging because of the wide spectrum of signs and symptoms that develop throughout the course of the disease, the difficulties in examining the ears of young children who may be uncooperative or have occluding cerumen, and the overlap of symptoms

Management

Management goals for AOM are to decrease severity and duration of symptoms, principally by controlling pain and fever, to improve hearing outcomes, and to prevent complications.7, 36

Complications

AOM can progress to severe complications, including acute mastoiditis, meningitis, and intracranial abscess. Complications can be thought of as (a) intracranial, extratemporal, (b) intratemporal, extracranial, and (c) extratemporal, extracranial (Table 3). The most common complication seen by the clinician is TM perforation with suppuration and otorrhea, but a busy clinician can expect to see facial nerve paralysis or acute mastoiditis (Fig. 1) in a young child with AOM as well. Such

Recurrent AOM and tympanostomy tubes

Recurrent AOM is defined as at least 3 episodes of AOM in 6 month or 4 episodes in 1 year, with one of these episodes in the preceding 6 months.⁷ Risk factors that have been identified for recurrent AOM include group child care attendance, male gender, winter season, passive smoking, pacifier uses, presence of siblings, lack of breastfeeding, and symptoms for longer than 10 days at presentation.⁵² The 2013 AAP guideline examines the role of both prophylactic antibiotic therapy and tympanostomy

Prevention

Several anticipatory health interventions and environmental factors can reduce the incidence of AOM and are endorsed in the 2013 AAP guideline. Vaccination with the conjugate pneumococcal vaccine (PCV7) decreased physician visits for AOM, although there was a subsequent trend toward serotype replacement where AOM (and complications) were caused by nonvaccine serotypes.17, 19 Vaccination with the more recent PCV13, which covers 6 additional S pneumoniae serotypes, should be encouraged.17, 19, 20

Complementary and alternative medicine

Although many dietary modifications and complementary and alternative medicine options have been proposed and are available for prevention and treatment of AOM, high-quality evidence does not exist to support their use. Naturopathic herbal extracts have been used as topical analgesics and have been found to provide similar rates of pain relief to conventional anesthetic ear drops,⁴¹ although good evidence of benefit is lacking.³⁹

A randomized, double-blind, placebo-controlled study involving 328

“At-risk” children and otitis media

Children with medical comorbidities, neurocognitive and/or communication impairment, and craniofacial anomalies that affect Eustachian tube function may be at increased risk for frequent AOM or consequences of middle ear disease and associated conductive hearing loss. These children are usually excluded from clinical trials that evaluate the management and outcomes of otitis media, and in fact are excluded from the 2013 AAP AOM guideline recommendations. The AAO-HNS Clinical Practice guideline

Summary

Management of AOM requires keen diagnostic skills to recognize the signs, symptoms, and severity of the illness and to determine the otoscopic hallmarks of acute middle ear infection. Recent clinical practice guidelines emphasize the need for precise diagnosis, whereas understanding the generally favorable natural history of AOM may allow many children to be observed without initial antibiotic treatment. Prevention of AOM can include vaccinations, environmental modifications, maintenance of