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Otitis media is the most common outpatient pediatric diagnosis. There are approximately 25 million office visits for this condition in the U.S., with direct costs greater than $5 billion per year.1 Otitis media is inflammation of the space of the middle ear. Otitis media is a general term that has been used to describe multiple disorders of the middle ear, including acute otitis media, chronic otitis media, and otitis media with effusion. This chapter discusses acute otitis media, otitis media with effusion, otitis externa, and acute mastoiditis.

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Acute Otitis Media

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Epidemiology

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Otitis media accounts for 13% of all visits (including children and adults) to U.S. EDs.2 Accurate data on the true incidence of acute otitis media are lacking, as previous surveys have not made the distinction between acute otitis media, otitis media with effusion, and eustachian tube dysfunction. There is considerable overlap between presenting signs and symptoms of upper respiratory illnesses and acute otitis media, especially in the preverbal child.

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The peak incidence of otitis media is between 6 and 18 months of age.3 In the U.S., up to 50% of children will have had at least one episode of acute otitis media by the age of 1 year.1 The incidence is higher in children who are Native Americans, Eskimos, males, day care attendees, exposed to tobacco smoke, born with craniofacial anomalies, prone position sleepers, pacifier users, diagnosed with their first episode of acute otitis media at <6 months, or born with immunodeficiency syndromes.1,3 The incidence is lower in infants who are breastfed.1

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Acute otitis media spontaneously resolves in most cases.4 Acute otitis media and the development of otitis media with effusion may be natural occurrences as the anatomy and immune system develop in the pediatric population. Environmental insults, such as tobacco smoke, lack of breastfeeding, and exposure to children in day care who frequently receive antibiotics, may lead to episodes that would not otherwise occur. Prevention of the disease burden is possible through the use of newer vaccines such as the contemporary pneumococcal vaccine that includes protection from seven serotypes of Streptococcus pneumoniae.5

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Pathophysiology

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The middle ear is a laterally compressed cavity within the temporal bone bounded by the tympanic membrane laterally and the eustachian tube medially. In the healthy state, this space is aerated and contains the ossicular chain, which serves to transmit sound energy to the inner ear. In children, as compared with adults, the eustachian tube is shorter and more horizontally oriented. This orientation is the anatomic rationale for the increased incidence of disease seen in children. An upper respiratory tract infection can obstruct the eustachian tube and disrupt its function of aerating the middle ear. Thus, an obstructed eustachian tube prevents equilibration of air pressure between the middle ear and the atmosphere and creates conditions favorable to the development of sterile or purulent effusions.

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