Children between the ages of 6 months and 2 years are at highest risk of developing acute otitis media (AOM). Children at increased risk of recurrent AOM contract their first episode prior to 12 months, have a sibling with a history of recurrent AOM, are in day care, or have parents who smoke.
AOM is an acute inflammation and effusion of the middle ear. Otoscopy should focus on color, position, translucency, and mobility of the tympanic membrane (TM). Compared with the TM of a normal ear, AOM causes the TM to appear dull, erythematous or injected, bulging, and less mobile. The light reflex, normal TM landmarks, and malleus become obscured. Pneumatic otoscopy and tympanometry enhance accuracy in diagnosing AOM.
The pathogenesis of AOM is eustachian tube dysfunction, allowing retention of secretions (serous otitis) and seeding of bacteria.
Viral, bacterial, and fungal pathogens cause AOM. The most common bacterial isolates are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes. There is an increased prevalence of antimicrobial resistance for S pneumoniae and β-lactamase producing strains of H influenzae.
Patient presentations and complaints vary with age. Infants with AOM have vague, nonspecific symptoms (irritability, lethargy, and decreased oral intake). Young children can be irritable, often febrile, and frequently pull at their ears, but they may also be completely asymptomatic. Older children and adults note ear pain, decreased auditory acuity, and occasionally otorrhea.
Emergency Department Treatment and Disposition
Although AOM generally resolves spontaneously, most patients are treated with antibiotics and analgesics. Steroids, decongestants, and antihistamines do not alter the course in AOM but may improve upper respiratory tract symptoms.
Patients should follow up in 10 to 14 days or return if symptoms persist or worsen after 48 hours. Refer patients who have significant hearing loss, have failed two complete courses of outpatient antibiotics during a single event, have chronic otitis media (OM) with or without acute exacerbations, or have failed prophylactic antibiotics to an otolaryngologist for further evaluation, an audiogram, and possible tympanostomy tubes.
TABLE 5.1 AOM TREATMENT BASED ON AGE, SEVERITY OF ILLNESS, AND CERTAINTY OF DIAGNOSIS |Favorite Table|Download (.pdf)
TABLE 5.1 AOM TREATMENT BASED ON AGE, SEVERITY OF ILLNESS, AND CERTAINTY OF DIAGNOSIS
|Age||Certain Diagnosis||Uncertain Diagnosis|
|<6 mo||Antibacterial therapy||Antibacterial therapy|
|6 mo-2 yr||Antibacterial therapy||Antibacterial therapy; observation option if nonsevere|
|>2 yr||Antibacterial therapy if severe illness: observation option if nonsevere illness||Observation option|