Etiology

The most common causes are viruses, such as respiratory syncytial virus (RSV) and influenza virus, and bacteria, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Risk factors for middle ear infection include age under 2 years, exposure to family members or others with respiratory infections, day care attendance, lower socioeconomic status, exposure to second-hand smoke or wood-burning stoves, allergies, excessive use of a pacifier, and feeding with a propped bottle or in a supine position.

signs and symptoms

There may be pain in the ear, drainage of fluid from the ear canal, ear-tugging, and hearing loss. Systemic signs include fever, irritability, headache, lethargy, anorexia, and vomiting. Diarrhea is also a common sign of AOM in infants. History of a recent upper respiratory infection is common.

Treatment

Since AOM is usually self-limiting and resolves in 1 to 2 weeks without antibiotics, the best approach is to watch and wait. Parents should be told that if the child does not show improvement in 2 to 3 days, an antibiotic may be needed, but that inappropriate use of antibiotics leads to bacteria that are resistant to these drugs. Antibiotics, however, should be prescribed for the child under age 2 or when the eardrum is bulging and fever is present. Amoxicillin is the drug of choice when antibiotics are required. Parents should be warned that if improvement is not seen in 2 to 3 days on this therapy, the primary care provider should be notified, because this may indicate that the causative bacteria are amoxicillin-resistant, requiring a different drug, such as amoxicillin-clavulanate (Augmentin), cefuroxime (Ceftin) or ceftriaxone (Rocephin). Anesthetic eardrops may be prescribed if the tympanic membrane is intact and there is no discharge from the ear. Antihistamines, decongestants, homeopathic, and naturopathic remedies are not beneficial in AOM and should not be given. Pain is usually treated with acetaminophen or ibuprofen. Cold or hot pack applications help to ease the pain, as does positioning the child with the head propped up. Some evidence suggests that vaccinations against common viral illnesses (such as influenza and RSV) will diminish the incidence of AOM.

Vaccination against Streptococcus pneumoniae prevents ear infections and limits the need for giving antibiotics in children.

Diagnosis

Clinical diagnosis relies on the visualization of a red tympanic membrane with limited mobility (established by pneumatic otoscopy or tympanogram). Definitive diagnosis of the causative organism relies on tympanocentesis, that is, puncturing the eardrum with a needle to aspirate and culture the fluid in the middle ear. This test is rarely performed in routine outpatient care.

Patient care

Because some children are prone to recurrences, parents should be taught to recognize signs of otitis media and seek medical assistance when their child complains of pain or when they observe the child tugging his ears or demonstrating pain in other ways. Parents should be taught to help prevent recurrent AOM by not smoking or allowing smoking around children. Parents who smoke should be encouraged to quit or at least to limit their smoking to out-of-doors. Use of pacifiers should be limited because the pressure of vigorous sucking opens the eustachian tubes and allows nasopharyngeal secretions to enter the middle ear. Breast-feeding should be encouraged for at least the first 3 months to enhance transfer of antibodies and reduction of infections. Bottle-fed infants should never be propped with the bottle and should have the head elevated during feedings. Parents should be reminded that good hand hygiene is the best way to prevent the spread of infections and that, if the child is in day-care, they should make sure the facility has soap and sinks readily available and enforces hand hygiene policies. Failure to treat acute and chronic ear infections may lead to spontaneous rupture of the eardrum, temporary or permanent hearing loss in children, and subsequent communication disorders; therefore, parents must understand the importance of proper medical follow-up. The child should be referred to an ear, nose, and throat (ENT) specialist for evaluation in the presence of recurrent AOM (6 episodes in 12 months), associated complications (mastoiditis), AOM that does not respond to treatment, and problems with hearing, speech, or language.

Treatment

Nasal decongestants may afford symptomatic relief. The use of antibiotics is controversial. Adenoidectomy and bilateral myringotomy may be necessary if conservative measures, including insertion of a ventilation or tympanostomy tube, are not effective. Adenoidectomy is not advisable in children under 4 years of age. See: tympanocentesis; tympanostomy tube

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