Acute Otitis Media – CPS 2009

Why do children get AOM?

  1. shorter and more horizontal eustachian tube that prone to obstruction by enlarged adenoids
  2. Viral infections and allergies
  3. Decreased levels of secretory immunoglobulin A – causing recurrent OM


Eustachian tube obstructed –> mucociliary clearance impaired, trapping mucus in the middle ear –> resorption of gases within the middle ear space creates a pressure differential, pulls bacteria from the nasopharynx into the middle ear.

Risk Factors

  1. Young age
  2. Daycare attendance, household crowding, exposure to cigarette smoke
  3. Orofacial abnormalities, eg. cleft palate, premature birth, Immunodeficiency
  4. Not being breastfed
  5. Family Hx of OM, First Nations or Inuit ethnicity

1 Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).


Acute Middle ear effusion + inflammation (indicating the fluid is pus)

  1. Signs of a middle ear effusion:
    • immobile TM (demonstrated by pneumatic insufflation, tympanogram, acoustic reflectometry) or
    • Acute otorrhea
    • +/- Opacification of the tympanic membrane (not secondary to scarring)
    • +/- Loss of the bony landmarks behind TM (loss of the short or lateral process of the malleus)
    • +/- A visible air fluid level behind the tympanic membrane
  2. Signs of middle ear inflammation
    • Bulging TM with marked discoloration (hemorrhagic, red, gray or yellow)
  3. Acute onset of symptoms
    • Rapid onset of otalgia or unexplained irritability in a preverbal child

Common bacterial causes:

  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Moraxella catarrhalis

Risk factors for resistanct S pneumoniae

  1. 4hr/week with at least 2 unrelated children)
  2. Frequent otitis media
  3. Recent antimicrobial use (within the past 3 months)
  4. failed initial Abx for AOM

2 Include pain referred from other sources in the differential diagnosis of an earache (eg. Tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.).

3 Consider serious causes in the differential diagnosis of an earache (eg. tumors, temporal arteritis, mastoiditis).

Normal TM Exam:
  • Common dx: TMJ, pharyngitis, Tooth abscess, ET dysfunction, cervical spine arthritis
  • Uncommon dx: Tumors, Trigeminal neuralgias, Bell’s Palsy, Temporal arteritis (>50, elevated ESR)
Abnormal TM exam:
  • Common dx: AOM, O Externa, FB, barotrauma (perfusion and blood), cholesteatoma (TM retraction pocket, otorrhea)
  • Uncommon dx: Malignant otitis externa (DM, immunocompromised), Ramsay Hunt syndrome, mastoiditis, Wegner’s granulomatosis, tumor (smoker, constitutional symptoms)

4 In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (e.g., through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (e.g., reassessment in 48 hours).

5 Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.) 

6 In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics). 

Tx: Peds

>6mo with mild s/sx (mild otalgia, Watchful waiting approach

  • observation w/o abx (use acetaminophen or ibuprofen) for 48-72hr if f/u can be assured
  • parents capable of recognizing signs of worsening illness & can readily access meidcal care
  • either arrange f/u or Rx filled at the parents’ discretion (deferred prescription)

NOT appropriate for

  • severe symptoms: appear toxic, severe otalgia, high fever (>39 po)
  • Aboriginal children, child with immunodeficiency, chronic cardiac or pulm dz, anatomical abn of H/N, Down syndrome
  • Hx of complicated otitis media (otitis media accompanied by suppurative complications or chronic perforation)

1st line Tx: Amoxicillin 75-90 mg/kg/day (high dose) div bid (max 500mg/dose)

  • excellent middle ear penetration, inexpensive, well tolerated, and relatively narrow antimicrobial spectrum

Type 1 hypersensitivity to Amoxicillin (urticaria, anaphylaxis)

  • Use Macrolide – clarithromycin 15mg/kg/d div bid or azithromycin 10mg/kg/d x 1 then 5mg/kd/d x 4

Not type 1 hypersensitivity to amoxicillin

  • Use 2nd generation cephalosporin: cefuroxime axetil 30mg/kg/d div bid
  • Ceftriaxone 50mg/kd/d IM / IV x 1

If symptoms not improved after 2-3 days

change abx to targets both penicillin-resistant S. pneum & β-lact-producing organisms

  1. Amoxicillin (90mg/kg/d) /clavulanate (6.5mg/kd/d) div bid (tricky dosing amoxicillin)
  2. Ceftriaxone 50mg/kd/d IM / IV x 3 doses
  3. Ref to ENT or ID if not resolving

Duration of Tx – 5 days

10 days if

  1. <2yo
  2. frequent recurrent AOM or otitis media with perforated TM
  3. If + abx-related s/e between day5-10 – stop abx (don’t need to Rx alt)
  4. failed initial abx

except azithro (5days) and ceftriaxone (1dose for uncomplicated OM)

Tx: Adults

Tx with abx (UpToDate)

  1. Mild – moderate dz:  amoxicilli500 mg every 12 hours x 5-7 days
  2. Severe disease (eg, patients with fever, significant hearing loss, severe pain, and/or marked erythema):
    • Amoxicillin 875 mg every 12 hours, or 500 mg every 8 hours x 10 days
  3. Amoxicillin-clavulanate should be considered for patients with severe otalgia or elevated temperature to cover the possibility of beta-lactamase producing NT H. influenzae.

If no improvement in 2-3 days: 2nd line regimens for another 10 days

Ruptured TM: Oral + topical antibiotics + preventing water entry into the ear canal

  •  perforation that persists for six weeks or longer (+/- suppurative drainage) – ENT ref


In most cases, OME develops from a mechanical/obstructive cause and resolves spontaneously w/o Tx.

  • Simple maneuvers such as autoinsufflation may be helpful
  • no evidence that decongestants and antihistamines are beneficial in the treatment of OME in children.
  • Most pt Tx w/ decongestants, antihistamines, or nasal steroids despite no data
  • A majority of effusions will resolve < 12 weeks and can be observed over this time period. – Myringotomy if not resolved or needs to provide pressure equalization (airplane travel)

Myringotomy indications

  • OME >3mo or lack of response to abx >3mo
  • Recurrent AOM >7/6mo
  • Conductive hearing loss >20db
  • Craniofacial anomalies predisposing to AOM (eg Cleft palate)
  • Chronic retraction of the TM or pars flaccid
  • contraindicated in patients with irreversible eustachian tube dysfunction secondary to etiologies such as cancer or radiation therapy involving the eustachian tube. Placement of a tube in such patients can potentially result in chronic otorrhea. Hearing loss from an effusion in these patients must be weighed against the potential development of a chronically draining ear with tympanostomy tube placement

7 In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever).*

8 Test children with recurrent ear infections for hearing loss.


  1. Mastoiditis (NNT 2500)
  2. Meningitis
  3. Intracranial abscess
  4. Hearing loss
  5. Serous labyrinthitis —  nausea, vomiting, vertigo, tinnitus, and hearing loss in the setting of both acute and chronic ear infections. Not associated with permanent auditory or vestibular dysfunction.
    • Med Tx, unless persistent granulation tissue or cholesteatoma are present.
  6. Purulent labyrinthitis presents with intense vertigo, tinnitus, hearing loss, vomiting, nausea, and a picture of acute toxicity.


  1. Simple hygienic practices – hand hygiene
  2. Exclusive BF till 3mo
  3. No pacifier use (?)
  4. Limiting daycare exposure for very young children (highest risk in the 1st yr of life)
  5. Childcare providers to implement hand hygiene, toy & environmental cleaning
  6. Smoking cessation
  7. Influenza vaccine for children >6mo, parents, caregivers
Posted in 33 Earache, 99 Priority Topics, ENT

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