K. Myra Lalas
Peds PGY 2
Definitions
 1. Otitis media with effusion (OME)- presence of
middle ear effusion without sings or symptoms of
infection
 2. Acute Otitis Media (AOM)- infection of the middle
ear with acute onset of signs and symptoms, MEE, and
signs and symptoms of middle ear inflammation.
 3. Treatment- failure AOM- lack of improvement in
signs and symptoms w/in 48-72 hrs after beginning
antibiotics
 4. Recurrent AOM- >=3 episodes of AOM occurring in
the previous 6 mns or >=4 episodes in the past 12 mns
 5. Chronic OM- OME persisting > 3mns
 6. Chronic suppurative otitis media (CSOM)- purulent
otorrhea assoc with a chronic TM perforation
persisting > 6 wks despite appropriate treatment for
AOM
Symptoms of AOM
 Otalgia
 Fever
 Otorrhea
 Recent onset of anorexia
 Irritability
 Vomiting
 Diarrhea
Epidemiology
 seasonal peak: winter
 peak age incidence: 6-18 mns of age
Risk Factors for
Developing Acute or Chronic OME or AOM
● Age <2 years
● Atopy
● Bottle propping
● Chronic sinusitis
● Ciliary dysfunction
● Cleft palate and craniofacial anomalies
● Child care attendance
● Down syndrome and other genetic conditions
● First episode of AOM when younger than 6 months
of age
● Immunocompromising conditions
Pathogenesis
 The middle ear space
experiences slight negative
pressure relative to the
environment. Opening the
eustachian tube intermittently
during yawning or chewing
relieves the negative pressure.

 Eustachian tube dysfunction
(URI, GER, AR, craniofacial
abnormalities)- negativ e P
deepens (TM retracts)nasopharyngeal or
oropharyngeal contents may
reflux through the eustachian
tube; inc neg P can also cause
increased vasuclar permeability
(effusion may develop).
Microbiology
 1. S. pneumoniae
 2. Nontypeable H. influenzae- usu seen in those with







recurrent AOM or AOM with treatment failure
- otitis-conjunctivitis syndrome is assoc with isolation of
this pathogen from the middle ear and cinjunctiva in older
kids
3. M. catarrhalis
4. S. pyogenes
5. Group B Strep
6. S. aureus
7. for CSOM- P. aeruginosa, S. aureus, anaerobes occ, S.
pneumoniae and nontypeable H. influenzae rarely
PE Findings
TM landmarks
Normal TM
OME: opaque or cloudy
TM; visible AFL or air
bubbles in middle ear;
immobile TM on
pneumatic otoscopy
A normal (left) ear drum and an ear with acute otitis media (right).
Note the thin clear tympanic membrane (ear drum) on the left. The
ear with acute otitis media has a bulging tympanic membrane (due to
pus in the middle ear) and increased redness over portions of the
drum.
AAP Recommendations
 Evidence-based clinical practice guideline that
provides recommendations to PCP’s for the
management of children from 2 months -12 years of
age with uncomplicated AOM.

Excluded are: anatomic abnormalities such as cleft
palate, genetic conditions such as Down syndrome,
immunodeficiencies, and the presence of cochlear
implants. Also excluded are children with a clinical
recurrence of AOM within 30 days or AOM with
underlying chronic OME.
Criteria for Initial Antibacterial-Agent Treatment or
Observation in Children With AOM
Age
<6 mo
6 mo to 2 y
2y
Certain Diagnosis
Antibacterial
therapy
Antibacterial
therapy
Antibacterial
therapy if severe
illness; observation
option* if nonsevere
illness
Uncertain
Diagnosis
Antibacterial
therapy
Antibacterial
therapy if severe
illness;* observation
option if nonsevere
illness
Observation option*
If the patient fails to respond to the initial management option within 48
to 72 hours, the clinician must reassess the patient to confirm AOM and
exclude other causes of illness. If AOM is confirmed in the patient
initially managed with observation, the clinician should begin
antibacterial therapy. If the patient was initially managed with an
antibacterial agent, the clinician should change the antibacterial agent.
Temperature
39°C and/or
Severe
Otalgia
Clinically Defined
Treatment Failure at 48–
72 Hours After Initial
At Diagnosis for Patients
Being Treated Initially
Management With
Observation Option
With Antibacterial Agents
Recom
Alternative
for Penicillin
Allergy
Recom
Alternative
for Penicillin
Allergy
Clinically Defined
Treatment Failure at 48–
72 Hours After Initial
Management With
Antibacterial Agents
Recom
Alternative
for Penicillin
Allergy
No
Amoxicillin, Non-type I: Amoxicillin, Non-type I: Amoxicillin- Non-type I:
80–90 mg/kg cefdinir,
80–90 mg/kg cefdinir,
clavulanate, ceftriaxone,
per day
cefuroxime, per day
cefuroxime, 90 mg/kg per 3 days; type
cefpodoxime
cefpodoxime day of
I:
; type I:
; type I:
amoxicillin clindamycin
azithromycin
azithromycin component,
, clarithro
, clarithro
with 6.4
mg/kg per
day of
clavulanate
Yes
Amoxicillin- Ceftriaxone,
clavulanate, 1 or 3 days
90 mg/kg per
day of
amoxicillin,
with 6.4
mg/kg per
day of
clavulanate
Amoxicillin, Ceftriaxone, Ceftriaxone, Tympanocen
clavulanate, 1 or 3 days 3 days
tesis,
90 mg/kg per
clindamycin
day of
amoxicillin,
with 6.4
mg/kg per
day of
clavulanate
Antimicrobial prophylaxis for recurrent OM
 Children < 2yo benefit the most
 if a child has had > = 3 episodes of AOM in 6 mns or 4
episodes in 4 mns, s/he should be considered a
candidate for chemoprophylaxis.
 give 1/2 the treatment dose of either amoxicillin or
sulfonamides qdaily over 6 mns ideally during winter
and spring
 a new episode of AOM in a child receiving
chemoprophylaxis should be managed with a different
antibiotic
Treatment
 CSOM- topical antibiotics (usu ciprofloxacin); if with
copious amount of pus, do daily suctioning before instilling
the topical antibiotics

 OME- expectant management for low-risk children. Risk
factors: developmental delay, hearing loss, evidence of
injury to the TM or middle ear



- tympanostomy tube placement for those with
persistent OME or those with risk factors for
developmental delay or evidnece of damage to the middle
ear
Complications
 Intratemporal
 Intracranial
Hearing loss
TM perf
CSOM
Cholesteatoma
Tympanosclerosis
Mastoiditis
labyrinthitis
Meningitis
Subdural empyema
Brain abcess
Extradural abscess
Lateral sinus thrombosis
Cholesteatoma
 Destructive and
expanding growth
consisting of
keratinizing epithelium
in the middle ear and/or
mastoid process, usu
from tear in the TM
TM perforation
Mastoiditis
 A 2½-year-old boy is not yet saying any words. His
parents are worried that he is not developing like his
peers and are concerned that he is not yet talking.
Other than two episodes of otitis media in the past
year, he has been in good health. A formal audiology
evaluation reveals normal hearing. His head
circumference is at the 90th percentile; his weight and
height are at the 75th percentile. His physical
examination findings are normal. His father did not
talk until he was 3 years old.
Of the following, the MOST appropriate next step is to
 order electroencephalography
 order head magnetic resonance imaging
 reassure the parents and have the child return in 6
months
 refer the child for developmental evaluation
 refer the child for neurologic evaluation
 You are precepting a group of residents in continuity
clinic. Several of them have seen patients who have
earaches and have diagnosed acute otitis media. One
resident says that he read that antibiotic treatment is
not always necessary in these cases, and he wants to
observe one of his patients with pain medication only.
You tell him that this is only a reasonable option for
certain children, and proper follow-up must be
ensured.
Of the following, the patient who would be treated
MOST appropriately with observation and pain
management rather than antibiotic therapy is
 a 4-month-old who has a temperature of 38.4°C and an air-



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fluid level behind a mobile, erythematous tympanic
membrane
a 6-month-old who has a temperature of 38.9°C and fluid
behind an erythematous, immobile tympanic membrane
a 9-month-old who has a temperature of 38.0°C and a
shiny, pink tympanic membrane that moves well with
insufflation
a 15-month-old who has a temperature of 39.5°C and
purulent drainage from the external auditory canal
a 21-month-old who has a temperature of 38.1°C and an
erythematous, bulging tympanic membrane
References
Gould, JM and PS Matz. Otitis media. Peds in Rev:
2010; 31; 102-116.
Subcommittee on Management of Otitis Media.
Diagnosis and Management of Otitis Media.
Pediatrics: 2004; 113; 1451-1465.
aap.org
emedicine.com