Otitis Media

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Last Updated: May 23, 2005

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Synonyms and related keywords: OM, acute otitis media, AOM, middle ear infection, middle ear effusion, MEE, otitis media with
effusion, OME
AUTHOR INFORMATION

Section 1 of 11

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Author: Kathy A Cook, MD, Consulting Staff, Department of Emergency Medicine, Providence Memorial Hospital
Coauthor(s): Matthew Walsh, MD, Chair, Associate Professor, Department of Emergency Medicine, Texas Tech University Health
Sciences Center
Kathy A Cook, MD, is a member of the following medical societies: American College of Emergency Physicians, American Medical
Association, Society for Academic Emergency Medicine, and Texas Medical Association
Editor(s): Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Medical Director, Saint
Barnabas Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark W Fourre, MD, Program Director,
Department of Emergency Medicine, Maine Medical Center, Associate Clinical Professor, Department of Surgery, University of Vermon
School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine,
Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School;
and William K Mallon, MD, Program Director, Internship Training, Associate Professor, Department of Emergency Medicine, University
Southern California

Disclosure

INTRODUCTION

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Background: The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians
(AAFP) define acute otitis media as an infection of the middle ear with acute onset, presence of middle ear effusion
(MEE), and signs of middle ear inflammation. Acute otitis media most commonly occurs in children and is the most
frequent specific diagnosis in children who are febrile. Physicians, including those in the ED, often overdiagnose
acute otitis media.
Bulging of the tympanic membrane is the highest predictive value when evaluating the presence of MEE.
Other findings that indicate the presence of MEE include limited mobility of the tympanic membrane with pneumatic

otoscopy and fluid visualized behind the tympanic membrane or in the ear canal (with perforation).
Distinguishing between acute otitis media and otitis media with effusion (OME) is important. OME is more common
than acute otitis media. When OME is mistaken for acute otitis media, antibiotics may be prescribed unnecessarily.
OME is fluid in the middle ear without signs or symptoms of infection. OME is usually caused when the Eustachian
tube is blocked and fluid becomes trapped in the middle ear. Signs and symptoms of acute otitis media occur when
fluid in the middle ear becomes infected.
Recurrent otitis media is defined as 3 episodes of acute otitis media within 6 months or 4 or more episodes within
1 year.
Pathophysiology: Acute otitis media usually arises as a complication of a preceding viral upper respiratory infection
(URI). The secretions and inflammation cause a relative occlusion of the eustachian tubes. Normally, the middle ear
mucosa absorbs air in the middle ear. If air is not replaced because of relative obstruction of the eustachian tube,
a negative pressure is generated and causes a serous effusion. This effusion of the middle ear provides a fertile
media for microbial growth, and, with the URI, introduction of upper airway viruses and/or bacteria into the middle
ear may occur. If growth is rapid, the patient will have a middle ear infection. If the infection and the resultant
inflammatory reaction persist, perforation of the tympanic membrane or extension into the adjacent mastoid air cells
may be present.
Frequency:

In the US: Otitis media is common, with 50% of children having an episode before their first birthday and

80% of children having one by their third birthday. An estimated 3-4 billion dollars are spent each year on
care of patients with acute otitis media and related complications.
Mortality/Morbidity:

Mortality is rare in countries where treatment for complications is available, and it is not frequent in countries
where treatment is not available.

Morbidity may be significant for infants in whom persistent MEE develops. MEE leads to hearing deficits and
speech delay. Most spontaneous perforations eventually heal, but some persist. Frequent recurrences of

acute otitis media are relatively common.

Otitis is not considered a major source of bacteremia or meningeal seeding, but local brain abscess has
been documented, demonstrating that it is possible for acute otitis media to extend.

Race: Otitis media is more frequent in certain racial groups (eg, Inuit and American Indians) than in others.

Other factors in the environment (eg, crowding, daycare setting, nutrition) may be more important than race,
but they have not been fully delineated.

Otitis media is less common in groups with high rates of breastfeeding than in groups with low rates of
breastfeeding.

Sex: Boys are affected more commonly than girls, but no specific causative factors have been found.

is a minor determinant of infection.

Age:

Ear infection occurs in all age groups, but it is considerably more common in children, particularly those aged 6 months to
3 years, than in adults. This age distribution is presumably due to immunologic factors (eg, lack of pneumococcal antibodies)
and anatomic factors (eg, a low angle of the eustachian tube with relation to the nasopharynx).

Children with significant predisposing factors (eg, cleft palate) acquire infections so frequently that some authors advocate
the routine placement of polyethylene tubes in their tympanic membranes to maintain aeration of the middle ear.

CLINICAL

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History: Patients who can communicate usually describe feelings of pain or discomfort in the affected ear. However, most cases
occur in children who are unable to communicate specific complaints.

Acute otitis media

o

Earache

Fever (not required for the diagnosis)

Accompanying or precedent URI symptoms (very common)

Decreased hearing

Acute otitis media in infants

o

Infants may be asymptomatic.

Irritability may be the only symptom.

Serous OME
o

Patients are usually asymptomatic

Decreased hearing may be demonstrated on audiometry.

Physical: If the canal is clean and if the patient is cooperative, physical examination is easy. If the canal is occluded with cerumen
or debris, if the canal is anatomically small, or if the patient is unable to cooperate, examination may be difficult.

Inflammation of the tympanic membrane and diminished movement of the membrane with insufflation or decreased visibility
of the landmarks of the middle ear are the hallmarks of otitis media.
o

Injection of the membrane is common in crying infants, and it may mislead the casual observer to believe the patient
has acute otitis media. Therefore, pneumatic otoscopy is helpful in examining any patient with an injected tympanic
membrane.

A history suggestive of acute otitis media and an ear canal full of purulent exudate is usually considered sufficient to
diagnosis acute otitis media with perforation.

Acute otitis media should be painless. If pain is present, suspect that a foreign body in the ear canal is causing the
infection or that the patient has otitis externa.

Remove cerumen and other debris from the canal, as necessary, to allow clear visualization of the entire tympanic
membrane.
o

Removal may be difficult if the patient is uncooperative.

Irrigation may be useful, as it may soften and dislodge cerumen so that it can be removed more easily.

Soft plastic curettes are preferred to metal ones, but a firm tool may be necessary to remove a hard block of

cerumen.
o

Patients may require a referral if sufficient time and resources are not available for the proper and safe removal of
cerumen.

Care should be taken to avoid perforation of the tympanic membrane.

The association between bacterial conjunctivitis and otitis media is well described.
o

Any patient with purulent conjunctival exudate should receive thorough examination of the tympanic membranes.

Sinusitis and purulent rhinitis frequently accompany otitis in children and infants.

Causes: Anatomic and immunologic factors in the presence of acute infection are the main causes of acute otitis media.

Pneumococcus species, Haemophilus influenzae (untypeable), and Moraxella species are the bacteria most commonly
involved in otitis media.

Less common causes are other bacteria, Mycoplasma species, and viruses.

Sterile effusions occur in approximately 20% of cases studied.

Risk factors for otitis media have been identified.

o

Daycare leads to an increased incidence of URIs.

Bottle-feeding increases the incidence compared with breastfeeding.

Smoking in the household clearly increases the incidence of all forms of respiratory problems in childhood.

Male sex is a minor determinant of infection.

A family history of middle ear disease increases the incidence.

Acute otitis media in the first year of life is a risk factor for recurrent acute otitis media.

DIFFERENTIALS

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Brain Abscess
Dysbarism
Foreign Bodies, Ear
Herpes Zoster
Herpes Zoster Oticus
Labyrinthitis
Mastoiditis

Otitis Externa
Peritonsillar Abscess
Sinusitis

Other Problems to be Considered:

Coexistent conjunctivitis
Acute hearing loss
Tympanosclerosis
Erythema caused by crying
Pain referred from the teeth or jaw
Bullous myringitis
Parotitis (ie, mumps)
Cavernous sinus thrombosis
WORKUP
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Lab Studies:

No definitive laboratory examination exists; however, the WBC count may be elevated in association with any infection.

Blood cultures are positive in only about 3% of febrile patients with acute otitis media and are not routinely recommended.

Imaging Studies:

Imaging studies are not valuable for diagnosis of acute otitis media.

Radiography and/or CT scanning of the mastoid air cells may be helpful in select cases of suspected mastoiditis.

Other Tests:

Tympanometry is easy to perform on any ear. Even when the tympanic membrane cannot be visualized, the results indicate
the presence or absence of MEE.
o

The findings cannot be used to differentiate between acute otitis media and chronic serous OME.

Tympanometry cannot be recommended as a routine screening test for acute otitis media. However, in a patient in
whom examination is difficult, normal tympanometric results may help rule out acute otitis media.

Hearing tests are not helpful in diagnosing acute otitis media.

Nasopharyngoscopy may reveal anatomic factors involved in acute otitis media and show purulent matter at the nasal

opening of the eustachian tube, but the findings are of no acute diagnostic value.
Procedures:

Tympanocentesis with a needle and syringe may be appropriate in an immunocompromised patient or in patients with
persistent fever in the face of antibiotic therapy to delineate the etiology of an acute otitis media.

If acute otitis media is present in infants younger than 2-3 months, some authors recommend tympanocentesis.

This procedure often is performed by the ear, nose, and throat (ENT) consultant.

Myringotomy is indicated only for patients with intractable pain.

TREATMENT

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Emergency Department Care:

According to AAP and AAFP guidelines for the treatment of acute otitis media, an observation period may be recommended
depending on the patient's age, the diagnostic certainty, and the severity of illness.
o

Diagnostic certainty is based on all 3 of the following criteria: acute onset, MEE, and middle ear inflammation.

Severe illness is defined as moderate-to-severe otalgia or temperature greater than 39C, whereas nonsevere
illness is defined as mild otalgia and temperature less than 39C.

The following recommendations were made:

o

Infants younger than 6 months should receive antibiotics.

Children aged 6 months to 2 years should receive antibiotics if the diagnosis is certain. If the diagnosis is uncertain,
an observation period can be considered if the illness is nonsevere, and antibiotic therapy can be considered for
severe illness.

Children aged 2 years and older should receive antibiotics if the diagnosis is certain and if the illness is severe.
An observation period is an option when the diagnosis is uncertain or when it is certain and nonsevere.

The observation option is a 48- to 72-hour period of symptomatic treatment with analgesics and without antibiotics, followed
by reexamination.

For an observation option to be considered, the parent must be able to communicate with the physician and have access
to follow-up care whenever problems ensue or symptoms worsen.

Pain management is an important part of treating acute otitis media, especially in the first 24 hours. Appropriate analgesics
should be offered.

Consultations:

In general, patients with acute otitis media seen in the ED should be referred to a primary care physician for follow-up care.

Patients discharged with a full course of therapy should be reexamined 4-6 weeks after their initial presentation for evidence
of middle ear aeration.

Patients whose symptoms (eg, pain, fever) do not resolve within 48 hours of treatment should be reevaluated.
Most treatment failures are due to compliance problems or anatomic factors rather than antibiotic resistance.

MEDICATION
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In the United States, antibiotic therapy is usually prescribed for patients with any hint of acute otitis media. In other parts of the world,
many patients are monitored for evidence of spontaneous clearing or onset of complications instead of routine antibiotic use.
Studies have shown that antibiotics provide little benefit beyond placebo in mild cases of acute otitis media. Antipyretics and
analgesics may be necessary and should be prescribed liberally. Steroids, decongestants, and antihistamines are not effective in
the treatment of acute otitis media, and they may cause complications.
Drug Category: Antibiotics -- Empiric coverage for Streptococcus pneumoniae, H influenzae, and Moraxella species may be
provided to children; adults have H influenzae infection less frequently than children. Controlled studies of effective antibiotics in
the United States have demonstrated 90-95% efficacy. Studies in other parts of the world demonstrate about 80% resolution with
observation alone. The AAP and AAFP recommend the use of high doses and short courses of amoxicillin.
If antibiotic therapy is chosen, amoxicillin 80-90 mg/kg/d is the antibiotic of choice. The length of treatment is 10 days for younger

children and patients with severe illness, and a 5- to 7-day course is recommended for children older than 6 years. If additional
beta-lactamasepositive H influenzae and/or Moraxella catarrhalis coverage is desired, high-dose amoxicillin and clavulanate
potassium is recommended.
If the patient is allergic to amoxicillin, alternatives are cefdinir, cefpodoxime, or cefuroxime if the allergic reaction is not a type
1 hypersensitivity. Patients with type 1 hypersensitivity should be given azithromycin or clarithromycin. Other alternatives are
clindamycin and ceftriaxone given intravenously or intramuscularly. Ceftriaxone 50 mg/kg/d is recommended for children who
are unable to take oral antibiotics and for patients with compliance problems.
In patients whose condition fails to improve after initial antibiotic therapy, a 3-day course of ceftriaxone offers outcomes better
than those of a 1-day course.
Drug Name

Amoxicillin (Amoxil, Biomox) -- Interferes with synthesis of cell wall mucopeptides during active multiplication,
resulting in bactericidal activity against susceptible bacteria. Inexpensive and effective, even in populations with ce

Adult Dose

250-500 mg PO q8h

Pediatric Dose

80-90 mg/kg/d PO divided q8h for 10d in younger children and in patients with severe disease

Contraindications Documented hypersensitivity

Interactions
Pregnancy
Precautions

Reduces efficacy of oral contraceptives

B - Usually safe but benefits must outweigh the risks.
Adjust dose in renal impairment; use in Ebstein-Barr viral mononucleosis increases risk of severe rash

Drug Name

Amoxicillin and clavulanate potassium (Augmentin) -- Drug combination treats bacteria resistant to
beta-lactam antibiotics. For children >3 mo, base dosing protocol on amoxicillin content. Because of different
amoxicillin and clavulanate ratios in 250-mg tab (250/125) vs 250 mg chewable tab (250/62.5), do not use
250-mg tab until child weighs >40 kg.

Adult Dose

500-875 mg PO q12h PO or 250-500 mg PO q8h

Pediatric Dose

90 mg/kg (amoxicillin) with 6.4 mg/kg (clavulanate) divided PO q12h

Contraindications Documented hypersensitivity

Interactions

Coadministration with warfarin or heparin increases risk of bleeding

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Give for minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever);
after treatment, perform cultures to confirm eradication of streptococci

Drug Name

Cefuroxime (Ceftin) -- Second-generation cephalosporin maintains gram-positive activity of first-generation

cephalosporins; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae,
and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determines
proper dose and route.

Adult Dose

125-500 mg PO q12h

Pediatric Dose

30 mg/kg PO q12h

Contraindications Documented hypersensitivity

Interactions

Disulfiramlike reactions may occur when alcohol consumed within 72 h after dose; may increase
hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent
diuretics, such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Reduce dosage by half if creatinine clearance 10-30 mL/min and by three quarters if <10 mL/min
(high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may
occur with prolonged or repeated therapy

Drug Category: Analgesics -- Relief of pain is one of the prime functions of effective treatment. Oral analgesics or topical

medications may be required for relief of pain. Appropriate doses of acetaminophen or ibuprofen are available in tablet or liquid form. C
it may provoke emesis or constipation.
Drug Name

Benzocaine (Americaine, Cylex) -- Inhibits neuronal membrane depolarization, blocking nerve impulses.
Drops may be used as local anesthetic, with some benefit.

Adult Dose

2-3 gtt q4-6h prn

Pediatric Dose

Administer as in adults

Contraindications Documented hypersensitivity

Interactions

None reported

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Not intended for use when infection present

Drug Name

Acetaminophen (Tylenol, Tempra, Panadol) -- Used worldwide for antipyretic effects and mild analgesic effects.
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease,
or with oral anticoagulation. May be used with ibuprofen for additive effects.

Adult Dose

650 mg PO q4-6h; not to exceed 4 g/d

Pediatric Dose

15-20 mg/kg/dose q4-6h; not to exceed 2.6 g/d

Contraindications Documented hypersensitivity; G-6-PD deficiency

Interactions

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and
isoniazid may increase hepatotoxicity

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Hepatotoxicity possible in chronic alcoholism at various doses; severe or recurrent pain or high or continued
fever may indicate serious illness; contained in many OTC products, and combined use of products may result
in cumulative doses exceeding recommended maximum

Drug Name

Ibuprofen (Motrin, Ibuprin, Advil) -- DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by
decreasing prostaglandin synthesis. Approved for use in children. Available as inexpensive liquid form,
allowing for effective dosing in infants.

Adult Dose

400-800 mg PO q6-8h for pain or fever; not to exceed 3.2 g/d

Pediatric Dose
Contraindications

Interactions

10 mg/kg PO (100 mg/5 cc) q6h for pain or fever

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency,
or high risk of bleeding
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid
may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril,
and beta-blockers; may decrease diuretic effects of furosemide and thiazides; closely monitor PT
(instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels
may be increased when administered concurrently

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

At therapeutic doses, can cause renal failure and/or gastric upset (more common in elderly persons but also
described in children); category D in third trimester of pregnancy; caution in congestive heart failure,
hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during
anticoagulant therapy

FOLLOW-UP
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Further Outpatient Care:

Most cases of otitis media are self-limited. The incidence of complications is high enough that all patients should be
encouraged to have a follow-up visit with their regular physician or clinic approximately 14-21 days after the initial visit.

Patients with persistent pain or fever should be reexamined within 48 hours.

If an observation period is chosen, failure to improve within 48-72 hours should prompt initiation of antibiotic therapy.

If antibiotics were started initially and if the patient's condition fails to improve, the antibiotic should be changed, and
compliance must be emphasized.

Infants with frequent recurrences may benefit from daily antibiotic prophylaxis with sulfamethoxazole or amoxicillin for
a period of several months.

An osteopathic manipulation technique (ie, Galbreath technique) has been described. It may help some patients open
their eustachian tubes and treat or prevent middle ear fluid accumulation. No blinded studies of this technique
have been performed.

Deterrence/Prevention:

Breastfeeding decreases the incidence of acute otitis media.

Cigarette smoking in the household should be eliminated.

In adults and older children, regular exercises to increase upper airway pressure and to force inflation of the middle ear
may be useful (see the reference to the Galbreath technique above). Blowing up balloons is effective in some small children.

Complications:

Serous OME is the most common complication.

o

It may cause mild discomfort in some patients; however, if it is bilateral, hearing loss with resultant speech delay

may occur in infants.

o

Treatment of this condition is not the responsibility of an ED physician. The patient should be referred.

Mastoiditis used to be a common complication, but now with antibiotic treatment it is rare. Patients with any mastoid
tenderness or edema accompanying otitis should be treated aggressively in consultation with an ENT specialist.

Perforation of the tympanic membrane is a frequent, but usually not serious, complication. Treatment is not changed from
that described above, but follow-up care is more important. With proper treatment, most perforations heal within
a couple of weeks, with no residual complications.

Intracranial complications, such as epidural abscess or cavernous sinus thrombosis, are rare and should be treated with
admission to a critical care unit. They usually present primarily rather than as a late complication of treated otitis.

Prognosis:

The prognosis of patients with acute otitis media is excellent. However, patients and/or their parents still should be
encouraged to finish the prescribed medication and to keep their follow-up appointments.

Symptoms usually improve within 24 hours and almost always within 48-72 hours.

Patient Education:

Parent education by the physician is the most important factor contributing to the proper use of medications and follow-up
care.
o

Failure to finish a course of antibiotic therapy usually occurs because the prescribing physician fails to explain
the importance of the medication and the need to finish the entire course of therapy.

Therefore, the physician must discuss the process and the specific treatment plan with the patient and/or the
parents.

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center . Also, see eMedicine's patient
education article Earache.
MISCELLANEOUS

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Medical/Legal Pitfalls:

Diagnosis and treatment of otitis media are rare causes of legal problems. However, failure to diagnose
meningitis in a sick child with associated otitis can lead to inadequate treatment for the meningitis and
significant legal problems for the provider.

Do not allow the presence of acute otitis media deter further diagnostic workup if the patient appears significantly ill.

Failure to recognize contiguous spread to mastoid air cells is a pitfall.