Acute otitis media (AOM) is an inflammatory process of the middle ear. The condition may occur at any age but mainly affects children, peaking between 6 and 18 months of age.[1] An estimated 30% of all antibiotics prescribed for children in the United States are prescribed for AOM.[2] Common specific symptoms include pain, the feeling of the ear being “blocked” (aural fullness), and partial temporary hearing loss. Vertigo is uncommon and should prompt investigation for alternative diagnoses. Nonspecific findings in young children include fever, irritability, reduced activity or expressivity, vomiting, and decreased appetite. An upper respiratory infection often precedes AOM, as resultant congestion can obstruct the eustachian tube, creating an accumulation of middle-ear secretions and a potential breeding ground for infections.[3] Spread of infection from the middle ear may result in mastoiditis, or, uncommonly, facial nerve paralysis or meningitis, as well as disease of other contiguous structures. Worsening of seasonal allergic rhinitis can predispose to AOM in adults.[1]

Risk Factors

AOM incidence peaks during the winter months.[4] Seasonal allergic rhinitis may also contribute.

The following factors are associated with risk for AOM:

Age < 10 years. Peak is between 6 months and 18 months.[1]

Pacifier use.[5] Bottle feeding, used in place of breastfeeding, may also increase risk, as noted below.

Recent URI.

Day care attendance.[3]

Tobacco smoke exposure.[6]

Air pollution.[7]

Hereditary factors.[5]

Low socioeconomic status.[8]

Diagnosis

The most specific sign of acute otitis media is a bulging tympanic membrane.[9] Diagnosis requires an acute onset of ear pain or discomfort, erythema of the tympanic membrane, and a middle-ear effusion. Effusion can be demonstrated by a bulging and immobile tympanic membrane (or one with decreased mobility as demonstrated with pneumatic otoscopy), an air-fluid level, or otorrhea (if there is a perforation in the tympanic membrane).[10] If there is otorrhea and the ear canal is particularly tender, consider a diagnosis of acute otitis externa rather than otitis media. Tympanometry or acoustic reflectometry may substitute for pneumatic otoscopy when the presence of middle-ear effusion is uncertain.

An erythematous tympanic membrane alone should not be presumed to be due to AOM. Only 15% of such cases are caused by AOM.[11] Bulging, immobility of the tympanic membrane, an air-fluid level, or bubbles behind the TM must be present to make the diagnosis.

Bacterial culture of a middle ear aspirate is only indicated in the case of immunosuppression, severe illness (with AOM as the likely source), or refractory AOM.

Treatment

Suggestions in the Nutritional Considerations section below should be considered early in the treatment of AOM; they may reduce the need for other treatments, which can often be difficult and taxing.

Decongestants and antihistamines have no proven benefit in AOM.[12]

The immediate treatment goal is to control pain. Several treatment options are available for otalgia.

NSAIDs and acetaminophen may improve symptoms.[13] Caution must be taken with acetaminophen in children as there is a narrower therapeutic window and therefore a higher risk of accidental overdose. Occasionally, opioids may be warranted for severe pain that is inadequately controlled with initial analgesic therapy.[14]

The American Academy of Pediatrics[7] and the American Academy of Family Physicians[12] make the following recommendations regarding use of antibiotics for AOM:

  • All patients under 6 months of age should receive antibiotics, even if the diagnosis of AOM is uncertain.
  • Patients aged 6 months to 2 years should receive antibiotics if the diagnosis is clear. If the diagnosis is uncertain, antibiotics should be given if otalgia is moderate to severe, lasts more than 48 hours, if AOM is bilateral, or if the patient’s temperature is ≥ 39°C. Otherwise, observation may be considered.
  • Patients older than 2 years with a definite diagnosis of AOM should start an antibiotic if otalgia is moderate to severe, or if fever reaches 39°C. Otherwise, observation may be considered.
  • Observation alone is permissible only if rapid initiation of antibiotics and follow-up can be guaranteed. Two-thirds of children will recover without the need for antibiotics.[15] Antibiotics should be started if no improvement occurs in 2-3 days.
  • Amoxicillin, 90 mg/kg divided into 2 doses for 10 days, is the first-line therapy.
  • For penicillin-allergic patients, cephalosporins may be used, provided patients did not develop hives or anaphylaxis with penicillin.[16] Macrolides or trimethoprim-sulfamethoxazole may also be used, but bacteria are often resistant to these medications.
  • Amoxicillin/clavulanate is used in certain regions with increased resistance or when broader coverage is desired.

Recurrent ear infections may warrant additional treatments, such as, tympanostomy with pressure equalization tube placement, and adenoidectomy (to improve Eustachian tube function).

Tympanostomy with pressure equalization tube placement is indicated for recurrent otitis media, or persistent, serous effusion causing hearing loss.

Adenoidectomy may benefit those who have recurrent AOM despite tympanostomy. Adenoidectomy may also reduce future AOM episodes when it occurs concomitantly with tympanostomy.[17]

Children suspected of having AOM should be evaluated by an otolaryngologist if they also have developmental delay, established hearing loss, or anatomic variants.[12]

Nutritional Considerations

Breastfeeding. Evidence suggests that breastfeeding for at least 6 months is protective against AOM.[8],[18]

Cow’s milk. Introducing cow’s milk before 4 months may increase risk of AOM.[19]

Allergies. Although most AOM follows viral infection, food and other environmental allergies can result in chronic otitis media in 35% to 40% of cases.[20] Diets that eliminate foods suspected of causing allergy have resulted in improvement in 86% of affected children, and most relapse when the offending foods are reintroduced.[10] These occurrences may be related to immunoglobulin G (IgG)-food antigen complexes, particularly those of cow’s milk protein.[21] A cohort study with 260 children found that those with cow’s milk allergy experienced significantly more recurrent otitis media.[22]

Nutritional status. Some children with otitis media have evidence of poor antioxidant status,[23] ,[24] suggesting that inadequate nutritional status may increase risk or prolong the condition. Specifically, low zinc, iron, vitamin A, and vitamin D levels are associated with AOM,[25] ,[26] and micronutrient supplementation in populations with poor nutrition has shown to be beneficial.[27] Antioxidant-rich and nutrient-dense fruits and berries may be protective.[28]

Orders

See Basic Diet Orders Chapter

Consider an elimination diet. For guidelines, see Anaphylaxis and Food Allergy chapter.

What to Tell the Family

Acute otitis media may be prevented in some cases by breastfeeding, avoiding crowded environments (such as day care), preventing exposure to tobacco smoke and (food) allergens, eliminating dairy products, refraining from the use of pacifiers, administering age-appropriate vaccinations,[29] and providing a diet with adequate micronutrients to support immune function. Antibiotic therapy is not always necessary, as 80% resolve spontaneously, and is contingent on severity, and signs and symptoms of bacterial infection. Repeated episodes of infection may require surgery.

References

  1. Bluestone C, Klein J. In: Otitis Media In Infants And Children . 4th ed. Hamilton: Valley Stream, New York: BC Decker; 2007:73.
  2. Nyquist AC et al: Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 279:875, 1998  [PMID:9516004]
  3. Chonmaitree T, Heikkinen T: Viruses and acute otitis media. Pediatr Infect Dis J 19:1005, 2000  [PMID:11055605]
  4. Lieberthal AS et al: The diagnosis and management of acute otitis media. Pediatrics 131:e964, 2013  [PMID:23439909]
  5. Uhari M, Mäntysaari K, Niemelä M: A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis 22:1079, 1996  [PMID:8783714]Uhari M, Mäntysaari K, Niemelä M: A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis 22:1079, 1996  [PMID:8783714]
  6. Amani S, Yarmohammadi P: Study of Effect of Household Parental Smoking on Development of Acute Otitis Media in Children Under 12 Years. Glob J Health Sci 8:81, 2015  [PMID:26652088]
  7. Brauer M et al: Traffic-related air pollution and otitis media. Environ Health Perspect 114:1414, 2006  [PMID:16966098]
  8. Minja BM, Machemba A: Prevalence of otitis media, hearing impairment and cerumen impaction among school children in rural and urban Dar es Salaam, Tanzania. Int J Pediatr Otorhinolaryngol 37:29, 1996  [PMID:8884404]
  9. Toll EC, Nunez DA: Diagnosis and treatment of acute otitis media: review. J Laryngol Otol 126:976, 2012  [PMID:22809689]
  10. Nsouli TM et al: Role of food allergy in serous otitis media. Ann Allergy 73:215, 1994  [PMID:8092554]Nsouli TM et al: Role of food allergy in serous otitis media. Ann Allergy 73:215, 1994  [PMID:8092554]
  11. Pelton SI: Otoscopy for the diagnosis of otitis media. Pediatr Infect Dis J 17:540, 1998  [PMID:9655557]
  12. American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media With Effusion: Otitis media with effusion. Pediatrics 113:1412, 2004  [PMID:15121966]
  13. Bertin L et al: A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol 10:387, 1996  [PMID:8871138]
  14. Harmes KM et al: Otitis media: diagnosis and treatment. Am Fam Physician 88:435, 2013  [PMID:24134083]
  15. Marchetti F et al: Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care. Arch Pediatr Adolesc Med 159:679, 2005  [PMID:15997003]
  16. Persky MJ et al: Cephalosporin use in penicillin-allergic patients: a survey of otolaryngologists and literature review. Laryngoscope 125:1822, 2015  [PMID:25752938]
  17. Coyte PC et al: The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes. N Engl J Med 344:1188, 2001  [PMID:11309633]
  18. Sabirov A et al: Breast-feeding is associated with a reduced frequency of acute otitis media and high serum antibody levels against NTHi and outer membrane protein vaccine antigen candidate P6. Pediatr Res 66:565, 2009  [PMID:19581824]
  19. Brennan-Jones CG, Whitehouse AJ, Park J, et al. Prevalence and risk factors for parent-reported recurrent otitis media during early childhood in the Western Australian Pregnancy Cohort (Raine) Study. J Paediatr Child Health. 2015;51:405-409.
  20. Bernstein JM: The role of IgE-mediated hypersensitivity in the development of otitis media with effusion: a review. Otolaryngol Head Neck Surg 109:611, 1993  [PMID:8414590]
  21. James JM: Respiratory manifestations of food allergy. Pediatrics 111:1625, 2003  [PMID:12777602]
  22. Juntti H et al: Cow's milk allergy is associated with recurrent otitis media during childhood. Acta Otolaryngol 119:867, 1999  [PMID:10728925]
  23. Cemek M et al: Oxidant and antioxidant levels in children with acute otitis media and tonsillitis: a comparative study. Int J Pediatr Otorhinolaryngol 69:823, 2005  [PMID:15885336]
  24. Yariktas M et al: The role of free oxygen radicals on the development of otitis media with effusion. Int J Pediatr Otorhinolaryngol 68:889, 2004  [PMID:15183579]
  25. Bondestam M, Foucard T, Gebre-Medhin M: Subclinical trace element deficiency in children with undue susceptibility to infections. Acta Paediatr Scand 74:515, 1985  [PMID:4024922]
  26. Esposito S et al: Role of vitamin D in children with respiratory tract infection. Int J Immunopathol Pharmacol 26:1, 2013 Jan-Mar  [PMID:23527704]
  27. Elemraid MA et al: Nutritional factors in the pathogenesis of ear disease in children: a systematic review. Ann Trop Paediatr 29:85, 2009  [PMID:19460262]
  28. Tapiainen T et al: Diet as a risk factor for pneumococcal carriage and otitis media: a cross-sectional study among children in day care centers. PLoS ONE 9:, 2014  [PMID:24599395]
  29. Ben-Shimol S et al: Near-elimination of otitis media caused by 13-valent pneumococcal conjugate vaccine (PCV) serotypes in southern Israel shortly after sequential introduction of 7-valent/13-valent PCV. Clin Infect Dis 59:1724, 2014  [PMID:25159581]

Last updated: November 14, 2017

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TY - ELEC T1 - Acute Otitis Media ID - 1342024 Y1 - 2017/11/14/ PB - Nutrition Guide for Clinicians UR - https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342024/all/Acute_Otitis_Media ER -