ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; 127(4): 386–390 DOI: 10.1080/00325481.2015.1028872


Acute otitis media Helen Atkinson, Sebastian Wallis and Andrew P. Coatesworth

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Department of Otolaryngology, Head and Neck Surgery, York Teaching Hospitals NHS Foundations Trust, York, UK



Acute otitis media (AOM) is a common problem facing general practitioners, paediatricians and otolaryngologists. This article reviews the aetiopathogenesis, epidemiology, presentation, natural history, complications and management of AOM. The literature was reviewed by using the PubMed search engine and entering a combination of terms including ‘AOM’, ‘epidemiology’ and ‘management’. Relevant articles were identified and examined for content. What is the take-home message? AOM is a very common problem affecting the majority of children at least once and places a large burden on health care systems throughout the world. Although symptomatic relief is often enough for most children, more severe and protracted cases require treatment with antibiotics, especially in younger children.

Acute, otitis media, otology, pediatrics

Introduction This is the second of three papers reviewing otitis media in this issue. The first paper dealt with otitis media with effusion (OME). This paper will review acute otitis media (AOM). The third will focus on chronic otitis media. Each review will outline the theories of aetiopathogenesis, modes of presentation, and diagnosis and management options for middle ear disease. The key features of AOM are the presence of an infected middle ear effusion and signs and symptoms of infection, which are of rapid onset. Infection may present both locally and also with systemic upset manifested by fever.

Aetiopathology There is a clear link between OME and AOM. AOM has been found to be a risk factor for developing OME [1,2]. Following treatment for AOM, 62 and 24% of children have a persistent middle ear effusion at 2 weeks and 2 months respectively [3]. Therefore, OME can be said to be a possible sequelae of AOM. The reverse, however, cannot be said to be true. AOM is often a sequela of a viral upper respiratory infection (URI). Viral URI is a pre-existing condition in 70% of AOM [4]. This URI causes nasopharyngitis, which leads to changes in the mucus secretions and dysfunction of the Eustachian tube. The mucus formed in the nasopharynx become thicker and there is an increase in inflammatory markers, such as cytokines. There is also an increase in the levels of the bacteria that usually colonize the nasopharynx, namely; Streptococcus pneumoniae, non-typable Haemophilus

History Received 8 December 2014 Accepted 10 March 2015

influenza, Streptococcus pyogenes and Moraxella catarrhalis. These are the most common bacteria causing AOM (see Table 1). The dysfunctional Eustachian tube leads to reduced middle ear pressure and the nasopharyngeal mucus is sucked into the middle ear cleft [5]. This explains the presence of both bacteria and virus pathogens in the middle ear aspirates of patients with AOM [6–8]. Ninety-two percent of middle ear aspirates contain bacteria [4]. Aspirates may also include Staphylococcus aureus, but this is likely to be an external ear contaminant as it is part of the normal flora of this area. Since the introduction of the pneumococcal conjugate vaccine, the prevalence of S. pneumoniae, although taking an initial dip, has now re-emerged as the most common bacteria to cause AOM. This is due to other subtypes of the bacteria becoming more prevalent. Newer vaccines are now targeting these subtypes so this may cause further variation in S. pneumoniae seen in the middle ear [9,10].

Epidemiology AOM is predominantly a disease of childhood. Males are more commonly affected than females [11]. It accounted for 532,000 primary care consultations [6] and 6000 hospital bed days per year in England in 2012 [12]. In the USA, 8.7 million diagnoses of AOM are made every year and it is one of the most common reasons for paediatric outpatient consultation. The direct cost for the condition is therefore substantial and indirect cost due to time from work for parents adds to this. In 2014, the estimated cost in the USA was $2.88 billion [13]. The peak incidence is during the first year of life when 22% of children develop the condition. By the end of the

Coresspondence: Seb Wallis, ENT Department, York Hospitals NHS Foundations Trust, Wigginton Road, York, YO31 8HE, UK. E-mail: [email protected]  2015 Informa UK, Ltd.

Acute otitis media – a review

DOI: 10.1080/00325481.2015.1028872

Table 1. Pathogens found in acute otitis media infections. Virus Respiratory syncytial Parainfluenza Influenza

Bacteria (frequency) Streptococcus pneumoniae (40-50%) Non-encapsulated Haemophilus influenzae (30–40%) Moraxella catarrhalis (10-15%) Streptococcus pyogenes Staphylococcus aureus

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Data from [4-6].

third year of life, 80% have had at least one episode [14,15]. Cases are seen more commonly in winter months and in those born in the autumn months [10]. As in OME, risk factors are more commonly associated with lower social class (see Table 2). The rise in incidence over recent years is thought to be due to increasing uptake of public day care [16].

Presentation and diagnosis The American Academy of Pediatrics clinical guideline defines AOM as the rapid onset of signs and symptoms of inflammation in the middle ear. It further divides the condition into severe or non-severe, depending on the presence or absence of severe otalgia and a temperature greater than 39 C. Uncomplicated AOM is described as AOM in the absence of otorrhoea [17]. The new guidelines are based on studies with strict criteria for the diagnosis of AOM and remove the potential of including children in the trials who may have OME [18,19]. These guidelines outline the criteria for diagnosis of AOM as the presence of any of the below: . . .

Severe or moderate bulging of the tympanic membrane. New-onset otorrhoea without otitis externa being present. Mildly bulging tympanic membrane associated with recent (10 children in a group Avoidance of supine feeding Dummy/pacifier use Increased number of siblings Positive family history Prematurity Recurrent upper respiratory tract infectiona GORDa

Data from [14,56-59]. a Denotes limited evidence. GORD = Gastro-oesophageal reflux disease.


Table 3. Complications of acute otitis media. Local/extracranial complications

Intracranial complications

Permanent perforation of ear drum Mastoiditis/subperiosteal abscess Facial nerve palsy Labyrinthitis Gradenigo’s syndrome Neck abscesses: Bezold’s, Citelli’s, Luc’s and zygomatic root

Lateral sinus thrombosis Meningitis Temporal lobe abscess Extradural/subdural abscess Otogenic hydrocephalus


H. Atkinson et al.

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Mastoiditis. Inflammation spreads through the middle ear into the mastoid air cell system via the mastoid aditus. This in itself is not a complication, as the middle ear cleft is one continuous cavity. Mastoiditis develops as inflammation spreads via the emissary veins into the mastoid periosteum. Resulting periostitis leads to pain and swelling of the postauricular muscles displacing the pinna anteriorly. If left untreated subperiosteal abscess formation occurs, requiring surgical drainage. Mastoiditis occurs in 1.1/1000 cases of AOM in the UK. There has been concern that the incidence of mastoiditis is increasing but this is not the case in the UK or USA according to recent statistical analysis [12,31–35]. Abscess. Abscess formation may occur in other areas locally when the mastoid abscess progresses. These include Bezold’s, Citelli’s and Luc’s abscess affecting the sternocleidomastoid, posterior belly of digastric and posterior ear canal, respectively. These abscesses are rare since the advent of antibiotics.

Postgrad Med, 2015; 127(4):386–390

a complication of AOM. Abscesses are most commonly seen in the temporal lobe. Lateral sinus thrombosis. Thrombosis develops due to its close proximity to the mastoid. Antibiotics have had a huge impact on this previously fatal condition. Less than half may have otological signs at presentation [41]. The use of prolonged anticoagulation to treat the condition is controversial. Otitic hydrocephalus. Hydrocephalus develops secondary to inflamed cerebrospinal fluid causing ventricular inflammation, scarring and ultimately obstruction. All intracranial complications need to be under the shared care of both neurosurgery and otolaryngology. Early intervention is advocated for best outcome [42].

Management Facial nerve palsy. Palsy of the seventh cranial nerve has decreased in incidence secondary to AOM from 0.5 to 0.005% of cases since the introduction of antibiotics [36]. Oedema and nerve compression are caused by infection in the middle ear spreading to the nerve via a dehiscence in the nerves bony covering and causing paralysis. There may also be ischaemia of blood supply to the nerve [26]. Most patients will return to normal or near normal function with antibiotic and steroid treatment. Surgical decompression is often advocated with insertion of a grommet following myringotomy. Labyrinthitis. Labyrinthitis results when inflammation infiltrates the cochlea via the round window causing hearing loss and vertigo. Treatment with antibiotics and vestibular suppressants is usually sufficient until the acute phase settles. Gradenigo’s syndrome. Otherwise known as petrous apicitis, Gradenigo’ syndrome, is inflammation in the petrous apex leading to a triad of abducens nerve palsy (due to compression), retrobulbar pain or trigeminal distribution pain and ear discharge. It can usually be treated conservatively [37]. Intracranial complications Patients who present with altered conscious level, vomiting, photophobia and persistent headache should be investigated for an intracranial complication. Meningitis. Meningitis is uncommon, with an incidence of 0.42 per 100,000 secondary to AOM. Since the introduction of the H. influenzae type b vaccination, pneumococcal meningitis is now the most common pathogen responsible [38,39]. Abscess. Intracranial abscesses are secondary to otorhinogenic disease in 38% of cases [40]. They are seen more commonly secondary to Chronic Otitis Media but can develop as

Adequate treatment of AOM results in resolution of symptoms and prevention of complications. Analgesia is a mainstay of treatment. Ibuprofen and paracetamol have been shown to significantly reduce symptoms [28,43]. Adequate analgesia should not be underestimated and is often of secondary consideration for clinicians [26]. Topical analgesics add little benefit [44]. Antibiotics prescribing – When? Antibiotic prescribing varies widely internationally. Australia and the USA prescribe in up to 98% of cases at initial presentation. Much lower levels are seen in the Netherlands at 31% [36]. In the UK, AOM is the leading cause of antibiotic prescribing in children under 6 years [45]. A Cochrane review of antibiotic use in AOM found antibiotics reduced pain from days 2–7 of the episode (number needed to treat = 20) [46]. The same review also suggested there was no increase in complications if antibiotic prescribing was delayed. The review was, however, based on data from some trials where the diagnostic criteria for AOM were vague. Both the Scottish Intercollegiate Guidance Network and National Institute for Clinical Excellence guidelines are based on this review. New studies clearly demonstrate the importance of prompt prescribing of antibiotics in children under 2 years of age [18,19]. It is noted that younger children particularly will suffer more from the side effects of antibiotics; however, given the reduction in treatment failure from 45 to 18% when Co-Amoxiclav was prescribed, it is considered worthwhile. The American Academy of Pediatrics guidelines recommend the use of antibiotics for all severe cases of AOM, all non-severe cases in those under 2 years old where the disease is bilateral, and the option of antibiotics (either prompt or delayed) given to the parents if the child has unilateral disease under 2 years or is an older child [17]. The potential cost to European health systems if the latter guideline is followed may be considerable; however, it may be less than anticipated if diagnosis is based on the new stricter criteria. Which antibiotic? Given that the three most common pathogens are S. pneumoniae, H. influenzae and M. catarrhalis, these bacteria must be susceptible to the antibiotic of

Acute otitis media – a review

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DOI: 10.1080/00325481.2015.1028872

choice. Most S. pneumoniae and H. influenzae are susceptible to Amoxicillin [47,48], M. catarrhalis, however, is resistant to Amoxicillin, as are some strains of H. influenzae [49]. It is recommended by the American Academy of Pediatrics guidelines to use Co-Amoxiclav instead of Amoxicillin if these pathogens are isolated, or in cases where treatment failure has occurred within 30 days with Amoxicillin [17]. Macrolides are best reserved for penicillin-sensitive children as they are more associated with treatment failure [50]. Surgical intervention may be required in those children with recurrent AOM. It involves myringotomy (making a hole in the tympanic membrane) alone or with the insertion of a ventilation tube (grommet). A Cochrane review looking at two studies found a 1.5 episode reduction for the six months following insertion of grommets [38]. A significant number of children had no attacks during this initial period. A recent guideline from the USA advises not to insert ventilation tubes in patients with recurrent AOM unless an effusion is present at the time of assessment, however if effusion is present, regardless of whether it is unilateral or bilateral, bilateral tubes should be offered as a treatment option [51]. Most meta-analyses of the effect of tube insertion showed limited benefit of tube insertion and advocated antibiotic treatment as first line [52-54]. The addition of adenoidectomy does not effect recurrent AOM [55].

Summary AOM accounts for over half a million primary care consultations per year in the UK and nearly 9 million in the USA. Diagnosis is made in the presence of a bulging tympanic membrane in most cases. Management includes symptomatic relief and antibiotics in children under 2 years old. Antibiotics for older children are recommended in severe cases and should be considered for others by the clinician. Surgery may be considered in recurrent AOM. Although rare, lifethreatening complications of AOM can occur and should always be considered. Strict diagnostic criteria should be followed in order for treatment to be effective.

Declaration of interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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Acute otitis media.

Acute otitis media (AOM) is a common problem facing general practitioners, paediatricians and otolaryngologists. This article reviews the aetiopathoge...
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