Otitis Media: Diagnosis and Treatment



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Am Fam Physician. 2013 Oct 1;88(7):435-440.

  Related editorials: Should Children with Acute Otitis Media Routinely Be Treated with Antibiotics? Yes: Routine Treatment Makes Sense for Symptomatic, Emotional, and Economic Reasons and No: Most Children Older Than Two Years Do Not Require Antibiotics

  Patient information: A handout on otitis media is available at http://familydoctor.org/familydoctor/en/diseases-conditions/ear-infections/treatment.html.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz.

Author disclosure: No relevant financial affiliations.

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate, should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist.

Otitis media is among the most common issues faced by physicians caring for children. Approximately 80% of children will have at least one episode of acute otitis media (AOM), and between 80% and 90% will have at least one episode of otitis media with effusion (OME) before school age.1,2 This review of diagnosis and treatment of otitis media is based, in part, on the University of Michigan Health System's clinical care guideline for otitis media.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

8

Middle ear effusion can be detected with the combined use of otoscopy, pneumatic otoscopy, and tympanometry.

C

9

Adequate analgesia is recommended for all children with AOM.

C

8, 15

Deferring antibiotic therapy for lower-risk children with AOM should be considered.

C

19, 20, 23

High-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is the first choice for initial antibiotic therapy in children with AOM.

C

8, 10

Children with middle ear effusion and anatomic damage or evidence of hearing loss or language delay should be referred to an otolaryngologist.

C

11


AOM = acute otitis media.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

C

8

Middle ear effusion can be detected with the combined use of otoscopy, pneumatic otoscopy, and tympanometry.

C

9

Adequate analgesia is recommended for all children with AOM.

C

8, 15

Deferring antibiotic therapy for lower-risk children with AOM should be considered.

C

19, 20, 23

High-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is the first choice for initial antibiotic therapy in children with AOM.

C

8, 10

Children with middle ear effusion and anatomic damage or evidence of hearing loss or language delay should be referred to an otolaryngologist.

C

11


AOM = acute otitis media.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Etiology and Risk Factors

Usually, AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Bacteria can be isolated from middle ear fluid cultures in 50% to 90% of cases of AOM and OME. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most common

The Authors

KATHRYN M. HARMES, MD, is medical director of Dexter Health Center in Ann Arbor, Mich. She is a clinical lecturer in the Department of Family Medicine at the University of Michigan Medical School in Ann Arbor.

R. ALEXANDER BLACKWOOD, MD, PhD, is an associate professor in the Department of Pediatrics at the University of Michigan Medical School.

HEATHER L. BURROWS, MD, PhD, is a clinical assistant professor in the Department of Pediatrics and is associate director of education in the Division of General Pediatrics at the University of Michigan Medical School.

JAMES M. COOKE, MD, is an assistant professor in the Department of Family Medicine and is the director of the Family Medicine Residency Program at the University of Michigan Medical School.

R. VAN HARRISON, PhD, is a professor in the Department of Medical Education at the University of Michigan Medical School.

PETER P. PASSAMANI, MD, is an assistant professor in the Department of Pediatric Otolaryngology at the University of Michigan Medical School.

Address correspondence to Kathryn M. Harmes, MD, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 (e-mail: jordankm@umich.edu). Reprints are not available from the authors.

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