Otitis Media: Rapid Evidence Review

 

Am Fam Physician. 2019 Sep 15;100(6):350-356.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/ear-infection/.

Author disclosure: No relevant financial affiliations.

Acute otitis media (AOM) is the most common diagnosis in childhood acute sick visits. By three years of age, 50% to 85% of children will have at least one episode of AOM. Symptoms may include ear pain (rubbing, tugging, or holding the ear may be a sign of pain), fever, irritability, otorrhea, anorexia, and sometimes vomiting or lethargy. AOM is diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa, and in children with mild bulging and either recent-onset ear pain (less than 48 hours) or intense erythema of the tympanic membrane. Treatment includes pain management plus observation or antibiotics, depending on the patient's age, severity of symptoms, and whether the AOM is unilateral or bilateral. When antibiotics are used, high-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is first-line therapy unless the patient has taken amoxicillin for AOM in the previous 30 days or has concomitant purulent conjunctivitis; amoxicillin/clavulanate is typically used in this case. Cefdinir or azithromycin should be the first-line antibiotic in those with penicillin allergy based on risk of cephalosporin allergy. Tympanostomy tubes should be considered in children with three or more episodes of AOM within six months or four episodes within one year with one episode in the preceding six months. Pneumococcal and influenza vaccines and exclusive breastfeeding until at least six months of age can reduce the risk of AOM.

Acute otitis media (AOM) is commonly diagnosed in children in primary care offices. It is also a leading contributor to antibiotic prescriptions and medical costs in children.1 This article provides a summary and review of the best, most recent evidence to guide the diagnosis and treatment of AOM.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

AOM should be diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by otitis externa, and in children with mild bulging and either recent-onset ear pain (less than 48 hours) or intense erythema of the tympanic membrane.7

C

Practice guideline from the AAP, which is based on consistent evidence from observational studies

Pneumatic otoscopy with or without tympanometry should be used to assess the tympanic membrane for effusion in patients with suspected AOM.7,9

C

Expert opinion and practice guideline from the AAP, which is based on consistent evidence from observational studies

If antibiotics are used for AOM, high-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is first-line therapy.7

C

Practice guideline from the AAP, which is based on consistent evidence from observational studies

Consider observation for 48 to 72 hours with deferment of antibiotic therapy in lower-risk children with AOM.7,10

B

Practice guideline from the AAP, which is based on consistent evidence from observational studies; Cochrane review on antibiotics for acute otitis media in children

Pain should be treated as needed in children with AOM.7

C

Practice guideline from the AAP, which is based on consistent evidence from observational studies


AAP = American Academy of Pediatrics; 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 https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

AOM should be diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by otitis externa, and in children with mild bulging and either recent-onset ear pain (less than 48 hours) or intense erythema of the tympanic membrane.7

C

Practice guideline from the AAP, which is based on consistent evidence from observational studies

Pneumatic otoscopy with or without tympanometry should be used to assess the tympanic membrane for effusion in patients with suspected AOM.7,9

C

Expert opinion and practice guideline from the AAP, which is based on consistent evidence from observational studies

If antibiotics are used for AOM, high-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is first-line therapy.7

C

Practice guideline from the AAP, which is based on consistent evidence from observational studies

Consider observation for 48 to 72 hours with deferment of antibiotic therapy in lower-risk children with AOM.7,10

B

Practice guideline from the AAP, which is based on consistent evidence from observational studies; Cochrane review on antibiotics for acute otitis media in children

Pain should be treated as needed in children with AOM.7

C

Practice guideline

The Authors

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HEIDI L. GADDEY, MD, is the director of medical education and the designated institutional official at David Grant Medical Center, Travis Air Force Base, Calif....

MATTHEW THOMAS WRIGHT, DO, is a resident in the University of Nebraska Medical Center/Offutt Air Force Base Family Medicine Residency, Omaha.

TRACY N. NELSON, MD, is medical director of the Offutt Air Force Base pediatric clinic and pediatric clerkship director at the University of Nebraska Medical Center/Offutt Air Force Base Family Medicine Residency. She is also an adjunct professor in the Department of Pediatrics at the University of Nebraska and an assistant professor in the Department of Pediatrics at the Uniformed Services University of the Health Sciences, Bethesda, Md.

Address correspondence to Heidi L. Gaddey, MD, David Grant Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535 (email: heidigaddey@yahoo.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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