Otitis Media
Definition:
Otitis media, usually referred to as acute otitis media (AOM), is a common middle ear infection that affects mainly children under the age of 6, and especially under the age of 2. However, otitis media can affect any person of any age.
AOM is defined as the acute onset of signs and symptoms of a middle ear infection. (See below for a full listing of the usual signs and symptoms.)
Debate among medical professionals currently involves whether AOM should be treated with or without antibiotics. AOM is the most common childhood infection to be treated with antibiotics.
Symptoms:
The most common symptoms of AOM include:
- Ear pain
- Irritability
- Discharge from the ear canal
- Fever above 101 F
- Pulling or tugging on the ear
- Decreased appetite
- Lethargy
- Sleep disturbance
Risk Factors:
- Predisposing conditions or situations that increase a child's risk for developing AOM include:
- Attendance at day care or group child care
- Frequent use of antibiotics
- Concurrent chronic illness, such as diabetes, asthma, kidney or liver disease
- Immunosuppression, such as HIV, leukemia, cancer
- Prematurity
- Frequent upper respiratory infections, such as common cold, sinusitis, pharyngitis
- Allergies
- Smoke exposure
Risk reducers include:
- Breastfeeding for the first 6 months of life
- Avoiding bottle feeding a child while on his or her back
- Reducing or eliminating pacifier use in the second 6 months of life
- Avoiding smoke exposure
- Updated vaccination status
Medical providers diagnose AOM by history and physical exam. Symptoms are listed above. Signs that are sought include:
- Discharge in the ear canal
- Fever above 101 F
- Irritability
- Bulging ear drum (the best predictor of AOM)
- Red ear drum
- Limited or absent mobility of the ear drum (confirmed by using pneumatic otoscopy, also known as an “insufflator bulb”)
- Pocket(s) of fluid behind the ear drum [middle ear effusion, (MEE)]
Assessing the eardrum of a child is relatively easy and is best accomplished by using an otoscope (light source placed in the ear canal) and an “insufflator bulb”.
Medical authorities agree that a certain diagnosis of AOM meets all 3 of the following criteria:
- Rapid onset of symptoms
- Presence of MEE
- Signs and symptoms of middle-ear inflammation
Occasional uncertainty may still remain when examining young children due to:
- Blocked ear canal due to wax build up
- Mild redness of ear drum due to crying fit
- Premature presentation of the child before a full-blown infection is present
Teaching Point: Medical providers diagnose AOM based on the presence or absence of specific symptoms and signs, along with use of an insufflator to check for ear drum mobility.
Treatments:
Debate is ongoing regarding what is the best management of an uncomplicated AOM. The main reason for this debate is two-fold:
1. Overuse of antibiotics has contributed to the creation of “super-bacteria”, known to be resistant to conventional antibiotics. These super-bacteria, responsible for many other infections and known in the lay press by nicknames such as “flesh-eating bacteria” or “super-bugs” are not overpowered and killed easily. Stronger and higher doses of antibiotics are required to get rid of these bacteria.
2. Many viruses are now known to cause AOM and it is often very difficult to distinguish whether a virus or bacteria are directly responsible for AOM. Often, doctors err on the side of treating with antibiotics to subdue a presumed bacterial infection. However, antibiotics have no effect on viruses and can lead to a state of imbalance, predisposing to the rise of “super-bacteria” (See above).
Essentially, treatment of AOM involves antibiotics, pain relievers and decongestants, as needed. Duration of antibiotic therapy is usually 10 days for children under the age of 6; a shorter course of only 5-7 days is now recommended for otherwise healthy children with AOM.
Analgesics such as over the counter acetaminophen or Tylenol and ibuprofen have been shown in scientific studies to provide adequate relief of the pain and fever associated with AOM in infants and children. Exercising the observation option for treating AOM is reserved for children whose parents are able to readily contact the medical provider or bring the child back for a repeat exam within 48 to 72 hours. Observation provides an opportunity for the child to improve without antibiotics. Historically, this approach works well for children who are otherwise in good health and without severe symptoms. Benefits of observation include avoidance of antibiotic side effects, such as nausea, vomiting, diarrhea and allergic reaction and decreased development of drug-resistant super-bacteria.
Ask your trusted health care provider whether observation without antibiotics for AOM is appropriate or not for your child.
One last issue is regarding complementary or alternative treatment, such as homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements. While all of these therapies may help some children, and most are harmless, no scientific studies have confirmed their general usefulness in treating AOM.
Teaching Point: Treatment of AOM is generally a combination of pain relievers, antibiotics and decongestants, as needed. Talk to your doctor about whether an observation period without antibiotics or alternative treatment is appropriate for your child.
Complications:
The most worrisome complications of AOM are rarely seen and include:
- Mastoiditis, an infection in the bone under the outer ear. This infection requires antibiotic therapy without fail
- Chronic and recurrent otitis media, with or without effusion
- Meningitis
- Sepsis (blood-borne infection)
- Deafness or hearing impairment (usually due to recurrent AOM)
Teaching Point: Complications of AOM are fairly rare.
The final word:
AOM is very common and can affect any child. Some children are more prone. Antibiotics are curative, but so is watchful and close observation in many instances. The best advice is to bring your child to see your trusted health care provider for guidance and discussion. Please consult your family doctor for further information.
References:
1. Ferro, TJ. Overview of national Treatment Guidelines for Common Respiratory Tract Infections. American Journal of Therapeutics. 2004. 11(Supplement 1): S9-14.
2. Subcommittee on Management of Acute Otitis media. Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004. 113(5): 1451-1465.
3. Saez-Llorens, X, et.al. Treatment of Recurrent and Nonresponsive Otitis Media in Children. The Pediatric Infections Disease Journal. 2005. 24(4): 293-300.
4. Leibovitz, E. Acute Otitis Media in Children Aged less Than 2 Years: Drug Treatment Issues. Pediatric Drugs. 2006. 8(6): 337-346.
5. Holcomb, SS. New Guidelines Improve Treatment of Otitis Media. The American Journal of Nurse Practitioner. 2004. 29(10): 6-13.
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