Acute Otitis Media Definition

Acute Otitis Media (AOM) is an acute infection of the middle ear that usually lasts for less than 6 weeks; approximately 3 out of 4 children experience an ear infection by the time they are 3 years of age.

What is Acute Otitis Media?

Acute Otitis Media is a very common ear infection in children (but can occur at any age) and affects the middle ear, hence it is a type of middle ear infection (Otitis media). Recurrent acute otitis media mostly occur in children with Eustachian tube dysfunction which may occur as a result of upper respiratory tract infections (URTIs) or obstruction from enlarged adenoids or due to cleft palate or Down syndrome a child having any of these disorders may have dysfunctional Eustachian tube leading to reoccurrence of acute otitis media.

Acute Otitis Media Causes

The most common cause of acute otitis media includes Streptococcus pneumoniae, Haemophilus influenza and viruses.

Acute Otitis Media Risk factors

1. Day care attendance
2. Exposure to passive cigarette smoke
3. Bottle propping
4. Formula feeding (as opposed to breastfed)
5. Male gender
6. Winter season
7. Getting infected with acute otitis media before the age of 6 months
8. Having a sibling with recurrent acute otitis media

Acute Otitis Media Symptoms and Signs

1. Purulent exudate (Ear discharge) – usually present in the middle ear
2. Deafness
3. Anorexia (loss of appetite)
4. Pain in the affected ear
5. In children, the child may be irritable
6. Tugging or pulling of the affected ear may be observed in a child who has not learnt how to talk
7. Sometimes, there may be no symptoms (Asymptomatic)
8. Examination of the affected ear shows a red, inflamed and bulging tympanic membrane with loss of light reflex

Severe symptoms of Acute Otitis Media

1. Moderate or severe ear pain (otalgia)
2. Fever of 39C or above
3. Systemic symptoms such as Vomiting
4. Perforation of tympanic membrane with purulent ear discharge
5. Occurrence of bilateral Acute otitis media (when two ears are affected at the same time)

 

Acute Otitis Media Treatment

Treatment of acute otitis media using ampicillin shortens the duration of symptoms and generally, the prognosis of acute otitis media is good even when the tympanic membrane has been perforated. Analgesia is given to relief pain especially in children but antibiotics should not be routinely used in uncomplicated cases of acute otitis media.

Acute Otitis Media Treatment Guidelines

1. 80% of children having acute otitis media get better by day 3 without the use of antibiotics
2. It is reasonable to prescribe analgesia to reduce otalgia (pain in the ears)
3. Antibiotics should not be used routinely and prescribing them just increases parental belief and re-attendance rates
4. Adenoidectomy as the first surgical treatment of acute otitis media in children of 10 to 24 months with recurrent acute otitis media is not effective in preventing further episodes, neither is Chemoprophylaxis.
5. A good compromise to the use of antibiotics in the treatment of acute otitis media is the use of delayed prescription whereby the antibiotics are given only when there is no improvement in symptoms after 72hours

When to use Antibiotics in Treatment of Acute Otitis Media

Some children with acute otitis media may significantly benefit from antibiotics especially in severe forms or complicated cases.

1. All children aged 6months and below
2. Children aged between 6months and 2years where the diagnosis is reasonably certain
3. Children older than 2years where there are severe symptoms of acute otitis media such as moderate or severe ear pain (otalgia) with a fever of 39C or above and systemic symptoms such as vomiting, perforation with purulent discharge or when it is bilateral Acute otitis media

Choice of antibiotics for middle ear infection (Antibiotics for acute otitis media)

1. Amoxicillin: this is the antibiotic used as first-line for the first 5days. When there are severe symptoms, high doses are used by doubling the standard doses. The dose is also doubled when there has been a previous episode of AOM within the last month.
2. Erythromycin: this is used as alternative to penicillin when there is allergic reaction due to penicillin; Erythromycin is usually given in high doses for treatment of Acute otitis media (AOM)
3. Clarithromycin: this is also used as alternative to penicillin when there is penicillin allergy and but the standard dose is given.

Treatment of Persistent Acute Otitis Media

There is Persistent Acute Otitis Media when a patient returns within 2 weeks with same complaints even after treatment. This is treated using analgesics and if the patient have not had antibiotics earlier, then give antibiotics such as amoxicillin by doubling the standard dose this should be given for 5 days.

If the patient had been previously treated, check if there has been compliance; if the patient is compliant with medications, then try 2^nd line Antibiotics such as Co-Amoxiclav (Amoxicillin/clavulanic acid),given at double the standard dose for 5 days.

Surgical management of Acute Otitis Media

An incision in the tympanic membrane (eardrum) is known as Myringotomy and this is another treatment option when there is accumulation of pus in the middle ear; it is often performed to relief severe pains. The tympanic membrane is numbed with a local anesthetic such as phenol or by iontophoresis (whereby an electrical current flows through a lidocaine-and-epinephrine solution to numb the ear canal and tympanic membrane). Myringotomy is painless and takes less than 15 minutes and it is usually done under microscopic guidance.

Acute Otitis Media Follow up

There should be active follow up of patients who meet the following criteria:

1. Children under 2years of age
2. Presence of systemic symptoms such as vomiting or high temperatures greater than 39C
3. Presence of discharge from the ear
4. When visualisation of the tympanic membrane is difficult; this should be re-examine after 2weeks to assess the integrity of the tympanic membrane and to check for complications.
5. When there is a perforation even after 6weeks, this should be referred to a higher health facility

Acute Otitis Media Prognosis

The outcome of AOM depends on the efficacy of therapy such as the prescribed dose of an oral antibiotic and the duration of therapy as well as the virulence of the bacteria and the physical status of the patient. The complications can be greatly reduced with early and appropriate broad-spectrum antibiotic therapy. If drainage occurs, an antibiotic otic preparation is usually prescribed. Acute otitis media may become subacute that lasts about 3 weeks to 3 months with persistent purulent discharge from the ear. Rarely does permanent hearing loss occur.

Complications of Acute Otitis Media

1. Secretory otitis media (glue ear)
2. Conductive deafness
3. Mastoiditis
4. Labyrinthitis
5. Intracranial sepsis
6. Facial nerve palsy.
7. Meningitis
8. Brain abscess
9. Perforation about 29.5% of children with Acute otitis media do have perforation of the eardrum and about 94% usually heal and close spontaneously within one month