Key points

Overview

According to the American Academy of Pediatrics (AAP) and the American Academy of Otolaryngology and Head and Neck Surgery, acute otitis media (AOM) is defined as a history of acute onset of signs and symptoms, the presence of middle ear effusion, and signs and symptoms of middle ear inflammation. As part of the treatment algorithm for AOM, it is important to consider it as part of a spectrum of disease processes. It should be differentiated from both recurrent acute otitis media (ROM, defined as acute otitis media at least 3 times within 6 months) and persistent otitis media with effusion (COM, defined as presence of middle ear fluid in the absence of symptoms for more than 8 weeks). AOM can also progress to intracranial (such as brain abscess) and extracranial (such as temporal bone abscess) complications as well.

AOM is diagnosed frequently in early childhood and peaks in incidence between 6 and 15 months of age. It typically results from a Streptococcus pneumoniae, Haemophilus influenzae , or Moraxella catarrhalis infection and is the most common reason for physician visits and antibiotic prescriptions in children. Eighty percent of AOM cases resolve without treatment within 3 days, and the most sensitive and specific way to diagnose it is with pneumatic otoscopy. The cost of treating middle ear infections in the United States is approximately $2.0 billion to $3.5 billion per year. Antibiotic therapy for AOM can result in significant expense in excess of $100 per episode.

Today almost half of all antibiotic prescriptions are for children with otitis media. In a study in 2010, Arguedas and colleagues interviewed 1800 physicians from France, Germany, Spain, Poland, Argentina, Mexico, South Korea, Thailand, and Saudi Arabia and found that although there was widespread concern over antibiotic resistance, 81% of physicians used antibiotics as first-line treatment for AOM.

The principle of observation or alternative treatments was popularized in the 1980s in areas of Western Europe. Van Buchem and colleagues in the Netherlands found infants could initially be treated with an analgesic agent and nose or ear drops with antibiotics administered only if the signs and symptoms persisted for more than 3 days. It was not until 2004 that the AAP and the American Academy of Family Physicians (AAFP) advocated in their guidelines for initial observation rather than immediate antibiotics in the treatment of AOM in selected children ( Box 1 ). As a result of the push for early observation, many patients and families have turned to complementary methods for symptomatic relief or even for resolution of the disease process.

Overview

According to the American Academy of Pediatrics (AAP) and the American Academy of Otolaryngology and Head and Neck Surgery, acute otitis media (AOM) is defined as a history of acute onset of signs and symptoms, the presence of middle ear effusion, and signs and symptoms of middle ear inflammation. As part of the treatment algorithm for AOM, it is important to consider it as part of a spectrum of disease processes. It should be differentiated from both recurrent acute otitis media (ROM, defined as acute otitis media at least 3 times within 6 months) and persistent otitis media with effusion (COM, defined as presence of middle ear fluid in the absence of symptoms for more than 8 weeks). AOM can also progress to intracranial (such as brain abscess) and extracranial (such as temporal bone abscess) complications as well.

AOM is diagnosed frequently in early childhood and peaks in incidence between 6 and 15 months of age. It typically results from a Streptococcus pneumoniae, Haemophilus influenzae , or Moraxella catarrhalis infection and is the most common reason for physician visits and antibiotic prescriptions in children. Eighty percent of AOM cases resolve without treatment within 3 days, and the most sensitive and specific way to diagnose it is with pneumatic otoscopy. The cost of treating middle ear infections in the United States is approximately $2.0 billion to $3.5 billion per year. Antibiotic therapy for AOM can result in significant expense in excess of $100 per episode.

Today almost half of all antibiotic prescriptions are for children with otitis media. In a study in 2010, Arguedas and colleagues interviewed 1800 physicians from France, Germany, Spain, Poland, Argentina, Mexico, South Korea, Thailand, and Saudi Arabia and found that although there was widespread concern over antibiotic resistance, 81% of physicians used antibiotics as first-line treatment for AOM.

The principle of observation or alternative treatments was popularized in the 1980s in areas of Western Europe. Van Buchem and colleagues in the Netherlands found infants could initially be treated with an analgesic agent and nose or ear drops with antibiotics administered only if the signs and symptoms persisted for more than 3 days. It was not until 2004 that the AAP and the American Academy of Family Physicians (AAFP) advocated in their guidelines for initial observation rather than immediate antibiotics in the treatment of AOM in selected children ( Box 1 ). As a result of the push for early observation, many patients and families have turned to complementary methods for symptomatic relief or even for resolution of the disease process.

Physiology and anatomy

Otitis media results from inflammation involving the middle ear space. The middle ear is a small air-filled cavity that is part of a larger functional system that includes the nasopharynx, Eustachian tube, and the mastoid air cells. The Eustachian tube is derived from the first pharyngeal pouch and is lined by respiratory mucosa (ciliated, pseudostratified, columnar epithelium). It is divided into an osseus intratemporal portion and a cartilaginous nasopharyngeal portion. It functions to protect the middle ear from reflux of nasopharyngeal secretions into the middle ear and provides aeration and pressure equalization to the middle ear. It is commonly believed that otitis media results in part from poor ventilation and clearance of secretions by the Eustachian tube (eg, Eustachian tube dysfunction). Infants and children have important anatomic differences in their Eustachian tubes compared with adults: the tube is shorter, and the cranial base is flatter in children than adults, describing a more horizontal course providing less protection. Through maturation, the angle of the cranial base increases and concomitantly the angle of the Eustachian tube increases, reaching adult size by age 7.

The only active dilator of the Eustachian tube is thought to be the tensor veli palatini. It has been suggested that many of the age-related changes in Eustachian tube function (and, therefore, decreased rates of otitis media with age) are related to more efficient muscular activity resulting in improved middle ear aeration such that the Eustachian tube is no longer a passive route for nasal secretions. It is also believed that maturation of the immune system assists in preventing infection.

There are other known risk factors for AOM, such as large daycare centers, bottle feeding, and smoke exposure. Finally, Beery and colleagues have shown there is a seasonal variation in otitis media and Eustachian tube dysfunction, with improvement in the spring and summer.

Symptoms

The symptoms of otitis media can be quite variable in children depending on the acuity of disease and age of the child. AOM may result in tugging at the ears or increased “fussiness” (eg, crying more than usual, decreased oral intake, decreased sleep). This may be associated with fever, nausea, or diarrhea. Older children may complain of ear pain, and occasionally the tympanic membrane can rupture, resulting in bloody otorrhea. In some cases, children can have imbalance. Rarely, facial nerve paralysis or paresis can ensue because of the position of the facial nerve in the middle ear, particularly if it is dehiscent of its bony covering. In COM, the symptoms may be more subtle, such as hearing loss or painless otorrhea.

Medical treatment approaches and outcomes

The mainstay of medical treatment for otitis media has traditionally been antibiotics. More recently, there has been an increasing interest in complementary or alternative medical treatments, which are discussed in later sections of this article. In the 1980s, AOM was almost exclusively treated with antibiotics. But with increased concern over side effects of antibiotics and resistance patterns of bacteria, there has been a shift in treatment patterns. In 2004, the AAP and the AAFP suggested initial observation in most patients and treatment only if it failed after 2 or 3 days (continued pain and fevers). Because of this change, there have been studies comparing treatment of AOM with either antibiotics or placebo. As AOM has a high rate of spontaneous resolution, a trial to prove any treatment effect must demonstrate rapid resolution of symptoms.

In a randomized controlled trial by Tähtinen and colleagues in 2011, 319 children aged 6 to 35 months with a new diagnosis of AOM were randomized to receive either amoxicillin-clavulanate or placebo and evaluated for treatment failure defined by the condition of the patient and clinical otoscopic signs. Of the children receiving amoxicillin-clavulanate, 18.6% failed by day 7, whereas 44.9% of those receiving placebo failed. Overall, amoxicillin-clavulanate reduced the progression to treatment failure by 62% and the need for rescue treatment by 81%. However, 47.8% of the children in the amoxicillin-clavulanate group had diarrhea, compared with 26.6% in the placebo group; there was also a greater rate of eczema (8.7% vs 3.2%) in the antibiotic group. There was no significant difference in analgesic rates. In a similar study in 2011, Hoberman and colleagues performed a randomized controlled trial of 291 children aged 6 to 23 months with AOM with 2 treatment groups: amoxicillin-clavulanate or placebo for 10 days. Treatment with antibiotics tended to reduce the time to resolution of symptoms, as well as overall symptom burden; it also reduced signs of acute infection on examination.

Amoxicillin is most commonly used as first-line antibiotic therapy (see Box 2 for dosing). In allergic patients, trimethoprim and sulfamethoxazole (Bactrim), erythromycin, and clindamycin plus a sulfonamide may be used. Cephalosporins present another option (ceftriaxone, cefdinir, and cefpodoxime). A small percentage of patients do not improve on these regimens and after 3 days are deemed “resistant.” In these cases, amoxicillin/clavulanic acid, cefuroxime, or ceftriaxone are typically effective. In cases of “resistant” AOM, targeted therapy via culture is often helpful because both H influenzae and M catarrhalis are often beta lactamase positive, and more than one-quarter of S pneumoniae are resistant.

In COM, medical treatments have been aimed at improving Eustachian tube function, with various results shown in the literature. Some approaches include the use of decongestants, nasal steroids, or treatment of underlying allergies. Sometimes topical or oral antibiotics are also used. The efficacy of these treatments continues to be studied.

Surgical treatment approaches and outcomes

Surgery for AOM is necessary only if it is accompanied by intracranial or extracranial complications, such as subperiosteal abscess or subdural abscess, or if a resistant organism is suspected. In recurrent AOM, myringotomy with pressure-equalizing tube placement may be indicated. In 2004, the AAFP, American Academy of Otolaryngology-Head and Neck Surgery, and AAP subcommittee on otitis media recommended surgery when 3 or more episodes of AOM occurred during the previous 6 months, or 4 or more episodes occurred during the previous year.

In COM, myringotomy tube placement is considered in children with 3 months or more of documented effusion, particularly if there is documented hearing loss or speech and language delays. In patients requiring a second myringotomy and tube placement, an adenoidectomy may also be considered.

Patient self-treatments and prevention

Symptomatic relief of AOM is of paramount importance to patients and families. Many find relief with warm compresses and steam. Gargling salt water may help as well (it is theorized that the salt water can help reduce inflammation of swollen mucosa and thereby help drain the Eustachian tubes). Judicious use of over-the-counter nasal sprays also helps some people. Herbal ear drops are also used for symptomatic relief. The composition is quite variable, but they usually contain some combination of the following: Calendula flores (marigold), garlic ( Allium sativum ), mullein ( Verbascum thapsus ), St. John’s wort ( Hypericum perforatum ), lavender, and vitamin E. In 2001, Sarrell and colleagues compared Otikon Otic Solution (Healthy-On Ltd, Petach-Tikva, Israel), a naturopathic herbal extract containing A sativum , V thapsus , C flores , and H perforatum in olive oil, with anesthetic (ear drops containing ametocaine and phenazone in glycerin) and found comparable rates of analgesia in patients with AOM. A Cochrane systematic review in 2004 concluded that naturopathic ear drops were “modestly therapeutic” for ear pain associated with otitis media with no safety concerns. But a subsequent Cochrane review in 2006 evaluated 4 trials and found there was insufficient evidence to know whether naturopathic ear drops were effective.

The identification of risk factors for otitis media has spurred research involving prevention ranging from lifestyle modification to immunization to diet. There are many well-documented studies that show increased rates of otitis media with bottle feeding compared with breast feeding. In a study by Sabirov and colleagues in 2009, among children with AOM, the prevalence of nontypeable H influenzae (a known otitis media pathogen) was higher in bottle-fed infants compared with breast-fed infants. Furthermore, they showed that specific immunoglobulin G antibodies to nontypeable H influenzae were lower in formula-fed infants, intermediate in breast-fed and bottle-fed infants, and highest in exclusively breast-fed infants. It has also been hypothesized that the position of the infant while feeding may make a difference in terms of nasopharyngeal reflux. Additionally, smoking inside the home or outside the home but wearing the same clothes around children can also play a role in AOM. Large day care settings and pacifier use have also been implicated ( Table 1 ).

Recently there has been interest in the role of nutrition and food allergies in the pathogenesis of otitis media. There have been reports that nutritional supplements can help prevent otitis media, and reports that nutritional deficiencies are associated with increased incidence of otitis media. In a recent study by Lasisi in 2008, patients with acute suppurative otitis media and COM were found to have retinol/vitamin A levels that were lower than in age-matched controls. The levels were also significantly lower in patients with recurrent AOM compared with those with a single episode of AOM. In a meta-analysis in 2009, Elemraid and colleagues reviewed rates of AOM or COM and vitamin supplementation. They found some evidence that deficiencies of zinc or vitamin A, or both, may lead to increased rates of otitis media. Abba and colleagues in 2010 reviewed 12 randomized controlled trials in which zinc was given at least once a week for at least once a month versus placebo. They examined rates of otitis media and found conflicting reports regarding the efficacy of treatment but did not find any serious adverse events with zinc supplementation.

Food allergies may also have a role in otitis media, and, thus, decreased consumption of allergenic foods may reduce the number of episodes of otitis media, although the precise pathogenesis remains speculative. Interestingly, nutrition as it relates to obesity may also affect the rate of otitis media. In a report by Nelson and colleagues in 2011, elevated body mass index in children was associated with an increase in otitis media requiring tympanostomy tubes.

In 2001, the Centers for Disease Control and Prevention recommended that the PCV7 (initial Prevnar vaccine) be administered to all infants and young children; this produced significant shortages that were not fully resolved until 2004. Research since then has shown an overall decrease in rates of otitis media caused by pneumococcus. Cost analyses have suggested that immunization of all healthy infants with this vaccine could prevent more than 1 million episodes of AOM and 12,000 cases of invasive pneumococcal disease. The Finnish Otitis Media Study Group demonstrated that not only was there a decreased incidence of pneumococcal AOM but also a decreased rate of tympanostomy tube placement for recurrent disease. Stamboulidis and colleagues showed an increased rate of penicillin-resistant pneumococcal strains causing otitis media (4% vs 13%) but a decrease in the proportion resistant to macrolides (44% vs 35%). They also found a decrease of 38% in rates of otorrhea visits per 10,000 emergency room visits. A second-generation 13-valent pneumococcal conjugate vaccine (PCV13) was licensed and recommended for universal immunization of children through age 5 years in 2010. Its introduction is intended to address the residual burden of pneumococcal diseases that persists a decade after the introduction of PCV7.

Otitis media often follows upper respiratory infections or other viral illnesses, such as influenza. In a study by Block and colleagues in 2011, influenza vaccination was thought to be protective for otitis media. They compared live attenuated influenza vaccine (approved for children older than 2 years) with placebo and found overall efficacy against influenza-associated AOM was 85%.

Integrative treatment approaches and outcomes

Although there has been much research into the effectiveness and safety of many complementary and integrative medical (CIM) treatments of otitis media, most of the studies have significant methodological flaws, making definitive conclusions difficult. Furthermore, studies of the cost-effectiveness of such treatments need to be performed. Through a family questionnaire, Marchisio and colleagues found that 46% of children aged 1 to 7 years with 3 or more episodes of AOM in 6 months used some component of CIM. Interestingly, they found many fewer were PCV7 or influenza vaccinated (34% and 15%, respectively). Patients spent between Euro 25 and Euro 50 per month in 27.6% of cases and Euro 50 per month or more in 16%.

Homeopathy

Homeopathy is based on the principle that “like cures like” (eg, any substance that produces symptoms in a healthy patient can relieve those same symptoms in an ill patient). Homeopathic remedies used for otitis media are dilute and generally are regarded as “safe” (see Table 2 for a list of the most common homeopathic remedies and their uses). There have been reports of an initial aggravation of symptoms in approximately 10% to 20% of patients. In one study, however, there were 3 cases of severe adverse events in one practice of homeopathic care over 7 years (1 perforation of a tympanic membrane, 1 cholesteatoma, and 1 case of mastoiditis), although it is unclear if these are necessarily directly attributable.

Table 2

List of common homeopathic remedies used to treat otitis media and conditions for which they are used

Homeopathic Remedy	Condition
Aconitum/Aconite/Aconitum napellus a	For throbbing ear pain that comes on suddenly after exposure to cold or wind and in children with high fever and whose ears are bright red or tender to the touch. Better in the initial stages of an ear infection.
Belladonna a	For throbbing and sharp pain accompanied by fever, intense heat, and flushing in the outer ear and along the side of the face. Some suggest it is better for the right ear. It comes from an extract from a poisonous plant of the nightshade family and should be used with caution.
Capsicum	Treats heat and inflammation, along with significant pain.
Chamomilla a	For children with otitis media who are very irritable, in great pain, and can’t be consoled.
Ferrum phosphoricum	In early otitis media, this a common remedy used; gradual onset of symptoms; patient has flushed face, doesn’t like noise, wants to lie still.
Hepar sulphuricum	Pain in ears especially with swallowing; yellowish-green discharge, wind or draft aggravates pain.
Kali muraticum	Popping and crackling sound heard in ear when swallowing and with nose blowing, hearing may be decreased, feeling of fullness and congestion in the ear. Also used to clear Eustachian tubes when fluid persists after acute otitis media.
Lycopodium	For right-side ear pain that is worse in the late afternoon and early evening; fullness of the ears, ringing or buzzing of the ears.
Magnesia phosphorica	Earache, especially after exposure to cold wind and drafts. May not be an infection at all, but rather nerve irritation, more right ear than left; pain relieved by heat, feels better with rubbing.
Mercurius	Good for chronic ear infections; for pain that is worse at night and may extend down into the throat; relief comes from nose blowing; earache may occur when damp or fog or weather changes occur, may salivate or sweat.
Pulsatilla a	For infection following exposure to cold or damp weather; the ear is often red and may have a yellowish/greenish discharge from ear or nose; ear pain may worsen after sleep and with warmth, may be alleviated by cool compresses.
Silica	For chronic or late-stage infection when the child feels chilly, weak, and tired; sweating may also be present.
Verbascum	Especially left-sided otitis media, may have a cough or laryngitis as well.

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