KEY LEARNING POINTS 


- Acute otitis media is a common childhood disease with plenty of literature available for reference.

- Diagnosing AOM can be challenging due to high levels of uncertainty, and there is an increasing bacterial resistance to antibiotics.

- AOM is defined as inflammation in the middle ear with a rapid onset and a duration of less than 3 weeks.

- The subgroups of AOM include sporadic episodes, resistant AOM, persistent AOM, and recurrent AOM.

- Microbiological factors, environmental factors, anatomical factors, altered host defense mechanisms, and genetic predispositions can all contribute to the development of AOM.

- Viruses are commonly associated with AOM, with respiratory syncytial viruses, influenza A viruses, and other viral agents playing a role in infection.

- The eustachian tube anatomy and its position change with age, affecting the susceptibility to middle ear infections.

- Environmental factors such as day care attendance, crowded living conditions, and tobacco exposure can increase the risk of AOM.

- Host factors like prematurity, low birth weight, young age, early onset, family history, and allergies can also predispose individuals to AOM.

- Genetic factors, allergy, and routes of spread through the eustachian tube are also important considerations in the etiology and pathogenesis of AOM.

- The clinical course of AOM can vary depending on the infecting organism, host immune response, and antibiotic therapy.

- AOM typically progresses through stages of hyperemia, exudation, suppuration, and may lead to complications if not properly managed.

- The signs and symptoms of AOM include otalgia, ear fullness, fever, hearing impairment, and potential tympanic membrane perforation.

- A diagnosis of AOM is based on specific criteria including recent onset of symptoms, middle ear effusion, and signs of middle ear inflammation.

- Investigations such as audiometry, tympanometry, tympanocentesis, and imaging may be used to confirm a diagnosis of AOM in high-risk or complicated cases.

- Treatment options for AOM include conservative measures, medical therapy with antibiotics and analgesics, and possibly surgical interventions like myringotomy.

- The decision to treat AOM with antibiotics should be based on the severity of symptoms, risk factors, and the potential benefits versus risks of antibiotic use.

- Watchful waiting may be appropriate in some cases of AOM, especially if improvement is seen within 2-3 days and in high-risk or recurrent cases.

- Immediate antibiotic treatment is recommended for high-risk children, those with craniofacial abnormalities, immunodeficiencies, and those under 2 years old suffering from recurrent AOM.- Acute Otitis Media (AOM) is characterized by symptoms such as higher temperature (> 37.5°C), vomiting, and the presence of TM perforation in some cases.

- For children over 2 years old, recurrent AOM is often seen in those with risk factors like cleft palate, Down's syndrome, or compromised immune function.

- Treatment duration for AOM can be a short course (5 days) or a long course (10 days), with failure rates varying between the two.

- The choice of antibiotic for AOM depends on factors like the likely etiologic agent, efficacy of specific antibiotics, drug allergies, and previous treatment success.

- Common antibiotics for AOM include Amoxicillin, Amoxicillin + Clavulanic acid, TMP/SMX, Cephalosporins (e.g., Cefaclor, Cefuroxime), and Macrolides (e.g., Azithromycin, Clarithromycin).

- Special considerations for AOM treatment include PCN allergies, treatment in infants, and potential surgical interventions like myringotomy or myringotomy with antibiotics.

- Medical prophylaxis strategies for recurrent AOM include the use of antibiotics, xylitol, vaccination, immunoglobulins, and surgical options like ventilation tubes for failed medical management.

- Surgical prophylaxis with adenoidectomy or adenotonsillectomy may be considered in cases of recurrent AOM or persistent middle ear effusion.

- Outcomes of AOM can vary, with potential impacts on auditory functioning, speech and language development, and the potential for complications like TM perforation.

- Barotrauma, a common injury resulting from pressure changes, is often seen in situations like commercial flights and can lead to symptoms like blocked ear, otalgia, and hearing loss.

- Management of barotrauma includes prevention strategies, medical interventions like topical nasal decongestants, and surgical options like myringotomy with ventilation tube insertion.


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Acute otitis media

One of the most common diseases of childhood
Plenty of literature available on AOM


STILL….
Hard to diagnose
High level of uncertainty over 
how it should be treated
↑ing bacterial resistance to antibiotics



Definition
Inflammation of middle ear cleft of rapid onset
Duration  < 3 weeks
May also involve inflammation of petrous apex, and perilabyrinthine air cells


Subgroups of AOM
Sporadic episodes:
→occurs as infrequent isolated event
Resistant AOM
→ persistence of S/S beyond 3-5 days of abx tt
Persistent AOM
→persistence or recurrence of S/S within 6 days of finishing a course of abx
Recurrent AOM
→≥ 3 episodes - 6 months period
Etiology
Microbiological factors
Microbiological factors
Viruses :
60-90% of AOM assoc with viral infection
Follows viral URTI
Agents:
Respiratory syncytial viruses (RSV)
Influenza A viruses
Para influenza viruses
Human rhinoviruses
Adenoviruses
Viruses …
Viral materails → 48-71% children with AOM        ( middle ear aspirates)
ET or hematogenous
RSV invades middle ear most 
frequently
Effects:
 ET dysfunction
 alteration of host immunity:               RSV → affects CMI       Influenza viruses → altered neutrophil fxn
↑ bacterial colonization and adherence in nasopharynx

Viruses …
ET dysfunction:
Viruses → release of infl. Mediators

↓ ciliated epit cells no
Inflammatory oedema
↑mucous production in ET

Temporary obstruction of ET
Negative middle ear pressure

Accumulation of transudate
Predisposes to AOM

Viruses …
Ciliated epithelium → 1st line defense against bacterial infection

↑ bacterial invasion
Delayed clearance from middle ear

2° bacterial infection

2/3rd cases : viral & bacterial infection coexist
↓
Much more likely to have poor response to abx



Bacterias
> 6 weeks:
 Str. Pneumoniae (29-40%)
H. Influenzae (20%)
M. Catarrhalis (10%)
Str. pyogenes
Others: Staph. aureus, Str. viridans, P. aeruginosa, anaerobes
Neonatal period (<6 weeks ):
Gram –ve bacterias ( E.coli, Enterococcus sps., group B streptococcus)
Most common – Str. pneumoniae (all age groups)

Anatomical factors
Craniofacial abnormalities     Cleft palate
(Treacher Collins syndrome)
Neuromuscular disease           TM perforation or VTI
Adenoid hypertrophy              Tonsillar hypertrophy
High arched palate                  Prone sleeping position
NG tubes, NT intubation        Use of pacifiers

Eustachian tube
Adults
ant 2/3- cartilaginous
post 1/3- bony
45 degree angle
isthmus 1-2 mm
nasopharyngeal orifice 8-9 mm
Children
longer bony portion

10 degree angle
isthmus larger
nasopharyngeal orifice 4-5 mm in infants
Eustachian tube…
Eustachian tube…
Auditory tube position changes with age
Lumen of tube in child is more horizontal and wider
The pharyngeal opening is:
•Below the level of the hard palate in the fetus.
•Is level with the palate at birth.
•Is 3 to 4 mm. above it at the fourth year.
•Is 10 mm. Above it as an adult

Cunningham’s Textbook of Anatomy, 10th Ed., 1964, p814.

Eustachian tube…
Eustachian tube…

An example of how liquid could get back up into area of Eustachian tube if soft palate and epiglottis are separated by a foreign object in the mouth.


Excessive digit sucking can also drive jaw and tongue back -and block off eustachian tubes.
Environmental factors
Day care attendance
Crowded living conditions
Low socioeconomic status
Allergans 
Tobacco & pollutant exposure
Seasonal variation ( fall or winter)


Host factors
Prematurity or LBW            Young age
Early onset                            Family history
Race                 Allergy
Bottle feeding

Immune factors:
Steroids, chemotherapy        Not breast fed
Low IgG (G2 subclass)          Low CD4 count (HIV)
Defective complement dependent opsonisation
Aberrant expression of critical cytokines
Immunology in AOM
 abs → clearance of middle ear effusion
Previous exposure or immunisation → suppress colonisation of nasopharynx by pathogens
 abs formation during attack → prevent or modify future attacks

Ab to polysachharides develops late
 IgG2 & IgG4
Nasopharyngeal IgA → prevents invasion

Not all Igs are protective


Factors predisposing bottle-fed infants to Otitis Media
Lack of IgA immunity from human breastmilk.
Bottles propped -infant on back -regurgitates into Eustachian tubes (ETs)
Confinement of the space in the area of the ETs due to the displacement of soft palate during bottle feeding.


Bottle-feeding forces tongue back. This elevates tongue at back, which in turn can block off Eustachian tubes.

NEVER bottle-feed an infant on it’s back like this!
Allergy and AOM
Role of allergy in the etiology and pathogenesis 
Middle ear acting as a shock organ,
Inflammatory swelling of the Eustachian tube or ET as a shock organ,
Inflammatory obstruction of the nose, or 
Aspiration of bacteria-laden allergic
nasopharyngeal secretion into the middle ear cavity

Genetic factors
Familial associations
Racial diff.
Syndromic associations:
Turner’s syndrome (>60% recurrent AOM)
Down syndrome
Cleft palate
Routes of spread
Eustachian tube: negative middle ear pressure, 
anatomical & physiological diff in ET
        → shorter, straighter & more patulous ↑risk  
        → poorer active tubal fxn (muscular opening)  
        → reflux, aspiration or active insufflations                                      
TM perforation or VTs
Hematogeneous 
Epidemiology
One of the most common illnesses of childhood
Highest incidence→ 6-12 months; then ↓
 2nd peak → 5yrs
Reported incidence varies
By age of 3 yrs:         50-70% -at least one episode 1/3rd will have 3 or more episodes
1st 2 yrs of life →AOM B/L in 80%
         > 6 yrs        → AOM U/L IN 86%
Clinical course
Depends on :
Virulence of infecting organism
Host immune response/resistance
Antibiotic therapy
4 stages:
Stage of hyperemia
Stage of exudation
Stage of suppuration
Stage of resolution
( Stage of coalescence and surgical mastoiditis
Stage of complication)
Stage of hyperemia
Oedema of mucoperiosteum, vascular engorgement in TM & tympanic cavity + mastoid antrum & air cells

C/F:
Otalgia 
Ear fullness
Fever
Hearing usu normal


Otoscopy:
Prominent vessels along 
manubrium, periphery of 
pars tensa and pars flaccida
Edematous drum
Landmarks still distinguished

Rx:
Abx
Symptom usu relief occurs within 12-24 hrs

Stage of exudation
Outpouring of fluid ( serum containing fibrin, RBCs & PMNs)
Filled with exudates under pressure
Quickly – virulent infection, after 12-24 hrs milder
C/F:
↑ otalgia & fever
Conductive hearing loss
Infants: very high fever, vomiting, convulsions & meningismus
Stage of exudation…
Otoscopy:
TM – red, thickened & bulging,
 loss of landmarks
Occasionally, may appear pale 




Mastoid tenderness may be present
Infants: oedema & hyperemia over cribriform area of antrum
Rx:
Abx ± Simple myringotomy
Stage of suppuration
Mucoperiosteum of tympanomastoid compartment is progressively thickened 
formation of new capillaries and fibrous tissue
+
Infiltration with L, P & PMNs


Thick mucosal lining
C/F:
↓ otalgia & fever
Worsening of hearing impairment (↑ossicular stiffness)
Stage of suppuration…
Otoscopy:
TM perforation with discharging mucopus ±






Rx
Abx 
Cleaning (toilet of EAC)
Coalescent mastoiditis
Infection persisting for >2 weeks

Thickening of mucoperiosteum
Obstruction of drainage of secretions

Reaccumulation of pus ↓pressure
+ hyperemia

Venous stasis, local acidosis

Dissolution of Ca from adjacent bony walls
Destruction of bony septa

Stage of coalescence of mastoid air cells
Coalescent mastoiditis…
C/F:
Deceptively mild
Timing more imp than severity of s/s 
Recurrence of otalgia & low grade fever
Otorrhea continues

Mastoid tenderness
Thickened periosteum
Fluctuant subperiosteal abscess→ displaces auricle outward and downward
Sagging of posterosuperior wall of EAC
Coalescent mastoiditis…
Imaging:
Opacification of tympanomastoid compartment with loss of bony septa

Rx
I.v. abx
Myringotomy
Surgical drainage ( subperiosteal abscess)
Cortical mastoidectomy
Stage of complication
Stage of resolution
↓ Discharge → finally cessation
Closure of TM perforation
Exudate → absorbed rapidly
Osteoblastic activity repairs any partially decalcified septa
Symptoms
Insufficient for Dx (nonspecific nature)
1/3rd children → no ear related symptoms
2/3rd children→ may be apyrexial

Rapid onset of otalgia
Hearing loss ( middle ear effusion)
Otorrhea → mucopurulent, may be blood-stained
Fever
Excessive crying, irritability, coryzal symptoms, vomiting, poor feeding
Ear pulling & clumsiness
Symptoms…
Symptoms…
signs
TM findings
usu opaque
Color : usu yellow or yellowish pink in color
red in ~18-19%
Position : bulging
↓ mobility (pneumatic otoscopy)
Perforation
Discharge ( if perforation or VT)
Signs…
Diagnosis
Non specific symptoms
+
Evidence of inflammation
+
Confirmation of a middle ear effusion

Clinicians diagnostic certainty 
(large multinational study)
~ 58% → in children < 1 yr of age 
~ 73% → in children >31 months of age

Elements of the definition of AOM are all of the following:
1. Recent, usually abrupt, onset of signs and symptoms of
middle-ear inflammation and MEE
2. The presence of MEE that is indicated by any of the following:
a. Bulging of the tympanic membrane
b. Limited or absent mobility of the tympanic membrane
c. Air-fluid level behind the tympanic membrane
d. Otorrhea
3. Signs or symptoms of middle-ear inflammation as indicated by either
a. Distinct erythema of the tympanic membrane or
b. Distinct otalgia (discomfort clearly referable to the ear[s]
that results in interference with or precludes normal activity or sleep)
Investigations
Audiometry: CHL
Tympanometry & pneumatic reflectometry: Middle ear effusion
Tympanocentesis & culture of middle ear fluid
Rarely reqd for dx
Considered in high risk children
Immunocompromised
Unwell neonate
Who fail to respond conventional tt
Seriously ill child
Child with complication of AOM
Investigations…
Imaging: 
X-Ray
CT/MRI → when complication is suspected

Other tests
CBC
Immunoglobulin assay
Inv for primary ciliary dyskinesia
Differential diagnosis
Pain → Tonsillitis, teething, TMJ disorder or URTI
Red TM → crying child, cerumen removal, fever
Others:
Acute mastoiditis, OME, otitis externa, trauma, Ramsey Hunt syndrome, bullous myringitis
Treatment
Treatment of acute episodes:
Conservative tt
Analgesics and antipyretics
Quiet supportive environment

Medical tt
Antibiotics(abx)
Antihistamines & decongestants→ use not recommended; rather if combined they are associated with more S/Es.

Surgical tt → myringotomy
Antibiotics
Treat or not to treat?
When to treat?
What to use?
How long?
What if not treated?
Role of prophylaxis?
To treat or not to treat?
With or without abx:
2/3rd recoverd within 24 hrs &
80% by 2-7 days
No diff in hearing loss
No significant diff on progression of disease or relapse of symptoms
No diff in complications of AOM
5% less children having pain between 2-7 days
However;
↑ S/Es
↑ risk of abx resistance
Glasziou et al,2002

No treatment…
Risks
follow up difficult
risk of complications
symptoms take longer to resolve
parental anxiety, lost work days

Benefits
reduce emergence of resistant pathogens
enhanced immune response

When to treat?
Fail to improve after 2-3 days of watchful waiting
All children with an irregular illness course
High risk children (defined by Dutch )
Children with craniofacial abnormalities
Down syndrome
Immunodeficiencies
< 2 years suffering a recurrent episode of AOM
When there is high incidence of complications of AOM in area

Children < 2 yrs benefit from abx

Immediate abx →presenting with higher temperature (> 37.5°C ) or vomiting

AOM → in presence of TM perforation or VT → oral or topical abx





How long to treat?
Short course (5 days) Vs. long course (10days)
Failure rates
8-19 days     19%    short course
    13.7%  long course
20-30 days     15.7%  short course
    12.5%  long course

Authors conclusion:
5 days of tt was appropriate in uncomplicated infections in low risk children > 2 yrs without recurrent AOM or TM perforation
Kozyrsky et al, 2002
Which antibiotic?
Depends on:
Knowledge of likely etiologic agent or recovery of specific pathogen from middle ear
Efficacy of specific abx for responsible organisms
 Abx penetration into middle ear fluid
Drug allergy hx
Compliance
 Drug side effects
Treatment failure or success of previous drug regimens for that child



Which antibiotic?...
Amoxicillin
Amoxicillin + clavulinic acid
TMP/SMX
Cefaclor/cefuroxime/Cefprozil/Cephalexin
Cefdinir/ceftriaxone/ cefixime
Azithromycin/Clarithromycin

If after 3 days of treatment and still AOM: 
High dose amox-clav
Cefuroxime
IM Ceftriaxone (50 mg/kg /day) for 3 consecutive days
Cefdinir


Which antibiotic?...
Amoxicillin: 
Still drug of choice 
Safe and well tolerated and inexpensive
Usually effective against S. pneumoniae  and H. influenzae
Higher doses have greater efficacy against more strains of S. pneumoniae

Cephalosporins:
Cefuroxime, cefpodoxime and ceftriaxone IM effective against both S. pneumoniae and H. influenzae


Which antibiotic?...
Ceftrixone
Advantages
short duration 3 days
compliance better
efficacious against all 3 organisms
alteration of gut flora is less
Disadvantages
painful injections multiple
expensive

Acute Otitis Media: 
Special Treatment
PCN Allergy: Clinda, Erythromycin, TMP/SMX, clarithromycin, azithromycin
Infant < 2wks old: 
GBS, S. aureus, Gram neg. Bacilli
Full septic W/U: CBC, Blood C/S, UA/C/S, LP/CSF C/S, CXR
Admit for IV abx: amp + Gent or ceftriaxone
If 2-6 wks old: possible septic W/U depending on appearance of infant, available close follow up

Surgical treatment
Myringotomy
Myringotomy + abx → no advantages over abx alone
Myringotomy alone → worse result than abx groups

Indications:
Severe cases when complication is present or suspected
To relieve severe pain or
When microbiology is strongly reqd

Management of 
recurrent AOM
Alteration of risk factors
Medical prophylaxis : antibiotics xylitol vaccination immunoglobulins benign commensals
Surgical prophylaxis:
Alteration of risk factors
Exposure to other children (day care)
Avoid passive smoke inhalation
Restrict use of pacifiers
Continue breastfeeding for atleast 6 months
Sitting child semi-upright if bottle fed
↑ vit C intake
Avoid alcohol (in 3rd trimester)
Medical prophylaxis
Antibiotics:
Recurrent  AOM
Broad spectrum drug
Sulfisoxazole, amoxicillin, ampicillin, pcn
Drawbacks:
↑ resistant organisms
Adverse drug rxn
Active disease may be masked
Reduction of approx 1.5 episodes per 12 months of abx tt given (metaanalysis)
Medical prophylaxis…
Xylitol:
Sweetener
Inhibits pneumococcal growth & attachment of pneumococci & hemophilus to nasopharyngeal cells
Useful in day care nurseries
Chewing gum or syrup
Use not yet recommended:
→ large quantities needed to consume
→concern over safety

Medical prophylaxis…
Vaccination:
Against viruses:
Influenza A 
→ only commercially available
→ 30-36% fewer AOM during influenza episode
→ ↓ influenza associated AOM by 83-93%
RSV vaccines : clinical trials
Parainfluenza vaccines : preparation phase

Medical prophylaxis…
Against bacterias:
Pneumococcal vaccine available 
→heptavalent conjugated vaccine (< 2 yrs)
 → 23 valent polysaccharide vaccine ( > 2 yrs)
Non typeable H. influenzae → being developed (phase I trial)
M. Catarrhalis → preclinical stage

Difficulty due to low immunogenicity of polysaccharide capsules
Medical prophylaxis…
Immunoglobulins:
No proven role in otitis prone children
Japan:
IVIG in IgG2 deficient → effective in preventing AOM

Benign commensals:
Α streptococci spray → inhibit growth of pathogenic bacterias
Surgical prophylaxis
Ventilation tubes:
Recurrent AOM
Failed medical strategies
Absolute reduction of 1.0 episode of AOM/child/yr
↓ prevalence - OME
79%→ improved quality of life (metanalysis)
S/E 
7% recurrent otorrhea,4% chronic otorrhea
↑ TS & TM atrophy
Amoxicillin (↓ AOM) Vs VT (↓ OME duration) Vs placebo




Surgical prophylaxis…
Adenoidectomy & adenotonsillectomy:
Evidence ±
In pt with VTI and subsequent AOM 

28% and 35% fewer episodes of AOM at 1st and 2nd yrs

OPD care
F/u
In 48 hrs if symptomatic
Otherwise f/u care after 10-14 days of acute event
Persistent middle ear effusion expected at initial f/u, pt should be encouraged to f/u until effusion subsides

Outcomes
May resolve rapidly with or without abx
May prove resistance to 1st line abx
May persist or recur shortly after a course of abx has finished
Subsequently recur
May persist & progress to TM perforation & complication

Middle ear effusions: (URTI → AOM → OME)
OME rates:   63% 2 weeks after AOM
40% at 1 months
26% at 3 months

Outcomes…

Auditory functioning:
1/3rd  → A-B gap > 20 dB at 1 month after infection
1/5th → …………………………….3 months……………………..
Small but significant loss of very high frequency hearing (11-16 kHZ) in those with many episodes of AOM

Speech & language development:
No separate literature on  AOM & OME
Effect on expressive language development
Natural history
Without abx tt:
Symptomatic relief from pain & faver 
( but not otorrhea)
Within 24 hrs → 60% children
2-3 days → 80% children
4-7 days→ 88% children
73% reach complete resolution by 7-14 days
Excluded:
High risk, < 2yrs and with complications
Acute necrotizing 
otitis media
Special form of ASOM
Scarlet fever, measles, pneumonia, influenza
Necrosis & sloughing of considerable areas of tissue
Agent : β hemolytic streptococci
Diff. from other AOM:
Early spontaneous TM perforation
Malodorous purulent discharge
Profound SNHL
Otoscopy: 
large TM perforation, occasionally ossicle necrosis
Traumatic otitis media
Compression injuries: 
changes in air pressure 
→Sudden (blast or slap injuries) 
→ gradual changes (barotrauma)
Penetrating injuries: 
TM perforations (Q-tips, bobby pins, keys, and paper clips)
Thermal injuries:
Lightning injuries:
Barotrauma…
Most commonly result of pressure changes experienced during commercial flights
Mechanism:
ET → blocked or lock

Unable to equalise middle ear pressure with surrounding pressure

Middle ear effusion or
 perforation of TM


Barotrauma…
↑ risk:
Faster speed of descend
Asleep during descend of flight
Distracted or working during descend

Degree of mastoid pneumatization→
 correlates with chance of developing middle ear barotrauma (inverse relation)


Barotrauma…
Symptoms
Sensation of blocked ear
Otalgia
Hearing loss (minimal, ↑ if MEE or even higher if damage to stapes foot plate, incus dislocation or # handle of malleus)
Sudden severe pain if perforation

Severe barotrauma
→ TM perforation ± ossicular damage

Barotrauma…
TM appearances ( Edmonds C et al, 1973)

Barotrauma…
Barotrauma…
Rx
Type I→ symptoms, but no (or minimal) signs
→ No specific tt
Type II → significant signs but no perforation
→ Conservative tt with either oral or topical nasal decongestants
Type III → with perforation
→ Initial observation
→ M’plasty if fail to heal spontaneously
Adv:
Await till complete resolution of symptoms before returning to diving or flying
Barotrauma…
Prevention
Medical:
 Topical nasal decongestant
 Oral pseudoephedrine
Surgical:
Myringotomy ± VTI
Summary
One of the commom illnesses of childhood
Dx can be difficult – very young children
Management recommendations varies
Modifiable risk factors – address
Emerging evidence – prophylactic strategies