Acute otitis media

Background

• Peak incidence: 6-18 months of age
• Etiology
  • Viral (70% of cases)
  • Bacterial
    • S. pneumo (50%)
    • Nontypable H. flu (30%)
    • Moraxella (30%)

Diagnosis

1. Acute onset (<48hr) AND
2. Middle ear effusion AND
3. Signs of middle ear inflammation
4. Notes
   1. Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level
   2. Middle Ear inflammation: erythema of TM or otalgia

DDX

Common

• Acute otitis media
• Chronic otitis media
• Serous otitis media
• Foreign body in external ear canal
• Otitis externa

Less common

• Accidental trauma
• Oral cavity disease (referred pain)
• Cholesteatoma
• PTA

Rare

• Mastoiditis
• Brain abscess
• Lemierre's Syndrome
• Herpes zoster oticus

Management

1. Analgesia
   1. Acetaminophen/ibuprofen and topical benzocaine (unless perforated TM)
2. Antibiotics (See also AAP Guidelines below)
   1. Indications:
      1. Age <6mo
      2. Ill-appearing
      3. Recurrent acute otitis media (w/in 2-4wk)
      4. Concurrent abx tx
      5. Other bacterial infections
      6. Immunocompromised
      7. Craniofacial abnormalities
   2. Wait-and-see antibiotic prescription
      1. If symptoms worsen or persist x48-72 then family fills the Rx

Antibiotics

Initial Treatment

1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses 7-10 days

Treatment during prior Month

1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
   • Clavulanate increases vomiting/diarrhea
2. Cefdinir 14mg/kg/day BID x7-10 days
3. Cefpodoxime 10mg/kg PO daily x7-10 days
4. Cefuroxime 15mg/kg PO BID x7-10 days
5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

• Suggestive of non-typeable H.flu

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
   • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
   • Use if cannot tolerate PO

Penicillin Allergy

1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
2. Clarithromycin 7.5mg/kg PO BID x 10 days
3. Clindamycin 10mg/kg PO three times daily
   • Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use

AAP Guidelines

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Complications

1. Mastoiditis
2. Meningitis
3. Brain Abscess
4. Lateral Sinus Thrombosis

See Also

Otitis Externa

Sources

• Tintinalli