From the EM Model
7.0 Head, Ear, Eye, Nose, Throat Disorders
7.1 Ear

Acute otitis media (AOM) is common in the pediatric age group. Over the years, however, a pathogen shift in AOM and increasing antibiotic resistance have resulted in a change in treatment recommendations.

In 2004, the American Academy of Pediatrics (AAP) jointly with the American Academy of Family Physicians (AAFP) unveiled a clinical practice guideline on the diagnosis and management of AOM.^1,2 Then in 2007, the AAFP independently published a review of the evaluation and management of otitis media,³ using the aforementioned clinical practice guideline as its primary reference. Both of these provide a good framework for diagnosing and treating uncomplicated AOM. There is continued monitoring of susceptibilities of pediatric bacterial isolates to follow resistance patterns.

Case Presentation

An 18-month-old boy is brought in by his mother because he has been vomiting this morning. He has had nasal congestion and difficulty sleeping for the past two days. There has been no diarrhea. No foul odor of the urine is noted and no apparent dysuria. He has no significant past medical history. He does not tolerate the taste of any medications well. Today the patient awoke later than usual and has been pulling at his left ear. His mother reports that he’s been fussy and seems to have no appetite. She says that he feels hot to the touch.

Vital signs are pulse rate 160, respiratory rate 20, temperature 39.5°C (103.1°F), and oxygen saturation 97% on room air. On examination, the patient is fussy but easily consolable by his mother and not in any evident distress. The left tympanic membrane has an obvious purulent fluid level and appears thickened and erythematous. The right tympanic membrane is dull and opaque. The eye examination is normal, including no conjunctival injection. There is no drainage from the nose. His oropharynx is clear. His lungs are clear to auscultation. His heart has a tachycardic rate, but his cardiovascular examination is otherwise unremarkable. The abdominal examination is benign, and the remainder of the physical examination is unremarkable. There are no signs of dehydration.

CRITICAL DECISION

What are the criteria for making the most accurate diagnosis of AOM?

The diagnosis of the acute infectious process of acute otitis can be made if three components are present: rapid onset, middle-ear effusion, and signs and symptoms of middle-ear inflammation. This has helped make the distinction between AOM and otitis media with effusion, a noninfectious process that does not require antibiotic treatment. Pneumatic otoscopy can be performed to detect impaired tympanic membrane mobility. An acutely inflamed tympanic membrane with purulence bulging from behind it will have reduced mobility.³

CRITICAL DECISION

What bacterial pathogens are most likely to be causing episodes of AOM in children?

The types of bacterial pathogens that cause serious bacterial infections have changed in recent decades. The introduction of the heptavalent pneumococcal conjugate vaccine in 2001 has resulted in successful reduction in Streptococcus pneumoniae bacteremia, pneumonia, and meningitis.⁴ Similarly, the introduction, a decade earlier, of the Haemophilus influenza type b vaccine reduced the incidence of H. influenzae type b as a cause of upper and lower respiratory tract infections and serious bacterial infections, although non-typeable H. influenzae strains are still commonly found causing upper respiratory tract infections.⁵ S. pneumonia, however, is still the primary bacterial cause of AOM. Respiratory viruses and Moraxella catarrhalis are the other pathogens seen in AOM.

CRITICAL DECISION

Which antibiotics are currently recommended for treatment of AOM?

S. pneumoniae has developed resistance to many antibiotics. It is no longer safe to use certain antibiotics empirically, including low-dose amoxicillin, sulfa drugs, and the macrolide class of antibiotics in children at risk for exposure to resistant strains of S. pneumoniae.^6-8 It has been shown that resistance rates (30% to 50%) are even higher in patients who have taken antibiotics within the past month.⁹ In addition, AOM caused by non-typeable H. influenzae is being found at higher rates than previously seen. If a patient has recently been treated for AOM and is experiencing a recurrence, it is important to use an antibiotic with Gram-negative coverage. Cefdinir has good efficacy against Gram-negative AOM pathogens but not as good activity against resistant S. pneumoniae.¹⁰ Studies in adults and older children have shown that AOM can be treated with shorter courses of antibiotic, but it is still recommended that infants and children under 6 years of age be treated with a full 10-day course, especially as this population of patients has higher resistance rates.^11-13 The AAP and its Section on Infectious Disease have made recommendations for antibiotic treatment considering these changes.² Other recent studies have further corroborated these findings.^10,14