Introduction
Background
Acute otitis media (AOM) is an infection of the middle ear. AOM accounted for approximately 25 million clinic visits and 20 million antibiotic prescriptions in 1990. However, with the introduction of the Haemophilus influenzae type b vaccine and the pneumococcal vaccine, the incidence has decreased significantly. The estimated direct costs (doctor visits and prescriptions) and indirect costs (time lost from school and work) in 1995 were $1.96 and $1.02 billion, respectively.
Pathophysiology
Children are prone to develop AOM because their eustachian tubes are shorter and more horizontal, have smaller orifices, and have less supporting cartilage compared with those of adults. These factors contribute to eustachian tube dysfunction. Mucosal inflammation and edema due to viral upper respiratory infections (URIs) further impair middle-ear drainage and interfere with host defenses. The cumulative effect predisposes children to the development AOM.
Frequency
United States
Approximately 75% of children experience at least one episode, making AOM the most common childhood infection for which antibiotics are prescribed in the United States.
Mortality/Morbidity
Morbidity of otitis media has decreased with the advent of antibiotics. In Europe, where several nations do not routinely use antibiotics, the disease is usually self-limited.
Race
AOM is more common in white and Native American children than in children of African descent.
Sex
Males are affected more often than females.
Age
AOM usually occurs between 2 months and 12 years of age, with a peak incidence between 6 months and 3 years.
Clinical
History
Symptoms of acute otitis media (AOM) include otalgia, ear pulling, sensation of a plugged ear, hearing loss, irritability, anorexia, vomiting, diarrhea, and fever (may be more closely related to a coexistent viral URI).
Physical
Evaluation for AOM requires visualization of the entire tympanic membrane (TM) and assessment of its mobility. Obstructing cerumen should be removed with a curette after softening. Pneumatic otoscopy or tympanometry can be used to detect a middle-ear effusion. Conductive hearing loss is consistent with an effusion but does not differentiate AOM from otitis media with effusion (OME). OME may accompany a viral URI or follow resolution of AOM.
- The diagnosis of AOM requires the following:
- Acute onset of symptoms
- Presence of a middle-ear effusion
- Signs of middle-ear inflammation
- Symptoms attributed to AOM should be directly referable to the ear under consideration. Bulging or reduced mobility of the TM or an air-fluid level in the middle ear defines an effusion. An inflamed TM appears yellow or erythematous, and bony landmarks are usually obscured. Note that fever or crying may cause the TMs to appear injected and red in the absence of AOM.
Causes
Nonmodifiable risk factors for AOM include prematurity, a family history of AOM, craniofacial abnormalities, male sex, white or Native American race, cohabitation with other children, and low socioeconomic status. Modifiable risk factors include day care attendance, exposure to tobacco smoke, and bottle-feeding. Clinicians should stress the reduction of modifiable risk factors when discussing the diagnosis of AOM with parents.
- Streptococcus pneumoniae, nontypeable H influenzae, Moraxella catarrhalis, and less commonly Streptococcus pyogenes and Staphylococcus aureus are the responsible bacterial organisms.
- The widespread use of the heptavalent pneumococcal vaccine appears to be reducing the incidence of AOM due to S pneumoniae. S pyogenes, S aureus, gram-negative organisms, and anaerobes account for a minority of cases. Viruses (without bacterial superinfection), including respiratory syncytial virus, rhinovirus, coronavirus, parainfluenza, influenza, adenovirus, and enterovirus, are responsible for many of AOM cases. No pathogen can be identified in 16-25% of middle-ear infections.
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References
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Further Reading
Keywords
AOM, acute otitis media, ear infection, ear infections, middle ear infection, earache, ear ache, inflammation of the middle ear, hearing loss, upper respiratory infection, URI, viral URI, otitis media in children, ear infection in children, otitis media with effusion, heptavalent pneumococcal vaccine, pneumococcal vaccine, Haemophilus influenzae type b vaccine, Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus, antibiotics for ear infection, complications of otitis media
