eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Otitis Media: Follow-up

Author: Muhammad Waseem, MD, Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Coauthor(s): Muhammad Aslam, MD, Instructor in Pediatrics, Harvard Medical School; Chief Clinical Fellow, Department of Newborn Medicine, Children's Hospital Boston; Leslie A Wilson, MD, Chief, Well-Baby Clinic and Chronic Ear Clinic, Department of Pediatrics, Wilford Hall Air Force Medical Center
Contributor Information and Disclosures

Updated: Jul 22, 2008

Follow-up

Further Inpatient Care

  • Inpatient care is indicated only in patients with intratemporal or intracranial complications of otitis media (OM).

Further Outpatient Care

  • Most acute OM (AOM) cases resolve with antibiotic therapy, but recurrences are frequent. By the time children are aged 7 years, more than one third have experienced 6 or more episodes of AOM. In addition, many patients who are treated for AOM subsequently develop asymptomatic OME. Monitoring by otoscopic examination, acoustic reflectometry, and/or tympanometry is necessary to determine which children require further follow-up care and therapy to prevent hearing loss and resultant speech and learning disabilities.
  • Although the precise timing of follow-up visits is a matter of debate, examination after 4-6 weeks is reasonable. At the 4-week to 6-week follow-up visit, children in whom OME has not resolved should be rescheduled for a second follow-up appointment 4-6 weeks after the first.
  • If effusion persists as long as 12 weeks, perform a hearing test.
  • Refer any child in whom the hearing loss in both ears exceeds 20 dB for surgical treatment with a bilateral myringotomy and TT placement.
  • Children with a hearing loss of less than 20 dB and an MEE that persists beyond 12 weeks can be monitored, with the understanding that significant spontaneous improvement of the MEE after 12 weeks is unlikely, or they can receive antibiotic therapy using a beta-lactam–stable agent.

Inpatient & Outpatient Medications

  • Antibiotics eradicate bacteria in the middle ear that cause the inflammatory response leading to MEE and the symptoms of AOM (see Medication). The most common bacteria are S pneumoniae, H influenzae, and M catarrhalis.

Deterrence/Prevention

Medical strategies to prevent OM include eliminating risk factors for AOM, immunologic interventions, and antibiotic prophylaxis. Surgical strategies to prevent recurrent OM include prophylactic myringotomy and TT insertion.

  • Risk factors: These include daycare attendance, secondary exposure to tobacco smoke, pacifier use, and breastfeeding for less than 3 months (breastfeeding >3 mo decreases risk).
    • Daycare attendance
      • A recent meta-analysis of studies of risk factors for AOM reported care outside the home increases the relative risk of recurrent AOM by approximately 2.5 fold, probably due to greater exposure to respiratory infections. Children in daycare have an increased frequency of URIs, and their infections are often more prolonged.
      • AOM risk correlates with the number of contacts with other children rather than the absolute number of children enrolled in a center. Rates of respiratory infections, including AOM, are higher among children in daycare centers than among those receiving family care.
      • The risk of increased infection associated with group daycare is greatest in the first 2 years of life and particularly in the first year.
    • Tobacco smoke exposure
      • Tobacco smoke is an upper respiratory irritant, and multiple studies have shown that passive smoke exposure places children at increased risk for pneumonia, bronchitis, bronchiolitis, chronic MEE, and more frequent and severe asthma.
      • Most of the prior controversy regarding the relationship between tobacco smoke exposure and OM resulted from faulty study design and a failure to objectively quantify tobacco smoke exposure. Studies have controlled for confounding factors more carefully, and many have measured serum or urine concentrations of cotinine, a nicotine metabolite, to objectively determine exposure to passive tobacco smoke. These studies consistently establish a direct relationship between parental smoking and increasing risk of AOM.
      • A recent meta-analysis of risk factors determined that parental smoking increases the risk of AOM by 66%. The average duration of MEE in children with elevated cotinine levels was 28 days, compared with 19 days' duration in children without elevated levels.
    • Pacifier use: This clearly increases the risk for AOM in infants and small children, although the reason for this predisposition is uncertain. In one study, the relative risk for recurrent AOM was 1.6 in children younger than 2 years who used a pacifier and 2.9 in children aged 2 and 3 years who used a pacifier. According to one theory, the constant sucking action associated with pacifier use exacerbates ETD, leading to inoculation of the middle ear with pathogenic bacteria.
    • Breastfeeding for a duration of less than 3 months
      • Breastfeeding protects young infants from OM and GI tract illness. A recent meta-analysis reported that breastfeeding for at least 3 months resulted in a relative AOM risk of 0.87 and a relative risk of recurrent AOM of 0.69. Breastfeeding for at least 6 months reduced the risk of AOM even further.
      • The risk reduction probably results from transferred immunoglobulins, cellular elements, and many nonspecific components in mother's milk that, collectively, exhibit antibacterial, antiviral, and antiparasitic properties.
  • Passive and active immunizations
    • Passive immunization with RSV immunoglobulin IV (RSV-IGIV) in selected infants
      • Prophylactic administration of RSV-IGIV before the beginning of the RSV season (ie, Oct-Dec) prevents serious lower respiratory infections and significantly reduces episodes of AOM in selected pediatric populations (ie, children <2 y with bronchopulmonary dysplasia who have required oxygen therapy within the 6 mo prior to the RSV season, infants born before 32 weeks' gestation).
      • The cost of this therapy is prohibitively high. A recent study reported that the cost of RSV-IVIG therapy in early 2001 was approximately $7000-$8000 per episode of AOM prevented.
      • RSV-IGIV immunization cannot be recommended beyond the specific population described above, and even then, can only be recommended to prevent lower respiratory infections rather than as prophylaxis for AOM.
    • Pneumococcus vaccine
      • In February 2000, the FDA approved use of heptavalent pneumococcal CRM197 conjugate vaccine (PCV7), marketed under the brand name Prevnar by Wyeth Pharmaceuticals. PCV7 is composed of 7 pneumococcal antigens (ie, polysaccharide serotypes 4, 6B, 9V, 14, 19F, 23F; oligosaccharide serotype 18C), conjugated to 20 mcg of CRM197 by reductive amination.
      • The recommended primary series is 3 doses administered at ages 2, 4, and 6 months, with a minimum of 6 weeks between doses. A fourth (booster) dose is recommended at age 12-15 months or at least 60 days after completion of the primary series. PCV7 provides potential serotype and serogroup cross-protection (eg, 6A) in 88% of cases of bacteremia, 82% of cases of meningitis, and 71% of cases of pneumococcal OM episodes in children younger than 6 years in the United States.
      • PCV7 had decreased the number of episodes of S pneumoniae AOM caused by the serotypes included in the vaccine. It had reduced the nasopharyngeal carriage of vaccine-type S pneumoniae, particularly antibacterial-resistant organisms, and had also prevented the spread to contacts in the community. A recent observation of increased rates of antibacterial-resistant nonvaccine serotype S pneumoniae may erode the success of PCV7.
      • Pneumococcal polysaccharide vaccines have been recommended since 1985 for children older than 2 years who are at high risk for invasive disease, but these vaccines were not recommended for younger children and infants because of poor antibody response in children younger than 2 years.
      • Prymula et al have described the effectiveness of a new vaccine that contains pneumococcal capsular polysaccharides conjugated to H influenzae– derived protein D in the prevention of a first episode of AOM.21 According to their data, at present, the full effectiveness of the vaccine in treating children is questionable, even in high-risk children.
      • Pneumococcal conjugate vaccines, such as PCV7, induce proposed protective antibody responses (>0.15 mcg/mL) in more than 90% of infants after a series of 3 doses administered at ages 2, 4, and 6 months. Following the priming doses, significant booster responses (ie, immunologic memory) are apparent when additional doses are administered in patients aged 12-15 months. In efficacy trials, this new vaccine was associated with a 7% decrease in OM and a 15-20% decrease in TT placement. 
    • Influenza vaccine
      • Influenza is a highly infectious viral illness that is common during the winter months. A small proportion of AOM is directly caused by influenza viruses and may be directly prevented by immunization with influenza vaccine. In addition, any influenza infection of the upper respiratory tract leads to respiratory epithelial inflammation and associated ETD, which predisposes the host to bacterial AOM.
      • Influenza vaccine is strongly recommended for any person older than 6 months in whom age or an underlying medical condition creates increased risk for complications of influenza.
      • Influenza vaccine can be administered to any person who wishes to reduce the chance of infection by the virus. The vaccine can be administered to children as young as 6 months. Many experts recommend that children who are prone to OM receive the annual vaccine, particularly those in group daycare who have increased risk of URIs and AOM.
  • Antibiotic prophylaxis
    • Many studies in the 1970s and 1980s showed the effectiveness of antibiotic prophylaxis in children with recurrent AOM. The most common regimens were sulfisoxazole (35 mg/kg/dose qd or bid) or amoxicillin (20 mg/kg/dose qd or bid). These therapies were usually administered in patients who had 3 or more episodes of AOM within a 6-month period or 4 or more episodes within 12 months.
    • The use of antibiotic prophylaxis for AOM has become widely questioned because of the increasing antibiotic resistance among bacterial pathogens responsible for middle ear infections. Even before the drastic rise in drug-resistant bacteria, the clinical effectiveness of antibiotic prophylaxis for AOM was unimpressive.
    • A meta-analysis of 1993 studies showed that a child must be treated for 9 months to prevent just one episode of AOM.22 The meta-analysis was based on decade-old data that are almost irrelevant now because of the new prevalence of drug-resistant bacteria. Most experts who supported antibiotic prophylaxis no longer recommend routine antibiotic prophylaxis for all children with recurrent AOM.

Complications

  • Mastoiditis
    • Mastoid infections have 2 forms, namely, acute coalescent mastoiditis or chronic mastoiditis with osteitis. Treatment for both types of mastoiditis is a mastoidectomy.
    • Acute coalescent mastoiditis occurs when obstruction of the aditus (the small opening between the epitympanum and the mastoid antrum) creates a sealed space in the mastoid antrum (the air space in the mastoid portion of the temporal bone that communicates with the tympanic cavity and mastoid air cells). Acute infection of the fluid in this space usually occurs as an extension of middle ear infection. Diagnosis is confirmed with a CT scan of the head that reveals loss of septation between mastoid air cells.
    • Chronic mastoiditis occurs when acute mastoiditis remains undetected, with subsequent changes in the mucosal lining of the mastoid air cells. Granulation tissue filled with inflammatory cells replaces the air spaces of the mastoid and middle ear, and bone necrosis with erosion may result, leading to an extracranial Bezold abscess or intracranial complication. Chronic mastoiditis may not be depicted on CT scans. MRI reveals regions of nonspecific bright signal, consistent with inflammation.
  • Cholesteatoma
    • Cholesteatomas are cystlike expanding lesions of the temporal bone, lined by stratified squamous epithelium and containing desquamated keratin and purulent material. The etiology of cholesteatoma is controversial. Although cholesteatoma development is complicated and incompletely understood, contributing factors include ETD, increased negative pressures in the middle ear, repeated infection, chronic MEE, loss of collagen fibers and structural support of the TM, collapse of the TM, and formation of chronic retraction pockets.
    • Diagnosis is difficult but can be made by an experienced clinician using a pneumatic otoscopic examination in patients with chronic middle ear disease and progressive conductive hearing loss.
    • Treatment is surgical excision or exteriorization. In very rare cases (eg, the patient is not a surgical candidate because the cholesteatoma is secondary to a comorbid disease), repeated cleansing under a surgical microscope may temporarily control the cholesteatoma.
  • Labyrinthitis
    • Inflammation of the labyrinth produces vestibular and auditory symptoms. In patients with COM, bacteria may infiltrate the bony labyrinth and produce a condition of suppurative labyrinthitis. Acute symptoms include hearing loss and vertigo, which usually improve after the body goes through a phase of central compensation for the damaged vestibular organs. Prolonged labyrinth infection leads to vestibular end-organ damage and permanent hearing loss.
    • Diagnosis of labyrinthitis in patients with COM is most often retrospectively confirmed. Vertigo and sensorineural hearing loss in these patients is presumptive evidence for labyrinthitis.
    • In patients in whom hearing or vestibular function recovers, labyrinthitis is classified as serous rather than suppurative; recovery indicates that the bacteria never truly invaded the labyrinth and that the symptoms were caused by severe inflammation of the vestibular organs without bacterial invasion.
    • Labyrinthitis treatment includes intravenous antibiotics directed against the common pathogens in COM to limit damage to vestibular organs. Vestibular suppressants are used in the acute period to relieve dizziness and nausea.
  • Facial paralysis
    • In patients with invasive OM (especially OM with cholesteatoma), infection and inflammation of the facial nerve leads to edema and nerve fiber compression that causes facial paralysis. The facial nerve courses through the temporal bone in the fallopian canal, protected by bone and epineurium. Naturally occurring bony dehiscences of the fallopian canal and reactive osteitis (often due to cholesteatoma) place the facial nerve at risk in invasive OM.
    • The combination of OM with concurrent ipsilateral facial paralysis suggests an obvious diagnosis, but other entities in the differential diagnosis for acute facial paralysis should be considered. Treatment is immediate administration of intravenous antibiotics and/or surgical treatment of the cholesteatoma involving the facial nerve.
  • Meningitis
    • Meningitis is among the most common intracranial complications of OM, occurring in children with either AOM or COM.
    • Fever accompanied by neck stiffness should immediately prompt a search for an intracranial complication. As with all intracranial complications, perform a contrast-enhanced CT scan or MRI.
    • Lumbar puncture and examination of the CSF is mandatory in patients in whom meningitis is suspected. CSF leukocytosis, with low glucose and high protein and lactate levels, is characteristic of meningitis. Studies of the CSF should include Gram staining, culturing, and testing for bacterial antigens.
    • The treatment of choice is immediate administration of broad-spectrum intravenous antibiotics, followed by directed therapy based on CSF culture results. Some experts have reduced neurologic and auditory sequelae resulting from meningitis by administering dexamethasone early in the treatment course.
  • Epidural abscess
    • Epidural abscesses secondary to OM occur near the temporal bone. Infection extends to the epidural space through venous channels in the bone or by bone erosion. The most common routes for extension are through the thin bone of the tegmen to the middle cranial fossa or through the bone adjacent to the sigmoid sinus and posterior cranial fossa.
    • Most intracranial complications are accompanied by a concomitant epidural abscess because of the pathways involved in OM spread.
    • Diagnosis relies on high clinical suspicion and is confirmed using contrast-enhanced CT scan or MRI.
    • Treatment requires surgical exploration, with a cortical mastoidectomy and thinning of the bone overlying the tegmen tympani, sigmoid sinus, and posterior fossa to allow the epidural space to be seen. If granulation tissue or purulent fluid is discovered in the epidural space, continue removing bone until noninflamed dura is encountered.
  • Lateral sinus thrombophlebitis
    • Lateral and sigmoid sinuses are relatively unprotected from direct extension of infections from the middle ear and mastoid. Direct extension occurs secondary to bone erosion from osteitis or necrosis. Indirect extension occurs via retrograde thrombophlebitis of the mastoid emissary veins.
    • Obstruction of venous drainage by thrombosis can produce elevated intracranial pressure (ICP) and headache. Otitic hydrocephalous can complicate the course of lateral sinus thrombosis, leading to vision changes and sixth cranial nerve (CN VI) palsy. Septic emboli can disseminate the infection to distant body sites, and the constant bacteremia produces febrile episodes.
    • The classic clinical picture of high spiking fevers, headache, and active ear disease is rare. Diagnosis of this complication relies on high clinical suspicion and is confirmed by MRI or contrast-enhanced CT scan demonstrating the thrombosis.
    • Early administration of intravenous antibiotics and surgical exploration are the mainstays of therapy. After exposing the sigmoid sinus, a needle may be used to aspirate the sinus. If free-flowing blood returns, no further surgery is needed. If no blood returns, open and drain the sinus.
  • Brain abscess
    • Brain abscess is the first or second most common intracranial complication of COM. Most abscesses form in the temporal lobe or cerebellum, supporting the theory that brain abscesses associated with OM are probably caused by direct extension of infection and not hematogenous spread of bacteria.
    • In addition to fever from the infectious process, symptoms and signs of brain abscess relate to abscess location and the overall mass effect of the abscess. Headache, vomiting, and lethargy may indicate increased ICP. Significant localizing signs include seizures, hemiparesis, cranial nerve palsies, and aphasia. Abscesses in the temporal lobe or cerebellum can exist with relatively few early localizing symptoms.
    • A contrast-enhanced CT scan or MRI is the diagnostic study of choice.
    • The initial therapy of choice is administration of broad-spectrum antibiotics. Consult with a neurosurgeon for decisions about abscess drainage. In some patients, mastoid surgery can be performed with a neurosurgical procedure. Otologic surgery can be delayed in patients who are less stable until neurologic stability is established.

Prognosis

  • The prognosis for almost all patients with OM is excellent; the exceptions are patients in whom OM involves intratemporal and intracranial complications (<1%).

Patient Education

  • Patient education topics should include the following:
    • Avoiding risk factors
    • Appropriate use of antibiotics
    • Understanding the implications of antibiotic-resistant bacteria in OM
  • Education for health care providers should focus on the following topics:
    • Antibiotic-resistant bacteria and the need to avoid overprescribing antibiotics
    • Importance of pneumatic otoscope examination to distinguish AOM from OME
    • Treatment differences between AOM and OME
  • For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Earache.

Miscellaneous

Medicolegal Pitfalls

  • Failure to identify intratemporal and intracranial complications of acute otitis media (AOM)
  • Failure to recognize recurrent AOM or persistent OME and to screen this at-risk population for hearing loss
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Michael Jones, MD, and David Malis, MD, to the development and writing of this article.



More on Otitis Media

Overview: Otitis Media
Differential Diagnoses & Workup: Otitis Media
Treatment & Medication: Otitis Media
Follow-up: Otitis Media
Multimedia: Otitis Media
References
[ CLOSE WINDOW ]

References

  1. Fireman P. Otitis media and eustachian tube dysfunction: connection to allergic rhinitis. J Allergy Clin Immunol. Feb 1997;99(2):S787-97. [Medline].

  2. Bercin S, Kutluhan A, Yurttas V, Yalciner G, Bozdemir K, Sari N. Evaluation of laryngopharyngeal reflux in patients with suspected laryngopharyngeal reflux, chronic otitis media and laryngeal disorders. Eur Arch Otorhinolaryngol. May 21 2008;[Medline].

  3. Harimaya A, Takada R, Hendolin PH, et al. High incidence of Alloiococcus otitidis in children with otitis media, despite treatment with antibiotics. J Clin Microbiol. Mar 2006;44(3):946-9. [Medline].

  4. de Miguel Martinez I, Macias AR. Serous otitis media in children: implication of Alloiococcus otitidis. Otol Neurotol. Jun 2008;29(4):526-30. [Medline].

  5. Tauriainen S, Oikarinen S, Taimen K, et al. Temporal relationship between human parechovirus 1 infection and otitis media in young children. J Infect Dis. Jul 1 2008;198(1):35-40. [Medline].

  6. Strachan DP, Cook DG. Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax. Jan 1998;53(1):50-6. [Medline].

  7. Greenberg D, Hoffman S, Leibovitz E, Dagan R. Acute otitis media in children: association with day care centers - antibacterial resistance, treatment, and prevention. Paediatr Drugs. 2008;10(2):75-83. [Medline].

  8. Elden LM, Coyte PC. Socioeconomic impact of otitis media in North America. J Otolaryngol. 1998;27 Suppl 2:9-16. [Medline].

  9. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance--a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. Jan 1999;18(1):1-9. [Medline].

  10. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. May 2004;113(5):1451-65. [Medline].

  11. Arguedas A, Dagan R, Leibovitz E, et al. A multicenter, open label, double tympanocentesis study of high dose cefdinir in children with acute otitis media at high risk of persistent or recurrent infection. Pediatr Infect Dis J. Mar 2006;25(3):211-8. [Medline].

  12. Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet. Oct 21 2006;368(9545):1429-35. [Medline].

  13. Chandler SM, Garcia SM, McCormick DP. Consistency of diagnostic criteria for acute otitis media: a review of the recent literature. Clin Pediatr (Phila). Mar 2007;46(2):99-108. [Medline].

  14. Vernacchio L, Vezina RM, Mitchell AA. Management of acute otitis media by primary care physicians: trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline. Pediatrics. Aug 2007;120(2):281-7. [Medline].

  15. Klein JO. Review of consensus reports on management of acute otitis media. Pediatr Infect Dis J. Dec 1999;18(12):1152-5. [Medline].

  16. Noel GJ, Blumer JL, Pichichero ME, Hedrick JA, Schwartz RH, Balis DA, et al. A Randomized Comparative Study of Levofloxacin Versus Amoxicillin/Clavulanate for Treatment of Infants and Young Children With Recurrent or Persistent Acute Otitis Media. Pediatr Infect Dis J. Jun 2008;27(6):483-489. [Medline].

  17. Fischer T, Singer AJ, Lee C, Thode HC Jr. National trends in emergency department antibiotic prescribing for children with acute otitis media, 1996-2005. Acad Emerg Med. Dec 2007;14(12):1172-5. [Medline].

  18. Stool SE, Berg AO. Otitis media with effusion in young children. Clinical practice guideline number 12. 1994.

  19. Rosenfeld RM. An evidence-based approach to treating otitis media. Pediatr Clin North Am. Dec 1996;43(6):1165-81. [Medline].

  20. Bluestone CD. Role of surgery for otitis media in the era of resistant bacteria. Pediatr Infect Dis J. Nov 1998;17(11):1090-8; discussion 1099-100. [Medline].

  21. [Best Evidence] Prymula R, Peeters P, Chrobok V, et al. Pneumococcal capsular polysaccharides conjugated to protein D for prevention of acute otitis media caused by both Streptococcus pneumoniae and non-typable Haemophilus influenzae: a randomised double-blind efficacy study. Lancet. Mar 4 2006;367(9512):740-8. [Medline].

  22. Foshee WS, Steele RW. Should prophylactic antibiotics be used for the otitis-media-prone child?. Pediatr Infect Forum. 2000;2:2-7.

  23. ACIP. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Apr 30 1999;48(RR-4):1-28. [Medline].

  24. Adderson EE. Preventing otitis media: medical approaches. Pediatr Ann. Feb 1998;27(2):101-7. [Medline].

  25. Adeli M, Bender MJ, Sheridan MJ, Schwartz RH. Antibiotics for simple upper respiratory tract infections: a survey of academic, pediatric, and adult clinical allergists. Ann Allergy Asthma Immunol. Apr 2008;100(4):377-83. [Medline].

  26. Aliphas A, Prufer N, Grundfast KM. Emerging therapies for the treatment and prevention of otitis media. Expert Opin Emerg Drugs. May 2006;11(2):251-64. [Medline].

  27. American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. May 2004;113(5):1412-29. [Medline].

  28. Aronovitz GH. Antimicrobial therapy of acute otitis media: review of treatment recommendations. Clin Ther. Jan 2000;22(1):29-39. [Medline].

  29. Asher E, Dagan R, Greenberg D, Givon-Lavi N, Libson S, Porat N. Persistence of pathogens despite clinical improvement in antibiotic-treated acute otitis media is associated with clinical and bacteriologic relapse. Pediatr Infect Dis J. Apr 2008;27(4):296-301. [Medline].

  30. Bauchner H, Marchant CD, Bisbee A, et al. Effectiveness of Centers for Disease Control and Prevention recommendations for outcomes of acute otitis media. Pediatrics. Apr 2006;117(4):1009-17. [Medline].

  31. Belshe RB, Gruber WC. Prevention of otitis media in children with live attenuated influenza vaccine given intranasally. Pediatr Infect Dis J. May 2000;19(5 Suppl):S66-71. [Medline].

  32. Bitnun A, Allen UD. Medical therapy of otitis media: use, abuse, efficacy, and morbidity. J Otolaryngol. 1998;27 Suppl 2:26-36. [Medline].

  33. Block SL. Management of acute otitis media in the 1990s: the decade of resistant pneumococcus. Paediatr Drugs. Jan-Mar 1999;1(1):31-50. [Medline].

  34. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S37-46. [Medline].

  35. Blumer JL. Fundamental basis for rational therapeutics in acute otitis media. Pediatr Infect Dis J. Dec 1999;18(12):1130-40. [Medline].

  36. Bradley JS. Oral vs. intramuscular antibiotic therapy for acute otitis media: which is best?. Pediatr Infect Dis J. Dec 1999;18(12):1147-51. [Medline].

  37. Brunton S, Pichichero ME. Acute otitis media: influence of the PCV-7 vaccine on changes in the disease and its management. J Fam Pract. Nov 2005;54(11):961-8. [Medline].

  38. Byington CL. The diagnosis and management of otitis media with effusion. Pediatr Ann. Feb 1998;27(2):96-100. [Medline].

  39. Bylander-Groth A, Stenstrom C. Eustachian tube function and otitis media in children. Ear Nose Throat J. Sep 1998;77(9):762-4, 766, 768-9. [Medline].

  40. Cameron C, Dallaire F, Vézina C, Muckle G, Bruneau S, Ayotte P. Neonatal vitamin A deficiency and its impact on acute respiratory infections among preschool Inuit children. Can J Public Health. Mar-Apr 2008;99(2):102-6. [Medline].

  41. Canalis RF, Lambert PR. Acute suppurative otitis media and mastoiditis. In: Canalis RF, Lambert PR, eds. The Ear: Comprehensive Otology. Lippincott; 2000:397-408.

  42. Canalis RF, Lambert PR. Chronic otitis media and cholesteatoma. In: Canalis RF, Lambert PR, eds. The Ear: Comprehensive Otology. Lippincott; 2000:409-31.

  43. Carlson L, Scudder L. Controversies in the management of pediatric otitis media. Are more definitive answers on the horizon?. Adv Nurse Pract. Feb 2004;12(2):73-7. [Medline].

  44. Casselbrant ML, Mandel EM, Kurs-Lasky M, et al. Otitis media in a population of black American and white American infants, 0-2 years of age. Int J Pediatr Otorhinolaryngol. Aug 1995;33(1):1-16. [Medline].

  45. Chao JH, Kunkov S, Reyes LB, Lichten S, Crain EF. Comparison of two approaches to observation therapy for acute otitis media in the emergency department. Pediatrics. May 2008;121(5):e1352-6. [Medline].

  46. Chartrand SA, Pong A. Acute otitis media in the 1990s: the impact of antibiotic resistance. Pediatr Ann. Feb 1998;27(2):86-95. [Medline].

  47. Chonmaitree T. Viral and bacterial interaction in acute otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S24-30. [Medline].

  48. Chonmaitree T, Heikkinen T. Role of viruses in middle-ear disease. Ann N Y Acad Sci. Dec 29 1997;830:143-57. [Medline].

  49. Conrad DA. Should acute otitis media ever be treated with antibiotics?. Pediatr Ann. Feb 1998;27(2):66-7, 70-4. [Medline].

  50. Coulson CJ, Drake-Lee AB, Plant T, Drayson MT. Total serum IgE and IgE antibodies specific to house dust mite found in two aged-matched cohorts of children with and without otitis media with effusion. Clin Otolaryngol. Apr 2006;31(2):130-3. [Medline].

  51. Dagan R, Leibovitch E, Fliss DM, Leiberman A. Treatment failures in otitis media--what can we learn?. Ear Nose Throat J. Jun 1998;77(6 Suppl):16-9; discussion 20-1. [Medline].

  52. Daly KA, Giebink GS. Clinical epidemiology of otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S31-6. [Medline].

  53. Elsheikh MN, Mahfouz ME. Up-regulation of MUC5AC and MUC5B mucin genes in nasopharyngeal respiratory mucosa and selective up-regulation of MUC5B in middle ear in pediatric otitis media with effusion. Laryngoscope. Mar 2006;116(3):365-9. [Medline].

  54. Eskola J, Kilpi T. Potential of bacterial vaccines in the prevention of acute otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S72-8. [Medline].

  55. Fergie JE, Purcell K. The role of inflammatory mediators and anti-inflammatory drugs in otitis media. Pediatr Ann. Feb 1998;27(2):76-81. [Medline].

  56. Finkelstein JA, Stille CJ, Rifas-Shiman SL, Goldmann D. Watchful waiting for acute otitis media: are parents and physicians ready?. Pediatrics. Jun 2005;115(6):1466-73. [Medline]. [Full Text].

  57. Giebink GS. Vaccination against middle-ear bacterial and viral pathogens. Ann N Y Acad Sci. Dec 29 1997;830:330-52. [Medline].

  58. Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2000;(2):CD000219. [Medline].

  59. Gravel JS, Wallace IF. Language, speech, and educational outcomes of otitis media. J Otolaryngol. 1998;27 Suppl 2:17-25. [Medline].

  60. Haddad MB, Porucznik CA, Joyce KE, De AK, Pavia AT, Rolfs RT. Risk factors for pediatric invasive pneumococcal disease in the Intermountain West, 1996-2002. Ann Epidemiol. Feb 2008;18(2):139-46. [Medline].

  61. Handler SD, Magardino TM. Otitis media with effusion. In: Canalis RF, Lambert PR, eds. The Ear: Comprehensive Otology. Lippincott; 2000:383-96.

  62. Hashisaki GT. Complications of chronic otitis media. In: Canalis RF, Lambert PR, eds. The Ear: Comprehensive Otology. Lippincott; 2000:433-45.

  63. Heikkinen T. Role of viruses in the pathogenesis of acute otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S17-22; discussion S22-3. [Medline].

  64. Heikkinen T, Chonmaitree T. Increasing importance of viruses in acute otitis media. Ann Med. Apr 2000;32(3):157-63. [Medline].

  65. Hoberman A, Paradise JL, Cohen R. Duration of therapy for acute otitis media. Pediatr Infect Dis J. May 2000;19(5):471-3. [Medline].

  66. Jacobs MR. Antibiotic-resistant Streptococcus pneumoniae in acute otitis media: overview and update. Pediatr Infect Dis J. Oct 1998;17(10):947-52. [Medline].

  67. Jacobs MR. Increasing antibiotic resistance among otitis media pathogens and their susceptibility to oral agents based on pharmacodynamic parameters. Pediatr Infect Dis J. May 2000;19(5 Suppl):S47-55; discussion S55-6. [Medline].

  68. Jung TT, Hanson JB. Classification of otitis media and surgical principles. Otolaryngol Clin North Am. Jun 1999;32(3):369-83. [Medline].

  69. Kaleida PH, Fireman P. Diagnostic assessment of otitis media. Clin Allergy Immunol. 2000;15:247-62. [Medline].

  70. Kenna MA. Diagnosis and management of otitis media with effusion. In: Cotton RT, Myer CM III, eds. Practical Pediatric Otolaryngology. Lippincott;1999:229-46.

  71. Kenna MA. Otitis media with effusion. In: Bailey BJ, Calhoun KH eds. Head and Neck Surgery: Otolaryngology. 2nd ed. Lippincott-Raven Pub; 1998:1297-310.

  72. Klein JO. Nonimmune strategies for prevention of otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S89-92. [Medline].

  73. Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, et al. Short course antibiotics for acute otitis media. Cochrane Database Syst Rev. 2000;(2):CD001095. [Medline].

  74. Laurens MB, Becker RM, Johnson JK, Wolf JS, Kotloff KL. MRSA with progression from otitis media and sphenoid sinusitis to clival osteomyelitis, pachymeningitis and abducens nerve palsy in an immunocompetent 10-year-old patient. Int J Pediatr Otorhinolaryngol. May 8 2008;[Medline].

  75. Leibovitz E. Acute otitis media in pediatric medicine: current issues in epidemiology, diagnosis, and management. Paediatr Drugs. 2003;5 Suppl 1:1-12. [Medline].

  76. Lim DJ. Recent advances in otitis media. Report of the sixth research conference. Ann Otol Rhinol Laryngol Suppl. Oct 1998;174:1-94.

  77. Lin YS, Lee FP, Peng SC. Complications in children with long-term cochlear implants. ORL J Otorhinolaryngol Relat Spec. 2006;68(4):237-42. [Medline].

  78. Marchant CD. Managing acute otitis media: current clinical strategies. In: Physician's Desk Reference 2000. Medical Economics; 2000:101-15.

  79. Marchetti F, Bua J, Ventura A. Pneumococcal vaccination for acute otitis media. Lancet. Jun 10 2006;367(9526):1897; author reply 1898. [Medline].

  80. [Best Evidence] McCormick DP, Chonmaitree T, Pittman C, et al. Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics. Jun 2005;115(6):1455-65. [Medline]. [Full Text].

  81. McCracken GH Jr. Prescribing antimicrobial agents for treatment of acute otitis media. Pediatr Infect Dis J. Dec 1999;18(12):1141-6. [Medline].

  82. Meisel SR, Shimon I, Edgington TS, et al. Leukaemia inhibitory factor enhances tissue factor expression in human monocyte-derived macrophages: a gp130-mediated mechanism. Br J Haematol. Dec 1999;107(4):747-55. [Medline].

  83. Meropol SB. Valuing reduced antibiotic use for pediatric acute otitis media. Pediatrics. Apr 2008;121(4):669-73. [Medline].

  84. Meropol SB, Glick HA, Asch DA. Age inconsistency in the American Academy of Pediatrics guidelines for acute otitis media. Pediatrics. Apr 2008;121(4):657-68. [Medline].

  85. Murphy TF. Bacterial otitis media: pathogenetic considerations. Pediatr Infect Dis J. May 2000;19(5 Suppl):S9-15; discussion S15-6. [Medline].

  86. Oomen KP, Rovers MM, van den Akker EH, et al. Effect of adenotonsillectomy on middle ear status in children. Laryngoscope. Apr 2005;115(4):731-4. [Medline].

  87. Paradise JL. Otitis media and child development: should we worry?. Pediatr Infect Dis J. Nov 1998;17(11):1076-83; discussion 1099-100. [Medline].

  88. Pichichero ME. Acute otitis media: Part I. Improving diagnostic accuracy. Am Fam Physician. Apr 1 2000;61(7):2051-6. [Medline].

  89. Pichichero ME. Acute otitis media: part II. Treatment in an era of increasing antibiotic resistance. Am Fam Physician. Apr 15 2000;61(8):2410-6. [Medline].

  90. Poole MD. Implications of drug-resistant Streptococcus pneumoniae for otitis media. Pediatr Infect Dis J. Oct 1998;17(10):953-6. [Medline].

  91. Pransky SM. Surgical strategies for otitis media. J Otolaryngol. 1998;27 Suppl 2:37-42. [Medline].

  92. Ramilo O. Role of respiratory viruses in acute otitis media: implications for management. Pediatr Infect Dis J. Dec 1999;18(12):1125-9. [Medline].

  93. Raza M, Jalil J, Shafique M, Ghafoor T. Frequency of otitis media with effusion in recurrent upper respiratory tract infection in children. J Coll Physicians Surg Pak. Apr 2008;18(4):226-9. [Medline].

  94. Rosenblut A, Santolaya ME, Gonzalez P, et al. Penicillin resistance is not extrapolable to amoxicillin resistance in Streptococcus pneumoniae isolated from middle ear fluid in children with acute otitis media. Ann Otol Rhinol Laryngol. Mar 2006;115(3):186-90. [Medline].

  95. Sixth Research Conference. Recent advances in otitis media. Report of the sixth research conference. Ann Otol Rhinol Laryngol Suppl. Oct 1998;174:1-94. [Medline].

  96. Steinmann K, Babl FE. Antibiotic prescribing rates for acute otitis media in a paediatric emergency department. J Paediatr Child Health. Apr 2006;42(4):204-5. [Medline].

  97. Tarlow M. Otitis media: pathogenesis and medical sequelae. Ear Nose Throat J. Jun 1998;77(6 Suppl):3-6. [Medline].

  98. Yilmaz T, Ceylan M, Akyon Y, et al. Helicobacter pylori: a possible association with otitis media with effusion. Otolaryngol Head Neck Surg. May 2006;134(5):772-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

otitis media, OM, inflammation of the middle ear, middle ear inflammation, acute otitis media, AOM, otitis media with effusion, OME, serous otitis media, mucoid otitis media, secretory otitis media, glue ear, chronic otitis media, COM, chronic suppurative otitis media, earache, ear infection, middle ear infection, middle ear disease, middle ear effusion, MEE, tympanic membrane, TM, eustachian tube, ET, eustachian tube dysfunction, ETD, tympanocentesis, tympanostomy tube, TT, TT insertion

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Muhammad Waseem, MD, Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Muhammad Waseem, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD, Instructor in Pediatrics, Harvard Medical School; Chief Clinical Fellow, Department of Newborn Medicine, Children's Hospital Boston
Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Medical Association, Massachusetts Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Leslie A Wilson, MD, Chief, Well-Baby Clinic and Chronic Ear Clinic, Department of Pediatrics, Wilford Hall Air Force Medical Center
Leslie A Wilson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Alan D Murray, MD, Pediatric Otolaryngologist, ENT for Children; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, The Pediatric Surgery Center
Alan D Murray, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Maureen Strafford, MD is a member of the following medical societies: American Medical Women's Association, American Pain Society, American Society of Anesthesiologists, International Anesthesia Research Society, Society for Education in Anesthesia, Society for Pediatric Anesthesia, and Society of Cardiovascular Anesthesiologists
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.