Otitis Media



Introduction:

Otitis media is an ear infection of the middle ear, the area just behind the eardrum. It happens when the eustachian tubes, which connect the middle ear to the nose, get blocked with fluid. Mucus, pus, and bacteria can also pool behind the eardrum, causing pressure and pain.Ear infections usually start with a cold. Although adults can get ear infections, they are most common in infants and young children. That's because a child's eustachian tubes are narrower and shorter than an adults', and it's easier for fluid to get trapped in the middle ear. In fact, 75% of all children get ear infections. They happen most often between the ages of 6 - 11 months. By age 1, 60% of children will have had at least one ear infection and 17% will have 3 or more.Ear infections usually clear up on their own. Although it used to be common for doctors to give antibiotics to children with ear infections, now guidelines from the American Academy of Pediatricians suggest taking a wait and see approach for the first 72 hours.With a severe ear infection, pressure may build up and cause the eardrum to rupture. Pus and blood may drain out. This usually relieves pain and pressure, and in most cases the eardrum heals on its own.

Signs and Symptoms:

There are two main types of ear infections: acute otitis media (AOM), and otitis media with effusion (OME), where fluid remains trapped in the ear even after the infection is gone.Acute otitis media causes pain, fever, and difficulty in hearing. If a child is too young to talk, signs of an ear infection can include crying, irritability, trouble sleeping, and pulling on the ears.Other symptoms that may be associated with an ear infection include sore throat (pharyngitis), neck pain, nasal congestion and discharge (rhinitis), headache, and ringing (tinnitus), buzzing, or other noise in the ear.

Causes:

Ear infections happen when the Eustachian tubes are blocked. Blockages can be caused by:

• A respiratory infection, such as cold or flu
• Allergies
• Exposure to cigarette smoke
• Infected or overgrown adenoids (tonsils)
• For infants, being fed lying down (drinking a bottle while lying on the back)

Ear infections happen most often in the winter. They are not contagious, but a cold may spread among a group of children and cause some of them to get ear infections.

Risk Factors:

Risk factors for otitis media include:

• Age -- children between 6 - 36 months are most likely to get ear infections
• Attending daycare
• Recent illness, such as a cold or sinus infection
• History of allergies, like hay fever, also called allergic rhinitis, or sinusitis
• Exposure to secondhand smoke
• Having family members who are prone to ear infections
• Using a pacifier

Diagnosis:

The doctor will ask questions about whether you (or your child) have had ear infections in the past and ask you to describe the current symptoms. He or she will use an otoscope to look inside the ear. If infected, there may be areas of dullness or redness or there may be air bubbles or fluid behind the eardrum. The fluid may be bloody or filled with pus. The doctor will also check for any sign of perforation -- a hole or holes -- in the eardrum.

Your doctor may also do other tests:

• Tympanometry, which uses a small handheld instrument to measure changes in air pressure in the ear. It can indicate if the eardrum is ruptured
• Reflectometry, in which a small instrument is placed near the ear and makes a sound. That allows the doctor to see if fluid is present behind the eardrum.
• A hearing test may be recommended if your child has had persistent ear infections.

Preventive Care:

You can reduce your child's risk of ear infection. Here are some tips:

• Don't expose your child to secondhand smoke.
• Keep your child away from other children who are sick.
• Always hold your infant in an upright, seated position during bottle feeding.
• Breastfeeding for at least 6 months can make a child less prone to ear infections.
• Don't use a pacifier.

The pneumococcal vaccine (Prevnar) prevents infections such as pneumonia and meningitis, and studies show it slightly reduces the risk of ear infections.

Diagnostic Criteria for Otitis Media

Type	Diagnostic criteria
Acute otitis media	Acute onset
		and
	Middle ear effusion, indicated by bulging tympanic membrane, limited or absent mobility of membrane, air-fluid level behind membrane
		and
	Symptoms and signs of middle ear inflammation, indicated by erythema of tympanic membrane or otalgia affecting sleep or normal activity
Persistent acute otitis media	Persistent features of middle ear infection during antibiotic treatment
		or
	Relapse within one month of treatment completion
Recurrent acute otitis media	Three or more episodes of acute otitis media within six to 18 months
Otitis media with effusion	Fluid behind the tympanic membrane in the absence of features of acute inflammation
Chronic otitis media with effusion	Persistent fluid behind intact tympanic membrane in the absence of acute infection
Chronic suppurative otitis media	Persistent inflammation of the middle ear or mastoid cavity
	Recurrent or persistent otorrhea through a perforated tympanic membrane

Agents Used in the Treatment of Otitis Media

Agent	Dosage	Comments
Antimicrobials*
Amoxicillin	80 to 90 mg per kg per day, given orally in two divided doses	First-line drug. Safe, effective, and inexpensive
Amoxicillin/clavulanate (Augmentin)	90 mg of amoxicillin per kg per day; 6.4 mg of clavulanate per kg per day, given orally in two divided doses	Second-line drug. For patients with recurrent or persistent acute otitis media, those taking prophylactic amoxicillin, those who have used antibiotics within the previous month, and those with concurrent purulent conjunctivitis
Azithromycin (one dose; Zithromax)	30 mg per kg, given orally	For patients with penicillin allergy. One dose is as effective as longer courses
Azithromycin (three-day course; Zithromax Tripak)	20 mg per kg once daily, given orally	For patients with recurrent acute otitis media
Azithromycin (five-day course; Zithromax Z-pak)	5 to 10 mg per kg once daily, given orally	For patients with penicillin allergy (type 1 hypersensitivity)
Cefdinir (Omnicef)	14 mg per kg per day, given orally in one or two doses	For patients with penicillin allergy, excluding those with urticaria or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Cefpodoxime (Vantin)	30 mg per kg once daily, given orally	For patients with penicillin allergy, excluding those with urticaria or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Ceftriaxone (Rocephin)	50 mg per kg once daily, given intramuscularly or intravenously. One dose for initial episode of otitis media, three doses for recurrent infections	For patients with penicillin allergy, persistent or recurrent acute otitis media, or vomiting
Cefuroxime (Ceftin)	30 mg per kg per day, given orally in two divided doses	For patients with penicillin allergy, excluding those with urticaria or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Clarithromycin (Biaxin)	15 mg per kg per day, given orally in three divided doses	For patients with penicillin allergy (type 1 hypersensitivity). May cause gastrointestinal irritation
Clindamycin (Cleocin)	30 to 40 mg per kg per day, given orally in four divided doses	For patients with penicillin allergy (type 1 hypersensitivity)
Topical agents†
Ciprofloxacin/hydrocortisone (Cipro HC Otic)	3 drops twice daily	—
Hydrocortisone/neomycin/polymyxin B (Cortisporin Otic)	4 drops three to four times daily	—
Ofloxacin (Floxin Otic)	5 drops twice daily (10 drops in patients older than 12 years)	—
Analgesics
Acetaminophen	15 mg per kg every six hours	—
Antipyrine/benzocaine (Auralgan)	2 to 4 drops three to four times daily	—
Ibuprofen (Motrin)	10 mg per kg every six hours	—
Narcotic agents	Variable	May cause gastrointestinal upset, respiratory depression, altered