Ear Infection (cont.)

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How is acute otitis media diagnosed?

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have determined the criteria which are needed to diagnose acute otitis media (AOM); acute onset, middle ear effusion (MEE), and middle ear inflammation. The new guidelines describe this as "moderate to severe bulging of the tympanic membrane (ear drum) or new onset of otorrhea (ear drainage) not due to external otitis (inflammation of the ear canal) or mild bulging of the ear drum, and recent ear pain (holding, tugging, rubbing ear in a nonverbal child) or intense reddening of the ear drum." The guideline also strongly recommends that clinicians should not diagnose AOM without the presence of MEE. Recurrent acute otitis media is defined as three acute otitis media episodes in 6 months or 4 acute otitis media episodes in a year. There is no definitive lab test for acute otitis media.

Identification of the three criteria is dependent on clinical observation; middle ear effusion and middle ear inflammation are the most difficult to observe and as a consequence there are studies that suggest acute otitis media is over diagnosed. One method that helps determine acute otitis media versus otitis media with effusion is pneumatic otoscopy (the normal eardrum moves readily with pressure changes) and the appearance of the tympanic membrane (acute otitis media has abnormal appearance, otitis media with effusion does not). However, not everyone is skilled at this technique; Pediatricians, Family Practice, ENT specialists, and ER doctors that work in pediatric ER's are likely to be skilled in the diagnostic procedure.

How is acute middle ear infection or inflammation treated?

The treatment for acute otitis media varies depending upon the age and symptoms of the child. The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend the following:

AAP and AAFP Recommendations 2013
Age
Certain Diagnosis
(Otorrhea with AOM or Unilateral or Bilateral AOM with Severe Symptoms)
Certain Diagnosis
(Bilateral AOM without Otorrhea)
Uncertain Diagnosis (Unilateral AOM without Otorrhea)
6 months-23 months

Antibiotics
Antibiotics if severe illness; *Observation without antibiotics if non-severe illness
≥2 years Antibiotics Antibiotics if severe illness; *Observation if non-severe illness Antibiotics if severe illness; *Observation without if non-severe illness

*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents can be started if symptoms persist or worsen within 2-3 days. The new guidelines also recommend “shared decision making” with the caregiver. Non-severe illness is represented by mild ear pain and fever <39 C (102.2 F) in the past 24 hours. Severe illness is defined as moderate to severe otalgia (ear pain) or any ear pain for at least 48 hours or fever 39 C.

If antibiotics are initiated, amoxicillin is usually recommended as the first line treatment. This is usually prescribed for 10 days. About 10% of children do not respond within the first 48-72 hours of treatment, and antibiotic therapy may have to be changed. Even after antibiotic treatment, some children are left with some fluid in the middle ear which can cause temporary hearing loss lasting for up to 3 to 6 weeks. In most children, this fluid eventually disappears spontaneously (on its own). Ceftriaxone (50mg/kg/d) injection is recommended for children that cannot take oral antibiotics; three days of this antibiotic is usually more effective than a single injection.

Children who have recurring bouts of otitis media may be referred to an otolaryngologist (ear nose and throat specialist or ENT). Some of these children may benefit from having an ear tube placed (tympanostomy tube) to permit fluid to drain from the middle ear. In addition, if a child has a bulging eardrum and is experiencing severe pain, a procedure to lance the eardrum (myringotomy) may be recommended to release the pus. The eardrum usually heals within a week. Prophylactic antibiotic therapy has not been shown to decrease the frequency of ear infections in those children with recurrent AOM.

Medically Reviewed by a Doctor on 7/11/2014

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