Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Otitis Media, Acute
An acute infection in the middle ear characterized by middle ear effusion, leading to partial or complete obstruction of the eustachian tube. It is generally associated with acute signs of illness.
I. Etiology
A. Major causative organisms are S. pneumoniae (25%–50%), H. influenzae (25%), and Moraxella catarrhalis (16%). A small percentage of cases are due to group A beta-hemolytic streptococci (5%) and S. aureus (2%).
B. Middle ear aspirates have identified a virus in 10% to 20% of cases of acute otitis. It is unclear whether the viruses are a primary cause of acute otitis or whether they promote bacterial superinfection.
II. Incidence
A. Otitis media is the second most common organic disease seen in pediatric practice (upper respiratory tract infection is the most common) and the most common infection for which antibiotics are prescribed.
B. Incidence corresponds to the incidence of acute upper respiratory infection.
C. Peak prevalence is in the 6to 36-month age group.
D. There is an increased incidence in children with cleft palate and with Down syndrome.
E. Approximately 93% of all children have at least one episode by age 7 years.
F. Diagnosis, treatment, and follow-up of otitis media comprise up to 33% of pediatric office visits.
G. Incidence declines at about 6 years of age.
H. Children younger than 2 years who are in day care, have a history of recurrent otitis media, or have been in contact with individuals treated with antibiotics are more likely to have resistant streptococcal pneumonia and beta lactamase-producing gram-negative organisms than those older than 2 years.
III. Subjective data
A. Usually present with a history of rapid onset on one or more of the following symptoms:
1. Rhinorrhea
2. Malaise
3. Irritability
4. Restlessness
5. Pulling or rubbing ear
6. Pain in ear
7. Purulent discharge from ear
8. Temperature may be elevated to 101F to 102F (38.3C to 38.8C)
9. Diarrhea or vomiting
B. Pertinent subjective data to obtain
1. History of upper respiratory infection
2. History of ear infections
3. Family history of allergies
4. Does hearing seem normal?
5. Does the child take a bottle to bed, or is he or she fed supine with a propped bottle or flat on mother’s lap?
6. Is child in day care or has child been around other children treated with antibiotics?
7. Does anyone smoke in the home?
IV. Objective data
A. Abrupt onset of any or all of the following:
1. Otalgia
2. Irritability
3. Otorrhea
4. Fever
B. Middle ear effusion
1. Bulging of TM best predictor of otitis media
2. Decreased or absent mobility as confirmed by
a. Pneumatic otoscopy
b. Tympanometry
c. Acoustic otoscopy
3. Air fluid level visualized behind TM
4. Discharge
C. Middle ear inflammation
1. Inflammation of tympanic membrane
2. Opacity or cloudiness not attributed to scarring
3. Bulla on tympanic membrane
D. Include evaluation for the following:
1. Mastoid tenderness
2. Adenopathy
3. Pharyngitis
4. Lower respiratory tract involvement
V. Assessment
A. Diagnosis is confirmed by
1. A history of acute onset
2. Presence of middle ear effusion
3. Signs of middle ear inflammation
B. Differential diagnosis
1. Hyperemia of the TM from crying or high temperature: TM is bright, landmarks are evident, and mobility is normal.
2. Eustachian tube obstruction: Causes transient pain, but TM is normal.
3. Otitis media with effusion or serous otitis: TM is not inflamed and will not move inward with positive pressure, although it may move outward on negative pressure. Air bubbles may be visualized behind TM (see Otitis Media with Effusion, p. 355).
4. External otitis: Diffuse inflammation of the ear canal with or without exudate; pain on movement of pinna. TM may be inflamed with widespread involvement.
VI. Plan
A. Antimicrobials for child with confirmed diagnosis
1. Usual duration of treatment
a. 10-day course for children through age 5 years
b. 7-day course for children age 5 years and over, with mild to moderate disease
2. Amoxicillin
a. 80–90 mg/kg/d
b. Recommended for most children
c. Risk factors for presence of species resistant to amoxicillin include day care attendance, recent treatment (less than 30 days) with antibiotics and age under 2 years
3. Augmentin
a. 90 mg/kg/d in 2 divided doses
b. Use with severe illness
(1) Moderate to severe otalgia
(2) Fever of 39C or above
4. Azithromycin
a. 10 mg/kg/d on day one
b. 5 mg/kg/d on days 2 through 5 or
5. Sulfamethoxazole-trimethoprim
a. 6–8 mg/kg/d of trimethroprim or
6. Clindamycin
a. 30–40 mg/kg/d in 3 divided doses
b. Use for known or suspected S. pneumoniae infection or
7. Ceftriaxone 50 mg/kg
a. Parenteral
b. Single or multiple dosing
c. Use if vomiting or cannot tolerate medication by mouth
B. Observation option: Recently included in treatment parameters because of increasing rates of antibacterial resistance.
1. For healthy children over 2 years of age with confirmed diagnosis with nonsevere illness
2. For children over 2 years of age with uncertain diagnosis and non severe illness
a. Mild otalgia
b. Fever less than 39C
3. Do not use if
a. Child has underlying conditions such as cleft palate, Down syndrome, or immunodeficiencies.
b. Recurrence of otitis media within 30 days.
c. Chronic otitis media with middle ear effusion
d. Unreliable caretaker
4. Reassess in 48–72 hours if no improvement or symptoms worsen
5. Provision must be made for follow-up visit and/or telephone contact.
6. Prescription may be given for reliable parent to fill after contact with office.
C. Antibiotic treatment after initial treatment failure of first line therapy or observation:
1. Observation failure
a. Amoxicillin 80–90 mg/kg/d
2. Failure with initial treatment with amoxicillin
a. Augmentin 90 mg/kg/d amoxicillin component
3. Failure with initial treatment with Augmentin
a. Cefdinir 14 mg/kg/d in 1 or 2 doses
Do not use if urticarial reaction to amoxicillin
b. Azithromycin
c. Clarithromycin
d. Ceftriaxone 50 mg/kg/d IM or IV for 3 days
(1) Therapy is for 3 days for children unresponsive to initial therapy.
(2) Preferred therapy, if Augmentin fails
E. Antihistamines and decongestants
1. Not recommended for treatment of otitis; therefore, order them only for symptomatic relief, not routinely.
2. Use an antihistamine/decongestant, such as Actifed or Dimetapp, for children with known allergic rhinitis.
3. Use a decongestant, such as Sudafed, for children with acute nasal congestion.
D. Acetaminophen for elevated temperature or pain, 10 to 15 mg/kg every 4 hours
E. Auralgan Otic Solution, 4 times a day, for relief of pain and reduction of inflammation if TM is not perforated
F. Do a record review with each incidence of otitis. Question parent about interval visits to emergency room or other health care provider. Followup plan may need to include prophylaxis.
VII. Education
A. Encourage fluids. Baby may not suck because of pain. Offer small amounts frequently by teaspoon or shot glass.
B. Medication
1. Give medication for full course.
2. If child cannot retain medication, call back immediately.
3. Side effects of antimicrobials are diarrhea, rash, and fever.
4. Side effects of antihistamine and decongestant preparations are lethargy or hyperactivity.
5. If using Auralgan: Fill canal with medication; do not touch ear with dropper; use cotton pledget in meatus after instilling. Use only for pain; discontinue use once pain has subsided; do not use if eardrum is ruptured. Do not use for future ear infections until ear has been evaluated.
C. Improvement should be noted within 24 hours of treatment.
D. Child may return to school once temperature has been normal for 24 hours.
E. There is no evidence that otitis media is transmitted person to person; rather, the viral infections predisposing a child to otitis are transmitted person to person.
F. Child may have temporary difficulty hearing. Notify school if applicable.
G. Complete resolution of middle ear effusion may require 8 to 12 weeks.
H. Explain disease process to parent. Reassure that earache did not occur because child went out without a hat or because the ears got wet during shampoo.
I. Explain postural factors implicated in otitis media. Discontinue bottle in bed or horizontal feedings.
J. Stress importance of follow-up. Recognize that treatment of an episode of otitis media can be very expensive, and if there are recurrences or two children in the same family have otitis media, parents may be concerned about the cost and may not return unless they understand why it is necessary.
K. Explain that there may be an increased incidence of otitis with new exposures when child enters day care or kindergarten.
L. Concurrent viral infections significantly interfere with the resolution of otitis media.
VIII. Follow-up
A. Call back if child vomits medication or if side effects to medication occur.
B. Return if child does not improve in 24 to 48 hours or if there is persistent fever, pain, or discharge.
C. Return visit in 3 to 4 weeks for evaluation for otitis media with effusion, hearing loss, or poor resolution of infection. Include otoscopic examination, pneumatic otoscopy, and audiogram, as well as tympanometry or acoustic otoscopy if available.
D. If symptoms have not improved within 48 hours, retreat for resistant organisms. Include subsequent follow-up on treatment plan.
E. Chemoprophylaxis is now controversial due to increasing antibiotic resistance. General guidelines include
1. Three episodes in 6 months or 4 in 1 year
2. Chemoprophylaxis should be continued during period of peak incidence of viral respiratory infections.
3. Recheck every 3 to 4 weeks (according to office protocol) if child on chemoprophylaxis.
4. Chemoprophylaxis: Half therapeutic dose once daily, preferably at bedtime
a. Sulfisoxazole, 50 mg/kg/d or
b. Amoxicillin, 20 mg/kg/d in a single daily dose
F. Recurrent otitis media while on chemoprophylaxis: Discontinue chemoprophylaxis and treat with another antibiotic.
IX. Complications
A. Recurrent otitis media
B. Perforation of tympanic membrane
C. Mastoiditis
D. Meningitis
E. Reaction to medication
X. Consultation/referral
A. Infants younger than 3 months
B. No improvement within 24 hours
C. Failure of tympanic membrane to regain normal appearance after 20 days of treatment
D. Cases of frequent recurrences (e.g., three in one season), consult or refer for chemoprophylaxis. Give one-half therapeutic dose of amoxicillin, sulfisoxazole, or trimethoprim sulfamethoxazole to suppress colonization.
E. Persistent diminished hearing
F. Myringotomy with tube insertion must be considered in a child with
1. Persistent middle ear effusion between recurrent episodes of acute otitis media.
2. Consistent hearing loss of more than 15 decibels (dB) for longer than 3 months
3. An effusion present for more than 3 months