Definition
A.Acute otitis media (AOM) is inflammation of the middle ear associated with an acute bacterial infection of the middle ear.
Incidence
A.AOM commonly occurs in children, but it may be seen in adults and geriatric patients.
Pathogenesis
A.Obstruction of the eustachian tube can lead to middle ear effusion and infection. Contamination of this middle ear fluid often results from a backup of nasopharyngeal secretions. The most common bacterial pathogens in adults are Streptococcus pneumoniae and Haemophilus influenzae.
Predisposing Factors
A.Recurrent otitis media (three or more episodes in the past 6 months).
B.Previous episode of otitis media or upper respiratory infection (URI) within the last month.
C.Medical condition that predisposes to otitis media (i.e., Down syndrome, AIDS, cystic fibrosis, cleft palate, immune disorders, and craniofacial abnormalities).
D.Native American/Inuit heritage.
E.Smoking in the household.
F.History of allergies.
Common Complaints
A.Ear pain.
B.Fever may or may not be present.
Other Signs and Symptoms
A.Sleeplessness within past 48 hours.
B.Decreased appetite.
C.Acute hearing loss.
D.URI symptoms.
E.Mastoiditis presenting with a swollen and red mastoid.
F.Perforated tympanic membrane (sudden severe pain followed by immediate relief of pain with fluid drainage from the ear).
G.Cholesteatoma (saclike structure in the middle ear accompanied by white, shiny, greasy debris).
Subjective Data
A.Elicit onset and duration of symptoms.
B.Inquire whether the patient recently had (or has concurrently) a URI.
C.Determine whether the patient has any change in hearing.
D.Assess the patient for any drainage from the ear(s).
E.Question the patient or his or her caregiver regarding risk factors.
F.Identify the patient’s history of otitis media.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Observe the canal and auricle for redness, deformity, drainage, or foreign body.
2.Inspect the tympanic membrane position to determine if it is neutral, whether landmarks are visible, retracted, full, or bulging.
3.Observe ears for decreased or absent tympanic membrane mobility (with pneumatic otoscope).
4.Inspect nose, mouth, and throat.
C.Auscultate: Auscultate heart and lungs.
Diagnostic Tests
A.Tympanogram shows flat or type B curve.
B.Hearing test should be done in patients with persistent otitis media (≥3 months duration).
C.Consider complete blood count if the patient appears toxic with a high fever.
Differential Diagnoses
A.AOM.
B.Otitis media with effusion (OME).
C.URI.
D.Mastoiditis.
E.Otitis externa.
Plan
A.General intervention: Pain relief with acetaminophen or ibuprofen. Auralgan may be used for a topical pain relief.
B.Patient teaching: Stress the importance of taking antibiotics as prescribed and finishing the prescription as ordered. If pain, fever, or other symptoms do not improve in 48 to 72 hours, then the patient should notify the provider for further evaluation.
C.Pharmaceutical therapy:
1.Drug of choice: With mild infection amoxicillin 500 mg orally every 12 hours or 250 mg orally every 8 hours for 5 to 7 days. For severe infection (fever, severe pain, hearing loss, etc.) amoxicillin 875 mg orally every 12 hours or 500 mg orally every 8 hours for 10 days.
2.For concerns of amoxil resistance, treatment failure, recent use of antibiotic in the previous 30 days, and/or concurrent other infections, use an antibiotic with beta-lactamase activity such as amoxicillin-clavulanate (Augmentin). Augmentin 500 mg orally every 12 hours or 875 mg orally every 12 hours for 7 to 10 days.
3.For penicillin allergy: Cefdinir 300 mg orally every 12 hours or 600 mg orally daily for 5 to 7 days:
a.Cefpodoxime 200 mg orally every 12 hours for 5 to 7 days.
b.Cefuroxime 500 mg orally every 12 hours for 5 to 7 days.
c.Ceftriaxone 2 g intramuscularly or intravenously once.
4.Other alternatives for patients known to have a severe allergy to beta-lactam antibiotics:
a.Macrolides (up to 50% S. pneumoniae resistant).
b.Azithromycin 500 mg orally as a single dose on Day 1, then 250 mg orally on Days 2 to 5 or clarithromycin 500 mg orally twice a day for 5 to 7 days.
c.Trimethoprim with sulfamethoxazole DS one tablet orally twice a day for 5 to 7 days.
5.Antibiotic treatment is recommended for all adults and geriatric patients diagnosed with AOM.
Follow-Up
A.Recheck the patient in 2 weeks to evaluate for resolution of the infection. Documentation of the resolution of the ear infection is valuable information if infections are recurrent.
B.If fever, pain, hearing loss, or other new symptoms present or if the patient is not improved in 48 to 72 hours, then a follow-up appointment is recommended.
Consultation/Referral
A.Consult or refer the patient to a specialist (otolaryngologist) if the patient appears septic or is diagnosed with mastoiditis.
B.A patient with persistent otitis media with a hearing loss of 20 dB or more should be referred to an otolaryngologist.
Individual Considerations
A.Pregnancy: Do not use sulfa medications (sulfonamides) in pregnant patients.
B.Geriatrics:
1.Elderly patients may present with OME and/or AOM secondary to blocked eustachian tube and/or an URI.
2.Bullous myringitis is a condition in which blisters are visible on the tympanic membrane that
can cause significant pain. Bullous myringitis may be caused by a viral, bacterial, or mycoplasmal infection.
3.Otitis media may cause inflammation of petrous bone adjacent to middle ear (mastoiditis), which could become critical for elderly in terms of further hearing loss, uncontrolled pain, and increased confusion.
4.Geriatrics are particularly vulnerable to recurrent otitis media (minimal three relapses in 6 months or minimal four annual infections).
5.Prevention strategies for elderly are to control modifiable risk factors such as (a) smoking cessation and diabetes control and (b) sufficiently treat each ear infection as soon as possible.