MIDDLE EAR INFECTION

Definition

Middle ear infection, or otitis media, is defined by the presence of inflammation, fluid, and pus involving the eardrum (tympanic membrane) and the middle ear space behind it. Depending on the signs and symptoms present, cases can be subdivided into acute otitis media (AOM), and otitis media with effusion (OME). It is important for clinicians to distinguish between the two types when considering antibiotic therapy, because OME typically does not respond to antibiotics. Cultures of ear fluid done in research studies show that otitis may be caused by bacterial or viral infection, and that in many cases middle ear fluid is sterile.

Risk Factors

Day care attendance.
Presence of siblings in the home.
Family history of recurrent otitis media.
Premature birth.
Male gender.
Presence of anatomical defects associated with Down’s syndrome or cleft palate.
Immunodeficiency syndromes.
Exposure to smoking.

Antibiotic Treatment

One of the greatest frustrations for the parents of young children can be the failure or apparent failure of antibiotics to cure middle ear infections. Until recently there has been a tendency to over-prescribe antibiotics, which has led The American Academy of Pediatrics and American Academy of Family Physicians to formulate practice guidelines for diagnosing and treating otitis media. The following are highlights of those recommendations published in May of 2004:

To diagnose AOM, there should be a history of acute onset of ear pain or irritability, signs of fluid in the middle ear space, and signs of middle ear inflammation.
Observation without the use of antibiotics for 48 to 72 hours in selected cases is an acceptable option. This option is based on the fact that numerous studies have shown that most children do well, without adverse outcome, even without antibacterial therapy.
If a decision is made to treat with an antibiotic, the clinician should prescribe amoxicillin for most children. Numerous studies have shown that the most common bacterial pathogens in AOM are Streptococcus pneumoniae, nontypeable H. influenzae, and M. catarrhalis. High dose amoxicillin (Amoxil) is the best choice for S. pneumoniae, which is less likely to spontaneously resolve and potentially more serious than the later two.
If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If the patient has already been started on an antibiotic, then it should be changed to a second or third line antibiotic.
For those patients with mild sensitivity to amoxicillin, acceptable alternatives include cefdinir (Omnicef), cefpodoxime (Cefzil), or cefuroxime (Ceftin). These agents, along with amoxicillin-clavulanate (Augmentin), are also commonly used as second or third line therapy. For those patients with more severe sensitivity to amoxicillin, alternatives include azithromycin (Zithromax) or other macrolides.
In those cases where a child is unable to take oral medicine due to vomiting, or in cases of ongoing severe infection despite multiple courses of oral antibiotics, injected ceftriaxone (Rocephin) may be used.
When possible, clinicians should encourage the prevention of AOM through the reduction of risk factors. Examples would include limiting day care attendance and breast feeding for the first 6 months to provide passive immunity. There has been a modest reduction of cases since the introduction of pneumococcal vaccine (Prevnar).
To date there are no studies that conclusively show a beneficial effect of alternative medicine therapies, steroids, or antihistamines in the treatment of otitis media.

Surgical Treatment

Some children develop problems with chronic middle ear fluid (otitis media with effusion, or OME) lasting weeks or even months. A previous task force involving the American Academy of Pediatrics, American Academy of Family Physicians, and the American Academy of Otolaryngology published guidelines which address surgical intervention for OME. These guidelines are intended for children between the ages of 1 and 3 years with no craniofacial or neurological abnormalities, who are otherwise healthy. The following is a summary:

A child who has had fluid in both middle ears for a total of 3 months should undergo hearing evaluation. Before 3 months of effusion, hearing evaluation is an option.
For a child who has had bilateral effusion for a total of 3 months and who has a bilateral hearing deficiency (defined as a 20 decibel loss in the better hearing ear), insertion of tympanostomy tubes becomes an additional treatment option. Placement of tympanostomy tubes is recommended after a total of 4 to 6 months of middle ear fluid in both sides and hearing loss on both sides.
Adenoidectomy is not an appropriate treatment for uncomplicated OME in the child younger than 4 years when adenoid pathology is not present.
Tonsillectomy, either alone or with adenoidectomy, has not been found effective for treating OME.
These recommendations are tempered by the fact that there is little research to support the theory that untreated OME results in speech/language delays or deficits.

Summary

There are over 20 million office visits per year related to the diagnosis and treatment of middle ear infections. The direct cost for office visits, medications, and placement of tubes exceeds 2 billion dollars per year. Published guidelines like those referenced above provide a framework for clinicians to work within, however, each child must be treated according to their own medical history and presentation of illness.

To Learn More

For more extensive information about otitis media, including diagrams or even short video segments, please go to our links section to search the f0llowing websites: American Academy of Otolaryngology, www.entnet.org (search under Kids E.N.T. Health); The National Institutes of Health, www.nih.gov (search under otitis media); or the American Academy of Pediatrics, www.aap.org (search under otitis media).