Otitis Media

Description

• Inflammation of the middle ear; usually accompanied by fluid collection
• Acute otitis media (AOM): inflammation of the middle ear. Rapid onset; cause may be infectious, either viral (AOM-v) or bacterial (AOM-b), but there is also a sterile etiology (AOM-s).
• Recurrent AOM: ≥3 episodes in 6 months or ≥4 episodes in 1 year with ≥1 in the past 6 months
• Otitis media with effusion (OME): fluid in the middle ear without signs or symptoms of infection
• Chronic otitis media with or without cholesteatoma
• System(s) affected: nervous, ENT
• Synonym(s): secretory or serous otitis media

Epidemiology

• AOM
  • Predominant age: 6 to 24 months; declines >7 years; rare in adults
  • Predominant gender: male > female
  • By age 7 years, 93% of children have had ≥1 episodes of AOM; 39% have had ≥6.
  • Placement of tympanostomy tubes is second only to circumcision as the most frequent surgical procedure in infants.
  • Increased incidence in the fall and winter
• OME
  • By age 4 years, 90% of children have had at least one episode.

• Most common infection for which antibacterial agents are prescribed in the United States
• Diagnosed 5 million times per year in the United States

Etiology and Pathophysiology

• AOM-b (bacterial): Usually, a preceding viral upper respiratory infection (URI) produces eustachian tube dysfunction.
  • Streptococcus pneumoniae: 20–35%, Haemophilus influenzae: 20–30%, Moraxella (B.) catarrhalis: 15%, group A streptococci: 3%, Staphylococcus aureus: 12% produce β-lactamases that hydrolyze amoxicillin and some cephalosporins.
• AOM-v (viral): 15–44% of AOM infections are caused primarily by viruses (e.g., respiratory syncytial virus, parainfluenza, influenza, enteroviruses, adenovirus, human metapneumovirus, and parechovirus).
• AOM-s (sterile/nonpathogens): 25–30%
• OME: eustachian tube dysfunction; allergic causes are rarely substantiated.

• Strong genetic component in twin studies for recurrent and prolonged AOM
• May be influenced by skull configuration or immunologic defects

Risk Factors

• Age
• Bottlefeeding while supine
• Routine daycare attendance
• Frequent pacifier use after 6 months of age
• Environmental smoke exposure
• Male gender
• Absence of breastfeeding
• Low socioeconomic status
• Family history of recurrent otitis
• AOM before age 1 year is a risk for recurrent AOM.
• Presence of siblings in the household
• Underlying ENT disease (e.g., cleft palate, Down syndrome, allergic rhinitis)

General Prevention

• Pneumococcal vaccine (PCV)-7 immunization reduces the number of cases of AOM by about 6–28% (however, evidence shows that this is offset by an increase in AOM caused by other bacteria). The effect of the introduction of the PCV-13 vaccine on the incidence of AOM has yet to be studied.
• Influenza vaccine reduces AOM.
• Breastfeeding for ≥6 months is protective.
• Avoiding supine bottlefeeding, passive smoke, and pacifiers >6 months may be helpful.
• Secondary prevention: Adenoidectomy and adenotonsillectomy for recurrent AOM have limited short-term efficacy and are associated with their own adverse risks.
• Vitamin D supplementation (1,000 IU/day to maintain vitamin D levels >30) may be helpful in reducing recurrent AOM, but further trials are needed.

Commonly Associated Conditions

URI