Otitis Media



  • 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), also known as suppurative otitis media, 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. This is also referred to as serous, secretory, or nonsuppurative otitis media.
  • Chronic otitis media (COM): recurrent or chronic ear infections; with or without cholesteatoma
  • System(s) affected: nervous



  • AOM
    • Predominant age: 6 to 24 months; declines >7 years; rare in adults
    • Predominant gender: male > female
    • 50%–85% of children have had at least 1 episode of AOM by age 3; 24% have had 3 or more episodes.
    • 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
    • 90% of children have had at least one episode by age 4.


  • Most common infection for which antibacterial agents are prescribed in the United States
  • >5 million cases diagnosed per year in the United States.

Etiology and Pathophysiology

  • AOM-b (bacterial): Usually, a preceding viral upper respiratory infection (URI) can produce eustachian tube dysfunction, leading to reduced clearance.
    • Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis are most frequent pathogens. Streptococcus pyogenes, Mycoplasma spp are less frequent.
  • AOM-v (viral): 15–44% of AOM infections are caused primarily by viruses (e.g., rhinovirus, respiratory syncytial virus, parainfluenza, influenza, enteroviruses, adenovirus, human metapneumovirus, and bocavirus).
  • AOM-s (sterile/nonpathogens): 25–30%
  • OME: middle ear inflammation and eustachian tube dysfunction; allergic causes are rarely substantiated.


  • Strong genetic component in twin studies for recurrent and prolonged AOM
  • Immunologic defects and genetic disorders (e.g., Down syndrome) can predispose changes in physical anatomy (e.g., more horizontal and ear canals) that increase likelihood in developing otitis media.

Risk Factors

  • Age—developing AOM prior to 1 year of age is a risk for recurrent AOM
  • Male gender
  • Race and ethnicity
  • Bottlefeeding while supine; pacifier use
  • Routine daycare attendance
  • Family history of AOM
  • Environmental smoke exposure
  • Absence of breastfeeding during first 6 months of life
  • Low socioeconomic status
  • Atopy
  • Underlying ENT disease (e.g., cleft palate, allergic rhinitis)

General Prevention

  • PCV-7 and PCV-13 vaccines have lead to a decrease incidence of streptococcal pneumonia induced otitis media (1).
  • Influenza vaccine (2)[B]
  • Breastfeeding for ≥6 months is protective (2)[B].
  • 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. Xylitol is effective at preventing AOM but requires dosing 5 times daily making it impractical as a common preventative treatment.

Commonly Associated Conditions


There's more to see -- the rest of this topic is available only to subscribers.