Acute Otitis Media: Diagnosis and Treatment

Diagnosis

Diagnosis requires a consistent acute history, otalgia or erythema and opacity of the tympanic membrane, and a middle–ear effusion. Effusion can be demonstrated by a bulging and immobile tympanic membrane (or one with decreased mobility as demonstrated with pneumatic otoscopy), an air–fluid level, or otorrhea.³

An erythematous tympanic membrane should not be presumed to be due to AOM. Only 15% of such cases are caused by AOM.⁴

To ensure a correct diagnosis, immobility of the tympanic membrane should be demonstrated.  Tympanometry may substitute for pneumatic otoscopy when the presence of middle–ear effusion is uncertain.

Bacterial culture of a middle ear aspirate is only indicated in the case of immunosuppression, severe illness (with AOM as the likely source), or refractory AOM.

Treatment

Suggestions in the Nutritional Considerations below should be considered early in the treatment of AOM; they reduce the need for other treatments, which can often be difficult and taxing.

Decongestants and antihistamines have no proven benefit in AOM.

Several possible treatment options are available for otalgia.

NSAIDs and acetaminophen may improve symptoms, although objective findings are not necessarily apparent.⁵

Benzocaine/antipyrine (Auralgan) otic solution and Otikon Otic (an herbal preparation including garlic) may also improve the condition.^6,7

The American Academy of Family Physicians (AAFP) makes the following recommendations regarding use of antibiotics for AOM³:

• All patients under 6 months of age should receive antibiotics, even if the diagnosis of AOM is uncertain.
• Patients aged 6 months to 2 years should receive antibiotics if the diagnosis is clear. If the diagnosis is uncertain, antibiotics should be given if otalgia is moderate to severe, or a temperature is greater than or equal to 39°C. Otherwise, observation may be considered.
• Patients older than 2 years with a definite diagnosis of AOM should start an antibiotic if otalgia is moderate to severe, or if they have a temperature greater than or equal to 39°C. Otherwise, observation may be considered.
• Observation should only be used if rapid initiation of antibiotics and follow–up can be guaranteed. Antibiotics should be started if no improvement occurs in 2 to 3 days.
• Amoxicillin, 80 to 90 mg/kg divided into 2 doses, is the first–line therapy, and 5 to 7 days is usually adequate.³
• For penicillin–allergic patients, cephalosporins may be used, provided patients did not develop hives or anaphylaxis with penicillin. Macrolides or trimethoprim–sulfamethoxazole may also be used, but bacteria are often resistant to these medications.

Recurrent ear infections may warrant additional treatments, such as prophylactic antibiotics, tympanostomy, and adenoidectomy.

Tympanostomy is indicated for severe or recurrent otitis media, or persistent, serous effusion.

Adenoidectomy (with or without tonsillectomy) may benefit those who have recurrent AOM despite tympanostomy. Adenoidectomy may also reduce future AOM episodes when it occurs concomitantly with tympanostomy.⁸