Acute otitis media (AOM) is defined by the presence of fluid in the middle ear accompanied by acute signs of illness and signs or symptoms of middle ear inflammation, including bulging (picture 1). (See 'Introduction' above and 'Definition' above.)
●Viral upper respiratory infection is the most common predisposing factor for the development of AOM. The incidence of AOM in the United States is highest between 6 and 18 months of age and during the respiratory virus season. In addition to young age, other risk factors for AOM include family history, day care attendance, not having been breastfed, exposure to tobacco smoke, pacifier use, and ethnicity (Native Americans and Alaskan and Canadian Inuit populations). (See 'Risk factors' above.)
●Inflammation of the upper respiratory tract predisposes to AOM via dysfunction of the eustachian tube, leading to negative pressure and accumulation of middle ear secretions and impairment in host defenses such as normal mucociliary action of the respiratory mucosa. Microbial growth in the middle ear secretions may result in suppuration and clinical signs of AOM. (See 'Pathogenesis' above.)
●Streptococcus pneumoniae, nontypeable Haemophilus influenzae (NTHi), and Moraxella catarrhalis account for most of the bacterial isolates from middle ear fluid. The most common viral pathogens include respiratory syncytial virus, rhinoviruses, influenza viruses, and adenoviruses. (See 'Microbiology' above.)
●Children with AOM, particularly infants, may present with nonspecific symptoms and signs (eg, fever, fussiness, headache, anorexia, vomiting, and diarrhea). Specific findings of AOM or complications/sequelae of AOM include ear pain, otorrhea, bulging of the tympanic membrane (TM) (picture 1), hearing loss, vertigo, nystagmus, tinnitus, swelling about the ear, and facial paralysis. (See 'Symptoms and signs' above.)
●AOM may occur in conjunction with conjunctivitis; this symptom complex is usually caused by NTHi. AOM also may occur with bullae on the TM (bullous myringitis (picture 2A)); the distribution of viral and bacterial pathogens in cases of bullous myringitis is similar to that in cases of AOM without bullae. (See 'Clinical syndromes' above.)
●The diagnosis of AOM requires evidence of middle ear inflammation (eg, bulging) and middle ear effusion. (See "Acute otitis media in children: Diagnosis", section on 'Diagnosis'.)
●Complications of AOM include mild conductive hearing loss; vestibular, balance, and motor dysfunctions; TM perforation; inflammation of the mastoid and/or mastoiditis; petrositis; and labyrinthitis. Intracranial complications are rare in developed countries; they include meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, and carotid artery thrombosis. (See'Complications and sequelae' above.)
Acute otitis media
Examples of the white, bulging tympanic membrane seen in acute otitis media. The "B" panel also demonstrates marked erythema along the handle of the malleus and an air-fluid level in the anterosuperior portion of the tympanic membrane.
Courtesy of Alejandro Hoberman, MD.
Graphic 63268 Version 3.0
Anatomy of the ear
This diagram illustrates the relationship of the middle ear to the external auditory canal and inner ear.
Reproduced with permission from Bluestone CD, Klein JO. Otitis Media in Infants and Children. WB Saunders, Philadelphia, 2001.
Graphic 62666 Version 3.0
Bacteria recovered from patients with acute otitis media 2008-2010*
| Bacteria | Number (percent) of aspirates |
| Streptococcus pneumoniae | 66 (31.7 percent) |
| Nontypeable Haemophilus influenzae | 59 (28.4 percent) |
| Moraxella catarrhalis | 29 (13.9 percent) |
* Based on aspirates of middle ear fluid in children 6 to 30 months of age with acute otitis media.
Adapted from: Casey JR, Kaur R, Friedel VC, Pichichero ME. Acute otitis media otopathogens during 2008 to 2010 in Rochester, New York. Pediartr Infect Dis J 2013; 32:805.
Graphic 61937 Version 5.0
Comparison of serotypes in pneumococcal vaccines
| Conjugate vaccines | Polysaccharide vaccine | ||||
PCV7
(Prevnar 7)
|
PCV10*
(Synflorix)
|
PCV13
(Prevnar 13)
| PCV15¶ |
PPSV23
(Pneumovax 23)
| |
| 4 | 4 | 4 | 4 | 4 | 2 |
| 6B | 6B | 6B | 6B | 6B | 8 |
| 9V | 9V | 9V | 9V | 9V | 9N |
| 14 | 14 | 14 | 14 | 14 | 10A |
| 18C | 18C | 18C | 18C | 18C | 11A |
| 19F | 19F | 19F | 19F | 19F | 12F |
| 23F | 23F | 23F | 23F | 23F | 15B |
| 17F | |||||
| 1 | 1 | 1 | 1 | 20 | |
| 5 | 5 | 5 | 5 | 22F | |
| 3 | 3 | 3 | 33F | ||
| 7F | 7F | 7F | 7F | ||
| 19A | 19A | 19A | |||
| 6A | 6A | ||||
| 22F | |||||
| 33F | |||||
PCV7: 7-valent pneumococcal conjugate vaccine; PCV10: 10-valent pneumococcal conjugate vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine.
* Not available in the United States.
¶ In development.
* Not available in the United States.
¶ In development.
Graphic 77274 Version 5.0
Bullous myringitis
Bullous myringitis is characterized by painful vesicles that appear on the tympanic membrane.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 86980 Version 1.0
Bullous myringitis
Bullous myringitis is characterized by painful vesicles that appear on the tympanic membrane.
Graphic 97986 Version 1.0
Appearance of the tympanic membrane in three children with acute otitis media
(A) Early acute otitis media with inflammation; subsequently progressed to effusion.
(B) Purulent effusion with air fluid level.
(C) Bulging purulent effusion filling the middle ear.
(B) Purulent effusion with air fluid level.
(C) Bulging purulent effusion filling the middle ear.
Graphic 97608 Version 1.0
Tympanosclerosis
Tympanosclerosis, asymptomatic whitish plaques of calcium and phosphate crystals, as depicted above, is common in children with middle ear disease and more common after tympanostomy tube placement.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 58460 Version 4.0
Collapse (atelectasis) of the tympanic membrane
Collapse (atelectasis) of the tympanic membrane is caused by poor eustachian tube function.
Courtesy of Glenn C Isaacson, MD.
Graphic 78843 Version 1.0
Acquired cholesteatoma of the pars flaccida with chronic purulent drainage
Acquired cholesteatoma of the pars flaccida. This lesion presented with chronic purulent drainage and a white mass behind the drum.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 76079 Version 1.0
Acute tympanic membrane perforation with otorrhea
Graphic 97987 Version 2.0
Draining tympanic membrane perforation
Graphic 91415 Version 1.0
Treatment of early retraction pocket cholesteatoma with middle ear ventilation
Panel A) Collapse of the drum with posterosuperior deep retraction pocket. Panel B) Retraction pocket after tube placement. Panel C) Reduction of the retraction.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 54514 Version 1.0
Focal granulation tissue on the surface of the tympanic membrane
Focal granulation tissue at the mouth of a deep retraction pocket (arrow) indicating cholesteatoma.
Courtesy of Glenn C Isaacson, MD.
Graphic 72182 Version 3.0
Anatomy of the mastoid bone
Graphic 74487 Version 1.0
Acute otitis media in children: Diagnosis
Acute otitis media (AOM) is defined by acute bacterial infection of middle ear fluid; it must be distinguished from otitis media with effusion (OME), which is defined by fluid in the middle ear cavity that is not infected. (See'Terminology' above.)
●Accurate diagnosis of AOM is facilitated by competent skills in pneumatic otoscopy and adherence to stringent diagnostic criteria. (See 'Importance of accurate diagnosis' above.)
●The key to distinguishing AOM from OME is the performance of otoscopy using appropriate tools and an adequate light source; otoscope bulbs should be replaced at least every two years. (See 'Otoscopy' above.)
●Systematic assessment of the tympanic membrane includes evaluation of position, translucency, mobility, color, and other findings (eg, air-fluid levels). (See 'Overview' above.)
●Clinical diagnosis of AOM requires a bulging tympanic membrane or other signs of acute inflammation and evidence of middle ear effusion (MEE). A diagnosis of AOM also can be established if the tympanic membrane has perforated, acute purulent otorrhea is present, and otitis externa has been excluded. (See 'Clinical diagnosis' above.)
●MEE, which may indicate either OME or AOM, can be confirmed by the observation of bubbles or an air-fluid level (picture 6), or at least two of the following (see 'MEE' above):
•Abnormal color (white, yellow, amber, or blue)
•Opacity not due to tympanosclerosis (involving part or all of the tympanic membrane)
•Impaired mobility (movie 2)
Anatomy of the tympanic membrane
Schematic of a right tympanic membrane indicating the quadrants. A line drawn along the manubrium (or "handle") of the malleus divides the tympanic membrane into anterior and posterior halves. A line drawn through the umbo (perpendicular to the first line) divides the tympanic membrane into superior and inferior halves.
Graphic 57110 Version 1.0
Normal tympanic membrane
Normal left tympanic membrane with pearly gray color.
Graphic 52626 Version 1.0
Appearance of the tympanic membrane in three children with acute otitis media
(A) Early acute otitis media with inflammation; subsequently progressed to effusion.
(B) Purulent effusion with air fluid level.
(C) Bulging purulent effusion filling the middle ear.
(B) Purulent effusion with air fluid level.
(C) Bulging purulent effusion filling the middle ear.
Graphic 97608 Version 1.0
Pneumatic otoscope
Pneumatic otoscope with enlargement of the head of the otoscope delineating the magnifying lens (which is moveable) and the nipple to which the insufflator bulb is attached.
Graphic 63633 Version 2.0
Acute otitis media
Examples of the white, bulging tympanic membrane seen in acute otitis media. The "B" panel also demonstrates marked erythema along the handle of the malleus and an air-fluid level in the anterosuperior portion of the tympanic membrane.
Courtesy of Alejandro Hoberman, MD.
Graphic 63268 Version 3.0
Retracted tympanic membrane
When there is a negative pressure in the middle ear cavity, the position of the tympanic membrane will be retracted.
Graphic 52819 Version 1.0
Tympanic membrane with air-fluid levels
An air-fluid level is appreciated when the tympanic membrane appears translucent above and opaque below a line demarcating the separation.
Graphic 67379 Version 1.0
Tympanoscelorsis (also known as myringosclerosis)
Notice areas of wispy, noncalcified changes and dense calcified regions.
Graphic 78073 Version 2.0
Bullous myringitis
Bullous myringitis is characterized by painful vesicles that appear on the tympanic membrane.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 86980 Version 1.0
Retractions of the tympanic membrane
Retractions of the tympanic membrane located in the regions of the pars flaccida (P), pars tensa (T), and incudostapedial joint (I).
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 82650 Version 2.0
Acquired cholesteatoma of the pars flaccida with chronic purulent drainage
Acquired cholesteatoma of the pars flaccida. This lesion presented with chronic purulent drainage and a white mass behind the drum.
Courtesy of Glenn C Isaacson, MD, FAAP, FACS.
Graphic 76079 Version 1.0
Acute otitis media in children: Prevention of recurrence
Recurrent acute otitis media (AOM) is defined as ≥3 distinct and well-documented episodes within six months or ≥4 episodes within 12 months. Infants who have their first episode of AOM before six months of age or who have siblings with severe and recurrent AOM are at risk for severe and recurrent AOM. (See 'Definitions' above.)
●Prevention strategies include identification and treatment of underlying conditions that predispose to recurrent AOM, parental education about the risk factors for AOM, vaccine administration, chemoprophylaxis, and tympanostomy tube placement. (See 'Interventions' above.)
●Factors that influence the choice of prevention strategy include the age of the child, the age at first episode of AOM, the time of year, day care attendance, family history, cognitive and language status, underlying conditions that predispose to AOM, and the effects of recurrent AOM on the quality of life for the child and family. (See 'Factors influencing choice' above.)
●Treatment of predisposing conditions and parental education are reasonable strategies for all children with recurrent AOM. (See 'Treatment of predisposing conditions' above and 'Education' above.)
●We recommend administration of the pneumococcal conjugate vaccine (PCV) and annual influenza vaccine according to the routine childhood immunization schedule (Grade 1A). We suggest that children with recurrent AOM who are between two and six years of age and have not received any doses of the 13-valent PCV (PCV13), receive a dose of PCV13 (Grade 2C). We also suggest that children older than two years of age with recurrent AOM receive a dose of the 23-valent pneumococcal conjugate vaccine at least eight weeks after PCV13 (Grade 2C). (See 'Vaccines' above and "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Supplemental dose' and "Seasonal influenza in children: Prevention with vaccines", section on 'Indications'.)
●We suggest antibiotic prophylaxis or tympanostomy tube placement for children who are younger than two years of age, have multiple risk factors for recurrent AOM, have underlying medical conditions that predispose to AOM, or have known or suspected developmental or language delays (Grade 2B). However, the ultimate decision about whether to use one of these more aggressive interventions and which intervention to use is made on a case-by-case basis after discussion of the potential benefits and risks with the caregivers. (See 'Choice of intervention(s)' above.)
●When the decision is made to use antibiotic prophylaxis, we typically use amoxicillin 40 mg/kg orally once per day. Sulfisoxazole 50 mg/kg orally once per day is an alternative. Antibiotic prophylaxis should be provided every day during the fall, winter, and early spring months. Children receiving chemoprophylaxis should be examined approximately every two months to determine the presence and duration of middle ear effusion. (See'Antibiotic prophylaxis' above.)
●Tympanostomy tube placement is an alternative to antibiotic prophylaxis for children who warrant more aggressive prevention strategies and an option for those who have had breakthrough episodes of AOM while receiving antibiotic prophylaxis. (See 'Choice of intervention(s)' above and 'Tympanostomy tubes' above.)
●Adenoidectomy is not an effective primary preventive measure for children with recurrent AOM but may be beneficial in those who continue to have recurrent AOM after extrusion of tubes and are undergoing repeat tympanostomy tube placement. (See 'Adenoidectomy or adenotonsillectomy' above.)
●We do not suggest xylitol, antiadhesive oligosaccharide, or probiotics for the prevention of recurrent AOM in children (Grade 2C). (See 'Other interventions' above.)
Comparison of serotypes in pneumococcal vaccines
| Conjugate vaccines | Polysaccharide vaccine | ||||
PCV7
(Prevnar 7)
|
PCV10*
(Synflorix)
|
PCV13
(Prevnar 13)
| PCV15¶ |
PPSV23
(Pneumovax 23)
| |
| 4 | 4 | 4 | 4 | 4 | 2 |
| 6B | 6B | 6B | 6B | 6B | 8 |
| 9V | 9V | 9V | 9V | 9V | 9N |
| 14 | 14 | 14 | 14 | 14 | 10A |
| 18C | 18C | 18C | 18C | 18C | 11A |
| 19F | 19F | 19F | 19F | 19F | 12F |
| 23F | 23F | 23F | 23F | 23F | 15B |
| 17F | |||||
| 1 | 1 | 1 | 1 | 20 | |
| 5 | 5 | 5 | 5 | 22F | |
| 3 | 3 | 3 | 33F | ||
| 7F | 7F | 7F | 7F | ||
| 19A | 19A | 19A | |||
| 6A | 6A | ||||
| 22F | |||||
| 33F | |||||
PCV7: 7-valent pneumococcal conjugate vaccine; PCV10: 10-valent pneumococcal conjugate vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine.
* Not available in the United States.
¶ In development.
* Not available in the United States.
¶ In development.
Graphic 77274 Version 5.0
Acute otitis media in children: Treatment
The diagnosis of acute otitis media (AOM) requires bulging of the tympanic membrane or other signs of acute inflammation and middle ear effusion (picture 1). The importance of accurate diagnosis is crucial to avoidance of unnecessary treatment. (See 'Diagnosis of AOM' above and "Acute otitis media in children: Diagnosis", section on 'Diagnosis'.)
●We suggest oral ibuprofen or acetaminophen to treat ear pain in children with AOM (Grade 2B). Topical benzocaine, procaine, or lidocaine preparations (if available) are an alternative for children ≥2 years, but should not be used in children with tympanic membrane perforation. We recommend NOT using decongestants and/or antihistamines (Grade 1A). (See 'Symptomatic therapy' above.)
●The choice of initial treatment with antibiotics or observation depends upon the age of the child and the laterality and severity of illness (see 'Antibiotic therapy versus observation' above):
•We recommend that children with AOM who are <6 months be treated with antibiotics (Grade 1A).
•We suggest that children with AOM who are between six months and two years be treated with antibiotics (Grade 2A).
•We suggest that children ≥2 years who appear toxic; have persistent otalgia for more than 48 hours; have temperature ≥102.2°F (39°C) in the past 48 hours; have bilateral AOM or otorrhea; or have uncertain access to follow-up be immediately treated with an appropriate antibiotic (Grade 2A). (See 'Initial antimicrobial therapy' above.)
•For children ≥2 years who are normal hosts (eg, immune competent, without craniofacial abnormalities) and have unilateral AOM with mild symptoms and signs and no otorrhea, initial observation may be appropriate if the caretakers understand the risks and benefits of such an approach.
●When antibiotic treatment is warranted, we suggest amoxicillin as the first-line therapy for AOM in most children (Grade 2B). The dose is 90 mg/kg per day (we use a maximum of 3 g/day) divided in two doses. We suggestamoxicillin-clavulanate as the first-line therapy for children with AOM who have received a beta-lactam antibiotic in the previous 30 days or have concomitant purulent conjunctivitis (Grade 2A). The dose is 90 mg/kg per day of amoxicillin and 6.4 mg/kg per day of clavulanate divided in two doses. (See 'First-line therapy' above.)
●Macrolides or clindamycin are an alternative for patients who have had immediate hypersensitivity reactions (eg, anaphylaxis, angioedema, bronchospasm, urticaria) to penicillin (table 1). However, macrolides and clindamycin lack activity against most Haemophilus influenzae isolates and approximately one-third of pneumococcal isolates. Patients with other types of allergic reactions may be treated safely with cefdinir, cefpodoxime,cefuroxime, or intramuscular ceftriaxone. (See 'Penicillin allergy' above.)
●We generally treat children <2 years, children with tympanic membrane perforation, and children with recurrent AOM for 10 days. We generally treat children ≥2 years without a history of recurrent AOM for five to seven days. (See 'Duration of therapy' above.)
●Treatment failure is defined by lack of symptomatic improvement 48 to 72 hours after initiation of antimicrobial therapy. We suggest that patients who fail first-line therapy be treated with amoxicillin-clavulanate (Grade 2B). Alternatives include cefdinir, cefpodoxime, cefuroxime, and ceftriaxone. (See 'Initial treatment failure' above.)
Acute otitis media
Examples of the white, bulging tympanic membrane seen in acute otitis media. The "B" panel also demonstrates marked erythema along the handle of the malleus and an air-fluid level in the anterosuperior portion of the tympanic membrane.
Courtesy of Alejandro Hoberman, MD.
Graphic 63268 Version 3.0
Persistence of middle ear effusion after acute otitis media
Percent of children with middle ear effusion persisting for up to 12 weeks after an episode of acute otitis media.
Adapted from: Bluestone CD, Klein JO, Otitis Media in Infants and Children, WB Saunders, Philadelphia 2001.
Graphic 81406 Version 2.0
Systemic antibiotics used for the initial treatment of acute otitis media in children
| Antibiotic | Route | Dose | Maximum daily dose |
| First-line agents | |||
| Amoxicillin | Oral | 90 mg/kg per day in two doses | 3 g/day |
| Amoxicillin-clavulanate*¶ | Oral | 90 mg/kg per day in two doses | 3 g/day (amoxicillin component) |
| Alternatives for children with mild or remote allergy to penicillins (ie, without anaphylaxis, bronchospasm, or angioedema) | |||
| Cefdinir | Oral | 14 mg/kg per day in one or two doses | 600 mg/day |
| Cefpodoxime | Oral | 10 mg/kg per day in two doses | 400 mg/day |
| Cefuroxime suspension¶Δ | Oral | 30 mg/kg per day in two doses | 1 g/day |
| Ceftriaxone¶ | Intramuscular or intravenous | 50 mg/kg per day for one to three days | 1 g/day |
| Alternatives for children with severe allergy◊ to beta-lactams including cephalosporins | |||
| Azithromycin | Oral | 10 mg/kg once on day one, then 5 mg/kg once per day on days two through five | 500 mg/day on day one; 250 mg/day on days two through five |
| Clarithromycin§ | Oral | 15 mg/kg per day in two doses | 1 g/day |
| Clindamycin | Oral |
10 to 25 mg/kg per day in three doses for mild to moderate infection
30 to 40 mg/kg per day in three doses for severe infection
| 1.8 g/day |
| Erythromycin-sulfisoxazole | Oral | 50 mg/kg (erythromycin component) per day in three to four doses | 2 g/day (erythromycin component) |
* For children who have received a beta-lactam antibiotic (eg, penicillins, cephalosporins) in the previous 30 days or have concomitant purulent conjunctivitis or have a history of recurrent otitis media unresponsive to amoxicillin.
¶ Frequently used if amoxicillin fails.
Δ For children who can swallow tablets whole and weigh >17 kg, may use cefuroxime tablets; the dose is 250 mg twice daily.
◊ Anaphylaxis, angioedema, bronchospasm, urticaria where skin testing is unavailable or contraindicated (eg, for serious cutaneous reaction).
§ Infrequently used because of drug interactions.
¶ Frequently used if amoxicillin fails.
Δ For children who can swallow tablets whole and weigh >17 kg, may use cefuroxime tablets; the dose is 250 mg twice daily.
◊ Anaphylaxis, angioedema, bronchospasm, urticaria where skin testing is unavailable or contraindicated (eg, for serious cutaneous reaction).
§ Infrequently used because of drug interactions.
Graphic 76491 Version 10.0
Tympanic membrane barotrauma
Airplane travel-related tympanic membrane barotrauma demonstrated by bleeding into the tympanic membrane.
Courtesy of Glenn C Isaacson, MD, FAAP.
Graphic 93461 Version 2.0
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