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Otitis Media (Acute)

By

Taha A. Jan

, MD, Vanderbilt University Medical Center

Reviewed/Revised Jan 2024
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Topic Resources

Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever, nausea, vomiting, diarrhea), especially in the very young. Diagnosis is based on otoscopy. Treatment is with analgesics and sometimes antibiotics.

Although acute otitis media can occur at any age, it is most common between ages 3 months and 3 years. At this age, the eustachian tube is structurally and functionally immature—the angle of the eustachian tube is more horizontal, and the angle of the tensor veli palatini muscle and the cartilaginous eustachian tube makes the opening mechanism less efficient.

The etiology of acute otitis media may be viral or bacterial. Viral infections are often complicated by secondary bacterial infection. In neonates, gram-negative enteric bacilli, particularly Escherichia coli, and Staphylococcus aureus cause acute otitis media. In older infants and children < 14 years, the most common organisms are Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, and nontypeable Haemophilus influenzae; less common causes are group A beta-hemolytic streptococci and S. aureus. In patients > 14 years, S. pneumoniae, group A beta-hemolytic streptococci, and S. aureus are most common, followed by H. influenzae.

Risk factors

The presence of smoking in the household is a significant risk factor for acute otitis media. Other risk factors include having a strong family history of otitis media, living in a low-resource or high air-pollution region, being bottle fed (instead of breastfed), and attending a day care center.

Complications

Complications of acute otitis media are uncommon. In rare cases, bacterial middle ear infection spreads locally, resulting in acute mastoiditis Mastoiditis Mastoiditis is a bacterial infection of the mastoid air cells, which typically occurs after acute otitis media. Symptoms include redness, tenderness, swelling, and fluctuation over the mastoid... read more , petrositis, or labyrinthitis Purulent Labyrinthitis Purulent labyrinthitis is bacterial infection of the inner ear, often causing deafness and loss of vestibular function. Purulent labyrinthitis usually occurs when bacteria spread to the inner... read more . Intracranial spread is extremely rare; it usually causes meningitis Overview of Meningitis Meningitis is inflammation of the meninges and subarachnoid space. It may result from infections, other disorders, or reactions to drugs. Severity and acuity vary. Findings typically include... read more . Brain abscess Brain Abscess A brain abscess is an intracerebral collection of pus. Symptoms may include headache, lethargy, fever, and focal neurologic deficits. Diagnosis is by contrast-enhanced MRI or CT. Treatment is... read more Brain Abscess , subdural empyema Intracranial Epidural Abscess and Subdural Empyema Intracranial epidural abscess is a collection of pus between the dura mater and skull. Subdural empyema is a collection of pus between the dura mater and the underlying arachnoid mater. Symptoms... read more , epidural abscess Intracranial Epidural Abscess and Subdural Empyema Intracranial epidural abscess is a collection of pus between the dura mater and skull. Subdural empyema is a collection of pus between the dura mater and the underlying arachnoid mater. Symptoms... read more , lateral sinus thrombosis, or otitic hydrocephalus may occur. Even with antibiotic treatment, intracranial complications are slow to resolve, especially in immunocompromised patients.

Symptoms and Signs of Acute Otitis Media

The usual initial symptom is an earache Earache Earache may occur in isolation or along with discharge or, rarely, hearing loss. Ear pain may come from a process within the ear itself or may be referred to the ear from a nearby nonotologic... read more , often with hearing loss. Infants may simply be cranky or have difficulty sleeping. Fever, nausea, vomiting, and diarrhea often occur in young children. Otoscopic examination can show a bulging, erythematous tympanic membrane with indistinct landmarks and displacement of the light reflex. Air insufflation (pneumatic otoscopy) shows poor mobility of the tympanic membrane. Spontaneous perforation of the tympanic membrane causes serosanguineous or purulent otorrhea Otorrhea Ear discharge (otorrhea) is drainage exiting the ear. It may be serous, serosanguineous, or purulent. Associated symptoms may include ear pain, fever, pruritus, vertigo, tinnitus, and hearing... read more , typically rapidly, relieving the pain.

Severe headache, confusion, or focal neurologic signs may occur with intracranial spread of infection. Facial paralysis or vertigo suggests local extension to the fallopian canal or labyrinth.

Diagnosis of Acute Otitis Media

  • Clinical evaluation

Diagnosis of acute otitis media usually is clinical, based on the presence of acute (within 48 hours) onset of pain, bulging of the tympanic membrane and, particularly in children, signs of middle ear effusion detected by pneumatic otoscopy. Unless fluid is obtained during myringotomy, cultures are usually not done.

Treatment of Acute Otitis Media

  • Analgesics

  • Sometimes antibiotics

  • Rarely myringotomy

Analgesia should be provided when necessary, including to preverbal children with behavioral manifestations of pain (eg, tugging or rubbing the ear, excessive crying, fussiness). Oral analgesics, such as acetaminophen or ibuprofen, are usually effective; weight-based doses are used for children. A variety of topical agents are available by prescription and over the counter. Although not well-studied, some topical agents may provide transient relief but probably not for more than 20 to 30 minutes. Topical agents should not be used when the tympanic membrane is perforated.

Most (80%) cases resolve spontaneously; however, in the United States, antibiotics are often given ([ 1 Treatment reference Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more Treatment reference ]; see table ). Antibiotics relieve symptoms more quickly (although results after 1 to 2 weeks are similar) and may reduce the chance of residual hearing loss and labyrinthine or intracranial sequelae. However, with the recent emergence of resistant organisms, pediatric organizations have strongly recommended initial antibiotics only for certain children, such as the following:

  • Those who are younger or more severely ill—see table )

  • Those with recurrent acute otitis media (eg, 4 episodes in 6 months)

Others, provided there is good follow-up, can safely be observed for 48 to 72 hours and given antibiotics only if no improvement is seen; if follow-up by phone is planned, a prescription can be given at the initial visit to save time and expense. Decision to observe should be discussed with the caregiver.

Table
Table

All patients are given analgesics (eg, acetaminophen, ibuprofen).

In adults, topical intranasal vasoconstrictors, such as phenylephrine or oxymetazoline, may improve eustachian tube function, although the efficacy of these preparations has not been clearly shown. To avoid rebound congestion, these preparations should not be used > 3 days. Systemic decongestants (eg, pseudoephedrine 30 to 60 mg orally every 6 hours as needed) may help relieve sinonasal congestion or pressure. Antihistamines (eg, chlorpheniramine 4 mg orally every 4 to 6 hours for 7 to 10 days) may improve eustachian tube function in people with allergies but should be reserved for the truly allergic.

For children, neither vasoconstrictors nor antihistamines are of benefit.

Myringotomy may be done by a specialist for a bulging tympanic membrane, particularly if severe or persistent pain, fever, vomiting, or diarrhea is present. Tympanometry is used to monitor tympanic membrane movement; the patient's hearing and tympanic membrane appearance and movement are monitored until normal. If facial nerve palsy or weakness occurs in patients with acute otitis media, patients must be urgently referred to a specialist for possible myringotomy and placement of a tympanostomy tube.

Treatment reference

Prevention of Acute Otitis Media

Key Points

  • Give analgesics to all patients.

  • Use antibiotics selectively, based on patient age, severity of illness, and availability of follow-up.

  • Antihistamines and decongestants are not recommended for children; oral or nasal decongestants may help adults, but antihistamines are reserved for adults with an allergic etiology.

Drugs Mentioned In This Article

Drug Name Select Trade
7T Gummy ES, Acephen, Aceta, Actamin, Adult Pain Relief, Anacin Aspirin Free, Aphen, Apra, Children's Acetaminophen, Children's Pain & Fever , Children's Pain Relief, Comtrex Sore Throat Relief, ED-APAP, ElixSure Fever/Pain, Feverall, Genapap, Genebs, Goody's Back & Body Pain, Infantaire, Infants' Acetaminophen, LIQUID PAIN RELIEF, Little Fevers, Little Remedies Infant Fever + Pain Reliever, Mapap, Mapap Arthritis Pain, Mapap Infants, Mapap Junior, M-PAP, Nortemp, Ofirmev, Pain & Fever , Pain and Fever , PAIN RELIEF , PAIN RELIEF Extra Strength, Panadol, PediaCare Children's Fever Reducer/Pain Reliever, PediaCare Children's Smooth Metls Fever Reducer/Pain Reliever, PediaCare Infant's Fever Reducer/Pain Reliever, Pediaphen, PHARBETOL, Plus PHARMA, Q-Pap, Q-Pap Extra Strength, Silapap, Triaminic Fever Reducer and Pain Reliever, Triaminic Infant Fever Reducer and Pain Reliever, Tylenol, Tylenol 8 Hour, Tylenol 8 Hour Arthritis Pain, Tylenol 8 Hour Muscle Aches & Pain, Tylenol Arthritis Pain, Tylenol Children's, Tylenol Children's Pain+Fever, Tylenol CrushableTablet, Tylenol Extra Strength, Tylenol Infants', Tylenol Infants Pain + Fever, Tylenol Junior Strength, Tylenol Pain + Fever, Tylenol Regular Strength, Tylenol Sore Throat, XS No Aspirin, XS Pain Reliever
Advil, Advil Children's, Advil Children's Fever, Advil Infants', Advil Junior Strength, Advil Migraine, Caldolor, Children's Ibuprofen, ElixSure IB, Genpril , Ibren , IBU, Midol, Midol Cramps and Body Aches, Motrin, Motrin Children's, Motrin IB, Motrin Infants', Motrin Junior Strength, Motrin Migraine Pain, PediaCare Children's Pain Reliever/Fever Reducer IB, PediaCare Infants' Pain Reliever/Fever Reducer IB, Samson-8
4-Way Nasal, Ah-Chew D, AK-Dilate, Anu-Med, Biorphen, Formulation R , Foster & Thrive Nasal Decongestion, Gilchew IR, Hemorrhoidal , IMMPHENTIV, Little Remedies for Noses, Lusonal, Mydfrin, Nasop, Nasop 12, Neofrin, Neo-Synephr, Neo-Synephrine, Neo-Synephrine Cold + Allergy, Neo-Synephrine Extra Strength, Neo-Synephrine Mild, Neo-Synephrine Non-Drowsy Cold + Allergy, Ocu-Phrin, PediaCare Children's Decongestant, PediaCare Decongestant, PediaCare Infants' Decongestant, Sinex Nasal, Sudafed PE, Sudafed PE Children's Nasal Decongestant , Sudafed PE Congestion, Sudafed PE Sinus Congestion, Sudogest PE, Vazculep
12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children's Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, Rhinase D, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L.R., Zicam Extreme Congestion Relief, Zicam Intense Sinus
Contac Cold 12 Hour, Dimetapp Decongestant, Drixoral, ElixSure Cold, ElixSure Congestion, Entex, Genaphed , KidKare , Myfedrine, NASAL Decongestant, Nasofed, Nexafed, PediaCare Infants' Decongestant, Pseudo-Time, Silfedrine, Sudafed, Sudafed 12 Hour, Sudafed 24 Hour, Sudafed Children's Nasal Decongestant, Sudafed Congestion, Sudafed Sinus Congestion, Sudogest, Sudogest 12 Hour, Sudogest Children's , Tylenol Children's Simply Stuffy, Zephrex-D
AHIST, Aller-Chlor , Allergy , Allergy Relief, Allergy Time , Chlorphen SR, Chlor-Pheniton, ChlorTan, Chlor-Trimeton, Chlor-Trimeton Allergy , Chlor-Trimeton Allergy 12 Hour, Diabetic Tussin Allergy Relief, ED Chlorped Jr., Ed ChlorPed Pediatric, ED-ChlorPed , ED-Chlortan, ED-Chlor-Tan , PediaPhyl , PediaTan, Pediox-S, P-Tann , Qdall AR, TanaHist-PD, Teldrin HBP
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NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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