Otitis Media

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Basics

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
  • Synonym(s): secretory or serous otitis media

Epidemiology

Incidence
  • AOM
    • Predominant age: 6 to 24 months; declines >7 years; rare in adults
    • Predominant gender: male > female
    • By age 3 year, ~60% of children have had ≥1 episodes of AOM; 24% have had ≥3.
    • 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.

Prevalence
  • 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) produces eustachian tube dysfunction, leading to reduced clearance.
    • Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis are most frequent pathogens. Less frequent: Streptococcus pyogenes, Mycoplasma spp.
  • 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.

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

Risk Factors

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

General Prevention

  • Pneumococcal vaccine (PCV)-7 immunization reduces the number of cases of AOM by about 29% (1)[B] (however, evidence shows that this is offset by an increase in AOM caused by other bacteria).
  • 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.
  • 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

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