Management of Pediatric Otitis Media

Ann McMahon Wicker, PharmD, BCPS; Brice Labruzzo Mohundro, PharmD

Disclosures

US Pharmacist 

In This Article

Abstract and Introduction

Introduction

Otitis media (OM) is a common illness affecting both infants and children, often multiple times during the first few years of life. Approximately 16 million office visits and 13 million antibiotic prescriptions during the year 2000 were associated with OM.[1] OM has many degrees of severity, including acute OM (AOM), OM with effusion (OME), and chronic suppurative OM (CSOM).

AOM is one of the most frequently occurring childhood diseases, second to upper respiratory infections. It is the leading cause of physician visits, antimicrobial therapy, and pediatric surgery in several countries.[2] In the United States, AOM is diagnosed more than 5 million times annually.[3] Although AOM can occur in adults, approximately 80% of cases occur in children, with the greatest incidence occurring in those aged 6 to 9 months. By 1 year of age, an estimated 75% of infants will have encountered one episode of AOM, while 17% will have suffered from at least three episodes.[2]

AOM develops after bacteria invade the middle ear. Factors leading to this invasion include nasopharyngeal colonization, upper respiratory tract infections, and eustachian tube dysfunction.[4] After viral respiratory tract infections, ciliary activity in respiratory mucosal cells may be impaired, leading to decreased protection from invading organisms. The eustachian tubes of children aged less than 2 years are shorter than in older children, resulting in shorter distances for bacteria to travel and increasing the probability of infection.[2] Additionally, the opening mechanism of the eustachian tubes may be impaired in infants and young children. Furthermore, genetic, infectious, immunologic, and environmental factors can predispose children to ear infections (Table 1).[5,6]

A clinical-practice guideline for the diagnosis and management of AOM was developed by the American Academy of Pediatrics and the American Academy of Family Physicians (AAP/AAFP). According to this guideline, for a diagnosis to be considered "certain," three specific criteria need to be met: rapid onset, confirmed presence of middle-ear effusion (MEE), and signs and symptoms of middle-ear inflammation. Signs and symptoms of middle-ear inflammation may be indicated by either distinct erythema of the tympanic membrane or distinct otalgia. In infants, pulling of the ear is often indicative of otalgia. Other signs and symptoms pediatric patients may present with, although not specific to AOM, include irritability in infants or toddlers, discharge from the ear, and fever. The presence of MEE is indicated by bulging of the tympanic membrane (the best predictor of AOM), limited or absent mobility of the tympanic membrane, air-fluid level behind the tympanic membrane, or otorrhea.[7]

AOM can progress to either persistent AOM or recurrent AOM. Persistent AOM occurs when there are persistent features of a middle-ear infection during antibiotic treatment or when a relapse occurs within 1 month of completion of therapy. If a child experiences three or more episodes of AOM within 6 to 18 months, the diagnosis of recurrent AOM should be made.[5]

OME, or secretory OM, is characterized by fluid in the middle ear without signs or symptoms of infection. It usually occurs when the eustachian tube is blocked and fluid becomes trapped in the middle ear.[8] OME may occur spontaneously as part of rhinosinusitis (inflammation of the nasal cavity and sinuses), or it may succeed a bout of AOM.[9] Approximately 90% of cases occur in children, with the greatest incidence taking place between 6 months and 4 years of age.[10]

CSOM, the severest form of OM, is usually a complication of AOM.[9,11] A persistent inflammation of the middle-ear cavity or mastoid air cells, CSOM is characterized by a discharge through a perforated tympanic membrane.[5] The condition usually is present for more than 2 to 6 weeks.[9]

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