Diagnosis and Treatment of Otitis Media

KALYANAKRISHNAN RAMAKRISHNAN, MD, FRCSE; RHONDA A. SPARKS, MD; and WAYNE E. BERRYHILL, MD
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

Diagnostic criteria for acute otitis media include rapid onset of symptoms, middle ear effusion, and signs and symp-
toms of middle ear inflammation. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. Fever, otalgia,
headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are com-
mon, but nonspecific symptoms. Detection of middle ear effusion
by pneumatic otoscopy is key in establishing the diagnosis. Obser-
vation is an acceptable option in healthy children with mild symp-
toms. Antibiotics are recommended in all children younger than
six months, in those between six months and two years if the diag-
nosis is certain, and in children with severe infection. High-dosage
amoxicillin (80 to 90 mg per kg per day) is recommended as first-line
therapy. Macrolide antibiotics, clindamycin, and cephalosporins are
alternatives in penicillin-sensitive children and in those with resis-

ILLUSTRATION BY john karapelou

tant infections. Patients who do not respond to treatment should be
reassessed. Hearing and language testing is recommended in chil-
dren with suspected hearing loss or persistent effusion for at least
three months, and in those with developmental problems. (Am Fam
Physician 2007;76:1650-8, 1659-60. Copyright © 2007 American
Academy of Family Physicians.)

A
Patient informa- Pathophysiology
▲

cute otitis media, a viral or bacte-

tion: A handout on ear
infections in children,
rial infection of the middle ear, Genetic, infectious, immunologic, and envi-
written by the authors of is the most common infection for ronmental factors predispose children to
this article, is provided on which antibiotics are prescribed ear infections (Table 1).4,7 In most cases, an
page 1659. for children in the United States.1,2 Direct allergy or upper respiratory tract infection
and indirect costs of treatment and time lost causes congestion and swelling of the nasal
from school and work because of acute oti- mucosa, nasopharynx, and eustachian tube.
tis media totaled nearly $3 billion in 1995.3 Obstruction at the eustachian tube isthmus
Acute otitis media is most common between (i.e., the narrowest portion) results in accu-
six and 24 months of age; by age three, mulation of middle ear secretions; second-
more than 80 percent of children have been ary bacterial or viral infection of the effusion
diagnosed.4 causes suppuration and features of acute
Otitis media with effusion is middle ear otitis media.8 The effusion may persist for
effusion in the absence of acute infection. weeks or months after the infection resolves.4
About 2.2 million cases of otitis media Otitis media with effusion may occur spon-
with effusion occur annually in the United taneously as a result of eustachian tube dys-
States.5 Chronic suppurative otitis media is function or as an inflammatory response
persistent infection and resultant perfora- after acute otitis media.5
tion of the tympanic membrane.6 This arti- Streptococcus pneumoniae, Haemophilus
cle will review recent evidence, including the influenzae, and Moraxella catarrhalis are the
evidence-based guideline from the Ameri- most common bacterial isolates from the
can Academy of Pediatrics and the Ameri- middle ear fluid of children with acute otitis
can Academy of Family Physicians, about media (Table 24,6-10).8-10 Penicillin-resistant
the diagnosis and treatment of acute otitis S. pneumoniae is the most common cause of
media and otitis media with effusion.1,5 recurrent and persistent acute otitis media.7

1650  American Family Physician www.aafp.org/afp Volume 76, Number 11 ◆ December 1, 2007
 SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Diagnosis of acute otitis media requires confirmation of acute onset, identification of signs C 1
of middle ear effusion, and evaluation for signs and symptoms of middle ear inflammation.
Antihistamines and decongestants should not be prescribed for children with acute otitis media B 5, 22
or otitis media with effusion.
Observation without antibiotic therapy is an option in selected children with acute otitis media. B 1, 22
Amoxicillin at a dosage of 80 to 90 mg per kg per day should be the first-line antibiotic for most B 1
children with acute otitis media.
Patients with otitis media who fail to respond to the initial treatment option within 48 to 72 hours C 1
should be reassessed to confirm the diagnosis. If the diagnosis is confirmed, antibiotics should be
started in patients for whom antibiotics were initially deferred, and a different antibiotic should
be prescribed for patients already taking an antibiotic.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1595 or http://
www.aafp.org/afpsort.xml.

Diagnosis
Diagnostic criteria for acute otitis media include rapid Table 1. Factors Affecting Risk  
onset of symptoms, middle ear effusion, and signs and of Acute Otitis Media
symptoms of middle ear inflammation (Table 31,2,6,7,11).1
Nonspecific symptoms of acute otitis media (e.g., fever, Factor Comments

headache, irritability, cough, rhinitis, listlessness, Age Maximal incidence between six and
anorexia, vomiting, diarrhea, pulling at the ears) are 24 months of age; eustachian tube
common in infants and young children. Otalgia is less shorter and less angled at this age.
Underdeveloped physiologic and
common in children younger than two years and more immunologic responses to infection in
common in adolescents and adults.4 Acute otitis media children
cannot be reliably differentiated from upper respiratory Breastfeeding Breastfeeding for at least three months is
tract infection on the basis of symptoms alone.10 How- protective; this effect may be associated
ever, otalgia, ear rubbing or pulling, and parental suspi- with position maintained during
breastfeeding, suckling movements, and
cion of otitis media have positive likelihood ratios (LR+) protective factors in breast milk
of 3.0 or more and are moderately useful for ruling in the Daycare Contact with multiple children and
diagnosis (Table 412-16).12,13 attendance* daycare providers facilitates spread of
bacterial and viral pathogens
pneumatic otoscopy and other diagnostic tests Ethnicity* Native American, Alaskan, and Canadian
Inuit children have increased incidence
Detection of middle ear effusion by pneumatic otoscopy
Exposure to Increased incidence with cigarette smoke
is key in establishing the diagnosis of acute otitis media.
cigarette smoke and air pollution, especially if parents
The tympanic membrane normally is convex, mobile, smoke
translucent, and intact; a normal color and mobility Male sex Slightly increased incidence
of the membrane indicate that otitis media is unlikely More than one Increased risk of antibiotic treatment
(negative likelihood ratio [LR–], 0.03).10 A bulging mem- sibling living failure
brane greatly increases the likelihood of otitis media at home*
(LR+, 20.3), as do impaired mobility of the membrane Pacifier use Increased incidence
(LR+, 4.7) and a distinctly red membrane (LR+, 2.6), Previous antibiotic Increased risk of antibiotic treatment
use* failure
albeit to a lesser extent.14
Previous otitis Increased risk of antibiotic treatment
Using pneumatic otoscopy with tympanometry media* failure
improves the accuracy of diagnosis. The handheld Season* Increased incidence in fall and winter
tympanometer records compliance of the tympanic Underlying Increased incidence in children with allergic
membrane and provides quantitative information on pathology* rhinitis, cleft palate, Down syndrome
structural function and the presence of middle ear effu-
sion.15 A flattened tracing with a low static admittance *—These factors also increase the risk of recurrent acute otitis media.

(type B tracing) indicates middle ear effusion; highly Information from references 4 and 7.
negative middle ear pressures (type C tracing) indicate

December 1, 2007 ◆ Volume 76, Number 11 www.aafp.org/afp American Family Physician  1651
 Table 2. Organisms in Acute and Chronic Suppurative Otitis Media

Organism Frequency (%) Comments

Acute otitis media

Streptococcus pneumoniae* 40 to 50 Most common pathogens are serotypes 19F, 23F, 14, 6B, 6A, 19A, and 9V
Haemophilus influenzae* 30 to 40 Nearly one half produce β-lactamase
Moraxella catarrhalis* 10 to 15 Most produce β-lactamase
Group A streptococcus* — Common in older children. More frequently associated with perforated tympanic
membrane and mastoiditis
Staphylococcus aureus* Rare More common in chronic infection
Anaerobic organisms Rare More common in chronic infection
Gram-negative bacilli — In newborns, immunosuppressed patients, and patients with chronic suppurative
otitis media
Viruses Less than 10 Respiratory syncytial virus, adenovirus, rhinovirus, or influenza virus may act in
synergy with bacteria. Coinfection with bacteria present in more than
40 percent of children with viral-induced acute otitis media
Other Rare Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia trachomatis
(in infants younger than six months), Mycobacterium tuberculosis (in
developing countries), parasitic infestation (e.g., ascariasis), mycotic infections
(e.g., candidiasis, aspergillosis, blastomycosis)
Chronic suppurative otitis media
Aerobic organisms — Pseudomonas aeruginosa, Proteus mirabilis, S. aureus, Streptococcus pyogenes,
Escherichia coli, or Klebsiella species
Anaerobic organisms — Bacteroides, Peptostreptococcus, or Propionibacterium species

note: No bacterial pathogen is identified in up to 20 to 30 percent of patients with acute otitis media.
*—Also responsible for recurrent and persistent otitis media.
Information from references 4, and 6 through 10.

a retracted tympanic membrane; and highly

Table 3. Diagnostic Criteria for Otitis Media positive peak pressures are consistent with
a bulging membrane15 (Figure 1). Acoustic
Type Diagnostic criteria reflectometry detects middle ear fluid by
analyzing the spectral gradient of sound
Acute otitis media Acute onset
and
reflected off the tympanic membrane.16
Middle ear effusion, indicated by bulging tympanic Tympanocentesis, followed by aspiration
membrane, limited or absent mobility of and culture of middle ear fluid samples, is
membrane, air-fluid level behind membrane useful in children who are toxic, have failed
and
multiple courses of antibiotics, or have
Symptoms and signs of middle ear inflammation,
indicated by erythema of tympanic membrane or
immune deficiencies.4 Although negative
otalgia affecting sleep or normal activity nasopharyngeal cultures correlate well with
Persistent acute Persistent features of middle ear infection during negative middle ear fluid cultures, they are
otitis media antibiotic treatment not routinely recommended.17
or Chronic suppurative otitis media pres-
Relapse within one month of treatment completion
ents with persistent or recurrent otorrhea
Recurrent acute Three or more episodes of acute otitis media within
otitis media six to 18 months
through a perforated tympanic membrane
Otitis media with Fluid behind the tympanic membrane in the
(active), or with a dry but permanent per-
effusion absence of features of acute inflammation foration of the tympanic membrane (inac-
Chronic otitis media Persistent fluid behind intact tympanic membrane tive).6 Other features include thickened
with effusion in the absence of acute infection granular mucosa, polyps, and choles-
Chronic suppurative Persistent inflammation of the middle ear teatoma in the middle ear.18 Aerobic and
otitis media or mastoid cavity
anaerobic bacteria may enter the middle
Recurrent or persistent otorrhea through
a perforated tympanic membrane
ear through the perforation.6 Rarely, Pseu-
domonas species may cause deep-seated
Information from references 1, 2, 6, 7, and 11. destructive infections of the middle ear and
the mastoid cavity. Diagnosis is made by

1652  American Family Physician www.aafp.org/afp Volume 76, Number 11 ◆ December 1, 2007
 1.8
Table 4. Usefulness of Clinical Findings and
Tests in the Diagnosis of Acute Otitis Media 1.5

Compliance (cm3 )
1.2
Sensitivity Specificity
Clinical feature (%) (%) LR+* LR–† 0.9

Signs 0.6
Bulging tympanic 61 97 20.3 0.4
membrane14 0.3

Cloudy tympanic 81 95 16.2 0.2 0.0

membrane14 -400 -200 0 +200
Impaired mobility 98 79 4.7 0.03 Air Pressure (mmH2O)
A
of tympanic
membrane14
Symptoms
1.8
Parental suspicion 70 80 3.4 0.4
of otitis media12 1.5

Compliance (cm3 )
Pulling at or 42 87 3.3 0.7
rubbing the ear13 1.2
Otalgia 13
54 82 3.0 0.6
0.9
Excessive crying13 55 69 1.8 0.7
Rhinitis13 75 43 1.3 0.6 0.6
Poor appetite13 36 66 1.1 1.0
0.3
Cough13 47 45 0.9 1.2
Fever 13
40 48 0.8 1.2 0.0
Diagnostic methods -400 -200 0 +200
Acoustic 65 to 97 85 to 99 B Air Pressure (mmH2O)
reflectometry16
Pneumatic 94 81 Figure 1. Sample tympanograms. (A) Results suggest mid-
otoscopy15 dle ear effusion. (B) Results correlate with retracted tym-
Portable 89 58 panic membrane.
tympanometry15 Information from Esse S, Thibodeau L. Pediatric hearing loss: diagnostic
Professional 34 to 94 49 to 94 evaluation. Accessed online July 23, 2007, at: http://www.utdallas.edu/~
tympanometry15 thib/rehabinfo/de.htm.

LR+ = positive likelihood ratio; LR– = negative likelihood ratio.

*—Higher values indicate a greater likelihood of acute otitis media
and minimizes emergence of resistant strains.23
when the sign or symptom is present. Symptomatic Treatment. Pain management is impor-
†—Lower values indicate a lower likelihood of acute otitis media tant in the first two days after diagnosis. Options include
when the sign or symptom is absent. acetaminophen (15 mg per kg every four to six hours)
Information from references 12 through 16. and ibuprofen (Motrin; 10 mg per kg every six hours).24
Antipyrine/benzocaine otic suspension (Auralgan) can
be used for local analgesia (Table 5).1,5,25
history and examination, including otoscopy. Exami- Antihistamines may help with nasal allergies, but they
nation may detect other foci of infection requiring may prolong middle ear effusion.26 Oral decongestants
treatment (e.g., nose, paranasal sinuses, lungs, phar- may be used to relieve nasal congestion. However, nei-
ynx). Careful cleaning of the ear is useful for visual- ther antihistamines nor decongestants improve healing
izing the tympanic membrane and the attic, and for or minimize complications of acute otitis media, and
excluding cholesteatoma.19 they are not routinely recommended.27 Corticosteroid
use has no benefit in acute otitis media.26
Treatment Antibiotics. A meta-analysis of randomized trials
acute otitis media found that antibiotics are most beneficial in children
Treatment goals in acute otitis media include symptom younger than two years with bilateral acute otitis media
resolution and reduction of recurrence.20 Most children and in children with acute otitis media and otorrhea.28
with acute otitis media (70 to 90 percent) have spontane- Antibiotics are recommended for all children younger
ous resolution within seven to 14 days; therefore, anti- than six months, for those six months to two years of
biotics should not routinely be prescribed initially for age when the diagnosis is certain, and for all children
all children.21,22 Delaying antibiotic therapy in selected older than two years with severe infection (defined as
patients reduces treatment-related costs and side effects moderate to severe otalgia or temperature greater than

December 1, 2007 ◆ Volume 76, Number 11 www.aafp.org/afp American Family Physician  1653
Otitis Media
Table 5. Agents Used in the Treatment of Otitis Media

Agent Dosage Comments

Antimicrobials*
Amoxicillin 80 to 90 mg per kg per day, given First-line drug. Safe, effective, and inexpensive
orally in two divided doses
Amoxicillin/clavulanate 90 mg of amoxicillin per kg per day; Second-line drug. For patients with recurrent or persistent
(Augmentin) 6.4 mg of clavulanate per kg per day, acute otitis media, those taking prophylactic amoxicillin,
given orally in two divided doses those who have used antibiotics within the previous month,
and those with concurrent purulent conjunctivitis
Azithromycin (one dose; 30 mg per kg, given orally For patients with penicillin allergy. One dose is as effective as
Zithromax) longer courses
Azithromycin (three-day 20 mg per kg once daily, given orally For patients with recurrent acute otitis media
course; Zithromax Tri-pak)
Azithromycin (five-day 5 to 10 mg per kg once daily, given For patients with penicillin allergy (type 1 hypersensitivity)
course; Zithromax Z-pak) orally
Cefdinir (Omnicef) 14 mg per kg per day, given orally in For patients with penicillin allergy, excluding those with urticaria
one or two doses or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Cefpodoxime (Vantin) 30 mg per kg once daily, given orally For patients with penicillin allergy, excluding those with urticaria
or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Ceftriaxone (Rocephin) 50 mg per kg once daily, given For patients with penicillin allergy, persistent or recurrent
intramuscularly or intravenously. One acute otitis media, or vomiting
dose for initial episode of otitis media,
three doses for recurrent infections
Cefuroxime (Ceftin) 30 mg per kg per day, given orally in For patients with penicillin allergy, excluding those with urticaria
two divided doses or anaphylaxis to penicillin (i.e., type 1 hypersensitivity)
Clarithromycin (Biaxin) 15 mg per kg per day, given orally in For patients with penicillin allergy (type 1 hypersensitivity).
three divided doses May cause gastrointestinal irritation
Clindamycin (Cleocin) 30 to 40 mg per kg per day, given For patients with penicillin allergy (type 1 hypersensitivity)
orally in four divided doses
Topical agents†
Ciprofloxacin/hydrocortisone 3 drops twice daily —
(Cipro HC Otic)
Hydrocortisone/neomycin/ 4 drops three to four times daily —
polymyxin B (Cortisporin
Otic)
Ofloxacin (Floxin Otic) 5 drops twice daily (10 drops in —
patients older than 12 years)
Analgesics
Acetaminophen 1 mg per kg every six hours —
Antipyrine/benzocaine 2 to 4 drops three to four times daily —
(Auralgan)
Ibuprofen (Motrin) 10 mg per kg every six hours —
Narcotic agents Variable May cause gastrointestinal upset, respiratory depression,
altered mental status, and constipation

*—These drugs should be given for 10 days, unless otherwise indicated. A five- to seven-day course is an option for patients six years and older.
These agents may cause diarrhea, vomiting, abdominal pain, rash, anorexia, and dermatitis.
†—These drugs should be used for seven to 10 days in patients with chronic suppurative otitis media.
Information from references 1, 5, and 25.

102.2° F [39° C]).1 Antibiotics may be deferred in other- Antibiotic Selection. High-dosage amoxicillin (80 to
wise healthy children six months to two years of age with 90 mg per kg per day, divided into two daily doses for
mild otitis in whom the diagnosis is uncertain, and in 10 days) is recommended as first-line antibiotic therapy in
children older than two years with mild symptoms or children with acute otitis media.1,24 In children older than
in whom the diagnosis is uncertain (Figure 2).1,5 If this six years with mild to moderate disease, a five- to seven-
option is chosen, it is mandatory to have a reliable care- day course is adequate.1 Amoxicillin is effective, safe, and
giver who will observe the child, recognize signs of seri- relatively inexpensive, and it has a narrow microbiologic
ous illness, and be able to access medical care easily. spectrum.29 First-line treatment with amoxicillin is not

1654  American Family Physician www.aafp.org/afp Volume 76, Number 11 ◆ December 1, 2007
 Management of Otitis Media
Acute otitis media

Child < 6 months of age?

Child 6 to 24 months of age
with diagnostic certainty?
Severe infection, sepsis,
immunocompromised status?

No Yes

Treatment option: topical or

systemic analgesics with close
observation and follow-up

Symptom resolution Persistent symptoms

Follow-up to ensure Amoxicillin, 80 to 90 mg per kg per day for

resolution of effusion 10 days (5- to 7-day course in older children)
Macrolide for children with type 1 penicillin allergy;
cephalosporin for children with non-type 1 allergy.
Consider ceftriaxone (Rocephin) or amoxicillin/
clavulanate (Augmentin) for children with severe
otalgia or temperature >102.2°F (39°C)

Symptom resolution Persistent symptoms

Follow-up to ensure Amoxicillin/clavulanate, 90 mg per kg

resolution of effusion per day for 10 days
or
Cefuroxime (Ceftin), 30 mg per kg per day
for 10 days
or
Ceftriaxone, 50 mg per kg per day for 3 days

Symptom resolution

Follow-up to ensure Recurrent otitis media

resolution of effusion

Watchful waiting or antibiotics Persistent symptoms

(antibiotics if repeated recurrences)

Clindamycin (Cleocin), 30 to 40 mg per kg per day

Tympanocentesis, culture
Change antibiotics
Imaging studies (CT, MRI if complications considered)
Tympanostomy for recurrent otitis media, hearing
loss, tinnitus, neurologic or balance problems,
septic complications

Figure 2. Treatment algorithm for acute otitis media. (CT = computed tomography; MRI = magnetic resonance imaging.)
Information from references 1 and 5.
Otitis Media

recommended in children with concurrent purulent con- otitis media with effusion
junctivitis, after antibiotic therapy within the preceding Persistent middle ear effusion after resolution of acute
month, in children taking amoxicillin as chemoprophy- otitis media does not indicate treatment failure and
laxis for recurrent acute otitis media or urinary tract requires only monitoring and reassurance. Risk factors
infection, and in children with penicillin allergy. for persistent acute otitis media with effusion include
Cephalosporins may be used in children allergic to hearing loss greater than 30 dB, prior tympanostomy
penicillin if there is no history of urticaria or anaphylaxis tube placement, adenoid hypertrophy, and onset during
to penicillin. If there is a history of penicillin-induced summer or fall.34
urticaria or anaphylaxis, a macrolide (e.g., azithromycin Clinical examination, pneumatic otoscopy, and tym-
[Zithromax], clarithromycin [Biaxin]) or clindamycin panometry may be performed during the observation
[Cleocin] may be used. A single dose of parenteral cef- period.5 There is no role for antihistamines and decon-
triaxone (Rocephin, 50 mg per kg) may be useful in chil- gestants; adverse effects include insomnia, hyperactivity,
dren with vomiting or in whom compliance is a concern.1 drowsiness, behavioral changes, and labile blood pres-
Single-dose azithromycin is safe and effective in uncom- sure.5 Oral and topical intranasal corticosteroids alone
plicated acute otitis media and compares well with lon- or in combination with an antibiotic produce faster
ger courses of azithromycin or other antibiotics.30 short-term resolution of otitis media with effusion, but
Persistent Acute Otitis Media. If there is no clinical there is no evidence of long-term benefit.35 Autoinflation
improvement within 48 to 72 hours, the patient must be (i.e., opening the eustachian tube by raising intranasal
reassessed to confirm the diagnosis, exclude other causes pressure) is useful in older children with persistent acute
of illness, and initiate antibiotic therapy in those on otitis media with effusion who are able to perform the
symptomatic treatment alone. Patients who are already Valsalva maneuver.36
taking antibiotics should be changed to second-line ther- Children older than two years who have otitis media
apy.1 Options include high-dose amoxicillin/clavulanate with effusion and no developmental issues must be seen
(Augmentin), cephalosporins, and macrolides. Paren- at three- to six-month intervals until effusion resolves,
teral ceftriaxone administered daily over three days is hearing loss is identified, or structural abnormalities of
useful in children with emesis or resistance to amoxi- the tympanic membrane or middle ear are suspected.5
cillin/clavulanate. Hearing and language testing is recommended in
For children who patients with suspected hearing loss or persistent effu-
A single dose of parenteral
do not respond to sion for at least three months, or when developmental
ceftriaxone may be useful
second-line antibi- problems are identified. Children with hearing loss of
in children who are vomit-
otics, clindamycin 20 dB or less who do not have speech, language, or devel-
ing or in whom compliance
and tympanocente- opmental problems can be observed. Those with hearing
is a concern.
sis are appropriate loss of 21 to 39 dB can be observed or referred for sur-
options. Although gery, and those with hearing loss of 40 dB or more should
it is not approved for use in children, levofloxacin (Leva- be referred for surgery.5
quin) is effective in children who have persistent or Tympanostomy with ventilation tube insertion is the
recurrent acute otitis media.31 preferred initial procedure. Meta-analyses of random-
Computed tomography (CT) is useful if bony exten- ized controlled trials evaluating the effect of ventilation
sion is suspected. Magnetic resonance imaging is on hearing, effusion duration, language development,
superior to CT in evaluating potential intracranial cognition, behavior, and quality of life show that benefits
complications.32 in children are marginal at best.37,38 Ventilation tubes
Recurrent Acute Otitis Media. Most children with may be more beneficial in young children in an environ-
recurrent acute otitis media improve with watchful wait- ment with a high infection load (e.g., children attending
ing.20 Although antibiotic prophylaxis may reduce recur- daycare) and in older children with hearing loss of 25 dB
rence, there are no widely accepted recommendations for or greater in both ears for at least 12 weeks.37 Adenoidec-
antibiotic choice or prophylaxis duration.33 Minimizing tomy may be considered in children who have recurrent
risk factors (e.g., exposure to cigarette smoke, pacifier otitis media with effusion after tympanostomy (20 to
use, bottle feeding, daycare attendance) decreases recur- 50 percent of children) if chronic adenoiditis is present
rence. Heptavalent pneumococcal vaccine (Prevnar) or if adenoidal hypertrophy causes nasal obstruction.5
reduces the incidence of acute otitis media, but it does Tonsillectomy does not improve outcomes. Complica-
not reduce recurrence. tions of tympanostomy include transient and persistent

1656  American Family Physician www.aafp.org/afp Volume 76, Number 11 ◆ December 1, 2007
 Otitis Media

otorrhea, tympanosclerosis, atrophy, perforation of the common in children and adults. Guidelines for antibiotic
tympanic membrane, and cholesteatoma.39 A mild con- use are the same in children and adults. Smoking should
ductive hearing loss may also occur as a result of changes be discouraged. Nasal and oral steroids may be beneficial
in the tympanic membrane. Topical antibiotics (e.g., qui- in patients with persistent acute otitis media and associ-
nolones, aminoglycosides, polymyxins) are more effec- ated allergies. Adults with unilateral middle ear effusion
tive than systemic antibiotics in clearing the infection lasting longer than two months should undergo imaging
in patients with chronic suppurative otitis media; topi- studies to rule out intracranial neoplasm, especially if the
cal quinolones are preferred.6 Nonquinolone antibiotics effusion is associated with cranial nerve palsy.11
may produce ototoxicity and vestibular dysfunction, but
these complications are unlikely with short-term use.39 The Authors
Oral or parenteral antibiotics are useful in patients with
kalyanakrishnan ramakrishnan, md, FRCSE, is an associate pro-
systemic sepsis or inadequate response to topical antibi- fessor of family and preventive medicine at the University of Oklahoma
otics. They should be selected on the basis of culture and Health Sciences Center, Oklahoma City. He received his medical degree
sensitivity results. Tympanoplasty (using a soft-tissue and his master’s degree in surgery from the Jawaharlal Institute of Post-
graft), with reconstruction of the ossicular chain if nec- graduate Medical Education and Research, Pondicherry, India, and com-
pleted a family medicine residency at the University of Oklahoma Health
essary, is an option in patients with chronic perforation Sciences Center.
and hearing loss. Mastoidectomy is often recommended
rhonda A. sparks, md, is an associate professor and medical direc-
for patients with chronic mastoiditis. tor of the Clinical Skills Education and Testing Center at the University of
Oklahoma Health Sciences Center. She received her medical degree and
Complications completed a family and preventive medicine residency at the University of
The overall incidence of complications from otitis media Oklahoma Health Sciences Center.
is extremely low; infratemporal and intracranial com- wayne e. berryhill, md, is an assistant professor of otolaryngology at
plications occur in one in 100,000 children and in one the University of Oklahoma Health Sciences Center. He received his medi-
cal degree and completed a residency in otolaryngology at the University
in 300,000 adults per year.40,41 Patients with middle ear of Minnesota Medical School, Minneapolis, and completed a fellowship
effusion may have persistent or fluctuating conductive in otology and neurotology at the University of Michigan Medical School,
hearing loss (loss of about 25 dB).4 Children with chronic Ann Arbor.
middle ear effusion score lower on tests of speech, lan- Address correspondence to Kalyanakrishnan Ramakrishnan, MD, FRCSE,
guage, and cognitive abilities.42 Central perforation of University of Oklahoma Health Sciences Center, 900 NE 10th St., Okla-
the eardrum may cause chronic infection in the middle homa City, OK 73104 (e-mail: kramakrishnan@ouhsc.edu). Reprints are
not available from the authors.
ear and mastoid cavity. Acute mastoiditis (i.e., pus in the
mastoid air cells) may erode through the bone, form- Author disclosure: Nothing to disclose.
ing a subcutaneous collection of pus (Bezold’s abscess).
Contiguous spread or hematogenous seeding may infect REFERENCES
the inner ear, petrous portion of the temporal bone, 1. American Academy of Pediatrics Subcommittee on Management of
meninges, and the brain. Mastoiditis and intracranial Acute Otitis Media. Diagnosis and management of acute otitis media.
complications of acute otitis media are more common in Pediatrics 2004;113:1451-65.
developing countries where persons have limited access 2. Hendley JO. Clinical practice. Otitis media. N Engl J Med 2002;
347:1169-74.
to medical care.4
3. Marcy M, Takata G. Management of acute otitis media. Evidence report/
Mild to moderate conductive hearing loss occurs technology assessment no. 15. Rockville, Md.: Agency for Healthcare
in one half of children with chronic suppurative otitis Research and Quality, Southern California Evidence-Based Practice Cen-
ter/RAND, 2001. AHRQ publication no. 01-E 010.
media, and extracranial and intracranial complications
4. Klein JO, Pelton S. Epidemiology, pathogenesis, clinical manifestations,
may also develop. Meningitis is the most serious intra- and complications of acute otitis media. Accessed May 15, 2007, at:
cranial complication. http://patients.uptodate.com /topic.asp?file = pedi_id /2870 &title =
Acute+Otitis+media [Subscription required].
Otitis Media in Adults 5. American Academy of Family Physicians, American Academy of Oto-
laryngology-Head and Neck Surgery, American Academy of Pediatrics
Adults make up less than 20 percent of patients presenting Subcommittee on Otitis Media With Effusion. Otitis media with effu-
with acute otitis media.43 H. influenzae and S. pneumoniae sion. Pediatrics 2004;113:1412-29.
are common bacterial isolates in these patients. Compared 6. Acuin J, for the World Health Organization. Chronic Suppurative Oti-
tis Media. Burden of Illness and Management Options. Geneva: World
with children, adults more often present with otalgia, ear
Health Organization, 2004. Accessed online July 23, 2007, at: http://
drainage, diminished hearing, and sore throat. Opac- www.who.int/child-adolescent-health/publications/CHILD_HEALTH/
ity and redness of the tympanic membrane are equally ISBN_92_4_159158_7.htm.

December 1, 2007 ◆ Volume 76, Number 11 www.aafp.org/afp American Family Physician  1657
Otitis Media

7. Arrieta A, Singh J. Management of recurrent and persistent acute oti- 27. Flynn CA, Griffin G, Tudiver F. Decongestants and antihistamines for acute
tis media: new options with familiar antibiotics. Pediatr Infect Dis J otitis media in children. Cochrane Database Syst Rev 2007;(2):CD001727.
2004;23(2 suppl):S115-24. 28. Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoi-
8. Rovers MM, Schilder AG, Zielhuis GA, Rosenfeld RM. Otitis media seaux RA, et al. Antibiotics for acute otitis media: a meta-analysis with
[Published correction appears in Lancet 2004;363:1080]. Lancet individual patient data. Lancet 2006;368:1429-35.
2004;363:465-73. 29. Dowell SF, Butler JC, Giebink GS, Jacobs MR, Jernigan D, Musher DM, et
9. McCracken GH Jr. Diagnosis and management of acute otitis media in al. Acute otitis media: management and surveillance in an era of pneu-
the urgent care setting. Ann Emerg Med 2002;39:413-21. mococcal resistance—a report from the Drug-resistant Streptococcus
10. Rothman R, Owens T, Simel DL. Does this child have acute otitis media? pneumoniae Therapeutic Working Group [Published correction appears
JAMA 2003;290:1633-40. in Pediatr Infect Dis J 1999;18:341]. Pediatr Infect Dis J 1999;18:1-9.
11. University of Michigan Health System. Guidelines for clinical care. 30. Arguedas A, Loaiza C, Soley C. Single dose azithromycin for the treat-
Otitis media. Accessed May 15, 2007, at: http://cme.med.umich. ment of uncomplicated otitis media. Pediatr Infect Dis J 2004;23(2
edu/pdf/guideline/om.pdf. suppl):S108-14.

12. Kontiokari T, Koivunen P, Niemela M, Pokka T, Uhari M. Symptoms of 31. Arguedas A, Dagan R, Pichichero M, Leibovitz E, Blumer J, McNeeley
acute otitis media. Pediatr Infect Dis J 1998;17:676-9. DF, et al. An open-label, double tympanocentesis study of levofloxacin
therapy in children with, or at high risk for, recurrent or persistent acute
13. Niemela M, Uhari M, Jounio-Ervasti K, Luotonen J, Alho OP, Vierimaa
otitis media. Pediatr Infect Dis J 2006;25:1102-9.
E. Lack of specific symptomatology in children with acute otitis media.
Pediatr Infect Dis J 1994;13:765-8. 32. Shah RK, Blevins NH. Otalgia. Otolaryngol Clin North Am 2003;
36:1137-51.
14. Karma PH, Penttila MA, Sipila MM, Kataja MJ. Otoscopic diagno-
sis of middle ear effusion in acute and non-acute otitis media. I. The 33. Halter R, Kelsberg G, Nashelsky J, Krist A. Clinical inquiries. Is antibi-
value of different otoscopic findings. Int J Pediatr Otorhinolaryngol otic prophylaxis effective for recurrent acute otitis media? J Fam Pract
1989;17:37-49. 2004;53:999-1001.
34. MRC Multi-centre Otitis Media Study Group. Risk factors for persis-
15. Onusko E. Tympanometry. Am Fam Physician 2004;70:1713-20.
tence of bilateral otitis media with effusion. Clin Otolaryngol Allied Sci
16. Kemaloglu YK, Sener T, Beder L, Bayazit Y, Goksu N. Predictive value of 2001;26:147-56.
acoustic reflectometry (angle and reflectivity) and tympanometry. Int J
35. Thomas CL, Simpson S, Butler CC, van der Voort JH. Oral or topical nasal
Pediatr Otorhinolaryngol 1999;48:137-42.
steroids for hearing loss associated with otitis media with effusion in
17. Gehanno P, Lenoir G, Barry B, Bons J, Boucot I, Berche P. Evaluation children. Cochrane Database Syst Rev 2006;(3):CD001935.
of nasopharyngeal cultures for bacteriologic assessment of acute otitis
36. Perera R, Haynes J, Glasziou P, Heneghan CJ. Autoinflation for hearing
media in children. Pediatr Infect Dis J 1996;15:329-32.
loss associated with otitis media with effusion. Cochrane Database Syst
18. Acuin J. Extracts from “Concise clinical evidence”: chronic suppurative Rev 2006;(4):CD006285.
otitis media. BMJ 2002;325:1159.
37. Rovers MM, Black N, Browning GG, Maw R, Zielhuis GA, Haggard MP.
19. Browning GG. Commentary: interpreting the evidence. BMJ 2002; Grommets in otitis media with effusion: an individual patient data
325:1160. meta-analysis. Arch Dis Child 2005;90:480-5.
20. Darrow DH, Dash N, Derkay CS. Otitis media: concepts and controver- 38. Lous J, Burton MJ, Felding JU, Ovesen T, Rovers MM, Williamson I.
sies. Curr Opin Otolaryngol Head Neck Surg 2003;11:416-23. Grommets (ventilation tubes) for hearing loss associated with otitis
21. Rosenfeld RM, Kay D. Natural history of untreated otitis media. Laryn- media with effusion in children. Cochrane Database Syst Rev 2005;(1):
goscope 2003;113:1645-57. CD001801.
22. Scottish Intercollegiate Guidelines Network. Diagnosis and management 39. Wilson SA, Mayo H, Fisher M. Clinical inquiries. Are tympanostomy tubes
of childhood otitis media in primary care. A national clinical guideline. indicated for recurrent acute otitis media? J Fam Pract 2003;52:403-4,
Accessed May 15, 2007, at: http://www.sign.ac.uk/pdf/sign66.pdf. 406.
23. Eskin B. Evidence-based emergency medicine/systematic review 4 0. Leskinen K, Jero J. Complications of acute otitis media in children in
abstract. Should children with otitis media be treated with antibiotics? southern Finland. Int J Pediatr Otorhinolaryngol 2004;68:317-24.
Ann Emerg Med 2004;44:537-9. 41. Leskinen K, Jero J. Acute complications of otitis media in adults. Clin
24. Bell LM. The new clinical practice guidelines for acute otitis media: an Otolaryngol 2005;30:511-6.
editorial. Ann Emerg Med 2005;45:514-6. 42. Teele DW, Klein JO, Chase C, Menyuk P, Rosner BA. Otitis media in
25. Hoberman A, Paradise JL, Reynolds EA, Urkin J. Efficacy of Auralgan infancy and intellectual ability, school achievement, speech, and lan-
for treating ear pain in children with acute otitis media. Arch Pediatr guage at age 7 years. Greater Boston Otitis Media Study Group. J Infect
Adolesc Med 1997;151:675-8. Dis 1990;162:685-94.
26. Chonmaitree T, Saeed K, Uchida T, Heikkinen T, Baldwin CD, Freeman 43. Culpepper L, Froom J, Bartelds AI, Bowers P, Bridges-Webb C, Grob P, et
DH Jr, et al. A randomized, placebo-controlled trial of the effect of anti- al. Acute otitis media in adults: a report from the International Primary
histamine or corticosteroid treatment in acute otitis media. J Pediatr Care Network [Published correction appears in J Am Board Fam Pract
2003;143:377-85. 1993;6:616]. J Am Board Fam Pract 1993;6:333-9.

1658  American Family Physician www.aafp.org/afp Volume 76, Number 11 ◆ December 1, 2007