Otitis media and otitis externa are common ear conditions affecting individuals of all ages. Symptoms can range from mild to severe ear pain. These conditions result from infections, immune responses, and environmental factors. Proper management requires use of up-to-date guidelines and advanced treatments to address the diagnosis, prevention, and therapy challenges. This article overviews current practices and recent developments in treating these common ear disorders.
Key points
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Acute otitis media (AOM) is more common in children than adults and leads to frequent antibiotic use.
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AOM-related pain (otalgia) can prompt parents to seek treatment for their children.
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Overdiagnosis of AOM leads to unnecessary antibiotic use, contributing to antibiotic resistance.
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Differentiating between AOM and otitis media with effusion is imperative to determine whether watchful waiting versus antibiotic treatment is indicated.
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Acute otitis externa is an inflammatory ear canal condition commonly caused by bacterial infection, mainly Pseudomonas aeruginosa and Staphylococcus aureus.
Introduction
Otitis media (OM) and otitis externa (OE) are distinct yet common ear conditions affecting a significant portion of the population across all age groups. The clinical presentation of these conditions is diverse, ranging from subtle or absent symptoms in cases of otitis media with effusion (OME) to acute pain and discomfort associated with acute otitis media (AOM), chronic suppurative otitis media (CSOM), and OE.
Despite their prevalence, OM and OE pathophysiology involves a complex interplay of microbial invasion, host immune response, and environmental factors. The complexity of treating otitides highlights the importance of a comprehensive approach to prevention, proper diagnosis, and treatment. The authors aim to explore the current OM and OE guidelines, highlighting the latest advances in treatment methods and the ongoing challenges in managing these ubiquitous ear conditions.
Anatomy of the ear
The ear is a sensory organ responsible for hearing and maintaining balance. It consists of 3 parts: the internal ear, the middle ear, and the external ear. The middle ear is an air-filled space composed of the tympanic membrane (TM) that posteriorly houses 3 auditory ossicles (malleus, incus, and stapes). The bones amplify and transmit high-amplitude, low-force sound waves into low-amplitude, high-force vibrations from the TM to the oval window. Beyond the oval window, the middle ear is also connected to the nasopharynx by the Eustachian tube, allowing fluid drainage and pressure equalization from the middle ear to the outer environment.
Acute Otitis Media
AOM is defined as the sudden onset of inflammation or infection of the middle ear resulting in the accumulation of purulent or suppurative fluid behind the tympanic membrane. OM is among the most common pediatric diagnoses in primary care, ranking among the leading diagnoses contributing to antibiotic overuse and antibiotic resistance. In the United States, over 5 million cases of AOM and 2.2 million cases of OME are reported annually. Although AOM may occur at any age, most cases occur in young children aged 6 to 24 months. The incidence peaks at 1 year of age and declines after the age of 5.
Etiology and risk factors
AOM is caused by fluid accumulation in the middle ear, leading to rapid inflammation and dysfunction in the Eustachian tube (ET) anatomy, in decreased fluid drainage, and increased inner ear pressure. Inflammation of the ET is often triggered by a viral or bacterial pathogen or allergens, resulting in fluid retention and purulent effusion in the middle ear. A shortened ET in children increases the risk of otitis infections.
Various risk factors can influence otitis media. Understanding these factors is essential for prevention and early management. Box 1 summarizes several contributing risk factors suspected of increasing the predisposition of AOM.
Male Gender
Age under 5 years old
Premature birth (less than 37 weeks gestation)
Immunodeficiency–congenital, human immunodeficiency virus
Diabetes
Anatomic abnormalities of the palate and associated musculature
Down syndrome
Gastroesophageal reflux
Allergies
Family members with a history or recurrence of acute otitis mediaIndigenous populations such as Native Americans, the Alaskan,
Canadian, and Greenland Inuit and Australian Aborigines
Large daycare attendance
Parental smoking exposure
Recurrent Upper Respiratory Infections
Presence of cochlear implant
Seasonality–Winter and Early Spring
Pacifier use
Supine bottle feeding
Lack of breast-feeding during infancy
Viral upper respiratory tract infections (URIs) pose a significant risk for AOM. URIs caused by respiratory syncytial virus, influenza virus, picornavirus, coronavirus, human metapneumovirus, and adenovirus are the most common viral causes of AOM. During a viral infection, bacteria migrate from the nasopharynx to the middle ear, causing AOM. Bacterial pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae , are believed to be the primary agents. Streptococcus pneumoniae is responsible for half of all cases of AOM, and the presence of penicillin-resistant strains lead to treatment failure and increased recurrence of AOM. Non-typeable Haemophilus influenzae, Moraxella catarrhalis , and Staphylococcus aureus also have notable roles in the pathogenesis of AOM. Conjugate vaccines effective against pneumococcus and H aemophilis influenzae could potentially reduce the burden of AOM in early infancy; however, their impact on all-cause AOM remains uncertain, based on evidence of low to moderate certainty. Moreover, there is no evidence of a beneficial effect on all-cause AOM in high-risk infants beyond early infancy or in older children with a history of respiratory illness.
Genetic factors are not just a side note in the pathogenesis of acute otitis media (AOM); they also play a significant role in influencing both the susceptibility to infection and the severity of the condition. Research has identified several genetic variants and polymorphisms associated with an increased risk of AOM, including variations in tumor necrosis factor-α and interleukin-6 and interleukin-10 alleles altering cytokine production, exacerbating inflammation, and increasing the frequency of AOM episodes. This underscores the importance of genetic research in understanding and potentially preventing AOM.
Clinical presentation and diagnosis
AOM primarily affects infants and children, who may initially exhibit otalgia, followed by irritability, poor appetite, sleep disturbances, and ear tugging due to severe pain. Box 2 summarizes the most common presenting symptoms of AOM.
Otalgia
Ear rubbing or tugging
Night restlessness
Fussiness or irritability
Decreased hearing
Fever
Otorrhea
Headache
Vomiting
Diarrhea
Loss of appetite
Less active or playful
The American Academy of Pediatrics (AAP) offers evidence-based clinical practice guidelines focusing on diagnosing and managing AOM in children. Key points covered in Table 1 include strategies for managing ear pain, guidance on when to observe versus prescribe antibiotics, recommendations for appropriate antibiotic choices, preventive measures, and addressing recurrent AOM. These guidelines aim to assist primary care clinicians by providing a structured framework for clinical decision-making, emphasizing that they serve as a valuable resource but do not replace individual clinical judgment. Accurate diagnosis is crucial for the proper management of AOM and OME. AOM diagnosis requires a thorough history, clinical assessment, and evidence of middle ear effusion.
| Current Recommendations | |
|---|---|
| Diagnostic Criteria | It necessitates significant bulging of the tympanic membrane, the emergence of otorrhea unrelated to external ear inflammation, or slight bulging of the eardrum coupled with a recent onset of ear pain (within 48 hours) or erythema. There should be objective evidence of middle ear effusion. |
| Initial Management of acute otitis media (AOM) | Should include adequate analgesia for all children and adults with acetaminophen or non-steroidal anti-inflammatory drugs |
| Mild otalgia for <48 hours Temperature: 39°C Should be started on a 10-d course of high dose of antibiotics Consider watchful waiting with close follow-up or a 10-day course of antibiotic therapy after a decision-making discussion with parents Watchful waiting with close follow-up and treatment with analgesics along with providing a safety net antibiotic prescription if symptoms persist if unable to follow up and symptoms persist within 48–72 hours Or Oral analgesia and High-dose amoxicillin for 5–7 days |
| Antibiotics for severe AOM Unilateral or Bilateral | Children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia; otalgia for 48 h or longer; temperature 39°C or higher):Should be started on a 10-d course of antibiotics. |
| Choice of antibiotic | High-dose amoxicillin (80–90 mg per kg per day in 2 divided doses) is preferred as a first choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin. |
| Second-line antibiotics | If the amoxicillin criteria are unmet, prescribe an antibiotic with additional beta-lactamase coverage, such as amoxicillin-clavulanate. |
| Re-evaluation in patient with unresolved symptoms | If symptoms worsen or do not respond to initial antibiotic treatment within 48–72 hours, change treatment if otitis media is present. Consider intramuscular ceftriaxone (Rocephin), clindamycin, or tympanocentesis if symptoms worsen despite adequate therapy. |
| Management of recurrent AOM ≥ 3 episodes in 6 mo or 4 in 1 year with ≥ 1 episode in the proceeding 6 months | Tympanostomy tubes (TTs) reduce the frequency of AOM episodes, decrease the risk of infections, and prevent persistent middle ear effusion (MEE); prophylactic antibiotics are not recommended; referral to otolaryngologist may be necessary |
| Persistent MEE | Monitor for 3–6 month intervals with hearing tests for effusions lasting longer than 3 months or any signs of speech or developmental delay. |
| Vaccination recommendations | Updated pneumococcal conjugate vaccine and annual influenza vaccine recommended for all children |
| Promotion of breastfeeding | Encourage exclusive breastfeeding for 6 months or longer |
The diagnosis of AOM and OME should start with an otoscopic inspection of the TM. This is shown in Fig. 1 A, B Medical professionals should note any abnormal TM characteristics as described in Table 2 . This should be followed by a pneumatic otoscopy to assess for middle ear effusion. No laboratory testing or imaging is required for a diagnosis unless it is to confirm or exclude a congenital or systemic disease. The diagnostic criteria for AOM include moderate to severe bulging of the tympanic membrane, new onset of otorrhea, or mild bulging associated with recent ear pain or erythema.
| Color | OME—opaque, yellow or blue tympanic membrane (TM) AOM—dark pink or light red Crying fever, cough or blowing nose–Hyperemia |
| Position | OME—Retracted or in the neutral position AOM—Bulging |
| Mobility | ETD—TM movement with negative pressure OME—Slight movement of TM with positive and negative pressure AOM—No movement of TM |
| Perforation | Single to multiple perforations |
Each examination should meticulously describe the TM, dividing it into 4 quadrants upon visualization. This comprehensive approach considers the following 4 TM characteristics: Color, Position, Mobility, and Perforation; a normal TM, as shown in Fig. 1 C, is neutral, not bulging or retracted, and pearly gray, translucent, and unperforated. This detailed description of the TM is a crucial part of every examination, providing a comprehensive understanding of the ear condition.
The absence of tympanic membrane movement during pneumatic otoscopy is the primary diagnostic tool for detecting AOM and OME, highlighting the importance of thorough cerumen removal from the external auditory canal. This method boasts a sensitivity and specificity of 70% to 90% compared to myringotomy. However, it is crucial to perform the procedure correctly, as many medical professionals may not do so, potentially resulting in misdiagnosis.
The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) updated guidelines on OME and recommended tympanometry screening for children aged 4 to 6 years at the start of school and 1 year later. Tympanometry failure, indicated by middle ear pressure above −200 daPa or a flat tympanometric curve, requires further assessment, especially if accompanied by a 20-dB hearing loss at specific frequencies. Retesting after 2 months is advised for unilateral or bilateral tympanometry failure, with persistent failure warranting immediate physician evaluation, including hearing, speech, and language assessment and appropriate therapy.
Alternative diagnostic methods like acoustic reflectometry have limited acceptance among otolaryngologists due to challenges in establishing interpretation standards. Instead, audiometry is a suitable method to assess middle ear effusions. Tympanocentesis is the preferred technique for identifying middle ear effusion and confirming bacterial infection, but it is underused in primary care settings. It enhances diagnostic accuracy and guides treatment, potentially reducing unnecessary interventions in recurrent cases. , Detecting OME is crucial, as it is often associated with allergies, upper respiratory tract infection, or Eustachian tube dysfunction. Observing OME for 3 months is recommended, as antibiotics are not proven to treat middle ear effusions.
Current treatment options
The initial approach to treating acute otitis media begins with properly addressing symptomatology, most notably otalgia, with topical or oral analgesics (acetaminophen or non-steroidal anti-inflammatory drugs [NSAIDs]) for mild to moderate ear pain, while severe pain may require narcotics. The AAP treatment guidelines are noted in Table 3 . Observation and pain management for 2 to 3 days without antibiotics is recommended for children aged 6 to 23 months with unilateral acute otitis media.. Antibiotics should be reserved for severe cases or children under 2 years old with bilateral acute otitis media, regardless of symptoms. A watch-and-wait approach may be acceptable for 2 out of 3 children, with a subsequent follow-up visit for those whose symptoms does not improve after 48 to 72 hours. An alternative is to provide a safety net antibiotic prescription for those unable to follow up or whose symptoms worsen.
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