Acute Otitis Media: Middle Ear Mayhem

-Case-
A 3-year-old boy is brought to the ED by his parents for tugging at his ear, irritability, and a fever of 101.5°F. His tympanic membrane is erythematous and bulging with decreased mobility on otoscopy. Separately, later that day, a 42-year-old woman presents with left ear pain and muffled hearing. Her TM appears dull and immobile with mild effusion.

-Evaluation-
Otitis media (OM) is an umbrella term for middle ear inflammation. In the ED, our focus is on acute otitis media (AOM) and otitis media with effusion (OME).

  • AOM Diagnostic Criteria:
    • Rapid onset of signs/symptoms
    • Middle ear effusion (confirmed by pneumatic otoscopy or tympanometry)
    • Signs of middle ear inflammation (erythema, bulging, otalgia)
  • Common Symptoms:
    • Fever, otalgia, ear tugging (pediatrics)
    • Muffled hearing, pressure, irritability, sleep disturbance
  • Common Pathogens:
    • Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
  • Adults vs. Kids:
    • Pediatric Eustachian tubes are shorter and more horizontal, making infections more common
    • Adults may present with concurrent sinusitis or upper respiratory infection

-Management-

  • Pain Control:
    • Acetaminophen or ibuprofen
    • Topical benzocaine for severe ear pain (older than 2 years)
  • Antibiotic Decision-Making:
    • Under 6 months: Treat all AOM with antibiotics
    • 6 months-2 years: Treat if diagnosis is certain and symptoms are severe
    • Over 2 years: Consider watchful waiting if symptoms are mild and follow-up is possible
  • First-Line Antibiotic:
    • Amoxicillin 80-90 mg/kg/day (peds) or 500-875 mg BID (adults)
  • Alternatives:
    • Amoxicillin-clavulanate, cefdinir, cefuroxime (for recent beta-lactam use)
    • Azithromycin, clindamycin (for penicillin allergy)
  • Complications to Watch For:
    • TM rupture, mastoiditis, hearing loss, facial nerve palsy

-Fast Facts-

  • Red TM alone ≠ AOM; need middle ear effusion
  • Overuse of antibiotics = resistant organisms and side effects
  • Persistent effusion without infection? Likely OME – not treated with antibiotics
  • Mastoiditis = red flag! Look for posterior ear tenderness/swelling

One kid’s tugging his ear, another adult says it feels like they’re underwater – same diagnosis, different flavors. In the ED, it’s all about confirming the diagnosis, controlling pain, and knowing when to treat. Toss in some antibiotic stewardship and you’ve mastered the art of otitis media!

Want to learn more? Read our in-depth study guide on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. doi:10.1542/peds.2012-3488
  2. Shaikh N, Hoberman A, Paradise JL, et al. Safety of withholding antibiotic treatment in children with nonsevere acute otitis media. JAMA Pediatr. 2016;170(10):956–962. doi:10.1001/jamapediatrics.2016.1248
  3. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1–S41. doi:10.1177/0194599815623467
  4. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002;287(23):3096–3102. doi:10.1001/jama.287.23.3096
  5. Lieberthal AS. Acute otitis media: diagnosis and treatment. N Engl J Med. 2023;388(16):1501–1510. doi:10.1056/NEJMcp2213815
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