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ACUTE OTITIS MEDIA (UNCOMPLICATED)
Overview
Acute otitis media (AOM) is defined as an acute infection of the middle ear for <3 weeks. This is distinct from the diagnosis of otitis media with effusion (OME), which is the presence of a middle ear effusion without acute infection. AOM typically presents with a rapid onset of symptoms including otalgia, conductive hearing loss, and sometimes fever. In younger children, the symptoms may be nonspecific including irritability, fussiness, poor sleep and ear pulling. Clinical diagnosis is made on otologic examination; signs typically include a bulging, erythematous tympanic membrane (TM) with or without purulent effusion or a perforated TM with suppurative otorrhea. The most common pathogens associated with AOM include Streptococ ofcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Differential diagnostic considerations should include otitis media with effusion (middle ear effusion, aural fullness, hearing loss, but without acute signs of acute infection), myringitis (severe otalgia with thickened erythematous tympanic membrane), otitis externa, ear trauma, or referred pain from pharyngitis or the temporomandibular joint.
Key Supplies for Consultation
Appropriate PPE including mask, eye protection, gloves, and gown
Otoscope
512-Hertz tuning fork
Consider culture swab if otorrhea present
If performing tympanostomy tube placement, will need operating microscope, size 4 or 5 ear speculum, myringotomy blade, size 5 or size 7 straight suction, suction source, and device to push tube in place (e.g., pusher or small right angle)
Management
Antibiotic management is recommended in most cases
In patients 6-23 months of age with non-severe unilateral disease, watchful waiting may be offered for 48-72 hours from onset of symptoms
Antibiotic therapy should be recommended in all other cases
Most typical cases of AOM can be successfully treated with amoxicillin 90mg/kg per day divided into two doses x 5-7 days (older than six years) or 10 days (younger than six years or more severe case)
Patients treated with amoxicillin within the last 30 days, allergy to penicillin, or prior failed therapy with amoxicillin should receive an alternative antibiotic to start
AOM with tympanic membrane perforation should be treated with the addition of ototopical antibiotics, most commonly Ciprodex: four drops twice daily for 7-10 days
Treatment should improve symptoms in first 48-72 hours; if symptoms persist or recur within the first several days, consider escalating antibiotic therapy for treatment failure
Failure with amoxicillin alone or cases of recurrent or severe AOM can be treated with amoxicillin-clavulanate (875mg/125mg BID in adults; 45 mg/kg per dose BID in children, max of 875 mg per dose) typically for 10 days in duration
Failure of oral medications may necessitate intramuscular or intravenous antibiotic therapy for both adults and children and consideration of tympanocentesis with culture directed therapy
In patients with pressure equalization tubes presenting with AOM, ototopical antibiotics may be used as single therapy if the tube is patent.
We recommend the AAO-HNS Clinical Practice Guidelines on otitis media with effusion and tympanostomy tubes in children for additional reading on these topics.
Complicated Acute Otitis Media
Overview
Rarely, untreated AOM can progress to extracranial or intracranial complications. Most commonly, the otolaryngologist will be asked about progression to mastoiditis when fluid is detected within the mastoid air cells on a CT scan. It is important to remember that the mastoid is in direct communication with the middle ear space through the antrum, and therefore fluid in the mastoid in the setting of AOM can be expected. As such, acute mastoiditis is a diagnosis that is primarily made clinically, rather than radiographically. Physical exam typically demonstrates erythema, edema (with possible proptosis of the ear), and tenderness over the mastoid process. The contralateral mastoid can often serve as a good “normal” comparison. It is also important to note that in many cases, the otolaryngologist will be asked to evaluate incidental (and often asymptomatic) limited mastoid “fluid” found on CT or MRI that generated the concern for mastoiditis. This finding is quite common and again, and in the absence of symptoms or physical examination findings, does not usually constitute true clinical mastoiditis.
Rapid diagnosis and treatment are critical as a diagnosis of acute mastoiditis is associated with an elevated risk of temporal and intracranial complications. In cases of clinical mastoiditis with neurologic symptoms, MRI and/or MRV should be performed to rule out intracranial involvement or dural sinus thrombosis. With acute mastoiditis, treatment will often consist of inpatient admission, intravenous antibiotics, and ototopical therapy. Intratemporal and intracranial complications are described below.
Intratemporal Complications
Coalescent mastoiditis
More advanced disease characterized by destruction of the mastoid bony septa that is often associated with subperiosteal abscess
Abscess evident on CT imaging
Fluctuance over the mastoid process may be appreciated
Broad spectrum antibiotic therapy is initiated, and consider MRI/MRV to rule out intracranial involvement if concerning CT findings present or neurological changes develop
In cases of abscess, cortical mastoidectomy with pressure equalizing tube placement is most commonly pursued
May develop concomitant abscess involving the insertion of the sternocleidomastoid muscle (i.e. Bezold abscess), digastric groove (i.e. Citelli abscess) or at the root of the zygoma (i.e., Luc abscess)
Petrous apicitis
Occurs when the infection extends medially into the air cells of the petrous apex
Symptoms classically characterized by Gradenigo’s triad (otorrhea, retroorbital pain, diplopia from abducens nerve palsy); though this triad of symptoms is frequently not present
Not all patients have a pneumatized petrous apex, so CT utility is often limited and comparison with the contralateral side along with obtaining MRI is necessary
CT will show destruction of the bony septa of the petrous apex and MRI will classically exhibit T1 hypointense, T2 hyperintense (due to fluid), and peripheral enhancement with gadolinium administration (characteristics of abscess)
Often managed with intravenous antibiotics with or without pressure equalization tube placement, but can require surgical debridement in more severe or recalcitrant cases
Facial paralysis
Occurs secondary to nerve edema or compression from suppurative AOM
Generally requires prompt treatment with a pressure equalization tube, oral and ototopical antibiotics, and high-dose oral corticosteroids if not medically contraindicated; consideration of simple cortical mastoidectomy with pressure equalization tube placement
Serous and Suppurative Labyrinthitis
Rare complications diagnosed clinically following a rapid progression of vertigo, nystagmus, tinnitus, and sensorineural hearing loss
Treatment geared towards preventing further complications and supportive care with antibiotics and pressure equilization tube placement
Disequilibrium may persist for weeks and hearing loss can be permanent
Intracranial Complications
Meningitis
Most common intracranial complication, especially in children
Patient will have classic symptoms including headache, fever, nuchal rigidity, photophobia, seizures, altered mental status
Diagnosis involves lumbar puncture (after CT imaging obtained to rule out increased intracranial pressure and signs of herniation)
Treatment requires high-dose intravenous antibiotics, steroids, and consideration of tympanocentesis for culture data. Neurosurgical consultation is recommended
Patients should be monitored for sensorineural hearing loss and if present, serial MRI should be considered to survey for labyrinthitis ossificans
Subdural abscess
Patients will present with rapid neurologic symptoms such as headache, delirium, seizures, lethargy, and focal neurologic deficits
Diagnosis often requires MRI with gadolinium to differentiate findings from non-enhancing reactive subdural effusion
Treatment involves high-dose intravenous antibiotics, neurosurgical consultation for drainage, and possible mastoidectomy
Epidural abscess
When symptomatic, patients present with a temporoparietal headache and often times with mental status changes
Diagnosis often requires MRI with gadolinium which shows biconvex disk-shaped enhancement
Neurosurgical consultation is recommended for surgical drainage
Treatment involves high-dose intravenous antibiotics and surgical drainage via a transmastoid approach or craniotomy depending upon location
Brain abscess
Patients may be asymptomatic in the setting of a well-organized abscess; if symptomatic, may have a temporoparietal headache, change in mental status, fever, seizures, focal neurological deficits
Treatment involves intravenous antibiotics, neurosurgical consultation for drainage, and possible mastoidectomy for source control if patient is stable
Lateral sinus thrombosis and thrombophlebitis
Often found in association with an epidural abscess, patients will commonly have a temporoparietal headache, “picket fence” spiking fevers, and Griesinger’s sign (edema and pain over mastoid from occlusion of a mastoid emissary vein)
Primary risk surrounds the possibility of a propagating clot and resultant elevated intracranial pressure or intracranial abscess
Diagnosis often includes MRI with gadolinium as well as MRA/MRV which will demonstrate thrombus formation
Treatment typically involves intravenous antibiotics and mastoidectomy. The benefits of sigmoid decompression, thrombus evacuation, and anticoagulation in this setting are controversial
Otitic hydrocephalus
Phenomena of increased intracranial pressure without associated hydrocephalus (dilation of ventricles); can be secondary to lateral sinus thrombosis
Patients present with symptoms of increased intracranial pressure (nausea, vomiting, papilledema, diplopia secondary to ipsilateral abducens nerve palsy)
Symptoms are often chronic in nature and can present weeks beyond resolution of AOM
Risk of blindness secondary to elevated intracranial pressure
Treatment aims to eradicate underlying infection and otologic complications, lower intracranial pressure, and ophthalmologic complications
Example Procedure Note
Procedure: Myringotomy with PE tube placement
After obtaining written and verbal consent, the patient’s head was turned, an ear speculum was inserted and obstructing cerumen was gently removed under the operating microscope. The tympanic membrane appeared ___. Topic anesthesia was obtained using ___. A posteroinferior myringotomy was fashioned with a myringotomy blade, the middle ear was suctioned (insert here if culture obtained), and a pressure equalization tube was placed. Ototopical drops were instilled and a cotton ball was placed. The patient tolerated the procedure well.
References
Arts, H.A., Adams, M.E. (2013). Intratemporal and Intracranial Complications of Otitis Media. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 2399-2409). Baltimore, MD: Lippincott Williams & Wilkins.
Rosenfeld, R. M., Shin, J. J., Schwartz, S. R., Coggins, R., Gagnon, L., Hackell, J. M., … Corrigan, M. D. (2016). Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology–Head and Neck Surgery, 154(1_suppl), S1–S41. https://doi.org/10.1177/0194599815623467
Rosenfeld, R. M., Schwartz, S. R., Pynnonen, M. A., Tunkel, D. E., Hussey, H. M., Fichera, J. S., … Schellhase, K. G. (2013). Clinical Practice Guideline: Tympanostomy Tubes in Children. Otolaryngology–Head and Neck Surgery, 149(1_suppl), S1–S35. https://doi.org/10.1177/0194599813487302
Schilder, A.G., et al (2020). Acute Otitis Media and Otitis Media with Effusion. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 2956-2969). Philadelphia, PA: Elsevier.