Acute Otitis Media

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Objectives
Define otitis media (OM), acute otitis
media (AOM) and otitis media with effusion
(OME)
Be familiar with the epidemiology of AOM
List causative pathogens in children with
AOM and current bacteriologic resistance
patterns
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1999 7th International Symposium on Recent Advances in Otitis Media

Terms and Definitions

Otitis Media (OM)

Inflammation of the middle ear without reference to cause or pathogenesis.1

Middle Ear Effusion (MEE)

Liquid in the middle ear but not the etiology, pathogenesis, or duration (recent onset,
acute, subacute or chronic).1
Serous: thin, watery liquid
Mucoid: a thick, viscid mucus-like liquid
Purulent: a pus-like liquid
A combination of these

Otitis Media with Effusion (OME)

Inflammation of the middle ear with a collection of liquid in the middle ear space.
Signs and symptoms of acute infection absent.1
Serous, secretory or non-suppurative otitis media are terms that are no longer
recommended.

Acute Otitis Media (AOM)

Inflammation of the middle ear that is of rapid and short onset in association with
signs and symptoms indicating acute infection. The tympanic membrane is full or
bulging, opaque, and has limited mobility. Erythema is an inconsistent finding.1
One or more local or systemic signs are present: otalgia, otorrhea, fever, irritability,
anorexia, vomiting or diarrhea.

Otorrhea

Discharge from:1
external auditory canal
middle ear
mastoid
inner ear or intracranial cavity

Eustachian Tube Dysfunction

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Middle ear disorder that can have symptoms similar to otitis media, such as hearing
loss, otalgia, and tinnitus, but middle ear effusion is usually absent.1

Distinguishing AOM from OME

Hoberman A. Clinical Pediatr 2002;41:373-390 (reprinted with permission)

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Prevalence of Otitis Media

1993 - 1995 (NCHS),2 OM accounted for
18% ambulatory visits (1-4 yr)
14% visits during the 1st yr of life

AOM episodes diagnosed2

81% in pediatric practices
13% in hospital ED
6% in hospital outpatient departments

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Prevalence of Otitis Media

Peak incidence of OM occurs during the first 2
years
60%-70% of children have >1 AOM before 1st
birthday4,5
Early onset (<6 mo) associated with recurrent
AOM and chronic OME
Recurrent AOM, >3 episodes/6 mo or >4
episodes/yr, ~ 20% of children

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Prevalence of Otitis Media

AOM and OME, segments of a disease
continuum7
Mean cumulative time with MEE (AOM or
OME)5

20.4% in 1st yr

16.6% in 2nd yr

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Risk Factors for OM

Host factors

Age/Gender
Genetic predisposition
Cleft palate/Down syndrome
Allergy/Immunity

Environmental factors

Daycare/Siblings
Bottle (versus breast) feeding
Pacifier use
Smoking
Low socioeconomic status
Season/Upper respiratory infections

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Host-Related Risk Factors

Age/Gender
AOM most prevalent between 6 and 11 mo
Shorter, horizontal lying eustachian tube
Males, higher cumulative time with OME

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Environmental Risk Factors

Day Care Attendance
Most important risk factor

50-70% children 6-18 mo attending day care have

bilaterally persistent OME
Number of children in day care, hours spent, age at
entry and siblings in daycare influence risk
Day care increases risk of infection, use of antibiotics,
thus increasing selection of resistant organisms

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Environmental Risk
Factors
Exposure to Household Cigarette Smoke
Positive relationship between smokers in
household and OM during 1st but not 2nd year5
Increased levels of cotinine in saliva correlated
with abnormal tympanograms and number of
smokers
Association between early AOM onset and
cotinine in urine not found
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Pathophysiology of AOM
Otitis Media
Infection

Host Factors

Anatomic/Physiologic
Dysfunction

Immature/impaired

Eustachian tube
dysfunction
Cleft Palate

immunology
Familial
predisposition
Type of milk (breast
or formula)
Gender
Race

Allergy

Environmental
Factors

Bluestone CD. Pediatr Infect Dis J. 1996:15:281-291 (reprinted with permission)

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Pathophysiology of AOM
Eustachian tube (ET) functions include ventilation,
protection and clearance of secretions
Impairment ET function MEE
URI inflammation of nasopharynyx (NP) and ET
Inflammation ET dysfunctionnegative middle
ear pressure
Organisms colonizing NP aspirated into middle ear
resulting in AOM

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Microbiology: Antimicrobial
Resistance
Resistant (MICs 2 g/mL)
Intermediate (MICs 0.12-1 g/mL)

Year
1988-891 1990-911 1992-931 1994-952 1997-982 1999-002 2001-023
# Isolates
476
524
799
1527
1601
1531
1925
1.
2.
3.

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Doern GV. Am J Med. 1995; 99:3S-7S

Doern GV. ACC. 2001;45:1721
Doern GV. Unpublished data

Bacterial Resistance Against -Lactam Abx

-lactamase
enzymes inactivate

Peptidoglycan cell wall

Plasma membrane

-lactam
antibiotics

Altered PBPs
Cytoplasm

Clavulanic acid
irreversibly binds to
-lactamase protecting

Resistance
increases as
altered PBPs
accumulate
Antibiotic
-lactamase
Clavulanic acid

Normal PBP
Altered PBP

-lactam antibiotics
from enzymatic
Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661.

Bacterial Resistance Against

Macrolides

Bacteria alter macrolide binding site

(ermAM gene, MLSB phenotype)

Macrolide unable to block protein

synthesis

Bacterial efflux pumps

(mefE gene, M phenotype)

Macrolide excreted from

cell

Ribosomes
50
30

50
30

50
30

Cytoplasm

Jacobs MR. Am J Manag Care. 1999;5(suppl 11):S651-S661

Macrolide

Antibiotic Options
1st Line
Amoxicillin : low versus high dose
Augmentin
PC allergy Zithromax

2nd Line
Cephalosporins
Zithromax

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The Observation Option

Limited to healthy kids over the age of 6mos
May observe age group 6 months to 2 years if
AOM is uncertain and pt has nonsevere illness.
What defines a severe illness?
fever 39 C or 102.2 F, severe otalgia
Older than 2 years if nonsevere illness
Family has access to doctor, and family
member to close eye on patient

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A picture is worth a
thousand words.

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Acute Otitis Media?

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Acute Otitis Media?

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What is your diagnosis?

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What is your diagnosis?

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Bonus Question -What is this?

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