Management of acute otitis media in children six months of age and older

Question 1

Why are children predisposed to AOM?

Answer 1

1. More frequent viral infections
2. Shorter eustachian tubes
3. More horizontal eustachian tubes

Question 2

What are risk factors for AOM?

Answer 2

1. Young age
2. Frequent contact with other children
3. Orofacial abnormalitis i.e. cleft palate
4. Household crowding
5. Exposure to cigarette smoke
6. Pacifier use
7. Shorter duration of breastfeeding
8. Prolonged bottle-feeding while lying down
9. Family history of otitis media
10. Children of First Nations or Inuit ethnicity
11. Lower levels of secretory IgA
12. Persistent biofilm in middle ear

Question 3

What are the most common bacteria causing AOM?

Answer 3

1. S. pneumoniae
2. H. influenzae
3. M. catarrhalis
4. GAS (less commonly)

Question 4

What symptoms are associated with AOM?

Answer 4

Non-specific

1. Poor sleep
2. Decreased activity
3. Irritability
4. Fever
5. Otalgia

Question 5

What are methods to diagnose of middle ear effusion?

Answer 5

1. Decreased TM mobility when both positive and negative pressure applied using a pneumatic otoscope
2. Automated tympanometry is unrealiable in infants <7mo and sensitivty and specificity depends on proper use and information
3. Otoscopy showing
   a) loss of bony landmarks
   b) presence of air-fluid level
   c) Bulging TM
   d) Red or yellow TM

Question 6

What are the diagnostic criteria for AOM?

Answer 6

1. Acute onset of symptoms (otalgia, or non-specific in non-verbal children)
2. Signs of middle ear effusion
3. WITH signs of inflammation of the middle ear (moderate or marked bulging of TM with marked erythema, hemorrhage, or yellow TM)

Question 7

Which bacteria is associated with spontaneous TM perforation?

Answer 7

S. pyogenes

Question 8

What is the DDx of ear drainage?

Answer 8

1. Perforation from AOM
2. Otitis externa
3. Chronic ear drainage from previous perforation
4. Drainage from T-tube

Question 9

What are common complications of bacterial AOM?

Answer 9

1. Acute mastoiditis (pain and swelling over the mastoid)
2. Acute facial (CN VII) nerve palsy from temporal bone inflammation
3. Gradenigo’s syndrome: 6th CN palsy (failure of ipsilatral eye abduction) due to petrous bone inflammation or infection
4. Labryinthitis due to spread to cochlear space
5. Venous sinus thrombosis of transverse, lateral or sigmoid venous sinuses
6. Meningitis

Question 10

What is the management of patients with spread beyond the middle ear?

Answer 10

1. Systematic antimicrobial therapy
2. Consider surgical intervention
3. Consider imaging to deliniate the extent of the infection

Question 11

What are the treatment recommendations for patients presenting with a perforated TM with symptoms of AOM?

Answer 11

1. Systemic antimicrobials x 10d

2. Examination for associated complications

Question 12

What does mildly ill mean in the context of AOM?

Answer 12

1. Alert
2. Responsive
3. No rigors
4. Responding to anti-pyretics
5. Mild otalgia
6. Able to sleep
7. <39 degrees C in absence of antipyretics
8. <48h of illness

Question 13

What does moderately or severely ill mean in the context of AOM?

Answer 13

1. Irritable
2. Difficulty sleeping
3. Poor response to antipyretics
4. Severe otalgia
5. > 39 degrees C in absence of antipyretics
6. > 48h of symptoms

Question 14

What are the treatment recommendations for patients with MEE present AND bulging TM who are mildly ill?

Answer 14

1. Discuss with caregivers
2. Observe for 24-48h and ensure f/u
3. Recommend analgesia
4. If not improved or worsening clinically, treat with antimicrobials (6m-2yo x 10d, >2y x5d)

Question 15

What are the treatment recommendations for patients with MEE present AND bulging TM who are moderately or severely ill?

Answer 15

Treat with antimicrobials:

1. 6m-2yo x 10d
2. > 2yo x 5d

Question 16

What are the treatment recommendations for patients without MEE OR with MEE but non-bulging or mildly erythematous TM?

Answer 16

1. Consider viral etiology (i.e. RSV, influenza) or other infection
2. r/a in 24-48h if not clinically improving or earlier if worsening clinically to verify presence of effusion and signs of middle ear inflammation such as bulging TM

Question 17

What are the recommendations if unable to determine if TM bulging?

Answer 17

If child:
1. only mildly ill
2. does not appear to have severe otalgia
3. feeding reasonably well
4. T <39 degrees C for <24h
5. Reliable caregivers
Observe w/ f/u in 24-48h

Question 18

Which bacteria cause AOM more likely to resolve spontaneously?

Answer 18

1. M catarrhalis

2. H influenza

Question 19

What is the first line treatment for AOM (no penicillin allergy)?

Answer 19

Amoxicillin 75-90mg/kg/day PO BID OR 45-60mg/kg/day PO TID

Question 20

What is the first line treatment if penicillin allergic?

Answer 20

1. Cefuroxime 30mg/kg/day PO BID or TID

2. Ceftriaxone 50mg/kg IM/IV daily x 3d

Question 21

What is the therapy if initial therapy fails (no symptomatic improvement after 2-3 days)?

Answer 21

<35kg: Amoxicillin-clavulanate 45-60mg/kg/day PO TID x 10d (400mg/5mL suspension of 7:1 formulation)
>35kg: 500mg PO TID x 10d

Question 22

What is the therapy if patient unable to tolerate oral antimicrobials or if amoxi-clav fails?

Answer 22

Ceftriaxone 50mg/kg/day IM/IV daily x 3d

Question 23

What are the CPS recommendations?

Answer 23

1. To diagnose AOM, there must be acute onset of symptoms such as otalgia (or nonspecific symptoms in nonverbal children), signs of a middle ear effusion associated with inflammation of the middle ear (ie, a TM that is bulging and, usually, very erythematous or hemorrhagic, and yellow or cloudy in colour) or a TM that has ruptured.
2. For otherwise healthy children ≥6 months of age who have mild illness with appropriately diagnosed AOM criteria or children who do not fully meet diagnostic criteria, a watchful waiting approach for 48 h is an option if follow-up can be assured. Advice regarding analgesics must be provided. It is recommended to:
   a) reassess the child within 24 h to 48 h to document the clinical course; OR
   b) have the caregiver return if the child does not improve or worsens anytime within 48 h; OR
   c) provide an antimicrobial prescription to be filled if the child does not improve.
3. Children with a bulging TM who are febrile (≥39°C) and moderately to severely systemically ill, or who have severe otalgia, or who have already been significantly ill for 48 h should be treated with antimicrobials.
4. If a decision is made to treat with antimicrobials, amoxicillin either divided twice per day at a dose of 75 mg/kg/day to 90 mg/kg/day or amoxicillin divided three times per day at a dose of 45 mg/kg/day to 60 mg/kg/day are the first choices for AOM therapy.
5. A five-day course of an appropriately dosed antimicrobial is recommended for most children ≥2 years of age with uncomplicated AOM, with a 10-day course being reserved for younger children (six to 23 months) and cases with a perforated TM or recurrent AOM.