INVITED REVIEW

Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 1-4

Otitis media in children

Naina Picardo, Mary John
Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
Dr. Naina Picardo
Department of ENT, Christian Medical College, Vellore - 632 004, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/cmi.cmi_1_18

Otitis media is a spectrum of diseases associated with middle ear infection. Acute otitis media is one of the most common acute infections in childhood, with a peak incidence in the second half of infancy. A diagnosis of acute otitis media is often challenging and requires three criteria to be met - acute onset of symptoms, signs of middle ear inflammation, and effusion. Otitis media with effusion is the presence of middle ear effusion without signs or symptoms of ear inflammation such as pain and fever as a result of impaired middle ear ventilation. Features of middle ear effusion in the absence of features of inflammation helps to make the diagnosis of otitis media with effusion. Most cases are self-resolving with 75%–90% showing complete resolution within 3 months.

Keywords: Acute otitis media, chronic suppurative otitis media, otitis media with effusion

Introduction

Acute Otitis Media

Streptococcus pneumoniae,  Haemophilus influenzae  /i> nontypable), and  Moraxella ^{More Details} catarrhalis are the most common organisms.^[6]H. influenzae infection has become relatively more prevalent among children with refractory AOM following introduction of pneumococcal vaccine.^[7]

Diagnosis

AOM is a clinical condition that is frequently underdiagnosed or overdiagnosed. An accurate diagnosis of AOM in infants and young children is challenging. The pneumatic otoscope is a necessary tool for the general practitioner in diagnosing AOM. The child can be examined in the mother's lap with the head well supported. The speculum size should be chosen to ensure a gentle seal at the external auditory canal.

A diagnosis of AOM requires three criteria to be met: (i) acute onset of symptoms, (ii) signs of middle ear inflammation, and (iii) effusion. [Table 1] shows the clinical features diagnostic of AOM.^[8]

Table 1: Diagnostic criteria for acute otitis media Click here to view

All three factors are needed in the diagnosis of AOM. Occasionally, the view of the tympanic membrane is occluded by cerumen. Gentle curetting or suction can be used to facilitate cleaning of the cerumen. Several factors have been implicated in the occurrence of AOM although the evidence in favor of them is conflicting. The clinician should also make a note of the presence of risk factors if any [Table 2] and counsel the parents regarding it.^[9]

Table 2: Risk factors for acute otitis media Click here to view

Management

Once the diagnosis is made based on symptoms and signs, pain is the first symptom that must be addressed. Pain relief is essential, especially at bedtime in order to prevent disruption of sleep in the child. Acetaminophen and ibuprofen have been shown to be effective in relieving pain as well as other features of inflammation. Topical analgesics such as benzocaine can also be helpful.^[8]

There are no reliable clinical predictors to predict if it is viral or bacterial in origin. Hence, the clinician may have a dilemma whether to prescribe antibiotics. [Table 3] lists the present guidelines for prescribing antibiotics.^[8] For the first episode, the antibiotic of choice would be amoxicillin in the dose of 80 mg/kg/day in two or three divided doses. For recurrent episodes, the drug of choice would be amoxicillin/clavulanate 80 mg/kg/day in two divided doses. If the child is allergic to amoxicillin or not tolerating, the alternatives are cefdinir, amoxicillin-sulbactam, macrolides, and cefixime.^[10],[11] In addition, nasal drops to relieve nasal stuffiness and topical ear drops in case of any discharge must be given.

Table 3: Management guidelines for acute otitis media Click here to view

Prevention

Ensuring complete immunization, early identification and counseling on the risk factors and adequate management of every child are steps which can ensure reduction in the incidence of AOM.^[5]

Otitis Media With Effusion

OME is the presence of middle ear effusion without signs or symptoms of ear inflammation such as pain and fever as a result of impaired middle ear ventilation.^[5]

OME may occur spontaneously because of poor eustachian tube function or as an inflammatory response following AOM. Poor eustachian tube dysfunction may be a function of chronic adenoid hyperplasia, chronic rhinitis, palatal defects as well as allergy. The risk factors for the development of OME include age between 2 and 5, male sex, low socioeconomic status, early introduction of cow's milk, passive smoking, and day-care attendance.^[12],[13] The colonization of nose and nasopharynx by otopathogenic organisms forming biofilms has also been cited as a cause of chronic inflammation going into the middle ear and also causing recurrent AOM.^[12],[14]

The clinical features of OME are often nonspecific, which is the reason for delay in seeking treatment. They may present with mild intermittent ear pain, fullness, or “popping” in older children or ear rubbing and sleep disturbances in infants. Very often, hearing loss is the presenting complaint even when not specifically described by the child. The parents may report that the child is not responding as well as before to sounds or is turning the TV volume too high. They may also present with recurrent episodes of AOM with persistent OME between episodes. Other infrequent complaints include delayed speech or language development, misarticulation, problems with school performance, problems with maintaining balance, and unexplained clumsiness.^[15]

The diagnosis is made by pneumatic otoscopy as well as audiological tests. The presence of middle ear effusion in the absence of features of inflammation helps to make the diagnosis of OME. On otoscopy, tympanic membrane may appear dull, opaque, or slightly bulging with loss of light reflex and restricted mobility [Figure 1] and [Figure 2]. Occasionally, air-fluid levels or bubbles may be seen. Pure tone audiometry is suggestive of conductive hearing loss with tympanometry showing a “B-” type curve.^[5]

Figure 1: Bulged congested tympanic membrane in acute otitis media. Click here to view

Figure 2: Dull tympanic membrane with air bubbles and distorted cone of light. Click here to view

Most cases of OME are self-resolving with 75%–90% showing complete resolution within 3 months. In children who are not at risk of any speech, delay can be managed with watchful waiting for 3 months from the date of onset or diagnosis of effusion. Clinicians should not perform tympanostomy tube insertion, i.e., myringotomy and grommet insertion in children with a single episode of OME of <3 months' duration.^[5]

In those children where the OME persists for more than 3 months whether unilateral or bilateral in the presence of symptoms such as hearing problems, vestibular problems, poor school performance, behavioral problems, ear discomfort can be offered tympanostomy tube insertion of life. Those who did not receive tympanostomy tube insertion should be followed up for 3–6 months. On follow-up, if the child is noted to have significant hearing loss or structural abnormality of the tympanic membrane, they should be considered for myringotomy and tympanostomy tube insertion.^[16] Adenoidectomy should be considered in children ≥3 years of age with nasopharyngeal obstruction and recurrent adenoiditis. Intranasal steroids can be prescribed for those with coexistent nasal allergies.

The indications for referring a child to a specialist in a general practice setting are enlisted in [Table 4].^[8] There is a subset of children who are at risk of speech delay in whom early intervention is recommended.^[16] They have been enumerated in [Table 5].

Table 4: When to refer a child with acute otitis media Click here to view

Table 5: Risk factors for speech delay Click here to view

The management of OME can be summarized as watchful waiting and follow-up after 3–6 months for any OME <3 months. Candidates for surgery and referral include children with OME lasting 4 months or longer with persistent hearing loss, recurrent or persistent OME in children at risk regardless of hearing status, OME causing structural damage to the tympanic membrane or middle ear and children with OME along with a history of recurrent AOM.

Conclusion

Otitis media in children is a common condition, especially in a developing country like ours. It can present as a spectrum starting from AOM to OME and chronic otitis media. The immaturity of the immune system of young children makes them incapable of handling the infection occasionally. This, along with the ET dysfunction, explains the long-lasting course of AOM as well as the high recurrence rate. Persistence of infection due to improper treatment or virulence of organism can lead to chronic otitis media. This can cause significant hearing loss, delay in speech, and decreased quality of life. Hence, it is imperative to have increased awareness about this clinical condition and manage it appropriately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

References

1.	Leach AJ, Morris PS. Antibiotics for the prevention of acute and chronic suppurative otitis media in children. Cochrane Database Syst Rev 2006;(4):CD004401.
2.	Casellas JM Jr., Israele V, Marín M, Ishida MT, Heguilen R, Soutric J, et al. Amoxicillin-sulbactam versus amoxicillin-clavulanic acid for the treatment of non-recurrent-acute otitis media in argentinean children. Int J Pediatr Otorhinolaryngol 2005;69:1225-33.
3.	Rupa V, Isaac R, Rebekah G, Manoharan A. Association of Streptococcus pneumoniae nasopharyngeal colonization and other risk factors with acute otitis media in an unvaccinated Indian birth cohort. Epidemiol Infect 2016;144:2191-9.
4.	Roy E, Hasan Kh, Haque F, Siddique AK, Sack RB. Acute otitis media during the first two years of life in a rural community in Bangladesh: A prospective cohort study. J Health Popul Nutr 2007;25:414-21.
5.	Corbeel L. What is new in otitis media? Eur J Pediatr 2007;166:511-9.
6.	Broides A, Dagan R, Greenberg D, Givon-Lavi N, Leibovitz E. Acute otitis media caused by moraxella catarrhalis: Epidemiologic and clinical characteristics. Clin Infect Dis 2009;49:1641-7.
7.	Pumarola F, Marès J, Losada I, Minguella I, Moraga F, Tarragó D, et al. Microbiology of bacteria causing recurrent acute otitis media (AOM) and AOM treatment failure in young children in spain: Shifting pathogens in the post-pneumococcal conjugate vaccination era. Int J Pediatr Otorhinolaryngol 2013;77:1231-6.
8.	Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99.
9.	Zhang Y, Xu M, Zhang J, Zeng L, Wang Y, Zheng QY, et al. Risk factors for chronic and recurrent otitis media-a meta-analysis. PLoS One 2014;9:e86397.
10.	Block SL, Schmier JK, Notario GF, Akinlade BK, Busman TA, Mackinnon GE 3rd, et al. Efficacy, tolerability, and parent reported outcomes for cefdinir vs. High-dose amoxicillin/clavulanate oral suspension for acute otitis media in young children. Curr Med Res Opin 2006;22:1839-47.
11.	Lee HJ, Park SK, Choi KY, Park SE, Chun YM, Kim KS, et al. Korean clinical practice guidelines: Otitis media in children. J Korean Med Sci 2012;27:835-48.
12.	Walker RE, Bartley J, Flint D, Thompson JM, Mitchell EA. Determinants of chronic otitis media with effusion in preschool children: A case-control study. BMC Pediatr 2017;17:4.
13.	Csákányi Z, Czinner A, Spangler J, Rogers T, Katona G. Relationship of environmental tobacco smoke to otitis media (OM) in children. Int J Pediatr Otorhinolaryngol 2012;76:989-93.
14.	Torretta S, Drago L, Marchisio P, Gaffuri M, Clemente IA, Pignataro L, et al. Topographic distribution of biofilm-producing bacteria in adenoid subsites of children with chronic or recurrent middle ear infections. Ann Otol Rhinol Laryngol 2013;122:109-13.
15.	Pang KP, Ang AH, Tan HK. Otitis media with effusion: An update. Med J Malaysia 2002;57:376-82.
16.	Hellström S, Groth A, Jörgensen F, Pettersson A, Ryding M, Uhlén I, et al. Ventilation tube treatment: A systematic review of the literature. Otolaryngol Head Neck Surg 2011;145:383-95.

Figures

  [Figure 1], [Figure 2]
 
 

Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]