Mastoiditis. Postauricular redness, swelling, and proptosis in a young child with acute mastoiditis. (Photo contributor: Lawrence B. Stack, MD.)
Children between the ages of 6 months and 2 years are at highest risk of developing acute otitis media (AOM). Children at increased risk of recurrent AOM contract their first episode prior to 12 months, have a sibling with a history of recurrent AOM, are in day care, or have parents who smoke.
AOM is an acute inflammation and effusion of the middle ear. Viral, bacterial, and fungal pathogens may cause AOM. The pathogenesis of bacterial AOM is eustachian tube dysfunction, typically following a viral infection, allowing retention of secretions (serous otitis) and seeding of bacteria. The most common bacterial isolates are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes. There is an increased prevalence of antimicrobial resistance for S pneumoniae and β-lactamase-producing strains of H influenzae. Vaccination for strains of S pneumoniae has resulted in a modest decrease in incidence of AOM.
Patient presentations and complaints vary with age. Infants with AOM have vague, nonspecific symptoms (irritability, lethargy, and decreased oral intake). Young children can be irritable, often febrile, and frequently pull at their ears, but they may also be completely asymptomatic. Older children and adults note ear pain, impaired hearing, and occasionally otorrhea.
Otoscopy should focus on color, position, translucency, and mobility of the tympanic membrane (TM). Compared with the TM of a normal ear, AOM causes the TM to appear dull, erythematous or injected, bulging, and less mobile. The light reflex, normal TM landmarks, and malleus become obscured. Pneumatic otoscopy and tympanometry enhance accuracy in diagnosing AOM.
Normal Left Tympanic Membrane. Normal tympanic membrane anatomy and landmarks. (Photo contributor: Richard A. Chole, MD, PhD.)
Early Acute Otitis Media. A mildly erythematous tympanic membrane is seen with a small purulent effusion in the middle ear. (Photo contributor: C. Bruce MacDonald, MD.)
Acute Otitis Media. The middle ear is filled with purulent material behind an erythematous, bulging tympanic membrane. (Photo contributor: Richard A. Chole, MD, PhD.)
Management and Disposition
Although AOM generally resolves spontaneously, most patients are treated with antibiotics and analgesics. Steroids, decongestants, and antihistamines do not alter the course in AOM but may improve upper respiratory tract symptoms.