1. family and parenting
2. children

Emergency Medicine Grand Rounds
Updated March 2013
Otitis Media
A
cute otitis media is different than otitis media
with effusion (fluid in the middle ear, secretory otitis
media, serous otitis, “glue ear”) and chronic otitis media
(chronic suppurative otitis media). People usually get
acute otitis media with, or after, a cold.1 Chronic otitis
Keith Conover, M.D., FACEP
media is rare in developed countries, because in about
1930 we started treating ear infections with antibiotics.
Before this, chronic otitis media was common, and often
led to deafness and other complications.2
Diagnosis of acute otitis media
A
cute otitis media is fluid in the middle ear
combined with signs or symptoms of acute local or
systemic illness. The ear may hurt, or may drain fluid;
or the patient may have fever.3 But the specifics for
diagnosis are not so clear. In 26 clinical trials, there were
18 different sets of diagnostic criteria. One survey of 165
pediatricians resulted in 147 different sets of criteria!4
The 2013 AAP-AAFP guideline The Diagnosis and Management of Acute Otitis Media5 provides the following
advice on diagnosing otitis media, trying to standardize
the diagnosis:
• Clinicians should [emphasis added] diagnose acute
otitis media (AOM) in children who present with
moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to
acute otitis externa.
• Clinicians may [emphasis added] diagnose AOM
in children who present with mild bulging of the
TM and recent (less than 48 hours) onset of ear
pain (holding, tugging, rubbing of the ear in a
nonverbal child) or intense erythema of the TM.
• Clinicians should not [emphasis added] diagnose
AOM in children who do not have middle ear effusion (MEE) (based on pneumatic otoscopy and/
or tympanometry).
Diagnosing a middle ear effusion is fairly easy. Do pneumatic otoscopy. That’s where you use a soft ear speculum
(to get a seal with the ear canal), with an insufflation
bulb attached to the otoscope, and puff air into the ear.
You look at the tympanic membrane (eardrum, TM) for
position, color, translucency, and mobility.3 In one study,
as confirmed by myringotomy (needle aspiration of the
middle ear to get fluid), pneumatic otoscopy was 93%
sensitive and 58% specific for effusion, which compares
favorably with tympanometry (see below) which was 90%
sensitive and 86% specific.6
A 2004 clinical guideline on otitis media with effusion
(OME) says: Distinct redness of the TM should not be a
criterion for antibiotic prescribing because it has poor predictive value for acute otitis media and is present in about
5% of ears with OME.7 Screaming babies always have a
red TM, and removing wax often makes the TM red.8
A retracted TM, which hurts, is from eustachian tube
dysfunction, and not a bacterial
infection.1
Predictive
Value (%)
Color
Position
Mobility
A recent study recommended
you diagnose acute otitis media
with two or more of
99
Cloudy
Bulging
Distinctly impaired
99
Cloudy
Bulging
Slightly impaired
97
Cloudy
Normal
Distinctly impaired
94
Distinctly red
Bulging
Distinctly impaired
94
Cloudy
Normal
Distinctly impaired
93
Slightly red
Bulging
Slightly impaired
89
Distinctly red
Normal
Distinctly impaired
85
Slightly red
Bulging
Distinctly impaired
83
Distinctly red
Bulging
Slightly impaired
47
Distinctly red
Normal
Slightly impaired
41
Slightly red
Normal
Slightly impaired
Normal
Normal
Retracted
Distinctly impaired
Normal
Normal
Normal
Normal
Retracted
Slightly impaired
Normal
Normal
• decreased or absent TM
mobility,
• yellow or white discoloration of the TM,
• opacification of the TM
not due to scarring, and
• visible bubbles or airfluid levels.9
Another study correlated color,
37
Cloudy
position and mobility with
29
Normal
acute otitis media (diagnosed
with myringotomy).10 A cloudy
15
Distinctly red
TM, and a bulging TM, and
7
Slightly red
a TM with decreased mobil3
Normal
ity (all three) correlated 99%
0.1
Normal
with acute otitis media (see
Table 1). You might want to
get your own insufflation bulb
(Welch-Allyn #23804), as it adds a lot to the accuracy of
your diagnosis; I did. You need soft speculum sheaths to
make a good seal with the external ear canal. The ED or
clinic should supply these, though most don’t. I bought a
A, Normal TM. B,TM with mild bulging. C,TM with moderate bulging. D,TM with severe bulging.
Courtesy of Alejandro Hoberman, MD.
box of 80 of each size of the Welch Allyn SofSeal sheaths,
24330 (med) and 24320 (small), that fit the speculums of
the Welch Allyn Macroview otoscopes in every ED and
clinic in which I have worked for the past 10 years. It cost
1
$44.50/box from schoolhealth.com.
for diagnosing a middle ear effusion.
A machine that tells you if the patient has a middle ear
effusion without digging the wax out of the ear of a
squirming, screaming infant sounds good. Tympanometry uses such a device to assess for middle ear effusion.
Since the early 1970s, tympanometers have been found
in many ENT offices and pediatric offices and a few
Emergency Departments. They’re easy to use, but results
are a bit hard to figure out. Basic tympanometers measure how much of a 226 Hz musical tone reflects back
from the TM, as the air pressure in the external canal is
varied, both above and below ambient air pressure. More
modern tympanometers use a pair of musical tones. The
tympanometer plots a pressure-versus-compliance curve
on a graph known as a tympanogram. The interpretation
of tympanograms is described in the medical literature
and online but is beyond the scope of this handout.11,12
Tympanometry is no better than pneumatic otoscopy
Like using an insufflation bulb, tympanometry requires
an airtight seal; however, spectral gradient acoustic reflectometry (SGAR), also known as acoustic reflectometry,
does not. SGAR machines emit tones from 1.8 to 4.4
kHz, and measure how much is reflected. As with tympanometry, accuracy depends on how experienced you
are,13 though SGAR is easier than tympanometry.9
Neither tympanometry or SGAR is better than history,
physical exam, and pneumatic otoscopy to diagnose
acute otitis media.14 As Combs writes: “No technology
can replace the careful history and otoscopic examination by an experienced physician.”15
Physicians can’t diagnose acute otitis media by symptoms alone. But parents can. Their sensitivity is 71% and
their specificity is 80%.16
Antibiotics for acute otitis media?
B
ack in the 1980s, when I was a resident, I was
taught that “any child with an earache has an acute
amoxicillin deficiency until proven otherwise.” In the
USA, parents bringing an infant or child to you with an
earache usually expect antibiotics. In Europe, though,
they seldom get antibiotics.17,18 In the USA 95% of kids
with acute otitis media get antibiotics; in the Netherlands, it’s only 31-56%.19-21
Having acute otitis media before you’re 6 months old
means you’re more likely to get recurrent acute otitis
media later in life. But family history of allergy, breastfeeding, day care, gender, and home environment make
no difference in how likely you are to get acute otitis
media.22 Recurrent acute otitis media tends to resolve as
children grow older.23 There is some evidence that, for
children with recurrent episodes of acute otitis media,
that prophylactic antibiotics, either throughout the
cold season, or with onset of a viral upper respiratory
infection, may help prevent acute otitis media.24 But the
2013 AAP-AAFP guidelines5 state: Clinicians should not
prescribe prophylactic antibiotics to reduce the frequency
of episodes of AOM in children
with recurrent AOM.
I was taught to prescribe antibiotics for acute otitis media
to decrease the incidence of
deafness. However, permanent
deafness comes primarily
from chronic otitis media (2
or more weeks of otitis media
with discharge) which is quite
rare in North America; 25 acute
otitis media does not cause
permanent deafness, but it’s
common to have a bit of temporary deafness from left-over
fluid in the middle ear.26 Worse
complications, such as permanent deafness or death from
brain infection, are rare outside the developing world.27
2
If we prescribe lots of antibiotics for red tympanic membranes, do we create resistant bacteria? Yes. Do we help
or hurt the patient? We may be hurting the patient.28 An
immediate antibiotic decreases crying during the day
and provides better sleep the first day. It decreases pain,
but only slightly, and only on the second day of antibiotics, when symptoms are already improving. This small
benefit may not outweigh complications such as diarrhea
and creating resistant bacteria.29
It’s now OK to give a “safety-net antibiotic prescription,”30 and tell parents not to fill it unless the ear pain
goes on for a couple of days. A lot of the time, parents
don’t fill the prescription. Parents are happy and you’re
creating fewer resistant bugs.30,31 Telling the parents to
call back for a prescription in a couple of days has the
same satisfaction rate, but seems to me as though it
would work better for offices than EDs.32,33 Nobody has
(yet) studied delayed antibiotics for adults.
The American Academy of Pediatrics and American
Academy of Family Physicians 2013 joint clinical practice
guideline5 says:
• The clinician should prescribe antibiotic therapy for
AOM (bilateral or unilateral) in children 6 months
and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours
or temperature 39°C [102.2°F] or higher).
• The clinician should prescribe antibiotic therapy
for bilateral AOM in children 6 months through 23
months of age without severe signs or symptoms (i.e.,
mild otalgia for less than 48 hours and temperature
less than 39°C [102.2°F]).
• The clinician should either prescribe antibiotic
therapy or offer observation with close follow-up
based on joint decision making with the parent(s)/
caregiver for unilateral AOM in children 6 months to
23 months of age without severe signs or symptoms
(i.e., mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure
follow-up and begin antibiotic therapy if the child
worsens or fails to improve within 48 to 72 hours of
onset of symptoms.
• The clinician should either prescribe antibiotic
therapy or offer observation with close follow-up
based on joint decision-making with the parent(s)/
caregiver for AOM (bilateral or unilateral) in
children 24 months or older without severe signs or
symptoms (ie, mild otalgia for less than 48 hours
and temperature less than 39°C [102.2°F]). When
observation is used, a mechanism must be in place
to ensure follow-up and begin antibiotic therapy if
the child worsens or fails to improve within 48 to 72
hours of onset of symptoms.
This may be summarized as: Treat with antibiotics if
severe acute otitis media, or if nonsevere bilateral acute
otitis media in young children. Treat with antibiotics or
“observe” (no antibiotics and have patient call back if not
improving, or provide a “safety net prescription”) if nonsevere unilateral acute otitis media in young children, or
if nonsevere acute otitis media in older children.
But there is a review of antibiotics for acute otitis media
in children from the Cochrane Collaboration.34 Unlike the US-only AAP-AAFP guideline, it represents
worldwide experts. It notes that antibiotics decrease
pain only slightly and only for a couple of days, and, they
don’t decrease temporary deafness, rupture of the TM,
or mastoiditis. And, 37% of those who get antibiotics get
vomiting, diarrhea or rash. So, the Cochrane Review says
that you should prescribe antibiotics only if:
• there is bilateral acute otitis media, or
• there is acute otitis media with otorrhea (discharge from the ear).
So what do you do? I treat acute otitis media only if I’m
absolutely sure it’s there and it looks bad, otherwise I
just treat for eustachian tube dysfunction, with oxymetazoline (AFRIN) nasal spray, as described below.
Bacteria that cause acute otitis media are often resistant
to amoxicillin (particularly pneumococcus: Streptococcus pneumoniae). But amoxicillin is still the first-line
antibiotic; it’s as good as other antibiotics, because the
amoxicillin concentrates in middle ear fluid, enough
to overcome the resistance.38,39 That is, if, instead of
standard-dose amoxicillin (25-50 mg/kg/day divided
BID or TID; maximum 30 mg/kg/day if child is < 3
months old) you prescribe high-dose (80-90 mg/kg/day
divided BID, though a conservative Cochran Review
says to give TID35), for a full 7-10 days.36 A single shot of
IM ceftriaxone, or 5 days of oral azithromycin, are good
alternatives.37
The 2013 AAP-AAFP guidelines succinctly but confusingly states: Clinicians should prescribe amoxicillin for
acute otitis media when a decision to treat with
antibiotics has been made and the child has
not received amoxicillin in the past 30 days or
the child does not have concurrent purulent
conjunctivitis or the child is not allergic to
penicillin. When I’m not playing doctor I play
computer nerd and think in Boolean logic, so
I would reword it thusly: prescribe amoxicillin unless ((the child has had amoxicillin in
Normal Tympanic Membrane
the past 30 days) OR (the child has otitis(Wikimedia Commons)
conjunctivitis syndrome) OR (the child is
allergic to penicillins)).
If, after three days of an antibiotic, the patient still has,
fever, ear pain, a red, bulging TM, or discharge from the
ear, what do you do? High-dose amoxicillin–clavulanate
(AUGMENTIN), or cefuroxime axetil (CEFTIN), or
intramuscular ceftriaxone (ROCEPHIN) for three days.38
And if you see a patient with this in the ED, emphasize
the need for primary-care follow-up!
Repeat episodes of acute otitis media (more than a
month after the first time) is almost always (>90%) from
a new virus or bacterium.39 Amoxicillin-clavulanate
(AUGMENTIN) is probably appropriate at this point.
BTW, when a mother (it always seems to be the mother,
not the father) says “amoxicillin never works for his/
her ear infections!” I believe the mother. Some kids are
probably colonized with highly amoxicillin-resistant
bacteria. Our scientific studies are not good enough yet
to tease out these outliers. So I prescribe something else,
and call it the art of medicine.
Other Treatments for acute otitis media
O
ral decongestants and antihistamines might
help just slightly, but cause so many problems that
the cure is worse than the disease.40,41 And taking them
during a cold doesn’t prevent acute otitis media.42
A decongestant nasal spray such as oxymetazoline (AFRIN) helps a bit: ~19% residual effusion at one month as
opposed to 27% residual effusion for oral decongestants,
antihistamines, or untreated controls.41 I recommend a
few days of oxymetazoline (AFRIN) nasal spray – less
than 10 days – to avoid rhinitis medicamentosa, which
I describe as “being addicted to nasal spray so you have
to use it to breathe through your nose.”43,44 I tell them to
spray into both nostrils, then lie flat on their backs for a
few minutes, so that they can taste the spray getting back
to where the Eustachian tubes drain out in the back of
the nose/throat.
Antipyrine and benzocaine ear drops (commonly known
as AURALGAN, though no longer available under that
brand name) may help the pain a bit.45,46
Otitis-Conjunctivitis Syndrome
C
onjunctivitis and otitis media are sometimes
occur together, and the combination is highly likely
to be caused by H influenzae;47 H. flu tends to be resistant
to amoxicillin and azithromycin (ZITHROMAX). So,
when treating otitis media, look for conjunctivitis; if you
see it, consider amoxicillin-clavulanate (AUGMENTIN),
cefuroxime (CEFTIN) or cefdinir (OMNICEF).48-52
For the same reason, if you see a child with purulent con-
junctivitis, take a look at the ears; roughly 2/3 will also
have otitis media.53 Treat with an oral antibiotic, but you
don’t need to prescribe eye drops. The tears have enough
of the oral antibiotic to work as antibiotic eye drops.54
3
Otitis Media with Effusion (OME; “Glue Ear”; Serous Otitis; Middle Ear Effusion)
S
ometimes people come to the ED with decreased
hearing, sometimes sudden-onset. The most common cause is earwax impaction. But if you look in the
ear, and rather than a cerumen impaction, you might see
a clear effusion – fluid behind the tympanic membrane.
Or, you might find the same on a routine ear exam.
Middle ear effusions are common after acute otitis
media. Two weeks after they have otitis media, about ¾
of kids will have a persistent effusion; a month after, half
will; and three months later, maybe ¼ will. Antibiotics
don’t help.3,55,56
Serous otitis may also come from eustachian tube
dysfunction (ETD) from other causes: chronic eustachian tube deformity, allergies,57 tobacco smoking and
esophageal reflux.58 Less common causes include chronic
sinus disease (particularly of the ethmoids), adenoidal
hyperplasia, and rarely head and neck tumors.59 People
with serous otitis may complain of a feeling of “water in
the ear,” mild pain or decreased hearing. Serous otitis is
defined as fluid in the middle ear without signs or symptoms of ear infection. Like otitis media, it’s more common in kids.7 Serous otitis is not a big deal in the ED,
but it’s a big deal for pediatricians and family doctors, as
decreased hearing causes problems in class.60
If you see a cloudy tympanic membrane, or a visible
effusion with an air-fluid level, or bubbles behind the
tympanic membrane, without symptoms of acute infection, you’ve diagnosed serous otitis. Refer the patient to
a primary care doctor for follow-up. It’s optional in the
ED, but decreased mobility with insufflation confirms
your diagnosis.61
Unfortunately, there is almost nothing we can do.
Antibiotics, antihistamines, oral decongestants, oral steroids, mucolytics like guaifenesin (e.g., ROBITUSSIN,
MUCINEX) and autoinflation with a Politzer device
(don’t ask) are all useless.7,62-66 Some think that many
cases of adult serous otitis are from allergies.67 Especially in adults with obvious nasal allergies, a nonsedating antihistamine and a steroid nasal spray might help.
Since it may help acute otitis media,41 a short course of
oxymetazoline (AFRIN) nasal spray – less than 10 days
to avoid rhinitis medicamentosa – might help, too.43,44 As
with acute otitis media, I recommend a few minute lying
supine after spraying the nose. Refer to an appropriate primary care physician. However, warn the patient
that “treatment” for kids with serous otitis is a three (3)
month period of “watchful waiting,” checking hearing
tests, and considering tympanostomy tubes.7
Acute otitis media With Tubes or Ruptured TM
T
ympanostomy tubes (myringotomy tubes, ventilation tubes, “grommets”) are sometimes surgically
inserted in the tympanic membranes of children with
recurrent acute otitis media or, particularly in children
> 3 years old, chronic otitis media with effusion (serous
otitis). The tubes are expected to drain fluid for days or
weeks after insertion. About 5% of children with tubes
develop chronic otorrhea (drainage from the ear), usually due to skin flora such as Pseudomonas aeruginosa and
Staphylococcus aureus.68
You may be unsure if a patient has a hole in the tympanic
membrane or not. A patient may have had tympanostomy tubes in the past, and you can’t tell if they are still
there. And, sometimes, the pressure from acute otitis
media will cause the tympanic membrane to rupture;
this may fill the ear canal enough that it’s hard to tell if
you’re dealing with otitis media with perforation or otitis
externa.
Two clues to a perforated tympanic membrane are (1)
people who can taste the drops after putting ear drops in
their ear, and (2) people who can blow air out their ear
when blowing their noses.69
You may see an infant or child with known tympanostomy tubes complaining of acute (sudden onset, severe)
otorrhea. This occurs in roughly half of children with
tubes.70 From the drainage, the external ear canal may
look eczematous.69 The patient may have a low-grade
temperature or fatigue, but due to the tubes, not much
pain.
4
About a third of kids with acute otitis media have a spontaneous rupture of the tympanic membrane during one
of their episodes of otitis media, more likely if they’ve
had prior otitis media. Usually the pain gets a lot better
when the tympanic membrane ruptures. Ninety-four
percent of the perforations were spontaneously healed
within a month. Children who have had a perforation are
twice as likely to have recurrent acute otitis media.71
The bacteria in ear drainage in those under age 3 is the
same as that in acute otitis media: a mixture of viruses
and airway-derived bacteria.72,73 In older children, it will
usually be skin flora including Pseudomonas aeruginosa
and Staphylococcus aureus.74
There are many treatments for such ear drainage, from
doing nothing (“observation”), through ear drops, to
oral antibiotics. In children younger than 3 years old
with acute tube-associated drainage, ear drops are as
good as oral antibiotics; ofloxacin ear drops (FLOXIN)
are as good as oral amoxicillin-clavulanate (AUGMENTIN).75 Given that ear drops are effective for tube-associated and perforation-associated ear drainage in all ages,
it seems prudent to use ear drops as the initial treatment,
unless there is severe ear pain or high fever, in which
case you should probably prescribe both ear drops (to
cover skin bacteria) and one of the usual otitis media oral
antibiotics.72,76
Prescribe only non-ototoxic eardrops when there might
be a tube or perforation, as some of the ear drops may
get into the middle ear.77 Neomycin and polymyxin B
and hydrocortisone otic suspension (CORTISPORIN)
contains both an ototoxic aminoglycoside (neomycin) as
well as ototoxic propylene glycol; acetic acid ear drops
(VOSOL, ACETASOL; VOSOL-HC, ACETASOL-HC)
also contain ototoxic propylene glycol, as well as being
acidic enough to make the middle ear hurt, so don’t
prescribe them if there might be a tube or perforation,
unless the benefits outweigh the risks. 77,78 Oflaxacin
(FLOXIN) and ciprofloxacin/dexamethasone (CIPRO-
DEX) drops are non-ototoxic.78 Including a steroid with
an antibiotic may make ear drops slightly more effective,
but generic ofloxacin (FLOXIN) drops are both cheap
and effective.79,80
If you see a child with tubes with discharge not improv-
ing with appropriate antibiotics, culture the drainage,
but don’t change treatment. Refer for primary care
physician follow-up and the physician may use culture
results to guide treatment. If there is new ear pain or
fever, and the patient is on just ear drops, start oral
antibiotics.72
Mastoiditis and Petrositis
I
n the early 1900s, a fifth of those with acute
otitis media got mastoiditis or petrositis. But since
antibiotics became available in the 1930s, they became
rare (<1%), especially in the US and other developed
nations.81
Mastoiditis is a symptomatic infection of the air cells in
the bony mastoid process behind the ear, most commonly in infants.82 Classic mastoiditis shows swelling
and perhaps warmth or redness over the mastoid, with
the pinna (auricle) pushed down and forwards. But
soon after the first use of antibiotics for otitis media,
in 1941, there were reports of “masked mastoiditis”:
patients with further complications of mastoiditis, such
as brain abscess, without classic signs and symptoms.83,84
Now, the most common findings are only seen with an
otoscope: an abnormal appearing tympanic membrane,
and sagging of the posterior wall of the external ear
canal.2 Although the ear may not be visible displace, but
sometimes the postauricular fold – the crease behind the
pinna (auricle) of the ear – is gone; compare with the
unaffected side.85
Trying to confirm a clinical suspicion of mastoiditis is
hard, as there are no accepted diagnostic criteria.86 And,
as with fluid in the sinuses on CT that occurs with most
any cold,87-89 fluid in the mastoid air cells on CT scan
doesn’t diagnose mastoiditis, as it’s found in many cases
of otitis media.90 If you do a high-resolution CT or MRI
and find bony resorption in the mastoid (the bony septae
between the mastoid air cells are being destroyed) then
you can diagnose “coalescent” mastoiditis, but CT or
MRI won’t help you diagnose earlier stages of mastoiditis.86,91,92
further workup and treatment. Myringotomy is usually performed and tympanostomy tubes are generally
placed. If there is neither subperiosteal abscess nor CNS
involvement, a period of 48 hours of observation and
broad-spectrum IV antibiotics is recommended prior to
considering mastoidectomy.93 Subperiosteal abscesses
are surgically drained.
The triad of deep facial pain, otitis media, and ipsilateral abducens nerve paralysis (inability to look to the
affected side) are the classic signs of petrositis (infection
of the petrous portion of the temporal bone; Gradenigo’s
Syndrome)94 However, as with mastoiditis, such classic
presentations are now rare.
If you see someone who
Key Points
presents with deep facial
• Chronic suppurative otitis
a couple of days.
media, which causes serious
pain and signs or symptoms
• High-dose amoxicillin, due
long-term problems, occurs
to high concentrations in the
of infection, and a history
almost entirely in the develmiddle ear that will kill even
oping world.
of chronic otitis media or
resistant organisms, is still the
surgery for mastoiditis, you
• You should diagnose acute
drug of choice for acute otitis
otitis media by:
media.
should suspect petrositis.95
·· signs and symptoms of acute
• Although nasal-spray deconGet a CT or MRI scan,
otitis media (fever, earache);
gestants may help acute otitis
and consider admitting the
and
media, oral decongestant and
antihistamines are not recompatient for further workup
·· evidence of a middle ear
mended (don’t help much or
and treatment. A CT scan
effusion.
at all, lots of side effects).
showing bony changes
• You should diagnose a middle
• Otitis-Conjunctivitis Synear
effusion
when
you
see:
in the petrous part of the
drome is usually from H influ·· fluid behind the tympanic
enzae; prescribe Augmentin
temporal bone clinches the
membrane,
or
rather than amoxicillin.
diagnosis.95 Mastoidectomy
·· decreased mobility with
• For otitis media with effusion
is a common inpatient
insufflation , or
(serous otitis), no acute treattreatment, but conservaments work, except maybe
·· opacity or discoloration of
decongestant nasal spray, or if
tive management with just
tympanic membrane (not
allergic, steroid nasal spray. It
counting scarring), or
antibiotics is reasonable as
is simply observed for months
96-98
·
·
evidence
from
tympanomwell.
for resolution.
etry or spectral gradient
acoustic reflectometry.
Patients with mastoiditis are generally admitted for
• Do not diagnose acute otitis
media when you just see
redness of the tympanic
membrane.
Bullous Myringitis
I
was taught that bullous myringitis – tiny blisters
on the tympanic membrane – clinches the diagnosis
mycoplasma-induced otitis media.99 But the bacteria
in ears with bullous myringitis are basically the same
as in any case of acute otitis media,100 though bullous
References
1. Hendley JO. Clinical practice. Otitis
media. N Engl J Med 2002;347:1169-74.
2. Fliss DM, Leiberman A, Dagan R.
Medical sequelae and complications of
acute otitis media. Pediatr Infect Dis J
1994;13:S34-40; discussion S50-4.
3. Dowell SF, Marcy SM, Phillips WR,
Gerber MA, Schwartz B. Otitis Media—
Principles of Judicious Use of Antimicrobial Agents. Pediatrics 1998;101:165-71.
4. Hayden GF. Acute suppurative otitis
media in children. Diversity of clinical
diagnostic criteria. Clin Pediatr (Phila)
1981;20:99-104.
5. Lieberthal AS, Carroll AE, Chon-
maitree T, et al. The diagnosis and management of acute otitis media. Pediatrics
2013;131:e964-99.
6. Finitzo T, Friel-Patti S, Chinn
K, Brown O. Tympanometry and
otoscopy prior to myringotomy: issues in
diagnosis of otitis media. International
journal of pediatric otorhinolaryngology
1992;24:101-10.
7. Rosenfeld RM, Culpepper L, Doyle
KJ, et al. Clinical practice guideline: Otitis
media with effusion. Otolaryngol Head
Neck Surg 2004;130:S95-118.
8. Weiss JC, Yates GR, Quinn LD.
Acute otitis media: making an ac-
myringitis hurts worse than
other types of acute otitis
media.100 As one review
put it, bullous myringitis is
just acute otitis media with
blisters on the eardrum.99
• Should you treat acute
otitis media with antibiotics?
Maybe. There are dueling
recommendations.
curate diagnosis. Am Fam Physician
1996;53:1200-6.
9. Chianese J, Hoberman A, Paradise
JL, et al. Spectral gradient acoustic reflectometry compared with tympanometry in
diagnosing middle ear effusion in children
aged 6 to 24 months. Arch Pediatr
Adolesc Med 2007;161:884-8.
10. Pelton SI. Otoscopy for the diagnosis
of otitis media. Pediatr Infect Dis J
1998;17:540-3; discussion 80.
11. Popelka GR. Acoustic immittance
measures: terminology and instrumentation. Ear and hearing 1984;5:262-7.
12. Tympanometry. ASHA Working
Group on Aural Acoustic-Immittance
Measurements Committee on Audiologic
Evaluation. The Journal of speech and
hearing disorders 1988;53:354-77.
13. Kimball S. Acoustic reflectometry:
spectral gradient analysis for improved
detection of middle ear effusion in children. Pediatr Infect Dis J 1998;17:552-5;
discussion 80.
14. Stewart MH, Siff JE, Cydulka RK.
Evaluation of the patient with sore throat,
earache, and sinusitis: an evidence based
approach. Emergency medicine clinics of
North America 1999;17:153-87, ix.
15. Combs JT. The diagnosis of otitis
• You can, for certain kids with
acute otitis media, give a
prescription for an antibiotic
but tell the parents not to fill it
unless the ear is still hurting in
• For acute otitis media with
tympanostomy tubes or a ruptured tympanic membrane,
treat not with oral antibiotics,
but with non-ototoxic ear
drops such as ofloxacin or
ciprofloxacin.
• Mastoiditis and petrositis
(Gradenigo’s Syndrome) are
quite rare in the developed
world, and while CT or MRI
may help a bit, you have to
make the initial diagnosis
clinically.
5
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media: new techniques. Pediatr Infect Dis
J 1994;13:1039-46.
16. Kontiokari T, Koivunen P, Niemela
M, Pokka T, Uhari M. Symptoms of
acute otitis media. Pediatr Infect Dis J
1998;17:676-9.
17. Del Mar C, Glasziou P, Hayem M.
Are antibiotics indicated as initial treatment for children with acute otitis media?
A meta-analysis. BMJ 1997;314:1526-9.
18. Van Zuijlen DA, Schilder AG, Van
Balen FA, Hoes AW. National differences
in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics
for acute otitis media? Pediatr Infect Dis J
2001;20:140-4.
19. Akkerman AE, Kuyvenhoven
MM, van der Wouden JC, Verheij TJ.
Analysis of under- and overprescribing
of antibiotics in acute otitis media in
general practice. J Antimicrob Chemother
2005;56:569-74.
20. Froom J, Culpepper L, Grob P, et
al. Diagnosis and antibiotic treatment
of acute otitis media: report from International Primary Care Network. BMJ
1990;300:582-6.
21. Froom J, Culpepper L, Green LA, et
al. A cross-national study of acute otitis
media: risk factors, severity, and treatment
at initial visit. Report from the International Primary Care Network (IPCN)
and the Ambulatory Sentinel Practice
Network (ASPN). J Am Board Fam Pract
2001;14:406-17.
22. Harsten G, Prellner K, Heldrup J,
Kalm O, Kornfalt R. Recurrent acute otitis media. A prospective study of children
during the first three years of life. Acta
Otolaryngol 1989;107:111-9.
23. Alho OP, Laara E, Oja H. What is
the natural history of recurrent acute otitis
media in infancy? The Journal of family
practice 1996;43:258-64.
24. Berman S. Otitis media in children.
N Engl J Med 1995;332:1560-5.
25. Davidson J, Hyde ML, Alberti PW.
Epidemiologic patterns in childhood
hearing loss: a review. International
journal of pediatric otorhinolaryngology
1989;17:239-66.
26. Berman S. Otitis media in developing
countries. Pediatrics 1995;96:126-31.
27. Acuin J. Chronic suppurative otitis
media: Burden of Illness and Management Options. Geneva, Switzerland:
World Health Organization; 2004.
28. Bluestone CD. Otitis media in
children: to treat or not to treat? N Engl J
Med 1982;306:1399-404.
29. Little P, Gould C, Williamson I,
Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two
prescribing strategies for childhood acute
otitis media. BMJ 2001;322:336-42.
30. Cates C. An evidence based approach
to reducing antibiotic use in children with
acute otitis media: controlled before and
after study. BMJ 1999;318:715-6.
31. Siegel RM, Kiely M, Bien JP, et al.
Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics 2003;112:527-31.
32. Chao JH, Kunkov S, Reyes LB,
Lichten S, Crain EF. Comparison of
two approaches to observation therapy
for acute otitis media in the emergency
department. Pediatrics 2008;121:e1352-6.
33. McCormick DP, Chonmaitree
T, Pittman C, et al. Nonsevere acute
otitis media: a clinical trial comparing
outcomes of watchful waiting versus
immediate antibiotic treatment. Pediatrics
2005;115:1455-65.
34. Sanders SL, Glasziou PP, Del Mar
CB, Rovers MM. Antibiotics for acute
otitis media in children. Cochrane
database of systematic reviews (Online)
2010:CD000219.
35. Thanaviratananich S, Laopaiboon M,
Vatanasapt P. Once or twice daily versus
three times daily amoxicillin with or
without clavulanate for the treatment of
acute otitis media. Cochrane Database of
Systematic Reviews. Chichester, UK: John
Wiley & Sons, Ltd; 2008.
36. Kozyrskyj A, Klassen TP, Moffatt
M, Harvey K. Short-course antibiotics for acute otitis media. Cochrane
database of systematic reviews (Online)
2010:CD001095.
37. Takata GS, Chan LS, Shekelle P,
Morton SC, Mason W, Marcy SM. Evidence assessment of management of acute
otitis media: I. The role of antibiotics in
treatment of uncomplicated acute otitis
media. Pediatrics 2001;108:239-47.
38. Dowell SF, Butler JC, Giebink GS, et
al. Acute otitis media: management and
surveillance in an era of pneumococcal
resistance--a report from the Drugresistant Streptococcus pneumoniae
Therapeutic Working Group. Pediatr
Infect Dis J 1999;18:1-9.
39. Leibovitz E, Greenberg D, Piglansky
L, et al. Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to
the original pathogen. Pediatr Infect Dis J
2003;22:209-16.
40. Coleman C, Moore M. Decongestants and antihistamines for acute
otitis media in children. Cochrane
database of systematic reviews (Online)
2007:CD001727.
41. Eyibilen A, Aladag I, Guven M,
Koc S, Gurbuzler L. The effectiveness of
nasal decongestants, oral decongestants
and oral decongestant-antihistamines in
the treatment of acute otitis media in children. Kulak burun bogaz ihtisas dergisi
: KBB = Journal of ear, nose, and throat
2009;19:289-93.
42. Randall JE, Hendley JO. A
decongestant-antihistamine mixture in
the prevention of otitis media in children
with colds. Pediatrics 1979;63:483-5.
43. Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane
Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2009.
44. Eccles R, Martensson K, Chen SC.
Effects of intranasal xylometazoline, alone
or in combination with ipratropium, in
patients with common cold. Curr Med
Res Opin 2010.
45. Hoberman A, Paradise JL, Reynolds
EA, Urkin J. Efficacy of Auralgan for
treating ear pain in children with acute
otitis media. Arch Pediatr Adolesc Med
1997;151:675-8.
46. Foxlee R, Johansson A, Wejfalk J,
Dawkins J, Dooley L, Del Mar C. Topical
analgesia for acute otitis media. Cochrane
database of systematic reviews (Online)
2006:CD005657.
47. Bodor FF, Marchant CD, Shurin
PA, Barenkamp SJ. Bacterial etiology
of conjunctivitis-otitis media syndrome.
Pediatrics 1985;76:26-8.
48. Bingen E, Cohen R, Jourenkova
N, Gehanno P. Epidemiologic study of
conjunctivitis-otitis syndrome. Pediatr
Infect Dis J 2005;24:731-2.
49. Bodor FF. Systemic antibiotics for
treatment of the conjunctivitis-otitis
media syndrome. Pediatr Infect Dis J
1989;8:287-90.
50. Harrison CJ, Hedrick JA, Block SL,
Gilchrist MJ. Relation of the outcome of
conjunctivitis and the conjunctivitis-otitis
syndrome to identifiable risk factors and
oral antimicrobial therapy. Pediatr Infect
Dis J 1987;6:536-40.
51. Gigliotti F, Williams WT, Hayden
FG, et al. Etiology of acute conjunctivitis
in children. J Pediatr 1981;98:531-6.
52. Gilbert DN. The Sanford guide to
antimicrobial therapy 2011. Sperryville,
VA: Antimicrobial Therapy, Inc.; 2011.
53. Bodor FF. Conjunctivitis-otitis
syndrome. Pediatrics 1982;69:695-8.
54. Nelson JD, Ginsburg CM, McLeland
O, Clahsen J, Culbertson MC, Jr., Carder
H. Concentrations of antimicrobial
agents in middle ear fluid, saliva and
tears. International journal of pediatric
otorhinolaryngology 1981;3:327-34.
55. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first
seven years of life in children in greater
Boston: a prospective, cohort study. J
Infect Dis 1989;160:83-94.
56. Teele DW, Klein JO, Rosner BA.
Epidemiology of otitis media in children.
Ann Otol Rhinol Laryngol Suppl
1980;89:5-6.
57. Bluestone CD. Eustachian tube function and allergy in otitis media. Pediatrics
1978;61:753-60.
58. Bluestone CD, Hebda PA, Alper
CM, et al. Recent advances in otitis me-
dia. 2. Eustachian tube, middle ear, and
mastoid anatomy; physiology, pathophysiology, and pathogenesis. Ann Otol Rhinol
Laryngol Suppl 2005;194:16-30.
59. Finkelstein Y, Ophir D, Talmi
YP, Shabtai A, Strauss M, Zohar Y.
Adult-onset otitis media with effusion.
Arch Otolaryngol Head Neck Surg
1994;120:517-27.
60. Klein JO. Otitis media. Clin Infect
Dis 1994;19:823-33.
61. American Academy of Pediatrics
Subcommittee on Management of Acute
Otitis M. Diagnosis and management of acute otitis media. Pediatrics
2004;113:1451-65.
62. Perera R, Haynes J, Glasziou P,
Heneghan CJ. Autoinflation for hearing
loss associated with otitis media with
effusion. Cochrane database of systematic
reviews (Online) 2006:CD006285.
63. Simpson SA, Lewis R, van der Voort
J, Butler CC. Oral or topical nasal steroids
for hearing loss associated with otitis
media with effusion in children. Cochrane
database of systematic reviews (Online)
2011:CD001935.
64. van Zon A, van der Heijden GJ, van
Dongen TM, Burton MJ, Schilder AG.
Antibiotics for otitis media with effusion
in children. Cochrane database of systematic reviews (Online) 2012;9:CD009163.
65. Griffin G, Flynn CA. Antihistamines
and/or decongestants for otitis media with
effusion (OME) in children. Cochrane
database of systematic reviews (Online)
2011:CD003423.
66. van der Merwe J, Wagenfeld DJ.
The negative effects of mucolytics in
otitis media with effusion. S Afr Med J
1987;72:625-6.
67. Bernstein JM. Role of allergy in
eustachian tube blockage and otitis media
with effusion: a review. Otolaryngol Head
Neck Surg 1996;114:562-8.
68. McLelland CA. Incidence of complications from use of tympanostomy tubes.
Archives of otolaryngology 1980;106:979.
69. Rosenfeld RM, Brown L, Cannon
CR, et al. Clinical practice guideline:
acute otitis externa. Otolaryngol Head
Neck Surg 2006;134:S4-23.
70. Gates GA, Avery C, Prihoda TJ,
Holt GR. Delayed onset post-tympanotomy otorrhea. Otolaryngol Head Neck
Surg 1988;98:111-5.
71. Berger G. Nature of spontaneous
tympanic membrane perforation in acute
otitis media in children. The Journal of
laryngology and otology 1989;103:11503.
72. Granath A, Rynnel-Dagoo B, Backheden M, Lindberg K. Tube associated
otorrhea in children with recurrent acute
otitis media; results of a prospective randomized study on bacteriology and topical
treatment with or without systemic antibiotics. International journal of pediatric
otorhinolaryngology 2008;72:1225-33.
73. Ruohola A, Meurman O, Nikkari S,
et al. Microbiology of acute otitis media
in children with tympanostomy tubes:
prevalences of bacteria and viruses. Clin
Infect Dis 2006;43:1417-22.
74. Mandel EM, Casselbrant ML, KursLasky M. Acute otorrhea: bacteriology of
a common complication of tympanostomy tubes. Ann Otol Rhinol Laryngol
1994;103:713-8.
75. Goldblatt EL. Efficacy of ofloxacin
and other otic preparations for acute otitis
media in patients with tympanostomy
tubes. Pediatr Infect Dis J 2001;20:116-9;
discussion 20-2.
76. Roland PS, Parry DA, Stroman DW.
Microbiology of acute otitis media with
tympanostomy tubes. Otolaryngol Head
Neck Surg 2005;133:585-95.
77. Saunders MW, Robinson PJ. How
easily do topical antibiotics pass through
tympanostomy tubes?--an in vitro study.
International journal of pediatric otorhinolaryngology 1999;50:45-50.
78. Daniel SJ, Munguia R. Ototoxicity
of topical ciprofloxacin/dexamethasone
otic suspension in a chinchilla animal
model. Otolaryngol Head Neck Surg
2008;139:840-5.
79. Emgard P, Hellstrom S, Holm S.
External otitis caused by infection with
Pseudomonas aeruginosa or Candida
albicans cured by use of a topical group
III steroid, without any antibiotics. Acta
Otolaryngol 2005;125:346-52.
80. Emgard P, Hellstrom S. A topical
steroid without an antibiotic cures external otitis efficiently: a study in an animal
model. Eur Arch Otorhinolaryngol
2001;258:287-91.
81. Smeraldi R. Clinica e diagnosi di
alcune mastoiditi atipichi Gazz Sanitar
1947;18:58-61.
82. Groth A, Enoksson F, Hultcrantz M,
Stalfors J, Stenfeldt K, Hermansson A.
Acute mastoiditis in children aged 0-16
years-A national study of 678 cases in
Sweden comparing different age groups.
International journal of pediatric otorhinolaryngology 2012.
83. Holt GR, Gates GA. Masked mastoiditis. Laryngoscope 1983;93:1034-7.
84. Hutchinson CA. Chemotherapy
in Acute Middle-ear Disease: “Masked
Mastoiditis”. Br Med J 1941;2:159-60.
85. Beers SL, Abramo TJ. Otitis externa
review. Pediatr Emerg Care 2004;20:2506.
86. van den Aardweg MT, Rovers MM,
de Ru JA, Albers FW, Schilder AG. A
systematic review of diagnostic criteria
for acute mastoiditis in children. Otol
Neurotol 2008;29:751-7.
87. Schwartz RH, Pitkaranta A, Winther
B. Computed tomography imaging of the
maxillary and ethmoid sinuses in children
with short-duration purulent rhinorrhea.
Otolaryngology--head and neck surgery
: official journal of American Academy of
Otolaryngology-Head and Neck Surgery
2001;124:160-3.
88. Gwaltney JM, Jr., Phillips CD, Miller
RD, Riker DK. Computed tomographic
study of the common cold. The New England journal of medicine 1994;330:25-30.
89. Kaiser L, Lew D, Hirschel B, et al.
Effects of antibiotic treatment in the
subset of common-cold patients who have
bacteria in nasopharyngeal secretions.
Lancet 1996;347:1507-10.
90. Dhooge IJ, Vandenbussche T,
Lemmerling M. Value of computed
tomography of the temporal bone in acute
otomastoiditis. Revue de laryngologie otologie - rhinologie 1998;119:91-4.
91. Antonelli PJ, Garside JA, Mancuso
AA, Strickler ST, Kubilis PS. Computed
tomography and the diagnosis of coalescent mastoiditis. Otolaryngol Head Neck
Surg 1999;120:350-4.
92. Vazquez E, Castellote A, Piqueras J,
et al. Imaging of complications of acute
mastoiditis in children. Radiographics : a
review publication of the Radiological Society of North America, Inc 2003;23:35972.
93. Nadal D, Herrmann P, Baumann A,
Fanconi A. Acute mastoiditis: clinical,
microbiological, and therapeutic aspects.
Eur J Pediatr 1990;149:560-4.
94. Gradenigo G. Über die paralyse des
nervus abducens bei otitis. Arch Ohrenheilunde 1907;774:149–87.
95. Chole RA, Donald PJ. Petrous
apicitis. Clinical considerations. Ann Otol
Rhinol Laryngol 1983;92:544-51.
96. Marianowski R, Rocton S, Ait-Amer
JL, Morisseau-Durand MP, Manach
Y. Conservative management of Gradenigo syndrome in a child. International
journal of pediatric otorhinolaryngology
2001;57:79-83.
97. Rossor TE, Anderson YC, Steventon
NB, Voss LM. Conservative management
of Gradenigo’s syndrome in a child. BMJ
case reports 2011;2011.
98. Ulkumen B, Kaplan Y. Conservative
treatment of Gradenigo’s syndrome triggered by acute otitis
media. Pak J Med Sci Q 2012;28:735-7.
99. Roberts DB. The etiology of bullous
myringitis and the role of mycoplasmas in ear disease: a review. Pediatrics
1980;65:761-6.
100.McCormick DP, Saeed KA, Pittman
C, et al. Bullous myringitis: a case-control
study. Pediatrics 2003;112:982-6.
g