Hey there! Welcome to The Oto Approach. This episode is all about Acute Otitis Media, and outlines the key things medical students should know to prepare for clinical rotations. Happy Listening!

Show Notes

Introduction:

Otitis media can actually refer to a few different pathologies, so it is important to specify what type you are referring to. In general, there are two types that are commonly seen: these are acute otitis media (AOM) and chronic otitis media with effusion (also known as serous otitis media) . Today, we’re going to focus on acute otitis media.

Acute Otitis media:

This is commonly referred to as “an ear infection” and can occur unilaterally or bilaterally. It’s usually seen in kids between 3 months and 3 years old, but can certainly extend beyond this age group, even into adulthood1! It’s commonly seen in children because the structures in the middle ear (including the eustachian tubes) aren’t fully mature, and are shorter and more horizontally oriented, so drainage doesn’t occur as readily1. In addition, children have large obstructive adenoids that contribute to their susceptibility to acute otitis media2. This, of course, is confounded by the fact that children have immature immune systems, and haven’t been primed for the many pathogens they will see in their lifetime, and are therefore less able to fight off infections than adults. Higher risk populations include patients with down syndrome, or cleft palate as these anatomical features are exaggerated3. 

Causes

The infection can be either bacterial or viral1. In neonates it’s often Escherichia coli, and Staphylococcus aureus1. When it comes to older kids, Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae are common1. In adults, the most common bacteria involved are Strep pneumoniae, Group A beta-hemolytic streptococcus, and S. aureus1. 

Presentation: 

Patients will present to you complaining of ear pain (otalgia), fever, or hearing loss (1). If the tympanic membrane perforates, there will also be ottorea (2). If the infection is more severe, patients may also present with systemic symptoms of nausea, and vomiting (2). On otoscopy, you will most likely see a red, bulging eardrum. You may see purulence behind the tympanic membrane as well.

If the patient is a child, it’s important to remember that kids are not good historians, so look out for other indications of an ear infection such as crankiness, trouble sleeping, and tugging of the ear (1). It is however, important to note that tugging on the ear in isolation may not be a sign of AOM (2). For example, children often have referred otalgia causing them to tug their ears when they are teething (2). 

Consult/clinic visit:

So let’s imagine your staff has just asked you to see a patient presenting with signs and symptoms suggestive of otitis media. When you go see the patient, first you’ll want to introduce yourself, and make sure they are stable before starting your history. If they are vitally unstable or look toxic, call for help!

History

In your history, you always want to start out with your history of present illness, or  HPI, and find out what brought them to hospital/clinic. Although you may have a working differential based on the reason for referral or the information your staff has given you, it’s still important to enter each interaction with an open mind. 

Good open ended questions include “What did you want to talk about today?” or “What’s been bothering you?”When getting the HPI, a mnemonic you can use is  CHLORIDE FPP (Character, location, onset, radiating, intensity, duration, events proceeding, Frequency, palliating/precipitating) or OPQRSTU AAA (Onset, Position, Quality, Radiation, Severity, Temporality, deja vu, Alleviating factors, Aggravating factors, Associated symptoms). Specific questions you'll want to ask patients that come in complaining of ear discomfort includes: acute onset otalgia, ear tugging, otorrhea, and decreased hearing. You will also want to do an infectious screen looking for fever, upper respiratory tract symptoms, diarrhea, recent travel, and sick contacts. This is especially important in the COVID-19 era.  

Next you’ll want to dive into the patient’s past medical history, family history, social history, medications, allergies, and habits. At the end it’s always a good idea to do a full review of systems to ensure you aren’t missing anything. 

Physical exam: 

Now you’ll want to move on to the physical exam. Here we have used Bates as a supplementary resource, which you can likely find on your school’s library website (4)! 

So, in this podcast we are going to assume a basic knowledge of the general physical exam you would have covered in pre-clerkship. When it comes to otitis media, there are a few pertinent positives and negatives to keep in mind when you do your examination! First, you’re going to be inspecting the ear and the areas around the ear- note any redness, lesions, visible fluid or foreign bodies (4). When you start palpation, ask your patient if they have tenderness when you press on their mastoid (the bony area behind their ear) (4). A serious complication of otitis media is mastoiditis, which presents as mastoid tenderness, swelling and erythema along with external ear proptosis. This is very important to rule out. If there is discharge from the ear, pull back on the outer part of the ear gently (pain may suggest otitis externa) (5). When you are ready to move on to your otoscopic exam, observe for any fluid, redness, foreign bodies, swelling, lesions, etc (4). Note how the tympanic membrane looks- in otitis media, it can appear red, inflamed, and bulging (4). If your centre has pneumatic otoscopy available, this should also be performed4. This exam will determine the mobility of the tympanic membrane in response to pressure changes(6). Normally, the tympanic membrane will move in response to changes in pressure BUT in acute otitis media, the tympanic membrane doesn’t move as well (this may be related to a middle ear effusion) (6). Cultures are not generally done for diagnosing otitis media (with the exception of fluid obtained during myringotomy- a procedure which will be discussed later)(1).

A differential diagnosis includes otitis media with effusion, also known as secretory otitis media. This is when there is a collection of fluid in the middle ear, but it is not infected (7). Therefore, antibiotics will not be effective in treating otitis media with effusion. This type of otitis media can occur from incomplete resolution of acute otitis media, or from obstruction of the eustachian tube (7). Although there may be hearing loss, and a sense of fullness, a differentiating factor between otitis media with effusion and acute otitis media is that otitis media with effusion rarely involves otalgia (7). Most cases of secretory otitis media resolve within a few weeks on their own (7). However, if the condition persists for several months, a myringotomy may be indicated, often with the insertion of a tympanostomy tube (7). 

Additionally, another differential diagnosis includes acute otitis externa, commonly known as “swimmer’s ear”. This has a rapid onset (generally within 48 hours) and includes symptoms such as otalgia, itching, fullness, hearing loss, and/or jaw pain (5). There will also be signs of ear canal inflammation such as tenderness of the tragus and pinna (5). There will often be foul smelling otorrhea, regional lymphadenitis, erythema of the tympanic membrane, and cellulitis of the pinna and adjacent skin (5). Acute otitis externa is most often caused by Pseudomonas aeruginosa, Staphylococcus aureus, or from a polymicrobial infection. 

Now back to Acute Otitis Media!

Treatment: 

The treatment for AOM is centered on analgesics and antibiotics. All patients should be given either acetaminophen or ibuprofen for pain relief (1).  

Due to increasing antibiotic resistance, many physicians will ask the patient to monitor their symptoms for 72 hours, and only prescribe antibiotics if the symptoms haven’t lessened in that time (1). However, if a repeat visit within 72 hours is very difficult for the family, for example, in rural settings where patients need to travel extremely far, antibiotics may be given.

The Choosing Wisely guidelines for the antibiotics for AOM include that antibiotics should always be prescribed for AOM in children less than 6 months, and usually prescribed for children 6 months to two years if the diagnosis is certain and there is moderate to severe otalgia (8). If the patient is over two years of age, they should receive antibiotics if they have severe symptoms (8). These could include, but are not limited to, moderate or severe otalgia, otalgia for 48 hours or longer, or a temperature 39°C or higher (8).

Some special circumstances in which patients should always be prescribed antibiotics for AOM include those who have a cleft palate, those who have down syndrome, those who have a cochlear implant, or those who have an immune disorder(9). 

For acute otitis media, the antibiotic of choice is high dose Amoxicillin (10). However, if the patient has either received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin, then, an antibiotic with additional beta-lactamase coverage should be prescribed (The spectrum app can be used to confirm local practices in your area). 

In addition to analgesics and antibiotics, there are a few other medications specifically for adults. A topical intranasal vasoconstrictor (decongestant nasal spray) containing phenylephrine may be used, although they should not be used for more than 4 days (1) . Additionally, oral decongestants such as pseudoephedrine may be recommended (1). Finally, in the rarer case of allergic etiology, antihistamines may be used (1). 

If a patient has recurrent otitis media (defined as more than 4 episodes within 6 months) (1) , myringotomy and tubes are indicated. 

• Myringotomy

  • A small incision is made through the layers of tympanic membrane permitting direct access to the middle ear space,  allowing the release of middle-ear fluid (11). 

• Tympanostomy tubes are tubes that are inserted into the tympanic membrane and help prevent the build up of fluid in the middle ear 

  • Can help prevent recurrences of acute otitis media and secretory otitis media (7).

Prevention 

Prevention of acute otitis media can be made through ensuring patients are up to date with their routine vaccinations (1). In addition, tobacco smoke and second-hand smoke should be avoided (1). It has also been shown that attendance in daycares is a risk factor for the development of otitis media, as there tends to be an increased spread of pathogens (1). However, that is not to say that children should not be enrolled in these programs.

Clinical Pearls:

• Always exam the post auricular area for erythema, tenderness, warmth, and fluctuance with protrusion of the auricle. The presence of which suggests mastoiditis, which is a serious complication of acute otitis media. 

• If the patient has signs and symptoms suggestive of acute mastoiditis, they should be sent to the emergency department and will likely be admitted for IV antibiotics and possible surgical management.

• Remember that Ciprodex drops are NOT useful unless the patient has an otitis externa, or if they have an acute suppurative otitis media (i.e. an otitis media with a tympanic membrane perforation). Drops are NOT useful if the tympanic membrane is intact.

  • You will often see these drops used to treat ottorhea in patients with patent tubes in place. It is important to note that these drops should only be used for a short period of time

• A very rare, but serious complication of acute otitis media is facial nerve weakness/paresis. This can occur because the facial nerve runs right through the middle ear, and the pressure from the infection can impact the function of the nerve. This requires urgent Otolaryngology consultation

Thank you so much for listening to our podcast! We hope you’ll tune into our next episode! 

See you next time,

The Oto Approach Team

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