DISCLAIMER: The information provided here is for educational purposes only and is designed for use by qualified physicians and other medical professionals. In no way should it be considered as offering medical advice. By referencing this material, you agree not to use this information as medical advice to treat any medical condition in either yourself or others, including but not limited to patients that you are treating. Consult your own physician for any medical issues that you may be having. By referencing this material, you acknowledge the content of the above disclaimer and the general site disclaimer and agree to the terms.


ACUTE OTITIS MEDIA (UNCOMPLICATED)

Overview
Acute otitis media (AOM) is defined as an acute infection of the middle ear for <3 weeks. This is distinct from the diagnosis of otitis media with effusion (OME), which is the presence of a middle ear effusion without acute infection. AOM typically presents with a rapid onset of symptoms including otalgia, conductive hearing loss, and sometimes fever. In younger children, the symptoms may be nonspecific including irritability, fussiness, poor sleep and ear pulling. Clinical diagnosis is made on otologic examination; signs typically include a bulging, erythematous tympanic membrane (TM) with or without purulent effusion or a perforated TM with suppurative otorrhea. The most common pathogens associated with AOM include Streptococ ofcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Differential diagnostic considerations should include otitis media with effusion (middle ear effusion, aural fullness, hearing loss, but without acute signs of acute infection), myringitis (severe otalgia with thickened erythematous tympanic membrane), otitis externa, ear trauma, or referred pain from pharyngitis or the temporomandibular joint. 

Key Supplies for Consultation

  • Appropriate PPE including mask, eye protection, gloves, and gown

  • Otoscope

  • 512-Hertz tuning fork

  • Consider culture swab if otorrhea present

  • If performing tympanostomy tube placement, will need operating microscope, size 4 or 5 ear speculum, myringotomy blade, size 5 or size 7 straight suction, suction source, and device to push tube in place (e.g., pusher or small right angle)

Management

  • Antibiotic management is recommended in most cases

  • In patients 6-23 months of age with non-severe unilateral disease, watchful waiting may be offered for 48-72 hours from onset of symptoms

  • Antibiotic therapy should be recommended in all other cases

  • Most typical cases of AOM can be successfully treated with amoxicillin 90mg/kg per day divided into two doses x 5-7 days (older than six years) or 10 days (younger than six years or more severe case)

  • Patients treated with amoxicillin within the last 30 days, allergy to penicillin, or prior failed therapy with amoxicillin should receive an alternative antibiotic to start

  • AOM with tympanic membrane perforation should be treated with the addition of ototopical antibiotics, most commonly Ciprodex: four drops twice daily for 7-10 days 

  • Treatment should improve symptoms in first 48-72 hours; if symptoms persist or recur within the first several days, consider escalating antibiotic therapy for treatment failure 

  • Failure with amoxicillin alone or cases of recurrent or severe AOM can be treated with amoxicillin-clavulanate (875mg/125mg BID in adults; 45 mg/kg per dose BID in children, max of 875 mg per dose) typically for 10 days in duration 

  • Failure of oral medications may necessitate intramuscular or intravenous antibiotic therapy for both adults and children and consideration of tympanocentesis with culture directed therapy

  • In patients with pressure equalization tubes presenting with AOM, ototopical antibiotics may be used as single therapy if the tube is patent.

We recommend the AAO-HNS Clinical Practice Guidelines on otitis media with effusion and tympanostomy tubes in children for additional reading on these topics.

Complicated Acute Otitis Media 

Overview
Rarely, untreated AOM can progress to extracranial or intracranial complications. Most commonly, the otolaryngologist will be asked about progression to mastoiditis when fluid is detected within the mastoid air cells on a CT scan. It is important to remember that the mastoid is in direct communication with the middle ear space through the antrum, and therefore fluid in the mastoid in the setting of AOM can be expected. As such, acute mastoiditis is a diagnosis that is primarily made clinically, rather than radiographically. Physical exam typically demonstrates erythema, edema (with possible proptosis of the ear), and tenderness over the mastoid process. The contralateral mastoid can often serve as a good “normal” comparison. It is also important to note that in many cases, the otolaryngologist will be asked to evaluate incidental (and often asymptomatic) limited mastoid “fluid” found on CT or MRI that generated the concern for mastoiditis. This finding is quite common and again, and in the absence of symptoms or physical examination findings, does not usually constitute true clinical mastoiditis. 

Rapid diagnosis and treatment are critical as a diagnosis of acute mastoiditis is associated with an elevated risk of temporal and intracranial complications. In cases of clinical mastoiditis with neurologic symptoms, MRI and/or MRV should be performed to rule out intracranial involvement or dural sinus thrombosis. With acute mastoiditis, treatment will often consist of inpatient admission, intravenous antibiotics, and ototopical therapy. Intratemporal and intracranial complications are described below.

Intratemporal Complications

Coalescent mastoiditis

  • More advanced disease characterized by destruction of the mastoid bony septa that is often associated with subperiosteal abscess 

  • Abscess evident on CT imaging

  • Fluctuance over the mastoid process may be appreciated

  • Broad spectrum antibiotic therapy is initiated, and consider MRI/MRV to rule out intracranial involvement if concerning CT findings present or neurological changes develop

  • In cases of abscess, cortical mastoidectomy with pressure equalizing tube placement is most commonly pursued

  • May develop concomitant abscess involving the insertion of the sternocleidomastoid muscle (i.e. Bezold abscess), digastric groove (i.e. Citelli abscess) or at the root of the zygoma (i.e., Luc abscess)

Petrous apicitis

  • Occurs when the infection extends medially into the air cells of the petrous apex

  • Symptoms classically characterized by Gradenigo’s triad (otorrhea, retroorbital pain, diplopia from abducens nerve palsy); though this triad of symptoms is frequently not present 

  • Not all patients have a pneumatized petrous apex, so CT utility is often limited and comparison with the contralateral side along with obtaining MRI is necessary 

  • CT will show destruction of the bony septa of the petrous apex and MRI will classically exhibit T1 hypointense, T2 hyperintense (due to fluid), and peripheral enhancement with gadolinium administration (characteristics of abscess)

  • Often managed with intravenous antibiotics with or without pressure equalization tube placement, but can require surgical debridement in more severe or recalcitrant cases 

Facial paralysis

  • Occurs secondary to nerve edema or compression from suppurative AOM 

  • Generally requires prompt treatment with a pressure equalization tube, oral and ototopical antibiotics, and high-dose oral corticosteroids if not medically contraindicated; consideration of simple cortical mastoidectomy with pressure equalization tube placement

Serous and Suppurative Labyrinthitis

  • Rare complications diagnosed clinically following a rapid progression of vertigo, nystagmus, tinnitus, and sensorineural hearing loss

  • Treatment geared towards preventing further complications and supportive care with antibiotics and pressure equilization tube placement 

  • Disequilibrium may persist for weeks and hearing loss can be permanent

Intracranial Complications

Meningitis  

  • Most common intracranial complication, especially in children 

  • Patient will have classic symptoms including headache, fever, nuchal rigidity, photophobia, seizures, altered mental status

  • Diagnosis involves lumbar puncture (after CT imaging obtained to rule out increased intracranial pressure and signs of herniation)

  • Treatment requires high-dose intravenous antibiotics, steroids, and consideration of tympanocentesis for culture data. Neurosurgical consultation is recommended

  • Patients should be monitored for sensorineural hearing loss and if present, serial MRI should be considered to survey for labyrinthitis ossificans

 Subdural abscess

  • Patients will present with rapid neurologic symptoms such as headache, delirium, seizures, lethargy, and focal neurologic deficits 

  • Diagnosis often requires MRI with gadolinium to differentiate findings from non-enhancing reactive subdural effusion 

  • Treatment involves high-dose intravenous antibiotics, neurosurgical consultation for drainage, and possible mastoidectomy

 Epidural abscess

  • When symptomatic, patients present with a temporoparietal headache and often times with mental status changes 

  • Diagnosis often requires MRI with gadolinium which shows biconvex disk-shaped enhancement 

  • Neurosurgical consultation is recommended for surgical drainage

  • Treatment involves high-dose intravenous antibiotics and surgical drainage via a transmastoid approach or craniotomy depending upon location 

Brain abscess

  • Patients may be asymptomatic in the setting of a well-organized abscess; if symptomatic, may have a temporoparietal headache, change in mental status, fever, seizures, focal neurological deficits 

  •  Treatment involves intravenous antibiotics, neurosurgical consultation for drainage, and possible mastoidectomy for source control if patient is stable  

 Lateral sinus thrombosis and thrombophlebitis

  • Often found in association with an epidural abscess, patients will commonly have a temporoparietal headache, “picket fence” spiking fevers, and Griesinger’s sign (edema and pain over mastoid from occlusion of a mastoid emissary vein)

  • Primary risk surrounds the possibility of a propagating clot and resultant elevated intracranial pressure or intracranial abscess

  • Diagnosis often includes MRI with gadolinium as well as MRA/MRV which will demonstrate thrombus formation

  • Treatment typically involves intravenous antibiotics and mastoidectomy. The benefits of sigmoid decompression, thrombus evacuation, and anticoagulation in this setting are controversial

 Otitic hydrocephalus

  • Phenomena of increased intracranial pressure without associated hydrocephalus (dilation of ventricles); can be secondary to lateral sinus thrombosis 

  • Patients present with symptoms of increased intracranial pressure (nausea, vomiting, papilledema, diplopia secondary to ipsilateral abducens nerve palsy)

  • Symptoms are often chronic in nature and can present weeks beyond resolution of AOM

  • Risk of blindness secondary to elevated intracranial pressure 

  • Treatment aims to eradicate underlying infection and otologic complications, lower intracranial pressure, and ophthalmologic complications

Example Procedure Note 

  • Procedure: Myringotomy with PE tube placement
    After obtaining written and verbal consent, the patient’s head was turned, an ear speculum was inserted and obstructing cerumen was gently removed under the operating microscope. The tympanic membrane appeared ___. Topic anesthesia was obtained using ___. A posteroinferior myringotomy was fashioned with a myringotomy blade, the middle ear was suctioned (insert here if culture obtained), and a pressure equalization tube was placed. Ototopical drops were instilled and a cotton ball was placed. The patient tolerated the procedure well.

References

  1. Arts, H.A., Adams, M.E. (2013). Intratemporal and Intracranial Complications of Otitis Media. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 2399-2409). Baltimore, MD: Lippincott Williams & Wilkins. 

  2. Rosenfeld, R. M., Shin, J. J., Schwartz, S. R., Coggins, R., Gagnon, L., Hackell, J. M., … Corrigan, M. D. (2016). Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology–Head and Neck Surgery, 154(1_suppl), S1–S41. https://doi.org/10.1177/0194599815623467

  3. Rosenfeld, R. M., Schwartz, S. R., Pynnonen, M. A., Tunkel, D. E., Hussey, H. M., Fichera, J. S., … Schellhase, K. G. (2013). Clinical Practice Guideline: Tympanostomy Tubes in Children. Otolaryngology–Head and Neck Surgery, 149(1_suppl), S1–S35. https://doi.org/10.1177/0194599813487302

  4. Schilder, A.G., et al (2020). Acute Otitis Media and Otitis Media with Effusion. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 2956-2969). Philadelphia, PA: Elsevier.