Earache/AOM
Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM).
Include pain referred from other sources in the differential diagnosis of an earache (eg. Tooth abscess, trigeminal neuralgia, TMJ dysfunction, pharyngitis, etc.).
Consider serious causes in the differential diagnosis of an earache (eg. tumors, temporal arteritis, mastoiditis).
In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (e.g., through proper patient selection and patient education because most otitis media is of viral origin), and by ensuring good follow-up (e.g., reassessment in 48 hours).
Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.)
In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics).
In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever). *See the key features on fever
Test children with recurrent ear infections for hearing loss.
DDx
AOM
Complications (rare, risk in pneumococcus and <2yo)
Acute mastoiditis (pain/swelling over mastoid bone)
Acute facial nerve palsy - associated with temporal bone inflammation
Sixth CN palsy (failure of ipsilateral eye abduction) due to petrous bone inflammation or infection (Gradenigo's syndrome)
Labyrinthitis
Venous sinus thrombosis
Meningitis
Middle ear
Otitis media with effusion (usually nasal infection or allergy)
Trauma (TM perforation/foreign body)
Cholesteatoma*
Tumor*
Otitis externa (normal TM, painful tender outer ear)
Treatment
Keep dry (Avoid water sports x 7-10d)
Clean ear canal
Analgesia
Mild, Buro-Sol 2-3 drops TID-QID
Moderate, Ciprodex 4 drops TID
If perforated consider systemic antibiotics.
r/o necrotizing/malignant otitis externa (elderly, diabetic, immunocompromised, otalgia despite antibiotics, granulation tissue in ear canal)
ESR, CRP, osteomyelitis on CT/MRI
Ciprofloxacin 750 mg PO BID PLUS Ciprodex 4 drops BID x 4-8w
Herpes zoster (Ramsay Hunt syndrome)
Secondary otalgia
Sinusitis / Stomatitis / Parotitis / Pharyngitis
Dental infection / abscess
TMJ dysfunction syndrome
Auricular lymphadenopathy
Facial nerve palsy
Trigeminal neuralgia
Temporal arteritis*
AOM
AOM characterized by acute otalgia, middle ear fluid with inflammation of middle ear (bulging, erythematous, yellow/cloudy) or rupture
Impaired mobility is most sensitive and specific (95%, 85%)
Bulging TM low sensitivity but high specificity (51%, >97%)
Acute perforation with purulent discharge (otorrhea) in the context of AOM supports bacterial cause
S pneumoniae is the predominant pathogens, M catarrhalis and H influenzae usually resolve spontaneously
Risk
Smoking exposure
Upper respiratory tract infection
Daycare (sick contacts)
Bottlefeed
Pacifier
Personal history, family history of AOM
Treatment
Immediate therapy if < 6months of age
Send to ER if <3 months old with T>38, suspect meningitis or mastoiditis, toxic looking
Healthy children ≥6 months with mild disease, consider:
Watchful waiting, and reassess in 24 to 48h (return if worsens anytime within 48h)
Antimicrobial prescription to start course if child does not improve
Acetaminophen 10-15mg/kg/dose q4-6h (max 75mg/kg/day)
Ibuprofen 5-10mg/kg/dose q6-8h (max 40mg/kg/day)
Bulging TM, febrile (≥39°C), moderately systemically ill, or severe otalgia, or significantly ill for 48h should be treated with antimicrobials
First-line treatment (no penicillin allergy)
Pediatric: Amoxicillin 75 to 90mg/kg/day (max 2000mg) ÷BID
Adults: Amoxicillin 500mg PO TID x 5-10d (can use 1g PO TID if high risk) in adults
Penicillin allergy
Non-anaphylactic: Cefuroxime 30 mg/kg/day ÷ BID-TID
Anaphylactic: Clarithromycin 15mg/kg/day PO ÷ BID x5-10d or Azithromycin 10mg/kg PO day 1, then 5mg/kg PO x 4d
Second-line (no response x 2-3d or recent amoxicillin use in 30 days)
Amoxicillin-clavulanate (7:1 formulation, 400 mg/5 mL suspension) 45 to 60 mg/kg/day ÷ TID (max 500mg PO TID) x 10d
Adults: 875/125mg BID or 2000/125mg BID x 10 days
Ceftriaxone 50 mg/kg IM/IV daily (max 1000mg) x 3 days
Duration of treatment
5 days in children ≥2 years of age with mild/uncomplicated disease
10 days if <2years of age, recurrent AOM or perforated TM
Special circumstances
Otitis-conjunctivitis syndrome - AOM with purulent conjunctivitis (usually M catarrhalis and H influenzae are common pathogens)
Treat with Amoxicillin-clavulanate or 2nd gen cephalosporin (eg. cefuroxime-axetil)
Allergy to penicillin
Non-anaphylactic: Cephalosporin (cefprozil 30mg/kg/d divided BID, cefuroxime-axetil)
Anaphylactic: Macrolide (azithromycin, clarithromycin 15mg/kg/d divided BID ) or clindamycin
ENT referral (Consider Audiology if recurrent episodes r/o hearing loss)
Tympanostomy Tube Indications
Recurrent AOM (3x/6 months or 4x/1 year) with middle ear effusion at the time of evaluation
Chronic OME >3 months
With risk of speech/learning problems
Bilateral OME with Hearing loss
Symptoms attributable with OME (vestibular problems, poor school performance, behavioural problems, ear discomfort)
Note: Water precautions should not be encouraged routinely in patients with tympanostomy tubes
Note: Topical antibiotic eardrops (Eg. Ciprofloxacin (Ciprodex) = 4 drops BID x 5 days) without oral antibiotics should be prescribed for children with uncomplicated acute tympanostomy tube otorrhea
AOM resistant to second-line antibiotics
Perforated TM non-resolved after 6w
References:
Otalgia
AOM
