Acute Otitis Media Management

                                                  Acute Otitis Media

Etiology

Most common bacteria responsible for AOM:

· Streptococcus pneumoniae (approximately 40%)

· nontypable Haemophilus influenzae (25% to 30%)

· Moraxella catarrhalis (10% to 15%).

· Staphylococcus aureus and Streptococcus pyogenes are far less common causative agents

AOM cases attributed to viral infections:

· Rhinovirus

· Adenovirus

· Coronavirus

· Influenza

· respiratory syncytial virus







Occurrence/Epidemiology

· Most common precipitating event is a recent or concurrent URI

· The incidence rate of AOM increases during the winter months, when the climate is colder

· AOM is most common in very young children, with a peak incidence between 6 and 18 months

· Elderly adults also have a significant risk of developing disease because of decreases in natural immunity.

· Men and women are affected equally, although AOM tends to be rare in adults.

· AOM occurs in less than 1% of adults.

· Higher incidence among boys


Clinical Presentation

Subjective

· Fever

· Otalgia

· Irritability

· Crying

· sleep disturbance

· vomiting

· poor appetite


Physical examination findings

· Examination of the external ear in patients with OME is typically unremarkable

· bulging, erythematous, or opaque tympanic membrane

· absent or obscured bony landmarks and cone of light reflex

· lymphadenopathy of the preauricular and posterior cervical nodes is common during acute episodes


Diagnostic Testing

· Clinical diagnosis

· Otoscopy Examination

· CBC is usually not indicated; however, patients with AOM may demonstrate leukocytosis, particularly if they are febrile.


Differential Diagnosis

· Otitis externa- Differs from AOM, due to the inflammation of the auditory canal and external ear, including the pinna and tragus.

· TMJ syndrome pain- Differs from AOM because the pain is being referred from the TMJ.

· Mastoiditis - Differs from main diagnosis in that, there is edema, erythema, and tenderness over the mastoid process.


Non-Pharmacologic Management

· The ear canal should be kept as dry as possible

· Avoid using cotton swabs or sharp objects of any kind to clean the ears

· Feed child with the head elevated and avoid pacifiers when possible

· Delayed antibiotic therapy is an option in healthy patients 6 months or older with reliable follow-up

· A recommended approach is to provide analgesia and observe for 2 to 3 days. If the patient remains symptomatic after the observation period ends, the antibiotic is started.


Pharmacologic Management

1. Oral or rectal analgesia

Acetaminophen

· Neonates- Dose: 10-15 mg/kg PO q6-8h prn; Max: 60 mg/kg/day

· Infants/children- Dose: 10-15 mg/kg PO q4-6h prn; Max: 75 mg/kg/day up to 1 g/4h and 4 g/day

· 12 yo and older- Dose: 325-650 mg PO q4-6h prn; Max: 1 g/4h and 4 g/day

Ibuprofen

· 6 mo-11 yo- Dose: 5-10 mg/kg PO q6-8h prn; Max: 40 mg/kg/day

· 12 yo and older- Dose: 400 mg PO q4-6h prn; Max: 2400 mg/day

2. Antibiotics are prescribed in a stepwise fashion beginning with a first-line antibiotic

FIRST LINE TREATMENT RECOMMENDED

· amoxicillin: children: 80-100 mg/kg/day orally given in divided doses every 12 hours for 10 days

· amoxicillin/clavulanate: children >3 months of age: 80-100 mg/kg/day orally given in divided doses every 12 hours for 10 days more

Secondary Options

· cefdinir: children >6 months of age: 14 mg/kg/day for 10 days

· cefuroxime axetil: children: 30 mg/kg/day orally given in divided doses every 12 hours for 10 days

Tertiary Options

· azithromycin : children ≥6 months of age: 10 mg/kg/day orally (immediate-release) on the first day, followed by 5 mg/kg/day for 4 days; or 10 mg/kg/day orally (immediate-release) for 3 days; or 30 mg/kg/day orally (immediate-release) as a single dose; or 60 mg/kg/day orally (extended-release) as a single dose

· ceftriaxone: children: 50 mg/kg/day intramuscularly/intravenously for 3 days


Follow-up

· Patients with AOM should be seen for follow-up in 48 to 72 hours if symptoms have not resolved. Otherwise, a follow-up appointment may be scheduled several days after the completion of pharmacotherapy.


References

Armengol, C. (2019). Acute otitis media. Epocrates. Retrieved from

https://online.epocrates.com/diseases/3911/Acute-otitis-media/Key-Highlights

Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2015). Primary Care: The

Art and Science of Advanced Practice Nursing, 4th Edition, Philadelphia: F.A. Davis

Company

Richardson, B. (2017). Pediatric Primary Care: Practice Guidelines for Nurses, 3rd Edition,

Burlington, MA. Jones & Bartlett Learning