#20: Acute Otitis Media: Q-tips and Tricks With Dr. Eric Baum

March 3, 2021 | By Justin Berk

Summary

We’re ear with a new episode with on acute otitis media joined by guest Dr. Eric Baum, a pediatric otolaryngologist in Connecticut. In this episode, we discuss important physical exam findings used to diagnose acute otitis media, as well as the role of pneumatic otoscopy in performing ear exams. Dr. Baum also tells us about treatment options for acute otitis media, how ear tubes work and when they are indicated, and complications to watch out for. Listen in to hear the latest on acute otitis media!

Credits

• Written, Produced, and Infographic by: Cleo Rochat
• Cover Art: Chris Chiu MD
• Hosts:  Justin Berk MD, Chris Chiu
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Eric Baum MD

AOM Pearls

1. Middle ear inflammation or acute change in pressure in the middle ear there is discomfort with swallowing or lying supine. Asking about anorexia can be a key part of history!  
2. Perforated AOM presents an opportunity to use drops as there is an opening, and therefore, direct access, to the middle ear.
3. AOM is the result of nasopharyngeal carriage plus mucosal edema in a patient with an immature eustachian tube.
4. If you are worried about AOM when performing pneumatic otoscopy, use negative pressure otoscopy to mitigate pain.
5. First-line antibiotics for treatment of AOM: amoxicillin or amoxicillin-clavulanate. Cephalosporins such as cefdinir are alternative options for the treatment of AOM. 
6. Patients with tympanostomy tubes who have AOM should be treated with topical antibiotic drops; they do not necessarily need oral antibiotics.

SPONSORS: VCU Health CE

We are excited to announce that the Cribsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out cribsiders.vcuhealth.org and create your FREE account!

Acute Otitis Media Show Notes

Obtaining a Good History for AOM

Parents are key resources for assessing acute otitis media

The middle ear is a cavity that develops a purulent collection in acute otitis media 

• Given the infectious etiology, we would expect there to be a fever when obtaining a history

Ask about a change in eating patterns (see Expert Opinion, below)

Expert Opinion: Middle ear inflammation or acute change in pressure in the middle ear causes discomfort with swallowing or lying supine. Asking about anorexia can be a key part of history!  

Perforated Acute Otitis Media

Spontaneous perforation is not common in AOM

Perforation can be followed by otorrhea and improved pain 

Expert opinion: Perforated AOM presents an opportunity to use drops as therapy as there is an opening, and therefore, direct access, to the middle ear

No-Miss Signs on Presentation: Complications of AOM

Expert Opinion: Complications that occur as a result of AOM are generally idiosyncratic and not a result of prolonged undertreatment or missing of the diagnosis 

Identifying complications of AOM on presentation can result in quicker treatment and improved outcomes

Symptoms that are concerning for complications of AOM include: 

• Facial weakness or paralysis → concerning for compression from inflammatory edema of the facial nerve
• Erythema, pain and swelling behind the ear → concerning for mastoiditis 
• Meningeal signs and change in mental status → concerning for intracranial process

Causes of Acute Otitis Media

Typically viral infections precede the development of AOM (Conmaitree et al, 2008)

AOM is the result of nasopharyngeal carriage plus mucosal edema in a patient with an immature eustachian tube

Diagnosis of AOM

A good history (Editor’s note: assessing for otalgia, signs of infection, otorrhea, ear tugging, irritability, changes in sleep, anorexia) provides useful pretest probability, and identifying the presence of purulent fluid on physical exam is helpful in making a diagnosis of AOM.

On otoscopy, increasing severity of AOM will display increased thickness and opacity of tympanic membrane, as well as increased bulging (Images on page e972 in Lieberthal et al, 2013)

Expert Opinion: On an otoscopic exam, try to discern what is behind the tympanic membrane and if there are engorged vessels on the surface of the tympanic membrane.

What is the role for pneumatic otoscopy in diagnosing AOM?

Pneumatic otoscopy can serve as a useful learning tool and provides helpful visual information

When using pneumatic otoscopy, ensure use of proper size and shape speculum 

• Expert opinion: The largest speculum that will fit provides better view and better lighting, and is safer, more comfortable for the patient.

Pneumatic otoscopy can be uncomfortable in patients with AOM 

• Expert opinion: If you are worried about AOM when performing pneumatic otoscopy, use negative pressure otoscopy (squeeze bulb → put otoscope in ear → let go) to decreased pain

Physical Exam

• To become more comfortable performing ear examinations and diagnosing AOM on exam, Dr. Baum recommends that trainees try to spend time in the operating room with an ENT surgeon or finding textbooks that have images of different ear exam findings: 

AOM Treatment

Middle Ear Effusions

Middle Ear Effusion (Image attributed to Michael Hawke, MD via Wikimedia licensed under the Creative Commons Attribution 4.0 International license) 

Non-inflamed fluid in the middle ear is not an indication for treatment; however, it should be followed in a non-emergent fashion as it may be indicative of poor drainage of the middle ear

• Can persist for up to 8 weeks in a healthy patient
• Often present following viral upper respiratory infection

Fluid in the middle ear can be a cause of conductive hearing loss, which has implications for children, particularly in children with other risk factors for learning challenges including social barriers  (Hogan et al, 2014; Su et al, 2020).

Persistent effusion in the long-term can be indicative of eustachian tube dysfunction 

• May be an indication for tympanostomy tubes by ENT

Eustachian tube dysfunction may be a risk factor for continued retraction, ossicular erosion, and cholesteatoma.

Cholesteatoma with perforated tympanic membrane (Image attributed to Michael Hawke, MD via Wikimedia licensed under the Creative Commons Attribution 4.0 International license) 

Antibiotic Choice 

Prevalence of Streptococcus pneumoniae and Nontypeable Haemophilus influenzae have changed over time due to the pneumococcal vaccine (Wald, 2019)

First-line antibiotic of choice is high-dose amoxicillin (Rettig, 2015)

•  Amoxicillin/clavulanate is also an option for initial treatment of AOM in patients who have previously failed antibiotics (Lieberthal et al, 2013). 
• Editor’s Note: This is to cover H.flu and Moraxella which, unlike S. pneumoniae, often use resistance strategies other than increasing Penicillin Binding Proteins that can be overcome with the higher-dose of amoxicillin.

There is some discrepancy in the suggested length of treatment for acute otitis media

• A 10-day course of antibiotics is generally recommended in children under 2 years old

• Editor’s note: AAP Guidelines also note a 7-day course of antibiotics in children 2-5 years old with mild-moderate AOM (Lieberthal et al, 2013) 
• A NEJM paper published in 2016 looked at reduced duration of treatment for AOM in children 6-23 months, and found that reduced duration (5 days) of therapy had less favorable outcomes as compared to the standard duration (10 days) of treatment (Hoberman et al, 2016)

Expert opinion: Cephalosporins such as cefdinir are also options for antibiotic treatment of AOM. 

• Some benefits of cefdinir: it is inexpensive, once daily dosing, few issues with the taste
• Dr. Baum notes that cefdinir fixes iron in the GI tract, causing the stool to appear rusty in color

While viral upper respiratory infections can be the initial cause of bacterial AOM, there is no role for antiviral medications as therapy

Persistent Symptoms Following 10 days of Amoxicillin: What’s Next?

Expert Opinion: After patients begin to improve with treatment, they should not get clinically worse. If they do have worsening symptoms on treatment, counsel patients to return to the clinic.

A myringotomy may be indicated in cases of in severe, worsening AOM following multiple trials of antibiotics

AOM can, in rare instances, be complicated by facial paralysis due to compression of the facial nerve or intracranial complications such as abscesses 

Perforated Acute Otitis Media

Expert Opinion: Perforated AOM can occasionally appear to have improved symptoms due to relief of pressure following perforation

Expert Opinion: Perforated AOM presents an opportunity to use antibiotic drops as there is a direct opening

• Treatment with oral antibiotics are still indicated because the perforation can heal spontaneously, closing the hole in the tympanic membrane

Expert Opinion: Fluoroquinolones are the topical antibiotic of choice in perforated AOM, allowing direct access to the middle ear in the case of perforation

• Editor’s note: Topical antibiotic therapy is not well studied in children with AOM and acute perforation (UpToDate)

Topical steroids may also be added in the treatment of perforated AOM to decrease the edema and increase drainage in the ear

Tympanostomy Tubes

Indicated in signs of persistent eustachian tube dysfunction, which may present with recurrent otitis media 

• Editor’s note: Definition of recurrent AOM is (Rosenfeld et al, 2013):
  • three or more episodes of AOM in 6 months OR 
  • at least four episodes in 12 months (with one episode in past 6 months) 

Recommendations for Tympanostomy Tubes:

• American Academy of Otolaryngology: Recurrent AOM (Editor’s note: without the presence of a middle ear effusion) is not an an indication for tympanostomy tubes (Grade A; Recommend against) (Rosenfeld et al, 2013)
• American Academy of Pediatrics:  Tympanostomy tubes may be offered for recurrent AOM (Grade B; Recommendation: Option)(Lieberthal et al, 2013)

Expert Opinion: Tympanostomy tubes work by improving air entry, allowing improved drainage through the eustachian tube 

• Placement of tubes in the tympanic membrane also provide alternate drainage pathway 

Patients with tympanostomy tubes who have AOM should be treated with topical antibiotic drops; they do not necessarily need oral antibiotics (Rosenfeld et al, 2013)

Links*

1. The White Coat Investor

2. The Bogleheads

3. Ear Disease: A Clinical Guide By Michael Hawke

Goal

Listeners will develop a deeper understanding of the diagnosis, management, and potential complications of acute otitis media in children.

Learning objectives

After listening to this episode listeners will…

1. Recognize common presentations of acute otitis media in different age groups
2. Identify the most common pathogens that cause acute otitis media
3. Understand the pathophysiology of acute otitis media
4. Learn what evidence-based therapies are available as treatment for acute otitis media and understand the evolution of antibiotic treatment for AOM 
5. Consider the potential acute or long-term complications of acute otitis media
6. Identify indications for tympanostomy tubes in patients with recurrent or chronic AOM

Disclosures

Dr Baum reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Baum E, Rochat C, Chui C, Berk J. “Acute Otitis Media: Q-tips and Tricks with Dr. Eric Baum”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/March, 2020.