Conductive hearing loss should be assumed to be present with persistent middle ear effusion; the loss is mild to moderate and often is transient or fluctuating. Normal tympanograms after 1 month of treatment obviate the need for further follow-up. In children at developmental risk or with frequent episodes of recurrent acute OM, 3 months of persistent effusion with significant bilateral hearing loss is a reasonable indicator of need for intervention with insertion of pressure equalization tubes.
Parents should be encouraged to continue exclusive breastfeeding as long as possible and should be cautioned about the risks of bottle-propping and of children taking a bottle to bed. The home should be a smoke-free environment.
Children identified at high-risk for recurrent acute OM are candidates for prolonged courses of antimicrobial prophylaxis, which can reduce recurrences significantly. Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer is used for prophylaxis.
The conjugate S. pneumoniae vaccine reduces pneumococcal OM caused by vaccine serotypes by 50%, all pneumococcal OM by 33%, and all OM by 6%. Annual immunization against influenza virus may be helpful in high-risk children.
Otitis externa, also known as swimmer’s ear, is defined byinflammation and exudation in the external auditory canal inthe absence of other disorders, such as otitis media or mastoiditis. The most common bacterial pathogens are Pseudomonas aeruginosa, especially in association with swimming in pools or lakes, and Staphylococcus aureus. Otitis externa develops in approximately 20% of children with tympanostomy tubes, associated with S. aureus, Streptococcus pneumoniae, Moraxellacatarrhalis, Proteus, Klebsiella, and occasionally anaerobes.Coagulase-negative staphylococci and Corynebacterium are isolated frequently from cultures of the external canal but representnormal flora. Malignant otitis externa is caused by P. aeruginosa in immunocompromised persons and adults with diabetes.
Otitis externa cases peak in summer, in contrast to otitis media, which occurs primarily in colder seasons in association with viral upper respiratory tract infections. Cleaning of the auditory canal, swimming, and, in particular, diving disrupt the integrity of the cutaneous lining of the ear canal and local defenses such as cerumen, predisposing to otitis externa.
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Pain, tenderness, and aural discharge are the characteristic clinical findings of otitis externa. Fever is notably absent, and hearing is unaffected. Tenderness with movement of the pinna, especially the tragus, and with chewing is particularly characteristic, symptoms notably absent in otitis media. Inspection usually reveals that the lining of the auditory canal is inflamed with mild to severe erythema and edema. Scant to copious discharge from the auditory canal may obscure the tympanic membrane. The most common symptoms of malignant otitis externa are similar, but facial nerve palsy occasionally occurs. The most common physical findings are swelling and granulation tissue in the canal, usually with a discharge from the external auditory canal.
The diagnosis of uncomplicated otitis externa usually is established solely on the basis of the clinical symptoms and physical examination findings without the need for additional laboratory or microbiologic evaluation. In malignant otitis externa, an elevated erythrocyte sedimentation rate is a constant finding. Cultures are required to identify the etiologic agent, which is usually P. aeruginosa, and the antimicrobial susceptibility.