Distinct erythema of the tympanic membrane Distinct otalgia (discomfort clearly referable to the ear that results in interference with or precludes normal activity or sleep) ear duct as pressure in the duct is varied. Measurements of the resulting tympanogram correlate well with the presence or absence of middle ear effusion.
Instruments using acoustic reflectometry are available for office and home use. Use of reflectometry as a screening test for acute OM should be followed by examination with pneumatic otoscopy when abnormal reflectometry is identified.
Bacteria recovered from the nasopharynx do not correlate with bacteria isolated by tympanocentesis. Tympanocentesis and middle ear exudate culture are not always necessary, but they are required for accurate identification of bacterial pathogens and may be useful in neonates, immunocompromised patients, and patients not responding to therapy.
The major difficulty is differentiation of acute OM from OM with effusion, which also is referred to as chronic OM. Acute OM is accompanied by signs of acute illness, such as fever, pain, and upper respiratory tract inflammation. OM with effusion is the presence of effusion without any of the other signs and symptoms.
Recommendations for treatment are based on certainty of diagnosis and severity of illness. A certain diagnosis can be made if there is rapid onset, signs of middle ear effusion, and signs and symptoms of middle ear inflammation. The recommended first-line therapy for most children with a certain diagnosis of acute OM or those with an uncertain diagnosis but who are younger than 2 years of age or have fever greater than 39° C or otalgia is amoxicillin (80 to 90 mg/kg/day in two divided doses). Children with an uncertain diagnosis who are older than 2 years of age may be observed if appropriate follow-up can be arranged. Failure of initial therapy with amoxicillin at 3 days suggests infection with β-lactamase-producing H. influenza, M. catarrhalis or resistant S. pneumoniae. Recommended next-step treatments include high-dose amoxicillin-clavulanate (amoxicillin 80 to 90 mg/kg/day), cefuroxime axetil, cefdinir, or ceftriaxone (50 mg/kg intramuscularly in daily doses for 1 to 3 days). Intramuscular ceftriaxone is especially appropriate for children younger than 3 years of age with vomiting that precludes oral treatment. Tympanocentesis may be required for patients who are difficult to treat or who do not respond to therapy. Acetaminophen and ibuprofen are recommended for fever. Decongestants or antihistamines are not effective.
Available @ StudentConsult.com
The complications of OM are chronic effusion, hearing loss, cholesteatoma (mass-like keratinized epithelial growth), petrositis, intracranial extension (brain abscess, subdural empyema, or venous thrombosis), and mastoiditis. Acute mastoiditis is a suppurative complication of OM with inflammation and potential destruction of the mastoid air spaces. The disease progresses from a periostitis to an osteitis with mastoid abscess formation. Posterior auricular tenderness, swelling, and erythema, in addition to the signs of OM, are present. The pinna is displaced downward and outward. Radiographs or computed tomography scan of the mastoid reveals clouding of the air cells, demineralization, or bone destruction. Treatment includes systemic antibiotics and drainage if the disease has progressed to abscess formation.
OM with effusion is the most frequent sequela of acute OM and occurs most frequently in the first 2 years of life. Persistent middle ear effusion may last for many weeks or months in some children but usually resolves by 3 months following infection. Evaluating young children for this condition is part of all well-child examinations.