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Emergent Management of Acute Otitis Media

Overview

Acute otitis media (AOM) is defined by convention as the first 3 weeks of a process in which the middle ear shows signs and symptoms of acute inflammation. One consideration in the emergent management of AOM is that diagnostic certainty for the disease is based on all three of the following criteria, as set forth by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP): acute onset, middle ear effusion (MEE), and middle ear inflammation. Studies have shown that, despite adequate access to clinical guidelines, the prescribing rates for antibiotics in acute otitis media (AOM) in some emergency departments remain high.

Severe illness is defined as moderate to severe otalgia or temperature greater than 39°C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39°C. AOM most commonly occurs in children and is the most frequent specific diagnosis in children who are febrile. Clinicians often overdiagnose AOM. Recurrent AOM is defined as 3 episodes within 6 months or 4 or more episodes within 1 year.

Distinguishing between AOM and otitis media with effusion (OME) is important. OME is more common than AOM. When OME is mistaken for AOM, antibiotics may be prescribed unnecessarily. OME is fluid in the middle ear without signs or symptoms of infection. It is usually caused when the eustachian tube is blocked and fluid becomes trapped in the middle ear. Signs and symptoms of AOM occur when fluid in the middle ear becomes infected. (See the images below.)

Drawing of a normal right tympanic membrane. Note

Drawing of a normal right tympanic membrane. Note the outward curvature of the pars tens (*) of the eardrum. The tympanic annulus is indicated anteriorly (a), inferiorly (i), and posteriorly (P). M = long process of the malleus; I = incus; L = lateral (short) process of the malleus.

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Tympanic membrane of a person with 12 hours of ear

Tympanic membrane of a person with 12 hours of ear pain, slight tympanic membrane bulge, and slight meniscus of purulent effusion at bottom of tympanic membrane. Reproduced with permission from Isaacson G: The natural history of a treated episode of AOM. Pediatrics. 1996; 98(5): 968-7.

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Days after onset of symptoms, vessels continue acr

Days after onset of symptoms, vessels continue across pars tensa, and a fluid layer of pus is noted. Reproduced with permission from Isaacson G: The natural history of a treated episode of AOM. Pediatrics. 1996; 98(5): 968-7.

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Using the Nationwide Emergency Department Sample database, Ren et al determined that between 2009 and 2011 the weighted total of emergency department visits for patients presenting with a primary diagnosis of AOM or acute mastoiditis reached more than 5.8 million, with the average patient age being 10.1 years. The investigators found that 0.26% of patients presented with a complication, with acute mastoiditis (0.16%), labyrinthitis (0.06%), and facial paresis (0.03%) being the most common and with complicated AOM tending to occur in adults (age 37 years) rather than children.

In a multisite, cross-sectional study, McLaren et al found that afebrile infants with AOM who were seen in emergency departments had a low prevalence of invasive bacterial infections and adverse events. Patients in the study were aged 90 days or younger, with blood and cerebrospinal fluid (CSF) cultures revealing no bacteremia or bacterial meningitis, respectively. An adverse event, specifically lymphadenitis or culture-negative sepsis, was seen in just two of the 645 infants (0.3%) who had 30-day follow-up. The investigators suggested that it may be reasonable for afebrile infants with clinician-diagnosed AOM to undergo outpatient management without diagnostic testing.

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