1. Acute otitis media (with adequate therapy) middle ear a viral upper
 Acute inflammation in
 < 3 weeks (month)
 Often associated with respiratory infection
 Most common reason
middle ear
a viral upper
for medical
therapy
for children younger than 5 years
 Recurrent otitis media:
At least 4 episodes/ year
At least 3 episodes/ 6 months
(with adequate therapy)

2. Epidemiology children have at least one episode of (by age 3, 50-85%)
incidence age 6-15 months
 Most
AOM
 Peak
 Increased incidence in the fall and winter
 Only 20% are adults
 >700 milion cases/year

3. Causes mucosa mucosa with nasopharynx Edema > narrowed lumen >
 Eustachian tube is lined with respiratory
mucosa
 Responds together
mucosa
with nasopharynx
Edema
>
narrowed
lumen
>
negative middle
ear pressure 
 Influx of pathogens
possible
from nasopharynx is

4. Causes the obstruction ear worsens Allergies
 Inflammatory response in middle
the obstruction
ear
worsens
 Trigger:
Allergies
Upper respiratory tract infections
GER (especially children)
Adenoid hypertrophy
Other

5. Causes Combined (15%) RSV Rhinovirus Coronavirus
 Viral (30-70%)
RSV
Rhinovirus
Coronavirus
Influenza, parainfluenza
 Bacterial (55%)
Streptococcus pneumoniae
(44%)
Haemophilus influenzae (41%)
Moraxella catarrhalis (14%)
Gram negative enteric bacteria
S. Aureus
Combined (15%) •

6. Risk factors  Age: <7
 Their Eustachian tubes are short, floppy, horizontal and poorly functioning

7. Handbook of Pediatric Otolaryngology : A Practical Guide for Evaluation and Management
of Pediatric Ear, Nose, and Throat Disorders

8. Risk factors Eustachian tube dysfunction Allergic tendencies
 Genetic predisposition
Eustachian tube dysfunction
Allergic tendencies
 Bottle feeding (first 3 months)
(breast milk contains
lactoferrin, oligosaccharide
and surface immunoglobulin A that inhibit
bacterial colonization)
(sucking generates negative pressure)
 Incorrect posture while breastfeeding

9. Risk factors Unrepaired cleft palate  Parental smoking
 Underlying pathology
Unrepaired cleft palate
 Parental smoking
 Large familys/attending daycare
 Immunocompromised states

10. Signs and symptoms (speech delay for children)  Otalgia (not always)
 Fever
 Hearing loss
(speech delay for
 Headache
 Nausea
 Cough
 Rhinitis
 Conjunctivitis
children)

11. Physical Examination (purulent, serous, mucoid) Red or opaque eardrum
 Pneumatic otoscopy/otoscopy:
Red or opaque eardrum
Retracted eardrum
Immobile or hypo-mobile eardrum
Presence of fluid behind eardrum
(purulent, serous, mucoid)
Retraction pockets
Bullous myringitis

14. Physical Examination ) tympanostomy tube, perforation nasal cavity
 Otorrhea (in case of
tympanostomy tube, perforation
 Mastoid tenderness
 Anteriorly rotated pinna
 Tympanometry
 Audiometry
 Inspection or pharynx and
nasal cavity

15. Diagnosis (hypomobile eardrum, air-fluid level) (erythema, otalgia)
 Acute onset of signs and syptoms
 The presence of middle ear effusion
(hypomobile eardrum, air-fluid level)
 Signs and symptoms of middle ear inflamation
(erythema, otalgia)

16. Complications  Acute mastoiditis  Abscess formation
 Facial paralysis
 Otitis media with effusion
 Persistent AOM
 Recurrent AOM
 Hearing loss
 Perforation of eardrum

17. Complications (rare)  Lateral sinus thrombosis  Otitic hydrocephalus
 Septic shock
 Meningitis
 Encephalitis
 Extradural abscess
 Labyrinthitis

18. Treatment paracetamol) Children of age <6months
 Antibacterial therapy for:
Children of age <6months
6 months to 2 years with severe
Recurrent or billateral AOM
Immunocompromised patients
illness
Patients with a perforated tympanic membrane
 Pain management (Ibuprofen, Diclofenac,
paracetamol)
 Decongestants and/or antihistamines, nasal steroids

19. After 24-48h (48-72h) No antibiotics > antibiotics
 If no improvemants:
No antibiotics > antibiotics
Antibiotics > change to a different antibiotics

20. Antibacterial therapy
Amoxicilin mg/day
mg/kg/day 
(has not recived amoxicilin in past 30 days and
allergy to penicilin)
Amoxicillin-clavulanate 875/125mg/day
90/6.4 mg/kg/day
(alternative for amoxicilin)
Ceftriaxone 1-2g/day 50mg/kg/day or
Cefuroxim 500mg/day 30mg/kg/day
has no  
Azithromycin, clarithromycin, erythromycin
case of allergy to penicilin
days in  

21. Recurrent AOM
treatment
 +Tympanostomy

22. Non-drug Treatment
 Myringotomy in case of sevare pain
 Tympanocentesis in case of severe pain a diagnostic procedure if there is no improvement with
2nd line of antibiotics (local anesthesia) (narcosis)
and as

23. Preventive measures Adenoidectomy Polipectomy S. Pneumonia (PCV-7)
 Avoiding risk factors if possible
 Vaccination: ?
S. Pneumonia (PCV-7)
Influenza
Adenoidectomy
Polipectomy •

24. Differential diagnosis  Otitis externa
 Impacted cerumen or foreign body in ear
 Tympanosclerosis
 Otitis media with effusion
 Injury of the ear

25. Sources
Shapiro, Nina L. Handbook Of Pediatric Otolaryngology : A Practical Guide For Evaluation And Management Of Pediatric Ear, Nose, And Throat Disorders. Singapore: World Scientific Publishing Company,
2012. eBook Academic Collection (EBSCOhost). Web. 5 Mar
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