1. Otitis Media

2. Definition Otitis media (OM):
second most common disease of childhood (after upper respiratory infection)
most common cause for childhood visits to a physician's office
Roughly 16 million office visits annually
Infection or inflammation of the middle ear cavity
Classified into many variants on the basis of etiology, duration, symptomatology, and physical findings.
this does not include visits to the emergency department.

3. Epidemiology
90% of children have at least one documented middle ear effusion by age of 2 years
OM is frequently recurrent
1/3 of children experience more than 6 episodes of acute OM by the age of 7 years

4. Classification

5. Signs and Symptoms
Acute Otitis Media (AOM) cause rapid onset of ≥ 1 of the following symptoms:
Otalgia
Otorrhea
Irritability
Fever
Loss of appetite
Young children may also tug on their ear(s)
Otitis Media with Effusion (OME) often follows an episode of AOM. Symptoms include :
Hearing loss
Tinnitus
Vertigo

6. Acute OM (AOM) Otoscopic Appearance:
Purulent effusion behind bulging tympanic membrane (TM)
Severely inflamed osseous canal
Increased vascularity R3

7. OM with Effusion (OME) Otoscopic Appearance: Erythema
Effusion (partial or complete)
Opacification
Bulging of TM outward

8. Adhesive OM Otoscopic Appearance:
Chief sign is tympanic membrane immobility
Appearance may vary from minimal scarring to TM thickening and opacity.
Severe retraction of the TM

9. Chronic Suppurative OM
Otoscopic Appearance:
Perforated TM with persistent drainage from the middle ear
Granulation tissue in the medial ear cavity
Edematous and pale middle ear mucosa

10. Diagnosis Pneumatic otoscopy is the gold standard examination
Examination should include description of the following four TM characteristics:
Color –Yellow or blue coloration of the TM is consistent with effusion
Position – In AOM: the TM is usually bulging whereas in OME, the TM is typically retracted or in the neutral position
Mobility – decreased TM mobility
Perforation – Single perforations are most common
Pneumatic Otoscopy Exam:

11. Diagnosis Lab testing Usually unnecessary
Sepsis workup is recommended in infants with <12 week with fever and AOM 
Appropriate laboratory studies to confirm the etiology for OM when suspecting systemic diseases or congenital syndromes as OM is commonly associated.

12. Diagnosis Imaging
Imaging usually not indicated (Exception include: Suspected intra-temporal or intracranial complications)
Contrast-enhanced CT
Diagnose complications such as mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, brain abscess, and subdural abscess.
MRI is usually performed if CT is unrevealing

13. Treatment
Pain management with acetaminophen or ibuprofen either in the presence or absence of antibiotic treatments
AAFP Recommendations for prescribing antibiotics include the following:
Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms and for nonsevere, bilateral AOM in children aged 6 to 23 months
On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6-23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding antibiotics unless the child worsens or does not improve within hours of symptom onset
Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians should prescribe an antibiotic with additional beta-lactamase coverage