Otitis Media: A Comprehensive review of Aetiology, Symptoms and Management

Otitis Media: A Comprehensive review of Aetiology, Symptoms and Management

Introduction:

Otitis media, an inflammation of the middle ear, is a common condition that can present as acute or chronic. In Australia, otitis media is a significant health concern, particularly in children. This blog aims to delve into the epidemiology, risk factors, symptoms, and management of acute and chronic otitis media in Australia, based on available data.

Epidemiology:

Otitis media is one of the most prevalent childhood diseases globally, with a substantial impact on healthcare systems. In Australia, it is estimated that over 70% of children will experience at least one episode of otitis media by the age of three. Indigenous Australian children are disproportionately affected, with rates of otitis media being significantly higher compared to non-Indigenous children. Chronic otitis media, in particular, is a significant cause of hearing loss in Indigenous communities.

Aetiology of acute otitis media

Acute otitis media is a common paediatric presentation in primary care, and antibiotics are commonly inappropriately prescribed for this condition. Acute otitis media is commonly a viral infection but can be bacterial or have both a viral and bacterial aetiology. Regardless of the cause, it is usually self-limiting. Spontaneous resolution occurs in more than 80% of children within 2 to 3 days; symptoms may persist for up to 8 days in some children.

In bacterial acute otitis media, the most common pathogens are Streptococcus pneumoniae, nontypeable Haemophilus influenzae and Moraxella catarrhalis. Aboriginal and Torres Strait Islander infants in some communities are more likely to be colonised with these organisms from a young age, as a consequence of socioeconomic disadvantage (eg crowded housing). In these children, acute otitis media often develops in the first months of life and recurs throughout childhood.

Acute otitis media can occur in adults but is less common than in children. Management is similar.

Risk Factors:

Several risk factors contribute to the development of otitis media in Australia. These include young age, exposure to second-hand smoke, attending daycare or preschool, living in crowded environments, and a history of recurrent upper respiratory infections. Indigenous children are at a higher risk due to factors such as socio-economic disadvantage, limited access to healthcare services, and higher rates of chronic diseases.

Symptoms:

The symptoms of acute otitis media typically include ear pain, fever, irritability, and difficulty sleeping. In chronic otitis media, symptoms may be more subtle and include persistent ear discharge, hearing loss, and recurrent ear infections. Children with otitis media may also exhibit behavioural changes, such as pulling or rubbing their ears, difficulty concentrating, and delayed speech and language development.

Diagnosis of acute otitis media

Acute otitis media is characterised by middle ear inflammation and middle ear effusion. The diagnosis is made if there is acute onset of either of the following signs of acute otitis media on examination:

• bulging of the tympanic membrane (strongly suggestive of middle ear inflammation)
• otorrhoea (indicative of tympanic membrane perforation and middle ear effusion, provided acute diffuse otitis externa has been excluded).
• 
  

Although visualising the tympanic membrane is considered important to confirm the diagnosis of acute otitis media, this may be difficult in the presence of copious otorrhoea, particularly in infants. If the tympanic membrane cannot be visualised initially, ensure the patient receives follow-up to check progress and reassess the membrane; review by an otolaryngologist or audiologist can aid diagnosis.

Middle ear effusion can be diagnosed by an immobile tympanic membrane on pneumatic otoscopy or a type B tympanogram; nonpneumatic otoscopy is not usually sufficient to detect effusion.

Middle ear effusion can occur in both acute otitis media (in which the effusion is infected) and otitis media with effusion, in which the effusion is not infected. If middle ear effusion is not accompanied by other signs or symptoms of AOM (eg acute onset of ear pain [in young children, tugging, holding or rubbing the ear may indicate ear pain], fever, irritability, poor feeding, bulging tympanic membrane), a diagnosis of otitis media with effusion should be made instead.

Pain alone is not sufficient for diagnosis of acute otitis media.

Management:

The management of otitis media in Australia involves a multi-faceted approach, including pharmacological and non-pharmacological interventions. Antibiotics are commonly prescribed for acute otitis media, particularly in cases where the infection is severe or recurrent. Pain management with analgesics, such as paracetamol or ibuprofen, can help alleviate discomfort. In chronic cases, surgical interventions, such as tympanostomy tube insertion or adenoidectomy, may be considered to improve ventilation and drainage in the middle ear.

Preventive strategies are also crucial in managing otitis media. These include promoting breastfeeding, reducing exposure to tobacco smoke, ensuring timely vaccination against common pathogens like Streptococcus pneumoniae and Haemophilus influenzae, and implementing good hygiene practices to reduce the spread of infections.

Approach to managing acute otitis media

Adequate and regular analgesia (with paracetamol or a nonsteroidal anti-inflammatory drug [NSAID]) is the mainstay of acute otitis media treatment, whether or not antibiotic therapy is used. For suitable analgesic regimens, see Oral drugs for mild, acute nociceptive pain in children.

Adequate and regular analgesia is the mainstay of acute otitis media treatment. For most children, antibiotic therapy can be safely withheld.

For most children with acute otitis media, antibiotic therapy can be safely withheld. However, antibiotic therapy is required in the following groups:

• infants younger than 6 months
• children younger than 2 years with bilateral infection
• children who are systemically unwell (e.g. lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapy
• children with otorrhoea
• Aboriginal and Torres Strait Islander children—for treatment recommendations, see the Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations [Note 1]
• children at high risk of complications (e.g. immunocompromised children).

For other children with acute otitis media, antibiotic therapy has a limited benefit—initial antibiotic therapy does not improve pain at 24 hours; for every 100 children treated with antibiotics, only five children will be better at 2 to 3 days as a consequence of taking antibiotics; and antibiotics only shorten the duration of symptoms by about 12 hours. Further, antibiotic therapy can cause harm (e.g. diarrhoea, rash or more serious hypersensitivity reactions, bacterial resistance).

Consequently, children not in the groups described above can be initially treated with analgesia alone. For children younger than 2 years, analgesia alone is appropriate; however, initial antibiotic therapy may be reasonable depending on the clinical context and likelihood of follow-up—clinical judgment is required.

Advise the patient or carer to return for follow-up if symptoms worsen, or do not improve within 48 to 72 hours; antibiotics may be required. If the patient is unlikely to return for follow-up, a delayed prescription for antibiotic therapy can be provided; however, it is essential that the patient is aware of the circumstances in which follow-up and reassessment are required.

Pain is a poor indicator of response to antibiotic therapy.

Many patients have an expectation of treatment with antibiotics. For children who do not require initial antibiotic therapy, effective communication with the patient or carer about the limited role of antibiotics in acute otitis media is essential. The discussion should address misconceptions about the effectiveness of antibiotic therapy and the expectation of an antibiotic prescription. Shared decision making, which involves a discussion of the evidence for the potential benefits and harms of therapy, provides a useful template for these discussions.

Antibiotic treatment is not required for children with otitis media with effusion.

Rare suppurative complications of acute otitis media include mastoiditis and facial palsy—urgent referral to an otolaryngologist is required.

Controlled trials showed decongestants, antihistamines and oral corticosteroids are not beneficial for acute otitis media.

Management in Children

In Infants, especially <6 months old, the diagnosis of AOM and OME can be inaccurate. Other diagnoses should be fully considered.  

Management may also differ for children from higher risk groups, such as those living in Aboriginal or Torres Strait Islander communities

Investigations

·        There is no role for routine diagnostic investigation for AOM

·        Diagnostic imaging such as CT and MRI is usually only required in children with suspected intracranial complications

Treatment

·        Most cases of AOM in children resolve spontaneously and antibiotics are not recommended

·        Treat pain with adequate and regular simple analgesia. See Acute pain management

·        As an adjunct, short-term use of topical analgesia eg 2% lignocaine, 1-2 drops applied to an intact tympanic membrane, may be effective for severe acute ear pain

·        Decongestants, antihistamines and corticosteroids are not effective in AOM

Conclusion:

In conclusion, otitis media is a prevalent and impactful condition in Australia, particularly among children and Indigenous populations. Understanding the epidemiology, risk factors, symptoms, and management strategies for acute and chronic otitis media is essential for healthcare professionals to provide effective care and support for affected individuals. By addressing risk factors, promoting early detection, and implementing evidence-based management approaches, we can improve outcomes and reduce the burden of otitis media in the Australian population.

Ref:

1.     https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Antibiotic&topicfile=otitis-media&guidelinename=Antibiotic&sectionId=toc_dle795#toc_dle795

2.     Note 1 Leach AJ, Morris P, Coates HLC, Gunasekaera H, Harkus S, Kong K, et al. 2020 otitis media guidelines for Aboriginal and Torres Strait Islander children. Darwin, NT: Menzies School of Health Research; 2020. [URL]

3.     https://www.rch.org.au/clinicalguide/guideline_index/acute_otitis_media/