Diagnosing and managing otitis media

A common problem in young children, ear infections often are the subject of debate when it comes to management techniques.

Experts at the American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition cleared the air in a session titled “Otitis media: The times they are a-changin’” that offered the latest guidelines for the diagnosis and treatment of all forms of otitis media (OM). The session on September 18, led by Ellen R. Wald, MD, FAAP, professor and chair of Pediatrics at the University of Wisconsin School of Medicine and Public Health, Madison, also revealed how the pneumococcal vaccine is affecting the incidence of OM and how it can be used in practice.

Nearly all children have at least 1 ear infection by age 2 years, Wald says. Incidence of acute OM in children peaks between the ages of 3 and 24 months, which coincides with the peak incidence for community-acquired viruses.

For diagnosis, otoscopy is key, as is the ability to differentiate acute OM from otitis media with effusion (OME). Otitis media with effusion is a sterile, nonbacterial inflammatory state that resolves spontaneously, according to Wald, and antibiotics are not appropriate or beneficial. Acute otitis media, on the other hand, is a bacterial infection.

Although infection may run alongside other illness, signs and symptoms of upper respiratory infection are not enough to distinguish children with acute OM from those with an uncomplicated upper respiratory infection, Wald says.

“Accurate otoscopy is the key to diagnosis and is a skill that is essential for all providers who care for children,” Wald points out. “A bulging tympanic membrane is the strongest indicator of an episode of acute OM and the need for treatment.”

One method of determining the difference is to follow an algorithm for children with suspected OM. A bulging tympanic membrane indicates acute OM. Without a bulging membrane, the clinician should assess opacification or air-fluid levels-without these the diagnosis is OM, with these it is OME.

Current guidelines recommend that children with moderate to severe bulging tympanic membranes, recent onset of otorrhea, or mild bulging along with severe otalgia or distinct erythema be diagnosed with acute OM. Children aged 6 months and younger with acute OM should be treated with antibiotics, as well as children with nonsevere bilateral acute OM aged between 6 and 24 months. Either observation or treatment is recommended for unilateral, nonsevere acute OM in children aged 6 months and older.

Although aspects of treatment have been a bit controversial in the last decade, it is recommended to treat all cases of severe acute OM and all children with nonsevere acute OM who are aged between 6 and 24 months, Wald says. The AAP recommends treatment with antibiotics or the observation option for all other cases of acute OM.

“My preference is treatment with antibiotics in all children with a bulging tympanic membrane,” Wald says. “Treatment with antibiotics for 10 days, rather than 5 days, is recommended for all children [aged younger] than 2 years.”

Clinicians should always have a plan in place should OM worsen in a few days, whether the child is on antibiotics or not, Wald says.

In terms of the microbiology of acute OM, there have been changes over the years. In 1990, Streptococcus pneumoniae caused 35% to 45% of acute OM cases; Haemophilus influenzae caused 25% to 30%; Moraxella catarrhalis caused 12% to 15%; and Streptococcus pyogenes caused 2% to 4%. After the pneumococcal conjugate vaccine PCV7 was licensed in 2000, there were some changes. By 2017, Streptococcus pneumoniae was linked to 20% to 25% of cases; Haemophilus influenzae to 45% to 50% of cases; Moraxella catarrhalis caused 10% to 15%; and Streptococcus pyogenes caused 5%.

“Current evidence suggests that nontypeable Haemophilus influenzae is the most common bacterial isolate accounting for approximately 45% of cases, Streptococcus pneumoniae is second most common causing 20 to 25% of cases, and Moraxella catarrhalis is least common accounting for 15% of cases,” Wald adds.