In an effort to cut down on cost, decrease
unnecesary antibiotic use and minimize side effects,
the American Academy of Pediatrics has devised a treatment
guideline for acute otitis media that has two categories.
The patient will either fall into the treatment category
or the watchful waiting, or observation category.
These guidelines are used in corporation
with the child's age, diagnostic certainty,
illness severity and the
likelihood to follow up.
On the left, these children are in the treatment category.
When they're in your clinic or in your hospital
setting, you will begin treating them immediately,
And this includes children less than
6 months old, with otitis media,
and then 6 months or older with
severe signs and symptoms,
children younger than 2 with bilateral acute
otitis media which means it's on both sides
even if they don't have severe signs or symptoms.
Children with craniofacial abnormalities,
immunosuppresion, Down's syndrome or cochlear implants
As these children are more likely to have complications.
And if your patient's going to be lost to follow up and
you won't be able to monitor them for the first 3 days.
Sometimes maybe a patient's gonna go camping,
and they're gonna be stuck in the woods
and they won't have a chance to get rechecked.
These are patients you would treat right away.
Now the observation group.
These are patients that can
have close patient monitoring.
It's available at home and the provider has
a trusting relationship with the parents.
Children 6-23 months with a unilateral, so one-sided acute otitis
media if they don't have severe signs or symptoms or a fever
and children 2 or older with bilateral or unilateral acute
otitis media if they also don'r have severe signs or symptoms.
Now remember a child can be on observation group initially
and then require treatment if they're not improving.
How do we manage acute otitis media?
Well it's painful so we want to treat their pain.
Over the counter analgesics are preferred
- either NSAIDS or acetaminophen.
I prefer to give my patients NSAIDS because in addition
to treating pain, it also helps with the inflammation
and a lot of the pain from the eardrum has
is because of the inflammatory property.
You can also use antibiotics vs observation.
And a surgical technique is
to use tympanostomy tubes.
The insertion of a tympanostomy tube is the most common
ambulatory surgery performed on children in the United States
These are small tubes that are surgically
placed into the child's eardrum
by an otolaryngologist, which is an
ear, nose and throat specialist
The tubes work in the same way as a small pipe.
They're placed in there to help drain the fluid of
the middle ear to reduce the risk of ear infections.
This trapped fluid can flow out of the middle ear and this
prevents hearing loss and reduces the risk of ear infections
These tympanostomy tubes stay in place for about
6-18 months and they'll fall out by themselves
Sometimes parents will say they'll find
in the bathtub or in the child's bed.
We tell them just throw them in the trash.
Here's an example on how a tympanostomy tube will work.
On the left, you'll see acute otitis
media, this patient has a normal ear canal
and then you'll see the eardrum that's bulging and there's a
purulent infection behind that eardrum in the middle ear.
The patient on the right, they have a
small green tympanostomy tube in place
and this allows the air, the infected fluid
and the serous fluid to drain from the tube.
There are some complications of otitis media.
A risk is that you can get a hole in the eardrum,
this is called perforation of the tympanic membrane,
and this is a risk whether you're treating
or not treating the ear infection.
I always have this discussion with my patients when we're doing
the observation or watchful waiting group that this is a risk.
And typically, perforations will heal in a few weeks.
If they don't heal, then we will refer
these children onto a specialist.
Children can develop speech and hearing delays or difficulty
Mastoiditis is a rare but serious complication and this
is an infection in the mastoid space behind the ear.
Rarely, children can develop bacterial
meningitis or a brain abscess
and this is where that bacteria will
translocate to another location.
Otitis media with effusion means there
is fluid or an effusion in the middle ear.
There is no infection.
Fluid in the middle ear can have a few
symotoms especially if it develops slowly
Otitis media with effusion is most common
in young children ages 2 and under
but it can affect people of any age.
On exam, the clinician will notice increased clear
fluid and bubbles trapped behind the eardrum
There is no erythema, so it's not red.
There is no increased opacity which
means you can see through the eardrum
and there's no fever because this
patient does not have an infection.
The child may feel pressure or pain
or have decreased hearing.
Here's an example of an eardrum with an effusion.
There's fluid behind the middle ear, you can
see the clear fluid and the extra bubbles.
You can see a defined air-fluid level.
Again, there's no bacterial infection present.
Anything that causes a change in the air and fluid
pressure behind the eardrum can cause an effusion.
This can occur due to viruses such as
the common cold, seasonal allergies,
eustachean tube dysfunction because
the fluid's not being drained.
Sudden increases in air-pressure if patients
go flying or scuba diving or diving deep into a pool,
patients exposed to cigarette smoke, and
this is common after acute otitis media,
and this is where we've cleared
the patient's infection.
They've taken antibiotics that have
cleared their acute otitis media,
however it sometimes take up to a month for
the fluid to resolve behind the eardrum,
and we always tell patients your pressure can
last but the pain and fever should be gone.
So feel free to check your patients but reassure
them it's okay and common after acute otitis media.