Pediatric Ear Infections

Home / About SAEM / Academies, Interest Groups, & Affiliates / CDEM / For Students / CDEM Curriculum / Peds EM Curriculum / Pediatric Ear Infections

 

Objectives

Upon finishing this module, the student will be able to:

  1. Understand the pathophysiology of an ear infection.
  2. Identify the common agents that cause ear infections.
  3. Recognize the common presenting complaints for otitis media and otitis externa.
  4. Discuss the current treatments for ear infections and special considerations.

 

Contributors

Update Author: Seema Bhatt, MD, MS.

Original Authors: Aditi Ghatak-Roy, MS2; and Margaret Strecker-McGraw, MD.

Update Editor: Erica R. Tabakin, MD.

Last Updated: August 2024

Introduction

Pediatric ear infections are one of the most pervasive illnesses in infants and children. Infections can occur in the middle ear (acute otitis media) or external ear (otitis externa). Acute otitis media (AOM) constitutes 13% of all emergency department (ED) visits and over 50% of children will experience at least one episode by the age of three. Incidence of AOM peaks between six to 15 months of age. As the leading cause of conductive hearing loss, it is important to correctly diagnose, treat, and prevent this condition. A decline in AOM coincided with the introduction of pneumococcal conjugate vaccine (PCV) in 2000. 

Risk factors for AOM include age under five years, craniofacial abnormalities, family history, male sex, prematurity, recent upper respiratory tract infection, Caucasian race, tobacco smoke exposure, gastroesophageal reflux, lack of breastfeeding, pacifier use beyond six months of age, and bottle propping. The most common bacterial agents are Streptococcus pneumonia, non-typeable Haemophilus influenza, and Moraxella catarrhalis. Young children with immunologic naiveté may not have achieved protection even after several doses of effective vaccines, contributing to a higher risk for infection.

Otitis externa (OE) is an inflammatory process of the external ear auditory canal most commonly caused by infection (bacterial and occasionally fungal). Excessive moisture (swimming) and trauma which impair the canal’s natural defenses, are the two most common precipitants of OE. The condition is often caused by Pseudomonas or Staphylococcus bacteria.

 

Case Study
An 18-month-old female presents to the ED with one week of cough and congestion. Today she has developed a fever and has been very fussy. The patient's mother reports she has been tugging on her right ear. On exam, she is febrile to 39C with copious nasal secretions. Her ear exam is notable for a right tympanic membrane that is bulging and erythematous with an effusion.
Initial Actions and Primary Survey
If an ear infection is suspected by history, an otoscopic evaluation should be performed to examine the external auditory canal, tympanic membrane (TM), and middle ear. Further, pneumatic otoscopy can be used to assess TM mobility. The lateral expansion of the TM, upon pressure release from the pneumatic attachment, is over 90% sensitive and specific for identifying a middle ear effusion.
Presentation

Acute otitis media (AOM) usually begins with a precipitating event, most commonly a viral upper respiratory tract infection (URI). URIs cause inflammation of the nasopharynx, precipitating edema and secretions, which impair the eustachian tube’s function leading to bacterial colonization. Patients usually present with nonspecific symptoms such as fever, irritability, otorrhea, headache, ear-pulling, anorexia, and vomiting. Otalgia is the most common complaint. The differential diagnosis of AOM includes otitis media with effusion (OME), tympanic membrane (TM) perforation, cholesteatoma, traumatic disruption of ossicles, hemotympanum, or basilar skull fractures. It is important to distinguish AOM and OME. OME is a condition involving asymptomatic middle ear effusion without acute signs of infection that can lead to hearing loss. 90% of children experience OME before five years of age, making it a more common diagnosis than AOM. It may precede or be an inflammatory response following AOM and does not necessitate antibiotics.

The diagnosis of AOM should be made in children who present with moderate to severe bulging of the TM, or mild bulging of the TM with recent onset of ear pain or intense erythema of the TM, or new onset otorrhea that is not due to otitis externa. Signs and symptoms of severe AOM include a temperature ≥ 39°C, moderate to severe otalgia, otalgia > 48 hours, or otorrhea from TM perforation.


Figure: Normal tympanic membrane (left) vs acute otitis media (right). Image courtesy of Michael Hawke, MD.

On otoscopic exam, it is important to remove cerumen via irrigation or manual extraction to clearly check the TM for color, opacification, position, and mobility. The TM is normally a translucent pearly gray with visible landmarks. The TM of AOM can be erythematous, cloudy, immobile, and must be bulging. The clinical history for otitis externa (OE) may be more helpful. There may be a history of swimming, scratching, or excessive cleaning. OE commonly presents with otalgia, pruritis, conductive hearing loss, tinnitus, or discharge.

Differential Diagnosis
Differential diagnoses include furunculosis, contact dermatitis, chondritis, AOM with perforated TM, or malignant OE. On physical exam, the external ear may be erythematous with edema and exudate. The TM should be mobile as opposed to AOM. Pulling on the tragus will elicit pain and tenderness. The mastoid bone should be palpated for tenderness to rule out mastoiditis. The internal ear should be examined with an otoscope to assess for redness, swelling, discharge, or masses.
Diagnostic Testing
Pneumatic otoscopy can be used to evaluate the patient’s tympanic membrane and middle ear by measuring the mobility of the TM in response to pressure changes. During the procedure, air is puffed against the eardrum to create a seal and increase pressure in the ear canal. A normal TM will push into the middle ear cavity, but if fluid is present the TM mobility will be restricted. Tympanocentesis can be performed to obtain a culture of the middle ear and may be considered to guide treatment in patients with ongoing AOM symptoms refractory to multiple antibiotics. This diagnostic test is especially relevant for recurrent infections or immunocompromised patients to identify the precise pathogen. A CT scan can be useful if there are concerns of complications of AOM or OE such as mastoiditis or if there is suspicion for a traumatic cause or malignancy.
Treatment

First-line treatment for AOM is high dose amoxicillin (80-90 mg/kg/day) in two divided doses, which is effective against common AOM pathogens. This drug is safe, low cost, has an acceptable taste, and a narrow microbiological spectrum. Patients who received amoxicillin in the last 30 days should be treated with high dose amoxicillin-clavulanate (Augmentin) (90/6.4 mg/kg/day in two doses). Augmentin should also be used in patients with AOM and associated purulent conjunctivitis. Alternatives in penicillin allergic patients include a second- or third-generation cephalosporin, such as cefdinir, cefuroxime, or cefpodoxime. A one-time dose of intramuscular ceftriaxone can be used in patients who will not take oral medication. The standard duration for treatment is ten days for children under two years of age or patients with severe symptoms. A five-seven day course is recommended for older children with mild to moderate AOM.

The 2013 AAP updated guidelines suggest an “either/or" approach (antibiotic prescription vs close observation with shared decision making) for non-severe, unilateral AOM in children <23 months of age and in non-severe AOM in older children as many of these cases of resolve spontaneously. Observation should be a joint decision with the parent/caregiver with close follow up and appropriate pain management. This approach intends to prevent adverse reactions and address antibiotic resistance issues. Despite this option, antibiotics continue to be prescribed in the majority of cases.

Signs and symptoms of severe AOM include a temperature over 39C, moderate to severe otalgia, otalgia over 48 hours, and otorrhea from perforation of TM.

Treatment for OE includes debriding the external auditory canal, insertion of a wick if swelling of the canal is severe, and combination antibiotic and steroid ear drops (i.e. Polymixin B, neomycin, and hydrocortisone drops) for five-seven days. Pain should be treated with oral ibuprofen or acetaminophen.

Pearls and Pitfalls
  • Acute otitis media (AOM) is diagnosed when there are acute onset of symptoms, presence of a middle ear effusion, and signs and symptoms of middle ear inflammation or new onset otorrhea without evidence of otitis externa (OE).
  • First-line treatment for AOM is high dose amoxicillin.
  • A watchful waiting approach for non-severe AOM is an option, but rarely followed by clinicians.
Case Study Resolution
The patient has evidence of unilateral otitis media. She is febrile and has severe otalgia, therefore she should be treated with a ten-day course of amoxicillin. A watchful waiting approach would not be indicated in this patient with severe AOM.
References
  1. Gaddey HL, Wright MT, Nelson TN. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019 Sep.
  2. Lee H, Kim J, Nguyen V. Ear Infections: Otitis Externa and Otitis Media. Primary Care. 2013 Sep.
  3. Lieberthal AS, Carroll AE, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013 Mar.
  4. Mandel EM, Casselbrant ML. Treatment of Acute Otitis Media in Young Children. Current Allergy and Asthma Reports. 2012 Dec.
  5. Nesbit CE, Powers MC. An Evidence-Based Approach to Managing Acute Otitis Media. Pediatric Emergency Medicine Practice. 2013 Apr.
  6. Pelton SI, Leibovitz E. Recent Advances in Otitis Media. The Pediatric Infectious Disease Journal. 2009 Oct.
  7. Smolinski NE, Antonelli PJ, Winterstein AG. Watchful Waiting for Acute Otitis Media. Pediatrics. 2022 Jul.
  8. Thomas NM, Brook I. Otitis Media: An Update on Current Pharmacotherapy and Future Perspectives. Expert Opinion on Pharmacotherapy. 2014 Jun.