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Otitis Media: Explained
A GlobalCastMD production

Matt Smith, MD, pediatric otolaryngologist:
Thanks for joining us today. My name is Matt Smith, and I'm one of the pediatric otolaryngologists here at Cincinnati Children's hospital.

Stacey Ishman, MD, MPH, pediatric otolaryngologist:
Hellow, I am Stacey Ishman, and I am also a pediatric ear, nose and throat surgeon at Cincinnati Children's hospital. I appreciate the opportunity to talk to you about ear infections with my colleague, Dr. Smith.

Smith:
I'm going to talk to you today about Otitis Media. It's surprising, but up to 90 percent of kids, by age 5, will have an episode of otitis media. Annually, 2 million children are diagnosed with otitis media in the United States. Here at Cincinnati Children's, wtihin our Division of Otolaryngology, we perform approximately 3,600 ear tubes every year for kids that have otitis media.

When seeing kids in clinic with otitis media, it's important to delineate between chronic otitis media with effusion or recurrent acute otitis media, as these entities are treated differently. Kits that have chronic otitis media with effusion typically do not present with fever, but instead present with ear pain and a middle ear effusion that does not clear.

The middle ear effusion will be serious or mucoid, typically not purulent. For recurrent otitis media, kids do present with fever. They also will present with ear pain and a purulent middle ear effusion. Sometimes, the eardrum can even be red as well When diagnosing either entity, it is important to perform a proper history and physical.

Ishman:
In this example, you can see a middle ear effusion with bubbles around the perifery of the drum.

Smith:
On the physical exam, it's important to look in the ear and specifically address the movement of the eardrum. Is there middle ear effusion present? It might be purulent, which would suggest recurrent acute otitis media. Or it might be mucoid or serous, which would suggest chronic otitis media with effusion. You want to perform pneumatic otoscopy in order to assess the movement of the eardrum itself.

Ishman:
Here, you can see two examples of pneumatic otoscopy. In these examples, you can see an eardrum that is moving easily with pressure changes. This confirms that the middle ear is mobile at the time of the assessment. Immobility may be due to middle ear fluid, a perforation of the tympanic membrane, or scarring of the drum, typically referred to as Myringo or tympanosclerosis.

Smith:
If you don't have that available but do have tympanometry available, that is recommended by our American Academy of Otolaryngology-Head and Neck Surgeons. On physical exam, if you notice a tympanic membrane perforation persistent middle ear effusion that's lasting longer than 3 months, cholesteatoma or signs of mastoiditis, which would include a red and swollen mastoid. Any of these red flags should prompt a referral to an ENT specialist.

Ishman:
Here, we see an example of tympanometry with a flat (type B) tracing. This suggests that there is middle ear pathology, which frequently includes fluid behind the eardrum (whether infected or not) or negative pressure in the middle ear. Flat (type B) tympanograms may also be seen in patients with an eardrum perforation, but these patients will have a middle ear volume (labeled here equivalent volume) that is increased, and is often greater than 1 milliliter. Here, we see volumes of 0.45 and 0.56 mililiters, suggesting that the eardrum is intact.

Smith:
The treatment for each of these entities is different. That's why it's important to delineate between the two. For chronic otitis media, when effusion antibiotics are not recommended. Proper pain control and making sure that the effusion clears is the most important thing to do for these children. For recurrent acute otitis media, antibiotics are the mainstay in treatment. First-line would be high-dose Amoxicillin or Augmentin. If patients are penicillin sensitive, then Cephalosporins are definitely a good choice. If patients have a severe penicillin allergy, then azithromycin or clindamycin would be recommended.

If kids have failed multiple treatments of antibiotics, it might be worthwhile to perform IM Recophin shots. If we're getting to that point, that's a reason to refer to an ENT specialist as well.

Ishman:
The American Academy of Otolaryngology - Head and Neck Surgery published an update of the guideline for the treatment of children with otitis media with effusion. This guideline recommends consideration of ear tube placement for children with at least 3 ear infections in 6 months or 4 ear infections in a year. For those with otitis media with effusion or a fluid that lasts at least 3 months, a hearing test with tympanogram is recommended. If the tympanogram is flat or type B, surgery can be offered. Treatment with steroids, antibiotics, decongestants or antihistamines is not recommended. If a ...
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