Acute Otitis Media in Children

What Is Middle Ear Infection?

The human ear is usually divided into three parts,

• External ear.

• Middle ear.

• Inner ear.

The middle ear, also called a tympanum or tympanic cavity, is an air-filled region. It is connected to the oropharynx by the eustachian tube and to the mastoid cavity by the mastoid antrum. A middle ear infection, also called otitis media, occurs when a virus or bacteria causes the area behind the eardrum to become inflamed.

This condition is more common in children. According to a study, a middle ear infection can occur in 80 percent of children nearing 3 years of age.

What Are The Types Of Middle Ear Infection?

The two types of middle ear infections are:

• Acute otitis media (AOM).

• Otitis media with effusion (OME).

What is Acute Otitis Media?

Otitis media is nothing but the inflammation of the middle ear cavity with or without inflammation in the mastoid cavity. Otitis media can be bacterial or viral. Acute otitis media (AOM), also called suppurative otitis media, is a middle ear infection. Children are often brought to the physician’s office seeking immediate medical care.

What Is the Pathophysiology of Acute Otitis Media?

Otitis media initiates as an inflammation after a viral upper respiratory tract infection affects the mucosa of the nose, middle ear mucosa, nasopharynx mucosa, and Eustachian tubes. The middle ear's limited space leads to edema obstructing the narrowest part of the Eustachian tube, reducing ventilation. This sets off a chain of events: negative pressure builds up in the middle ear, causing increased exudate from inflamed mucosa and mucosal secretions buildup. These conditions foster the growth of bacterial and viral organisms in the middle ear, resulting in suppuration and eventual purulence in the middle ear space. Clinically, this is observed as a bulging or erythematous tympanic membrane and purulent middle ear fluid. It's important to distinguish this from chronic serous otitis media (CSOM), which displays thick, amber-colored fluid in the middle ear and a retracted tympanic membrane during otoscopic examination. Both conditions show decreased tympanic membrane mobility on tests like tympanometry or pneumatic otoscopy.

What Are The Causes Of Acute Otitis Media?

Several reasons why children are more prone to middle ear infections include,

• Previous respiratory tract infection that has spread to the ears.

• Allergy.

• Adenoid infection or enlargement

• Blockage in the tube that connects the middle ear to the pharynx (eustachian tube), leads to collection of fluids behind the eardrum.

• Common cold or flu.

• Sinus infection.

• Bacterial growth in the fluid. The most common bacteria causing AOM are S. pneumoniae, non-typeable H. influenzae, and M. catarrhalis.

What Can Be The Symptoms Of Otitis Media In Children?

Symptoms of acute otitis media in children are:

• Crying.

• Inability to sleep.

• Irritability.

• Fever.

• Restlessness.

• Nausea and vomiting.

• Problems with hearing.

• Pulling the ear.

• Earache.

• Temporary hearing loss.

• Ear tugging.

• Clear, yellow, or bloody discharge from the ears.

• Loss of balance.

• Diarrhea.

• Decreased appetite.

• Congestion.

How Common Is Otitis Media?

Otitis media is more commonly seen in children than adults because the eustachian tube is shorter and more horizontal than in adults. These anatomical features cause the infection to spread more easily from the oropharynx to the middle ear cavity.

Otitis media is a common childhood illness. It occurs most commonly in children aged between 6 and 18 months but is expected until 4 years of age. It has been predicted that about 75 percent of children would have had otitis media at least once after starting school.

How to Diagnose Otitis Media?

In children over 3 years, the diagnosis of a diseased ear is easy as the child can talk and describe the illness. Also, an endoscopic ear examination is possible, which reveals middle ear inflammation. But, in children below 3 years, the diagnosis is difficult as the child cannot describe the illness. The child just cries loudly and sometimes hits his diseased ear with his palm.

In children below 3 years, diagnosis of otitis media can be missed by the physician. The sickness may be misdiagnosed as gastroenteritis because otitis media in this age presents with fever, vomiting, and diarrhea. Here, the endoscopic ear examination helps confirm middle ear infections.

How Is Acute Otitis Media Treated?

The treatment options for acute otitis media in children are classified according to the stage of the disease, whether with or without suppuration. Suppuration is the collection of pus behind the eardrum. Acute otitis media without suppuration is treated with antibiotics, mucolytics, vasoconstrictor nasal drops, and analgesics and if suppuration is present, the treatment is mainly surgical. Myringotomy is mandatory to drain the collected pus from behind the eardrum, and prophylactic treatment is prescribed.

Regarding recurrent acute otitis media, it should exclude surgical causes such as enlarged adenoid tissue. Ventilation tubes can be introduced through the eardrum for adequate middle-ear ventilation.

Child's surgeon may also suggest the removal of the adenoids if they are infected.

Antibiotics:

The first drug of choice for otitis media is Amoxicillin, and the effective second-line drugs for resistant beta-lactamase-producing bacterial strains include:

• Erythromycin-Sulfisoxazole.

• Trimethoprim-Sulfamethoxazole.

• Cefixime.

• Cefaclor.

• Cefuroxime.

While choosing an antibiotic, the physician should consider the efficacy, cost, side effects, age of the child, compliance issues, and spectrum of coverage. Children with recurrent infections can be treated with antibiotic prophylaxis. About 10 percent of children with episodes of acute otitis media develop a chronic middle ear effusion that persists beyond three months.

What Is The Prognosis For Acute Otitis Media?

Without antibiotic treatment, acute otitis media (AOM) symptoms can improve in 24 hours in about 60 percent of children, and it will settle immediately within three days in 80 percent of children. Serious complications of AOM include meningitis, acute mastoiditis, and, rarely, intracranial complications. If antibiotics are delayed, acute mastoiditis can occur in about 1 to 2 per 10,000 children.

What Are The Risk Factors Associated With Acute Otitis Media?

• Younger age.

• Allergies.

• Immunodeficiency.

• Exposure to group daycare.

• Upper respiratory infections.

• Craniofacial abnormalities.

• Family history of recurrent acute otitis media.

• Exposure to environmental smoke or any respiratory irritants.

• Gastroesophageal reflux.

• No breastfeeding

• Pacifier use.

How To Prevent Acute Otitis Media In Children?

• Influenza vaccine and pneumococcal vaccine can reduce the risk of upper respiratory tract infection, reducing the incidence of otitis media-related infection.

• Avoid tobacco smoking.

• Breastfed infants have reduced risk as compared to bottle-fed infants.

What Are The Complications Of Acute Otitis Media In Children?

If not treated, they may lead to:

• Hearing loss if the tympanic membrane is ruptured.

• Otitic meningitis if the infection spreads to the meninges (membrane of the brain).

• Brain abscess.

• Dural sinus thrombosis: Presence of a clot in the dural venous sinuses.

• Tympanic membrane ruptures due to the accumulation of pus.

Conclusion

Acute otitis media in children stems from upper respiratory infections, leading to middle ear inflammation. Prompt recognition and appropriate management are vital to prevent complications and ensure effective treatment.