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Otitis Media
Author: Muhammad Waseem, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP more... Updated: Dec 8, 2010

Background
Otitis media (OM) is the second most common disease of childhood, after upper respiratory infection (URI). OM is also the most common cause for childhood visits to a physician's office. Annually, an estimated 16 million office visits are attributed to OM; this does not include visits to the emergency department. OM is any inflammation of the middle ear without reference to etiology or pathogenesis. OM can be classified into many variants on the basis of etiology, duration, symptomatology, and physical findings. Acute OM (AOM) implies rapid onset of disease associated with one or more of the following symptoms: Otalgia Fever Otorrhea Recent onset of anorexia Irritability Vomiting Diarrhea These symptoms are accompanied by abnormal otoscopic findings of the tympanic membrane (TM), which may include the following: Opacity Bulging Erythema Middle ear effusion (MEE) Decreased mobility with pneumatic otoscopy AOM is a recurrent disease. More than one third of children experience 6 or more episodes of AOM by age 7 years. OM with effusion (OME), formerly termed serous OM or secretory OM, is MEE of any duration that lacks the associated signs and symptoms of infection (eg, fever, otalgia, irritability). OME usually follows an episode of AOM. Chronic suppurative OM is a chronic inflammation of the middle ear that persists at least 6 weeks and is associated with otorrhea through a perforated TM, an indwelling tympanostomy tube (TT; see image below), or a surgical myringotomy.
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Various tympanostomy tube styles and sizes.

Pathophysiology
The most important factor in middle ear disease is eustachian tube (ET) dysfunction. In ET dysfunction (ETD), the mucosa at the pharyngeal end of the ET is part of the mucociliary system of the middle ear. Interference with this mucosa by edema, tumor, or negative intratympanic pressure facilitates direct extension of infectious processes from the nasopharynx to the middle ear, causing OM. Esophageal contents regurgitated into the nasopharynx and middle ear through the ET can create a direct mechanical disturbance of the middle ear mucosa and cause middle ear inflammation. In children, developmental alterations of the ET, an immature immune system, and frequent infections of the upper respiratory mucosa all play major roles in AOM development. Studies have demonstrated how viral infection of the upper respiratory epithelium leads to increased ETD and increased bacterial colonization and adherence in the nasopharynx.[1] Certain viral infections cause abnormal host immune and inflammatory responses in the ET mucosa and subsequent microbial invasion of the middle ear. The host immune and inflammatory response to bacterial invasion of the middle ear produces fluid in the middle ear and the signs and symptoms of AOM. Although interactions between the common pathogenic bacteria in AOM and certain viruses are not fully understood, strong evidence indicates that these interactions often lead to more severe disease, lowered response to antimicrobial therapy, and OME development following AOM.

Epidemiology
Frequency
United States OM, the most common specifically treated childhood disease, accounts for approximately 20 million annual physician visits. Various epidemiologic studies report the prevalence rate of AOM to be 17-20% within the first 2 years of life, and 90% of children have at least one documented MEE by age 2 years. OM is a recurrent disease. One third of children experience 6 or more episodes of AOM by age 7 years. International Incidence and prevalence in other industrialized nations are similar to US rates. In less developed nations, OM is extremely common and remains a major contributor to childhood mortality resulting from late-presenting intracranial complications.

Mortality/Morbidity
US mortality rates are extremely low in this era of antimicrobial therapy (< 1 death per 100,000 cases). In developing nations with limited access to primary medical care and modern antibiotics, mortality rates are similar to US rates before antibiotic therapy. A study that examined the causes of death in Los Angeles County Hospital from 1928-1933, years prior to the advent of sulfa, showed 1 in 40 deaths was caused by intracranial complications of OM. Morbidity from this disease remains significant, despite frequent use of systemic antibiotics to treat the illness and its complications. Intratemporal and intracranial complications of OM are the 2 major types. Intratemporal complications Hearing loss (conductive and sensorineural) TM perforation (acute and chronic) Chronic suppurative OM (with or without cholesteatoma) Cholesteatoma Tympanosclerosis
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Mastoiditis Petrositis Labyrinthitis Facial paralysis Cholesterol granuloma Infectious eczematoid dermatitis Intracranial complications Meningitis Subdural empyema Brain abscess Extradural abscess Lateral sinus thrombosis Otitic hydrocephalus

Race
Until recently, prevalence of OM in the United States was reported to be higher in black and Hispanic children than in white children. A study that controlled for socioeconomic and other confounding factors showed equal incidence in blacks and whites. Hispanic children and Alaskan Inuit and other American Indian children have higher prevalence of AOM than white and black children in the United States. International studies show increased prevalence of AOM and chronic OM (COM) among Micronesian and Australian aboriginal children.

Sex
Several more recent studies have shown equal AOM prevalence in males and females; many previous studies had shown increased incidence in boys.

Age
Peak prevalence of OM in both sexes occurs in children aged 6-18 months. Some studies show bimodal prevalence peaks; a second, lower peak occurs at age 4-5 years and corresponds with school entry. Although OM can occur at any age, 80-90% of cases occur in children younger than 6 years. Children who are diagnosed with AOM during the first year of life are much more likely to develop recurrent OM and chronic OME than children in whom the first middle ear infection occurs after age 1 year.

Contributor Information and Disclosures

Author Muhammad Waseem, MD Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center Muhammad Waseem, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, and American Medical Association Disclosure: Nothing to disclose. Coauthor(s) Muhammad Aslam, MD Instructor in Pediatrics, Harvard Medical School; Staff Physician, Department of Medicine, Division of Newborn Medicine, Children's Hospital Boston Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Medical Association, Massachusetts Medical Society, and Southern Medical Association Disclosure: Nothing to disclose. Specialty Editor Board Orval Brown, MD Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern emedicine.medscape.com/article/994656-ov erv iew#showall Medical Center at Dallas
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Surgery, University of Texas Southwestern Medical Center at Dallas Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Alan D Murray MD, Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, Cook Children's Pediatric Surgery Center Plano Alan D Murray is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Texas Medical Association Disclosure: Nothing to disclose. Daniel Rauch, MD, FAAP Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine Disclosure: Baxter Honoraria Consulting Chief Editor Glenn C Isaacson, MD, FACS, FAAP Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Temple University School of Medicine Glenn C Isaacson, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society of Pediatric Otolaryngology, and Society of University Otolaryngologists-Head and Neck Surgeons Disclosure: Covidien Honoraria Consulting Additional Contributors The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Michael Jones, MD, David Malis, MD, and Leslie Wilson, MD, to the development and writing of this article.

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