History

Fact Explanation
Fever Fever may occur due to the infection.
Tugging at the ear Young children who can't complain about pain might tug the ear excessively. [1]
Ear pain Older children usually complain of severe, throbbing ear pain. [2] The pain is usually of acute onset. [3]
Purulent discharge from the ear Once the tympanic membrane ruptures due to the increasing pressure in the middle ear, pus will be discharged. Since the pressure is reduced in the middle ear the pain will be reduced with the appearance of the purulent discharge. The discharge will continue until the infection is settled. [2] The discharge is often blood-stained, profuse and mucoid at first, later becoming thick and yellow. [2]
Irritability, poor sleeping or eating habits When a young child presents with irritability, excessive crying, poor sleeping and poor feeding, Acute Otitis Media (AOM) should be suspected. [1] High index of suspicion should be maintained in young children because of these non specific symptoms. [4,5]
Hearing loss [2] Elderly patients will experience hearing loss in the affected ear. This is due to the poor conduction of sound waves through the fluid filled middle ear.
References
  1. NELSON. ed. Robert M. Kliegman. Bonita F. Stanton, Joseph W. St. Geme III, Nina F. Schor, Richard E. Behrman. Nelson Textbook of Pediatrics. 19th ed. London. Elsevier, 2011.
  2. BULL P.D. Lecture Notes on Diseases of the Ear, Nose and Throat. 9th ed. Oxford . Blackwell Science. 2002.
  3. O'BRIEN MA, PROSSER LA, PARADISE JL, RAY GT, KULLDORFF M, KURS-LASKY M, HINRICHSEN VL, MEHTA J, COLBORN DK, LIEU TA. New vaccines against otitis media: projected benefits and cost-effectiveness. Pediatrics [online] 2009 Jun, 123(6):1452-63 [viewed 20 July 2014] Available from: doi:10.1542/peds.2008-1482
  4. NIEMELÄ M, UHARI M, JOUNIO-ERVASTI K, LUOTONEN J, ALHO OP, VIERIMAA E. Lack of specific symptomatology in children with acute otitis media. Pediatr Infect Dis J.1994;13 :765– 768
  5. FROOM J, CULPEPPER L, GROB P, BARTELDS A, BOWERS P, BRIDGES-WEBB C, GRAVA-GUBINS I, GREEN L, LION J, SOMAINI B. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network.. BMJ [online] 1990 March, 300(6724):582-586 [viewed 20 July 2014] Available from: doi:10.1136/bmj.300.6724.582

Examination

Fact Explanation
Pyrexia. The temperature may be as high as 40°C. [1]
Tenderness to pressure on the mastoid antrum. [1] Due to inflammation of the mastoid antrum air cells.
Bulging tympanic membrane The intact tympanic membrane bulges due to the increased pressure in the middle ear. [1]
Erythematous tympanic membrane Normal color of the tympanic membrane is pearly white. Erythema suggests inflammation of the tympanic membrane. Prominent reddish small vessels around the periphery of the tympanic membrane and along the handle of the malleus may also be seen. [2]
Loss of tympanic light reflex [1] The normal tympanic membrane is shining and the inflammed tympanic is not.
Loss of translucency of the tympanic membrane The normal tympanic membrane will transmit the light through it. The inflamed tympanic membrane is thickened and the visibility through it is reduced. [3]
Features of systemic sepsis Eg: Fever, hypotension, tachycardia or bradycardia. These might be the features of an AOM in immune compromised patients. Presence of features of sepsis together with an ear discharge in an immune compromised patient should alert about the possibility of AOM.
References
  1. BULL P.D. Lecture Notes on Diseases of the Ear, Nose and Throat. 9th ed. Oxford . Blackwell Science. 2002.
  2. Diagnosis and Management of Acute Otitis Media. Pediatrics Vol. 113 No. 5 May 1, 2004. pp. 1451 -1465. Available from: http://pediatrics.aappublications.org/content/113/5/1451.full#ref-5
  3. MICHAEL E. PICHICHERO. Acute Otitis Media: Part I. Improving Diagnostic Accuracy. Am Fam Physician. 2000 Apr 1;61(7):2051-2056

Differential Diagnoses

Fact Explanation
Otitis media with effusion (OME) More acute onset of purulent otorrhea is indicative of AOM. In OME an air-fluid level or air bubbles may be visible to otoscopic examination, [1] The tympanic membrane does not bulge in OME, instead it might be retracted. [1]
Viral upper respiratory tract infection The symptoms like fever, irritability, inconsolable crying and poor feeding are suggestive of a viral upper respiratory tract infection, which is more common than AOM. Otorrhea (ear discharge) is the most important differentiating feature of an AOM. [2]
External otitis The mucous discharge will help in differentiating the two. The mucous glands are only seen in the middle ear. [3] So a mucoid discharge may appear through a perforated tympanic membrane and it favors the diagnosis of AOM.
Dental pain Due to the close proximity of the teeth and the ear, dental pain might be interpreted as earache or vice versa.
Temporomandibular joint pain Pain will be present over the tempro mandibular joint on movement, may be associated with Rheumatoid arthritis.
Trauma to the ear Blood stained discharge which might appear with AOM should make the clinician suspicious about a possibility of a traumatic injury as well.
References
  1. NELSON. ed. Robert M. Kliegman. Bonita F. Stanton, Joseph W. St. Geme III, Nina F. Schor, Richard E. Behrman. Nelson Textbook of Pediatrics. 19th ed. London. Elsevier, 2011.
  2. Diagnosis and Management of Acute Otitis Media. Pediatrics Vol. 113 No. 5 May 1, 2004. pp. 1451 -1465. Available from: http://pediatrics.aappublications.org/content/113/5/1451.full#ref-5
  3. BULL P.D. Lecture Notes on Diseases of the Ear, Nose and Throat. 9th ed. Oxford . Blackwell Science. 2002.

Investigations - for Diagnosis

Fact Explanation
None Usually this is a clinical diagnosis and no investigation is necessary to confirm the diagnosis. To diagnose AOM there should be a history of acute onset of symptoms, presence of signs of middle ear effusion, and the presence of signs and symptoms of middle-ear inflammation. [1]
Tympanometry (acoustic immittance testing) This measures the absorption of sound by the tympanic membrane and reflects the degree of stiffness of the tympanic membrane. Since the stiffness of the tympanic membrane increases with the middle ear effusion, this aids in the diagnosis of AOM. How ever this will not differentiate AOM from otitis media with effusion, because both of these conditions will have a fluid collection in the middle ear. [2]
Gram stain and culture of the ear swabs When an atypical organism is suspected (Eg: atypical bacteria or fungal infection) an ear swab can be taken for Gram stain and culture (fungal culture whenever necessary); therefore, the antibiotic treatment can be guided with the sensitivity pattern of the organism.
References
  1. Diagnosis and Management of Acute Otitis Media. Pediatrics Vol. 113 No. 5 May 1, 2004. pp. 1451 -1465. Available from: http://pediatrics.aappublications.org/content/113/5/1451.full#ref-5
  2. HELENIUS KK, LAINE MK, TäHTINEN PA, LAHTI E, RUOHOLA A. Tympanometry in discrimination of otoscopic diagnoses in young ambulatory children. Pediatr Infect Dis J [online] 2012 Oct, 31(10):1003-6 [viewed 20 July 2014] Available from: doi:10.1097/INF.0b013e31825cac94

Management - General Measures

Fact Explanation
Vaccination Although not routinely practiced, vaccines against Streptococcus pneumonia and Haemophilus influenzae are proven to be a cost effective method of reducing the incidence of AOM. [1,2,3]
Anti-pyretics It is proven that AOM is a self limiting condition where use of symptomatic management is adequate. [4] So anti-pyretics will also provide a symptomatic relief to the patient. Routine analgesics in combination with the topical analgesics (ear drops) will hasten the pain relief.
Analgesia Symptomatic management with analgesia will ease the patient. [1] Routine analgesics in combination with the topical analgesics (ear drops) will hasten the pain relief. Acetaminophen or ibuprofen can be used for mild to moderate pain. Narcotic analgesia with codeine or analogs, (Morphene, Pethidine) is effective for moderate to severe pain, but the side effects like respiratory depression, might occur. [1]
References
  1. Diagnosis and Management of Acute Otitis Media. Pediatrics Vol. 113 No. 5 May 1, 2004. pp. 1451 -1465. Available from: http://pediatrics.aappublications.org/content/113/5/1451.full#ref-5
  2. PRYMULA R, PEETERS P, CHROBOK V, KRIZ P, NOVAKOVA E, KALISKOVA E, KOHL I, LOMMEL P, POOLMAN J, PRIEELS JP, SCHUERMAN L. Pneumococcal capsular polysaccharides conjugated to protein D for prevention of acute otitis media caused by both Streptococcus pneumoniae and non-typable Haemophilus influenzae: a randomised double-blind efficacy study. Lancet [online] 2006 Mar 4, 367(9512):740-8 [viewed 20 July 2014] Available from: doi:10.1016/S0140-6736(06)68304-9
  3. O'BRIEN MA, PROSSER LA, PARADISE JL, RAY GT, KULLDORFF M, KURS-LASKY M, HINRICHSEN VL, MEHTA J, COLBORN DK, LIEU TA. New vaccines against otitis media: projected benefits and cost-effectiveness. Pediatrics [online] 2009 Jun, 123(6):1452-63 [viewed 20 July 2014] Available from: doi:10.1542/peds.2008-1482
  4. FOXLEE R, JOHANSSON A, WEJFALK J, DAWKINS J, DOOLEY L, DEL MAR C. Topical analgesia for acute otitis media. Cochrane Database Syst Rev [online] 2006 Jul 19:CD005657 [viewed 20 July 2014] Available from: doi:10.1002/14651858.CD005657.pub2

Management - Specific Treatments

Fact Explanation
Antibiotics Penicillin is the drug of choice in most cases, Intravenous penicillin should be given initially followed by oral medication. [1] However in children under the age of five use of amoxicillin is usually recommended. [2] Hemophillus influenzae is the most common organism causing AOM in this age group, which is sensitive to amoxicillin. [1] Watchful waiting without the use of antibiotics can be adopted in uncomplicated AOM. [2] However recent studies have found out that antibiotics are less beneficial than it was previously believed. [3]
Ear drops containing antibiotics Ear drops are useless if the tympanic membrane is intact. [1]
Myringotomy Myringotomy is indicated when the tympanic membrane is persistently bulging. This will enable drainage of pus in the middle ear and quicken the recovery. This is done under general anesthesia and with adequate antibiotic cover. [1] Myringotomy can be performed as a method of providing pain relief as well. [2]
References
  1. BULL P.D. Lecture Notes on Diseases of the Ear, Nose and Throat. 9th ed. Oxford . Blackwell Science. 2002.
  2. Diagnosis and Management of Acute Otitis Media. Pediatrics Vol. 113 No. 5 May 1, 2004. pp. 1451 -1465. Available from: http://pediatrics.aappublications.org/content/113/5/1451.full#ref-5
  3. FOXLEE R, JOHANSSON A, WEJFALK J, DAWKINS J, DOOLEY L, DEL MAR C. Topical analgesia for acute otitis media. Cochrane Database Syst Rev [online] 2006 Jul 19:CD005657 [viewed 20 July 2014] Available from: doi:10.1002/14651858.CD005657.pub2