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Overview |
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Definition |
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Otitis media is an infection with inflammation of the middle ear, common in
infants and children under the age of 7, due to their immature immune systems
and short, relatively horizontal, easily blocked eustachian tubes. Fluid may
persist in the middle ear for weeks or months, causing at least some temporary
hearing loss at an important time for language and cognitive development. Acute
otitis media (AOM) is usually accompanied by a viral upper respiratory
infection. Otitis media with effusion (OME) refers to the presence of fluid in
the middle ear. It is generally asymptomatic and is often diagnosed during
well-child examinations. |
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Etiology |
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Blockage and swelling of eustachian tubes resulting from one or more of the
causes listed below.
- Respiratory infection
- Allergies
- Tobacco smoke or other environmental irritants
- Infection and/or hypertrophy of the adenoids
- Sudden increase in pressure such as during an airplane
descent
- Drinking while lying on the back
- Excess mucus and saliva produced during
teething
The bacteria that cause most cases of acute otitis media are Streptococcus
pneumoniae (25% to 35% of cases), Haemophilus influenzae (20% to
25%), Moraxella catarrhalis (10% to 15%), Strep.
pyogenes—Group A (2% to 3%) and Staphylococcus
aureus (1%). Some of the remaining cases are caused by viral infections. For
OME, the most common causes are H. influenzae (15%), M.
catarrhalis (10%), Strep. pneumoniae (7% and rising), and Staph.
aureus (3%). Otitis media is not contagious in itself, but may be
precipitated in multiple children by a contagious respiratory
infection. |
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Risk Factors |
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- Youth
- Male gender
- Winter
- Bottle feeding, especially lying on the back
- Pacifier use
- Group day care
- Allergies
- Exposure to tobacco smoke
- Sibling(s) prone to ear infections
- Enlarged adenoids or chronic sinusitis
- Native American or Inuit background
- Down syndrome
- Craniofacial anomalies
- Compromised immune system
- Children who have their first episode before 6 months of age are more
likely to repeat
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Signs and Symptoms |
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- Pain in the ear, usually worse at night; crying, irritability,
disrupted sleep
- Feeling of "fullness," sometimes manifested in an infant as
head-shaking
- Difficulty hearing
- Fever
- Vomiting and diarrhea
- Bulging eardrum
An episode of AOM may be followed by several weeks of
OME. |
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Differential
Diagnosis |
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- Otitis externa
- "Ear-pulling" due to itching or
teething
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Diagnosis |
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Physical Examination |
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Otoscopic examination reveals a red, opaque, bulging eardrum in AOM.
Spontaneous perforation may occur. In OME, clear or yellow fluid may be seen
through a translucent eardrum. A retracted eardrum (short arm of the malleus is
prominent, long arm of the malleus appears shortened) indicates a partial vacuum
in the eustachian tube, inhibiting drainage. Alternatively, an eardrum distended
by fluid or fixed air pressure from a blocked eustachian tube obscures the
malleus. Pneumatic otoscopy may reveal decreased mobility of the eardrum,
indicating fluid or fixed air pressure in the middle ear. |
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Laboratory Tests |
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Tympanocentesis (needle aspiration) may be employed to identify the bacteria
involved in the infection, but this painful and invasive test should be done
only when (1) the child is seriously ill or has not responded to standard
antibiotic treatment and (2) precise identification of the disease-causing
organism is essential. |
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Imaging |
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Otomicroscope for detailed visualization if necessary. If AOM is complicated
by mastoiditis, computed tomography (CT) should be used to detect intracranial
complications such as epidural abscess. |
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Other Diagnostic
Procedures |
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Take patient history with special attention to recent respiratory infections
or other causative factors. Examine eardrums using a pneumatic otoscope. Take
temperature in both ears. A difference of more than 0.5º C is suggestive of AOM
in the warmer ear.
A tympanometer (a soft rubber probe with an airtight seal) is placed in the
ear canal, emits a sound, and measures its reflection, thus calculating the
amount of the sound that is transmitted to the middle ear. This transmission is
lower than normal in the fluid-filled ear.
An audiometer or other formal hearing test may be employed to discern any
hearing loss, especially as a complication of chronic
infection. |
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Treatment Options |
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Treatment Strategy |
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Many acute otitis media cases are self-limiting. However, delaying treatment
requires follow-up visits for monitoring, and complications can be significant.
Therefore, antibiotics are standard treatment. |
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Drug Therapies |
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AOM: First-line treatment is amoxicillin (Amoxil, 500 mg orally qid for 7 to
10 days), or azithromycin (Zithromax) if penicillin allergy is present.
Second-line treatment is amoxicillin-clavulanate (Augmentin, 500 mg orally qid
for 7 to 10 days) or cefuroxime axetil (Ceftin, 500 mg orally bid for 7 to 10
days). Parents should be reminded of the importance of completing the course.
Combine with pain relief measures such as acetaminophen and/or ibuprofen.
OME: Begin with observation alone, or with antibiotics. Administer a hearing
test if the condition is not resolved within 6 to 12 weeks. Guidelines advise
treating with either antibiotics or myringotomy with tympanostomy tube insertion
if fluid and a 20-dB hearing loss are present after 12 weeks. Tube insertion is
recommended if OME is still present four to six months after initial diagnosis.
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Complementary and Alternative
Therapies |
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A large percentage of otitis media cases are self-limiting. Nutritional
support, herbs, and homeopathic remedies are gentle ways to reduce recurrences
and alleviate pain and acute infection.
Otitis media with effusion (OME) has a strong association with allergies.
Suspect an allergic component if the child's first otitis occured before the age
of 6 months, at or near the introduction of solid food or formula, or infections
are recurrent and/or accompanied by eczema, asthma, or other atopic conditions.
The following guidelines pertain to both AOM and OME unless otherwise
indicated. |
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Nutrition |
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Eliminate all food allergens from the diet. The most common allergenic foods
are dairy, soy, citrus, peanuts, wheat, fish, eggs, corn, and tomatoes. An
elimination/challenge trial may be helpful in uncovering sensitivities. Remove
suspected allergens from the diet for two weeks. Re-introduce foods at the rate
of one food every three days. Watch for reactions which may include
gastrointestinal upset, mood changes, flushing, and exacerbation of symptoms. A
rotation diet, in which the same food is not eaten more than once every four
days, may be helpful in recurrent OME.
Essential fatty acids are anti-inflammatory and support immune function.
Children should be supplemented with cod liver oil or other fish oils (½ to 1
tsp./day). Vitamin C (100 to 250 mg bid to tid) enhances immunity and decreases
inflammation. Vitamin C from rose hips or palmitate is citrus-free and
hypoallergenic. |
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink two to four cups/day. Tinctures may be used singly or in
combination as noted.
Herbal eardrops may be effective at reducing infection, pain, and fluid
accumulation. Note: Eardrops are contraindicated if perforation of the tympanic
membrane is suspected. An ear oil from mullein flower (Verbascum
densiflorum) and garlic (Allium sativum) has pain reduction and
antimicrobial effects. For otitis with pain, include one of the following oils:
St. John's wort (Hypericum perforatum), Indian tobacco (Lobelia
inflata), or monkshood (Aconitum napellus). Place 3 to 5 drops in ear
bid to qid. Note that monkshood is toxic if taken internally.
Internal treatment should include one or more of the
following:
- Coneflower (Echinacea angustifolia, purpurea, and
pallida) may be taken as tincture or glycerite, 20 drops tid to qid. For
chronic otitis, consider the following herbs that support the lymphatics and
mucous membranes. Eyebright (Euphrasia officinalis), cleavers (Galium
aparine), marigold (Calendula officinalis), and elderberry
(Sambucus nigra) may be combined in a tea (2 to 4 oz. tid), tincture (10
to 20 drops tid), or glycerite (20 drops tid).
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Aconite for otitis that comes on suddenly after exposure to
cold or wind; child has bright red ears and high fever
- Belladonna for sudden onset of otitis with great sensitivity
and pain
- Chamomilla for otitis with intense irritability, especially
with teething
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Physical Medicine |
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A hot pack applied to ear and side of neck may relieve pain. Blanch one-half
of an onion, wrap in cheesecloth, and apply hot to ear. The sulfur bonds in the
onion will be soothing. May also use a hot water bottle or a sock filled with
raw rice and heated.
Craniosacral therapy may be effective in enhancing lymph
flow. |
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Massage |
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Gentle massaging of the neck may assist lymph
flow. |
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Patient Monitoring |
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Patient should return if AOM does not improve within 48 to 72 hours. Recheck
within two to four weeks to ensure that infection has cleared and determine
extent, if any, of effusion. Children with OME should be rechecked every four to
six weeks until the fluid resolves, with special attention to detecting any
retraction pocket ("pouch") in the eardrum that could lead to accumulation of
dead skin cells (cholesteatoma). Tubes should be checked two to three weeks
after insertion and every six months thereafter. |
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Other
Considerations |
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Prevention |
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Reduction of environmental factors such as exposure to tobacco smoke and
respiratory infections. Breast-feeding reduces incidence of AOM.
Xylitol-sweetened chewing gum helps prevent ear infections by inhibiting
Streptococcus. Prophylactic antibiotics may be prescribed for children
who are particularly prone to otitis media. Adenoidectomy has a modest benefit
in reducing the frequency of recurrent ear infections in patients for whom more
conservative measures have not been successful. The S. pneumonia vaccine
is becoming increasingly important, but current versions are not particularly
effective before 2 years of age; a preparation effective in children as young as
3 months old is under investigation. The H. influenzae (HIB) vaccine does
not protect against the "nontypeable" Haemophilus species that causes ear
infections. Conservative introduction of solid foods as child is weaning may
help prevent otitis and allergic conditions. If there is a strong family history
of allergies or atopic conditions and/or if the child's immunity has been
compromised in infancy, delay the introduction of highly allergenic foods until
1 year or older. |
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Complications/Sequelae |
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- Hearing loss, usually temporary
- Failure of perforation in eardrum to close, requiring repair
- Chronic purulent otitis media from external bacteria entering via
perforation
- External eczematoid otitis, from drainage via perforation
- Facial paralysis from pressure on nerve
- Ossicular discontinuity, requiring surgical correction
- Cholesterol granuloma, requiring surgical removal
- Labyrinthitis, requiring early treatment to preserve
hearing
- Mastoiditis
- Meningitis
- Brain abscess or empyema
- Cholesteatoma, a dangerous complication that can result in bone and
tissue destruction
Serious complications have become less common with the use of antibiotics.
However, physicians must be on guard for resistant
organisms. |
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Prognosis |
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Symptoms of AOM should improve within 48 to 72 hours. It tends to resolve
quickest in older children, during the summer, in mild cases, and in children
without significant prior history of ear infections. OME that does not resolve
within a few months with conservative treatment should be treated more
aggressively. |
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References |
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Bitnun A, Allen UD. Medical therapy of otitis media: use, abuse, efficacy and
morbidity. J Otolaryngol. 1998;27(suppl 2):26-36.
Bizakis JG, Velegrakis GA, Papadakis CE, Karampekios SK, Helidonis ES. The
silent epidural abscess as a complication of acute otitis media in children.
Int J Pediatr Otorhinolaryngol. 1998;45:163-166.
Cohen R, Levy C, Boucherat M, Langue J, de la Rocque F. A multicenter,
randomized, double-blind trial of 5 versus 10 days of antibiotic therapy for
acute otitis media in young children. J Pediatr. 1998;133:634-639.
Gehanno P, Nguyen L, Barry B, et al. Eradication by ceftriaxone of
streptococcus pneumoniae isolates with increased resistance to penicillin in
cases of acute otitis media. Antimicrob Agents Chemother.
1999;43:16-20.
Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North
Atlantic Books; 1992:243-245.
Reichenberg-Ullman J, Ullman R. Healing otitis media through homeopathy.
1996. Available at www.healthy.net/library/articles/rbullman/ottis.htm.
Uhari M, Kontiokari T, Koskela M, Niemela M. Xylitol chewing gum in
prevention of acute otitis media: double-blind randomised trials. Br Med J.
1996;313:1180-1184.
Wright ED, Pearl AJ, Manoukian JJ. Laterally hypertrophic adenoids as a
contributing factor in otitis media. Int J Pediatr Otorhinolaryngol.
1998;45:207-214. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |