Yvette C. Terrie, BSPharm, RPh
Informed counseling can help
patients and caregivers identify, treat, and prevent painful ear infections.
Otitis Media:
Otitis media is an infection of the middle ear and can be further classified
into 3 forms according to symptoms and degrees of severity. These include acute
otitis media (AOM), otitis media with effusion (OME), and chronic suppurative
otitis media (CSOM).
Acute Otitis Media
AOM is defined by the American Academy of Pediatrics (AAP) and the American
Academy of Family Physicians (AAFP) as an infection of the middle ear with acute
onset, presence of middle ear effusion (MEE), and signs of middle ear
inflammation.1 AOM is considered to be the most frequent diagnosis
among patients in the pediatric population, second only to the common cold.1,2
Although AOM can affect patients of all ages, it primarily affects infants and
young children with a peak incidence age between 6 and 36 months.2
An estimated two thirds of all children in the United States experience at
least 1 episode of AOM prior to the age of 1 year, and an estimated 80% have
had at least 1 case of AOM by the age of 3 years.1,3 There is a
second peak incidence of AOM cases around the age of 5 years that is believed
to be associated with entrance into school.4
AOM is also considered to be the most prevalent reason for physician office
visits within the pediatric patient population.5 Annually, an
estimated 20 million office visits are attributed to AOM, and this does not
include visits to the emergency department.5 Statistics report that
in the United States, AOM is the most common reason for outpatient
antimicrobial treatment among the pediatric patient population. 4,6
During the mid-1990s, treatment of otitis media cost $3.8 billion annually; 20%
of the more than 110 million prescriptions for oral antibiotics were prescribed
for this condition.4,5
In 2006, statistics reveal that an estimated 9 million children, ranging in age
from 0 to 17 years, were reported to have an episode of AOM.1 Of those
children, 8 million visited a physician or obtained a prescription drug to diagnose
and treat the condition.1 Although AOM primarily affects the
pediatric population, adults make up less than 20% of patients presenting with
AOM.6 Table 1 defines the 3 types of otitis media.5,7-9
Pathophysiology
The etiology of AOM may be viral or bacterial. 9, 10 Viral
infections are often complicated by a secondary bacterial infection.10
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and
Streptococcus pyogenes are responsible for the majority of AOM cases in
patients older than 6 weeks.3 S pneumoniae is the most common
pathogen responsible for AOM and for invasive bacterial infections in children
of all age groups.3 Other bacteria recovered and responsible in
cases of AOM include Staphylococcus aureus, Streptococcus viridans, and
Pseudomonas aeruginosa.3,5,10
AOM typically manifests itself as a complication of a preceding upper
respiratory tract infection.1,2,11 The secretions and inflammation
cause a relative obstruction of the Eustachian tubes and the middle ear mucosa
absorbs air in the middle ear under normal circumstances. If the air is not
replaced because of obstruction of the Eustachian tube, a negative pressure is
generated, which results in interstitial fluid entering the Eustachian tube and
creating an effusion.1-3 This effusion of the middle ear provides an
excellent medium for microbial growth and, if growth is rapid, a middle ear
infection develops.1,2
Risk Factors for Otitis Media
Various factors may increase an individual’s risk for developing AOM and, in
general, these factors may be classified as patient related or environmental.1,4,5
Examples of proven risk factors for otitis media include:1,4,5
Patient Factors
• Premature or low birth weight
• Young age
• Early onset of ear infections
• Familial history
• Native American, Inuit, and Australian Aborigine populations appear to have a
greater incidence
• Compromised immune system
• Craniofacial abnormalities
• Neuromuscular disease
• History of allergies and/or upper respiratory tract infections
Environmental Factors
• Day care attendance
• Crowded living conditions
• Exposure to tobacco and other pollutants
• Pacifier use
• Bottlefeeding increases risk compared with breastfeeding
• Prolonged bottle use
• Fall and winter months
Signs and Symptoms
The signs and symptoms commonly associated with AOM include fever, otalgia,
headache, irritability, cough, rhinitis, listlessness, vomiting, diarrhea, and
pulling at the ears.1-3,9-11
Infants may appear cranky, have difficulty sleeping, and pull at the affected
ear(s). Compared with children, adults more often present with otalgia, ear
drainage, diminished hearing, and sore throat.10 Opacity and redness
of the tympanic membrane are equally common in children and adults.1-4,10
Treatment
The AAP and the AAFP published updated guidelines in 2004 for the management
and treatment of AOM, which addressed pain management, initial observation
versus treatment with antibiotics, and appropriate choices of antibiotics. 10,12
According to these guidelines, the “observation option” for AOM refers to
deferring antibiotic treatment for healthy children aged 6 months to 2 years
with nonsevere illness and an uncertain diagnosis, as well as for patients
older than 2 years of age for 48 to 72 hours and limiting management to
symptomatic relief.12 The decision to observe or treat is based on
the child’s age, diagnostic certainty, and illness severity.12 For
patients under observation without initial antibiotic therapy, it is imperative
that the parent/ caregiver communicate with the health care professional
regarding the patient’s condition to prevent any further complications and
report if the symptoms appear to worsen.12
The guidelines stressed the importance of an accurate diagnosis to rule out
OME, which often is present before and after AOM and is not treated with
antibiotics. 4,10,12
Antibiotics are recommended in all patients younger than 6 months of age, in
those between 6 months and 2 years, if the diagnosis is certain, and in
children with severe infection.10,12 The recommended first-line
therapy is a dosage of 80 to 90 mg per kg/day of amoxicillin. Alternatives for
those who are sensitive or allergic to penicillin and with resistant infections
include the macrolide antibiotics, clindamycin, and cephalosporins.10,12
Patients who do not respond to treatment should be reassessed.10,12
Since pain is often present especially during the first 24 hours of AOM cases,
the AAP and AAFP recommend that pain management be addressed regardless of the
use of antibiotics.12 Pain treatment options include acetaminophen,
ibuprofen, and otic drops such as antipyrine/ benzocaine otic solution.1,12
Prior to use, patients should be screened for possible allergies,
drug%u2500drug interactions, and contraindications.
Preventive Measures
When counseling the parents and caregivers of patients with AOM, pharmacists
can provide key information for reducing or preventing the incidence of AOM.
Examples of these preventive measures include:1,7
• If appropriate, vaccinate children against the flu annually.
• Vaccinate the child with the 7-valent pneumococcal conjugate (PCV7) vaccine.
Studies show that this vaccine protects against a number of the most common
bacteria that cause ear infections and is indicated for the prevention of
otitis media (ear infection) caused by 7 strains of S pneumoniae.1,7,12-14
The Centers for Disease Control and Prevention recommends that all children
under age 2 years be vaccinated, starting at 2 months.1, 7, 13
Results from various studies have shown that vaccinated children get fewer ear
infections than children who were not vaccinated. The PCV7 vaccine is strongly
recommended for children in day care.1,7
• Practice routine hand-washing techniques to prevent the transmission of germs
to keep children healthy.
• Avoid exposing children to cigarette smoke fumes. Studies have shown that
infants who are around smokers have more ear infections.
• Never put an infant down for a nap, or for the night, with a bottle. PT
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