Otitis media typically presents as either acute otitis media (AOM), with symptoms including fever, otalgia, otorrhoea or irritability and short duration; or as otitis media with effusion (OME), which is often asymptomatic and characterised by accumulation of fluid in the middle ear.
Diagnostic certainty of otitis media is challenging, given the young age of patients and variability of symptoms.
Otitis media predominantly occurs as coincident to viral upper respiratory tract infections and/or bacterial infections.
Common viruses that cause upper respiratory tract infection are frequently associated with AOM and new-onset OME. These include respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza and coronavirus.
Predominant bacteria that cause otitis media are Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae.
Antibiotic therapy does not significantly benefit most patients with AOM, but long-term prophylactic antibiotic therapy can reduce the risk of otitis media recurrence among children at high risk.
In Australia, 84% of AOM is treated with antibiotic therapy, which contributes to development of antibiotic resistance.
Vaccine development is a key future direction for reducing the world burden of otitis media, but requires polymicrobial formulation and ongoing monitoring and modification to ensure sustained reduction in disease burden.
- 1. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004; 113: 1451-1465.
- 2. Rosenfeld RM, Culpepper L, Doyle KJ, et al. Clinical practice guideline: otitis media with effusion. Otolaryngol Head Neck Surg 2004; 130 (5 Suppl): S95-S118.
- 3. Legros JM, Hitoto H, Garnier F, et al. Clinical qualitative evaluation of the diagnosis of acute otitis media in general practice. Int J Pediatr Otorhinolaryngol 2008; 72: 23-30.
- 4. Pichichero ME. Preferred antibiotics for treatment of acute otitis media: comparison of practicing pediatricians, general practitioners, and otolaryngologists. Clin Pediatr (Phila) 2005; 44: 575-578.
- 5. Chonmaitree T, Revai K, Grady JJ, et al. Viral upper respiratory tract infection and otitis media complication in young children. Clin Infect Dis 2008; 46: 815-823.
- 6. Mandel EM, Doyle WJ, Winther B, Alper CM. The incidence, prevalence and burden of OM in unselected children aged 1-8 years followed by weekly otoscopy through the “common cold” season. Int J Pediatr Otorhinolaryngol 2008; 72: 491-499.
- 7. Alho OP, Oja H, Koivu M, Sorri M. Chronic otitis media with effusion in infancy. How frequent is it? How does it develop? Arch Otolaryngol Head Neck Surg 1995; 121: 432-436.
- 8. Winther B, Alper CM, Mandel EM, et al. Temporal relationships between colds, upper respiratory viruses detected by polymerase chain reaction, and otitis media in young children followed through a typical cold season. Pediatrics 2007; 119: 1069-1075.
- 9. Ruuskanen O, Arola M, Putto-Laurila A, et al. Acute otitis media and respiratory virus infections. Pediatr Infect Dis J 1989; 8: 94-99.
- 10. Winther B, Doyle WJ, Alper CM. A high prevalence of new onset otitis media during parent diagnosed common colds. Int J Pediatr Otorhinolaryngol 2006; 70: 1725-1730.
- 11. Heikkinen T, Ruuskanen O. Temporal development of acute otitis media during upper respiratory tract infection. Pediatr Infect Dis J 1994; 13: 659-661.
- 12. Mackenzie GA, Carapetis JR, Leach AJ, Morris PS. Pneumococcal vaccination and otitis media in Australian Aboriginal infants: comparison of two birth cohorts before and after introduction of vaccination. BMC Pediatr 2009; 9: 14.
- 13. Pirozzo S, Del Mar C. Acute otitis media. West J Med 2001; 175: 402-407.
- 14. Teele D, Klein J, Rosner B, et al. Epidemiology of otitis media during the first seven years of life in children in Boston: a prospective, cohort study. J Infect Dis 1989; 160: 83-94.
- 15. Palmu A, Herva E, Savolainen H, et al. Association of clinical signs and symptoms with bacterial findings in acute otitis media. Clin Infect Dis 2004; 38: 234-242.
- 16. Froom J, Culpepper L, Grob P, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ 1990; 300: 582-586.
- 17. Cripps AW, Otczyk DC. Prospects for a vaccine against otitis media. Expert Rev Vaccines 2006; 5: 517-534.
- 18. Lehmann D, Arumugaswamy A, Elsbury D, et al. The Kalgoorlie Otitis Media Research Project: rationale, methods, population characteristics and ethical considerations. Paediatr Perinat Epidemiol 2008; 22: 60-71.
- 19. Bernstein JM. Immunologic aspects of otitis media. Curr Allergy Asthma Rep 2002; 2: 309-315.
- 20. Stenstrom C, Bylander-Groth A, Ingvarsson L. Eustachian tube function in otitis-prone and healthy children. Int J Pediatr Otorhinolaryngol 1991; 21: 127-138.
- 21. Tonnaer EL, Mylanus EA, Mulder JJ, Curfs JH. Detection of bacteria in healthy middle ears during cochlear implantation. Arch Otolaryngol Head Neck Surg 2009; 135: 232-237.
- 22. Falk B. Negative middle ear pressure induced by sniffing. A tympanometric study in persons with healthy ears. J Otolaryngol 1981; 10: 299-305.
- 23. Heikkinen T, Chonmaitree T. Importance of respiratory viruses in acute otitis media. Clin Microbiol Rev 2003; 16: 230-241.
- 24. Yano H, Okitsu N, Hori T, et al. Detection of respiratory viruses in nasopharyngeal secretions and middle ear fluid from children with acute otitis media. Acta Otolaryngol 2009; 129: 19-24.
- 25. Alper CM, Winther B, Mandel EM, et al. Rate of concurrent otitis media in upper respiratory tract infections with specific viruses. Arch Otolaryngol Head Neck Surg 2009; 135: 17-21.
- 26. Williams J, Tollefson S, Nair S, Chonmaitree T. Association of human metapneumovirus with acute otitis media. Int J Pediatr Otorhinolaryngol 2006; 70: 1189-1193.
- 27. Fouchier R, Rimmelzwaan G, Kuiken T, Osterhaus A. Newer respiratory virus infections: human metapneumovirus, avian influenza virus and human corona viruses. Curr Opin Infect Dis 2005; 18: 141-146.
- 28. Kesebir D, Vazquez M, Weibel C, et al. Human bocavirus infection in young children in the United States: molecular epidemiological profile and clinical characteristics of a newly emerging respiratory virus. J Infect Dis 2006; 194: 1276-1282.
- 29. Segal N, Leibovitz E, Dagan R, Lieberman A. Acute otitis media — diagnosis and treatment in the era of antibiotic resistant organisms: updated clinical practice guidelines. Int J Pediatr Otorhinolaryngol 2005; 69: 1311-1319.
- 30. Chi DH, Hendley JO, French P, et al. Nasopharyngeal reservoir of bacterial otitis media and sinusitis pathogens in adults during wellness and viral respiratory illness. Am J Rhinol 2003; 17: 209-214.
- 31. Vergison A. Microbiology of otitis media: a moving target. Vaccine 2008; 26 Suppl 7: G5-G10.
- 32. Stenfors LE, Räisänen S. Abundant attachment of bacteria to nasopharyngeal epithelium in otitis-prone children. J Infect Dis 1992; 165: 1148-1150.
- 33. Smith-Vaughan H, Byun R, Nadkarni M, et al. Measuring nasal bacterial load and its association with otitis media. BMC Ear Nose Throat Disord 2006; 6: 10.
- 34. Faden H. Comparison of the local immune response to nontypable Haemophilus influenzae (nHI) and Moraxella catarrhalis (MC) during otitis media. Adv Exp Med Biol 1995; 371B: 733-736.
- 35. Leach AJ, Boswell JB, Asche V, et al. Bacterial colonisation of the nasopharynx predicts very early onset and persistence of otitis media in Australian Aboriginal infants. Pediatr Infect Dis J 1994; 13: 983-989.
- 36. Smith-Vaughan H, Byun R, Halpin S, et al. Interventions for prevention of otitis media may be most effective if implemented in the first weeks of life. Int J Pediatr Otorhinolaryngol 2008; 72: 57-61.
- 37. Kilpi T, Herva E, Kaijalainen T, et al. Bacteriology of acute otitis media in a cohort of Finnish children followed for the first two years of life. Pediatr Infect Dis J 2001; 20: 654-662.
- 38. Couzos S, Murray R. Aboriginal primary health care. An evidence-based approach. Oxford: Oxford University Press, 1999.
- 39. Jeffries-Stokes C, Lehmann D, Johnston J, et al. Aboriginal perspective on middle ear disease in the arid zone of Western Australia. J Paediatr Child Health 2004; 40: 258-264.
- 40. Leach AJ, Boswell JB, Asche V, et al. Bacterial colonisation of the nasopharynx predicts very early onset and persistence of otitis media in Australian Aboriginal infants. Pediatr Infect Dis J 1994; 13: 983-989.
- 41. Gibney KB, Morris PS, Carapetis JR, et al. The clinical course of acute otitis media in high-risk Australian Aboriginal children: a longitudinal study. BMC Pediatr 2005; 5: 16.
- 42. Arrieta A, Singh J. Management of recurrent and persistent acute otitis media: new options with familiar antibiotics. Pediatr Infect Dis J 2004; 23 (2 Suppl): S115-S124.
- 43. Leibovitz E, Greenberg D, Piglansky L, et al. Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to the original pathogen. Pediatr Infect Dis J 2003; 22: 209-216.
- 44. Libson S, Dagan R, Greenberg D, et al. Nasopharyngeal carriage of Streptococcus pneumoniae at the completion of successful antibiotic treatment of acute otitis media predisposes to early clinical recurrence. J Infect Dis 2005; 191: 1869-1875.
- 45. Leibovitz E. The challenge of recalcitrant acute otitis media: pathogens, resistance, and treatment strategy. Pediatr Infect Dis J 2007; 26 (10 Suppl): S8-S11.
- 46. Watson K, Carville K, Bowman J, et al. Upper respiratory tract bacterial carriage in Aboriginal and non-Aboriginal children in a semi-arid area of Western Australia. Pediatr Infect Dis J 2006; 25: 782-790.
- 47. Lehmann D, Weeks S, Jacoby P, et al. Absent otoacoustic emissions predict otitis media in young Aboriginal children: a birth cohort study in Aboriginal and non-Aboriginal children in an arid zone of Western Australia. BMC Pediatr 2008; 8: 32.
- 48. Hausdorff W, Yothers G, Dagan R, et al. Multinational study of pneumococcal serotypes causing acute otitis media in children. Pediatr Infect Dis J 2002; 21: 1008-1016.
- 49. Prymula R, Peeters P, Chrobok V, et al. 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 2006; 367: 740-748.
- 50. Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J 2004; 23: 829-833.
- 51. Macassey E, Dawes P. Biofilms and their role in otorhinolaryngological disease. J Laryngol Otol 2008; 122: 1273-1278.
- 52. Hall-Stoodley L, Hu FZ, Gieseke A, et al. Direct detection of bacterial biofilms on the middle-ear mucosa of children with chronic otitis media. JAMA 2006; 296: 202-211.
- 53. Moriyama S, Hotomi M, Shimada J, et al. Formation of biofilm by Haemophilus influenzae isolated from pediatric intractable otitis media. Auris Nasus Larynx 2009; 36: 525-531.
- 54. Tonnaer EL, Mylanus EA, Mulder JJ, et al. Detection of bacteria in healthy middle ears during cochlear implantation. Arch Otolaryngol Head Neck Surg 2009; 135: 232-237.
- 55. Roland PS. Chronic suppurative otitis media: a clinical overview. Ear Nose Throat J 2002; 81: 8-10.
- 56. Hall-Stoodley L, Nistico L, Sambanthamoorthy K, et al. Characterization of biofilm matrix, degradation by DNase treatment and evidence of capsule downregulation in Streptococcus pneumoniae clinical isolates. BMC Microbiol 2008; 8: 173.
- 57. Tote K, Berghe DV, Deschacht M, et al. Inhibitory efficacy of various antibiotics on matrix and viable mass of Staphylococcus aureus and Pseudomonas aeruginosa biofilms. Int J Antimicrob Agents 2009; 33: 525-531.
- 58. Coates H, Thornton R, Langlands J, et al. The role of chronic infection in children with otitis media with effusion: evidence for intracellular persistence of bacteria. Otolaryngol Head Neck Surg 2008; 138: 778-781.
- 59. Clancy RL, Cripps AW, Yeung S, et al. Salivary and serum antibody responses to Haemophilus influenzae infection in Papua New Guinea. P N G Med J 1987; 30: 271-276.
- 60. Noah TL, Becker S. Chemokines in nasal secretions of normal adults experimentally infected with respiratory syncytial virus. Clin Immunol 2000; 97: 43-49.
- 61. Kurono Y, Shimamura K, Shigemi H, Mogi G. Inhibition of bacterial adherence by nasopharyngeal secretions. Ann Otol Rhinol Laryngol 1991; 100: 455-458.
- 62. Whelan MA, Hwan WH, Beausoleil J, et al. Infants presenting with recurrent infections and low immunoglobulins: characteristics and analysis of normalization. J Clin Immunol 2006; 26: 7-11.
- 63. Aghamohammadi A, Cheraghi T, Gharagoziou M, et al. IgA deficiency: correlation between clinical and immunological phenotypes. J Clin Immunol 2009; 29: 130-136.
- 64. Yamanaka N, Hotomi M, Shimada J, Togawa A. Immunological deficiency in “otitis-prone” children. Ann N Y Acad Sci 1997; 830: 70-81.
- 65. Hotomi M, Yamanaka N, Saito T, et al. Antibody responses to the outer membrane protein P6 of non-typeable Haemophilus influenzae and pneumococcal capsular polysaccharides in otitis prone children. Acta Otolaryngol 1999; 119: 703-707.
- 66. Wiertsema SP, Sanders EA, Veenhoven RH, et al. Antibody levels after regular childhood vaccinations in the immunological screening of children with recurrent otitis media. J Clin Immunol 2004; 24: 354-360.
- 67. Smirnova M, Birchall J, Pearson J. The immunoregulatory and allergy-associated cytokines in the aetiology of the otitis media with effusion. Mediators Inflamm 2004; 13: 75-88.
- 68. Alper C, Winther B, Owen Hendley J, Doyle W. Cytokine polymorphisms predict the frequency of otitis media as a complication of rhinovirus and RSV infections in children. Eur Arch Otorhinolaryngol 2009; 266: 199-205.
- 69. Patel J, Nair S, Grady J, Revai K, et al. Systemic cytokine response profiles associated with respiratory virus-induced acute otitis media. Pediatr Infect Dis J 2009; 28: 407-411.
- 70. Emonts M, Veenhoven RH, Wiertsema SP, et al. Genetic polymorphisms in immunoresponse genes TNFA, IL6, IL10, and TLR4 are associated with recurrent acute otitis media. Pediatrics 2007; 120: 814-823.
- 71. Gunasekera H, Knox S, Morris P, et al. The spectrum and management of otitis media in Australian indigenous and nonindigenous children: a national study. Pediatr Infect Dis J 2007; 26: 689-692.
- 72. Glasziou PP, Del Mar CB, Sanders SL, Hayem M. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2004; (2): CD000219.
- 73. Williamson I. The rocky road to rational prescribing. Vaccine 2008; 26 Suppl 7: G11-G15.
- 74. Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006; 368: 1429-1435.
- 75. van Buchem FL, Peeters MF, van ’t Hof MA. Acute otitis media: a new treatment strategy. BMJ 1985; 290: 1033-1037.
- 76. Pan Y, Henderson J, Britt H. Antibiotic prescribing in Australian general practice: how has it changed from 1990–91 to 2002–03? Respir Med 2006; 100: 2004-2011.
- 77. Koopman L, Hoes AW, Glasziou PP, et al. Antibiotic therapy to prevent the development of asymptomatic middle ear effusion in children with acute otitis media: a meta-analysis of individual patient data. Arch Otolaryngol Head Neck Surg 2008; 134: 128-132.
- 78. Leach AJ, Morris PS, Mathews JD; Chronic Otitis Media Intervention Trial — One (COMIT1) group. Compared to placebo, long-term antibiotics resolve otitis media with effusion (OME) and prevent acute otitis media with perforation (AOMwiP) in a high-risk population: a randomized controlled trial. BMC Pediatr 2008; 8: 23.
- 79. Goossens H. European status of resistance in nosocomial infections. Chemotherapy 2005; 51: 177-181.
- 80. Beekmann SE, Heilmann KP, Richter SS, et al. Antimicrobial resistance in Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and group A beta-haemolytic streptococci in 2002-2003. Results of the multinational GRASP Surveillance Program. Int J Antimicrob Agents 2005; 25: 148-156.
- 81. Dagan R, Klugman KP. Impact of conjugate pneumococcal vaccines on antibiotic resistance. Lancet Infect Dis 2008; 8: 785-795.
- 82. Fedson DS, Musher DM, Eskola J. Pneumococcal vaccine. Vaccine 1999; 22: 553-607.
- 83. Veenhoven R, Bogaert D, Uiterwaal C, et al. Effect of conjugate pneumococcal vaccine followed by polysaccharide pneumococcal vaccine on recurrent acute otitis media: a randomised study. Lancet 2003; 361: 2189-2195.
- 84. Van Kempen M, Vermeiren J, Vaneechoutte M, et al. Pneumococcal conjugate vaccination in children with recurrent acute otitis media: a therapeutic alternative? Int J Pediatr Otorhinolaryngol 2006; 70: 275-285.
- 85. Jansen A, Hak E, Veenhoven R, et al. Pneumococcal conjugate vaccines for preventing otitis media. Cochrane Database Syst Rev 2009; (2): CD001480.
- 86. Hicks LA, Harrison LH, Flannery B, et al. Incidence of pneumococcal disease due to non-pneumococcal conjugate vaccine (PCV7) serotypes in the United States during the era of widespread PCV7 vaccination, 1998-2004. J Infect Dis 2007; 196: 1346-1354.
- 87. Nigrovic LE, Kuppermann N, Malley R; Bacterial Meningitis Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Children with bacterial meningitis presenting to the emergency department during the pneumococcal conjugate vaccine era. Acad Emerg Med 2008; 15: 522-528.
- 88. Cripps AW, Kyd JM. Bacterial otitis media: current vaccine development strategies. Immunol Cell Biol 2003; 81: 46-51.
- 89. Casey J, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J 2004; 23: 824-828.
- 90. Cohen R. The need for prudent use of antibiotics and routine use of vaccines. Clin Microbiol Infect 2009; 15: 21-23.
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