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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODYwMjI3LXRyZWF0bWVudA==\nDrugs & Diseases > Otolaryngology and Facial Plastic Surgery\nInflammatory Diseases of the Middle Ear Treatment & Management\nAuthor: Diego A Preciado, MD, PhD, FAAP; Chief Editor: Arlen D Meyers, MD, MBA more...\nInflammatory Diseases of the Middle Ear\nSections Inflammatory Diseases of the Middle Ear\nAcute otitis media (AOM) is the most common cause of severe pain in young children. Many infections are viral in origin, especially those that accompany coryza. The most common viruses isolated include respiratory syncytial virus (RSV), influenza viruses, adenovirus, and parainfluenza. Treatment is purely symptomatic and supportive.\nThe role of antibiotics in the treatment of AOM remains ill defined because studies have shown that antibiotics do not affect the outcome. For instance, studies of children with persistent symptoms of AOM have shown that resistant bacteria account for only approximately 20% of these cases. This has given credence to the theory that the middle ear mucosa is infected with both bacteria and viruses simultaneously, and eradication of the bacteria with antibiotics may not be sufficient to stop the inflammatory cascades in the middle ear.\nTherefore, some physician groups advocate observation and withholding antibiotics in children with uncomplicated AOM and no comorbid factors. [16] The withholding of antibiotics is based on diagnostic certainty, age, severity of the illness, and means for adequate follow-up. Observation involves monitoring the child for resolution of symptoms within 48-72 hours and re-evaluating the patient at this time.\nGuidelines from the American Academy of Pediatrics and American Academy of Otolaryngology-Head and Neck Surgery have helped clarify whom to definitely treat with antibiotics. For infants younger than 6 months, prescribing antibiotics is still recommended because of the increased risk of complications in this age group, even if the diagnosis of AOM is uncertain. If the child is aged 6 months to 2 years and is severely ill (fever ≥ 39°C or moderate-to-severe otalgia) and the diagnosis of AOM is uncertain, antibiotics should be considered.\nHowever, most doctors still universally prescribe antibiotics. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis cause most episodes of acute suppurative otitis media. First-line antimicrobial drugs include beta-lactamase–resistant medications, such as amoxicillin with or without clavulanate and cefuroxime. Adjunctive treatment includes analgesics and antipyretics.\nHigh doses of amoxicillin (90 mg/kg) are recommended by the guidelines; these doses result in middle ear fluid levels that exceed the minimum inhibitory concentration of all S pneumoniae, including those that have intermediate resistance to penicillin and many that are highly resistant. The recommended length of treatment is 10 days for children younger than 6 years and for children with severe symptoms; children older than 6 years can be treated for 5-7 days.\nIf no clinical response occurs after the first 48-72 hours of therapy, the patient should be reassessed, and further therapy should be chosen based on the most likely pathogens. H influenzae should be suspected as a causative agent in a child who has been immunized with the pneumococcal vaccine and who does not respond to first-line antibiotic therapy. Tympanocentesis should be reserved for patients in whom multiple courses of antibiotics fail in order to determine bacterial etiology.\nPain control is essential to treatment, especially in the first 24 hours after diagnosis, regardless of whether the patient is receiving antibiotics. This is an important recommendation because the pediatric population is often undertreated for pain. In addition to ibuprofen and acetaminophen, topical benzocaine can also be given for pain control. The guidelines also include the use of narcotic analgesia with codeine for severe pain.\nThe aim of medical treatment in uncomplicated cases of chronic suppurative otitis media (CSOM) is to eliminate infection and to control otorrhea. Treating an ear with chronic discharge requires regular otologic surveillance with microscopic aural toilet. Such treatment is particularly important when a topical medication is used to allow it to reach the middle ear in sufficient concentration.\nTopical liquid agents used in the treatment of chronic middle ear disease include a combination of antibiotics, antifungals, antiseptics, solvents, and steroids. The most commonly used topical antibiotics for CSOM include quinolone derivatives, such as ciprofloxacin and ofloxacin (eg, Cipro HC Otic, Floxin), and aminoglycosides. Theoretically, topical aminoglycosides can gain access through a perforated tympanic membrane to the inner ear through the round window membrane and cause cochleovestibular toxicity.\nThe scientific literature contains sporadic reports of sensorineural hearing loss associated with the use of topical agents; however, clinical studies in humans fail to show significant sensorineural hearing loss attributable to their use. In severe resistant cases of CSOM that involve diffuse mucosal disease, systemic antibiotics have been used in conjunction with topical agents.\nAntibiotic prophylaxis at one half of the daily therapeutic dose for an acute attack may be used and can be given for up to 6 months. Adverse effects are low. The development of increased drug resistance in upper respiratory tract organisms remains a possibility.\nPreventive measures for otitis media are integral in reducing its incidence and complications. This can be accomplished by educating parents about reducing known risk factors for otitis media, including exposure to passive smoke, bottle propping, and pacifier use.\nBecause S pneumoniae is the most commonly reported bacterial cause of AOM, accounting for 28-55% of cases, counseling parents to the use of pneumococcal vaccines in their children can significantly reduce the incidence of AOM. Multiple studies demonstrate significant population reductions in AOM rates and antibiotic usage after universal introduction of pneumococcal vaccination.\nViral vaccines have also been associated with reducing the incidence of AOM related to viral etiologies. Encouraging children to receive the influenza vaccine can protect against episodes of otitis media during influenza outbreaks. Their exact role in reducing rates of AOM, however, remains to be epidemiologically demonstrated.\nUpdated guidelines for the evaluation and management of otitis media with effusion were released in 2016 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation and include the following [17, 18] :\nA recommendation that children at high risk for developing otitis media with effusion—ie, those with an increased likelihood due to developmental issues or a syndrome or condition—be screened for it when the risk factor is diagnosed and again between age 12 and 18 months\nA strengthened recommendation that medical therapy for otitis media with effusion—including systemic antibiotics, systemic steroids, intranasal steroids, antihistamines, and decongestants—be employed only in exceptional circumstances\nA recommendation against using adenoidectomy to treat otitis media with effusion in children under age 4 years unless an indication for adenoid removal, such as nasal obstruction or chronic adenoiditis, is present\nWhen correctly indicated, the surgical procedure on a diseased middle ear and mastoid must be performed meticulously and precisely; such a procedure is often demanding. The aim of surgery is to achieve a dry, pain-free ear, with possible improvement in hearing, freedom from vertigo, and reversal of a facial palsy.\nMyringotomy is a technique in which an incision is made in the tympanic membrane to adequately drain the middle ear.\nMyringotomy is reserved for acute otitis media (AOM) associated with severe otalgia or high fever in patients who have had a poor response to antibiotics. Myringotomy is also indicated when a suppurative complication is present, in children who are acutely ill, in cases of AOM that occur during antibiotic treatment, in newborns, and in patients with primary or secondary immunodeficiency in whom an unusual organism may be present. When a myringotomy is performed, the effusion may be cultured, although it is not mandatory.\nMyringotomy is performed with a myringotomy knife. The incision is made in the anterior-inferior quadrant of the tympanic membrane in a radial fashion. The incision may be placed in the posteroinferior quadrant but never in the posterosuperior quadrant because the incudostapedial joint could be damaged. Unlike in secretory otitis media (SOM), local anesthesia is inadequate for AOM.\nIn a retrospective study of 248 pediatric patients who received tympanostomy tubes and postoperative otic drop therapy, Conrad et al found the highest rate of tube occlusion in patients with middle ear fluid and in those with longer time to postsurgical follow-up. The investigators determined that at first follow-up, one or both tubes were occluded in 10.6% of patients. The likelihood of having unobstructed tubes was three times higher in children with no serous fluid than in children with fluid. It was also found that the chance of occlusion increased in relation to the amount of time that existed between surgery and follow-up. [19, 20]\nRecurrent AOM in children may be due to chronic sinus infections, nasopharyngeal obstruction (enlarged and chronically infected adenoids), or cleft palate. Surgically treating these conditions (eg, with adenoidectomy) may decrease the number of ear infections.\nTranstympanic ventilation tubes may be used to prevent recurrent AOM, even in the absence of a middle ear effusion, although the reason for this remains unclear.\nThe removal of discharge from an ear with active CSOM is essential for successful treatment. Regular surveillance and microscopic aural toilet with suction are performed until resolution of discharge. Aural toilet is particularly important when a topical medication is used to allow sufficient application.\nIf a patient's fitness for general anesthesia permits, cholesteatoma should be surgically treated, regardless of its association with CSOM.\nCunningham M, Guardiani E, Kim HJ, Brook I. Otitis media. Future Microbiol. 2012 Jun. 7(6):733-53. [Medline].\nStol K, Diavatopoulos DA, Graamans K, Engel JA, Melchers WJ, Savelkoul HF, et al. Inflammation in the Middle Ear of Children with Recurrent or Chronic Otitis Media is Associated with Bacterial Load. Pediatr Infect Dis J. 2012 Jun 4. [Medline].\nMarom T, Nokso-Koivisto J, Chonmaitree T. Viral-Bacterial Interactions in Acute Otitis Media. Curr Allergy Asthma Rep. 2012 Sep 12. [Medline].\nDanishyar A, Ashurst JV. Otitis, Media, Acute. 2018 Jan. [Medline]. [Full Text].\nSeo Y, Nonaka M, Yamamura Y, Pawankar R, Tagaya E. Optimal control of asthma improved eosinophilic otitis media. Asia Pac Allergy. 2018 Jan. 8 (1):e5. [Medline]. [Full Text].\nIino Y, Nagamine H, Kakizaki K, et al. Effectiveness of instillation of triamcinolone acetonide into the middle ear for eosinophilic otitis media associated with bronchial asthma. Ann Allergy Asthma Immunol. 2006 Dec. 97(6):761-6. [Medline].\nHurst DS. The role of allergy in otitis media with effusion. Otolaryngol Clin North Am. 2011 Jun. 44(3):637-54, viii-ix. [Medline].\nCoughlin L. AHRQ data on antibiotic use in children with otitis media. American Family Physician. June 2005.\nTong S, Amand C, Kieffer A, Kyaw MH. Trends in healthcare utilization and costs associated with acute otitis media in the United States during 2008-2014. BMC Health Serv Res. 2018 May 2. 18 (1):318. [Medline]. [Full Text].\nKing LM, Bartoces M, Hersh AL, Hicks LA, Fleming-Dutra KE. National Incidence of Pediatric Mastoiditis in the United States, 2000-2012: Creating a Baseline for Public Health Surveillance. Pediatr Infect Dis J. 2018 Mar 27. [Medline].\nVayisoglu Y, Gorur K, Ozcan C, Korlu S. Unusual complication of otitis media with effusion: facial nerve paralysis. J Craniofac Surg. 2011 Jul. 22(4):1525-7. [Medline].\nBrowning GC. Medical management of chronic mucosal otitis media. Clin Otolaryngol Allied Sci. 1984 Jun. 9(3):141-4. [Medline].\nDubey SP, Larawin V, Molumi CP. Intracranial spread of chronic middle ear suppuration. Am J Otolaryngol. 2009 Mar 31. [Medline].\nMcCormick DP, Jennings K, Ede LC, Alvarez-Fernandez P, Patel J, Chonmaitree T. Use of symptoms and risk factors to predict acute otitis media in infants. Int J Pediatr Otorhinolaryngol. 2016 Feb. 81:55-9. [Medline].\nMiura T, Matsubara A, Kudo N, Hara R, Takahata J, Sasaki A. The expression of thymic stromal lymphopoietin in patients and animal models with eosinophilic otitis media. Acta Otolaryngol. 2018 May. 138 (5):447-51. [Medline].\nSakulchit T, Goldman RD. Antibiotic therapy for children with acute otitis media. Can Fam Physician. 2017 Sep. 63 (9):685-687. [Medline]. [Full Text].\nRosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngol Head Neck Surg. 2016 Feb. 154 (1 Suppl):S1-S41. [Medline]. [Full Text].\nFrellick M. Otitis Media: New Guideline Includes Screening At-Risk Kids. Medscape Medical News. 2016 Feb 4. [Full Text].\nBarclay L. Postop Tympanostomy Tube Obstruction Common. Medscape Medical News. Jul 2014. [Full Text].\nConrad DE, Levi JR, Theroux ZA, et al. Risk factors associated with postoperative tympanostomy tube obstruction. JAMA Otolaryngol Head Neck Surg. 2014 Aug 1. 140(8):727-30. [Medline].\nBalbani AP, Montovani JC. [Impact of otitis media on language acquisition in children]. J Pediatr (Rio J). 2003 Sep-Oct. 79(5):391-6. [Medline].\nMiddle ear anatomy.\nDiego A Preciado, MD, PhD, FAAP Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, George Washington University School of Medicine, Children's National Medical Center\nDiego A Preciado, MD, PhD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, Association for Research in Otolaryngology, American Society of Pediatric Otolaryngology, American Academy of Otolaryngology-Head and Neck Surgery\nGerard J Gianoli, MD Clinical Associate Professor, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Tulane University School of Medicine; President, The Ear and Balance Institute; Board of Directors, Ponchartrain Surgery Center\nGerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society\nArlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine\nArlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society\nDisclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .\nJohn C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center\nJohn C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, North American Skull Base Society\nThe authors and editors of Medscape Drugs & Diseases gratefully acknowledge previous authors Nasir Aziz, MD, MA, Resident Physician, Riverside Regional Medical Center, and Sanjeev Silva, MBBS, MRCS, DLO, Senior House Officer, Department of Otorhinolaryngology, Head and Neck, Facial Plastics, Great Ormond Street Hospital for Sick Children, UK, for their contributions to this article.\nencoded search term (Inflammatory Diseases of the Middle Ear) and Inflammatory Diseases of the Middle Ear\nOtitis Media With Effusion\nAcute Otitis Media\nComplications of Otitis Media\nChronic Suppurative Otitis Media\nEmergent Management of Acute Otitis Media\nAcute Otitis Media Empiric Therapy\nPneumococcal Conjugate Vaccine in Infancy Cuts Otitis Media\nA 14-Year-Old Boy With Painful Periorbital Edema\nOtitis Media Episodes Down After Introduction of PCV13\n15 Back-to-School Illnesses You Should Know\nAccording to Family Medicine Physicians\nNo, Patients Are NOT Consumers, and MDs Are NOT Providers\nFDA Finds High Systemic Absorption of Sunscreen Ingredients\nHigh Juice Consumption May Up Mortality Risk\nPhysician Salaries Up in 2019, Report Shows Who Earns the Most\n'Scary World' of Generic Drug Manufacturing, Revealed\nDiseases & Conditions Otitis Media\nNews Pneumococcal Conjugate Vaccine in Infancy Cuts Otitis Media\nProcedures Complications of Otitis Media\nProcedures Otitis Media With Effusion"