Few things evoke as much empathy as a mother approaching at closing time with a crying child holding his or her ear. I stayed past closing time on Christmas Eve for a family who was visiting from out of town and presented with a 4-year-old boy who was obviously suffering with ear pain. I assessed the condition and prescribed treatment in less than 20 minutes. I soon forgot all about the visit, because it was not out of the ordinary. But I was reminded of my actions a few weeks later, when a thank-you card arrived.

Pathophysiology and Causative Organisms

Acute otitis media (AOM) occurs in all age groups, but it is far more common in children. The typical case follows an upper respiratory infection (URI). Nasal mucosal inflammation and secretions prevent the eustachian tube from functioning properly. This can result in negative pressure in the middle ear space and, subsequently, middle ear effusion. In combination, the fluid and the environment within the middle ear create the perfect habitat for bacterial growth. Pneumococcus species, Haemophilus influenzae and Moraxella species are the most common culprits.

Diagnosis

According to the American Academy of Pediatrics and the American Academy of Family Physicians, three things are required to reach a diagnosis of AOM:

> acute, sudden onset of signs and symptoms: ear pain, fever, URI symptoms and decreased hearing

> middle ear effusion demonstrated by bulging of the tympanic membrane (TM), decreased TM mobility, air fluid level or otorrhea

> signs and symptoms of middle ear inflammation: erythema of the TM or ear pain.

On physical exam with otoscopic view, a bulging TM is typically present with AOM. It is the most specific indicator of middle ear effusion. This presentation, combined with decreased mobility and erythema of the TM, also aids in the diagnosis.

To Treat or Not to Treat

In general, infants 6 months and younger should always receive antibiotics. Of course, these medications should only be prescribed after thorough evaluation and based on a reasonable certainty of diagnosis. In children older than 2 years, an observation period of 48 to 72 hours, prior to starting antibiotics, is an option when follow-up can be facilitated and antibiotics can be started if symptoms fail to improve or worsen. The joint AAP-AAFP Subcommittee on the Management of Acute Otitis Media published the recommendations in the table and those described in the following sections.

Pain Management

Pain management is paramount for the first 24 to 48 hours. Oral OTC analgesics at the recommended dose are appropriate. In addition, analgesic otic drops may be used if the TM is intact.

Antibiotic Choice

The gold standard for treatment of AOM is high-dose amoxicillin. In children, the dose is 80 mg/kg/day to 90 m/kg/day. In severe illness or if additional coverage for beta-lactamase is required, amoxicillin-clavulanate (Augmentin) is the drug of choice.

For the patient who is penicillin sensitive, the cephalosporins are appropriate as long as the patient does not have a type I allergy (urticaria or anaphylaxis). For patients with a history of prior type I reactions to penicillin, azithromycin or clarithromycin should be used.

Follow-Up Care

In general, if the patient is not improving within 48 to 72 hours, reevaluation is necessary at the primary provider's office or in the retail clinic (if policy and patient choice permits). Encourage patients to follow up within 3 to 4 weeks to make sure the effusion has resolved and hearing has returned to normal.

One Final Note

A final thought: Beware of the recurrently draining ear. Such patients should be symptomatically treated and referred to their primary care provider or to an ENT specialist for evaluation.

Debra Schuerman is a family nurse practitioner who is the education coordinator for Take Care Health Systems in the St. Louis, Peoria, Ill., and Louisville, Ky., markets.