Clinical Guide

Otitis Media, Otitis Externa and Otitis with Tympanostomies in Children

1. Introduction

Ear infections are one of the most common conditions in pediatric practice. This guideline provides updated, evidence-based recommendations for the diagnosis, management and prevention of acute otitis media (AOM), acute otitis externa (AEO) and otitis associated with tympanostomy tubes in the pediatric population, promoting the judicious use of antibiotics and effective pain management.

More details about the Introduction

Otitis media, in particular, is the second most common diagnosis after upper respiratory tract infections and the main cause of antibiotic prescription in children. Almost 25% of children experience otitis media in their first year of life, and at least 60% suffer from it before the age of five. Improper treatment can lead to serious complications such as mastoiditis and hearing loss.

Otitis Externa, known as "swimmer's ear," affects approximately 2.4 million people annually in the United States, with a peak incidence in children ages 7 to 12 and during the summer months. Tympanostomy tube insertion is the most common outpatient surgery in children under 15 years of age in the US, used for the management of recurrent or persistent otitis.

Antimicrobial resistance is a growing concern, and pediatricians play a critical role in mitigating it through accurate diagnosis and appropriate use of antibiotics.

2. Acute Otitis Media (AOM)

Main Points

Etiology and Common Pathogens

AOM is caused by bacteria and viruses, and coinfection is common (approximately 66% of cases).

Bacterial Pathogens:

  • Streptococcus pneumoniae
  • Haemophilus influenzae not typifiable
  • Moraxella catarrhalis

Viral Pathogens:

  • Respiratory syncytial virus (RSV)
  • Coronavirus
  • Human metapneumovirus
  • Rhinovirus, Adenovirus, Influenza virus

It has been observed that pneumococcal organisms have evolved towards serotypes not covered by vaccines, which implies non-absolute protection despite vaccination.

Diagnosis

It requires acute onset of symptoms and otoscopic examination with signs of inflammation and effusion in the middle ear. The pneumatic otoscopy It is the tool of choice to confirm the immobility of the tympanic membrane (TM).

Diagnostic Criteria (AAP 2013/2014):

  • Moderate to severe bulging of the TM or otorrhea not attributable to otitis externa.
  • Mild bulging of the TM with recent ear pain (<48h) or intense erythema of the TM.
  • DO NOT diagnose AOM without middle ear effusion. A reddened TM without other signs is NOT AOM.
Management

Pain Management:

Priority, with or without antibiotics. First line options: Ibuprofen and Paracetamol. Never give aspirin to children (risk of Reye syndrome).

For severe pain, topical anesthetics (lidocaine 2%) may offer relief in intact TM. Decongestants, antihistamines and corticosteroids are NOT effective.

Antibiotic Treatment (Criteria and Options):

Most cases of AOM resolve spontaneously. The use of antibiotics must be judicious to reduce resistance.

Criteria for starting antibiotic treatment in AOM:

Observational Management ("Watchful Waiting"):

Valid option for non-severe AOM, with decision shared with parents. Close monitoring (48-72h). "Deferred" prescription may be offered.

Exclusion: Children with tympanostomy tubes or cochlear implants.

Complications
  • Suppurative complications: Mastoiditis (rare, severe), TM perforation with otorrhea.
  • Intracranial complications (rare but serious): Meningitis, brain abscesses, lateral sinus thrombosis, otic hydrocephalus. (High mortality, antibiotics can mask symptoms).
  • Hearing loss: Short and long term, impact on language and performance.
  • Facial paralysis: Uncommon (0.005%), conservative treatment with antibiotics and corticosteroids.
  • Cholesteatoma: Rare, associated with chronic AOM, destruction of middle ear bones. Surgical treatment.
Prevention
  • Vaccination: Antipneumococcal conjugate and influenza.
  • Breastfeeding: Exclusive for the first 6 months.
  • Avoid exposure to cigarette smoke.
  • Other measures: Avoid bottles in a supine position, good hand hygiene, avoid contact with sick people, control allergies.
3. Acute Otitis Externa (AEO)

Main Points

Etiology and Common Pathogens

Predominantly bacterial, also fungal.

Most common Bacterial Pathogens:

  • Pseudomonas aeruginosa
  • Staphylococcus aureus

Fungal Pathogens (less common):

  • species of Candida
  • species of Aspergillus

Contributing Factors:

  • Water retention in the CAE (swimming).
  • Aggressive ear cleaning (swabs).
  • EAC injury, dry skin, excess earwax.
  • Dermatological conditions (eczema).
  • Alteration of the protective acidic pH of earwax.
Diagnosis

Based on clinical presentation and physical examination (rapid onset <3 weeks).

Typical Symptoms and Signs:

  • Severe otalgia, exacerbated by manipulating the tragus/auricle.
  • Pruritus (more common in fungal infections).
  • Sensation of fullness/blockage, edema and diffuse erythema of the EAC.
  • Otorrhea (serous or purulent).
  • Pain when chewing, conductive hearing loss.

Distinctive sign: Tenderness on palpation of the tragus and pulling on the pinna.

It is crucial to visualize the TM to rule out perforation or tympanostomy tubes (affects choice of drops). In case of otorrhea, take swabs for culture and sensitivity.

Management

Pain Management:

Paracetamol and/or Ibuprofen as first line.

Dry Aural Cleaning:

If otorrhea is present, dry the ear with rolled tissue swabs every 6 hours. Ear washing STRICTLY CONTRAINDICATED.

Topical Optic Drops (First Line):

  • Without MT drilling: Combinations of antibiotics and corticosteroids (e.g. Dexamethasone + Framycetin + Gramicidin - SOFRADEX®). Duration: 7-10 days.
  • With TM perforation or tympanostomy tubes: Non-ototoxic preparations (e.g. Ciprofloxacin 0.3% - CILOXAN®). The addition of steroids improves effectiveness.
  • Suspected fungal infection: Drops with antifungals (e.g. Triamcinolone + Nystatin - KENACOMB/OTOCOMB® or Clotrimazole 1% cream).

Wick Insertion:

In cases of significant edema of the EAC to facilitate the administration of drops.

Systemic Antibiotics:

NOT recommended as initial therapy for uncomplicated OAS. Only if there is extension of infection (cellulitis, fever, lymphadenopathy), or host factors (immunocompromise, diabetes).

Precautions with Water:

Avoid water for 10-14 days (water sports, bathing precautions). Do not use headphones.

Complications
  • Temporary hearing loss: Due to inflammation and edema of the EAC.
  • Chronic infection (chronic otitis externa): Symptoms >3 months.
  • Cellulitis: Extension to deep layers of the skin.
  • Skull base osteomyelitis (malignant/necrotizing external otitis): Rare but serious, in immunocompromised people. It spreads to cartilage and bones.
Prevention
  • Keep ears dry: Tilt head, dry gently with towel/dryer.
  • Preventive home drops (if MT not perforated): Mix 1:1 white vinegar and isopropyl alcohol.
  • Cautious swimmers: Avoid contaminated water.
  • Protection during swimming: Earplugs or hats.
  • Avoid putting objects in the ear: No swabs, clips, etc.
4. Otitis with Tympanostomy Tubes

Main Points and Indications

Indications for Tube Insertion
  • Persistent otitis media with effusion (OME):
    • Unilateral or bilateral ≥3 months.
    • Any duration in children at risk of developmental problems (hearing loss, speech delay, developmental disorders, syndromes, craniofacial anomalies).
    • OME with attributable symptoms (balance, school performance, behavior, discomfort).
  • Recurrent acute otitis media (AOM): 3 episodes in 6 months or 4 episodes in 1 year (with 1 in the preceding 6 months), especially with effusion at the time of evaluation.
  • Chronic middle ear infection that does not improve with antibiotics.
  • Chronic suppurative inflammation of the middle ear with perforation and continuous drainage.

Hearing testing is recommended if OME persists ≥3 months or language/learning delay is suspected.

Management of Tube-Associated Otorrhea

Otorrhea is the most common complication (16% in 4 weeks, 26% during the life of the tube). Postoperative otorrhea (up to 30 days) is common.

Treatment of Acute Uncomplicated Otorrhea:

  • Exclusive use of antibiotic ear drops (no oral).
  • Examples: Ciprofloxacin 0.3% or Ofloxacin.
  • The addition of topical steroids improves effectiveness.
  • Crucial to use topical non-aminoglycoside antibiotics (such as fluoroquinolones) to avoid ototoxicity.

Meta-analysis demonstrates superiority of topical antibiotics over oral ones.

Complications of Tympanostomy Tubes

Low risk of serious problems, but they can occur:

  • Otorrhea.
  • Obstruction of the tube lumen.
  • Formation of granulation tissue.
  • Premature tube extrusion.
  • Tube displacement.
  • Changes in the tympanic membrane (tympanosclerosis/myringosclerosis, atrophy, atelectasis, retraction pockets, persistent perforation).
  • Recurrent infections (usually milder, require ear drops).
  • Problems related to general anesthesia (rare but possible).
  • Fear of noises (temporary due to normalization of hearing).
Post-Insertion Care and Follow-up

Registration the same day. Drowsiness, irritability, nausea/vomiting on the day of surgery are common.

Postoperative Care:

  • Drainage: Small amount of normal clear/yellowish/bloody fluid for 1-2 days. Contact doctor if it persists >1 week or is yellow/brown/bloody.
  • Pain management: Mild, with paracetamol or ibuprofen.
  • Medications: Antibiotic ear drops for a few days, follow instructions.
  • Activity and diet: No diet restrictions. Normal physical activity after 1 day of rest.
  • Precautions with water: Earplugs are generally not needed for swimming/bathing unless directed by your doctor. Avoid pouring water directly or submerging your head.
  • Air travel: They can travel, tubes help equalize pressure.

Follow-up:

  • Appointment in a few weeks to check tubes.
  • Additional appointments every 4-6 months with ENT/pediatrician.
  • Post-surgery audiogram if there was previous hearing loss.
5. When to Refer to an Otorhinolaryngologist (ENT)?

It is essential to know when an ear infection requires evaluation by a specialist. Consider bypass in the following cases:

6. Antibiotic therapy in Acute Otitis Media (AOM)

The following table summarizes the antibiotic treatment options for AOM, their dosage and duration, according to clinical guidelines.

Antibiotic Indication Dose Duration
7. Additional Considerations and Patient Education
Differential Diagnosis of Pain and Otorrhea

Ear pain and otorrhea can have multiple causes. A differential diagnosis is crucial:

  • Foreign body in the ear.
  • Parotitis.
  • Referred pain (oropharynx, teeth, TMJ).
  • Eustachian tube dysfunction.
  • Otitis media with effusion (OME) or "glue ear".
  • Infectious myringitis.
  • Acute mastoiditis.
  • Herpes zoster oticus (Ramsay Hunt Syndrome).
  • Perforation of the tympanic membrane.
  • Eczema and other skin irritations.
  • Cholesteatoma.
Warning Signs and When to Seek Urgent Medical Care

Parents should know when to seek immediate medical attention:

  • Fever of $39^\circ\text{C}$ ($102.2^\circ\text{F}$) or higher.
  • Pus, discharge, or fluid from the ear (yellow, brown, bloody) that lasts more than a week.
  • Worsening of symptoms despite treatment.
  • Ear infection symptoms that last more than 2-3 days.
  • Severe ear pain or pain that does not respond to pain relievers.
  • Swelling, redness or tenderness behind the ear (over mastoid), or if the ear sticks out (suggests mastoiditis).
  • Hearing loss.
  • Facial weakness or asymmetry (suggests facial paralysis).
  • Persistent vomiting or inability to keep fluids down.
  • For children under 3 months, any fever of $38^\circ\text{C}$ ($100.4^\circ\text{F}$) or higher.
Patient Education and Parent Communication Strategies

Effective communication is essential:

  • Appropriate use of antibiotics: Explain why they are not always necessary and the risks of resistance.
  • Watchful waiting: Criteria, monitoring and deferred prescription.
  • Pain management: Correct doses of paracetamol/ibuprofen; aspirin ban.
  • Prevention: Vaccination, breastfeeding, smoke avoidance, hygiene; for OAS, keep ears dry.
  • Warning signs: Make sure parents know them.

Proper administration of ear drops:

Detailed instructions:

  1. Preparation: Check medication, dosage. At body temperature. Wash hands.
  2. Positioning: Child lying with affected ear facing upwards.
  3. Straighten duct:
    • <3 years: Gently pull the pinna down and back.
    • >3 years: Gently pull the pinna up and back.
  4. Application: Bottle lightly over the ear, drop drops to one side of the canal.
  5. Absorption: Press gently in front of the ear, hold for 1-2 minutes with the ear facing up.

Communication strategies for children with temporary hearing loss (due to OME):

  • Get closer to the child (speak at <1 meter).
  • Get their attention before you speak.
  • Speak clearly, straight ahead, normal tone and volume, repeat words.
  • Use visual cues (gestures, images).
  • Reduce background noise.
  • Encourage interaction and monitor speech/language development.
8. Conclusions

The management of ear infections in pediatrics requires a precise and evidence-based approach. Accurate diagnosis, judicious use of antibiotics, effective pain management, and robust patient education are key pillars to optimize clinical outcomes and combat antimicrobial resistance. Monitoring for complications and timely referral to the ENT are crucial to prevent serious sequelae.

Summary of key points

Accurate diagnosis of AOM requires confirmation of effusion and bulging of the tympanic membrane, beyond simple redness. For OAS, tragus/pinna sensitivity is key, leading toward topical treatment.

Therapeutic management must be individualized: analgesics are essential; Antibiotics for AOM depend on age, severity and laterality, with "watchful waiting" as an option if there is no severity. OAS is mostly treated with topical drops. Otorrhea associated with tympanostomy tubes is also managed with non-ototoxic topical antibiotic drops.

Monitoring for warning signs (persistent fever, prolonged otorrhea, neurological signs) is vital for the early detection of serious complications such as mastoiditis or cholesteatoma. Continuing education of parents is essential to empower them in the care of their children and ensure compliance with treatment and preventive measures.

In summary, a deep understanding and commitment to prevention and education are essential to improve outcomes in the pediatric population.

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