Acute Otitis Media: Still Common, Still Complex

 Acute Otitis Media: Still Common, Still Complex

Acute otitis media (AOM) remains one of the most frequently diagnosed infections in children under 2, despite declines in incidence due to pneumococcal vaccination and stricter diagnostic criteria.

By age 2:

- 41% of children will have had ≥1 episode

- 13% will have had ≥3 episodes

Key risk factors?

Exposure to large numbers of other children, shorter breastfeeding duration, male sex, second-hand tobacco smoke, and immunologic vulnerabilities.

It’s a bacterial complication of viral URI — usually within 4 days — caused mainly by:

- Haemophilus influenzae (34%)

- Streptococcus pneumoniae (24%)

- Moraxella catarrhalis (15%)

Bulging tympanic membrane is diagnostic.

Otoscopic criteria now dominate diagnosis, especially as fussiness, fever, or ear-tugging lack specificity.

Antibiotics? Not always.

- High-dose amoxicillin remains first-line

- Amoxicillin-clavulanate if risk for H. influenzae (recent antibiotics, conjunctivitis–otitis syndrome, or TM rupture)

- Treatment with antibiotics for 10 days resulted in less treatment failure and less use of rescue antibiotics than treatment for 5 days

- Observation appropriate for mild/moderate cases

Tubes or antibiotics for recurrent AOM?

A large trial showed no difference in AOM episodes over 2 years — challenging long-held assumptions about tympanostomy tubes.

Complications are rare (e.g., mastoiditis: 2–4 per 10,000), and antibiotic side effects + long-term risks (e.g., allergy, obesity) must be weighed carefully.

In short:

Less overdiagnosis. Better criteria. Smarter treatment.

Still a long way to go in optimizing care for this very common pediatric illness.