By: Janet R Casey, MD, and Michael E Pichichero, MD
In May 2004, the American Academy of Pediatrics (AAP) joined with the American Academy of Family Physicians to publish a clinical practice guideline on the diagnosis and management of acute otitis media (AOM).1 In 2013, the AAP revised the guideline with important changes presented in this review.2
The 2004 guideline was not without critics, and the same is true of the 2013 revision. The main areas of controversy surround diagnostic criteria for AOM, the notion of “uncertain diagnosis” and the watchful waiting option, and the selection of empiric antibiotic treatments recommended. Each of these issues will be discussed. We also discuss the otitis-prone child and the emergence of biofilms as a problem contributing to recurrent AOM and chronic otitis media with effusion (OME).
The 2004 guideline criteria for diagnosis of AOM were insufficiently precise. Children with OME could fit the definition intended only to identify AOM. In the 2013 guideline, the diagnosis was refined and improved. Table 1 shows the key summary statements regarding diagnostic criteria from the 2013 guideline.2
The most important diagnostic feature for AOM noted in the new guideline is a bulging or full tympanic membrane (TM) associated with middle ear effusion, and the TM is opaque. Experts in otitis media diagnosis are in consensus supporting this change.3 The bulging occurs from pressure behind the TM caused by inflammation in the middle ear space. The AOM is not associated with a retracted TM, so a determination of retraction of the TM with middle ear effusion, regardless of TM opacity, is not AOM. A bulging compared with a retracted TM can be difficult to distinguish.
Because of the inflammation in the middle ear space during AOM, typically the TM becomes thickened and nontranslucent or completely opaque. A translucent TM is not seen with AOM. With a translucent or semitranslucent TM and middle ear fluid visualized behind the TM, the likely diagnosis is OME.3
Redness of the TM is not generally a valuable diagnostic sign of AOM. An exception would be the presence of a single red TM and the other TM not red, suggesting inflammation of the TM, consistent with the diagnosis of AOM if there is fluid visualized behind the TM. Most likely, such an examination represents an early AOM before inflammation has persisted to cause the TM to become more white or yellowish and opaque.
Acute otitis media is not associated with inflammation, so prior diagnostic definitions of OME stipulated absence of symptoms other than hearing loss. A child with OME may feel discomfort, however, and may feel popping noises that may cause ear tugging or even crying.4
Use of pneumatic otoscopy is very helpful to improve diagnostic accuracy, and its use is advocated in the 2013 guideline.2 Positive pressure on insufflation will result in movement backwards by a bulging TM, and negative pressure will result in movement forward by a retracted TM. Thus, properly used, pneumatic otoscopy can allow the clinician to have a better appreciation for the position of the TM, a key diagnostic feature.
An otoscope head that permits insertion of an insufflator is also needed. The challenge is to get a good seal with an otoscope speculum and to restrain the child long enough to perform the insufflation procedure. To achieve a seal, use of a speculum with a softer rubber sleeve midshaft of the speculum may be helpful.