Acute Otitis Media (AOM) in Adults

Background

• Acute otitis media is a usually painful middle ear inflammation, typically secondary to infection and is one of the common causes of otalgia.
• Acute otitis media is more common in children, but around 36% of acute otitis media outpatient visits are generated by adults with about 3% occurring in patients over the age of 65.
• Acute otitis media often happens concurrently with a viral infection, but antibiotics are indicated based on the high prevalence of bacteria in the middle ear effusion such as Streptococcus pneumoniae, nontypeable Hemophilus influenza, and Moraxella catarrhalis.

Evaluation

• Acute otitis media is characterized by the acute onset of ear pain, typically following a recent upper respiratory infection. Pain is typically continuous and progressive.
• The diagnosis of acute otitis media is made clinically based on the history of ear pain and otoscopic exam findings of moderate-to-severe bulging of the tympanic membrane or mild bulging accompanied by erythema.
• Chronic suppurative otitis media, defined as 6 weeks or longer of an inflammatory process, often complicated by a perforated tympanic membrane.
• Otitis media with effusion (also called serous otitis media), a chronic inflammatory condition that is more often associated with a feeling of fullness and/or hearing loss than intense pain, and may be secondary to acute infection or allergies but also may be a secondary to more serious or persistent conditions.
• Other causes of ear pain to exclude include otitis externa, barotrauma, foreign bodies in the ear canal, and referred otalgia from the oropharynx, temperomandibular joint or neck.

Management

• There is very limited evidence for management of acute otitis media in adults. Most regimens and suggestions are extrapolated from data in children with acute otitis media.
  • In adults, antibiotics plus symptom management are the first-line approach for acute otitis media.
    • The "wait and see" approach that delays the use of antibiotics to see if spontaneous resolution occurs has been evaluated in children but not adults.
    • Suggested length of therapy should be for 5-7 days or 10 days if severe signs or symptoms present.
    • Antibiotic options include:
      • amoxicillin 500 mg orally every 12 hours suggested for mild-to-moderate acute otitis media
      • amoxicillin 875 mg orally every 12 hours or 500 mg every 8 hours suggested for more severe acute otitis media
      • alternatives for patients with penicillin allergy include
        • cefdinir 300 mg orally every 12 hours or 600 mg orally every 24 hours
        • cefuroxime axetil 250 mg orally every 12 hours
        • cefpodoxime proxetil 200 mg orally every 12 hours
        • azithromycin 500 mg orally as single dose on day 1, then 250 mg orally once daily on days 2-5
        • clarithromycin 500 mg orally every 12 hours
        • cefprozil 250 mg orally every 12 hours or 500 mg orally every 12 hours for more severe infections
    • Consider oral analgesics such as acetaminophen and/or ibuprofen for pain control.
    • Most patients may be managed as outpatients but if the patient does not improve after 48-72 hours of initial antibiotic therapy, consider alternative antibiotics (for another 5-10 days) including:
      • amoxicillin-clavulanate 500 mg/125 mg orally every 12 hours or 250 mg/125 mg orally every 8 hours; or if severe infection 875 mg/125 mg orally every 12 hours or 500 mg/125 mg orally every 8 hours
      • levofloxacin 750 mg orally every 24 hours for 5 days, or 500 mg orally every 24 hours
      • moxifloxacin 400 mg orally every 24 hours
  • If complications develop, such as acute mastoiditis, facial paralysis, labyrinthitis or petrositis, consider urgent advanced imaging, inpatient management with IV antibiotics, and/or otolaryngology consult.
  • Indications for otolaryngology consultation may include
    • facial nerve paralysis and/or other focal neurological signs
    • pain and swelling behind the ear developing after otitis media, or new onset vertigo
    • signs or symptoms suggestive of head and neck cancer
    • persistent symptoms after adequate treatment or signs of severe infection