Elsevier

The Lancet

Volume 363, Issue 9407, 7 February 2004, Pages 465-473
The Lancet

Seminar
Otitis media

https://doi.org/10.1016/S0140-6736(04)15495-0Get rights and content

Summary

Otitis media (OM) continues to be one of the most common childhood infections and is a major cause of morbidity in children. The pathogenesis of OM is multifactorial, involving the adaptive and native immune system, Eustachian-tube dysfunction, viral and bacterial load, and genetic and environmental factors. Initial observation seems to be suitable for many children with OM, but only if appropriate follow-up can be assured. In children younger than 2 years with a certain diagnosis of acute OM, antibiotics are advised. Surgical candidacy depends on associated symptoms, the child's developmental risk, and the anticipated chance of timely spontaneous resolution of the effusion. The recommended approach for surgery is to start with tympanostomy tube placement, eventually followed by adenoidectomy. The ideal intervention for OM, however, does not yet exist, and an urgent need remains to explore new and creative options based on modern insights into the pathophysiology of OM.

Section snippets

Advances in epidemiology

Most children have at least one episode of AOM, with a peak incidence between ages 6 and 11 months; by age 3 years, 50–85% of children have had acute OM.35, 36 Recurrent AOM (⩾3 episodes) is common, affecting 10–20% of children by age 1 year. Nearly 40% of older children eventually have six or more total episodes.36

The lack of acute symptoms with OME makes prevalence difficult to estimate, but the point prevalence of MEE on screening tests is about 20%.36 Peak incidence is at roughly age 1 year.

Advances in pathogenesis

OM is mainly an infectious disease, resulting from interplay between microbial load (viral and bacterial) and immune response. All factors known to cause OM relate to these two core elements (figure 1): host factors, such as age, genetic predisposition, and atopy relate to the impaired immune system, whereas environmental factors such as siblings (generally older), group day care, and season of year relate to microbial load. The Eustachian tube is the port of entry for middle-ear pathogens from

Advances in diagnosis

MEE is a prerequisite for AOM and OME. Compared with myringotomy, which is the gold standard, pneumatic otoscopy offers the optimum balance of sensitivity (94%) and specificity (80%) in diagnosing MEE.9 Pneumatic otoscopy requires clinical skills because it combines visual assessment of tympanic-membrane mobility and appearance. Tympanometry is a simple and objective quantitative method of assessing tympanic-membrane mobility and middle-ear function, with similar sensitivity but lower

Watchful waiting vs initial antibiotics for AOM

In three independent meta-analyses (table 1),7, 13, 26 with varying sample sizes and methods of data pooling, around 80% of children with AOM had spontaneous clinical relief within 2–14 days, with a 95% CI of about 70–90%. The rate for children younger than 2 years is less certain because not all source articles contained young children. Findings from studies restricted to this population suggest a lower spontaneous resolution of about 30% after a few days.30, 91 All rates exclude MEE, which

Advances in prevention

Research in the past decade has focused on pneumococcal vaccines for preventing OM, because S pneumoniae is the most common bacterial pathogen.124 The 23-valent polysaccharide vaccine covers 90% of all known pneumococcal infections in developed countries, but has no efficacy for preventing OM in children younger than 2 years. The vaccine has marginal benefit for older children, favouring those with previous AOM episodes.23

The pneumococcal conjugate vaccines, in which the pneumococcal capsular

Future direction

The ideal intervention, preventive or curative, for OM would be non-toxic and have sustained efficacy for at least several months. Such an intervention does not yet exist, and, therefore, an urgent need remains to explore new and creative treatments based on modern insights into the pathophysiology of OM.

Search strategy and selection criteria

Because of the large number of articles identified—a MEDLINE search with the subject heading “otitis media” resulted in 15 057 hits—and limitations for quoting references in this paper, we started the work of this review with the two latest versions of the research conference reports on recent advances in otitis media, which were published in October, 1998, and March, 2002. Second, we used the evidence reports on acute OM and OME of the American Agency for Healthcare Research and Quality,

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