Sandbox aom

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [4]

Overview

Acute otitis media (AOM) usually follows a viral upper respiratory tract infection leading to Eustachian tube dysfunction with impaired clearance and pressure regulation of the middle ear. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without otorrhea or children older than 2 years with unilateral or bilateral AOM without otorrhea. Antibiotics targeting common bacterial pathogens (e.g., Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae) have been used with success in selected patients to accelerate the recovery and reduce the complications of acute otitis media.

Medical Therapy

Initial management of uncomplicated AOM with high certainty of diagnosis

Clinical Practice Guideline from the American Academy of Pediatrics

Age	AOM With Otorrhea	AOM With Severe Symptoms†	Bilateral AOM Without Otorrhea	Unilateral AOM Without Otorrhea
6 mo to 2 y	Antibiotic therapy	Antibiotic therapy	Antibiotic therapy	Antibiotic therapy or additional observation
≥ 2 y	Antibiotic therapy	Antibiotic therapy	Antibiotic therapy or additional observation	Antibiotic therapy or additional observation

^† A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.

Observation

Due to the self-limited nature of most episodes of AOM (particularly in children 2 years and older), initial observation is advisable for selected patients if close follow-up can be ensured and rescue antibiotics administered for persistent or worsening symptoms in 48 to 72 hours.

Antibiotic Therapy

The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria from tympanocentesis cultures. A significant benefit of immediate antibiotic therapy is evident in bilateral AOM, AOM with severe symptoms, AOM with otorrhea, or Streptococcus pneumoniae infection.

When a decision to treat with antibiotics has been made, amoxicillin should be used if all of the following criteria are fulfilled:

• The patient has not received amoxicillin in the past 30 days.
• The patient does not have concurrent purulent conjunctivitis.
• The patient is not allergic to penicillin.

Additional β-lactamase coverage should be considered if any of the following criteria is fulfilled:

• The patient has received amoxicillin in the past 30 days.
• The patient has concurrent purulent conjunctivitis.
• The patient has a history of recurrent AOM unresponsive to amoxicillin.

Treatment of acute otitis media is controversial. Much of the controversy centers around the difficulty of distinguishing viral infection from bacterial infection and the fact that viral infection can progress to bacterial infection at any time. Primary care providers, such as general practitioners and pediatricians, often have a monocular otoscope and perhaps a tympanometer as their only diagnostic tools, which makes this distinction difficult, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to causing distention of the small blood vessels on it, mimicking the redness associated with otitis media. Because of a tradition of inappropriate prescribing of antibiotics for viral acute otitis media, their use has recently been condemned by many primary care practitioners for most cases of acute otitis media. Ear specialists tend to disagree with this philosophy and promote efforts to distinguish between viral and bacterial infection, so as to optimize treatment results by giving antibiotics only for bacterial infection. Acute bacterial otitis media can cause pain that leads to sleepless nights for both children and parents, can cause eardrum perforations, not all of which heal, and can spread to cause mastoiditis and/or meningitis, brain abscess, and even death if a severe infection goes untreated long enough. High fever can occur and can cause febrile seizures. Appropriate antibiotic administration prevents most such complications. On the other hand, it is generally agreed that acute otitis media that is purely viral will usually resolve without antibiotic treatment, although associated persistent middle ear effusions may require medical intervention.

Many guidelines now suggest deferring the start of antibiotics for one to three days avoiding the need for antibiotics for two out of three children without adverse effect on longterm outcomes for those whose treatment is deferred. First line antibiotic treatment, if warranted, is amoxicillin. If the bacteria is resistant, then amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is used.

Antibiotics Used in the Treatment of Otitis Media Preferred Regimen ▸ Amoxicillin 80 to 90 mg per kg per day, given orally in two divided doses Recurrent or persistent acute otitis media, those used amoxicillin, or antibiotics within the previous month, or with concurrent purulent conjunctivitis ▸ Amoxicillin-clavulanate 90 mg of amoxicillin per kg per day; 6.4 mg of clavulanate per kg per day, given orally in two divided doses For patients with penicillin allergy ▸ Azithromycin 30 mg per kg, given orally one dose For recurrent acute otitis media ▸ Azithromycin 20 mg per kg once daily, given orally x 3 days For penicillin allergy type 1 hypersensitivity ▸ Azithromycin 5 to 10 mg per kg once daily, given orally x 5 days For patients with penicillin allergy excluding type 1 hypersensitivity ▸ Cefdinir 14 mg per kg per day, given orally in one or two doses OR ▸ Cefpodoxime 30 mg per kg once daily, given orally OR ▸ Ceftriaxone 50 mg per kg once daily, IM or IV. One dose for initial episode of otitis media, three doses for recurrent infections OR ▸ Cefuroxime 30 mg per kg per day, given orally in two divided doses OR ▸ Clarithromycin 15 mg per kg per day, given orally in three divided doses OR ▸ Clindamycin 30 to 40 mg per kg per day, given orally in four divided doses

Topical agents ▸ ciprofloxacin/dexamethasone 3 drops twice daily OR ▸ Ofloxacin 5 drops twice daily (10 drops in patients older than 12 years) OR ▸ Hydrocortisone/neomycin/polymyxin B 4 drops three to four times daily

Analgesics ▸ Acetaminophen 15 mg per kg every six hours OR ▸ Ibuprofen 10 mg per kg every six hours OR ▸ Antipyrine/benzocaine 2 to 4 drops three to four times daily

Chronic Otitis Media with Effusion

In chronic cases or with effusions present for months, surgery is sometimes performed. It is possible to use the Valsalva maneuver to reestablish middle ear ventilation, although repeated use of the Valsalva maneuver can cause infected matter to enter the eye cavity and cause conjunctivitis.

Alternative Therapies

Alternatives to conventional medical approaches include chiropractic and osteopathic spinal manipulations, targeted to relieve muscle tension to enhance lymphatic flow and allow normal opening of the Eustachian tube. Such alternatives are becoming increasingly widely used. Otitis Media has also been found to respond to homeopathic remedies. Eardoc treatment reduces the fluids in the middle ear by opening the Eustachian tube. Its efficiency can be viewed and tested with a tympanometer.