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Otitis Media Revisited

Guidance now on caring for children with middle ear infections, and more to come

Otitis media remains the most common infection for which children receive antibiotics. Drawing on systematic reviews of the published literature, four leading "ear experts" offer the following observations:

• Breast-feeding is protective against acute otitis media (AOM).
  
• Daycare outside of the home, parental smoking, and pacifier use increase the risk for AOM.
  
• Middle ear effusion (MEE) is a prerequisite for the diagnosis of both AOM and otitis media with effusion (OME); pneumatic otoscopy offers excellent sensitivity and specificity for detecting MEE.
  
• Although AOM resolves spontaneously in about 80% of older children, this rate is substantially lower in children younger than 2 years.
  
• Children younger than 2 years with a firm diagnosis of AOM should be treated with antibiotics; children who are older or who have an unclear diagnosis may be observed.
  
• Antibiotic treatment should last 7 to 10 days in young children and 5 to 10 days in older children.
  
• Children with AOM who do not receive antibiotics should still receive adequate analgesia for 24 to 48 hours.
  
• Surgery to prevent middle ear disease should be considered in the context of the individual child. Recurrent disease, poor language development, and an unfavorable home environment all should lower the threshold for surgery.
  
• Initial surgery to prevent recurrent disease should include myringotomy and tympanostomy tubes; repeat surgery should include myringotomy and adenoidectomy, with or without tubes.
  

Comment: These recommendations are consistent with my experience and reading of the literature. First and foremost, it is important to ensure that a child has MEE before diagnosing AOM. Second, antibiotic therapy confers significant benefit in children younger than 2 years. For older children who are relatively well (low-grade fever, little pain), it is less certain how much benefit antibiotics offer, and these children can probably be observed rather than treated. Finally, it is difficult to demonstrate improved language development in children with recurrent AOM or OME who receive tympanostomy tubes, but tubes certainly reduce the likelihood of MEE and improve hearing in children with hearing deficits. Children with recurrent ear disease and hearing loss who are at risk for poor language development should be considered candidates for surgery. The AAP and the American Academy of Family Practitioners have also released new guidelines for the treatment of AOM, which we will review in a future issue.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 29, 2004

Citation(s):

Rovers MM et al. Otitis media. Lancet 2004 Feb 7; 363:465-73.

• Medline abstract (Free)