Acute otitis media in children: treatment, follow-up and prevention
- Treatment is based on careful diagnosis (Diagnosis of otitis media: symptoms, clinical examination and findings). If acute otitis media (AOM) is only suspected antimicrobial drugs are not indicated.
- Treatment is always individual: antimicrobials will hasten recovery (fever and ear pain), but AOM often resolves without antimicrobials [Evidence Level: A].
- Analgesics should always be given (unless contraindicated) as pain evaluation is difficult with small children and pain left untreated will strengthen future experiences of pain.
- Paracetamol (15–20 mg/kg four times daily) may be combined with naproxen (5 mg/kg twice daily) or ibuprofen (10 mg/kg three times daily). Anaesthetic ear drops may also be combined with analgesia [Evidence Level: B] (cinchocaine, a prescription is not necessary).
- Antihistamines and decongestants do not promote healing in AOM [Evidence Level: A].
- Before an antimicrobial drug is started, each case warrants individual consideration taking into account the severity of the illness and, additionally, the adverse effects of the drugs (diarrhoea and increased resistance) and the parents’ wishes.
- Antimicrobial drug should be started if spontaneous perforation has occurred or if the tympanic membrane is bulging strongly.
- Antimicrobial drug will make fever and ear pain disappear faster.
- The evidence is conflicting regarding the impact of antimicrobial treatment on the duration of middle ear effusion.
- If antimicrobial pharmacotherapy is started
- The first choice drug, according to the Finnish Current Care guideline, is either amoxicillin at a dose of 40 mg/kg/day or amoxicillin/clavulanic acid 40 mg/5.7 mg/kg/day, both divided into 2 daily doses.
- In penicillin allergy, e.g. cefaclor, cefuroxime axetil, or sulpha-trimethoprim (the latter at a dose of 25 mg/8 mg/kg/day) divided into 2 daily doses, or a macrolide, is an alternative.
- Sulpha, however, must not be used in the treatment of spontaneous perforation, since sulpha is not effective against Streptococcus pyogenes bacteria, which causes the most complications.
- Macrolides have no effect on Haemophilus influenzae bacteria.
- The usual duration of the antimicrobial course is 5 to 7 days.
- If antimicrobial pharmacotherapy is not started
- Re-examination is not routinely required. It should be arranged if the parents are worried about the child's health or the symptom picture has changed.
- Delayed prescribing of antimicrobials [Evidence Level: A] (the prescription is issued but the parents are advised only to start medication if the child shows no clear signs of recovery within 2–3 days) is an alternative.
- Delayed onset of medication does not reduce the effect of the treatment but the waiting time may increase the child’s symptoms and the parents’ absence from work by, on average, 1–2 days.
- Myringotomy (tympanocentesis) does not promote healing .
- It is indicated in some cases in order to clarify aetiology or if effective pain medication has not relieved the pain.
Table 1. The efficacy of various antimicrobial drugs against different bacteria causing acute otitis media is indicated by +++/++/+/–. When selecting the antimicrobial drug to be used, take into account, in addition to the efficacy, also adverse effects and risk of complication. The table can also be shown to the parents when discussing with them. Local variation in the efficacy may exist.
|Adverse effects|| Streptococcus pneumoniae |
Common, causes complications
| Haemophilus influenzae |
Common, may cause complications
| Moraxella catarrhalis |
Common, does not cause complications
| Streptococcus pyogenes |
Rare, causes complications
- Routine follow-up examination is no longer recommended. The purpose of a potential follow-up examination is to check that the effusion does not persist for too long.
- It is normal that middle ear effusion persists even for several weeks after AOM [Evidence Level: A]. The effusion as such is not dangerous but it causes a slight decrease in hearing ability which will be corrected when the middle ear effusion has disappeared. The risk of prolonged duration of middle ear effusion is low if an otherwise healthy child does not have recurrent middle ear infections.
- The need and timing of a follow-up examination are considered individually taking into account the patient's history of recurrence of otitis media, patient’s age, language development and underlying diseases.
- Tympanometry (Tympanometry) alone may be considered sufficient as a follow-up examination.
- If the effusion has persisted for more than 3 months, the child should be referred to an ear specialist for further treatment.
Referral to specialist care
- An existing or suspected complication (e.g. mastoiditis, facial paralysis): requires an emergency referral to specialist care.
- A referral to specialist care should be considered in the following situations:
- symptomatic inflammation persists despite second-line antimicrobials (urgency rating: within 1–7 days)
- middle ear effusion persists for more than 3 months (”glue ear” (Otitis media with effusion (glue ear)): urgency rating: 7–30 days).
- frequent episodes of AOM (> 3 episodes/6 months or > 4 episodes/12 months; urgency rating: 7–30 days)
- the child has pre-existing hearing impairment (urgency rating: as considered appropriate)
- a child < 3 months of age (urgency rating: as considered appropriate).
- The avoidance of risk factors (Otitis media in children: risk factors and pathogenesis) focuses on limiting exposure to infections.
- Tympanostomy tubes[Evidence Level: B] (grommets (Tympanostomy tubes)) are beneficial for those in whom the middle ear effusion does not disappear between consecutive otitis media.
- Xylitol administered 5 times daily has been shown to reduce the number of AOM episodes [Evidence Level: A].
- The beneficial effect of vaccines (influenza [Evidence Level: A] and pneumococci [Evidence Level: A]) in the prevention is small as otitis media can be caused by a wide variety of microbes.
- The beneficial effect of antimicrobial prophylaxis in the prevention of AOM is small and is only indicated in special cases after careful consideration [Evidence Level: A].
- The beneficial effect of adenoidectomy is minor and debatable [Evidence Level: C].
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