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 and relieve ear-related symptoms, but AOM can also resolve without antimicrobials [Evidence Level: A].
- Analgesics should always be considered as pain evaluation is difficult with small children.
- 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, the parents’ wishes and the adverse effects of the drugs (diarrhoea and increased resistance).
- Antimicrobial medication accelerates the resolution of middle ear effusion and decreases the risk of glue ear.
- The first choice drug 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. sulpha-trimethoprim at a dose of 25 mg/8 mg/kg/day divided into 2 daily doses is an alternative. The usual duration of the antimicrobial course is 5 to 7 days. Macrolides are not recommended, since they are not effective against Haemophilus influenzae.
- Spontaneous perforation of the tympanic membrane is a clear indication for antimicrobial treatment. Other factors predicting the need for antimicrobial medication are not known. It has been suggested that bilateral AOM in a child aged less than 2 years would support the starting of antimicrobial treatment [Evidence Level: B].
- If antimicrobials are not prescribed the child must be re-examined within a few days if the parents are worried about the condition of the child or if 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, but it is not recommended as a routine practice. 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.
- Myringotomy (tympanocentesis) does not promote healing .
- It is indicated in some cases in order to clarify aetiology, to ease pressure-induced pain and, rarely, due to the child’s general condition.
- It is normal that middle ear effusion persists even for several weeks after AOM. The purpose of a follow-up examination is to check that the effusion does not persist for too long. 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 need and timing of a follow-up examination can be considered individually taking into account the patient’s age, language development and underlying diseases. Tympanometry (Tympanometry) alone may be considered sufficient.
- If the effusion has not resolved after 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 not resolved after 3 months (”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 focuses on limiting exposure to infections.
- Tympanostomy tubes (grommets (Tympanostomy tubes)) appear to reduce the number of AOM episodes to some extent [Evidence Level: B], but the insertion of such tubes does not improve the quality of life.
- Xylitol administered 5 times daily has been shown to reduce the number of AOM episodes [Evidence Level: A].
- The beneficial effect of vaccines (influenza and pneumococci [Evidence Level: B]) 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].
- Adenoidectomy has not been shown to have a significant effect in the prevention of AOM [Evidence Level: C].
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