Acute otitis media in children: treatment, follow-up and prevention

Essentials

Treatment

  • 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
Amoxicillin few +++ ++ +++
Amoxicillin/clavulanic acid many +++ +++ +++ +++
Cefaclor many +++ +++ +++ +++
Cefuroxime axetil many +++ +++ +++ +++
Sulpha-trimethoprim many ++ ++ +++
Macrolides moderately ++ +++ ++

Follow-up

  • 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.

Evidence Summaries

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).

Prevention

Evidence Summaries

References

1. Hoberman A, Paradise JL, Rockette HE et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011;364(2):105-15.  [PMID:21226576]

2. Tähtinen PA, Laine MK, Huovinen P et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med 2011;364(2):116-26.  [PMID:21226577]

3. Kaleida PH, Casselbrant ML, Rockette HE et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics 1991 Apr;87(4):466-74.  [PMID:2011422]

4. Tähtinen PA, Laine MK, Ruohola A. Prognostic Factors for Treatment Failure in Acute Otitis Media. Pediatrics 2017;140:e20170072.  [PMID:28790141]

5. Tähtinen PA, Laine MK, Ruuskanen O et al. Delayed versus immediate antimicrobial treatment for acute otitis media. Pediatr Infect Dis J 2012;31(12):1227-32.  [PMID:22760531]

6. Tapiainen T, Kujala T, Renko M et al. Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: a placebo-controlled trial. JAMA Pediatr 2014;168(7):635-41.  [PMID:24797294]

7. Ruohola A, Laine MK, Tähtinen PA. Effect of Antimicrobial Treatment on the Resolution of Middle-Ear Effusion After Acute Otitis Media. J Pediatric Infect Dis Soc 2018;7(1):64-70.  [PMID:28340091]

8. Kujala T, Alho OP, Kristo A et al. Quality of life after surgery for recurrent otitis media in a randomized controlled trial. Pediatr Infect Dis J 2014;33(7):715-9.  [PMID:24445832]

9. Kujala T, Alho OP, Luotonen J et al. Tympanostomy with and without adenoidectomy for the prevention of recurrences of acute otitis media: a randomized controlled trial. Pediatr Infect Dis J 2012;31(6):565-9.  [PMID:22466327]

10. Uitti JM, Tähtinen PA, Laine MK ym. Close Follow-up in Children With Acute Otitis Media Initially Managed Without Antimicrobials. JAMA Pediatr 2016;170(11):1107-1108.  [PMID:27599067]


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