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Acute otitis media has been the subject of increased discussion in recent months. The American Academy of Pediatrics recommends waiting a few days before starting antibiotics in a child with an ear infection, as some cases of acute otitis media may clear up on their own without the use of antibiotics.
Yet the New England Journal of Medicine (NEJM) has recently published two separate studies—A Placebo-Controlled Trial of Antimicrobial Treatment for Acute Otitis Media, and Treatment of Acute Otitis Media in Children under 2 Years of Age—showing that the sooner antibiotics are started in patients with well-documented acute otitis media, the better the clinical outcome compared to placebo. Pediatric Views sat down with Kenneth R. Whittemore, Jr., MD, MS, Instructor in the Department of Otolaryngology and Communication Enhancement, to find out where Children's stands on the subject.
The difference in these articles compared to prior studies is two-fold: having a strict diagnosis of acute otitis media and implementing a broader spectrum antibiotic (amoxicillin/clavulonic acid) as the first line. In the two studies featured in the NEJM, the authors were very clear about what they considered to be acute otitis media, as opposed to earlier studies that appear to be less stringent. Patients in earlier studies may not have had, by the definition described in the more recent studies, acute otitis media. Many of them may have had fluid behind the eardrum with inflammatory characteristics and may have gotten better because they did not have as severe an infection as patients in the newer studies.
The choice of antibiotics is interesting because both of the studies in the NEJM used Augmentin, which is not classically considered a first-line antibiotic for acute otitis media. Typically, amoxicillin is the first line, with the use of amoxicillin/clavulonic acid as second-line therapy if the infection does not resolve or recurs quickly. The use of a broader-spectrum antibiotic may be another reason why these studies showed improvement.
There are several classic symptoms and signs suggestive of acute otitis media:
- tugging at the ear
- irritability
- crying
- poor sleep
- decreased activity
- decreased appetite
- fever
- bulging or hypervascular tympanic membrane
- pus behind the ear drum
At least some of these things need to be present for the consideration of acute otitis media. Defining what is and isn't actually acute otitis media is the most important step in achieving a successful treatment outcome.
If a child comes in with signs and symptoms, as previously noted, and is subsequently diagnosed with acute otitis media, I would start her on antibiotics at that office visit. Which antibiotic to start with is somewhat controversial, but at this time I would still start with amoxicillin unless there were other clinical reasons not to. Amoxicillin is reasonable to start with, and I recommend treating children for ten days.
There are two different categories of patients whom pediatricians might consider referring:
- A child who has an acute active ear infection and has undergone multiple trials of antibiotics on a broad spectrum, but continues to have acute otitis media that might need surgical drainage. Or if a child has gone on to develop complications from an ear infection, such as mastoiditis, meningitis or facial nerve paralysis.
- A child with recurrent acute otitis media. I think the minimum for which I would ever consider placing tubes is four infections in a six-to-nine-month period. If a child has four or more in that period, consider a referral. You may want to make the criteria less strict if the child is immunocompromised, displaying speech or language delays that may suggest a problem with hearing, developing multiple allergies to antibiotics or having severe complications from antibiotic therapy.
There are a few paths I take, depending on the history:
- counseling patients regarding potential risk factors that could be modified to reduce the number of ear infections a child gets, e.g., child is in day care, exposure to smoke
- Continued observation and medical therapy, with or without possible prophylactic antibiotics. Prophylactic antibiotics are somewhat controversial because of the potential for developing resistant bacteria. I consider prophylaxis in children who are being seen near the end of cold and flu season, and I am trying to bridge them to spring.
- a medical workup to determine why a child is having recurrent ear infections, e.g., immunodeficiency, gastric reflux
- placement of tubes
A lot depends on a child's medical history and social situation when considering the appropriate workup and management of children with acute otitis media. I generally consider the placement of ear tubes a last resort, but if the proper patient population is chosen, then the results are generally excellent.
Make a referral: 617-355-6462
childrenshospital.org/oto
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