From the Guidelines
Otitis media should be managed with a focus on accurate diagnosis, watchful waiting for mild cases, and targeted antibiotic treatment to reduce the risk of complications and antibiotic resistance, as emphasized by recent guidelines 1.
Diagnosis and Management
The diagnosis of otitis media (OM) depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane for acute otitis media (AOM), and hearing loss for otitis media with effusion (OME) 1.
- For AOM, antibiotics are typically prescribed, with amoxicillin being the first-line treatment (40-45 mg/kg/day divided twice daily for 5-10 days in children; 500-875 mg twice daily for 5-7 days in adults) 1.
- For pain management, acetaminophen (10-15 mg/kg every 4-6 hours in children; 650 mg every 4-6 hours in adults) or ibuprofen (10 mg/kg every 6-8 hours in children; 400-600 mg every 6-8 hours in adults) can be used.
- Watchful waiting may be appropriate for mild cases in children over 2 years without severe symptoms, as it can help reduce unnecessary antibiotic use and the risk of antibiotic resistance 1.
Recurrent Otitis Media and Otitis Media with Effusion
- For recurrent otitis media, tympanostomy tubes might be recommended to reduce the frequency of episodes and improve quality of life 1.
- Otitis media with effusion often resolves without antibiotics within 3 months, and management largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays, or learning difficulties 1.
Prevention
Preventive measures include avoiding secondhand smoke, practicing good hand hygiene, and keeping vaccinations up to date, which can help reduce the risk of developing otitis media and its complications 1.
From the FDA Drug Label
Safety and efficacy using azithromycin 30 mg/kg given over 3 days Protocol 4 In a double-blind, controlled, randomized clinical study of acute otitis media in pediatric patients from 6 months to 12 years of age, azithromycin (10 mg/kg per day for 3 days) was compared to amoxicillin/clavulanate potassium (7:1) in divided doses q12h for 10 days Each patient received active drug and placebo matched for the comparator. For the 366 patients who were evaluated for clinical efficacy at the Day 12 visit, the clinical success rate (i.e., cure plus improvement) was 83% for azithromycin and 88% for the control agent. For the 362 patients who were evaluated at the Day 24 to 28 visit, the clinical success rate was 74% for azithromycin and 69% for the control agent.
Azithromycin is effective in treating acute otitis media in pediatric patients, with a clinical success rate of 83% at Day 12 and 74% at Day 24-28 when given 10 mg/kg per day for 3 days 2.
- The most common side effects were diarrhea/loose stools, vomiting, and rash.
- The incidence of treatment-related adverse events was 10.6% with azithromycin and 20.0% with the control agent.
- Azithromycin can be considered a treatment option for acute otitis media in pediatric patients, but the decision should be made based on the individual patient's needs and medical history.
From the Research
Definition and Diagnosis of Otitis Media
- Otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever 3.
- Acute otitis media (AOM) is the most common diagnosis in childhood acute sick visits, and by three years of age, 50% to 85% of children will have at least one episode of AOM 4.
- AOM is diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa, and in children with mild bulging and either recent-onset ear pain or intense erythema of the tympanic membrane 4.
Causes and Risk Factors of Otitis Media
- Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection 3.
- Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid 3.
- Risk factors for recurrent otitis media (rAOM) include modifiable factors such as exposure to tobacco smoke, attendance at childcare, and lack of breastfeeding 5.
Treatment of Otitis Media
- Management of acute otitis media should begin with adequate analgesia, and antibiotic therapy can be deferred in children two years or older with mild symptoms 3.
- High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin 3, 4.
- For children with recurrent infections, antibiotic prophylaxis may be beneficial, and referral for insertion of tympanostomy tubes is most appropriate for patients with documented language delay and/or significant medical complications 3, 6.
- Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving pain in children with AOM, but the evidence is limited, and further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol 7.
Prevention of Otitis Media
- Removal of modifiable risk factors should be first-line therapy for prevention of rAOM 5.
- Conjugate pneumococcal vaccine and influenza vaccine can reduce the risk of AOM, and sulfisoxazole prophylaxis should be reserved for children who are immunocompromised or have concurrent disease states exacerbated by AOM 5.
- Exclusive breastfeeding until at least six months of age can also reduce the risk of AOM 4.