What is the best course of action for a 6-year-old male with a history of recurrent otitis media, allergic rhinitis, and reactive airway disease, presenting with left ear discomfort?

From the Guidelines

The patient, a 6-year-old male with a history of recurrent otitis media, allergic rhinitis, and reactive airway disease, should not be started on antibiotic treatment at this time, given his current afebrile state and denial of ear pain during the office visit, as supported by the most recent guideline on tympanostomy tubes in children 1. The decision to hold off on antibiotic treatment is based on the absence of active infection signs and the patient's upcoming ENT and audiology appointments in August.

• The child's history of multiple ear tube placements (three sets, with the most recent in June) and the pulmonology finding of increased fluid behind the tympanic membrane suggest ongoing middle ear issues that are being managed with antihistamines.
• Watchful waiting with the option to start antibiotics if symptoms worsen is a reasonable approach to avoid unnecessary antibiotic use while ensuring prompt treatment if a bacterial infection develops, as recommended by the guideline on diagnosis and management of acute otitis media 1.
• The mother should contact ENT to schedule an appointment for cerumen (earwax) removal, which may be contributing to the child's ear discomfort.
• The patient's allergic rhinitis and reactive airway disease should be managed concurrently, with consideration of the potential interactions between the upper and lower airways, as noted in the guideline on the diagnosis and management of rhinitis 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

For a 6-year-old male patient, the dose would depend on the patient's weight.

• If the patient weighs between 25-37 kg (approximately 55-81 lbs), the recommended dose is 15 mL (300 mg) for the 3-day regimen or 22.5 mL (900 mg) for the 1-day regimen.
• If the patient weighs between 38-50 kg (approximately 84-110 lbs), the recommended dose is 30 mL (1200 mg) for the 3-day regimen or 37.5 mL (1500 mg) for the 1-day regimen. However, no antibiotic was prescribed at this time. The patient is to start the antibiotic if a fever develops or ear pain increases. Key points:
• The patient has a history of recurrent otitis media and has had tubes inserted three times.
• The patient is currently afebrile and denies any ear pain.
• The decision to hold off on antibiotics was made after discussing treatment options with the mother.
• The mother has been advised to call the ENT to schedule an appointment for cerumen removal. 2

From the Research

Patient Presentation and History

• The patient is a 6-year-old male with a history of reoccurring otitis media, allergic rhinitis, and reactive airway disease.
• He has had three sets of tubes, with the last set being in June, and has follow-up appointments with ENT and audiology in August.
• The patient presented with ear pain in his left ear after getting off the school bus, but currently denies any ear pain and is afebrile.

Treatment Options and Decisions

• The decision was made to hold off on antibiotics at this time, with a prescription sent to the pharmacy in case the patient develops a fever or increasing ear pain.
• The patient's mother was advised to call ENT to schedule an appointment for cerumen removal, as increased fluid was noted in the patient's ear during a previous pulmonology visit 3.
• The use of antihistamines, such as second-generation antihistamines, may have increased efficacy in the treatment of otitis media with effusion (OME) and acute otitis media (AOM) due to their greater selectivity for histamine receptors and lack of anticholinergic activity 4.

Evidence for Treatment

• Acute otitis media (AOM) is typically diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa 3.
• Treatment for AOM includes pain management plus observation or antibiotics, depending on the patient's age, severity of symptoms, and whether the AOM is unilateral or bilateral 3.
• Amoxicillin-clavulanate is often recommended as the first-line antibiotic for AOM, with high-dose amoxicillin (80-90 mg per kg per day) being the therapy of choice for uncomplicated AOM in children 5, 6.
• Alternative antibiotics, such as azithromycin, may be effective in treating AOM, but their efficacy compared to amoxicillin-clavulanate is still being studied 5, 7.