What are the next steps for treating acute otitis media (AOM) with tympanic membrane perforation in a 3-year-old child?

From the Guidelines

For a 3-year-old with acute otitis media (AOM) and eardrum perforation, immediate antibiotic treatment is recommended. The most recent and highest quality study is not available in the provided evidence, but based on the available studies, amoxicillin at 80-90 mg/kg/day divided twice daily for 10 days is considered first-line therapy 1. If the child has taken antibiotics in the past 30 days or has severe symptoms, consider amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) instead, as suggested by the 2003 study 1.

Pain management with acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) is important to alleviate symptoms. It is crucial to keep the ear dry by avoiding water entry during bathing and swimming until the perforation heals. A follow-up appointment in 2-3 weeks should be scheduled to confirm healing of the perforation. Most small perforations heal spontaneously within weeks, but persistent perforations beyond 3 months may require ENT referral.

The goals of antimicrobial therapy for AOM, as outlined in the 1992 study 1, include the rapid resolution of signs and symptoms of disease, sterilization of the middle ear effusion, prevention of suppurative sequelae, reduction of the occurrence of relapse and recurrences, and decrease in time spent with middle ear effusion. The preferred antimicrobial agent should be active against S. pneumoniae, H. influenzae, and M. catarrhalis, which are the most common bacterial pathogens causing AOM.

Key considerations in managing AOM with eardrum perforation include:

• Monitoring for signs of worsening infection such as increasing pain, fever, dizziness, or facial weakness, which would warrant immediate medical attention
• Ensuring the child completes the full course of antibiotic therapy to prevent recurrence and reduce the risk of complications
• Providing guidance to parents on how to manage their child's symptoms and prevent further complications.

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 3-year-old child with acute otitis media (AOM) and tympanic membrane perforation, the next steps for treatment would be to:

• Administer azithromycin at a dose of 30 mg/kg as a single dose, or
• Administer azithromycin at a dose of 10 mg/kg once daily for 3 days, or
• Administer azithromycin at a dose of 10 mg/kg as a single dose on the first day, followed by 5 mg/kg/day on Days 2 through 5. 2

From the Research

Treatment Options for Acute Otitis Media (AOM) with Tympanic Membrane Perforation

• For a 3-year-old child with AOM and tympanic membrane perforation, the treatment options include oral antibiotics, such as amoxicillin/clavulanic acid 3, or topical antibiotics, such as hydrocortisone-bacitracin-colistin eardrops 4.
• The choice of treatment depends on the severity of the infection, the presence of other symptoms, and the risk of complications.

Oral Antibiotics

• Amoxicillin/clavulanic acid is a well-established broad-spectrum antibacterial treatment that is effective and well-tolerated in the treatment of AOM in pediatric patients 3.
• High-dose amoxicillin/clavulanic acid (90/6.4 mg/kg/day) may be considered for children with AOM caused by penicillin-intermediate and -resistant S. pneumoniae 3.
• However, a study found that high-dose amoxicillin did not have a significant benefit over standard-dose amoxicillin in children with AOM who were at low risk for infection with antibiotic-resistant bacteria 5.

Topical Antibiotics

• Topical antibiotics, such as hydrocortisone-bacitracin-colistin eardrops, may be effective in treating AOM with tympanic membrane perforation, as they can directly enter the middle ear and reduce the risk of systemic side effects 4.
• A study is currently underway to compare the effectiveness of topical antibiotics with oral antibiotics in children with AOM and ear discharge due to a spontaneous tear or perforation of the eardrum 4.

Expectant Observation

• For children with mild AOM, an expectant observational approach may be justified, as most cases of AOM spontaneously remit without complications 6.
• A study found that immediate antibiotics may not reduce the risk of pain at 11 to 14 days, and may increase the risk of vomiting, diarrhea, or rash 6.
• However, children with severe bulging of the tympanic membrane may benefit most from antimicrobial treatment of AOM 7.