What is the treatment for otitis media in adults?

Treatment of Otitis Media in Adults

Amoxicillin is the first-line treatment for acute otitis media (AOM) in adults, with initial pain management and consideration for observation without antibiotics in mild cases. 1

Diagnosis

• AOM is diagnosed based on:
  • Recent-onset otalgia (ear pain)
  • Fever
  • Bulging eardrum on otoscopy
  • Middle ear effusion
  • Physical evidence of middle ear inflammation 2, 1

Treatment Algorithm

Step 1: Pain Management

• Begin with adequate analgesia before considering antibiotics
• Options include:
  • Acetaminophen or ibuprofen for systemic pain relief 3
  • Topical analgesics for faster relief (within 10-30 minutes) 3

Step 2: Antibiotic Decision

• For mild symptoms in otherwise healthy adults:

  • Consider observation without antibiotics for 48-72 hours 1
  • Provide clear instructions for follow-up if symptoms worsen

• Immediate antibiotic therapy is indicated for:

  • Severe symptoms (high fever, severe pain)
  • Immunocompromised patients
  • Anatomic abnormalities
  • Complications (mastoiditis, hearing loss)
  • Symptoms persisting beyond 48-72 hours 2, 1

Step 3: Antibiotic Selection

First-line therapy:

• Amoxicillin at high doses (80-90 mg/kg/day, maximum 3 g/day) 3, 2, 1
  • Take with food to reduce gastrointestinal irritation 3
  • Typical duration: 10 days 3

For treatment failures or penicillin allergy:

• Amoxicillin-clavulanate for treatment failures after 48-72 hours of amoxicillin 3, 2
• For non-Type I penicillin allergy:
  • Cefuroxime axetil or cefpodoxime proxetil 3
• For Type I/severe penicillin allergy:
  • Clindamycin (when S. pneumoniae is suspected) 3

Microbiology and Resistance Considerations

• Common pathogens:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis 2, 4
• When perforated eardrum with pus is present:
  • Consider staphylococci and pseudomonas in addition to pneumococci 1
• Avoid trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole due to high resistance rates 3

Follow-up

• Reassess in 48-72 hours if symptoms persist despite antibiotic therapy 3, 2
• Switch to a second-line agent if no improvement after initial therapy 2
• Improvement should be seen within 48-72 hours of starting appropriate antibiotics 3

Special Considerations

• Distinguish otitis media with a perforated eardrum from external otitis 1
• Otitis media with effusion (OME) is defined as middle ear effusion without acute symptoms
  • Antibiotics, decongestants, and nasal steroids are not recommended for OME 2
• Consider probiotic supplements (taken 2 hours before or after antibiotics) to reduce gastrointestinal side effects 3

Referral Indications

• Evidence of anatomic damage
• Persistent hearing loss
• Language delay
• Recurrent infections not responding to treatment
• Persistent middle ear effusion beyond 3 months 2, 5