What is the treatment for otitis media with spontaneous perforation?

Treatment of Otitis Media with Spontaneous Perforation

For otitis media with spontaneous perforation, the first-line treatment is oral amoxicillin (40-90 mg/kg/day divided in 2-3 doses for children; 500-875 mg twice daily for adults) for 7-10 days, with topical ofloxacin drops (10 drops twice daily for 14 days) added for direct treatment of the perforation and middle ear infection. 1, 2

Antibiotic Selection Algorithm

First-line therapy:

• Oral antibiotics:

  • Amoxicillin: 40-90 mg/kg/day divided in 2-3 doses for children; 500-875 mg twice daily for adults 1
  • Duration: 7-10 days

• Plus topical therapy:

  • Ofloxacin otic drops: 10 drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for 14 days 2

Second-line therapy (if no improvement within 48-72 hours):

• Switch to:
  • Amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in 2 divided doses 3, 1
  • Continue topical ofloxacin drops as above

Rationale for Treatment

Spontaneous perforation indicates a more severe infection requiring immediate antibiotic therapy rather than watchful waiting 1. The combination of systemic and topical therapy addresses both the underlying infection and provides direct antimicrobial action at the site of perforation.

Key pathogens to target:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis 3

Amoxicillin remains the standard regimen for AOM as it is effective against most strains of the three major pathogens and is well tolerated 3. However, with increasing beta-lactamase production in H. influenzae (20-30%) and M. catarrhalis (50-70%), a beta-lactamase-stable agent may be necessary in cases of treatment failure 3.

Proper Administration of Ear Drops

1. Warm the solution by holding the bottle in hand for 1-2 minutes to prevent dizziness
2. Position patient with affected ear upward
3. Instill drops into the ear canal
4. Pump the tragus 4 times to facilitate penetration into the middle ear
5. Maintain position for 5 minutes
6. Repeat for opposite ear if necessary 2

Special Considerations

Beta-lactamase producing organisms:

If there is high suspicion of beta-lactamase producing organisms or in areas with high resistance rates, consider starting with amoxicillin-clavulanate instead of amoxicillin 1.

Treatment failure indicators:

• Persistent symptoms after 48-72 hours of therapy
• Worsening of symptoms
• Development of complications 3

Monitoring and Follow-up

• Reassess within 48-72 hours if symptoms persist or worsen 3
• Consider otolaryngology referral if:
  • Perforation does not heal within one month
  • Significant hearing loss is present
  • Vertigo accompanies the perforation
  • Chronic drainage persists despite appropriate antibiotic therapy 1

Complications to Watch For

Without appropriate treatment, complications may include:

• Persistent middle ear effusion
• Chronic suppurative otitis media
• Conductive hearing loss
• Mastoiditis
• Spread of infection to surrounding structures 1

Novel Adjuvant Therapies

For perforations that do not heal with standard therapy, newer approaches being investigated include:

• Tissue-engineered myringoplasty with basic fibroblast growth factor, which has shown 98.1% closure rate compared to 10% with saline in clinical trials 3
• Bioengineered scaffolds to enhance tympanic membrane perforation repair 3

These novel approaches should be considered for referral to specialists if standard therapy fails to achieve perforation closure.