What is the treatment for otitis media?

Treatment of Otitis Media

For acute otitis media (AOM), treatment should begin with adequate pain management followed by antibiotics for severe cases or high-risk patients, with high-dose amoxicillin as first-line therapy and amoxicillin-clavulanate for recurrent cases or recent amoxicillin use. 1, 2

Diagnosis and Classification

Otitis media presents in several forms:

• Acute Otitis Media (AOM): Middle ear inflammation with rapid onset of symptoms and signs of infection
• Recurrent AOM: ≥3 episodes in 6 months or ≥4 episodes in 12 months
• Otitis Media with Effusion (OME): Middle ear fluid without signs of acute infection

Treatment Algorithm for Acute Otitis Media

Step 1: Pain Management

• Essential for all patients regardless of antibiotic prescription 1, 2
• Use acetaminophen or ibuprofen for pain relief
• Consider topical analgesics for additional relief

Step 2: Antibiotic Decision

Based on age, symptom severity, and risk factors:

Immediate Antibiotic Therapy for:

• Children <6 months of age
• Children 6-23 months with severe symptoms (moderate to severe otalgia, fever ≥39°C)
• Children 6-23 months with bilateral AOM regardless of severity
• Children with otorrhea (drainage from ear)
• Children with high-risk conditions 1, 2

Observation Option (Watchful Waiting) for:

• Children 6-23 months with unilateral AOM without severe symptoms
• Children ≥24 months with bilateral or unilateral AOM without severe symptoms 1, 2
  • Requires reliable follow-up within 48-72 hours
  • Provide prescription to be filled if symptoms worsen or don't improve

Step 3: Antibiotic Selection

First-line therapy:

• High-dose amoxicillin: 80-90 mg/kg/day divided in 2 doses for 5-10 days 1, 2, 3
  • Effective against most S. pneumoniae strains
  • Duration: 10 days for children <2 years; 5-7 days for children ≥2 years

Alternative first-line therapy (if used amoxicillin in past 30 days or has concurrent conjunctivitis):

• Amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses 2, 4
  • Provides coverage for beta-lactamase-producing H. influenzae and M. catarrhalis
  • Clinical trials showed 87% efficacy at end of therapy 4
  • Significantly lower incidence of diarrhea with twice-daily dosing (14%) compared to three-times-daily dosing (34%) 4

For penicillin allergy:

• Non-type I hypersensitivity: Cefdinir, cefuroxime, or cefpodoxime
• Type I hypersensitivity: Azithromycin or clarithromycin
  • Note: Azithromycin showed lower efficacy (82%) compared to amoxicillin-clavulanate in eradicating pathogens 5

Step 4: Treatment Failure Assessment

• Reassess if symptoms worsen or fail to improve within 48-72 hours 2
• For treatment failure with initial amoxicillin:
  • Switch to amoxicillin-clavulanate
• For treatment failure with amoxicillin-clavulanate:
  • Consider ceftriaxone or specialist consultation 2

Management of Recurrent Acute Otitis Media

Medical Management:

• Amoxicillin-clavulanate is the drug of choice for recurrent cases 2
• Preventive strategies:
  • Reduce risk factors (day care attendance, tobacco smoke exposure) 1
  • Pneumococcal conjugate and influenza vaccines 1
  • Long-term prophylactic antibiotics are generally discouraged 1

Surgical Options:

• Consider referral for tympanostomy tubes for children with:
  • ≥3 episodes in 6 months or ≥4 episodes in 12 months 2
  • Persistent middle ear effusion with hearing loss 1
• The additive benefit of adenoidectomy to tympanostomy tubes remains controversial and age-dependent 1, 2

Management of Otitis Media with Effusion (OME)

• Watchful waiting is recommended initially for most cases 1
• Age-appropriate hearing testing is essential 1
• Medical treatments (antibiotics, decongestants, nasal steroids) are not recommended 3
• Surgical intervention with tympanostomy tubes is recommended for:
  • Bilateral OME lasting >3 months
  • Significant hearing loss (>25-40 dB)
  • Impact on child's development, behavior, or well-being 1

Common Pitfalls to Avoid

• Overdiagnosis and overtreatment: Ensure accurate diagnosis with proper otoscopic examination 1, 2
• Inadequate pain management: Always address pain regardless of antibiotic decision 1, 2
• Inappropriate antibiotic selection: Using first-line amoxicillin for recurrent cases when broader coverage is needed 2
• Inadequate dosing: Using standard doses rather than high-dose regimens 2
• Relying on macrolides: Azithromycin has higher failure rates compared to amoxicillin-clavulanate 2, 5
• Failing to consider surgical options: Tympanostomy tubes should be considered for frequent recurrences 2
• Misinterpreting persistent effusion: Middle ear effusion often persists after successful treatment (60-70% at 2 weeks) and does not indicate treatment failure if symptoms have resolved 2