What is the management of otitis media in Australian children?

Management of Otitis Media in Australian Children

The management of otitis media in Australian children should follow a structured approach that prioritizes watchful waiting for most cases, with antibiotics reserved for specific high-risk situations or when symptoms persist or worsen.

Types of Otitis Media

Otitis media (OM) encompasses several conditions:

• Acute Otitis Media (AOM): Middle ear effusion with signs of acute infection
• Otitis Media with Effusion (OME): Middle ear fluid without acute symptoms
• Chronic Suppurative Otitis Media (CSOM): Persistent ear discharge through a perforated eardrum

Diagnostic Approach

Accurate diagnosis requires:

• History: Acute onset of ear pain, irritability, fever
• Physical examination:
  • Bulging tympanic membrane
  • Limited mobility of tympanic membrane
  • Air-fluid level behind tympanic membrane
  • Otorrhea
  • Distinct erythema of tympanic membrane 1

Management Algorithm for AOM

Initial Management

1. Pain management:

   • Acetaminophen or ibuprofen at age-appropriate doses
   • Topical analgesics may provide additional relief 1

2. Watchful waiting approach (for low-risk children):

   • Appropriate for children ≥2 years with mild symptoms 2
   • Provide parents with clear follow-up instructions
   • Prescribe rescue antibiotics to be used if symptoms persist or worsen after 48-72 hours 2

3. Immediate antibiotic therapy for:

   • Children <2 years of age 3
   • Severe symptoms (moderate to severe otalgia, fever ≥39°C)
   • Bilateral AOM
   • Tympanic membrane perforation with otorrhea
   • High-risk populations (including remote Aboriginal and Torres Strait Islander children) 4
   • Recurrent AOM

Antibiotic Selection

When antibiotics are indicated:

• First-line: High-dose amoxicillin (80-90 mg/kg/day divided in 2-3 doses) for 5-7 days 1, 5
• Second-line (for treatment failure or beta-lactamase-producing organisms):
  • Amoxicillin-clavulanate 1, 3
  • Cefuroxime, cefpodoxime, or cefprozil 1
• For penicillin allergy:
  • Non-type I allergy: Cephalosporins (cefdinir, cefuroxime, cefpodoxime)
  • Type I allergy: Azithromycin or clarithromycin 1, 6

Follow-up

• Reassess within 48-72 hours if symptoms persist or worsen
• Consider tympanometry to assess middle ear status after treatment

Management of OME

1. Watchful waiting for 3 months from diagnosis 2

2. Hearing evaluation if OME persists ≥3 months 2

3. Referral to otolaryngologist if:

   • Persistent bilateral OME >3 months with documented hearing loss
   • Speech/language delays or learning difficulties
   • Recurrent or persistent AOM unresponsive to antibiotics 2

4. Surgical options:

   • Ventilation (tympanostomy) tubes for children with chronic effusions and hearing loss 2
   • Adenoidectomy may be beneficial for children ≥4 years with recurrent or persistent OME 2

Special Considerations for Australian Children

• Urban Aboriginal and Torres Strait Islander children: Consider watchful waiting if low risk for complications 4
• Remote Aboriginal and Torres Strait Islander children: Higher risk of CSOM; more aggressive management may be warranted 4
• Bacterial testing of nasopharyngeal aspirate is recommended for recurrent cases, especially in daycare settings 3

Ineffective Treatments (Not Recommended)

• Antihistamines
• Decongestants
• Intranasal corticosteroids 2

Prevention Strategies

• Pneumococcal vaccination (though benefits for recurrent AOM may be limited) 3
• Reducing risk factors:
  • Limiting daycare attendance when possible
  • Eliminating exposure to tobacco smoke
  • Breastfeeding for infants 1

Common Pitfalls to Avoid

1. Misdiagnosing OME as AOM, leading to unnecessary antibiotic use
2. Inadequate pain management, focusing only on antibiotic therapy
3. Premature referral for tympanostomy tubes before adequate watchful waiting period
4. Using ineffective treatments like decongestants or antihistamines 1
5. Not distinguishing between children at high vs. low risk for complications

The management approach for otitis media in Australian children balances the benefits of reducing antibiotic use through watchful waiting with the need to prevent complications in high-risk populations, ultimately aiming to improve outcomes while practicing antimicrobial stewardship.