What is the treatment for otitis media?

Treatment of Otitis Media

For acute otitis media (AOM), treatment should include pain management for all patients, with antibiotics reserved for specific cases based on age and severity, while otitis media with effusion (OME) initially requires watchful waiting with possible surgical intervention for persistent cases. 1, 2

Acute Otitis Media (AOM) Treatment

Pain Management

• Pain relief is considered paramount in all treatment guidelines and should be addressed regardless of whether antibiotics are prescribed 1, 2
• Analgesics should be continued as long as needed to control pain, especially during the first 24 hours 1

Initial Management Decision: Observation vs. Antibiotics

Immediate Antibiotic Treatment Indicated For:

• Children <6 months of age 1, 2
• Children 6-23 months with severe AOM (moderate to severe otalgia or fever ≥39°C) 1, 2
• Children 6-23 months with bilateral AOM, even if non-severe 1, 2
• Children ≥24 months with severe symptoms 1, 2
• Patients with specific risk factors (immune deficiency, Down syndrome) 3

Observation With Delayed Antibiotics Appropriate For:

• Children 6-23 months with non-severe unilateral AOM 1, 2
• Children ≥24 months with non-severe AOM 1, 2
• When observation is chosen, a mechanism must be in place to ensure follow-up and initiation of antibiotics if symptoms worsen or don't improve within 48-72 hours 3, 1

Antibiotic Selection When Indicated

• First-line: High-dose amoxicillin (80-90 mg/kg/day divided into two doses) for patients without penicillin allergy 1, 4
• Alternative first-line for patients who received amoxicillin in the previous 30 days, have concurrent purulent conjunctivitis, or have high risk of resistant organisms: Amoxicillin-clavulanate 1, 5
• For penicillin-allergic patients: Cefdinir, cefpodoxime, or cefuroxime 1
• For treatment failures after 48-72 hours: Switch to amoxicillin-clavulanate or consider a single dose of intramuscular ceftriaxone 5, 6

Follow-up

• Reassess if symptoms worsen or fail to improve within 48-72 hours 1
• If initially managed with observation, begin antibiotics if symptoms persist 1, 7
• If initially treated with antibiotics, change to a second-line agent if symptoms persist 1

Otitis Media with Effusion (OME) Treatment

Initial Management

• Watchful waiting is recommended initially for most cases 2
• Age-appropriate hearing testing should be performed at diagnosis 2
• Medical treatments (antibiotics, decongestants, nasal steroids) are not recommended as they do not hasten clearance of middle ear fluid 4
• Follow-up is recommended at 3 months with repeated hearing testing 2

Surgical Intervention

• Tympanostomy tubes (TTs) are recommended in selected cases with:
  • Bilateral OME persisting for ≥3 months 2
  • Hearing loss (varies across guidelines from >25 to >40 dB HL in the better ear) 2
  • Impact on child's well-being, behavior, and development 2
• Concomitant adenoidectomy and/or tonsillectomy are recommended only if there is concomitant pathology 2
• Parents should be involved in the decision-making process 2

Chronic Otitis Media Treatment

Surgical Options

• For chronic perforations, cartilage tympanoplasty provides better structural outcomes (fewer postoperative TM perforations) than temporalis muscle fascia, though hearing outcomes are similar 2
• Novel adjuvant therapies like gelatin sponge scaffolds with fibroblast growth factor (b-FGF) show promise for TM perforation repair 2

Prevention Strategies

• Reduce risk factors where possible:
  • Modify daycare attendance patterns 1, 2
  • Encourage breastfeeding for at least six months 1
  • Avoid supine bottle feeding 1
  • Reduce tobacco smoke exposure 2, 1
• Immunization with pneumococcal conjugate vaccines and influenza vaccine is recommended 1, 2

Common Pitfalls and Caveats

• Overdiagnosis of AOM is common - up to 50% of AOM diagnoses may not be supported by physical examination findings, leading to unnecessary antibiotic prescriptions 8
• Delayed antibiotic treatment does not worsen overall recovery from AOM but may be associated with transient worsening of symptoms and parental work loss 7
• Chronic otitis media requires specialist referral as it can lead to significant hearing loss and potential complications if left untreated 9
• Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist 4