What is the treatment for otitis media?

Treatment of Otitis Media

The treatment of otitis media should follow a structured approach based on the type of otitis media, patient age, symptom severity, and risk factors, with pain management as the cornerstone of treatment regardless of whether antibiotics are prescribed. 1, 2

Types of Otitis Media and Initial Management

Acute Otitis Media (AOM)

• Pain relief should be addressed immediately using oral analgesics such as acetaminophen or ibuprofen, regardless of antibiotic prescription decision 1, 2
• Treatment decisions should be based on age and symptom severity:
  • For children <6 months: Immediate antibiotic therapy is recommended 1
  • For children 6-23 months with severe AOM or bilateral non-severe AOM: Immediate antibiotic therapy is recommended 1
  • For children 6-23 months with non-severe unilateral AOM: Either antibiotics or observation with close follow-up (watchful waiting) 1
  • For children ≥24 months with severe AOM: Immediate antibiotic therapy 1
  • For children ≥24 months with non-severe AOM: Either antibiotics or observation with close follow-up 1

Otitis Media with Effusion (OME)

• Watchful waiting is recommended initially for most cases 3
• Medical treatment is generally discouraged 3
• Follow-up is recommended at 3 months with repeated hearing testing 3
• Surgical intervention (tympanostomy tubes) should be considered for:
  • Bilateral OME persisting >3 months 3
  • Significant hearing loss (varies across guidelines from >25 to >40 dB HL in better ear) 3
  • Impact on child's well-being, behavior, or development 3

Antibiotic Selection When Indicated

• First-line therapy: High-dose amoxicillin (80-90 mg/kg/day divided into two doses) 1, 4
• Alternative first-line options for penicillin allergy:
  • For non-type I hypersensitivity: cefdinir, cefpodoxime, or cefuroxime 1, 2
  • For type I hypersensitivity: azithromycin or clarithromycin 2
• Second-line therapy (if patient received amoxicillin in past 30 days, has concurrent purulent conjunctivitis, or fails initial therapy):
  • Amoxicillin-clavulanate (high-dose) 1, 5
  • Clinical efficacy rates for amoxicillin-clavulanate in pediatric AOM are approximately 87% at end of therapy and 67% at follow-up 5

Follow-up and Treatment Failure

• If symptoms worsen or don't improve within 48-72 hours:
  • Reassess to confirm AOM diagnosis 1, 2
  • Begin antibiotics if initially managed with observation 1, 2
  • Change to a second-line agent if initially treated with antibiotics 1, 2
• Delayed initiation of antibiotics after watchful waiting does not significantly worsen overall recovery but may be associated with prolonged symptoms of fever, ear pain, poor appetite, and decreased activity 6

Prevention Strategies

• Reduce modifiable risk factors:
  • Modify daycare attendance patterns when possible 1
  • Encourage breastfeeding for at least six months 1
  • Avoid supine bottle feeding 1
  • Reduce or eliminate pacifier use after six months of age 1
  • Minimize tobacco smoke exposure 3, 1
• Immunization:
  • Pneumococcal conjugate vaccines (PCVs) 3, 1
  • Annual influenza vaccine 3, 1

Special Considerations

• Accurate diagnosis is essential - studies show up to 50% of AOM diagnoses may not be supported by physical examination findings, leading to unnecessary antibiotic prescriptions 7
• Watchful waiting with proper instructions has been shown to result in 57% fewer filled prescriptions 7
• For chronic or recurrent cases, referral to an otolaryngologist may be necessary, especially with evidence of anatomic damage, hearing loss, or language delay 4

Common Pitfalls to Avoid

• Failing to provide adequate pain management, which should be the priority regardless of antibiotic decision 1, 2
• Prescribing antibiotics for otitis media with effusion, which does not benefit from antibiotics 3, 4
• Using decongestants or nasal steroids for otitis media with effusion, which do not hasten clearance of middle ear fluid 4
• Misdiagnosing AOM based on inadequate physical examination findings, leading to inappropriate antibiotic use 7