What is the treatment for suppurative otitis media?

Treatment of Suppurative Otitis Media

Distinguishing Acute vs. Chronic Suppurative Otitis Media

The treatment approach fundamentally differs based on whether you are managing acute suppurative otitis media (acute otitis media with purulent effusion) versus chronic suppurative otitis media (CSOM with persistent tympanic membrane perforation and otorrhea). 1

For Acute Suppurative Otitis Media (Acute Otitis Media)

Amoxicillin 80-90 mg/kg/day divided twice daily for 10 days is the first-line antibiotic treatment for most children with acute otitis media. 2 This recommendation is based on its effectiveness against common bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, and narrow microbiologic spectrum. 1, 2

Initial Management Decision Algorithm:

• Immediate antibiotics are indicated for: 2

  • All children under 6 months of age
  • Children with severe symptoms (moderate-to-severe otalgia, otalgia >48 hours, or temperature ≥39°C)
  • Children with bilateral AOM in those under 2 years
  • Patients with concurrent purulent conjunctivitis

• Watchful waiting (observation without immediate antibiotics) is appropriate for: 1, 2

  • Children ≥2 years with mild-to-moderate, unilateral disease
  • Only when reliable follow-up within 48-72 hours is ensured
  • Must provide rescue antibiotic prescription if symptoms worsen or fail to improve

Pain Management:

Address pain immediately in all patients regardless of antibiotic decision, especially during the first 24 hours. 2 Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited. 1

Alternative Antibiotic Regimens:

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) if: 2

• Patient received amoxicillin in the previous 30 days
• Concurrent purulent conjunctivitis is present
• Coverage for beta-lactamase producing organisms (H. influenzae, M. catarrhalis) is needed

For penicillin-allergic patients, use: 2

• Cefdinir 14 mg/kg/day in 1-2 doses
• Cefuroxime 30 mg/kg/day in 2 divided doses
• Cefpodoxime 10 mg/kg/day in 2 divided doses
• Ceftriaxone 50 mg IM or IV daily for 1-3 days

Note that cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these cephalosporins generally safe for non-severe penicillin allergy. 2

Treatment Duration:

• Children <2 years or those with severe symptoms: 10-day course 2
• Children 2-5 years with mild-to-moderate AOM: 7-day course is equally effective 2
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course 2

Treatment Failure Management:

If symptoms worsen or fail to improve within 48-72 hours: 2

• Reassess to confirm AOM diagnosis (not just persistent middle ear effusion)
• Switch to amoxicillin-clavulanate if initially on amoxicillin
• Consider intramuscular ceftriaxone 50 mg/kg/day for 1-3 days if failing amoxicillin-clavulanate 2
• A 3-day course of ceftriaxone is superior to a 1-day regimen for treatment failures 2

Critical pitfall: After successful treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 10-25% at 3 months. 2 This persistent effusion without acute symptoms is otitis media with effusion (OME), not treatment failure, and does not require antibiotics. 2

Recurrent Acute Otitis Media:

For children with recurrent episodes (≥3 episodes in 6 months or ≥4 episodes in 12 months): 1

• Consider tympanostomy tube placement, which reduces treatment failure rates from 34% (no surgery) to 21% (tubes alone) or 16% (tubes with adenoidectomy) 1
• Long-term prophylactic antibiotics are discouraged 1
• Risk reduction strategies include pneumococcal and influenza vaccination, reducing daycare exposure, eliminating tobacco smoke exposure, and limiting pacifier use 1, 2

For Chronic Suppurative Otitis Media (CSOM)

CSOM is defined as persistent tympanic membrane perforation with chronic otorrhea, representing a fundamentally different disease from acute otitis media. 1, 3

Medical Management:

Topical antibiotics combined with aural toilet is more effective than systemic antibiotics alone for resolving otorrhea. 4 The evidence shows:

• Topical treatment (antibiotics or antiseptics) with aural toilet is significantly more effective than aural toilet alone (OR 0.31,95% CI 0.23-0.43) 4
• Topical treatment is more effective than systemic antibiotics (OR 0.46,95% CI 0.30-0.69) 4
• Topical quinolones are superior to non-quinolone topical antibiotics (OR 0.26,95% CI 0.16-0.41) 4
• Combining topical and systemic antibiotics provides no additional benefit over topical antibiotics alone 4

For pediatric CSOM, parenteral antimicrobial therapy with daily aural toilet can achieve resolution in 89% of cases without surgery (mean treatment duration 9.7 days). 5 This approach is particularly relevant for children with tympanostomy tubes who develop CSOM. 5

Surgical Management:

The definitive curative treatment for CSOM is tympanoplasty (surgical closure of the tympanic membrane perforation), not conservative antimicrobial therapy. 3 Medical management controls infection but does not close the perforation. 3

For surgical repair: 1

• Cartilage tympanoplasty provides better structural outcomes (fewer postoperative perforations) than temporalis muscle fascia, though functional hearing outcomes are similar
• Novel adjuvant therapies using fibroblast growth factor with gelatin scaffolds show significantly higher closure rates (98.1% vs 10%) with no adverse events 1

Important distinction: Chronic suppurative otitis media without cholesteatoma is managed differently than CSOM with cholesteatoma, which always requires surgical intervention. 1, 3