What is the management of recurrent otitis media?

Management of Recurrent Otitis Media

Definition and Risk Factors

Recurrent acute otitis media (AOM) is defined as 3 or more episodes in 6 months or 4 or more episodes in 12 months (with at least 1 episode in the preceding 6 months), and management should focus on both acute treatment and prevention strategies. 1

Key risk factors include:

• Winter season, male gender, and passive smoke exposure 1
• Age under 2 years (50% will experience recurrence within 6 months) 1
• Day care attendance and siblings with recurrent AOM history 2

Acute Episode Management

First-Line Antibiotic Therapy

For acute episodes, high-dose amoxicillin (80-90 mg/kg/day divided twice daily) remains the first-line treatment, providing adequate coverage against intermediately resistant Streptococcus pneumoniae. 1, 3

• Treatment duration should be 10 days for children under 2 years and those with severe symptoms 1
• Children 2-5 years with mild-moderate disease can receive 7-day courses 1
• Children 6 years and older with mild-moderate disease should receive 10-day courses 1

Treatment Failures

When amoxicillin fails, switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in a 14:1 ratio) to cover beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis. 1, 4

Alternative second-line options include:

• Ceftriaxone (50 mg/kg once daily for 3 days intramuscularly) 4, 5
• Cefuroxime axetil (30 mg/kg/day) 4

After multiple antibiotic failures, tympanocentesis with culture and susceptibility testing should be performed before considering unconventional agents like levofloxacin or linezolid. 1

Prevention Strategies

Antibiotic Prophylaxis

Antibiotic prophylaxis provides only modest benefit and is NOT routinely recommended. 1

• Prophylaxis reduces AOM episodes by approximately 1 episode per child-year, requiring treatment of 5 children for 1 year to prevent 1 episode 1
• Benefits cease immediately after stopping prophylaxis, with no long-term protective effect 1
• The small benefit must be weighed against cost, adverse effects (allergic reactions, diarrhea), and contribution to antibiotic resistance 1

Tympanostomy Tubes

Tympanostomy tube placement is an OPTION for recurrent AOM, with the decision made jointly between clinician and parents, particularly for children with 6 or more episodes in the preceding year. 1

Evidence for tubes:

• Tubes reduce AOM episodes by 1.5 episodes in the 6 months following surgery 1
• One randomized trial showed no difference between tubes and placebo over 2 years 1
• Tubes improve disease-specific quality-of-life measures 1

For children with previous tubes who present with current infection and functioning tubes still in place, topical antibiotic eardrops are first-line treatment rather than oral antibiotics. 3

Risks include:

• Anesthesia/surgical risks, cost, tympanic membrane scarring, chronic perforation, cholesteatoma, and otorrhea 1

Adenoidectomy

Adenoidectomy may provide additional benefit in preventing recurrent episodes, particularly in children under 2 years of age. 3

Special Considerations

Children with Previous Tubes

If tubes are blocked or extruded and symptoms resemble typical AOM, treat with high-dose amoxicillin as first-line therapy. 3

If tubes are functional with ear drainage present, use topical antibiotic eardrops for faster symptom resolution and reduced antibiotic resistance. 3

Pain Management

Provide acetaminophen or ibuprofen at age-adjusted doses for all children with AOM, regardless of antibiotic choice, as pain relief is a primary treatment goal. 3

Referral Indications

Refer to otolaryngology for:

• Multiple treatment failures 3
• Extruded tubes with continued recurrent infections 3
• Risk factors for speech, language, or learning problems 3

For children with middle ear effusion at assessment, offer new tympanostomy tube insertion; for those without effusion, watchful waiting is appropriate. 3

Key Clinical Pitfalls

Avoid misdiagnosing otitis media with effusion (OME) as recurrent AOM, as OME requires monitoring but not antibiotic therapy. 1 After successful AOM treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months—this is OME, not treatment failure. 1

Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole as second-line agents after amoxicillin failure, as resistance to these agents is substantial. 1