From the Guidelines
Referral to an ENT specialist is not immediately recommended for children under 2 years with recurrent acute otitis media (AOM) without middle ear effusion (MEE), as the natural history is quite favorable and benefits of tympanostomy tubes for this clinical indication are uncertain. According to the most recent guideline update 1, children with recurrent AOM without MEE at the time of assessment for tube candidacy do not have a reduced incidence of AOM with tympanostomy tube insertion. Before considering referral, ensure proper diagnosis of each AOM episode with documented signs of acute inflammation. Initial management should include appropriate antibiotics such as amoxicillin (40-50 mg/kg/day divided twice daily for 10 days) for first-line treatment, or amoxicillin-clavulanate for treatment failures, as well as pain management with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) 1.
Key Considerations
- ENT referral is particularly warranted if the child has complications like hearing loss, speech delays, or persistent effusion beyond 3 months, as noted in the 2013 guideline 2.
- The specialist may consider tympanostomy tube placement for children with recurrent AOM and MEE, as it helps ventilate the middle ear, equalize pressure, and prevent fluid accumulation, addressing the anatomical factors that predispose young children to recurrent infections.
- While awaiting the ENT appointment, continue treating acute episodes and consider preventive measures like avoiding secondhand smoke exposure, limiting pacifier use after 6 months of age, and ensuring proper feeding position.
Exceptions and Special Considerations
- At-risk children, children with histories of severe or persistent AOM, immunosuppression, prior complication of otitis media, or multiple antibiotic allergy or intolerance may require earlier referral and consideration of tympanostomy tube insertion 1.
- The 2022 update 1 emphasizes the importance of watchful waiting for children with recurrent AOM without MEE, as about two-thirds of children can be managed successfully without requiring tympanostomy tube insertion.
From the Research
ENT Referral for Recurrent AOM in Children Under 2
- The decision to refer a child under 2 with recurrent Acute Otitis Media (AOM) to an ENT specialist for tympanostomy tube insertion is supported by several studies 3, 4, 5, 6.
- A study from 1986 found that tympanostomy tube insertion was effective in reducing the incidence of AOM in children with recurrent episodes 3.
- A 2018 Cochrane review of five randomized controlled trials (RCTs) found that grommet (tympanostomy tube) insertion was more effective than active monitoring, antibiotic prophylaxis, and placebo medication in reducing the frequency of AOM recurrences in children 4.
- However, a 2021 study published in the New England Journal of Medicine found that tympanostomy-tube placement did not significantly reduce the rate of AOM episodes in children 6 to 35 months of age compared to medical management 5.
- The American Academy of Pediatrics recommends tympanostomy tube insertion for children with recurrent AOM and an abnormal ear examination at the time of clinic evaluation 6.
- Topical fluoroquinolone agents, with or without a corticosteroid, are recommended for the treatment of acute otitis media with tympanostomy tubes due to their effectiveness and lower risk of ototoxicity and antibiotic resistance 7.
Indications for Tympanostomy Tube Insertion
- Recurrent AOM (three or more episodes in six months, or four or more in one year) 4, 6
- Abnormal ear examination at the time of clinic evaluation 6
- Presence of middle ear effusion (OME) at the time of initial visit 3