What is the treatment for otitis media?

Treatment of Otitis Media

Accurate Diagnosis is the Critical First Step

Before initiating any treatment, confirm the diagnosis by documenting middle ear effusion with signs of acute inflammation (bulging, erythematous tympanic membrane) and acute symptoms (ear pain, fever, irritability), as misdiagnosis leads to unnecessary antibiotic use and resistance. 1

Immediate Pain Management for All Patients

• Initiate analgesics (acetaminophen or ibuprofen) within the first 24 hours for every patient with acute otitis media (AOM), regardless of antibiotic decision, as pain relief is the most critical intervention and antibiotics provide no symptomatic benefit in the first 24 hours. 1
• Continue pain management throughout the acute phase, as 30% of children under 2 years have persistent pain or fever even after 3-7 days of antibiotics 1

Decision Algorithm: Antibiotics vs. Observation

Immediate Antibiotics Required For:

• All children <6 months of age 1
• Children 6-23 months with severe AOM (moderate-to-severe otalgia lasting ≥48 hours or temperature ≥39°C) OR bilateral non-severe AOM 1
• Children ≥24 months with severe symptoms 1
• Any age when reliable follow-up within 48-72 hours cannot be ensured 1

Observation Without Immediate Antibiotics Appropriate For:

• Children 6-23 months with non-severe unilateral AOM 1
• Children ≥24 months with non-severe AOM 1
• This requires joint decision-making with parents, a mechanism for follow-up within 48-72 hours, and immediate antibiotic initiation if symptoms worsen or fail to improve 1

First-Line Antibiotic Selection

High-dose amoxicillin (80-90 mg/kg/day divided into 2 doses for children; 1.5-4 g/day for adults) is the definitive first-line antibiotic for most patients with AOM due to its effectiveness against common pathogens, safety profile, low cost, and narrow spectrum. 1

Use Amoxicillin-Clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) Instead When:

• Patient received amoxicillin in the previous 30 days 1
• Concurrent purulent conjunctivitis is present 1
• Coverage for beta-lactamase-producing organisms (H. influenzae, M. catarrhalis) is needed 1

Penicillin Allergy Alternatives:

• Cefdinir (14 mg/kg/day in 1-2 doses), cefuroxime (30 mg/kg/day in 2 doses), or cefpodoxime (10 mg/kg/day in 2 doses) 1
• Ceftriaxone (50 mg IM or IV per day for 1-3 days) 1
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe for non-severe penicillin allergy 1

Treatment Duration

• Children <2 years: 10-day course 1
• Children 2-5 years with mild-to-moderate AOM: 7-day course 1
• Children ≥6 years with mild-to-moderate AOM: 5-7 day course 1

Management of Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours, reassess to confirm AOM diagnosis and switch antibiotics. 1

Second-Line Treatment:

• Switch to amoxicillin-clavulanate if initially on amoxicillin 1
• Switch to intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) if failing amoxicillin-clavulanate, with 3-day course superior to 1-day regimen 1

Multiple Treatment Failures:

• Consider tympanocentesis with culture and susceptibility testing 1
• Consult infectious disease specialist before using unconventional antibiotics 1

Critical Pitfalls to Avoid

• Do not use topical antibiotics for AOM without tympanic membrane perforation or tympanostomy tubes—these are only indicated for tube otorrhea or otitis externa 2
• Do not use corticosteroids routinely for AOM, as current evidence does not support their effectiveness 1
• Do not use antihistamines or decongestants, as they are ineffective 3
• Recognize that antibiotics do not eliminate the risk of complications like mastoiditis, as 33-81% of mastoiditis patients had received prior antibiotics 1

Post-Treatment Expectations and Follow-Up

• 60-70% of children have middle ear effusion at 2 weeks post-treatment, 40% at 1 month, and 10-25% at 3 months—this is otitis media with effusion (OME), not treatment failure 1
• OME requires watchful waiting for 3 months, not antibiotics, unless there is documented hearing loss, bilateral disease with hearing difficulty, or structural abnormalities 1, 3

Recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months)

Prevention Strategies:

• Pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination 1
• Encourage breastfeeding for at least 6 months 1
• Reduce/eliminate pacifier use after 6 months 1
• Avoid supine bottle feeding 1
• Eliminate tobacco smoke exposure 1

Surgical Intervention:

• Consider tympanostomy tube placement for recurrent AOM, with failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy 1
• The additive benefit of adenoidectomy is age-dependent and controversial 4

Otitis Media with Effusion (OME) Management

Watchful waiting for 3 months is the standard approach, as 75-90% of OME resolves spontaneously within this timeframe. 3

• Do not use antibiotics, antihistamines, decongestants, or corticosteroids for OME, as they lack long-term efficacy and may cause harm 3
• Refer to otolaryngology for tympanostomy tubes if bilateral OME persists >3 months with documented hearing loss or significant impact on child's well-being 1, 3
• Children with severe visual impairments require special attention, as they rely more heavily on hearing 3

Tympanostomy Tube Otorrhea

Topical antibiotics (such as ciprofloxacin-dexamethasone) are the treatment of choice for acute tube otorrhea, not oral antibiotics. 4