Otitis Media: Acute Otitis Media (AOM) and Otitis Media with Effusion (OME)

Effective Date: January 1, 2010

Recommendations and Topics

Scope

This guideline applies to otherwise healthy children over the age of six months presenting with AOM or OME. It does not include children with craniofacial abnormalities, immune deficiencies, complications of AOM (e.g. mastoiditis, facial paralysis, etc.) or serious underlying disease.

Definitions

Acute otitis media (AOM) is defined as the presence of inflammation in the middle ear accompanied by the rapid onset of signs and symptoms of an ear infection.1 Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear without signs and symptoms of an ear infection.

Diagnostic Codes

381 (Nonsuppurative otitis media and Eustachian tube disorders); 382 (Suppurative and unspecified otitis media)

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Prevention and Risk Factors

Hand washing prevents colds and flu - the major risk factor for otitis media.2 Other risk factors for AOM include: environmental tobacco smoke, daycare attendance, pacifier use, and bottle feeding in a supine position.3-5 Breastfeeding5,6 or immunizations24 may offer some protection against AOM.

Diagnosis and Investigation

Children with AOM present with combinations of ear pain (otalgia), loss of landmarks and an opaque, bulging, inflamed tympanic membrane on direct otoscopy. Additional non-specific symptoms include: irritability, fever, night waking, poor feeding, cold symptoms, conjunctivitis and occasional balance problems.7

Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear without acute infection. The child may have ear discomfort but the ear is not acutely painful. The fluid may range from clear to opaque. Decreased mobility on pneumatic otoscopy supports the diagnosis of OME.1

Although pneumatic otoscopy is helpful in the diagnosis of AOM, it is not routinely performed as it may elicit severe pain.

It is important to distinguish between AOM and OME. Ear discomfort, a red tympanic membrane, or fever alone are not specific diagnostic criteria for AOM.7 Pneumatic otoscopy is a useful tool in diagnosing OME.

If acute otitis media (AOM) is diagnosed or suspected, proceed to Part I
If otitis media with effusion (OME) is diagnosed or suspected, proceed to Part II

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Part I: Acute Otitis Media

Management of AOM

For most children, antibiotics are not warranted. Spontaneous resolution of AOM is to be expected in approximately 80 per cent of children.4-10

  • AOM does not always require antibiotics, providing that good follow up is provided.11
  • Aggressively manage pain with adequate systemic analgesics (not ASA).1,12-16
  • If a child is significantly unwell after 48-72 hours of analgesics, treat with antibiotics regardless of age.
  • Decongestants, antihistamines and steroids are not beneficial in the treatment of AOM.4,12,15

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Pharmacological Management*1,4,6,7,11,12,17-20

Table 1: Initial Treatment of AOM for Children Over 6 Months of Age

* Abbreviations: div = divided; TMP/SMX = trimethoprim/sulfamethoxazole
** β-lactam = Any of a class of broad-spectrum antibiotics that are structurally and pharmacologically related to the penicillins and cephalosporins.
*** 10 days of therapy with macrolides is preferred because of lower activity in this class of medication compared to the beta lactams

Duration of Therapy for AOM

Five days of therapy has equal efficacy to the standard ten day regimen in children with uncomplicated AOM and is recommended in children two years of age and over.25 For children less than two years of age or those who present with perforation of the tympanic membrane, ten days of antibiotic therapy are still recommended.26 Failure of initial treatment of AOM with antibiotics is defined as the persistence or worsening of moderately severe symptoms (pain and fever) after three to five days of antibiotic therapy with findings of continued pressure and inflammation (bulging) behind the tympanic membrane.12,13

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Table 2: Failure of Initial Treatment of AOM

*There are two formulations of amoxicillin:clavulanate, 4:1 and 7:1 ratios. Higher doses of clavulanate increase the likelihood of GI side effects. If a patient has failed standard dose amoxicillin, these patients should receive 2 prescriptions: one for amoxicillin and one for the 7:1 ratio of amoxicillin:clavulanate. This combination gives a high dose of amoxicillin plus a therapeutic dose of beta lactamase inhibitor (clavulanate) which is low enough to reduce the risk of diarrhea. If a patient has failed high dose amoxicillin, they are more likely to have an illness caused by a beta lactamase producing bacteria, hence the 4:1 ratio of amoxicillin:clavulanate maximizes the amount of beta lactamase inhibitor (clavulanate) but using this product increases the risk of diarrhea.

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Table 3: Agents NOT Recommended for AOM11

Cephalexin

No activity against Penicillin intermediate resistant S. pneumoniae
No activity against Haemophilus influenzae/ Moraxella catarrhalis

Cefaclor

No activity against Penicillin intermediate resistant S. pneumoniae
Marginal activity against Haemophilus influenzae/ Moraxella catarrhalis

Cefixime

No activity against Penicillin intermediate resistant S. pneumoniae
Excellent activity against Haemophilus influenzae

Ceftriaxone

Routine use of this agent is not recommended due to potential for increased resistance to 3rd generation cephalosporins. May be an option in severe cases who have failed therapy, in immunosuppressed patients or neonates. NB: 3 days of IM/IV therapy recommended. (single dose not as effective in eradicating penicillin resistant S. pneumoniae)

Clindamycin

No activity against Haemophilus/ Moraxella spp.(Clindamycin may be an option for S. pneumoniae in severe penicillin allergic patients)

Erythromycin

Poor activity against Haemophilus influenzae
Significant macrolide resistance in S. pneumoniae

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On Going Care

  • Re-examine child if he/she is not improving within 48 to 72 hours.
  • If perforation occurs, this is not a serious complication as this generally heals without intervention.Water and objects such as cotton tip swabs should be kept out of the ear canal. There is no need to refer to an otolaryngologist for a simple rupture of the tympanic membrane. Manage as for AOM. Refer to an otolaryngologist if the perforation does not heal in six weeks.
  • Routine follow-up examination is not required until three to six months post-infection to evaluate OME.
  • Refer to an otolaryngologist urgently if complications occur such as: facial paralysis or mastoiditis (symptoms include fever and persistent, throbbing otalgia; signs include purulent otorrhea, redness, swelling, tenderness, and fluctuation over the mastoid process; the pinna is typically displaced laterally and inferiorly).
  • Refer to an otolaryngologist electively if three or more episodes of AOM occur in six months or four episodes of AOM occur in 12 months.

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Rationale for AOM Recommendations

Studies have demonstrated that the number needed to treat during initial treatment may be as high as 20 to effect one cure and a greater percentage of children who receive antibiotics experience side effects such as vomiting, diarrhea and rash than those who receive placebo.5,7,9,27-30

Twenty to 30 per cent of episodes of AOM are caused by viruses.1,4,13,15,28 Determining which cases of AOM are caused by bacteria is often challenging. Bacterial pathogens include S. pneumoniae, non-typable Haemophilus influenzae, Moraxella catarrhalis, Group A streptococcus, and S. aureus.1 S. pneumoniae has the lowest spontaneous resolution rate and carries the highest morbidity.

Pneumatic otoscopy can detect the presence of fluid behind the tympanic membrane;1 however, the pressure applied to an already infected ear may worsen the pain and should not be done. Perforation of the tympanic membrane allows the fluid to drain from the middle ear and often hastens the healing process. Rarely, meningitis, facial paralysis, and mastoiditis complicate an episode of AOM and require urgent medical or surgical referral.

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Part II: Otitis Media with Effusion (OME)

OME is associated with ear discomfort and recurrences of acute otitis media (AOM) and often follows an episode of AOM. Transient hearing loss is frequently associated with OME. Spontaneous resolution of OME occurs in 90 per cent of patients within three months of infection.20,31

On Going Care

When OME has been present for at least 12 weeks, observation is advised at 3 month intervals until the resolution of effusion. If there are concerns of ‘significant’ hearing loss or structural abnormalities of the tympanic membrane, a formal hearing evaluation and referral to an otolaryngologist is recommended.9,20,26,27,29,30

Note: Decongestants, antihistamines, steroids, and antibiotics are NOT recommended in the treatment of OME.20

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Rationale for OME Recommendations

After an episode of AOM, fluid will be present in 50 per cent of patients after one month, in 25 per cent of patients after two months, and in 10 per cent of patients at three months.28,30,31 Pneumatic otoscopy can be a useful clinical skill to help detect the presence of fluid behind the tympanic membrane.1 OME does not require antibiotic treatment.

While OME has been linked to hearing loss and impaired development in children, recent evidence indicates that persistent middle-ear effusion in otherwise normal children does not cause long term developmental impairments.8,10,30Surgical treatment of chronic OME may prevent middle ear complications, including: atelectatic tympanic membrane, permanent conductive hearing loss, cholesteatoma, etc. If a child does become a candidate for surgery, tympanostomy tube insertion is the preferred initial procedure.7

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References

  1. Alberta Medical Association. Guideline for the diagnosis and treatment of acute otitis media in children. Alberta Clinical Practice Guidelines Program 2000.
  2. Ear Infections. ADAM, Harvard Medical School, Report #78 2007.
  3. Niemela M, Pihakari O, Pokka T, Uhari M. Pacifier as a risk factor for acute otitis media: a randomized, controlled trial of parental counselling. Pediatrics 2000;106:483-488.
  4. Rosenfeld RM, Bluestone CD. Evidence-based otitis media. Hamilton, Ont: BC Decker Inc; 1999.
  5. Neto J, Hemb L, Brunelli E, Silva D. Systematic Literature Review of modifiable risk factors for recurrent acute otitis media in childhood. J Pediatr (Rio J) 2006;82(2):87-96.
  6. Toward Optimized Practice. Guideline for the Diagnosis and Management of Acute Otitis Media, Alberta Clinical Practice Guidelines: Towards Optimized Practice, 2008 Update.
  7. Pichichero ME. Acute otitis media: Part I. Improving diagnostic accuracy. Am Fam Phys. 2000;61:2051-2056.
  8. Le Saux N, Gaboury I, Baird M et al.A randomized, double -blind, placebo-controlled non-inferiority trial of amoxicillin for clinically diagnosed acute otitis media in children 6 month to 5 years of age. Can Med Assoc J. 2005;172(3):335-341.
  9. Paradise JL, Feldman HM, Campbell TF et al. Typanostomy tubes and developmental outcomes at 9-11 years of age. N Engl J Med. 2007;356:248-61.
  10. Park TR, Brooks JM, Chrischilles EA, Bergus G. Estimating the effects of treatment rate changes when the benefits are heterogeneous: Antibiotics and Otitis Media, Value in Health. 2008;11(2):304-314.
  11. Blondel-Hill E, Fryters S. Bugs and Drugs. Capital Health; Edmonton AB, 2006.
  12. Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of otitis media in children. Bloomington, MN: Institute for Clinical Systems Improvement; 2008.
  13. Canadian Paediatric Society. Antibiotic management of acute otitis media. Clinical Practice Guideline ID 97-03. Paediatr Child Health. 1998;3:265-267.
  14. Agency for Healthcare Research and Quality. Management of acute otitis media: summary. June 2000. Available from:http://www.ahcpr.gov/clinic/epcsums/otitisum.htm
  15. Walsh RM, Bath AP, Hawke M, Rutka JA. Acute otitis media: four out of five kids. Can J Diag 1999;16:106-121.
  16. Ipp M. New evolving strategies for the management of acute otitis media. Pediatr Child Health 1999;4:451-457. Available from:http://www.pulsus.com/Paeds/04_07/ipp_ed.htm
  17. Segal N, Leibovitz E, Dagan R, Leiberman A. Acute otitis media diagnosis and treatment in the era of antibiotic resistant organisms: Updated clinical practice guidelines. Int. J of Pediatr Otorhinolaryngol. 2005;69:1311-1319.
  18. Ramakrishnana K, Sparks R, Berryhill W. Diagnosis and treatment of Otitis Media. Am Fam Physician. 2007;76:11:1650- 1658.
  19. Pichichero M, Casey J. AOM: Making sense of recent guidelines on antimicrobial treatment. J Fam Pract. 2005; 54(4): 313-322.
  20. American Academy of Pediatrics. Otitis Media Guideline Panel. Managing otitis media with effusion in young children. Pediatrics. 1994;94:766-793.
  21. Rovers M, Schilder A, Zielhuis G et al. Otitis Media. The Lancet. 2004;363:465-473.
  22. Spiro D, Arnold D. The concept and practice of a wait and see approach to acute otitis media. Curr Opin Pediatr. 2008;20: 72-78.
  23. McCormick D, Chonmaitree T, Pittman,C et al. Nonsevere acute otitis media: A clinical trial comparing outcomes of watchful waiting vs. immediate antibiotic treatment. Pediatrics. 2005:115(6):1455-1465.
  24. Lieberthal, MD. Acute Otitis Media Guidelines: Review and Update. Curr Allergy Asthma Rep. 2006;6:334-341.
  25. Klein JO. Microbiologic efficacy of antibacterial drugs for acute otitis media. Pediatric Infectious Disease Journal. 1993;12:973- 5.
  26. Dowell S, Butler J, Giebink S et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance – a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. 1999;18:1-9.
  27. Del Mar CB, Glasziou PP, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta- analysis. BMJ. 1997;314:1526-1529.
  28. Worall G. Acute Otitis Media. Can Fam Physician. 2007;53: 2147-2148.
  29. Rovers MM, Ingels K, van der Wilt GJ et al. Otitis media with effusion in infants: Is screening and treatment with ventilation tubes necessary? CMAJ. 2001;165:1055-1056.
  30. Berman S. The end of an era in otitis research. N Engl J Med. 2007;356(3):300-302.
  31. Mandell E, Casselbrant M. Recent Developments in the Treatment of Otitis Media with Effusion. Drugs. 2006; 66(12):1565-1576.

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Resources:

For parents: http://www.dobugsneeddrugs.org
For physicians: http://www.bugsanddrugs.ca
Link to CPS for drug monographs: http://www.e-therapeutics.ca

Appendices

Appendix A - Prescription Medication Table for Acute Otitis Media (PDF, 88KB)

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This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.
Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site:
Clinical Practice Guidelines

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

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