New Guidelines Improve Treatment of Otitis Media

Nurse Practitioner, Oct 2004 by Simmons, Susan

Acute otitis media (AOM), usually referred to as an ear infection, is the most common infection diagnosed in children today. It is also the most common pédiatrie infection to be treated with antibiotics. The estimated number of antibiotic prescriptions written for otitis media is 809 per 1,000 visits, translating to more than 20 million prescriptions each year. This led to concerns regarding overuse and inappropriate use of antibiotics, as well as the increasing resistance to antibiotics in the United States. In response to these concerns, the American Academy of Pediatrics (AAP) in conjunction with the American Academy of Family Physicians (AAFP) recently released new guidelines for the management of AOM in children ages 2 months to 12 years.

Many countries in Europe have already adopted the practice of treating symptoms only in uncomplicated cases of AOM to cut back on the unnecessary usage of antibiotics. Indeed, without actual aspiration (tympanocentesis) and culture of a red, bulging tympanic membrane (TM), it cannot be ascertained whether the infection is bacterial or viral. As a result, the treatment of AOM with an antibiotic may not occur unless symptoms fail to abate or worsen.

The AAP and AAFP took the cue from Europe and devised these guidelines to apply to uncomplicated otitis media in children where no signs of a more serious systemic infection or concomitant infection are evident, and in children who do not have other comorbid conditions that may make them more susceptible to complications of AOM. Potential comorbid conditions include, but are not limited to, cleft palate, Down's syndrome, immunodeficiency syndromes, cochlear implants, and recurrence (less than 30 days) of AOM in the presence of chronic otitis media with effusion. Mastoiditis, which was the reason to initiate antibiotics for AOM, has not increased in countries where the "watch and wait" philosophy has been instituted. The current guidelines outline the following six recommendations for AOM management.

* Accurate Diagnosis

First, the practitioner must be able to clinically diagnose AOM. The clinical definition and diagnosis of AOM are: acute onset of signs and symptoms, presence of middle-ear effusion (MEE), and signs and symptoms of middle-ear inflammation. Signs and symptoms of AOM include otalgia, irritability, otorrhea, and/or fever. The guidelines suggest that in infants, otalgia may be represented by pulling/tugging the ear. Note, however, that these signs and symptoms are not specific for AOM, with the exception of otorrhea, and may represent an uncomplicated upper respiratory infection (URI). Because symptoms associated with AOM are, for the most part, nonspecific for AOM, symptoms and history do not have adequate predictive value for the diagnosis of AOM.

Signs associated with the presence of MEE include a bulging TM, limited or absent mobility of the TM, air-fluid level behind the TM, and otorrhea. Mobility of the TM should be ascertained via the use of pneumatic otoscopy, which may be difficult in an infant or younger child due to cooperation problems. Also, in order to correctly use pneumatic otoscopy, several factors are necessary: the correct speculum size to create a seal, and the otoscope must have good lighting. The canal also must be free of cerumen. Tympanometry and acoustic reflectometry can also be used to help establish TM mobility.

Signs and symptoms of middle-ear inflammation also include erythema of the TM or distinct otalgia that interferes with normal activity such as sleep. The guidelines state that when combined with erythema and mobility, bulging is the best predictor of AOM. Other causes of erythema should be considered, including crying and fever.

It must also be determined if the child has otitis media with effusion or AOM. Otitis media with effusion, or serous otitis media, is more common than AOM and may accompany URIs, allergic rhinitis, and elevation changes such as when flying.

* Treatment of Pain

The second recommendation of the guideline states that management of AOM should include treatment of pain. Treatment of pain may include over-the-counter (OTC) analgesics, home remedies, topical agents, homeopathic agents and narcotics, as well as tympanostomy or myringotomy. Undoubtedly, tympanostomy and myringotomy must only be performed by those skilled in the procedure.

* Antibiotics: When to Prescribe

The third recommendation of the guideline calls for observation and withholding antibiotics in children wilh uncomplicated AOM and no comorbid factors. The withholding of antibiotics is also based on diagnostic certainty, age, severity of the illness, and means for adequate follow-up. Observation, or the "wait and see" approach, involves monitoring the child for resolution of symptoms within 48 to 72 hours. However, there are exceptions. For infants younger than 6 months of age, it is still recommended to prescribe antibiotics even if the diagnosis of AOM is uncertain, due to the increased risk of complications in this age group. If the diagnosis of AOM is uncertain in children aged 6 months to 2 years, and if the child is severely ill, having a fever ≥ 39.0°C or moderate-to-severe otalgia, antibiotics should be considered. Again, one reason for these exceptions to observation is that acute mastoiditis is more common in infants and young children and may even be the initial presentation of AOM. Note, however, that even with increased use of antibiotics, the incidence of mastoiditis is the same as using observation for 48 to 72 hours. There is also no compelling evidence that supports withholding antibiotic treatment of suspected AOM increases the incidence of bacterial meningitis or pneumonia.