9 Diagnosis and Management of Otitis Media
Joint Guidelines From the American Academy of Pediatrics and American Academy
of Family Physicians Richard Neill,
MDCONTENTS
INTRODUCTION
DIAGNOSIS
MANAGEMENT OFPAIN
TREATMENTOPTIONS
TREATMENTFAILURE
RISKFACTORREDUCTION
COMPLEMENTARYMEDICINEAPPROACHES TOAOM SOURCES
INTRODUCTION
Acute otitis media (AOM) is one of the most common reasons for sick child visits in the United States. Controversy over its diagnosis and appropriate man- agement has led the American Academy of Pediatrics and American Academy of Family Physicians to author evidence-based clinical practice guidelines.
These guidelines are used for the healthy children aged 2 mo to 12 yr. The guidelines do not apply to children with underlying conditions that alter the nature of middle ear disease. Underlying conditions include anatomic abnor- malities such as cleft palate and genetic conditions such as Down syndrome, immunodeficiencies, and the presence of cochlear implants.
The guidelines categorize its recommendations according to the strength of evidence supporting the recommendation. Four levels of recommendations
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From: Current Clinical Practice: Essential Practice Guidelines in Primary Care Edited by: N. S. Skolnik © Humana Press, Totowa, NJ
included are the strong recommendation, recommendation, option, and no rec- ommendation. There are six key recommendations included in the guidelines:
1. Recommendation: To diagnose AOM, the clinician should confirm a history of acute onset, identify signs of middle ear effusion, and evaluate for the presence of signs and symptoms of middle ear inflammation (MEI).
2. Strong recommendation: The management of AOM should include an assess- ment of pain. If pain is present, the clinician should recommend treatment to reduce pain (1).
3a. Option: Observation without use of antibacterial agents in a child with uncom- plicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up.
3b. Recommendation: If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. Option: When amox- icillin is used, the dose should be 80–90 mg/kg/d.
4. Recommendation: If the patient fails to respond to the initial management option within 48–72 h, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent, the clinician should change the antibacterial agent.
5. Recommendation: Clinicians should encourage the prevention of AOM through reduction of risk factors.
6. No recommendation: There is insufficient evidence to make a recommendation regarding the use of complementary and alternative medicines (CAMs) for AOM.
DIAGNOSIS
The guidelines provide a common definition of AOM comprised of three required elements: abrupt onset of symptoms, presence of a middle ear effusion (MEE), and signs or symptoms of MEI (seeTable 1). Even with clear criteria for diagnosis, application of the criteria in real life presents many challenges.
For adequate examination, it is often difficult to clear the external canal of ceru- men. Even when visible, documenting MEE can be a challenge.
The biggest diagnostic challenge is differentiating AOM from otitis media with effusion, a similar condition defined by the presence of fluid in the middle ear cavity without signs or symptoms of acute middle ear infection.
A diagnosis of AOM requires all of the following:
1. A history of recent, usually abrupt, onset of signs, and symptoms of MEI.
2. The presence of middle ear effusion that is indicated by any of the following:
a. Bulging of the tympanic membrane.
b. Limited or absent mobility of the tympanic membrane.
c. Air–fluid level behind the tympanic membrane.
d. Otorrhea.
3. Signs or symptoms of MEI as indicated by:
a. Distinct erythema of the tympanic membrane or
b. Distinct otalgia (discomfort clearly referable to the ears that results in inter- ference with or precludes normal activity or sleep).
MANAGEMENT OF PAIN
All patients should have an assessment of pain, including adequate treat- ment, especially within the first 24–48 h of onset. Oral ibuprofen and acetamin- ophen are the mainstays of treatment, although topical agents such as benzocaine may offer a brief incremental benefit in children more than 5 yr old. Home remedies such as external heat or cold, distraction, or oil may have limited effectiveness. Tympanostomy may be used when the potential benefit out- weighs the risk of the procedure.
TREATMENT OPTIONS
Clinicians have two initial treatment options based on the child’s age (i.e., the certainty of the diagnosis and severity of illness). Uncertain diagnosis means less than three diagnostic criteria met from among history, MEE and MEI, whereas severe illness is defined as fever of at least 39°C or moderate to severe otalgia.
Initial observation is appropriate for children 2 yr or older with nonsevere ill- ness without regard to diagnostic certainty. Children 6 mo or older and nonsevere illness might be observed only if the diagnosis is uncertain. Antibiotics should be used in all children 6 mo old and older and in those ages from 6 mo to 2 yr with a certain diagnosis.
Table 1
Diagnosis of Acute Otitis Media A diagnosis of acute otitis media requires all of the following:
1. A history of recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation
and
2. The presence of middle ear effusion that is indicated by any of the following:
a. Bulging of the tympanic membrane
b. Limited or absent mobility of the tympanic membrane c. Air-fluid level behind the tympanic membrane d. Otorrhea
and
3. Signs or symtoms of middle-ear inflammation as indicated by:
a. Distinct erythema of the tympanic membrane or
b. Distinct otalgia (discomfort clearly referable to the ear[s] that results in inter- face with or precludes normal activity or sleep)
In all instances in which observation is chosen, it should be reserved only for children in whom follow-up can be ensured. A parent or adult should be iden- tified who will reliably observe the child, recognize signs of serious illness, and should be able to provide prompt access to medical care, if improvement does not occur.
If antibiotic therapy is chosen, high-dose amoxicillin (80–90 mg/kg/d divided into two or three doses) is the preferred agent for patients with non- severe illness. Patients with severe illness should receive amoxicillin–clavulanate.
Penicillin-allergic patients should receive a second-generation cephalosporin (if no type I allergy) or macrolide (if a type I penicillin allergy). Penicillin- allergic children with severe illness should receive ceftriaxone.
TREATMENT FAILURE
A clear plan for follow-up should be negotiated with the adult caregiver at the initial visit. Improvement in fever, irritability, eating, and sleeping patterns should be expected in the first 48–72 h. If no improvement occurs, either another disease is present or the therapy is inadequate and re-evaluation of the child is warranted.
Children who have failed initial observation should be offered antibiotic therapy as if they are diagnosed initially (amoxicillin for nonsevere illness and amoxicillin–clavulanate for severe illness). Initial amoxicillin failure should be treated with amoxicillin–clavulanate, whereas, initial amoxicillin–clavulanate failure should be treated with ceftriaxone.
Failure of antibiotic treatment in penicillin-allergic children should include ceftriaxone or clindamycin. Failure in penicillin-allergic children with severe illness should be treated with clindamycin preferentially.
Secondary antibiotic therapy failure warrants consideration of tympanocen- tesis for bacterial identification.
RISK FACTOR REDUCTION
Whenever possible, parents should be encouraged to modify or eliminate known risk factors that cause otitis media. Although the magnitude of effect varies among the interventions, encouragement of breast-feeding, reducing child care attendance, avoiding supine bottle feeding, reducing or eliminating pacifier use in the second 6 mo of life, eliminating exposure to passive tobacco smoke, and age-appropriate immunization have all been shown to reduce episodes of AOM.
COMPLEMENTARY MEDICINE APPROACHES TO AOM
The panel found insufficient evidence to make a recommendation regarding the use of CAM for AOM. Treatments studied include homeopathy, acupuncture,and nutritional supplements, although none of them showed convincing evi- dence of benefit. Clinicians should remain aware of parents’ health beliefs and encourage discussion of treatments with an eye toward potential benefits or risks.
SOURCES
1. Diagnosis and Management of Acute Otitis Media. Subcommittee on Management of Acute Otitis Media, American Academy of Pediatrics and American Academy of Family Physicians. Pediatrics 2004, 113(5):1451–1465.
