A Practitioner's Guideline for Children Suspected of Having a Middle Ear Infection

1999

Prepared by
The New York State Department of Health and
The Capital Region Otitis Project Committee

  • Susan Birkhead, B.S.N., M.P.H., Child Care Consultant, Troy
  • Samuel Bosco, M.D., Chief of Emergency Medicine, St. Peter’s Hospital, Albany
  • Bradley Ford, M.D., Mohawk Valley Physicians’ Health Plan; Pediatrician, Schenectady
  • Foster Gesten, M.D., NYS Department of Health, Office of Managed Care
  • Lyon Greenberg, M.D., Pediatric Otolaryngology, Albany
  • Donna Haskin, B.S.N., NYS Department of Health, Office of Medicaid Management
  • Lyn K. Hohmann, Ph.D., M.D., Capital District Physicians’ Health Plan, Albany
  • Christopher Kus, M.D., M.P.H., NYS Department of Health, Center for Community Health
  • Martha L. Lepow, M.D., Pediatric Infectious Disease Specialist, Albany Medical College
  • Sheila McGuire, R.N., C.N.P., Pediatric Nurse Practitioner, Voorheesville
  • Harry Miller, M.D., Kaiser Permanente/Community Health Plan; Pediatrician, Ellis Hospital, Schenectady
  • William O’Dwyer, M.D., Pediatrician, Latham
  • Richard Propp, M.D., NYS Department of Health, Office of Medicaid Management
  • Patricia Pulver, M.P.H., P.A., Physician Assistant Faculty, Albany Medical College
  • Jacob Reider, M.D., Family Practice Faculty, Albany Medical College
  • Denise Spor, B.A., R.N., NYS Department of Health, Office of Medicaid Management

  1. Criteria for middle ear effusion — presence of 2 of the following:
    1. Decreased or absent mobility
    2. Yellow or white discoloration of the TM
    3. Opacification of the TM (loss of landmarks)
    4. Visible air-fluid interfaces
  2. Criteria for presence of inflammation — two of the following
    1. Otalgia within 24 hours
    2. Distinct bulging or retraction of the TM
    3. Red, inflamed TM
  3. Most children with AOM will resolve spontaneously. Consider observation when
    1. Child is otherwise healthy
    2. Over 2 years of age
    3. No pus draining from the ear
    4. Most recent episode of AOM > 3 months ago
    5. Receptive parents
    6. Medical follow-up assured
  4. First-line antibiotic treatment
    1. TMP/SMX is an alternative in penicillin sensitive children
    2. Duration of treatment: 5 day course is adequate, although some providers may prefer 10 days in selected patients
  5. For detailed review of OME management, see Stool, SE, Berg, AO, Berman, S et al. Otitis Media with effusion in young children. Clinical Practice Guideline, AHCPR Publication no. 94-0622 1994
N. B. Most emergency and urgent care physicians think that the initial treatment of choice in accurately diagnosed patients with AOM includes antibiotics, due to the episodic nature of their practice and lack of assured follow-up. In cases where follow-up in 48 hours is assured, the observation option is a valid choice

Background

Otitis media is the most common childhood infection for which antibiotics are prescribed. By 1 year of age, over 60% of children have had one episode of acute otitis media (AOM), and nearly 20% have had 3 or more episodes.1 By 3 years, 83% of children have had at least one episode of AOM, and 46% have had 3 or more episodes. 1 Accurate differentiation between (AOM) and otitis media with effusion (OME) could reduce the number of unnecessary antibiotic prescriptions by over 6 million each year.2 While antimicrobial treatment has been the standard of care in the United States for AOM, emerging drug resistance in community acquired infections requires practitioners to use antibiotics judiciously.

Scope and Purpose of Guideline

This guideline concerns the diagnosis, treatment and follow-up of AOM and OME in otherwise healthy children aged 6 months to 18 years.

Target Audience

Primary care physicians, mid-level providers, urgent care providers, and ENT physicians.

Key clinical points

  • AOM is distressing, but is not an emergency. Symptomatic treatment with ACETAMINOPHEN or IBUPROFEN may be given immediately. AOM is most appropriately seen in the primary provider’s office. Urgent evaluation may be appropriate if there are signs or symptoms of an associated, more serious illness.
  • Diagnosis should be based on careful pneumootoscopy. No one sign or symptom is diagnostic of AOM. The greater the number and severity of abnormal findings on pneumo-otoscopy, the more likely AOM is present.3 Practitioners should assess the color, position and mobility of the tympanic membrane. Red or opaque color, bulging position, and distinctly impaired mobility have high predictive values when seen together. Color alone, in context of normal position and mobility, has very low predictive value for diagnosis of AOM.
  • OME does not usually require antibiotic treatment. OME may be residual effusion following an episode of AOM, or it may be co-incident with an upper respiratory infection. 4,5
  • Treatment of AOM.
    • In most children, symptoms of AOM will resolve spontaneously,6 and some providers are comfortable observing selected children over two years of age for 48 hours without antibiotics. Nonetheless, the most common practice in the United States has been antibiotic treatment.7
    • Treatment of AOM for five days is as effective as longer courses for both acute and recurrent otitis media. 8
    • Treatment of AOM with second-line agents is no more effective than treatment with first-line agents. 9
    • Symptom relief with ACETAMINOPHEN or IBUPROFEN is usually helpful for the initial phases of the illness. Some providers may choose to use a topical anesthetic drop such as Auralgan, with the understanding that this may preclude accurate observation of the tympanic membrane in subsequent days. 10
    • Follow-up. Children with persistent symptoms should be re-evaluated.
    • To ensure resolution of AOM
      • Children > 15 months. If the parents of a child aged 15 months or older feel that symptoms have resolved, then the likelihood that follow-up otoscopic examination will reveal persistent AOM is less than 2% .11
      • Children < 15 months. No combination of symptoms accurately predicts resolution of AOM. Local consensus advises follow-up at 2-4 weeks in a child who appears to be improving.
    • To detect OME
      • Following AOM, 40% of children will have OME at 1 month, decreasing to 10% at 3 months. 12
      • Otoscopy should be performed at each visit, with appropriate subsequent management if OME is persistent for > 3 months.
  • Recurrent Acute Otitis Media. Greater than 3 or more separate episodes in 3 months, 4 or more in 6 months, or 6 or more in 12 months. Management options include prophylactic antibiotics and tympanostomy tubes. 13 Prophylaxis with SULFISOXAZOLE is preferred over other agents, because it does not promote beta-lactamase, has a long shelf life, and is inexpensive.
  • Environmental risk factor counseling. Several factors are clearly linked with AOM and recurrences: passive smoking, exposure to wood smoke, childcare attendance and bottle-feeding. Parents should be counseled regarding these risk factors.
First-line antibiotics for acute otitis media
Drug Dose/24 hrs. Frequency Comments
AMOXICILLIN 40mg/kg Divided t.i.d. 1st choice. Covers H. influenzae, S. pneumoniae, some staphylococci
TRIMETHOPRIM SULFAMETHOXZOLE Dosage based on TMP component: 8 mg/kg Divided b.i.d Alternative to amox in PCN allergic children. Effective against S. pneumoniae and H. influenzae including some beta-lactamase producers.
“high dose” AMOXICILLIN 80mg/kg Divided t.i.d. 2nd line alternative to 40mg/kg amox – even in cases of PCN-resistant S. pneumoniae

Please Note: The recommendations in this brochure do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

References

1 Teele DW, Klein JO, Rosner B J Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. Infect Dis 1989 Jul; 160(1): 83-94

2 Stool, SE, Berg, AO, Berman, S et al. Otitis Media with effusion in young children. Clinical Practice Guideline. AHCPR Publication no. 94-0622 1994.

3 Pelton SI Otoscopy for the diagnosis of otitis media. Pediatr Infect Dis J 1998 Jun; 17(6): 540-3; discussion 580.

4 Williams RL, Chalmers TC, Stange KC, et al. Use of antibiotics in preventing recurrent acute otitis media and in treating otitis media with effusion. A meta-analytic attempt to resolve the brouhaha. JAMA 1993 Sep 15; 270(11): 1344-51.

5 Moody SA, Alper CM, Doyle WJ Daily tympanometry in children during the cold season: association of otitis media with upper respiratory tract infections. Int J Pediatr Otorhinolaryngol 1998 Oct 2; 45(2): 143-50.

6 Culpepper L, Froom J Routine antimicrobial treatment of acute otitis media: is it necessary? JAMA 1997 Nov 26; 278(20): 1643-1645.

7 Klein JO, McCracken GH Jr Current assessments of diagnosis and management of otitis media. Pediatr Infect Dis J 1998 Jun; 17(6): 539

8 Hueston, WJ, Ornstein, S, Jenkins, RG et al. Treatment of Recurrent Otitis Media after a Previous Treatment Failure: Which antibiotics work best? J Fam Pract. 1999 Jan; 48(1): 43-46.

9 Berman S, Byrns PJ, Bondy J, Smith PJ, Lezotte D Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric Medicaid population. Pediatrics 1997 Oct; 100(4): 585-92

10 Hoberman A, Paradise JL, Reynolds EA, Urkin J Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med 1997 Jul; 151(7): 675-8

11 Hathaway TJ, Katz HP, Dershewitz RA, Marx TJ Acute otitis media: who needs posttreatment follow-up? Pediatrics 1994 Aug; 94(2 Pt 1): 143-7

12 Klein JO, Teele DW, Pelton SI New concepts in otitis media: results of investigations of the Greater Boston Otitis Media Study Group. Adv Pediatr 1992; 39: 127-56.

13 Bluestone CD Role of surgery for otitis media in the era of resistant bacteria. Pediatr Infect Dis J 1998 Nov; 17(11): 1090-8.