Acute Otitis Media in Children

By Ah-See, Kim

CLINICAL REVEW 1. Epidemiology and aetiology

Acute otitis media is predominantly a disease of young children under three years of age with a peak incidence between six and 11 months. By the age of one year, 60 per cent of children will have suffered one and 17 per cent at least three episodes.

It is the most common reason for antibiotic prescription in children in the US.

In the UK, about 30 per cent of children under the age of three visit their GP each year and up to 97 per cent will receive antimicrobial treatment.

Inflammatory condition

Otitis media refers to any inflammatory condition of the middle ear space. It can be categorised into acute, recurrent acute, otitis media with effusion (glue ear) and chronic suppurative otitis media.

Acute otitis media is characterised by rapid onset of local signs and symptoms of inflammation and infection, often following a viral URTI.

The most common organisms in the UK and US are Haemophilus influenza, Streptococcus pneumoniae and Moraxella catarrhalis.

The most important risk factors for infections are young age, male gender and attendance at day care centres.

Other risk factors are listed in the box above. The prognosis of acute otitis media is good.

With symptomatic treatment alone, 60 per cent of children will have improved within 24 hours and in 80 per cent the condition will have resolved within three days. Serious complications are rare.

Acute suppurative otitis media: symptoms have a rapid onset, often following a URTI

Risk factors for acute otrtis media in children

Major

* Young age.

* Male gender.

* Attendance at day care centre.

Minor

* History of tonsillitis.

* Enlarged adenoids.

* Asthma.

* Multiple previous episodes.

* Bottle feeding.

* Recurrent ear infections in parents or siblings.

2. Diagnosis

Acute otitis media is a clinical diagnosis. Most commonly, the child will have suffered flu-like symptoms or a viral URTI prior to the onset of acute otitis media. It develops rapidly with local and systemic signs apparent over several hours. Otalgia is the cardinal sign. Otorrhoea might also be present. Other signs include fever, malaise, ear pulling, irritability and cough.

Investigations

The most reliable examination is otoscopy, to identify a red and bulging tympanic membrane with impaired mobility. If the tympanic membrane is of normal colour, a diagnosis of acute otitis media is unlikely.

Culture of ear discharge offers no advantage for the management of acute otitis media. Cultures of middle ear fluid gained via tympanocentesis offer more accurate diagnosis of the causative organism.

This does not influence the management and is not feasible in the primary care setting.

By the time culture results become available, acute otitis media in the majority of cases will have resolved.

Complications

Uncomplicated acute otitis media is limited to the middle ear cleft.

Serious complications are rare in otherwise healthy children, but can include hearing loss, mastoiditis, meningitis and recurrent infections.

Suppurative complications occur in less than 0.5 per cent of patients if antibiotics are withheld.

Resolution of acute otitis media is marked by cessation of pain and improved otoscopic appearances.

Key points

* Most children diagnosed with acute otitis media do not require antibiotics.

* However, children who are more severely ill are more likely to benefit from early antibiotic intervention.

* Delayed antibiotic treatment (prescription collected at parent’s discretion if the child has not improved within 72 hours) is an approach often used in primary care.

* If an antibiotic is to be prescribed, a conventional five-day course is recommended and is as effective as a prolonged 10-day course.

* The role of surgery in recurrent acute otitis media remains unclear.

3. Managing the condition

Internationally, there are different approaches to the treatment of acute otitis media. In the US, antibiotics are routinely used, while in the Netherlands antibiotics are only used in about one- third of cases.

The use of antibiotics has come under increased scrutiny as resistant and multi-resistant bacteria have become more prevalent.

The natural course of acute otitis media is of spontaneous resolution within 24 hours or 72 hours at most. It is therefore debatable whether antibiotic use in the short term is of benefit, especially as antibiotics can lead to side-effects like diarrhoea, nausea and vomiting, and rashes.

‘Wait and see’ approach

Guidelines have been introduced and most suggest a ‘wait and see’ approach with analgesia only for up to three days and the option of antibiotic treatment at that stage if the child has not improved clinically. The recommendations for children under the age of two differ around the world. In the UK it is the same as for older children and does not include early antibiotics unless the child is systemically unwell.

No benefit has been demonstrated for the use of longer antibiotic courses (seven to 10 days) over shorter courses (five to seven days). The recommended antibiotics are amoxicillin (or erythromycin if allergic) as first-line treatment and co-amoxiclav as second- line treatment. Further interventions that have not proven to be helpful are decongestants and antihistamines.

There is little evidence to support the surgical option of myringotomy. Two randomised controlled trials showed higher rates of persistent infection with myringotomy and placebo compared with antibiotic alone, while one randemised controlled trial found no benefit from either intervention.

Based on current trials, the use of pneumococcal vaccine for prevention of acute otitis media is not yet recommended. There is insufficient evidence to support the use of long-term antibiotics for the prevention of recurrent otitis media.

Contributed by Mr Kim Ah-See, consultant ENT surgeon, Aberdeen Royal Infirmary

Copyright Haymarket Business Publications Ltd. Aug 3, 2007

(c) 2007 GP. Provided by ProQuest Information and Learning. All rights Reserved.