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PaulaTähtinen
JohannaNokso-Koivisto

Acute Otitis Media in Children: Treatment and Follow-Up

Essentials

Treatment Short Course Antibiotics for Acute Otitis Media, Once or Twice Versus Three Times Daily Amoxicillin for Acute Otitis Media, Oral Pain Medications in the Treatment of Ear Pain, Persistence of Effusion in the Middle Ear after an Acute Otitis

  • Analgesics should always be given.
    • Pain evaluation is difficult with small children.
    • In addition to paracetamol (15-20 mg/kg 4 times daily, no more than 60 mg/kg/day, for children from neonates),
      • ibuprofen (10 mg/kg 3 times daily for children ≥ 3 months) or
      • naproxen (5 mg/kg twice daily for children ≥ 12 months).
    • Anaesthetic ear drops, as necessary Anaesthetizing Eardrops in the Treatment of Ear Pain (cinchocaine, available without prescription).
  • Before an antimicrobial drug is started, each case should be considered individually.
    • Take into account the severity of the illness, any adverse effects of the drugs (diarrhoea and increased resistance) and the parents' wishes.
    • An antimicrobial drug should be started if spontaneous perforation has occurred or if there is severe bulging of the tympanic membrane (Images).
      • A bacterial culture sample of secretions from the perforated tympanic membrane should be taken and the antimicrobial treatment specified depending on the results.
      • Antimicrobial medication will cause fever and ear pain to subside more quickly.
      • There is conflicting evidence regarding the impact of antimicrobial treatment on the duration of middle ear effusion.
  • If antimicrobial medication is started
    • The first choice drug is either amoxicillin at a dose of 40 mg/kg/day or amoxicillin/clavulanic acid 40 mg/5.7 mg/kg/day, each divided into 2 daily doses.
    • Amoxicillin/clavulanic acid is also effective against beta lactamase producing bacteria (Moraxella catarrhalis and some Haemophilus influenzae strains).
    • A double dose of amoxicillin is effective against pneumococci with decreased sensitivity.
    • If oral medication cannot be used due to vomiting, for instance, 50 mg/kg/day of i.m. ceftriaxone can be used for 1-3 days.
    • In penicillin allergy, e.g. sulpha-trimethoprim at a dose of 25 mg/8 mg/kg/day divided into 2 daily doses, or a macrolide, is an alternative.
      • Sulpha, however, must not be used in the treatment of spontaneous perforation, since sulpha is not effective against Streptococcus pyogenes bacteria, which cause the most complications.
      • Macrolides have no effect on Haemophilus influenzae bacteria.
    • The usual duration of the antimicrobial treatment is 5 to 7 days.
  • If antimicrobial pharmacotherapy is not started
    • Re-examination is not routinely required. It should be arranged if the parents are worried about the child's health or the symptom picture has changed.
    • Delayed prescribing of antimicrobials Delayed Antibiotic Prescribing for Acute Otitis Media in Children (the prescription is issued but the parents are advised only to start medication if the child shows no clear signs of recovery within 2-3 days) is an alternative.
      • This way, the use of antimicrobials can be reduced, as some children recover without them.
      • Delayed starting of medication does not diminish the effect of the treatment but the waiting time may extend the child's symptoms by, on average, 1-2 days.
  • Myringotomy (tympanocentesis) does not promote healing.
    • It is indicated in some cases in order to clarify aetiology or if the pain is exceptionally severe and not relieved by appropriate pain medication.

The efficacy of various antimicrobial drugs against different bacteria causing acute otitis media is indicated by +++/++/+/-. When selecting the antimicrobial drug to be used, take into account, in addition to the efficacy, also adverse effects and risk of complications. The table can also be shown to the parents when discussing the treatment with them.

Adverse effectsStreptococcus pneumoniae
Common, causes complications		Haemophilus influenzae
Common, may cause complications		Moraxella catarrhalis
Common, does not cause complications		Streptococcus pyogenes
Rare, causes complications
Amoxicillinfew+++++-+++
Amoxicillin/clavulanic acidmany++++++++++++
Sulpha-trimethoprimmany+++++++-
Macrolidesmoderate number++-+++++

Follow-up

  • Routine follow-up examination is no longer recommended.
  • The purpose of a potential follow-up examination is to check that the effusion does not persist for too long.
  • It is normal for middle ear effusion to persist for as long as several weeks after AOM Persistence of Effusion in the Middle Ear after an Acute Otitis.
    • The effusion may cause a slight decrease in hearing ability which will return to normal when the middle ear effusion has disappeared. The effusion does not usually cause any other harm.
  • The need for and timing of a follow-up examination should be considered individually.
    • A follow-up examination should be done in 1-2 months if
      • there is a history of recurrent otitis media
      • a child < 12 months has bilateral otitis media
      • language development is significantly delayed
      • hearing impairment has been diagnosed previously or
      • there is an underlying condition that may increase the risk of prolonged middle ear effusion (such as Down's syndrome, cleft palate, midfacial hypoplasia).
  • If considered appropriate, follow-up examination may be carried out by tympanometry alone Tympanometry.
  • If the effusion has persisted for more than 3 months, the child should be referred to an ear specialist for assessment.

Referral to specialized care

  • An existing or suspected complication (e.g. mastoiditis, facial paralysis): requires emergency referral to an otorhinolaryngologist in specialized care.
  • Referral to specialized care should be considered in the following situations:
    • Symptomatic inflammation persists uninterrupted despite second-line antimicrobial (urgent referral)
    • There are frequent episodes of AOM (≥ 4 episodes/6 months or ≥ 5 episodes/12 months; non-urgent referral); see Recurrent acute otitis media and its prevention Recurrent Acute Otitis Media and its Prevention.
    • There is recurring purulent discharge from a tympanostomy tube or perforation.
    • Purulent ear discharge continues for more than a week despite appropriate treatment.
    • Middle ear effusion persists for more than 3 months (non-urgent referral); see Otitis media with effusion (glue ear) Otitis Media with Effusion (Glue Ear).
    • The child has pre-existing significant hearing impairment (urgency rating as considered appropriate).
    • A child < 3 months of age (urgency rating as considered appropriate).

    References

    • Ruohola A, Laine MK, Tähtinen PA. Effect of Antimicrobial Treatment on the Resolution of Middle-Ear Effusion After Acute Otitis Media. J Pediatric Infect Dis Soc 2018;7(1):64-70 [PubMed]
    • Tähtinen PA, Laine MK, Ruohola A. Prognostic Factors for Treatment Failure in Acute Otitis Media. Pediatrics 2017;140(3): [PubMed]
    • Uitti JM, Tähtinen PA, Laine MK, et al. Close Follow-up in Children With Acute Otitis Media Initially Managed Without Antimicrobials. JAMA Pediatr 2016;170(11):1107-1108 [PubMed]
    • Tapiainen T, Kujala T, Renko M, et al. Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: a placebo-controlled trial. JAMA Pediatr 2014;168(7):635-41 [PubMed]
    • Tähtinen PA, Laine MK, Ruuskanen O, et al. Delayed versus immediate antimicrobial treatment for acute otitis media. Pediatr Infect Dis J 2012;31(12):1227-32 [PubMed]
    • Tähtinen PA, Laine MK, Huovinen P, et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med 2011;364(2):116-26 [PubMed]
    • Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 2011;364(2):105-15 [PubMed]
    • Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics 1991;87(4):466-74 [PubMed]