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JohannaNokso-Koivisto
PaulaTähtinen

Recurrent Acute Otitis Media and its Prevention

Essentials

  • The incidence of acute otitis media is highest in children aged 6-24 months.
  • Recurrent acute otitis media is associated with recurrent upper respiratory tract infections Viral Respiratory Infection and Acute Otitis Media.
  • To avoid risk factors, it is essential to reduce infection exposure.
  • Starting at a day care centre increases the number of viral upper respiratory tract infections and consequently of cases of acute otitis media.
  • When considering surgical treatment, it important to assess the overall situation.
    • If there are few risk factors and the season is associated with a low level of infections, watchful waiting is sufficient.
    • If there are several risk factors and the infection season is beginning, the patient should be referred to specialized care.
  • If the child has a history of many other bacterial infections or severe infections requiring hospital treatment, consider consulting a paediatrician to detect any immunodeficiency.

Definition

  • In international guidelines, recurrent acute otitis media in children is usually defined as acute purulent otitis media 3 times in 6 months or 4 times within a year.

Prevention of recurrent otitis media Probiotics for Preventing Acute Otitis Media in Children, Adenoidectomy for Otitis Media in Children

  • The parents or caregivers of children with recurrent otitis media should be informed about the risk factors of otitis media and the possibilities for influencing the number of infections.
  • Avoiding risk factors
    • The most significant risk factor is viral upper respiratory tract infection. Any measures for reducing upper respiratory tract infections are most effective in preventing acute otitis media.
      • Washing hands with soap and water prevents rhinovirus infections.
    • Avoiding large groups of children
      • Day care in smaller groups or at home
    • Avoiding exposure to tobacco smoke
      • Smoking by parents or caregivers, even outside, increases the risk of recurrent infections.
      • Smoking parents are more often nasopharyngeal carriers of bacteria.
    • Stopping using a dummy
  • Xylitol five times daily will reduce the occurrence of otitis media but, in practice, such use is challenging in young children Xylitol for Prevention of Acute Otitis Media.
    • Orodispersible xylitol tablets can also be used by smaller children.
  • The efficacy of prophylactic antimicrobial treatment Antibiotics for the Prevention of Acute and Chronic Suppurative Otitis Media in Children in preventing otitis media is insignificant and such treatment should only be used exceptionally, after careful consideration.
  • The preventive efficacy of (influenza Influenza Vaccines for Preventing Acute Otitis Media in Infants and Children and pneumococcal Pneumococcal Vaccines for Preventing Otitis Media) vaccines is minor because otitis media is caused by a wide spectrum of microbes.
    • Nevertheless, vaccination can be used to prevent individual infections and thus to reduce the use of antimicrobial medication.
  • Surgical treatment
    • The decision to operate must always be made individually, and any advantages or disadvantages of surgical procedures should first be assessed by an otorhinolaryngologist.
    • Tympanostomy tubes Grommets (Ventilation Tubes) for Recurrent Acute Otitis Media in Children are beneficial for patients in whom the middle ear does not become discharge-free between episodes.
      • Constant discharge may be a sign of eustachian tube dysfunction, and a tympanostomy tube may help to keep the middle ear aerated.
      • A tympanostomy tube will probably not prevent recurrent infections but it can alleviate symptoms and facilitate diagnosis and taking samples for bacterial culture.
    • Adenoidectomy should not be performed to prevent recurrent otitis media in young children .
  • Nasal decongestants or decongestant/antihistamine combinations , nasal glucocorticoids or probiotics 7 are not useful in preventing recurrent otitis media.

Referral to specialized care

  • If the criteria for recurrent otitis media are fulfilled, consider referral for assessment by an otorhinolaryngologist.
    • Patients with at least 4 separate episodes of acute otitis media within 6 months or at least 5 episodes of acute otitis media within a year.
    • However, the patient's overall situation, such as risk factors, underlying diseases and severity of symptoms, must be taken into account.
    • If there are few risk factors, watchful waiting is sufficient for the time being.
      • Factors favouring watchful waiting include age over 2 years, home care, no genetic susceptibility and heading towards a season with less infections (summer).
      • Beginning day care may lead to a vicious cycle of infections that often eases up after six months.
  • Recurrent purulent discharge from the ear either from a tympanostomy tube or from rupture (see Ear with tympanostomy tube Tympanostomy Tubes).
  • If the child has a history of other bacterial infections, severe infections requiring hospital treatment or difficult intestinal or skin symptoms in addition to recurrent otitis media, consider referral for assessment by a paediatrician.

    References

    • Rosenfeld RM, Tunkel DE, Schwartz SR. Office Insertion of Tympanostomy Tubes and the Role of Automated Insertion Devices. Otolaryngol Head Neck Surg 2022;166(2):219-223 [PubMed]
    • Hoberman A, Preciado D, Paradise JL, et al. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media. N Engl J Med 2021;384(19):1789-1799 [PubMed]
    • Marchisio P, Bortone B, Ciarcià M, et al. Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention. Pediatr Infect Dis J 2019;38(12S Suppl):S22-S36 [PubMed]
    • Chonmaitree T, Trujillo R, Jennings K, et al. Acute Otitis Media and Other Complications of Viral Respiratory Infection. Pediatrics 2016;137(4): [PubMed]
    • Nokso-Koivisto J, Marom T, Chonmaitree T. Importance of viruses in acute otitis media. Curr Opin Pediatr 2015;27(1):110-5 [PubMed]
    • Kujala T, Alho OP, Luotonen J, et al. Tympanostomy with and without adenoidectomy for the prevention of recurrences of acute otitis media: a randomized controlled trial. Pediatr Infect Dis J 2012;31(6):565-9 [PubMed]
    • Hatakka K, Blomgren K, Pohjavuori S, et al. Treatment of acute otitis media with probiotics in otitis-prone children-a double-blind, placebo-controlled randomised study. Clin Nutr 2007;26(3):314-21 [PubMed]
    • Niemelä M, Pihakari O, Pokka T, et al. Pacifier as a risk factor for acute otitis media: A randomized, controlled trial of parental counseling. Pediatrics 2000;106(3):483-8 [PubMed]

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