eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Otitis Media: Treatment & Medication

Author: Brenda Liz Natal, MD, Clinical Assistant Instructor and Staff Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate, Brooklyn
Coauthor(s): Jennifer H Chao, MD, FAAP, Clinical Assistant Professor of Pediatric Emergency Medicine, University Hospital of Brooklyn; Attending Physician, Pediatric Emergency Department, Kings County Hospital, Brooklyn
Contributor Information and Disclosures

Updated: Nov 2, 2009

Treatment

Emergency Department Care

• Diagnostic certainty is based on all 3 of the following criteria: acute onset, middle ear effusion (MEE), and middle ear inflammation.
• Severe illness is defined as moderate-to-severe otalgia or temperature greater than 39°C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39°C.

Diagnosis: The definition of acute otitis media (AOM) is relatively uniform; however, the diagnosis is not always as clear. It is this uncertainty in diagnosis which may lead to overdiagnosis and unnecessary antibiotic use or to underdiagnosis and an increase in complications.

• Overdiagnosis of acute otitis media is frequently a result of all of the following:
  • Difficulty in differentiating AOM from otitis media with effusion (OME)
  • Difficulty in confirming middle ear effusion
  • Poor compliance with guidelines for diagnosis (Diagnosis of AOM meets all 3 of the criteria: rapid onset, presence of MEE, and signs and symptoms of middle ear inflammation.)
• Several studies have demonstrated the difficulty and inconsistency with which practitioners diagnose acute otitis media.^7,8 In a study of inter-rater agreement of AOM in children, Blomgren et al noted a substantial discrepancy concerning practitioner impressions of the tympanic membrane. The clinicians agreed only on 64% of the diagnoses of AOM. The use of a pneumatic otoscopy and tympanometry reduces the number of acute otitis media diagnoses by greater than 30%, suggesting that acute otitis media is misdiagnosed often.⁹

Treatment recommendations are as follows:

• Infants younger than 6 months should receive antibiotics.
• Children aged 6 months to 2 years should receive antibiotics if the diagnosis is certain. If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere, and antibiotic therapy can be considered for severe illness.
• Children aged 2 years and older should receive antibiotics if the diagnosis is certain and if the illness is severe. An observation period is an option when the diagnosis is uncertain or when it is certain and nonsevere.
  • The observation option is a 48- to 72-hour period of symptomatic treatment with analgesics and without antibiotics.
  • For an observation option to be considered, the parent or caregiver must be able to communicate with the clinician and have access to follow-up care whenever problems ensue or symptoms worsen.
  • Pain management is an important part of treating AOM. Appropriate analgesics should be offered.
  • If prescribed antibiotics, children younger than 2 years old and those aged 2-5 years with severe disease should receive 10-days of therapy. For those who are 6 years old and older with mild to moderate disease, 5-7 days is appropriate.
  • Studies in the ED setting have shown that the observation option is both feasible and well accepted.^10,11
• Recent studies have also shown that, despite adequate access to clinical guidelines, the prescribing rates for antibiotics in AOM in some emergency departments remain high.¹²

Criteria for Initial Antibacterial Agent Treatment or Observation in Children With Acute Otitis Media²

Open table in new window

Consultations

• In general, patients with acute otitis media seen in the ED should be referred to a primary care provider for follow-up care.
• Patients discharged with or without antibiotic therapy should be reexamined 4-6 weeks after their initial presentation for evidence of middle ear aeration.
• Patients whose symptoms (eg, pain, fever) do not resolve within 48-72 hours of treatment should be reevaluated.  
• Patients with persistent symptoms or recurrent acute otitis media (AOM) should be referred to an otorhinolaryngologist for evaluation and possible tympanocentesis.

Medication

• Studies have shown that antibiotics provide little benefit beyond placebo in mild cases of acute otitis media (AOM).
• Infants with frequent recurrences may be considered for daily antibiotic prophylaxis with sulfamethoxazole or amoxicillin for a period of several months. However, the decrease in frequency of recurrent episodes is small to none.^13,14
• The potential consequences of excessive antibiotic use are also well known, and newer recommendations are that antibiotic prophylaxis for AOM should be avoided whenever possible.
• The management of AOM should always include assessment of pain and fever. Antipyretics and analgesics may be necessary and should be prescribed liberally. Steroids, decongestants, and antihistamines are not effective in the treatment of AOM, and they may cause complications.
• Several complimentary and/or alternative medicine (CAM) therapies, such as homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements, have been used by parents/caregivers for the treatment of AOM. The preferred therapy is largely dependent on cultural background and/or practices. Data supporting complimentary and alternative therapies are limited and controversial. Currently, there are no recommendations for the use of CAM for the treatment of AOM.²
• If antibiotic therapy is chosen, the AAP and FAAP recommend that amoxicillin 80-90 mg/kg/d is the antibiotic of choice. The length of treatment is 10 days for younger children and patients with severe illness, otherwise, a 5- to 7-day course is appropriate.
• Routine use of the conjugated heptavalent pneumococcal vaccine (PCV 7) in children younger than 2 years may have changed the microbiology of AOM in vaccinees, by increasing the proportion of gram-negative bacteria as a cause; in which case, an antibiotic with beta-lactamase activity may be preferable. Currently though, the recommendations for antibiotics remain unchanged.¹⁵
• If additional beta-lactamase-positive H influenzae and/or Moraxella catarrhalis coverage is desired, high-dose amoxicillin and clavulanate potassium is recommended.
• If the patient is allergic to amoxicillin, alternatives are cefdinir, cefpodoxime, or cefuroxime if the allergic reaction is not a type 1 hypersensitivity. Patients with type 1 hypersensitivity should be given azithromycin or clarithromycin. Other alternatives are clindamycin and ceftriaxone given intravenously or intramuscularly. Ceftriaxone 50 mg/kg/d is recommended for children who are unable to take oral antibiotics and for patients with compliance problems.
• In patients whose condition fails to improve after initial antibiotic therapy, a 3-day course of ceftriaxone offers outcomes better than those of a 1-day course.
• When prescribing antibiotics to the pediatric population, one also has to consider the probability of noncompliance to therapy. In this age group, the palatability of a drug may influence adherence to treatment. If prescribing cephalosporins, consider the use of cefdinir (Omnicef) as it has a more accepted taste when compared with the other recommended cephalosporins (eg, cefuroxime).¹⁶
• Topical quinolones are the preferred agents for the treatment of AOM in children with tympanostomy tubes (AOMT) and/or perforations. The treatment options for AOMT, as discussed in a clinical review by Schmelzle et al include systemic or topical antibiotics. Topical treatment with fluoroquinolones is superior than systemic antibiotics and results in less antibiotic resistance and fewer adverse effects (ototoxicity) than other treatments.¹⁷
• Topical aminoglycosides should be avoided and not used to treat the draining ear because of potential ototoxicity.¹⁷
• Addition of dexamethasone to a topical antibiotic may decrease the length of time necessary for middle ear drainage when compared with a topical antibiotic alone. The evidence for superior outcomes with the addition of steroids is lacking strength, and the addition of the steroids to the management exacerbates overall treatment costs; and this may lead to nonadherence to treatment.¹⁷

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Cefdinir (Omnicef)

Used to treat acute bacterial otitis media. Classified as a third-generation cephalosporin and inhibits mucopeptide synthesis in the bacterial cell wall. Typically bactericidal, depending on organism susceptibility, dose, and serum or tissue concentrations.

Ofloxacin (Floxin)

Inhibits bacterial growth by inhibiting DNA gyrase.

Amoxicillin (Amoxil, Biomox)

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Inexpensive and effective, even in populations with certain highly resistant bacteria.

Amoxicillin and clavulanate potassium (Augmentin)

Drug combination treats bacteria resistant to beta-lactam antibiotics. For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin and clavulanate ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Analgesics

Relief of pain is one of the prime functions of effective treatment. Oral analgesics or topical medications may be required for relief of pain. Appropriate doses of acetaminophen or ibuprofen are available in tablet or liquid form. Codeine may be used as an ancillary agent; however, it may provoke emesis or constipation.

Benzocaine (Americaine, Cylex)

Inhibits neuronal membrane depolarization, blocking nerve impulses. Drops may be used as local anesthetic, with some benefit.

Acetaminophen (Tylenol, Tempra, Panadol)

Used worldwide for antipyretic effects and mild analgesic effects. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or with oral anticoagulation. May be used with ibuprofen for additive effects.

Ibuprofen (Motrin, Ibuprin, Advil)

DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Approved for use in children. Available as inexpensive liquid form, allowing for effective dosing in infants.

• Search for CME/CE on This Topic »

• Middle Ear, Acute Otitis Media, Medical Treatment (Otolaryngology and Facial Plastic Surgery)
• Complications of Otitis Media (Otolaryngology and Facial Plastic Surgery)
• Middle Ear, Acute Otitis Media, Surgical Treatment (Otolaryngology and Facial Plastic Surgery)
• Middle Ear, Otitis Media With Effusion (Otolaryngology and Facial Plastic Surgery)

• PAS 2009: AAP Guidelines for Acute Otitis Media May Encourage Overtreatment
• Broad-Spectrum Antibiotic Use for Otitis Media Increased
• Monitoring, Aggressive Treatment Key for Otitis Media in Transplant Candidates

• When Do Adults With Otitis Media With Effusion Need an ENT Referral?
• URIs and the Development of Acute Otitis Media
• Novel Type of Streptococcus pneumoniae Causing Multidrug-Resistant Acute Otitis Media in Children

• Otitis Media Resource Center