eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid

Middle Ear, Acute Otitis Media, Medical Treatment: Follow-up

Author: John D Donaldson, MD, FRCS(C), FAAP, FACS, Chairman, Board of Directors, Lee Memorial Health System; President-elect, Florida Pediatric Society
Contributor Information and Disclosures

Updated: Sep 28, 2009

Follow-up

Further Outpatient Care

  • Reexamine patients within 48 hours if no evidence of decreasing acuity manifests, if symptoms become more severe, or at anytime a complication becomes evident. Otherwise, follow-up care is normally scheduled 10-14 days after the acute event.
  • Persistent middle ear effusion should be expected at the initial follow-up visit; statistically, only 30% of patients show complete resolution. In the absence of acuity, further treatment is unwarranted, but the patient should be scheduled to return at intervals until the effusion resolves.

Deterrence/Prevention

  • Children with recurrent AOM have no effusion within the middle ear cleft between attacks of acute disease. Management of this condition is confined to the following 7 options:
    • Episodic management: Each episode is considered a new attack and is treated with antibiotics; the patient is monitored until the episode resolves.
    • Immunotherapy: Preventative treatment involves the administration of a conjugated heptavalent pneumococcal vaccine. Recent studies indicate that while the vaccine is intended to combat invasive effects in infants, immunized children have a reduced incidence of AOM, a reduced need for antibiotic therapy or tympanostomy tubes, and a reduced risk of invasion or hearing loss.3 No vaccine exists for nontypeable H influenzae. Correspondingly, research has been commenced on immunization against the common viruses that induce AOM, ie, RSV, adenoviruses, influenzae A and B viruses, and rhinoviruses.
    • Antibiotic prophylaxis: This option is becoming less popular as resistant strains emerge. Amoxicillin and sulfisoxazole have both been used extensively. The former has better coverage against S pyogenes but may promote nasopharyngeal colonization with beta-lactam–resistant pneumococci and H influenzae. Reserve prophylaxis for otitis-prone children who are younger than 2 years or in day care and who have had 3 or more attacks in a 6-month period. Both amoxicillin and sulfisoxazole can cause serum sickness reactions.
    • Tympanostomy tube placement: This decreases episodes of AOM. Ventilation has been used more frequently when evidence of MDRSP exists. In the author's practice, resistance is noted most frequently in infants and children aged 6-14 months who are in day care. Tympanostomy tubes are also beneficial in children with recurrent AOM and coexistent reactive airway disease and should be considered when recurrent episodes of AOM destabilize control of other systemic conditions. Examples include alterations in seizure thresholds, otitic hydrocephalus, or control of diabetes. Similarly, early tympanostomy tube placement might be considered for children with sensorineural hearing loss, speech development abnormalities, or learning dysfunction to give the child a consistent hearing model.
    • Control of rhinitis: Control of nasal inflammation in children, whether caused by an allergy or recurrent infection, appears to decrease the recurrence of AOM. Trials are being conducted to determine the efficacy of topical nasal steroids for decreasing middle ear disease, in an attempt to confirm anecdotal information that supports this treatment modality.
    • Environmental manipulation: Some of the risk factors discussed under epidemiology can be removed by such efforts as alteration of child care arrangements, provision of a tobacco-free living space, and cessation of bottle use in children older than 1 year.
    • Adenoidectomy: In children with recurrent AOM, adenoidectomy has demonstrated efficacy. However, determining which children will benefit from this treatment modality is not yet possible. Few pediatric otolaryngologists recommend adenoidectomy initially over tympanostomy tube placement alone, unless coexistent nasal symptoms are present. The procedure might be considered for older children who require replacement of their tympanostomy tubes.

Complications

  • The complications of AOM are classified by location as the disease spreads beyond the mucosal structures of the middle ear cleft. Complications are as follows:
    • Intratemporal - Perforation of the tympanic membrane, acute coalescent mastoiditis, facial nerve palsy, acute labyrinthitis, petrositis, acute necrotic otitis, or development of chronic OM
    • Intracranial - Meningitis, encephalitis, brain abscess, otitis hydrocephalus, subarachnoid abscess, subdural abscess, or sigmoid sinus thrombosis
    • Systemic - Bacteremia, septic arthritis, or bacterial endocarditis

Prognosis

  • With effective antibiotic therapy, the systemic signs of fever and lethargy should begin to dissipate, along with the localized pain, within 48 hours.
    • Note that middle ear effusion and conductive hearing loss can be expected to persist well beyond the duration of therapy, with up to 70% of children expected to have middle ear effusion after 14 days, 50% at 1 month, 20% at 2 months, and 10% after 3 months, irrespective of therapy.
    • Children with fewer than 3 episodes are 3 times more likely to resolve with a single course of antibiotics, as are children who develop AOM in nonwinter months.
    • In most instances, persistent middle ear effusion can merely be observed without antimicrobial therapy; however, a second course of either the same antibiotic or a drug of a different mechanism of action may be warranted to prevent a relapse before resolution.
    • Expect patients to recover the conductive hearing loss associated with AOM.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Medicolegal problems associated with AOM are rare. Problems are primarily related to failure to diagnose and/or appropriately manage a complication of AOM.
 


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Differential Diagnoses & Workup: Middle Ear, Acute Otitis Media, Medical Treatment
Treatment & Medication: Middle Ear, Acute Otitis Media, Medical Treatment
Follow-up: Middle Ear, Acute Otitis Media, Medical Treatment
Multimedia: Middle Ear, Acute Otitis Media, Medical Treatment
References
Further Reading
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Further Reading

Clinical guidelines
Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for medical management of acute otitis media in children 2 months to 13 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2004 Oct. 16 p.

University of Michigan Health System (UMHS). Otitis media. Ann Arbor (MI): University of Michigan Health System (UMHS); 2007 July. 12 p.

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Keywords

acute otitis media, AOM, OM, acute suppurative otitis media, acute otitis, otitis media with effusion, OME, chronic otitis media, COM, ear infection, ear ache, eustachian tube destruction, upper respiratory infection, URI, upper respiratory tract infection, URTI, bacterial ear infection, viral ear infection, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Moraxella catarrhalis, M catarrhalis, Streptococcus pyogenes, S pyogenes, Staphylococcus aureus, S aureus, Streptococcus viridans, S viridans, Pseudomonas aeruginosa, P aeruginosa, staph infection, strep infection, otorrhea, ear bacteremia, middle ear effusion, otalgia, ear tugging, tympanocentesis, myringotomy

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Contributor Information and Disclosures

Author

John D Donaldson, MD, FRCS(C), FAAP, FACS, Chairman, Board of Directors, Lee Memorial Health System; President-elect, Florida Pediatric Society
John D Donaldson, MD, FRCS(C), FAAP, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, and American Society of Pediatric Otolaryngology
Disclosure: Nothing to disclose.

Medical Editor

Carol A Bauer, MD, FACS, Associate Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine
Carol A Bauer, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Neurological Association, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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