Otitis Media

3.03 Otitis Media

Presentation
Adults and older children will complain of ear pain. There may or may not be accompanying symptoms of upper respiratory infection. In younger children and infants, parents may report that their child is irritable and sleepless, with or without fever, and possibly pulling at his ears. The tympanic menbrane is inflammed and may be bulging with loss of landmarks. It may be dull or opacified with reduced mobility on pneumatic otoscopy. and may or may not be accompanied by otorrhea.
What to do:



Investigate for any other underlying illness.



Inquuire as to whether or not the patient has had a recent or unresponsive ear infection, and whether or not the patient has recently been on an antibiotic.



If the patient has no recent histoyr of otitis media or antibiotic use, then prescribe an appropriate dose of amoxicillin for ten days. Trimethoprim plus sulfamethoxazole may be substituted in the penicillin-allergic patient.



More expensive antibiotics such as amoxicillin plus clavulinate, erythromycin plus sulfamethoxazole, and cephalosporins should be reserved for treatment failures and where there is associated illness requiring a beta-lactamase-stable antimicrobial



Provide pain and fever control with acetaminophen or ibuprofen elixir.



Recommend a ten-day follow-up examination on all patients under two years of age and in those cases where the parents do not feel the infection has resolved or where a child's symptoms persist, there is a family history of recurrent otitis or the accuracy of the parental observations may be in doubt.
What not to do:



Do not overlook serious underlying illness such as meningitis.



Do not prescribe antihistamines or decongestants. These drugs do not decrease the incidence nor hasten the resolution of otitis media. Antihistamines can make children drowsy and decongestants can cause irritability.
Discussion
Most otitis is caused by a viral infection, and most patients do well regardless of the antibiotic chosen. Despite the increase in antimicrobial resistance of community-acquired Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and the plethora of alternative antibiotics available, amoxicillin remains the drug of choice, because it concentrates in middle ear fluid.
References:



Niemela M, Uhari M, Jounio-Ervasti K et al: Lack of specific symptomology in children with acute otitis media. Pediatr Infect Dis J 1994;13:765-768.



Rosenfeld RM, Vertrees JE, Carr J et al: Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994;124:355-367.