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Otitis Media: Physician Information Sheet (Pediatrics)

Careful Antibiotic Use

Otitis media with effusion does not require antibiotic treatment
Acute otitis media does not always require antibiotic treatment

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Otitis Media

Differentiating Acute Otitis Media (AOM) from Otitis Media with Effusion (OME):
A tool for promoting appropriate antibiotic use.1, 2

""
Always use pneumatic otoscopy or
tympanometry to confirm middle ear effusion
arrow rightNo effusion
Not OME or AOM
""
arrow-down
Yes effusion present
Signs or symptoms of AOM-including ear pain, fever,
and bulging yellow or red TM
Yes
arrow down
arrow down
No
AOM

  • History of acute onset of signs and symptoms
    WITH
  • The presence of middle ear effusion (indicated by bulging of the TM or limited/absent TM mobility or otorrhea or air-fluid level)
    WITH
  • Signs or symptoms of middle-ear inflammation (indicated by distinct erythema of the TM or distinct otalgia)
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Treatment

Management should include assessment of pain → if pain is present, clinician should recommend treatment to reduce pain.
Age
Certain Diagnosis
Uncertain Diagnosis
< 6 mo Antibacterial therapy Antibacterial therapy
6 mo
to 2 y
Antibacterial therapy Antibacterial therapy if
severe illness; observation
option* if nonsevere illness
> 2 y Antibacterial therapy if
severe illness; observation
option* if nonsevere illness
Observation option*

*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Nonsevere illness is mild otalgia and fever <39°C in the past 24 hours. Severe illness is moderate to severe otalgia or fever > 39°C. A certain diagnosis of AOM meets all 3 criteria:

  1. rapid onset,
  2. signs of middle ear effusion, and
  3. signs and symptoms of middle-ear inflammation.
OME

Presence of effusion (including immobility of the tympanic membrane)
WITHOUT
Signs or symptoms of acute infection. Nonspecific signs and symptoms (rhinitis, cough, diarrhea) are often present.

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Treatment


Antibiotic treatment has not been demonstrated to be effective in long-term resolution of OME. A single course of treatment for 10-14 days may be used when a parent or caregiver expresses a strong aversion to impending surgery.


Share this algorithm with parents. Explain when the risks of using antibiotics outweigh the benefits.

Avoiding unnecessary treatment of OME would save up to 6-8 million courses of antibiotics each year.3

If the patient fails to respond to the initial management option within 48-72 hours, clinician must reassess to confirm AOM and exclude other causes of illness. If AOM is confirmed in:

  • Patient initially managed with observation, begin antibacterial therapy.
  • Patient initially managed with antibacterial agent, change the agent.

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References

  1. American Academy of Pediatrics and American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media.
    Pediatrics 2004;113(5):1451-65.
  2. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media-Principles of judicious use of antimicrobial agents. Pediatrics 1998;101(1 Suppl Pt 2):165-71.
  3. Stool SE, Berg AO, Berman S, et al. Otitis media with effusion in young children. Clinical practice guideline. AHCPR Publication no 94-0622 1994.
  4. American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis
    media with effusion. Pediatrics 2004;113(5):1412-29.

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