November 2000
WASHINGTON, DC - A physician facing a child with recurrent bouts of acute otitis media (AOM) has many options for treatment and prevention.
Each option depends on an accurate diagnosis, said Charles D. Bluestone, MD, Eberly Professor of Pediatric Otolaryngology at the University of Pittsburgh School of Medicine and director of pediatric otolaryngology at the Children's Hospital of Pittsburgh.
"The most important goal for the clinician today is to make the correct diagnosis," Bluestone said. This will help eliminate overuse of antibiotics and unnecessary procedures if the clinician makes sure the child really has AOM, not otitis media with effusion (OME); AOM is associated with otalgia and fever (Fig. 1), whereas OME is a relatively asymptomatic middle-ear effusion (Fig. 2).
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| Figure 1 is the right tympanic membrane from a child with fever, otlagia and a diagnosis of AOM. The eardrum is opaque, bulging and was immobile to pneumatic otoscopy. | Figure 2 is a right tympanic membrane from a child who had OME. Note the air-fluid level and bubbles behind the translucent eardrum, which had limited mobility to pneumatic otoscopy. |
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"I think that's the most important message we should give to our pediatricians, they've got to make a distinction between these two disease entities because you're not going to treat OME unless it becomes chronic," he said.
Because of bacterial resistance, many physicians withhold antibiotics, but Bluestone said that may be an option for some children, especially older kids who have mild symptoms. "But I would recommend that all infants who have documented or confirmed acute otitis media be treated and older children who have severe attacks that are associated with earache and fever, should be treated.
"But older children with non-severe acute otitis media - and you might consider older infants above the age of 12 months of age, who are verbal and can tell you about whether they're still in pain - might be eligible for watchful waiting or even a short course of antibiotic therapy, such as five to seven days."
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Children who should be treated, irrespective of the age or severity, are those who are unlikely to be brought back to the physician for a follow-up visit if they continue to have symptoms. "In this country in which we have a multitude of cultures mixed in with approximately 11 million children who are not covered by any health-care plan, whose parents or guardians frequently will bring them in for crises intervention, into the doctor's office or to an emergency facility, we usually end up treating those kids. Therefore, you have to individualize this issue," he said.
Regarding the option of using tympanocentesis or myringotomy, Bluestone recommended tympanocentesis for patients who are seriously ill, toxic, or when antibiotics fail to relieve the symptoms; those who have suppurative complications, such as acute mastoiditis; and otitis media in newborns or in the immunologically deficient patient in whom an unusual organism may be present. Tympanocentesis is the recommended method to identify the bacterial pathogen causing the AOM, which is more important today with the rising rate of antibiotic-resistant bacteria causing these middle-ear infections. (Fig. 3) Myringotomy, using a myringotomy knife, can relieve ear pain and provide temporary drainage of the middle-ear effusion.
But, for uncomplicated AOM, neither tympanocentesis nor myringotomy is routinely recommended. In a study his group published in Pediatrics in 1991 in which children with severe AOM were treated with either amoxicillin or myringotomy or both, the addition of myringotomy to the amoxicillin treatment did not improve the outcome of treating the subjects with only amoxicillin. Also in that clinical trial, myringotomy without amoxicillin resulted in significantly more early treatment failures than those treated with amoxicillin, with or without the addition of myringotomy. "You don't have to do a myringotomy on every kid who walks in the door, but amoxicillin in these kids who have acute severe infection is indicated."
Vaccination, especially now with the new pneumococcal conjugate vaccine (Prevnar, Wyeth Lederle), is another option open to physicians. The vaccine is recommended for only selected older children. But, older children who have recurrent attacks of AOM may benefit from this vaccine he said. "Now, is this vaccine going to make otitis media go away?" It is unlikely, because the vaccine only reduced office visits for otitis media by 9% in the California clinical trial conducted by Black and his colleagues. But, that study showed an almost 23% reduction in those children who had five or six episodes of the AOM in 12 months. "So it's not going to make a tremendous dent in the number of patients being seen by primary care physicians and otolaryngologists etc., but for those kids who are otitis prone and have multiple episodes, this vaccine may be very effective in reducing that rate, and we recommend it," he said.
The study by Black and associates also showed a 20% decrease in the tympanostomy tube placement rate. "So that could make some impact upon the tubes being inserted in the future, but if we keep giving unnecessary antibiotics, which can cause resistant organisms, and keep putting kids in day care, we'll probably see lots of tubes anyway."
--- Tympanocentesis
can be performed through an otoscope with a surgical head
attached and with use of tuberculin syringe attached to an 18-gauge spinal
needle; the needle is bent to permit visualization of the tip.
Some children are candidates for tube placement: those with chronic fluid that are unresponsive to antibiotics; kids who have recurrent AOM; children who have suppurative complications; and those with eustachian tube dysfunction.
"Now, why are tubes indicated in children who have chronic otitis media with effusion? We reported on two clinical trials that showed that tympanostomy tube placement was more effective than either myringotomy without tube insertion or no surgery; myringotomy alone provided no advantage over no surgery," he said. "Also, we showed in another trial that tympanostomy tube placement effectively reduced the rate of otitis media in infants and young children who had had recurrent attacks in the past."
Based on the outcomes of clinical trials, he does not routinely add adenoidectomy to initial tympanostomy tube placement, when prevention of otitis media is the only indication, but he would consider it for the child who is going for a second set of tubes. A study conducted in Pittsburgh did show improvement if a child was receiving another set of tubes when the adenoidectomy was added to the operation. But, a more recent publication by his group revealed limited benefit from performing an adenoidectomy, with or without a tonsillectomy, as the initial procedure for children who had had recurrent AOM. "So, we recommend putting tubes in kids first, and unless they have other compelling indications to take out the adenoids, such as moderate-to-severe obstruction of the nasal airway, we withhold the adenoidectomy. If they need a second set of tubes, then we recommend adenoidectomy irrespective of adenoid size," he said. Tonsillectomy is not recommended at any stage of OM unless there are other compelling reasons for their removal, such as recurrent acute tonsillitis.
Another new technique is to do a myringotomy with a laser, but Bluestone said there are no good data from this temporary procedure, so he does not recommend it until long-term, randomized clinical trials are reported demonstrating it is safe and effective.
For more information:
- Siegel GJ, Bluestone CD, Rosenfeld RM, Poole MD. Great debates in otitis media: observation, medication ventilation. Presented at the 2000 annual meeting of the America Academy of Otolaryngology - Head and Neck Surgery Foundation. Sept. 24-27. Washington, D.C.
- Otitis Media in Infants and Children. In: Bluestone CD, Klein JO. 3rd ed. Philadelphia, W.B. Saunders, 2000;135.
- Shinefield HR, Black S. Efficacy of pneumococcal conjugate vaccines in large scale field trials. Pediatr Infect Dis J. 2000;19(4):394-7.
- Paradise JL, Bluestone CD, Colborn DK, et al. Adenoidectomy and adenotonsillectomy for recurrent acute otitis media: parallel randomized clinical trials in children not previously treated with tympanostomy tubes. JAMA. 1999;282(10):945-53.
- Casselbrant ML, Kaleida PH, Rockette HE, et al. Efficacy of antimicrobial prophylaxis and of tympanostomy insertion for prevention of recurrent acute otitis media of a randomized clinical trial. Pediatr Infect Dis J. 1992;11(4):278-86.
- Mandel EM, Rockette HE, Bluestone CD, et al. Efficacy of myringotomy with and without tympanostomy tubes for chronic otitis media with effusion. Pediatr Infect Dis J. 1992;11(4):270-7.
- Paradise JL, Bluestone CD, Rogers KD, et al. Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement. Results of parallel randomized and nonrandomized trials. JAMA. 1990;263(15):2066-73.
- Mandel EM, Rockette HE, Bluestone CD, et al. Myringotomy with and without tympanostomy tubes for chronic otitis media with effusion. Otolaryngol Head Neck Surg. 1989;115(10):1217-24.
- Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310(11):674-83.
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