Otitis Media To Treat or Not to Treat

"The first objective in the effective management of otitis media is not whether or when to treat, but to accept that this is a disorder that is still badly diagnosed and that adequate diagnosis is the keystone to adequate management."

Robin T. Cotton

"Otitis media is a multifactorial disease process involving immunology, infectious disease, anatomic considerations, social and socioeconomic issues, and genetics, among other factors. Before physicians can attain a clear understanding of otitis media, a clear universally accepted classification system will need to be developed."

Brian J. Wiatrak

"Even though most patients will improve spontaneously without the benefit of an antimicrobial agent, the clinician cannot determine at the onset of the infection who will and will not be at risk of developing these complications. Thus, all patients require treatment."

Charles D. Bluestone

Otitis Media: To Treat or Not to Treat

Michael J. Rutter and Robin T. Cotton

CHAPTER 76

There have been few true advances in the treatment of otitis media since Armstrong's reintroduction of the tympanostomy tube in 1954.1 Management decisions have revolved around three primary options: not to treat, to use antibiotics, or to recommend tympanostomy tubes. Other modalities have been suggested, some shown to be of little benefit (decongestants, antihistamines),2 and others to have a limited degree of efficacy (Xylitol gum, Otovent balloons, steroids).3-7 However, with the millenium, there is the promise of new treatment options (laser myringotomy, vaccination), coexistent with the rapid proliferation of drug resistant Streptococcus pneumoniae.

Otitis media management has always been dogged by controversy. Any disorder in the United States alone that is estimated to cost $5 billion year,8 yet for which the benefits of intervention are often not evidence-based, is bound to generate controversy. It remains the commonest cause for visits to the doctor in the pediatric population (24.5 million visits/year in the United States), generating the largest number of antibiotic prescriptions (23.6 million).9

Otitis media research also has the potential to confuse and confound as much as it contributes to our knowledge. There are three main reasons for this. First, clinical research has to deal with so many coexistent factors (e.g., season, age, child care, upper respiratory tract infections [UTI]) that significance tends to be diluted, unless very large numbers are involved. Second, much research deals with surrogate outcomes (effusion resolution for example), while long-term true outcomes (e.g., IQ, employment status) are much harder to come by. Meta-analy-sis is particularly amiss when it comes to grouping subtly disparate studies. Finally, we are overwhelmed by definitions, and what seems very obvious is not always so. For example, Hay-den10 illustrated this nicely when he surveyed 165 pediatricians, who had 147 different definitions for acute otitis media.

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