Summary

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. Even as simple a step as the routine use of the pneumatic otoscopy would be a major advance. The significant recent change in management results from the increasing prevalence of drug resistant S. pneumoniae, and the realization that we have brought this upon ourselves from inappropriate overuse of antibiotics.40'50'51 However, we still have the opportunity to reverse the trend, should we have the fortitude.52 It is important to remember that more than 50% of antibiotics used in the pediatric population in the United States is for the treatment of otitis media.53 If we do not take on board that restrictions in antibiotic utilization are required, the trend will not be reversed.

What is encouraging in this endeavor is that limiting antibiotics usage will not alter the clinical outcome for most of our patients. Accurate diagnosis of AOM, and a higher threshold for the use of prophylactic antibiotics with recurrent AOM, are achievable aims. Limiting initial antibiotic exposure in OME is also essential. To quote Rosenfeld, "Children with OME fall into two groups—those who get better in a few months no matter what treatment they receive, and those who don't."54

REFERENCES

Rutter and Cotton—CHAPTER 76

1. Armstrong BW. A new treatment for chronic secretory otitis media. Arch Otolaryngol 1954;59:653-654

2. Mandel EM, Rockette HE, Bluestone CD, et al. Efficacy of amoxicillin with and without decongestant-antihistamine for otitis media with effusion in children. Results of a double-blind, randomized trial. N Engl J Med 1987;316:432-437

3. Uhari M, Kontiokari T, Koskela M, Niemela M. Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ 1996;313:1180-1184

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6. Stangerup SE, Sederberg-Olsen J, Balle VH. Treatment with the Otovent device in tubal dysfunction and secretory otitis media in children. [In Danish.] Ugeskrift Laeger 1991;153:3008-3009

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8. Gates GA. Cost-effectiveness considerations in otitis media treatment. Otolaryngol Head Neck Surg 1996;114:525-530

9. Ruben RJ. Sequelae of antibiotic therapy for acute otitis media and otitis media with effusion. In: Lim DJ, et al., ed. Sixth International Symposium on Recent Advances in Otitis Media. Fort Lauderdale, FL: BC Decker; 1995:369-373

10. Hayden GF. Acute suppurative otitis media in children: diversity of clinical diagnostic criteria. Clin Pediatr 1981;20:99-104

11. Weir N. (Otolaryngology: An Illustrated History. 1st Ed. London: Butterworths; 1990

12. Rudberg R. Sulfonamide and penecillin in acute otitis media. Acta Otolaryngol (Stockh) 1954;44(suppl):45-65

13. Ruben RJ, Wallace IF, Gravel J. Long-term communication deficiencies in children with otitis media during their first year of life. Acta Otolaryngol (Stockh) 1997;117:206-207

14. Stewart IA, Silva PA, Williams S. Relationships of otitis media with effusion in early childhood to educational and behavioural disadvantage during the teenage years. In: Lim DJ, et al., ed. Sixth International Symposium on Recent Advances in Otitis Media. Fort Lauderdale, FL: BC Decker; 1995:337-339

15. Teele DW, Klein JO, Chase C, et al. Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. Greater Boston Otitis Media Study Group. J Infect Dis 1990;162:685-694

16. Teele DW. Long-term sequelae of otitis media: fact or fantasy? Pediatr Infect Dis J 1994;13:1069-1073

17. Roberts JE, Burchinal MR, Clarke-Klein SM. Otitis media in early childhood and cognitive, academic, and behavior outcomes at 12 years of age. J Pediatr Psychol 1995;20:645-660

18. van Buchem FL, Peeters MF, van't Hof MA. Acute otitis media: a new treatment strategy. BMJ 1985;290:1033-1037

19. Van Buchem FL. Antibiotics for otitis media [letter]. JR Coll Gen Pract 1987;37:367

20. Claessen JQ, Appelman CL, Touw-Otten FW, et al. A review of clinical trials regarding treatment of acute otitis media. Clin Otolaryngol Allied Sci 1992;17:251-257

21. Froom J, Culpepper L, Grob P, et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ 1990;300:582-586

22. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A metaanalysis. BMJ 1997;314:1526-1529

23. Froom J, Culpepper L. Otitis media in day-care children. A report from the International Primary Care Network. J Fam Pract 1991;32:289-294

24. Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, et al. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA 1998;279:1736-1742

25. Klein JO. Preventing recurrent otitis: what role for antibiotics? Contemp Pediatr 1994;11:44-60

26. Paradise JL. Managing otitis media: a time for change. Pediatrics 1995;96(4 Pt 1):712-715

27. Roark R, Berman S. Continuous twice daily or once daily amoxicillin prophylaxis compared with placebo for children with recurrent acute otitis media. Pediatr Infect Dis J 1997;16:376-381

28. Williams RC, Stange KC, Chalmers FT, Bowlin SJ. Use of antibiotics in preventing recurrent acute otitis media and in treating otitis media with effusion. A meta-analytic attempt to resolve the brouhaha. JAMA 1993;270:1344-1351

29. Ryding MK, Kalm O, Prellner K. Sequelae of recurrent acute otitis media. Ten-year follow-up of a prospectively studied cohort of children. Acta Paediatr 1997;86:1208-1213

30. Hoberman AP, Wald ER. Tympanocentesis technique revisited. Pediatr Infect Dis J 1997;16:S25-26

31. Teele DW, Klein JO, Rosner BA. Epidemiology of otitis media in children. Ann OtolRhinolLaryngol 1980;89(3 Pt 2) (suppl):5-6

32. Bachmann KRA. Early identification and intervention for children who are hearing impaired. Pediatr Rev 1998;19:155-165

33. Managing otitis media with effusion in young children. Agency for Health Care Policy and Research. Clin Pract GuidelQuick Ref Guide Clin 1994;12:1-13

34. Rosenfeld RM, Madell JR, McMahon A. Auditory function in normal-hearing children with middle ear effusion. In: Lim DJ, et al., ed. Sixth International Symposium on Recent Advances in Otitis Media. Fort Lauderdale, FL: BC Decker; 1995:354-356

35. Rosenfeld RM, Post JC. Meta-analysis of antibiotics for the treatment of otitis media with effusion. Otolaryngol Head Neck Surg 1992;106:378-386

36. Bodner EE, Browning GG, Chalmers FT, Chalmers TC. Can meta-analysis help uncertainty in surgery for otitis media in children. J Laryngol Otol 1991;105:812-819

37. Marchant CD, Carlin SA, Johnson CE, Shurin PA. Measuring the comparative efficacy of antibacterial agents for acute otitis media: the "Pollyanna phenomenon." J Pediatr 1992;120:72-77

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39. Otitis Media Guideline Committee. Evidence based clinical practice guideline for otitis media in children under 6 years of age. In: Health Policy and Clinical Effectiveness Clinical Practice Guidelines, Children's Hospital Medical Center, Cincinnati, March 1999

40. Dowell SF, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumoccocal resistance—a report from the drug-resistant Streptoccocus pneumoniae. Therapeutic Working Group. Pediatr Infect Dis J 1999;18:1-9

41. Gates GA, Muntz HR, Gaylis B. Adenoidectomy and otitis media. Ann Otol Rhinol Laryngol 1992;155(suppl):24-32

42. Gates GA. Adenoidectomy for otitis media with effusion. Ann Otol Rhinol Laryngol 1994;163(suppl):54-58

43. Maw AR, Bawden R. Does adenoidectomy have an adjuvant effect on ventilation tube insertion and thus reduce the need for re-treatment? Clin Otolaryngol Allied Sci 1994;19:340-343

44. 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;263:2066-2073

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49. Giebink GS. Vaccination against middle-ear bacterial and viral pathogens. Ann NY Acad Sci 1997;830:330-352

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Otitis Media: To Treat or Not to Treat

Brian J. Wiatrak

CHAPTER 77

Otitis media is one of the most common ailments of childhood and is the most common complaint that brings a child to the health care provider.1 Approximately 70% of children below the age of 3 will develop an episode of otitis media2 and by the age of 7 years, 65 to 95% of children will experience one or more episodes of acute otitis media. Approximately $3.5 billion per year is spent on the management of otitis media in the United States.3 A large portion of this is spent on antimicrobial therapy. With such a significant impact on our health care system, it is not surprising that numerous controversies exist regarding the medical and surgical management of otitis media.

It is apparent from review of the literature regarding otitis media that a clear, descriptive classification system does not exist. 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.

Although it is clear that serious bacterial infections should be treated with antibiotics, it is not clear that all otitis media is an infectious process necessitating treatment with antimicrobial therapy. In addition, evidence is emerging that the traditional 10-day treatment course for treatment for acute otitis media may not be necessary and that shorter treatment courses may be satisfactory. The role of antibiotic prophylaxis for recurrent acute otitis media has also come under criticism due to the emergence of resistant strains of Streptococcus pneumoniae, which may be related to the overutilization of antimicrobial therapy for children with upper respiratory tract infections.4

In addition to the controversy surrounding antimicrobial therapy for otitis media, numerous other medical therapeutic options have been described in the literature that also tend to complicate a clear understanding of the management of this disease process. Some of these treatment options include antihistamine/decongestants, inhalation or systemic corticos-teroids, desensitization for inhalation or food allergies, and alternative medicine treatment modalities. The role of vaccinations is gaining significant exposure in both the medical literature and lay press.

Surgical treatment options for otitis media are also not without controversy. The standard surgical treatment modality of myringotomy with placement of tympanostomy tubes has recently5 been called into question and the role of alternative surgical options (i.e., the role of adenoidectomy as well as laser myringotomy) has also been examined in recent years. An attempt will be made to address some of these controversial issues and to make recommendations regarding the appropriate treatment for otitis media.

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