Much of the evidence base for conventional management of Acute otitis media shows modest benefit or remains inconclusive.
Approaches may differ between generalist and specialist settings where the prevailing severity of presentation varies.
Analgesia
Treatment of AOM calls for immediate pain control as ear pain is cardinal to children's and parents' experience of the illness. Generally, this can be accomplished with simple analgesics.
Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) demonstrated better short-term ear pain relief than placebo in children with AOM.
There was insufficient evidence of a difference between ibuprofen and paracetamol. Whether the combination of ibuprofen and paracetamol is more effective than either agent alone remains uncertain.
Evidence to support antihistamines or decongestants in the treatment of AOM is lacking.
Immediate antibiotic therapy
Once pain control is adequately addressed, the physician and family can consider the need for antibiotic therapy.
Oral antibiotics have been a mainstay of treatment, but can have adverse effects and their overuse has led to antibiotic resistance. [ref-1]
Therefore, treatment with oral antibiotics should be instituted only after diagnosis of AOM has been confirmed.
Therapeutic effectiveness
When using a bulging tympanic membrane as the criteria for diagnosis, antibiotics resulted in fewer clinical failures and modest improvements in clinical scores versus placebo.[ref-2]
In meta-analyses, rates of clinical resolution, particularly symptom relief, have been demonstrated to be similar for placebo and antibiotic groups after 1 day of therapy but are higher for the antibiotic group at 1 week. [ref-3]
Antibiotics shortened recovery by 1 day on average, and 10 to 20 patients needed to take an antibiotic to benefit 1 child, while the number needed to treat (NNT) for an additional harm was 14. [the same ref-3]
In rich countries, antibiotics may be most beneficial in children under 2 years of age with bilateral AOM (NNT = 4) or in children with both AOM and otorrhoea suggestive of tympanic membrane perforation (NNT = 3).
Choice and duration of therapy
Antibiotics are prescribed in a stepwise fashion.[ref-4]
Amoxicillin-based therapy is the mainstay of antibiotic treatment. Although the optimal antibiotic regimen is not entirely clear, there is some evidence to suggest that amoxicillin or amoxicillin/clavulanic acid may be preferable to a range of other antibiotics.[ref-5]
Azithromycin is a suitable option in patients allergic to beta-lactam antibiotics.
The optimal duration of therapy for patients with AOM is uncertain. The conventional 10-day course of therapy was derived from the duration of treatment of streptococcal pharyngotonsillitis.
Several studies and the American Academy of Pediatrics (AAP) recommend standard 10-day therapy over shorter courses for children younger than 2 years of age. [ref-6]
The AAP advises that a 7-day course of oral antibiotic appears to be effective in children 2 to 5 years of age with mild or moderate AOM.
For children 6 years and older with mild to moderate symptoms, a 5- to 7-day course is adequate.
A lack of improvement in the patient's condition may require a change to a second- or third-line agent.
Delayed antibiotic therapy
Delayed therapy is appropriate in healthy patients 6 months or older with reliable follow-up, particularly patients who do not meet the diagnostic criteria or have a less certain diagnosis.
This approach calls for immediate pain management during an initial observation period of 2 to 3 days.
Several studies have reported on the success of a safety net antibiotic prescription or a wait-and-see prescription, whereby physicians write an antibiotic prescription and instruct the family to fill it only if the child has not improved subjectively within 48 to 72 hours.
These studies found that only two-thirds of prescriptions were subsequently filled, and that patients in the immediate treatment group fare no differently than those in the delayed treatment group.
Children under 2 years of age and with bilateral disease or who have severe tympanic membrane bulging may respond less well with this approach.[ref-7]
Delayed antibiotic therapy may reduce the number of unnecessary antibiotic courses, decrease the occurrence of adverse antibiotic reactions, improve the benefit provided by antibiotics, and reduce healthcare expenditures, although its effect on rare complications of AOM (such as mastoiditis) is unclear.
Tympanocentesis
Tympanocentesis can relieve pressure in the middle ear space and provide relief from otalgia.
This procedure may benefit patients with persistent disease unresponsive to antimicrobial therapy or those in need of immediate pain relief.
Tympanocentesis involves risks including trauma to the tympanic membrane and middle ear structures, as well as risks associated with anaesthesia.
Treatment algorithm
Here is a standard algorithm for the treatment of Acute otitis media.
1st line – oral or rectal analgesia
Pain control is central to managing the condition.
Rectal preparations can be used as needed until the symptoms have resolved.
Oral paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) demonstrated better short-term ear pain relief than placebo in children with AOM.
There was insufficient evidence of a difference between ibuprofen and paracetamol. Whether the combination of ibuprofen and paracetamol is more effective than either agent alone remains uncertain.
Evidence to support the use of antihistamine or decongestant treatment for AOM is lacking.
Analgesic otic drops (e.g., antipyrine/benzocaine) are sometimes recommended; however, they may not be available in some countries.
Primary optioms:
Delayed antibiotic therapy
Delayed therapy is an option in healthy patients 6 months or older with reliable follow-up, particularly patients who do not meet the diagnostic criteria or have a less certain diagnosis.
A recommended approach is to provide analgesia and observe for 2 to 3 days. If the patient remains symptomatic after the observation period ends, the antibiotic is started.
Delayed antibiotic therapy may reduce the number of unnecessary antibiotic courses, decrease the occurrence of adverse antibiotic reactions, improve the benefit provided by antibiotics, and reduce healthcare expenditures.
Children under 2 years of age and with bilateral disease or who have severe tympanic membrane bulging may respond less well with this approach.
Antibiotics are prescribed in a stepwise fashion beginning with a first-line antibiotic.[33] Although the optimal antibiotic regimen is not entirely clear, there is some evidence to suggest that amoxicillin or amoxicillin/clavulanate may be preferable to a range of other antibiotics.[34][35][36]
The optimal duration of therapy for patients with AOM is uncertain. The conventional 10-day course of therapy was derived from the duration of treatment of streptococcal pharyngotonsillitis. Several studies and the American Academy of Pediatrics (AAP) recommend standard 10-day therapy over shorter courses for children younger than 2 years of age. Duration of therapy in children 6 to 23 months of age should be 10 days.
The AAP advises that a 7-day course of oral antibiotic appears to be effective in children 2 to 5 years of age with mild or moderate AOM.
For children 6 years and older with mild to moderate symptoms, a 5- to 7-day course is adequate.
A lack of improvement in the patient's condition may require a change to a second- or third-line agent.
Azithromycin is a suitable option in patients allergic to beta-lactam antibiotics.
One study reports that a single dose of extended-release azithromycin is as effective as a 10-day regimen of amoxicillin/clavulanate in the treatment of children with AOM.
Various azithromycin regimens may be used.