In children aged younger than 1 year in whom otoscopy can be quite difficult, tympanometry can be a useful tool for detecting a middle ear effusion.16 An abnormal type B tympanogram (flat curve with no distinct peak) in infants presenting with acute symptoms is strong evidence in favor of AOM, although a normal test is not helpful in ruling out the diagnosis.
The diagnosis of AOM can be influenced by the physician’s perception of parental expectations for antibiotics.17 A study of children presenting with ear pain or other upper respiratory symptoms found that physicians diagnosed AOM 49% of the time when they perceived parents wanted antibiotics and only 13% of the time when they thought parents did not want antibiotics. Physicians were 23 times more likely to prescribe an antibiotic for an upper respiratory illness if they perceived that parents expected antimicrobials.
Treatment
A recent systematic review18 found that the symptoms of AOM (mainly otalgia) spontaneously resolved in two thirds of children by 24 hours and in 80% at 2 to 7 days. This was also observed in 2 earlier meta-analyses.10,19 Seventeen children would need to be treated with antibiotics (vs placebo) for 1 child to have less pain at 2 to 7 days (number needed to treat [NNT]=17). There were no differences between antibiotic and placebo groups in other clinical outcomes, such as tympanometry findings, perforation, and recurrences. Also, children treated with antibiotics were almost twice as likely to have vomiting, diarrhea, or a rash.
Initially not treating uncomplicated AOM with antibiotics is an acceptable alternative. In a study by van Buchem and colleagues,20 90% of children with AOM recovered (symptoms resolved) in the first 4 days with nose drops and oral analgesics and without the use of antibiotics. Only 3% of the 4860 children in this study had a clinical course that required further treatment with antibiotics or myringotomy. A recent randomized controlled trial of 315 children demonstrated that children treated immediately with antibiotics had 1 less day of symptoms, but that 1 in 5 of these had diarrhea.21 The group not treated with antibiotics had no serious sequellae and used more analgesics. There were no differences in the number of missed school days, and more than 75% of the parents were satisfied with this “wait and see” approach. These studies also emphasize that antibiotics have a very modest effect on the clinical course of AOM and seem to decrease the duration of symptoms only to a small degree.
Physicians often recommend other symptomatic treatments for ear infections. Non–aspirin analgesics are effective in relieving pain,21 as are ibuprofen22 and Auralgan.23 Antihistamine-decongestant preparations offer no added benefit in resolution of symptoms and have no effect on clinical outcomes when given with antibiotics.24,25
If antibiotics are used, the meta-analysis by Rosenfeld and colleagues10 showed there were no differences in outcomes between treatment with cefaclor, cefixime, erythromycin, trimethoprim-sulfamethoxazole, amoxicillin clavulanate, or erythromycin sulfisoxazole, and treatment with amoxicillin or ampicillin. Broader spectrum and/or more expensive antibiotics therefore offer no advantage over amoxicillin for the initial treatment of AOM. In another meta-analysis, Kozyrskyj and coworkers26 showed that a 5-day antibiotic course was an acceptable alternative to a 8- to 14-day treatment course. There was a slightly increased risk of treatment failure at 1-month follow-up with the shortened course of antibiotics; the NNT to prevent 1 excess failure at 30 days was 17. There were no differences in long-term outcomes (2-3 months) or medication side effects (vomiting, diarrhea, rash) between the short and long antibiotic courses. The broader spectrum azithromycin and intramuscular ceftriaxone offered no advantage over amoxicillin. Children aged younger than 2 years deserve special mention, since they are at higher risk for treatment failures,27,28 persistent symptoms,29 and recurrent otitis media.30 Few well-designed studies exist to guide treatment in this age group. Although children aged younger than 2 years were not excluded, neither review by Glasziou and colleagues18 or Rosenfeld and coworkers10 specifically examined this age group.
Another review demonstrated that (as with older children) routinely using antibiotics initially does not seem to add any clinical benefit.31 A recent randomized controlled trial of 240 children demonstrated that 8 children in this age group would have to be treated with amoxicillin for 1 child to have fewer symptoms (fever, crying, irritability) at 4 days (NNT=8).32 The major benefit of amoxicillin in this study was 1 day less of fever (P=.004). Adverse effects were almost twice as likely in the amoxicillin group, although this difference was not statistically significant. There were also no differences between the groups in clinical failure rates at 11 days or in the likelihood of recurrent otitis media, antibiotic use, specialist referrals, or surgery at 6 weeks. Effects on hearing were not measured. The authors conclude that “this modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed.” Also, Kozyrskyj and colleagues26 demonstrated in their meta-analysis that as a subgroup there were no differences in clinical failures between 5 and 10 days of antibiotics in children aged younger than 2 years. However, there were only 118 children in this age group. Table 2 shows treatment options for AOM.