Acute Otitis Media

Treatment of AOM involves the following.

Adequate analgesia

Usually with an oral agent such as paracetamol. Topical anaesthetic drops such as amethocaine, benzocaine or lidocaine have some efficacy at 30 minutes after administration, but not more than paracetamol once they have been absorbed.⁸ Topical anaesthetic drops should not be administered when there is a perforation as they may enter the inner ear and cause vertigo.

Antibiotic therapy

The current recommendations are that children older than 2 years who are not very ill (ie. no systemic features such as significant fever or vomiting) can be treated with observation only; the parents can be given a prescription to be filled if the child is still in pain after 48 hours.⁹ However, there are groups of children who should be treated. These include:
• children 2 years of age or younger, because:
• – they are not able to describe their symptoms
• – they are more likely to have suppurative complications such as meningitis and mastoiditis
• – they are less likely to improve spontaneously
• children with severe illness with pain, or a tympanic membrane perforation (these imply a more virulent organism)
• a child with known immunodeficiency
• indigenous children, including Aboriginal, Torres Strait Islander and Maori and other Pacific Islander children
• children with a cochlear implant.

The usual antibiotic recommended is amoxycillin, 15 mg/kg up to 500 mg three times per day for 5 days. If the child has an allergy to penicillin (excluding immediate hypersensitivity), the alternative medication is cefuroxime in a dose of 10 mg/kg up to 500 mg twice per day for 5 days, or ceflacor in a dose of 10 mg/kg up to 250 mg three times per day for 5 days.¹⁰ The efficacy of ceflacor is thought to be similar to that of amoxycillin but it may be less as it penetrates middle ear mucosa less efficiently.⁶

With a perforation of the eardrum, topical antibiotic drops are useful both to treat the middle ear and also to treat secondary otitis externa if present. The recommended antibiotics are quinolones such as ciprofloxacin with or without steroid, which are not ototoxic when there is a tympanic membrane perforation.⁶ If the tympanic membrane is intact there is no advantage in treating with topical antibiotics.

Follow Up:

Patient should be reviewed in 2 days if he is no better. At that stage, if the AOM has not resolved, institute change to an antibiotic such as amoxycillin/clavulanate.

Patient should also be reviewed at the 2 week mark to ensure that the perforation of the tympanic membrane has healed. Note that at 2 weeks following an episode of AOM, 70% of children will still have a middle ear effusion but most perforations will have healed.



Prevention:
• reduce contact with people with upper respiratory infections, especially large group childcare centres
• avoid tobacco smoke both during and after pregnancy. Children exposed to passive smoking are more likely to have recurrent otitis media and have middle ear effusions that persist for longer
• breastfeed for at least 6 months, preferably 12 months. If bottle fed, prop the baby up as milk can reflux into the ear if lying flat, causing inflammation
• avoid pacifiers/dummies – this possibly increases the risk of AOM by inadvertent sharing in childcare centres
• vaccination with the polyvalent pneumococcal vaccine reduces the incidence of AOM by 8%