British Medical Journal: Clinical Evidence

Acute Otitis Media



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Am Fam Physician. 2002 Feb 1;65(3):467-468.

Questions Addressed

• What are the effects of treatments for acute otitis media?

• What are the effects of preventive interventions for acute otitis media?

Questions Addressed

• What are the effects of treatments for acute otitis media?

• What are the effects of preventive interventions for acute otitis media?

Summary of Interventions

Treatment

Prevention

Related topics coveredin Clinical Evidence

Likely to be beneficial

Likely to be beneficial

Myringotomy

Ibuprofen

Xylitol chewing gum or syrup

Surgery

Acetaminophen

Trade off

Otitis media with effusion

Trade off

Long-term antibiotic prophylaxis

Antibiotics

Summary of Interventions

View Table

Summary of Interventions

Treatment

Prevention

Related topics coveredin Clinical Evidence

Likely to be beneficial

Likely to be beneficial

Myringotomy

Ibuprofen

Xylitol chewing gum or syrup

Surgery

Acetaminophen

Trade off

Otitis media with effusion

Trade off

Long-term antibiotic prophylaxis

Antibiotics

Definition

Otitis media is an inflammation in the middle ear. Subcategories include acute otitis media (AOM), recurrent AOM, and chronic suppurative otitis media. AOM presents with systemic and local signs, and has a rapid onset. The persistence of an effusion beyond three months without signs of infection defines otitis media with effusion (also known as glue ear). Chronic suppurative otitis media is characterized by continuing inflammation in the middle ear causing discharge (otorrhea) through a perforated tympanic membrane.

Incidence/Prevalence

AOM is common and has a high morbidity and low mortality rate. In the United Kingdom, about 30 percent of children younger than three years visit their family practitioner with AOM each year, and 97 percent receive antimicrobial treatment.1 By three months of age, 10 percent of children have had an episode of AOM. It is the most common reason for out-patient antimicrobial treatment in the United States.2

Etiology/Risk Factors

The most common bacterial causes for AOM in the United States and United Kingdom are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Similar pathogens are found in Colombia.3 The incidence of penicillin-resistant S. pneumoniae has risen, but rates differ between countries. The most important risk factors for AOM are young age and attendance at day care centers such as nursery schools. Other risk factors include being white; male sex; a history of enlarged adenoids, tonsillitis, or asthma; multiple previous episodes; bottle-feeding; a history of ear infections in parents or siblings; and use of a soother or pacifier. The evidence for an effect of environmental tobacco smoke is controversial.1

Definition

Otitis media is an inflammation in the middle ear. Subcategories include acute otitis media (AOM), recurrent AOM, and chronic suppurative otitis media. AOM presents with systemic and local signs, and has a rapid onset. The persistence of an effusion beyond three months without signs of infection defines otitis media with effusion (also known as glue ear). Chronic suppurative otitis media is characterized by continuing inflammation in the middle ear causing discharge (otorrhea) through a perforated tympanic membrane.

Incidence/Prevalence

AOM is common and has a high morbidity and low mortality rate. In the United Kingdom, about 30 percent of children younger than three years visit their family practitioner with AOM each year, and 97 percent receive antimicrobial treatment.1 By three months of age, 10 percent of children have had an episode of AOM. It is the most common reason for out-patient antimicrobial treatment in the United States.2

Etiology/Risk Factors

The most common bacterial causes for AOM in the United States and United Kingdom are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Similar pathogens are found in Colombia.3 The incidence of penicillin-resistant S. pneumoniae has risen, but rates differ between countries. The most important risk factors for AOM are young age and attendance at day care centers such as nursery schools. Other risk factors include being white; male sex; a history of enlarged adenoids, tonsillitis, or asthma; multiple previous episodes; bottle-feeding; a history of ear infections in parents or siblings; and use of a soother or pacifier. The evidence for an effect of environmental tobacco smoke is controversial.1

Prognosis

In about 80 percent of children, the condition resolves in about three days without antibiotic treatment. Serious complications are rare but include hearing loss, mastoiditis, meningitis, and recurrent attacks.1 The World Health Organization estimates that each year 51,000 children younger than five years die of complications from otitis media in developing countries.4

Clinical Aims

To reduce the severity and duration of pain and other symptoms, prevent complications, and minimize adverse effects of treatment.

Clinical Outcomes

Pain control (in infants this can be assessed by surrogate measures such as parental observation of distress or crying and analgesic use); incidence of complications such as deafness (usually divided into short- and long-term hearing loss), recurrent attacks of AOM, mastoiditis, and meningitis; resolution of otoscopic appearances; incidence of adverse effects of treatment.

Evidence-Based Medicine Findings

search date: CLINICAL EVIDENCE UPDATE SEARCH AND APPRAISAL JUNE 2001

Evidence-Based Medicine Findings

search date: CLINICAL EVIDENCE UPDATE SEARCH AND APPRAISAL JUNE 2001

Treatment

ANALGESICS

One randomized controlled trial (RCT) found that ibuprofen or acetaminophen versus placebo reduced earache after two days in children receiving antibiotic treatment.

ANTIBIOTICS

Systematic reviews have found conflicting evidence about antibiotics versus placebo in AOM. The most recent review found that antibiotics reduced the proportion of children still in pain at two to seven days and reduced the risk of developing contralateral AOM. We found no clear evidence favoring any particular antibiotic. One RCT found that immediate versus delayed antibiotic treatment reduced the number of days of earache, ear discharge, and amount of daily acetaminophen used after the first 24 hours of illness, but found no difference in daily pain scores. It also found an increase in diarrhea with immediate versus delayed antibiotic treatment.

SHORT VS. LONGER COURSES OF ANTIBIOTICS

One systematic review has found that 10-day courses of antibiotics versus five-day courses reduce treatment failure, relapse, or reinfection in the short term (at eight to 19 days), but found no significant difference in the long term (at 20 to 30 days). Two subsequent RCTs found similar results.

Prevention

LONG-TERM ANTIBIOTIC TREATMENT

One systematic review has found that long-term antibiotic prophylaxis versus placebo reduces recurrences of acute otitis media. However, one subsequent RCT found no significant difference between antibiotic prophylaxis and placebo. We found insufficient evidence on which antibiotic to use, for how long, and how many episodes of acute otitis media justify starting preventive treatment.

XYLITOL CHEWING GUM OR SYRUP

One RCT found that patients receiving xylitol syrup or chewing gum versus those receiving control syrup or gum had a reduced incidence of acute otitis media. It found no significant difference with xylitol lozenges versus control gum. More children taking xylitol versus control withdrew because of abdominal pain or other unspecified reasons.

Adapted with permission from O'Neill P. Acute otitis media. Clin Evid 2002;7:In press.

 

REFERENCES

1. Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ. 1997;315:98–102.

2. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ. 1997;314:1526–9.

3. Berman S. Otitis media in developing countries. Pediatrics. 1995;96:126–31.

4. World Health Organization. World development report 1993: investing in health. Oxford: Oxford University Press, 1993:215–22.

This is one in a series of chapters excerpted from Clinical Evidence, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence is published in print twice a year and is updated monthly online. The complete text for this topic, as well as additional information, is available to subscribers at www.clinicalevidence.com. This series is part of AFP's CME. See “Clinical Quiz” on page 000.



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