Decongestants and Antihistamines Do Not Relieve Symptoms of Otitis Media with Effusion

Clinical Question

Do decongestants and/or antihistamines relieve symptoms of otitis media with effusion in children?

Evidence-Based Answer

Children with otitis media with effusion do not benefit from decongestants or antihistamines. Common adverse effects of these therapies are gastrointestinal upset, irritability, drowsiness, and dizziness (number needed to harm = 9).

Practice Pointers

Most acute otitis media episodes in children resolve spontaneously; however, the effusion persists in some children. Over-the-counter decongestants and antihistamines have been proposed as treatment options for children with persistent effusion.

This Cochrane review included 16 randomized controlled trials (1,737 total patients) of otherwise healthy patients younger than 18 years with otitis media with effusion (studies of patients with acute otitis media were not included). Oral or nasal decongestants, antihistamines, or a decongestant/antihistamine combination were compared with no medication or placebo. Outcomes were resolution of the effusion at less than one month, one to three months, and more than three months. Five of the 16 trials took place in community clinics. Although the meta-analysis had sufficient power to detect a benefit, no clinical benefit was found for any intervention or outcome.

Observation without antibiotics is an option for children with otitis media. The American Academy of Family Physicians and the American Academy of Pediatrics strongly recommend assessment and treatment of pain in patients with otitis media1; however, based on this Cochrane review, antihistamines and decongestants should be avoided.

Effective Topical Treatments for Nongenital Warts

Clinical Question

What is the best topical treatment for cutaneous nongenital warts?

Evidence-Based Answer

Topical salicylic or lactic acid and cryotherapy are effective treatments for nongenital warts. Although cryotherapy is somewhat more effective, it is associated with more pain and blistering than salicylic or lactic acid. The spontaneous cure rate of nongenital warts is 50 to 70 percent after three months; therefore, no treatment should always be presented to patients as a valid option.

Practice Pointers

Cutaneous nongenital warts are caused by the human papillomavirus. Although these warts are not dangerous, they are unsightly and may be uncomfortable. Therefore, patients often seek treatment from their primary care physician. There are a variety of topical treatments for nongenital warts. Although salicylic acid, lactic acid, and cryotherapy are used most often, some physicians use podophyllin, fluorouracil, glutaraldehyde, or formaldehyde for the treatment of resistant warts.

This Cochrane review included randomized controlled trials of topical treatments for warts. Five trials (322 total patients) compared six to 12 weeks of treatment with salicylic or lactic acid with placebo. Active treatment had a significantly higher cure rate than placebo (73 versus 48 percent; number needed to treat [NNT] = 4; 95% confidence interval [CI], 3 to 7). Only two poor-quality studies compared cryotherapy with placebo. Although no significant difference was found, one study found an unusually low cure rate (9 percent) with cryotherapy, and the other study found an unusually high cure rate (40 percent) with placebo.

Comparisons of aggressive and gentle cryotherapy regimens (e.g., two minutes versus 15 seconds or double versus single freezes) found that aggressive cryotherapy is more effective than gentle cryotherapy (52 versus 31 percent; NNT = 5; 95% CI, 3 to 7). However, in one study of more than 200 patients, aggressive freezing caused more pain and blistering (64 versus 44 percent; number needed to harm = 5; 95% CI, 3 to 15).

The three studies that compared different freezing intervals found no difference in cure rates with two-, three-, or four-week intervals. Two studies comparing salicylic or lactic acid with cryotherapy found no significant difference among the therapies, although they found a trend toward greater benefit with combined therapy than with salicylic or lactic acid alone.

There was insufficient or limited evidence for the effectiveness of intralesional bleomycin (Blenoxane), topical fluorouracil, intralesional interferons, topical dinitrochlorobenzene, photodynamic therapy, and pulsed dye laser. These therapies are not recommended because of their cost, complexity, and possible toxicity. No practice guidelines on this topic were identified in the National Guideline Clearinghouse.