Otitis media

We pediatricians see so much otitis media that I imagine we oftentimes sound like the proverbial broken record –“your child has an earache” over and over.  Perhaps it would be helpful if we just tattoo the diagnosis on our foreheads?  Long articles or even books have been written about otitis media; let me summarize a few important points.

Not every acute otitis media (AOM) requires immediate treatment with antibiotics.  As with so many acute conditions, after a few days of watchful waiting spontaneous resolution is likely.  So, for otherwise healthy young children, pain management with OTC analgesics, pain drops, and fluids is often all that is required.  Prompt initiation of antibiotics are indicated for:

  1. < 2 years of age
  2. Fever > 101
  3. Severe pain
  4. Pain >48 hours
  5. Bilateral pain
  6. Underlying chronic illness like asthma

Amoxicillin is still the mainstay as first line for non-allergic children but current recommendations are for 7 days of therapy at markedly higher dosages–80mg/kg/day.  This means that a typical 45 lb 5 year old should get 500 mg 3x daily–previously considered “adult” dosing.

A special note about otitis media with effusion (OME).  This is a common complication of AOM although it also can occur on its own.  Negative pressure in the middle ear (typically from inflammation from infection) causes fluid being “sucked” into the space from surrounding tissue which can result in hearing loss or feeling of “fullness” in the ear.  The fluid is typically very thick so the condition is sometimes called “glue ear.”  All kinds of interventions have been tried without success: antibiotics, antihistamines and decongestants, oral steroids.  Nasal steroids do seem to offer some small benefit.

Again, here, watchful waiting will most commonly result in resolution.  I recommend that the child blow his nose regularly or blow up balloons (but be careful).  Recent information shows that nasal balloons are quite effective and probably safer.  More definitive treatment is placement of pressure equalizing tubes by an otolaryngologist (ENT).  They stay in for 9-12 months and usually correct the problem.  However this apporach must be considered carefully: 1/6 children will require multiple sets of tubes, particularly if the first set is placed in children < 3 years old.

Generally, tubes are reserved for children who:

  1. Have documented hearing loss > 40 dB (decibels)
  2. Hearing loss > 20dB > 3 mo
  3. >3 mo duraiton with evidence of speech delay, behavior problems, poor school performance, or balance problems (assuming those problems are likely caused by the OME)

One final point.  While (or perhaps because) these conditions are so common, I believe there is likely some element of “overdiagnosis” here–particularly by practitioners who are unfamiliar with your child.  So consider carefully ER visits for those otherwise routine URI/febrile illnesses.  As always, please don’t hesitate to call me with questions about this; and thanks for following.

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