Health Care Guideline:
Diagnosis and Treatment of Otitis Media in Children
General Implementation October 1998
Copyright © 1998 by Institute for Clinical Systems Integration
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Work Group Members
Work Group Leader
Paul Berry, MD, HealthPartners
Family Practice
Brian Ebeling, MD, Quello Clinic, Ltd.
Mark Hagberg, MD, HealthSystem Minnesota
Pediatrics
Paul Berry, MD, HealthPartners
William Barbaresi, MD, Mayo Clinic
Robert Karasov, MD, HealthSystem Minnesota
Pediatric Nurse Practitioner
Jane Spencer, PNP, HealthSystem Minnesota
Pediatric Nursing
Kate Libra, RN, HealthPartners
ENT
Barbara Malone, MD, Otolaryngology & Head and Neck Surgery, P.A.
Health Education
Janet Williams, HealthPartners
Measurement Advisor
Diane Jacobsen, MPH, ICSI
Buyers Health Care Action Group Representative
Ann Robinow, BHCAG
Facilitator
Julie Persoon, RN, ICSI
Children from birth to age 18.
Priority Aims for Medical Groups When Using This Guideline
1. Increase appropriate antibiotic usage for otitis media infections.
Possible measures of accomplishing this aim:
a. Percentage of children with a diagnosis of acute otitis media who were prescribed first line antibiotics.
b. Percentage of children with a diagnosis of acute otitis media who were prescribed second line antibiotics who met the indications for second line antibiotics.
2. Increase the timely and appropriate clinical follow-up for patients with a diagnosis of otitis media.
Possible measures of accomplishing this aim:
a. Percentage of children referred to ENT meeting the criteria for referral.
b. Percentage of children with a diagnosis of acute otitis media who had an appropriate routine follow-up visit within the recommended time interval.
3. Improve parents' (caretakers') knowledge of symptoms suggestive of otitis media, appropriate indicators for a provider visit, risk factors, and outcomes of otitis media.
Possible measures of accomplishing this aim:
a. Percentage of parents (caretakers) receiving education on the symptoms suggestive of otitis media, appropriate indicators for a provider visit, risk factors, and outcomes of otitis media.
Clinical Algorithms & Annotations
Otitis Media with Effusion Algorithm
1. Caregiver or
Patient Calls with Otitis Media-related Symptoms or Concerns or OM Found on Exam
2. Symptoms Suggestive of OM?
3. Triage for
Illness and/or Reassurance
4. Schedule
Appointment Within 24 Hours
5. Meets Diagnostic Criteria for AOM or OME?
6. Discuss Otitis Media
Prevention
7. Initiate Appropriate
Treatment
8. History of Recurrent AOM?
9. Consider Prophylactic
Regimen
10. Schedule Follow-up in 3-4
Weeks
11. AOM Resolved?
12. Criteria for Referral to ENT Met?
Otitis
Media with Effusion Algorithm Annotations
14. Consider Treatment Options
15. Schedule Follow-up in 4-6 Weeks
16. OME Resolved?
1. Caregiver or Patient Calls with Otitis Media-related Symptoms or Concerns or OM Found On Exam
Entrance into the guideline occurs when a caregiver calls regarding an ill child whose symptoms are suggestive of otitis media, or when a provider discovers findings of otitis media on exam.
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Children less than 3 years old more often present with non-specific symptoms (irritability, fever, night waking, poor feeding, coryza, conjunctivitis, and occasionally balance problems). 90% of infants and toddlers with otitis media have associated rhinitis symptoms.
Ear pulling without associated symptoms is usually not a symptom of otitis media.
3. Triage for Illnesses and/or Reassurance
For symptoms not suggestive of otitis, reassurance and anticipatory education of the symptoms of otitis should be provided. If symptoms suggestive of another illness are described, refer to the appropriate guideline.
4. Schedule Appointment Within 24 Hours
While symptoms of acute otitis media are often dramatic, the illness is rarely an emergency. Most children can be treated symptomatically through the night unless symptoms of a more serious illness are present. Comfort measures can be discussed with parent/caretaker.
Diagnosis of otitis media is made by exam. Diagnosis by phone should be avoided except in special circumstances (children with a history of multiple sets of ventilating tubes or children in high risk categories such as cleft palate or Down's syndrome who present with bloody or purulent drainage and who are well known to the provider, and in whom follow-up is assured).
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5. Meets Diagnostic Criteria for AOM or OME?
Diagnostic criteria for AOM
Middle ear effusion (seen on examination and/or confirmed by pneumatic otoscopy) with either (a) or (b):
a. local signs of inflammation (redness, bulging)
b. symptoms associated with AOM
AOM is characterized by middle ear effusion with acute inflammation. (The tympanic membrane is usually full or bulging [decreased mobility by pneumatic otoscopy]. Color is usually red, yellow or cloudy.) Symptoms may include otalgia, otorrhea, irritability, restlessness, poor feeding or fever. Tympanometry is usually not necessary to establish the diagnosis of AOM. Pneumatic otoscopy is highly recommended and should be used routinely.
Diagnostic criteria for OME
Middle ear effusion (seen on examination and/or confirmed by pneumatic otoscopy) or abnormal tympanometry or acoustic reflectometry without signs or symptoms of AOM.
The diagnosis of OME is distinguished from AOM by the presence of an effusion with a lack of signs or symptoms of inflammation or pressure behind the eardrum. Tympanic membrane findings: opaque or yellow, position neutral or retracted, decreased mobility or air fluid level. Tympanometry or pneumatic otoscopy may be useful in establishing the diagnosis.
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6. Discuss Otitis Media Prevention
Parents/caretakers should be counseled about otitis media prevention. Elimination of controllable risk factors should be encouraged whenever possible.
Otitis media prevention measures to discuss include:
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7. Initiate Appropriate Treatment
Treatment options for AOM
1. Therapeutic (10 day) course of antibiotics
2. For patients with life-threatening allergic reactions to penicillin or cephalosporins, use clindamycin after tympanocentesis to document clindamycin-sensitive pathogen.
3. Observation with or without provisional prescription if symptoms of AOM should worsen. This option is not recommended in the acutely ill child but may be considered in an asymptomatic or only mildly symptomatic child with mild findings on exam. Parents should be instructed to call back if symptoms persist, if the child is inconsolable, or if the child is becoming more ill.
For a child with ventilating tubes or perforation, antibiotic ear drops such as cortisporin suspension or ophthalmic antibiotic solutions administered to the ear should be added to the treatment regimen.
The use of nasal decongestants and corticosteroids is not supported in the literature.
Treatment of resistant AOM
Resistant AOM is defined as persistence of moderately severe symptoms (pain and fever) after 3 to 5 days of antibiotic therapy with findings of continued pressure and inflammation (bulging) behind the tympanic membrane. A second antibiotic should be chosen; the alternative first line medication may be an appropriate choice. (Referral to ENT specialist may be indicated if significant pain and fever continue for 4-5 days on the second medication or if complications of otitis media occur.)
Treatment of persistent AOM
Persistent AOM is defined as continued findings of AOM present within 6 days of finishing a course of antibiotics. A second course of therapy with a different antibiotic is indicated for persistent AOM.
Evidence supporting these conclusions is of classes:
First line medications: A, R, M
Second line medications: A, R
Treatment of resistant AOM: A, C, R, M, X
Treatment of Persistant AOM: R.
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History should be reviewed or elicited at the time of diagnosis of AOM. If criteria of recurrent AOM are present a prophylactic antibiotic regimen follows the therapeutic course of antibiotics. Children in high risk categories may be considered for more aggressive or earlier intervention with prophylactic antibiotics. The decision for prophylaxis should be based on both the diagnostic criteria and the child's risk factors.
Diagnostic Criteria for recurrent AOM
Children at increased risk of recurrent AOM
Evidence supporting this conclusion is of classes: B, C, D, R
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9. Consider Prophylactic Regimen
Prophylactic treatment options
The usual duration of antibiotic prophylaxis is 2-6 months. Parents should be advised that prophylaxis has been shown to reduce the frequency of AOM by 40-50% but will not eliminate its occurrence. Periodic monitoring of WBC for evidence of bone marrow suppression is advisable while on sulfa medications.
10. Schedule Follow-up in 3-4 Weeks
Follow-up considerations
Timing of rechecks
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Resolution is defined as a return to normal on exam with no evidence of effusion or inflammation and/or normal mobility. Tympanometry is not routinely needed to document resolution.
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12. Criteria for Referral to ENT Met?
Criteria for ENT referral for consideration of ventilating tubes:
(child needs to meet one of the following criteria)
1. Recurrent AOM which fails medical management (> 3 episodes in 6 months or >4 episodes in one year) with either:
a. Failure of prophylaxis defined as recurrence x 2 on prophylaxis in a 2-6 month time period. (Prophylactic regimen described in algorithm box #9)
b. High risk category:
2. Refractory acute otitis media with moderate to severe symptoms unresponsive to at least 2 antibiotics. (Refer to Annotation #7, Resistant AOM.)
3. Bilateral or unilateral OME persisting for at least 3 months with hearing threshold of 20 dB or worse.
4. Development of advanced middle ear disease involving tympanic membrane atrophy, retraction pockets, ossicular erosion or cholesteatoma.
5. Medical treatment failure secondary to multiple drug allergy or intolerance.
6. At least 2 recurrences of otitis media within 2-3 months following ventilating tube extrusion with failed medical management.
7. Impending or actual complication of otitis media including:
a. Mastoiditis
b. Facial nerve paralysis
c. Lateral sinus thrombosis
d. Meningitis
e. Brain abscess
f. Labyrinthitis
8. History of six or more months of effusions out of the previous twelve months.
Children at increased risk for otitis media include those under two years of age, those who have an episode of otitis media at less than 6 months of age, children in day care, and children who have a positive family history of otitis media.
Counseling Messages
When counseling parents/caregivers about otitis media prevention, encourage measures to diminish risk factors when possible. (Refer to Annotation #6.) Discussions with parents should take place regarding medical versus surgical treatment.
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Otitis Media with Effusion Algorithm
14. Consider Treatment Options
Treatment options to be considered include:
1. Observe - rechecking in 4-6 weeks.
Course of antibiotics should be given as a trial prior to referral for ventilating tubes. Ten day course of antibiotics using first and second line criteria. (Refer to Annotation #7, Appropriate Treatment.)
2. Referral for ventilating tubes if patient meets ENT referral criteria.
Course of antibiotics should be given as a trial prior to referral for ventilating tubes. Ten day course of antibiotics using first and second line criteria. (Refer to Annotation #7, Appropriate Treatment.)
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15. Schedule Follow-up in 4-6 Weeks
More frequent rechecking than every 4-6 weeks of OME is unnecessary and inappropriate. 90-95% of OME will resolve in 3-4 months. Continued observation to assure complete resolution is appropriate since hearing loss accompanies OME.
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Mobility of the eardrum should be normal or results of tympanogram or pneumatic otoscopy should confirm resolution.
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Individual research reports are assigned a letter indicating the class of report based on design type: A, B, C, D, M, R, X. A full explanation of these designators is found in the Discussion and References section of this guideline.
In future versions of this guideline, selected conclusions will include a statement of the grade assigned to the conclusion.
I. CLASSES OF RESEARCH REPORTS
A. Primary Reports of New Data Collection:
Class A: Randomized, controlled trial
Class B: Prospective cohort study Case-control study nested within a prospective
cohort study
Class C: Non-randomized trial with concurrent or historical controls Case-control
study (except as above) Retrospective cohort study Study of sensitivity and specificity of
a diagnostic test Population-based descriptive study
Class D: Cross-sectional study Case series Case report
B. Reports that Synthesize or Reflect upon Collections of Primary Reports:
Class M: Meta-analysis Decision analysis Cost-benefit analysis
Cost-effectiveness study
Class R: Review article Consensus statement Consensus report
Class X: Medical Opinion