following groups are more likely to benefit from antibiotics:12.
•Child under 2 years of age.
•Bilateral acute otitis media.
•Systemic symptoms, including high temperature (above 38.5°C) or vomiting.
•Local signs that suggest the infection is severe, such as a particularly bulging or inflamed tympanic membrane.
Although not included in this list, the reader may like to include where the eardrum is obviously ruptured as there is pus draining from the ear.
The above may be summarised as follows:.
•If the child is very hot and unwell and especially if under 2, give antibiotic.
•If the child is only mildly unwell, hold back but be prepared to reconsider.
•If in doubt, use the delaying strategy.
This is in keeping with a large meta-analysis13 that concluded that antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea. For most other children with mild disease an observational policy seems justified.
The Health Protection Agency and the BNF recommend a course of 3 to 7 days and SIGN recommends 5 days.12
If symptoms persist past 7 days, or reoccur within 14 days, treatment failure may have occurred and co-amoxiclav is the second line antibiotic if there is no allergy to penicillin.12.
.Further management
Children with a discharging ear or a perforated ear drum should be seen again in 2 or 3 weeks time to check progress and told to avoid getting water in the affected ear until then. If it is not fully resolved after 3 weeks, they should in a further interval of 2 or 3 weeks and at this stage any child with persistent problems should be referred for a specialist opinion, as should children with 4 or more episodes in 6 months.8 If pus is pouring from the ear, it will not be possible to see the drum but it is fair to assume that it must be ruptured.
A few children will go on to develop a degree of otitis media with effusion with impaired hearing and any child that is thought to have hearing problems should be referred for formal assessment with audiometry.
Children under the age of 3 who go on to develop OME with bilateral effusions and hearing loss of less than 25 decibels, but with no speech, language or developmental problems may be observed initially. Children over the age of three who go on to develop OME or with language or behavioural problems may benefit from surgical intervention such as the insertion of grommets and should be referred for a specialist opinion.14.
.Complications
•Most cases of acute otitis media will resolve spontaneously with no sequelae.
•Perforation of the ear drum in not uncommon and progression to chronic suppurative otitis media may occur.
•Labyrinthitis, meningitis, intracranial sepsis or facial nerve palsy are very rare and occur in less than 1 in 1,000.6
•Recurrent episodes may lead to scarring of the drum with permanent hearing impairment, chronic perforation and otorrhoea, cholesteatoma or mastoiditis. In recurrent cases, be more ready to use antibiotics.
•In a small child with a high temperature there is a risk of febrile convulsions. This is discussed more fully in its own article.
.Prognosis
With the exception of the few complications given above, there is usually complete resolution in a few days..
.Prevention
In children at high risk of recurrent acute otitis media there may be benefit from prophylactic antibiotics. A Cochrane review15 found that for children at risk, antibiotics given once or twice daily will reduce the risk while the child is on treatment. The average incidence falls from around 3 to around 1.5 episodes per year. Larger absolute benefits are likely in high-risk children.
Pneumococcal vaccine does not appear to be beneficial in reducing the incidence of otitis media
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