AAP reviews common issues: AOM, OME

June 2004

---Philip A. Brunell, MD

In the May issue of Pediatrics there is a committee statement concerning acute otitis media (AOM) and another on otitis media with effusion (OME). These related topics are presented in separate reports, as the issues are quite distinct, although clearly related. OME appears transiently in most children following AOM. It is likely that the inclusion of cases of OME in evaluations of the effect of antimicrobials on AOM may have obfuscated the results of many studies. If one includes patients who are not expected to benefit from therapy, eg, patients with OME, in evaluating antibiotics, it is more difficult to show differences between the treatment groups.

OME and AOM may be difficult to differentiate clinically. Poor mobility of the tympanic membrane and effusion are common to both. Redness of the tympanic membrane is said to be present in about 5% of children with OME. The main points of differentiation are acute onset and inflammation, which are present in AOM and not in OME.

Signs of inflammation found in AOM are erythema or pain that interferes with normal activity or sleep. Bulging or fullness of the membrane are the most predictive signs of AOM, especially when combined with erythema. It may be useful in making a differentiation to clearly define the physical and historical findings in the chart in writing. This also may be useful retrospectively. “Otitis media” is not a physical finding — it is a diagnosis.

Poor motility, which is present in both, is best assessed with a pneumatic otoscope. It is emphasized that “the otoscope should be fully charged; the bulb, halogen or luminescent; and the insufflator bulb attached firmly to the head to avoid the loss of an air seal.” Bulbs and batteries should be changed frequently, and it is suggested the negative pressure be applied on insertion to detect negative pressure in the middle ear. Probably the most valuable reference in the bibliography is one co-authored by one of our editorial board members, Dick Schwartz, MD, of Clinical Practice Primer.

In the American Journal of Diseases of Children (1986;140:1237), Schwartz discusses the need to check on the bulb and the batteries frequently and also to use the proper type of speculum. It is suggested that a new bulb be kept and tested against the old frequently to assure the bulb is not burned out. Recharging batteries should be done frequently (I leave mine plugged into the wall outlet) and rechargeable batteries replaced in a timely manner. Tympanometry or acoustic reflectometry are alternative methods for evaluating mobility.

He also discusses otoscope care in the April 2001 issue of Infectious Diseases in Children (to read the article, click here).

Goals of therapy

AOM in most cases is a self-limited disease. Spontaneous resolution of symptoms and disappearance of organisms from the middle ear are the rule rather than the exception. Pneumococcus appears to produce a more acute course and slower resolution than Moraxella or Haemophilus. The goals of therapy are to relieve pain, hasten the resolution of symptoms and prevent recurrences and the rare complications that may ensue. The report states that mastoiditis is a very uncommon complication that was as frequent in children treated immediately as compared with those in whom therapy was withheld and that even some children on antibiotics presented with this complication.

One should not neglect the management of pain whether or not antimicrobial therapy is prescribed initially. The most commonly used analgesics are ibuprofen, 5-10 mg/kg/day q4-6 hours or acetaminophen, 10-15 mg/kg/day not to exceed five doses in a 24-hour period.

Given that AOM is a self-limited disease and that antimicrobial therapy may decrease the symptoms by only a day or so, it is suggested that therapy in children 6 to 24 months old who do not have severe disease and in whom the diagnosis is uncertain and in older children who have uncertain diagnosis or do not have severe symptoms, therapy may be withheld. But patients must be followed closely and there must be reassessment at 24 to 36 hours. One may wish to consider this when seeing a child on Friday. If symptoms worsen in this interval or fail to improve at the end of this time, antimicrobials should be prescribed. The recommended initial treatment continues to be amoxicillin 80 to 90 mg/kg/ day. This dosage is believed to be capable of achieving middle ear levels adequate to treat many nonsusceptible strains of pneumococcus, including some that are highly resistant. For those younger than 2 years, a 10-day course appears to be appropriate, as well as for those 2 to 6 years old and older children with severe disease. A five- to seven-day course may be adequate for the others. Good data on duration of therapy are wanting.

Avoiding developmental delays

OME occurs transiently following AOM; thus, once identified, children with OME should be followed periodically to determine whether it has resolved spontaneously. The main concern here is that prolonged effusion not interfere with hearing to the point where speech and learning are impaired. This is particularly important in children who have other conditions that may compromise development. Watchful waiting is appropriate for children without complicating conditions as OME is common, particularly during the winter, affecting as many as half of day care attendees and 25% of school-aged children.

Most OME following AOM will resolve in three months, and many cases will resolve after an additional period of observation. Observation beyond three months is acceptable for many children who do not have other factors that might compromise communication and learning. Hearing testing should be performed if OME persists three months or longer or if hearing seems to be significantly impaired. This will provide information on the extent and laterality of the deficit. Children with the greatest hearing impairment are at increased risk of impaired speech and language development and impaired academic performance. In the interim, parents and teachers should be assessed of the need to optimize hearing and learning. Comprehensive hearing evaluation may be needed in children who fail primary evaluation and in certain other high-risk children. Language testing is advised for children with significant hearing loss. The use of antihistamines, corticosteroids or antibiotics is not likely to yield sustained relief, nor is allergic management exclusively for OME likely to be worthwhile.

When you feel it would be appropriate, an otolaryngologist should be engaged as a consultant rather than simply referring the child for surgery. Optimally, one should pick up the phone and discuss the problem. The rush to tubes has slowed somewhat. If tubes are placed, adenoidectomy need not be done initially but is recommended if there is a recurrence of OME and tubes need to be reinserted. Tonsillectomy is not recommended.

These two reports are well worth reading. They are evidence-based recommendations, not commandments, and must be tailored for each individual child. There are special concerns about children with conditions that may compromise learning or who cannot be followed carefully with OME and AOM respectively. The authors are sensitive to the difficulties that frequently arise in examination of children believed to have AOM. They readily admit that there are deficits in our database, eg, length of treatment of otitis and the uncertainty about the value of interventions in OME on future development. But they are very well done and should be kept at one’s elbow.

For more information:

• American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, AAP Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. 2004;113:1412-1429.
• AAP Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451-1465.