Dr Charles Sears finds that there is still room for the art of medicine in the management of acute otitis media

Otitis media takes up a large amount of medical time, and resources, including antibiotics and symptom-relieving medication. It also causes morbidity, disrupting the lives of the children and their parents. Occasionally there are more serious consequences, such as mastoiditis, and there may be prolonged middle-ear effusions, with deafness and consequential educational impact.

The management of acute otitis media (AOM) varies from country to country. In the UK, we have tended to start antibiotics as soon as possible. In some countries, myringotomy has been the treatment of choice. It has been suggested that AOM should be treated with analgesics alone, and some advocate decongestants.

Recently there has been a move towards avoiding the early use of antibiotics, and current research may back this up. In looking for support for any guidelines on efficacy of treatment, one needs evidence. Systematic reviews and meta-analyses provide the best evidence, and although many of these are being published, there is a wide variation in quality.

Interpretation of the evidence requires a team approach, and it makes good sense to approach guidelines on the management of AOM with the whole primary healthcare team, representatives from secondary care, and, if possible, a pharmacist and a patients' representative.

There are two main, recent meta-analyses on antibiotic treatment of AOM.1,2 Rosenfeld gave a qualified yes to the question of whether antibiotics should be part of the initial empirical therapy in children, while Del Mar concludes that there should be open discussion with the parents, giving them information on which to balance benefits against risks and costs.

Evidence suggests that broad-spectrum, beta-lactamase-resistant antibiotics confer no significant benefit (over simpler drugs such as amoxycillin,1 and that a long course of antibiotics has little advantage over a short one.3

It would seem logical to involve the patients/parents more in management decisions, discussing the pros and cons of antibiotic use, and selecting a short course of one of the simpler antibiotics, if going for that option.

The New Zealand Guidelines Group,4 which is considering AOM, proposes to recommend this sort of strategy. They propose amoxycillin and co- trimoxazole as the antibiotics of choice. They also plan to recommend follow-up at 48 hours for children with persisting symptoms, and routine follow-up after a month to look for otitis media with effusion. Although they hope to see fewer inappropriate recalls, this seems to involve an act of faith, while taking on more work up front.

They expect antibiotic use to be reduced. Projections based on a 25% and 50% reduction in antibiotic prescriptions show a financial gain from reduced, and less wasteful prescribing, and also a reduction in antibiotic side-effects. However, they also concede less reduction of pain over the first week, and a higher occurrence of otitis media in the other ear.

The trials and meta-analyses bring new aspects to our understanding, but it is, perhaps, heartening that there is no absolute answer or truth, and there is still room for the art of medicine – 'amusing the patient while nature effects a cure' (Voltaire 1694-1778).

  1. Rosenfeld R et al. An evidence-based approach to treating otitis media. Pediatr Clin North Am 1996; 43: 6.
  2. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ 1997; 314: 1526-9.
  3. AL Kozyrskyi, GE Hildes-Ripstein, SE Longstaffe et al. Treatment of acute otitis media with a shortened course of antibiotics. JAMA 1998; 279: 1736-42.
  4. Acute Otitis Media Guidelines (in production). New Zealand Guidelines Group http://www.nzgg.org.nz/library/gl_reg_wip/otolaryn_aom/

Other world wide web references

Antibiotics for acute otitis media. Bandolier. June 1995; 16-3. http://www.jr2.ox.ac.uk/bandolier/band16/b16-3.html

Sears C. Information for patients on otitis media, with linked table of pros and cons of antibiotic use. Medinfo. December 1998. http://www.medinfo.co.uk/conditions/otitismedia.html

Guidelines in Practice, March 1999, Volume 2
© 1999 MGP Ltd
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