The SIGN guideline on otitis media will help target antibiotics at those children who will benefit most, says Dr Rob Wicks
My first impression of the recently published SIGN guideline on otitis media was that, at 20 sides of A4, it was quite long for something that in essence is a simple subject. I couldn’t have been more wrong, because it provides an overview that is both concise and to the point.
We all see otitis media frequently. One in four children will get acute otitis media (AOM) before the age of 10 years, peak incidence being between the ages of 3 and 6 years. One study suggested that 80% of children get otitis media with effusion (OME; glue ear) before the age of 4 years. How many GPs, however, have a concrete management plan for the condition?
The guideline sets out recommendations based on an overview of the best and most recent clinical evidence, and as a result it will be a useful tool in general practice. It covers definitions and diagnosis of otitis media and otitis media with effusion as well as diagnostic techniques.
Children at high risk of OME are identified, i.e. those in day care; with older siblings; with parents who smoke; and those who present with hearing or behavioural problems.
The guideline states that in many studies pneumatic otoscopy has a role in diagnosis of OME, but acknowledges that this technique is not used in primary care. In common with, I would guess, many others I have had no teaching in this technique and it may be something to consider for my personal development plan for next year! Audiological assessment is best performed by the ENT department.
The ‘meat’ of the guideline concerns whether or not to treat AOM or OME with antibiotics. It seems that antibiotic treatment has no more effect on pain 24 hours after presentation than non-treatment; antibiotics do, however, almost double the incidence of diarrhoea, vomiting and rash. One meta-analysis found that at 2-7 days only 14% of children taking placebo still had pain.
It is suggested that a more rational strategy may be to target those with fever or vomiting as well as the usual symptoms of AOM because these children are more likely to do badly without treatment.
Delayed prescription is another useful strategy. The guideline highlights one study, which found that in a ‘delayed prescription’ group (prescription to be collected at parents’ discretion after 72 hours if the child has not improved) only 24% of parents collected the antibiotics.
In summary, there is little place for antibiotics in routine treatment of AOM. There is also little evidence to support antibiotic use in OME for either symptom control or prevention of later speech or hearing problems.
A useful section on when to refer for ENT opinion forms part of the excellent summary sheet at the end of the guideline. In fact, the guideline is a mine of information that will be useful to GPs, and for those who don’t have the time or inclination to read the whole document it is condensed into one sheet at the end.
I enjoyed reading this guideline because it reinforced what I already knew about otitis media and reminded me that it is yet another illness that is more common as a result of smoking. It gives scientific backup in a common clinical situation, and supports GPs’ decisions not to prescribe antibiotics – bringing benefit to patients and our prescribing budgets, and helping to combat antibiotic resistance.
SIGN 66: Diagnosis and management of childhood otitis media in primary care can be downloaded free of charge from the SIGN website: www.sign.ac.uk