Key Treatment

Antibiotics are most beneficial in children younger than 2 years with bilateral acute otitis media (AOM) and/or otorrhea (SOR: A). For most other children with mild disease, close observation and follow-up is an option (SOR: A) (Vouloumanou et al., 2009). Administration of the seven-valent pneumococcal vaccine (PCV7) in infancy reduces the risk for AOM by 6% to 7%. Administering PCV7 to older children with a history of AOM appears to have no benefit in preventing further episodes (SOR: A) (Jansen et al., 2009). Second- and third-generation cephalosporins may be used to treat AOM in penicillin-allergic patients (SOR: A) (Pichichero and Casey, 2007).

Uncomplicated AOM may be treated for 5 to 7 days (Pichichero and Brixner, 2006). SOR: A

Otitis Media with Effusion

Otitis media with effusion (OME) is defined as persistent middle ear fluid without pain, fever, or redness of the tympanic membrane. It is often the result of AOM but can occur de novo. About 90% of children have OME before they reach school age. About 80% to 90% of cases resolve within

3 months and 95% within 1 year. Table 19-3 provides the Agency for Health Care Policy and Research (AHCPR) guidelines for treatment of OME.

Tympanometry can be used to judge the presence of middle ear fluid. It is important to document the affected ear, the duration of the effusion, and the presence and severity of symptoms associated with OME. The latter include a feeling of fullness in the ear, popping, mild pain, hearing loss, balance problems, and delayed language development.

If OME persists for 3 months, a comprehensive hearing evaluation should be performed. A 40-decibel (dB) loss (or worse) in hearing bilaterally mandates referral for evaluation for polyethylene (PE) tube placement. Management of hearing loss between 6 and 39 dB depends on parent or caregiver preferences and can include strategies to improve the listening and learning environment or referral for tube placement. If the hearing loss is 5 dB or less, repeat testing in 3 months may be performed if the middle ear effusion continues at that time. Follow-up testing is recommended every 3 to 6 months until the effusion resolves, unless significant hearing loss occurs or there is evidence for structural abnormalities of the eardrum or middle ear. In these patients, PE tube placement is the preferred course.

When referring to a surgeon, the primary care physician must provide an adequate history of the duration of the middle ear effusion, developmental state of the child, and pertinent information such as a history of AOM. Physician and parental expectations for the referral should be clarified. Ultimately, the decision for PE tube placement should be based on a consensus among all parties involved. The possibility of repeat surgery after tube extrusion is 20% to 50%, and with reoperation, adenoidectomy is recommended in children with normal palates because it reduces the need for future surgery by 50%.

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