Treatment:

Many of the treatments for ear infections, particularly antibiotic use and surgical procedures, are often unnecessary in many children.

Doctors continue to argue about the best approach for treating ear infections. The major debates rest on the use of antibiotics, surgery, and watchful waiting in both acute otitis media (AOM) and otitis media with effusion (OME).

Until recently, nearly every American child with an ear infection who visited a doctor received antibiotics. Major studies now indicate that antibiotics are unnecessary in most cases of acute otitis media. Between 80 - 90% of all children with uncomplicated ear infections recover within a week without antibiotics. Likewise, receiving antibiotics for an acute ear infection does not seem to prevent children from having fluid behind the ears after the infection is cleared up. Antibiotics are rarely recommended for otitis media with effusion.

Antibiotic Resistance. The intense and widespread use of antibiotics has led to a serious global problem of bacterial resistance to common antibiotics. In the U.S., nearly a quarter of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are the most heavily prescribed.

Watchful Waiting for AOM. Because of the high rate of antibiotic resistance, and the fact that non-severe AOM usually resolves on its own without antibiotics, many pediatric guidelines recommend a “watchful waiting” period before antibiotics are prescribed. Current guidelines released by the American Academy of Pediatrics and the American Academy of Family Physicians recommend an initial observation period of 48 - 72 hours for select children. Pain relief can initially be given with acetaminophen (Tylenol), ibuprofen (Advil), or topical benzocaine drops.

If there is no improvement or symptoms worsen, parents can schedule an appointment with the child's doctor to determine if antibiotics are needed. (Parents should contact the doctor within the first 24 hours if their child is 6 months or younger and has fever or other severe symptoms.) Another option is to ask the doctor for a Safety Net Antibiotic Prescription (SNAP) that can be filled if symptoms do not improve within 48 - 72 hours

While children with non-severe AOM who are given antibiotics may recover slightly more quickly, they often have a high number of side effects and antibiotic-resistant bacterial strains. Studies have found that giving parents the option of delaying antibiotic treatment helps to reduce the unnecessary use of antibiotics without causing any health problems for the children. Unfortunately, surveys indicate that although medical guidelines recommend watchful waiting, few doctors regularly practice it.

Treatment Guidelines for Acute Otis Media (AOM)

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) guidelines and recent evidence support the following recommendations:

• Accurate diagnosis of AOM including differentiation from OME.
• Children fewer than 6 months of age should receive immediate antibiotic treatment.
• Children 6 months or older should be treated for pain within the first 24 hours with either acetaminophen or ibuprofen.
• An initial observation period of 48 - 72 hours is recommended for select children to determine if the infection will resolve on its own without antibiotic treatment. (Most children do improve within 72 hours.)
• For children aged 6 months - 2 years, criteria for recommending an observation period are an uncertain diagnosis of AOM and a determination that the AOM is not severe. For children older than 2 years, the observation period criteria are non-severe symptoms or uncertain diagnosis. Severe AOM symptoms include moderate to severe pain and a fever of at least 102.2° F (39° C).
• Preventive antibiotics (antibiotic prophylaxis) may be recommended for recurrent acute otitis media. Which children should be treated this way, as well as which antibiotics and for how long, have not been clearly determined.

Treatment Guidelines for Otitis Media with Effusion (OME)

The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) released updated clinical practice guidelines for OME in 2004. These guidelines include the following treatment recommendations:

Watchful Waiting for OME. The child is typically monitored for the first 3 months. Antibiotics are not helpful for most patients with OME. For one, the condition resolves without treatment in nearly all children, especially those whose OME followed an acute ear infection. About 75 - 90% of OME cases that result from AOM resolve within 3 months. If OME last longer than 3 months, a hearing test should be conducted. Even if OME lasts for longer than 3 months, the condition generally resolves on its own without any long term effects on language or development and intervention may not be necessary. The doctor will re-evaluate the child at periodic intervals to determine if there is risk for hearing loss.

Drug Treatment. It is important for parents to recognize that persistent fluid behind the eardrum after treatment for acute otitis media does not indicate failed treatment. Antibiotics, decongestants, antihistamines and corticosteroids do not help and are not recommended for routine management of OME. These drugs are not effective for OME, either when used alone or in combination. Antihistamines and decongestants may cause more harm than good by provoking side effects such as stomach upset and drowsiness. At present, there is no compelling evidence to indicate that allergy treatment can assist with OME management nor has a causal relationship between allergies and OME been established.

Surgery. The decision to pursue surgery must be determined on an individual basis. Ear tube insertion may be recommended when fluid builds up behind your child's eardrum and does not go away after 4 months or longer. Fluid buildup may cause some hearing loss while it is present. But most children do not have long-term damage to their hearing or their ability to speak even when the fluid remains for many months.

Children with OME lasting longer than 4 months may be considered candidates for surgery if they have:

• Hearing loss greater than 40 dB
• Hearing loss between 21 - 39 dB (Children in this group may be observed or considered for surgery)
• Hearing loss of 20 dB or less, when speech, language, or developmental problems are observed
• OME and structural damage to the ear canal, eardrum, or middle ear

Tympanostomy (the insertion of tubes into the eardrum) is the first choice for surgical intervention. Adenoidectomy (removal of adenoids) plus myringotomy (removal of fluid), with or without tube insertion, is sometimes recommended as a repeat surgical procedure. (Myringotomy alone is not recommended for OME treatment. Between 20 - 50% of children who undergo this procedure may have OME relapse and need additional surgery). Tube insertion may be advised for children younger than 4 years of age. Adenoidectomy is not recommended as an initial procedure unless some other condition (chronic sinusitis, nasal obstruction, adenoiditis) is present.

Tonsillectomy (removal of tonsils) is not recommended for OME treatment.