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What are the risk factors for otitis media? Bulging, opacity and immobility are all highly predictive of
The main factors influencing the risk of a child developing acute otitis media.
otitis media are host-related or environmental (Table 1, over
page). Children living in communities where overcrowding
is common are at increased risk of developing otitis media.3 Management of acute otitis media
Mori and Pacific children are more likely to be affected by Reassurance is an important aspect of the management of otitis
otitis media than European children in New Zealand, however, media. Symptom relief with analgesics and watchful waiting
reliable estimates of prevalence by ethnicity are not available. is recommended, as approximately 80% of children with
BPJ Issue 46 25
acute otitis media have spontaneous resolution within two When antibiotics are required, first-line treatment is amoxicillin
to 14 days.2 Paracetamol is the first-line analgesic. Ibuprofen 40 mg/kg/day in two to three divided doses (up to 1.5 g daily),
is known to reduce inflammation and pain associated with for five days. Treat for seven to ten days in a child aged under
acute otitis media, however, it should not be given if the two years, with an underlying medical condition, perforated
child displays signs of dehydration or has concurrent asthma eardrum or chronic or recurrent infections.7, 10 N.B. Some
(NSAIDs can potentially worsen asthma symptoms). There is clinicians are now recommending using amoxicillin 80 mg/kg/
no evidence that antihistamines or decongestants provide day as it is more effective in treating resistant Streptococcus
benefit.7 pneumoniae strains, however, current guidelines reflect the
lower dose. Co-trimoxazole, cefaclor and erythromycin are
Antibiotics are not routinely required in the treatment of alternative antibiotics to amoxicillin, although erythromycin
uncomplicated acute otitis media. However, a recent study would be trialled last as it has poor activity against Haemophilus
suggests that empiric antibiotic treatment of acute otitis media influenza, which is a common pathogen associated with otitis
in infants can reduce symptoms and decrease the likelihood of media.1, 10
persistent infection.8
Delayed (back pocket) prescribing may be appropriate in
Antibiotic treatment should be considered in children:7, 9 some cases. Providing a prescription with advice to only use
Aged under six months it if the symptoms persist for more than 24 48 hours can
Aged under two years, with bilateral acute otitis media or reduce antibiotic use without reducing family satisfaction
severe illness with treatment.7 This can also be written on the prescription in
order to allow pharmacists to provide counselling on delayed
With acute otitis media and perforation
use when parents request immediate dispensing of antibiotics.
With systemic symptoms, e.g. fever
Alternatively, the prescription could be dated in advance.
Who have not improved following 48 hours of watchful The family should be asked to return if the childs condition
waiting worsens despite the use of antibiotics, or if they have concerns
about the childs health.
Table 1: Patient and environmental factors influencing a childs risk of developing otitis media4
Patient-related factors
Age Otitis media peaks between ages 6 - 24 months and between ages 4 5 years
Reduced breast feeding Breast feeding for at least three months reduces the rates of acute otitis media by
13%
Use of a dummy (pacifier) After age 11 months dummy use increases the risk of children developing acute
otitis media by 24%
Environmental factors
Attendance at early childhood care The most significant environmental factor and directly related to the number of
children at each centre
Overcrowded homes and/or a large As with daycare, relating to increased close contact between siblings
number of older siblings
Winter Upper respiratory tract infections are more common in winter and viruses are
often associated with acute otitis media
26 BPJ Issue 46
Otitis media with effusion (OME) due to OME can affect language development, although no
causal relationship has been clearly established.7
OME is defined as the presence of fluid in the middle ear without
signs or symptoms of an infection.1 It can occur spontaneously,
as part of rhinosinusitis, or following an episode of acute otitis Diagnosing otitis media with effusion
media. It is the most frequent cause of balance disorder and A diagnosis of OME can be confirmed if pneumatic otoscopy or
acquired conductive hearing loss in childhood.4, 11 tympanometry shows reduced or absent tympanic membrane
mobility.5 Other signs include abnormal colouring of the
Following acute otitis media, OME is present in approximately tympanic membrane, e.g. yellow or amber, opacity not due to
half of patients at one month, 20% of patients at two months scarring (which may be present in patients with a history of
and 10% of patients at three months. 12 A study which inner ear issues) or the presence of air bubbles.
included tympanometry as part of an assessment of routine
development in over 1000 Pacific children, found that at age
two years one in four were affected by OME.11 Management of otitis media with effusion
Watchful waiting is recommended as most cases of OME
Most children with OME will improve spontaneously within resolve spontaneously.7 Antibiotics provide little or no long-
three months.7 There is concern that persistent hearing loss term benefit for children with OME.13
Interpretation of tympanometry
Type A
Static admittance
Type B
BPJ Issue 46 27
Reducing the risk of otitis media-related Referral to an otolaryngologist should be considered in
complications children who have recurrent acute otitis media. This is defined
as more than three episodes in a six month period, or four
In New Zealand, there is limited epidemiological data regarding times in one year.14 Grommets have been shown to reduce
complications associated with otitis media. In Australia, the incidence of recurrent acute otitis media in the six months
indigenous children, particularly those living in isolated rural following insertion (see Grommets indications, outcomes
communities, are most at risk of complications.7 and complications).15 Referral is also indicated for children
with OME and hearing loss lasting longer than three months
The two most significant modifiable risk factors for otitis media that has been confirmed by otoscopy or tympanometry.14
are dummy (pacifier) use after the age of 11 months and
passive smoking.4 Smoking rates are higher amongst Mori To confirm hearing loss, a hearing test should be arranged for
and Pacific peoples compared to Europeans in New Zealand, all children with bilateral OME that persists for longer than
therefore reducing smoking rates is likely to reduce the rate three months.1
of otitis media in Mori and Pacific children. Breast feeding is
thought to protect against the development of otitis media.4 The Kidz First hearing and vision testing service provides
Teaching and encouraging young children to blow their noses a free mobile service to children with high needs within the
may also assist in routinely clearing the eustacian tubes. Counties Manukau region. There are also community-based
The association between persistent hearing loss caused recurrent acute otitis media in the first six months
by OME and adverse language and behavioural outcomes following surgery.15
is controversial. Grommets (tympanostomy tubes) are
often inserted to restore hearing in children with chronic Otorrhoea (discharge) will be experienced by one in four
OME. A Cochrane review found that grommet insertion children at some stage while the grommets are in place.19
could improve hearing loss associated with OME in In approximately 4% of infants, this complication will
children, however, this effect was limited to six to nine develop into chronic suppurative otitis media (CSOM),
months post surgery, by which time natural resolution the most severe form of otitis media.19 Grommet insertion
also led to improved hearing in non-surgically treated is a significant cause of CSOM in children, but it can also
children.16 The review concluded that a policy of watchful develop as a complication of acute otitis media with
waiting for three months in children with bilateral OME perforation.20
and a hearing impairment is justified, as during this
period, approximately 50% of children will experience A diagnosis of CSOM can be made when there is discharge
spontaneous resolution.16 This guidance is in line with through a perforated tympanic membrane, which persists
United Kingdom NICE referral guidelines for the surgical for two to six weeks.1 Topical quinolones are the first-line
management of OME in children.17 It is also supported treatment, as there is a small risk of ototoxicity associated
by another Cochrane review, which found no clinically with the use of non-quinolone topical antibiotics such
significant benefits to language and behaviour outcomes as aminoglycosides.1 Ciprofloxacin with hydrocortisone
of screening and early treatment of OME in the first four ear drops (not subsidised) are effective in treating CSOM.
years of life.18 The external auditory canal should be cleaned using
suction prior to administration to allow the antibiotic to
Grommet insertion is also used to prevent recurrent acute penetrate affected tissues. Children who fail to respond to
otitis media. A Cochrane review found that grommet topical antibiotics should be referred for more intensive
insertion was effective in reducing the frequency of treatment.
28 BPJ Issue 46
clinics in this region. Further information is available from: References
www.healthpoint.co.nz. Similar services also exist in other 1. Morris PS, Leach AJ. Acute and chronic otitis media. Pediatr Clin North
Am 2009;56(6):138399.
regions. Local DHBs should be contacted for details.
2. Rovers MM, Schilder AGM, Zielhuis GA, Rosenfeld RM. Otitis media.
Lancet 2004;363(9407):46573.
10. New Zealand Formulary (NZF). NZF v2.1. NZF, 2012. Available from:
www.nzf.org.nz (Accessed Aug, 2012).
11. Paterson JE, Carter S, Wallace J, et al. Pacific Islands families study:
the prevalence of chronic middle ear disease in 2-year-old Pacific
children living in New Zealand. Int J Pediatr Otorhinolaryngol
2006;70(10):17718.
13. Gasper K. Clinical inquiries: are antibiotics effective for otitis media
with effusion? J Fam Pract 2003;52(4):3213.
associated with acute otitis media.21 Prevenar 13 is 18. Simpson SA, Thomas CL, van der Linden MK, et al. Identification of
available for children at high risk of pneumococcal children in the first four years of life for early treatment for otitis media
with effusion. Cochrane Database Syst Rev 2007;(1):CD004163.
disease, e.g. immunodeficient or with cochlear
implants. These children should also receive the 19. Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube
sequelae. Otolaryngol Head Neck Surg 2001;124(4):37480.
pneumococcal polysaccharide vaccine Pneumovax
23 after age two years. 20. van der Veen EL, Schilder AGM, van Heerbeek N, et al. Predictors of
chronic suppurative otitis media in children. Arch Otolaryngol Head
Neck Surg 2006;132(10):11158.
For further information see: Pneumococcal
21. Walls T, Best E, Murdoch D, Mills N. Vaccination to prevent otitis media
vaccine for adults: Pneumovax 23, BPJ 35 (Apr, 2011).
in New Zealand. N Z Med J 2011;124(1340):69.
BPJ Issue 46 29