With onset of winter season ENT clinic are flooded with children with ear pain, because upper respiratory infections and ear infections in children are most common with colder temperature during the winter months. An anxious Mother of 3 year-old boy with fever says he has cold and his ear hurts, she than inquires with concern does he need an antibiotic?
To decide we need to make a diagnosis first…
Otitis media is the second most common reason after the common cold for visits to doctor and the most frequent reason for prescribing antibiotics to children. About 90% of children have OME (Otitis Media with effusion) at some time before school age and 75% of children have at least one episode of AOM (Acute Otitis Media) by the age of 2 years which usually resolves spontaneously
Appropriate treatment of children with “ear infection” requires distinguishing AOM from OME by careful history and pneumatic otoscopic examination (single most important tool).
To understand the definitions- What is AOM and OME?
Acute otitis media AOM – an acute bacterial infection of the middle ear of less than 6 weeks duration
There is usually pain in the ear and fever. If ear drum ruptures there may be pus discharge (Otorrohea) from the ear with rapid relief of pain. Pus may be mixed with blood.
Chronic suppurative otitis media (CSOM) – If ear drum infection persists for more than 3 months and is associated with a chronic perforation of the tympanic membrane.
Otitis media with effusion (OME) – Fluid in the middle ear without signs or symptoms of inflammation
It can occur just prior to AOM or persist after AOM for a few days or up to many weeks.
How we decide about giving antibiotic?
Age and severity of symptoms are deciding factors but most important is correct diagnosis.
- If it is OME antibiotics are unnecessary.
- Uncomplicated AOM in an otherwise healthy child above 2 years of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic.
- If child is less than 6 months of age antibiotics are to be given even if diagnosis is not certain. (Contrary to parent’s belief that small kid should not be given antibiotics).
- Most controversies exists in treating child above 6 months but less than 2 years of age where current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians) advises to avoid antibiotic for uncertain diagnosis or if illness is mild.
So How Do We Diagnose Ear Infection?
Distinguishing OME (Otitis Media with Effusion) and AOM (Acute Otitis Media)
OME is usually caused when the eustachian tube is blocked or mucus production is more and fluid becomes trapped in the middle ear. This often occurs after a common cold or viral infection, but it can also occur after an episode of AOM.
It is common in a child because eustachian tubes are shorter and more horizontal as compare to adults and muscles to close the tube are not properly developed in children.
Symptoms – The child with OME does not have ear pain or draining ear. He may have slight hearing impairment. There may be history of frequent URTI & mouth breathing.
Examination of Ear by Pneumatic otoscope– Single most important diagnostic tool –
- Tympanic membrane may be dull looking, Pulled in (retracted) and immobile.
- Ear drum is not red or bulging as it is in AOM.
- Air Fluid level seen as bubbles
Tympanometry can be advised to confirm the diagnosis of OME
AOM occurs when fluid in the middle ear becomes infected, usually following a common cold or viral upper respiratory infection.
Symptoms – Child usually have fever and sudden ear pain after a common cold or stuffy nose. Infant may be irritable with pulling of ear. If tympanic membrane gets ruptured liquid may be coming out from ear (Otorrhoea/ear discharge).
Examination of ear– symptoms alone are not enough to diagnose AOM and examination of ear drum with otoscope to see the signs of inflammation (redness or erythema) and pneumatic otoscopy to conform the fluid in the middle ear is necessary. (Opacification & Bulging of ear drum with reduced mobility)
If tympanic membrane is ruptured Ear discharge may be present, and hole (Perforation) in the ear drum may be seen
Audiogram may show mild to moderate conductive hearing impairment.
Tympanogram may show type “B” curve
How to treat AOM and OME?
Management of children with OME
- Aim is resolution of fluid, restoration of ear drum mobility and restoration of hearing
- As OME usually resolves without treatment for 3 months it is just wait and watch.
- Antihistamines and decongestants are not effective and antibiotics are not recommended for routine management.
- Steroids with beta lactame antibiotics are proven to be beneficial in few studies and and no benefit in others.
- Children with persistent effusion reexamined at 3-6 months interval till it resolve.
- Hearing testing is done if OME persists for more than 3 months or if Child is at risk of speech or language delay.
- If the effusion persists for more than 3 months and/or hearing loss exceeds 20 dB surgery Tympanostomy tube (Grommet) insertion is done.
- Adenoidectomy is done if indication for surgery is present.
Management of Children with acute otitis media
Aim is to relieve pain and fever, to treat infection and restore hearing along with prevention of recurrence.
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline for OME emphasizes the management of pain as a major management goal.
- Analgesics are usually prescribed to provide relief from pain; acetaminophen and ibuprofen are commonly given medicines.
- Uncomplicated AOM in an otherwise healthy child above 2 years of age or very mild infection in children below 2 yrs but more than 6 months of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic or amoxicillin can be used.
- If there is no response within 2-3 days antibiotic is to be started or antibiotic is changed.
- Ear drops (Ototopical formulations) antibiotic with or without steroid are prescribed if ear drum is ruptured as steroid reduces inflammation and antibiotic improves infection eradication.
- Tympanic membrane perforation in children usually heals spontaneously in 1-2 months. During this time child should come for periodic follow to visits to assess the healing process, water entry in the ears should be avoided and all possible preventive measure to reduce chances of catching common cold are to be taken.
Role of Surgery in brief
Surgical management of otitis media is indicated for recurrent AOM, AOM with complications, chronic suppurative otitis media (CSOM) and otitis media with effusion where chances of hearing and speech problem are predicted
Most common surgical procedure is placement of tympanostomy tubes (Grommets).
Tympanostomy tubes allow drainage of fluid in the middle ear and ventilaton of middle earspace. Grommets usually fall out of the tympanic membrane within 6-14 months.
Coming Back to original question
It is important to distinguish between the presence of middle ear fluid (OME) and the presence of middle ear fluid with infection (AOM) by pneumatic otoscopy. If wax is obscuring the view of ear drum it has to be removed.
OME does not benefit from antibiotic therapy; child should be carefully monitored for recurrent AOM and hearing loss, which, if chronic, can impair speech and language development. AOM, if it does not resolve spontaneously, can result in serious complications, and benefits from antibiotic therapy.
So with utmost patience and gentleness we examine the crying 3 year old of worried parents and find that ear drum is red and bulging, our diagnosis is AOM.
So again the question of mother – Is Antibiotic Required?
We reassess the situation, explain the risk and benefit of antibiotic and we feel parents are anxious but motivated to come for follow up visit after 2 days, we give symptomatic treatment and avoid antibiotic.
Child of more than 2 years age observation without use of antibiotics is an option for treatment of acute otitis media but children must be followed carefully and antibiotics should be prescribed if spontaneous resolution does not occur.
Child if less than 2 years but more than 6 months of age and diagnosis of AOM is certain I usually prefer to give appropriate antibiotics in proper dose after explaining to parents as usually child has already waited or took treatment with family doctor or pediatrician with pain medicines and because there is chance of ear drum rupture unless parents are concerned about use of antibiotics or it is first day of onset of symptom which are mild. We keep a strict watch and wait in these children with assurance of prompt visit in case of worsening symptoms, fever, or drainage from the ear.
Antibiotics should be prescribed if child is —
Most of the parents usually scared of the word ‘antibiotic’. Antibiotic does have side effects like loose stools or stomach upset but most feared side effect is development of resistance means antibiotic becomes ineffective to kill the bacteria. Thus when there is nothing to fix it should not be fixed but parents should be given time in busy opd hours and explained to understand what doesn’t need to be done and why?
During the winter months, viral upper respiratory infection is the most common cause of Eustachian tube dysfunction and ear infection in children. Adenoids may also cause obstruction.
Though this winter is prolonged and there are more number of children with ear infection but in general awareness about preventive measures and vaccination against influenza and pneumococcus have decreased the incidence of winter AOM.
According to current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians for use of antibiotics –
“Otitis Media with effusion does not require antibiotics and Acute Otitis Media does not always require antibiotics“.