Acute Suppurative Otitis Media

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Acute

Suppurative

Otitis

Media

PEDIATRICS Vol. 56 No. 2 August 1975 285

D. Stewart Rowe,

M.D.

From the Department of Pediatrics, University of California, San Francisco

Most pediatricians recognize and treat acute

otitis media several times each day. Yet there is

wide disagreement about certain aspects of its

diagnosis and treatment, despite a large and

growing literature on the subject. This review

at-tempts to summarize what is known about acute

otitis media in children.

DEFINITION

Acute suppurative otitis media is distinguished

from secretory (serous) otitis media by the

pres-ence of purulent fluid in the middle ear.

Patho-genic bacteria may be cultured from the majority

of needle aspirates of this purulent fluid. In secre-tory otitis media, relatively few

polymorphonu-clear cells are present in the middle ear fluid,

which is either thin and straw-colored (serous) or

thick and translucent grey (mucoid).’ The fluid

has the chemical characteristics either of a

tran-sudate of plasma2 or of a mucoid secretion,3

pre-sumably produced by goblet cells and mucous

glands which are greatly increased in the middle

ear mucosa of patients with secretory otitis

me-dia.4 Cultures of this middle ear fluid are usually

negative for pathogenic bacteri&’2’5 and

vi-ruses.6’7 Suppurative otitis media can be

diag-nosed positively only by aspiration of purulent

fluid from the middle ear, but this procedure is

rarely necessary for initial diagnosis and manage-ment. Clinical findings helpful in distinguishing

suppurative from secretory otitis media are

dis-cussed below.

INCIDENCE

In a study of 847 British children during the

first five years of life, 19% had at least one

epi-sode of otitis media; one third of these had more

than one episode.8 This was considered to

be a minimal estimate in these children, since

otorrhea was the chief criterion for diagnosis. A

retrospective study of 772 children, followed in a

private practice from birth (or early infancy)

through 7#{189}to 13#{189}years of age, demonstrated

that 84% had at least one episode of otitis media

diagnosed by redness of the tympanic membrane;

40% had four or more episodes.9 The incidence is

increased in infants born prematurely’#{176}” and in

those fed in a supine position by bottle.’2 An

unexplained high prevalence of purulent otitis

media is reported in certain populations,

includ-ing Alaskan Eskimos, American Indians, the

Maon of New Zealand, and the aborigines of

Australia. 13

PATHOGENESIS

Children with recurrent suppurative and/or

chronic secretary otitis media have evidence of

eustachian tube dysfunction which can be

dem-onstrated by a variety of techniques. Bluestone

and associates14”5 have described the mechanisms

by which children may develop eustachian tube

obstruction and/or abnormal reflux of

nasopha-ryngeal secretions into the middle ear.

Eu-stachian tube obstruction results in high negative

pressures within the middle ear because of

ab-sorption of oxygen from the middle ear cavity.

The sterile middle ear effusion frequently

associ-ated with this condition may result from

trans-udation of plasma into the atelectatic middle ear,

although active secretion by the damaged middle

ear mucosa is probably a more important source

of the effusion.3’16 Because of the pressure

gradient between the nasopharynx and the middle

ear, intermittent opening of the eustachian tube

can result in aspiration of nasopharyngeal

secre-tions into the middle ear. This intermittent

con-tamination of the middle ear is more likely to

occur if the eustachian tube is abnormally

com-pliant and if the infant is in a supine position.’4

ADDRESS FOR REPRINTS: Department of Pediatrics,

University of California, San Francisco, California 94143.

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

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286 ACUTE OTITIS MEDIA

The increased incidence of otitis media during

infancy and early childhood presumably results

from factors which predispose to tubal

obstruc-tion (relatively hypertrophied lymphoid tissue,

increased frequency of upper respiratory

infec-tions) and tubal reflux (relatively short and less

angulated eustachian tubes, poorly developed

cartilaginous portions of the tube’7).

ETIOLOGY

Bacteria have been isolated from a majority of

needle aspirates of middle ear exudates from

children with acute suppurative otitis media.’829

Pneumococci have been cultured from 25% to

50% of middle ear exudates from infants and

chil-dren older than 6 weeks of age.’829 Hemophilus

influenzae has been recovered from 15% to 25%

of children less than 5 years of age.1829 The

ques-tion of the importance of H. influenzae in older

children deserves further investigation. In two

older studies in Denmark’8 and Sweden19 and a

relatively small study in Boston, 24 H. influenzae

was rarely found in children older than 4 or 5

years of age. But in two recent large studies in

Finland’3 and Alabama,28 H. influenzae was

cul-tured from 12% to 14% of children older than 7

or 8 years of age. Streptococci have been

cul-tured from relatively few children (< 1% to 6%)

in most recent studies.2429 Neisseria catarrhalis

has been isolated from 2% to 9% of middle ear

as-pirates and is regarded as a significant pathogen

by most investigators.’527’29 The presence of

Staphylococcus aureus and S. epidermidis in

middle ear aspirates is difficult to interpret

be-cause of the possibility of contamination with

or-ganisms in the external auditory canal. The

fre-quency of isolation of S. aureus is greatly reduced

when middle ear exudate is obtained by careful

needle aspiration, avoiding gross contamination

from the external canal.20”2 However, the

possi-bility that S. aureus and S. epidermidis may be

primary pathogens in some children with otitis

media has not been excluded. Feigen et al.3#{176}

re-ported the isolation of S. epidermidis in pure

cul-hire from middle ear aspirates from ten of 130

children with otitis media. In nine of these

aspi-rates, gram-positive cocci were seen within

poly-morphonuclear leukocytes. S. epidermidL was

not recovered from external canal cultures in five

of the ten patients. In a study of neonatal otitis

media, coliform bacteria and S. aureus were the

most common pathogens isolated from middle

ear exudates obtained by needle aspiration after

careful cleansing of the external canal.’#{176}Cultures

of the external canals were usually sterile or

yielded only diphtheroids or coagulase-negative staphylococci.

Attempts to prove a viral etiology have been

largely unsuccessful23’26334 except during some

influenza35 and respiratory syncytial virus

epi-demics.36’37 A viral etiology cannot be assumed

on the basis of failure to isolate bacteria from

middle ear aspirates. Middle ear exudate from

children with otitis media inhibits bacterial

growth.2#{176}It contains immunoglobulins as well as

phagocytic cells. Therefore, middle ear fluid may

be sterile at the time of aspiration because host

mechanisms have already eliminated pathogenic

bacteria.

The role of Mycoplasma pneumoniae was

sug-gested by a study of experimental infections in 27

adult antibody-negative volunteers; 12 developed

myringitis, two with bullae.38 M. pneumoniae

was cultured from the throat of one child with

bullous myringitis3’ and from middle ear

exu-dates of two children, one of whom had bullous

myringitis39 and one nonbullous otitis media.3’

However, M. pneumoniae was not recovered

from middle ear exudates in five series, including patients with bullous myringitis.2’26’2932’34

CLINICAL FINDINGS

Presenting

Complaints

Presenting symptoms are variable and

non-specific.10’14’4#{176} Rhiitis and cough are usually

present. Hearing loss may be the presenting

com-plaint. Ear-pulling in infants and earache in

older children may be reported, but these

com-plaints are not reliable indicators of otitis media.

Occasionally vomiting and/or diarrhea are the

predominant complaints. Some infants and even

older children present only with irritability or

fe-ver. Fever is absent at the time of examination in

33% to 57% of infants and children with

bacterio-logically proven otitis media.2”2628 In a study of

infants ten days to six weeks of age, only four of

18 infants with positive cultures of middle ear

as-pirates presented with temperatures 38 C.’#{176}

Tympanic Membrane

The clinical diagnosis of acute suppurative

otitis media rests upon the abnormal appearance

of the tympanic membrane (TM). Unfortunately,

there is no final agreement about which

abnor-malities should be considered diagnostic.

Al-though the diagnosis is made by many physicians

on the basis of redness alone,9’20’40 others have

found redness of the tympanic membrane to be

an unreliable criterion.’4’26 Halsted et al.26

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PEDIATRICS FOR THE CLINICIAN 287

tempted needle aspiration of the middle ears of

15 children with diffusely red TMs without any

other abnormality; no fluid was obtained and

cul-tures of the needle tips were sterile. On the other

hand, many children with bacterial otitis media,

proven by needle aspiration, have grey or yellow

TMs.20’26

Bulging of the TM, indicated by partial or

complete obscuration of the bony landmarks, is

probably the most useful indication of acute

sup-purative otitis media. Halsted et al.26 aspirated

fluid from the middle ears of all 81 children who

had moderate or marked bulging of the TM, with

or without erythema. Of 14 children who had

only partial obscuration of the bony landmarks

and absence of the light reflex, cultures yielded

pathogenic bacteria in three. Of 67 children with

total absence of the normal landmarks, cultures

were positive in 61 (91%).

Impaired mobility of the TM is considered by

some physicians to be a criterion for diagnosis.’4

However, studies proving the sensitivity and

reli-ability of this finding in acute suppurative otitis

media have not been reported. Technical

diffi-culties in determining TM mobility with

avail-able pneumo-otoscopes are apparent.’4 Another

problem is that the bulging TMs of children with

suppurative otitis media are rarely competely

immobile. The detection of slight impairment of

mobility depends on the experience (and perhaps

the bias) of the examiner. Finally, impaired

mo-bility does not help in differentiating suppurative from secretory otitis media, since both conditions are associated with this finding. In spite of these limitations, however, assessment of TM mobility

is useful in differentiating questionably bulging

TMs from those which are only thickened or

ap-pear slightly full as a variant of normal. This is

particularly true in assessing the TMs of

neo-nates.

TM compliance may be determined

objec-tively by tympanometry using an electroacoustic

impedance bridge.’4 When low compliance is

measured during application of negative and

pos-itive pressures through the external canal, middle

ear effusion is frequently present. Bluestone et

al.4’ performed tympanometry on 52 children (87

ears) with recurrent or persistent middle ear

effu-sion prior to myringotomy. Of 71 TMs with low

compliance, a middle ear effusion was found in

58 (82%). No effusion was found in 16 ears with

normal compliance at normal or negative

pres-sures. Technical difficulties include obtaining an

airtight seal in the external canal and

main-taming immobility of young children long

enough to complete the test. Jerger42 was able to

complete tympanometry in 77% of 398

consecu-tive well children 3 months to 6 years of age.

(

Some of these children were given sedative

med-ication.) Although the procedure has the

advan-tage of providing objective evidence of the

likeli-hood of middle ear effusion, its practical value as

an aid in diagnosing acute suppurative otitis

me-dia in children has not yet been demonstrated.

How can suppurative otitis media be

differ-entiated from secretory otitis media? In both

conditions TM mobility is impaired and the color

of the TM is variable and not diagnostic. In cases

of mild secretory otitis media, bubbles or air fluid

levels may be seen behind the TM, but this is not

true when the process is more severe and the

middle ear is completely filled with fluid. The

two conditions are most reliably differentiated on

the basis of TM bulging in suppurative otitis

me-dia. In secretory otitis media, the TM usually

ap-pears retracted, with abnormal prominence of

the bony landmarks. TM retraction is a result of

the negative pressure in the middle ear,

demon-strated in the majority of children with chronic

secretory otitis media by means of

tympanome-try.’5 It is important to assess TM mobility in

children with suspected secretory otitis media

because some children with apparent TM

retrac-tion have normal middle ear pressures and no

ef-fusions.’4 On the other hand, retraction is not

pronounced in some children with secretory

otitis media because the middle ear pressure may

be normal or only slightly negative. Rarely,

chil-dren with sterile secretory otitis media, proven

by needle aspiration, appear to have bulging

TMs. Abnormal mucoid secretions in the middle

ear, combined with eustachian tube obstruction,

can result in increased pressure and TM bulging.

Even without increased pressure, an abnormally

thickened TM, resulting in obscuration of the

bony landmarks, may be difficult to distinguish

from true bulging. Therefore, diagnostic needle

aspiration or myringotomy sometimes is required

to distinguish suppurative from chronic secretory

otitis media.

Bullous myringitis should be treated in the

same manner as acute otitis media without

bullae. Most cultures of middle ear aspirates

from children with bullous myringitis yield

bac-terial pathogens.20’24’25

Diagnostic criteria have not been firmly

estab-lished for otitis media in neonates. Tympanic

membranes in apparently well neonates

fre-quently appear dull, red, and thickened, with a

reduced or absent light reflex.4346 However, the

short process of the malleus is almost always

vis-ible.4345 Superior bulging which causes

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288 ACUTE OTITIS MEDIA

tion of the short process is probably a useful

diag-nostic criterion. Impaired mobility has also been

described as a useful criterion in this age group,’#{176}’45

but the sensitivity of this finding has not been

proven.

Cultures

Cultures of the nasopharynx and pharynx are

of limited value because of the poor correlation

between pathogens isolated from these sites and

from middle ear aspirates.’#{176}’2”24’27’35

Cultures of middle ear exudate obtained by

needle aspiration provide useful information in

certain cases. The feasibility and safety of

per-forming diagnostic needle aspirations in large

numbers of infants and children have been amply

demonstrated.’#{176}’2428’4749 Although the exact

mdi-cations for this procedure have not been defined,

its value is most obvious in three situations: (1)

otitis media during the neonatal period, when

gram-negative bacilli and staphylococci are

fre-quent pathogens; (2) persistence of severe

symp-toms (not attributable to a suppurative

complica-tion or other infection) in spite of compliance

with antibiotic therapy; and (3) persistence of

TM bulging and impaired mobility after two or

three ten-day courses of antibiotic treatment,

even in the absence of significant symptoms. In

almost every study of the etiology of otitis media,

organisms which may be resistant to commonly

used antibiotics have been recovered from a

small number of children.

THERAPY Antibiotics

In spite of the proven bacterial etiology of

most cases of acute otitis media, there has been

debate about the value of antibiotics because the

infection is self-limited in many children. Two

recent studies265#{176} compared the short-term

out-come of children treated with placebo and

van-ous antibiotics; both demonstrated significant but

not dramatic differences in favor of antibiotic

therapy. Howie and Ploussard49 compared the

ef-fect of placebo and antibiotics on the rate of

elimination of bacteria from the middle ear.

When repeat middle ear aspirates were cultured

two to seven days following treatment with

am-picillmn, most cultures were negative. When

pla-cebo was given, most of the repeat cultures were

still positive. Considering the proximity of the

middle ear to the meninges, this rapid

elimina-tion of bacterial pathogens seems worthwhile.

Older studies20’5’ have demonstrated clearly a

de-creased incidence of suppurative complications

in children treated with penicillin when

com-pared with those treated with myringotomy

alone during the same period.

The following data, though incomplete,

provde a useful framework for choosing

appro-priate antibiotic therapy.

In Vitro Seusitivity Studies-Pneumococci and

streptococci are sensitive to penicillin and

ampi-cillin, very rarely resistant to erythromycin, and

occasionally resistant to tetracycline.5254 H.

in-fi

uenzae are relatively resistant to penicillin

V27,5556 and relatively sensitive to

ampicil-lin27’55’57 and the sulfonamides.58 N. catarrhalis is sensitive to both penicillin and ampicillin.59

Antibiotic Concentrations in Middle Ear Exu-dates-Orally given penicillin V achieves

concen-trations which would be expected to eliminate

pneumococci and streptococci from middle ear

exudates.60’6’ Concentrations adequate to

elimi-nate some strains of H. influenzae may be

accom-plished with relatively high doses (40,000

U/kg/dose).6#{176} Sufficient data for orally given pen-icillin G are lacking,6’ but variability in

absorp-tion, especially after meals, is a major

dis-advantage. Penicillin levels in middle ear

exudates following intramuscularly administered

procaine and benzathine penicillin have not

been reported. After intramuscularly

adminis-tered crystalline penicillin G, middle ear levels

are highly variable but generally are less than

20% of serum levels obtained simultaneously one

or two hours after injection.6’ If middle ear

exu-date levels were also about 20% of serum levels

achieved with procaine56 or benzathine

penicil-lin,62 one would predict adequate levels in the

middle ear exudate to eliminate most

pneu-mococci and streptococci after procaine but

bor-derline or inadequate levels after benzathine

penicillin. Even crystalline penicillin G given

in-tramuscularly does not result in levels in the

middle ear which are adequate to eliminate most

strains of H. influenzae.61’63

Intramuscularly given ampicillin results in

high concentrations in middle ear exudates, more

than sufficient to eradicate H. influenzae.64

Lev-els following orally administered ampicillin have

not been reported, but studies of serum levels

suggest that doses of 25 mg/kg/dose may be

re-quired to achieve reliable therapeutic levels.6566

Intramuscularly administered tetracycline

fre-quently does not achieve levels adequate against

streptococci and H. influenzae.6’ Sulfonamide

concentrations have not been reported.

Erythro-mycin concentrations are adequate to eradicate

pneumococci and streptococci but may not be

sufficient to eradicate H. influenzae.67

Age-As indicated above, some studies2328

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PEDIATRICS FOR THE CLINICIAN 289 suggest that H. influenzae may cause otitis media

in older children as frequently as in young

in-fants. If these observations are confirmed,

treat-ment with antibiotics effective against H.

influ-enzae would seem advisable throughout

childhood. However, there is preliminary

evi-dence that older children with H. influenzae

otitis media do well with penicillin V therapy

(5% therapeutic failure rate), compared with

in-fants less than 2 years of age (30% failure rate).’8 Therapeutic Trials.-Therapeutic trials are dif-ficult to perform for several reasons. Since the

in-fection is self-limited in many children, large

numbers must be studied to show relatively subtle differences between different treatment

regimens. The diagnosis of suppurative otitis

me-dia may be questioned in studies which do not

document the presence of middle ear exudate by

myringotomy or needle aspiration. Compliance in taking the medication is difficult to document.

Differences in certain subgroups of children, e.g.,

those with H. influenzae infection, may be

masked by looking only at the results of

treat-ment for the entire group. Most reported clinical

trials suffer from these or other problems.

Nilson et al.27 performed a double-blind

clini-cal trial in 306 children to compare ampicillin,

penicillin V and sulfonamide, and penicillin V

alone. Compliance was checked by measuring

Se-rum antibiotic levels at two and ten days. In

chil-dren with H. influenzae otitis media, treatment with penicillin alone was associated with a signif-icantly greater number of treatment failures at

10 to 12 days. Critics of this study point out the

small number of children with H. influenzae

otitis media in each treatment group.1’9 Very

large numbers of children need to be evaluated similarly in order to overcome this problem.

Howie and Ploussard48’49 recultured middle ear

aspirates at two to seven days after beginning one

of several antibiotic regimens. Ampicillin and

penicillin V-sulfonamide or

erythromycin-sul-fonamide combination therapy were equally

effective in eradicating H. influenzae.

Erythro-mycin alone was no better than placebo in

elimi-nating H. influenzae. Penicillin V alone was not

systematically studied, but culture of middle ear

aspirates were frequently positive for H.

influ-enzae several days after starting therapy.48

The optimal duration of therapy has not been

studied. Most investigators have administered

an-tibiotics for seven to ten days.

Side Effects of Antibiotics.-Ampicillin

ther-apy is frequently associated with diarrhea477

and a maculopapular rash477077 which is

appar-ently not related to true penicillin allergy.7’ 72

These side effects are not doserelatedt6 70 and

not usually severe enough to warrant a change of

therapy. Diarrhea and rash also occur frequently

with penicillin-sulfonamide combination

ther-apy.47 The manufacturers of amoxicillin (an

analog of ampicillin with a similar bactericidal

spectrum) report that amoxicillin suspension is associated with diarrhea less often than ampicil-lin suspension.7374 However, no difference in the

frequency of diarrhea was noted between

amoxi-cillin capsules and ampicillin capsules. Detailed

controlled studies have not been reported.

Decongestants

Sympathomimetic agents and antihistamines

are given frequently because of the possibility

that they diminish eustachian tube obstruction.75

However, their value in the treatment of acute

otitis media remains unproven.40’76

Myringtotomy

In a controlled study of 181 children with

acute otitis media, Roddey et al.77 demonstrated

that routine myringotomy had no effect on the

speed of resolution. Many physicians agree with

these investigators that the main indication for

myringotomy at the time of initial diagnosis is

“severe earache not relieved after a period of

hours by analgesics in addition to antibiotics.”

Very few patients fit into this category.

COMPLICATIONS AND SEQUELAE Suppurative Complications

Mastoiditis, common in the preantibiotic era,

is now a very rare complication.20’40’51’78 Men-ingitis is also a rare complication,5’ although chil-dren with meningitis frequently have otitis me-dia.79’8#{176}Other intracranial complications (lateral

sinus thrombosis, brain abscess, subdural

em-pyema) are usually associated with chronic

sup-purative otitis media.78’8’

Early Treatment Failures

Although no symptomatic improvement at 24

to 72 hours is reported in 10% to 40% of

pa-tients,264077 persistent severe symptoms or

wors-ening of symptoms within two weeks after

start-ing therapy occurs in only 3% to 10%.26404776 At

10 to 14 days after the start of therapy, 20% to

30% of children still have significantly abnormal

TMs, including secretory and persistent

suppura-tive otitis media.27’47’77 Bacteriological data for

these early treatment failures are limited. Repeat cultures_{at Viet Nam:AAP Sponsored on September 8, 2020}of middle ear aspirates of six treatment www.aappublications.org/news

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failures at 3 or 14 days by Halsted et al.26

demon-strated different organisms from those isolated

initially in 3 cases.

Recurrent Suppurative Otitis

Media

Early recurrences (relapses) within two weeks

to one month after initial successful tratment

oc-cur in 2% to 5% of cases.40’47 Later recurrences

are more common. Of 23 children followed four

months after initial successful treatment, ten had

at least one recurrence.82 Similar recurrence rates

have been reported by others.’6 Organisms

iso-lated from middle ear aspirates during

recur-rences are often different from those isolated

dur-ing the previous episode.25’26’82

Chronic Secretory

Otitis Media and Hearing

Loss

More information is needed about the

fre-quency of secretory otitis media and significant

hearing loss following acute suppurative otitis

media. Short-term follow-up studies have not

clearly distinguished sterile effusions from

per-sistent or recurrent suppurative otitis

me-dia.77’83’84 Long-term studies have not

distin-guished persistent from recurrent middle ear

effusions.8587 Audiometric evaluations have been

reported mainly for older children.

In spite of these limitations, several studies

suggest that significant numbers of children have

persistent middle ear fluid with mild to moderate

hearing loss for variable periods following acute

otitis media. Olmsted et al.83 followed 82

chil-dren 2#{189}to 12 years of age following suppurative

otitis media treated with orally given

tetracy-dine or penicillin G for three to six days.

My-ringotomies were performed on 37 patients. Fifty

(61%) had hearing loss

(

> 15 dB loss in any one

frequency) at one month, and 10 (21%) had

hear-ing loss which persisted for the six-month period

of observation. Of 35 children followed by

Rod-dey et al.77 eight had abnormal hearing

(

> 15 dB

in any one frequency) at two weeks, five at one

month, and one at two months. Myringotomies

were performed on some of these children during

the follow-up period. Of 136 children followed

by Jeppson et al.,84 49 (36%) had hearing loss after ten days. Some of these were retreated with

anti-biotics, and six (4%) still had abnormal hearing at

20 days after initial treatment.

In long-term follow-up studies, significant

hearing losses have been reported in many

chil-then with a history of one or more episodes of

otitis media. Lowe et al.85 performed audiometry

on 62 children in a general practice six months

after an episode of otitis media, often treated

only symptomatically; 34 (55%) had hearing

losses of> 30 dB. Fry et al.86 studied 403 children

in general practice in London five to ten years

following at least one episode of acute otitis

me-dia. Many of these children had not been treated

with antibiotics. Seventeen per cent had a

hear-ing loss of 20 dB in at least two frequencies,

compared with 4.5% of matched control

chil-dren. In a follow-up study of 268 Alaskan Eskimo

children 7 to 11 years of age with a history of one

or more episodes of otorrhea, hearing loss of > 25

dB was found in 19%.88

Although the risk of persistent middle ear

effu-sion and hearing loss probably varies in different

age groups and populations, it is clear that the

risk is not negligible in any population. The

con-sequences of overlooking this moderate hearing

loss are great. Language acquisition and school

learning may be significantly impaired.88’89

Mod-erate hearing loss in children may result in

be-havior which is interpreted as negative or

defiant. Although systematic studies have not

been reported, the effects of secretory otitis

me-dia on the social and emotional development of

children may be even more important than the

effects on language development and academic

skills.

MANAGEMENT OF PERSISTENT AND

RE-CURRENT OTITIS MEDIA

Evaluation and Management of Underlying Abnormalities

Children with persistent secretory and/or

fre-quent suppurative otitis media usually have

evi-dence of eustachian tube obstruction or

dysfunc-tion.14’15 In the absence of other significant

infections, immunologic deficiency is exceedingly

rare as a cause of recurrent otitis media. The

fol-lowing causes of eustachian tube abnormalities

should be considered.

Allergic Rhinitis.-Allergic problems, includ-ing allergic rhinitis, are evident in many children

with chronic secretory or frequent suppurative

otitis media.90’91 Secretory otitis media is a

fre-quent finding in children with allergic rhinitis,

and treatment by elimination of allergens and

hyposensitization therapy is associated with

reso-lution in many of them.92 However, controlled

observations of this therapeutic approach have

not been reported.

Adenoid Hypertrophy.-Studies of the value of

adenoidectomy in recurrent or persistent otitis

media present conflicting conclusions. All are

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PEDIATRICS FOR THE CLINICIAN

291

inadequate for a number of reasons.93 Until

con-clusive studies are reported, the indications for this common procedure will continue to vary greatly according to local opinion.

Eustachian Tube “Floppiness”-Although

knowledge of intrinsic eustachian tube

dysfunc-tion is incomplete, it seems certain that some

children have recurrent or chronic otitis media

on the basis of abnormally compliant eustachian tubes.’4”5 Some children demonstrate reflux of ra-diopaque dye into the middle ear during swal-lowing without radiographic evidence of

eu-stachian tube obstruction.42’95 It may be

important to identify these patients, since there

is preliminary evidence that children with tubal

reflux but not obstruction may be worsened by

adenoidectomy.95 At present, however, tests of

eustachian tube function are not generally

avail-able, and their value in determining appropriate therapy for different patients requires further

study.

Tympanostomy

Tubes

Children with eustachian tube obstruction

may benefit temporarily from insertion of poly-ethylene tubes through the TMs.96 However, more information is needed about the long-term

benefits and possible hazards of this form of treat-ment.’497

Long-Term Antibiotic Therapy

Two well-controlled studies in selected

popu-lations have suggested the value of prophylactic

antibiotics. In a study of Alaskan Eskimo chil-dren, the frequency of otorrhea was significantly reduced in those treated with a single daily dose

of ampicillin for one year compared with those given a placebo.98 Perrin et al.99 studied children

1 1 months to 8 years of age in a suburban

pedi-atric practice who had had three or more

epi-sodes of otitis media during the previous 18 months and/or five or more episodes at any time.

Fifty-four children were treated with either

sulfi-soxazole (500 mg, twice daily) or a placebo for

three months; then the drugs were changed, so

that each child served as his own control for the

next three months. In this double-blind study the

attack rate of otitis media was significantly less in children under 6 years of age during sulfisoxazole

treatment. Although these results are

encour-aging, more information is needed concerning

the effects of this form of treatment on the

pos-sible emergence of antibiotic-resistant bacteria.

The question of whether the demonstrated

short-term benefits can be sustained for longer periods

of treatment also needs investigation.

CONCLUSIONS

AND RECOMMENDATIONS

This review has emphasized the uncertainties

which still plague pediatricians in diagnosing and

treating acute suppurative otitis media. The

fol-lowing conclusions and recommendations are

necessarily based in part on the author’s opinions

as well as on some well-established facts.

The diagnosis must be based on the abnormal

appearance of the TM since symptoms of

sup-purative otitis media are variable and

nonspe-cific even in older children. The most reliable

criterion for diagnosis is bulging of the TM,

mdi-cated by decreased prominence or absence of the

bony landmarks. Impaired mobility of the TM,

determined by pneumo-otoscopy, is useful in

confirming the presence of a middle ear effusion.

TM mobility is also diminished in secretory otitis

media, which is usually associated with

retrac-tion rather than bulging of the TM. Redness of

the TM is an unreliable criterion for diagnosis.

Bacteria may be cultured from the middle ear

exudates of most children with acute suppurative

otitis media. During the first six weeks of life,

gram-negative bacilli and staphylococci are most

commonly responsible for otitis media.

Appropri-ate antibiotic therapy is best determined by the

results of culture of the middle ear exudate

ob-tamed by tympanocentesis. Until results of the

culture are available, broad-spectrum antibiotic

treatment, e.g., ampicillin and kanamycmn,

should be begun.

After the neonatal period, pneumococci and

H. influenzae are most commonly cultured from

middle ear exudates; some studies indicate that

H. influenzae is a significant pathogen even in older children. Since penicillin or erythromycin

alone are not always effective against H

influ-enzae, oral antibiotic treatment for infants and young children (less than 5 years of age) should consist of one of the following regimens: ampicil-un, 50 to 100 mg/kg/day; or penicillin V, 50 mg/kg/day combined with sulfisoxazole, 150 mg/kg/day; or erythromycmn ethyl succinate or

estolate, 50 mg/kg/day, combined with

sulfisoxa-zole. Older children (more than 5 years of age)

may also be treated with one of these antibiotic regimens, but on the basis of current information,

penicillin V or erythromycin alone are

reason-able alternatives. Antibiotic treatment should be

continued for the seven- to ten-day periods used

empirically in most clinical trials.

Decongestant medications are rational

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292

ACUTE OTITIS MEDIA

juncts to antibiotic therapy, but their value

re-mains unproven. Myringotomy is indicated rarely

to relieve severe pain not controlled by

analge-sics.

Diagnostic tympanocentesis should be

em-ployed to identify unusual bacterial pathogens

which may be responsible for early treatment

failures in a few children.

All children should be evaluated within two to

three weeks following the beginning of treatment

to identify persistent suppurative or secretory

otitis media. These sequelae of acute suppurative

otitis media may cause no apparent symptoms

but can result in hearing loss, which may

signifi-cantly interfere with learning and social

inter-action. Examination with a pneumo-otoscope is

necessary to identify secretory otitis media;

ideally, evaluation should include screening

au-diometry in children old enough to cooperate.

If secretory otitis media is identified, the child

should be given a decongestant medication and

reevaluated two weeks later. Persistent serous

otitis media requires consideration of possible

causes of eustachian tube obstruction.

If suppurative otitis media (indicated by TM

bulging) is still present two weeks following

ii-tial treatment, another ten-day course of

anti-biotic treatment should be given. If TM bulging

persists at the end of the second period,

tym-panocentesis is indicated to obtain middle ear

exudate for microscopic examination and

cul-ture. Subsequent treatment is based on results of

that culture.

The child with frequent suppurative or

chronic secretory otitis media should be

eval-uated for possible causes of eustachian tube

dys-function. If there is historical evidence of allergic

rhinitis, treatment of that problem may decrease

the frequency of middle ear effusions. Adenoidal

hypertrophy may be a cause of eustachian tube

obstruction. Adenoidectomy seems justified for

certain severely affected children, but reliable

criteria for selecting children who would benefit

from this procedure have not been developed.

Abnormal compliance of the eustachian tube is

also associated with recurrent or chronic otitis

media, but tests of tubal function are not

gener-ally available and methods for management of

this problem have not been investigated.

Tympa-nostomy tubes provide temporary relief of

symp-toms, but the long-term benefits and the risk of

complications need further study. Preliminary

evidence suggests that prophylactic antibiotics

may result in a reduction of the frequency of

sup-purative otitis media in certain high-risk

popu-lations, but more information is needed about the

long-term effects of this therapy.

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1975;56;285

Pediatrics

D. Stewart Rowe