Tympanic membrane now keys otitis media diagnosis

Dr. Stephen I. Pelton* comments:

The guidelines address five important areas and provide update,

clarification, and greater granularity than the original guidelines did.

They emphasize the diagnostic criteria, and strengthen

the significance of bulging as a diagnostic requirement for AOM as well as the

requirement for the presence of middle ear effusion. This will be challenging

as many clinicians are not well trained in the use of pneumatic otoscopy. The

guidelines were not written to apply to infants younger than 6 months, and in

the youngest infants, tympanometry and acoustic reflectometry may be less

accurate.

The initial approach remains assessment of the need

for antibiotic treatment based on age and severity, as well as assessment of

pain and appropriate management of pain. The choice between antibiotic

management and observation is further clarified in these guidelines based on

current evidence. The new guidelines discuss but do not highlight the results

of two recent randomized clinical trials that showed that half of the children

in the placebo group did not have a satisfactory resolution. Presumably, this

information should be included in any discussion with parents about the role

for antibiotics in treating young children with AOM. The criteria recommended

for the routine use of antibiotics in children less than 2 years old –

bilateral disease, acute otorrhea, or high fever – all are supported by

evidence.

The choice of amoxicillin or amoxicillin-clavulanate

as the first-line antibiotics is appropriate. The lack of any recommendation

for azithromycin will hopefully help educate clinicians about its limited

activity against Haemophilus in children with culture-positive AOM and

the significant prevalence of macrolide-resistant pneumococci in the community.

The pneumococcal conjugate vaccine has proven

beneficial, both for preventing AOM and recurrent AOM, and for obviating

tympanostomy tube insertion. It is important that the vaccine be administered

early in life, before recurrent AOM can develop. Influenza vaccine also is

valuable during influenza seasons for preventing flu and its AOM complication.

Although the guidelines take an absolute approach

against antibiotic prophylaxis, there may be some specific children where it

may still have value despite concerns about promoting resistance through

selective pressure.

Dr. Stephen I. Pelton is chief of pediatric

infectious disease and also is the coordinator of the maternal-child HIV

program at Boston

Medical Center.

He was not involved in development of the AAP guidelines and responded to a

request to comment on the guidelines.

Updated: 3/4/13 Dr. Pelton's misspelled first name corrected