Letters

Acute otitis media

BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7228.182 (Published 15 January 2000) Cite this as: BMJ 2000;320:182

Norwegian consensus is that only children with recurrent episodes of otitis media need antibiotics

  1. Morten Lindbaek (morlind{at}vestfoldnett.no), associate professor
  1. Department of General Practice, University of Oslo, PO Box 1130, N-0317 Oslo, Norway
  2. Royal National Throat, Nose and Ear Hospital, London WC1X 8DA.
  3. Department of Otolaryngology-Head and Neck Surgery, St Michael's Hospital, Bristol BS2 8EG
  4. Royal Berkshire Hospital, Reading RGI 5AN
  5. Norton Medical Centre, Stockton on Tees TS20 1AN

    EDITOR—O'Neill's review of the management of acute otitis media from Clinical Evidence was interesting.1 Straand et al showed that 64% of children aged 0-12 years with acute otitis media in a Norwegian county received antibiotic treatment,2 but in a study from an accident and emergency department in Tromsø 91% of the children with acute otitis media received antibiotics.3 This shows the conflict between day to day practice and clinical guidelines that recommend no standard antibiotic treatment for acute otitis media.

    O'Neill also addresses the question whether children with recurrent otitis media benefit from antibiotic treatment. The latest Norwegian consensus recommends identifying children who should have antibiotic treatment every time they have otitis media.4 These children have had three or more episodes of acute otitis media during the previous six months or four or more episodes during the previous year. Before the age of 2 years 40% of all children will have an episode of acute otitis media, and 4% will have recurrent episodes. Several studies have been performed to explain why these children are prone to ear infections. Risk factors include a genetic disposition, the age of the first ear infection, and male sex.4 Concentrations of antibody against pneumococcus capsule antigens 6A, 14, and 19F are low, and children with recurrent infections are hypothesised to have delayed production of specific immunoglobulins, being unable to increase their own production until the age of 6.4

    These factors are reasons for giving children with recurrent episodes antibiotic prophylaxis as an alternative to surgical treatment. In a meta-analysis of 958 children one in nine showed improvement after antibiotic treatment.1 In a small Swedish study intermittent antibiotic treatment with penicillin V for 10 days was given every time the child had an upper respiratory infection.5 This resulted in a 50% reduction in acute otitis media in the group that received antibiotic prophylaxis.

    This shows why finding children with recurrent episodes of acute otitis media is an important issue in general practice. Studies are needed to identify how substantial the benefit from antibiotics is in this particular group. The most important issue, however, is to reduce the overuse of antibiotics in the children who will not have recurrent episodes and will therefore recover just as well without antibiotics.

    References

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    Evidence base on managing acute otitis media had inaccuracies

    1. G Sandhu (g.sand{at}btinternet.com), specialist registrar in otolaryngology,
    2. A Frosh, specialist registrar in otolaryngology,
    3. A Wright, professor of otolaryngology
    1. Department of General Practice, University of Oslo, PO Box 1130, N-0317 Oslo, Norway
    2. Royal National Throat, Nose and Ear Hospital, London WC1X 8DA.
    3. Department of Otolaryngology-Head and Neck Surgery, St Michael's Hospital, Bristol BS2 8EG
    4. Royal Berkshire Hospital, Reading RGI 5AN
    5. Norton Medical Centre, Stockton on Tees TS20 1AN

      EDITOR—We think that O'Neill's definition of acute otitis media—inflammation in the middle ear—should be expanded.1 The reasons for this become clear if a more complete explanation of the aetiology of acute otitis media is given. Tympanocentesis studies show that viruses can be the sole cause of acute middle ear inflammation in about 20% of cases—acute secretory otitis media.2 Respiratory epithelium is found in both the eustachian tube and the middle ear, and a preceding viral infection may alter the ability of this epithelium to resist subsequent bacterial infection—acute suppurative otitis media.2 This partly explains why acute otitis media resolves in 80% of children without antibiotic treatment.1 Unfortunately the clinical presentation and appearance of the tympanic membrane are often identical in the early stages of both acute secretory and acute suppurative otitis media, the gold standard for differential diagnosis being myringotomy.

      The practical value of O'Neill's review article is limited because it has no stated guidelines on the management of this common childhood problem. We are concerned about the 20% of patients whose condition has not improved by the third day and who probably have acute suppurative otitis media. The article gives the impression that there are no serious consequences of untreated acute otitis media, yet otolaryngologists still see cases of perforated ear drums, acute mastoiditis, and chronic suppurative otitis media. The incidence of acute mastoiditis has declined dramatically over the past 50 years because of the use of antibiotics to treat acute otitis media.3 4 The complications of acute mastoiditis are serious and include facial paralysis, labyrinthitis, permanent hearing loss, meningitis, and intracranial abscesses.

      On the basis of O'Neill's findings we suggest that patients presenting within 48 hours of onset of acute otitis media should initially be managed by analgesics alone. Patients who continue to have symptoms after the second day or who present with at least a three day history of unresolving acute otitis media should be prescribed a broad spectrum antibiotic.

      References

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      Surgery has a limited but important role in managing acute otitis media

      1. Peter Williamson, locum consultant ear, nose, and throat surgeon,
      2. Suresh Patel (suresh_patel{at}hotmail.com), specialist registrar in otorhinolaryngology
      1. Department of General Practice, University of Oslo, PO Box 1130, N-0317 Oslo, Norway
      2. Royal National Throat, Nose and Ear Hospital, London WC1X 8DA.
      3. Department of Otolaryngology-Head and Neck Surgery, St Michael's Hospital, Bristol BS2 8EG
      4. Royal Berkshire Hospital, Reading RGI 5AN
      5. Norton Medical Centre, Stockton on Tees TS20 1AN

        EDITOR—O'Neill's evidence based review of the management of acute otitis media did not mention the limited but important role of surgery in the treatment of this condition.1 It also did not mention that the advent of antibiotics has dramatically reduced the incidence of acute mastoiditis in acute otitis media.

        As O'Neill pointed out, most cases of acute otitis media are effectively managed with medical treatment and are treated by general practitioners in the community. Surgery should be reserved for acute otitis media refractory to antibiotics, acute otitis media with complications (for example, acute mastoiditis or facial palsy), and recurrent acute otitis media.

        Myringotomy alone has been shown to hasten resolution of acute otitis media, especially when antibiotic treatment has not worked.2 In addition to providing immediate relief by draining a middle ear abscess, tympanocentesis will provide fluid for microbiological investigation to direct further antibiotic treatment. This is particularly relevant in this time of increasing antibiotic resistance.

        Several well conducted studies have shown that adenoidectomy with or without grommet insertion can reduce the incidence of recurrent acute otitis media in children. 3 4 Adenoidectomy can improve eustachian tube dysfunction, which is a key factor in the development of recurrent acute otitis media. In addition, adenoidectomy combined with a tonsillectomy may decrease the incidence further.5

        In conclusion, although medical treatment is important in managing most cases of acute otitis media, surgery has a valuable role in a specific population of children affected by this common condition.

        References

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        Surgical treatments should have been discussed

        1. Rory Herdman (rcdherdman{at}doctors.org.uk), consultant otolaryngologist
        1. Department of General Practice, University of Oslo, PO Box 1130, N-0317 Oslo, Norway
        2. Royal National Throat, Nose and Ear Hospital, London WC1X 8DA.
        3. Department of Otolaryngology-Head and Neck Surgery, St Michael's Hospital, Bristol BS2 8EG
        4. Royal Berkshire Hospital, Reading RGI 5AN
        5. Norton Medical Centre, Stockton on Tees TS20 1AN

          EDITOR—In his article on clinical evidence in acute otitis media O'Neill has totally ignored surgical treatment.1 The second question of the article, “What are the effects of preventive interventions?” should accurately read, “What are the effects of preventive non-surgical interventions?”

          The small note at the beginning of the article that myringotomy will not be covered does not permit a total disregard of any surgical intervention. There are numerous randomised clinical trials indicating the efficacy of both inserting tympanostomy tubes (grommets) and adenoidectomy in preventing recurrent acute otitis media. 2 3 4 Sepsis in the sinuses is also often treated to try to prevent recurrent acute otitis media.

          Even if none of the published articles satisfy O'Neil's criteria for inclusion, common sense must be used in writing what may be interpreted by some clinicians or managers as a definitive article on the subject. Surgery is often used for treatment of recurrent acute otitis media, and readers are entitled to know the validity or otherwise of this form of treatment. Would it be acceptable to write an article on recurrent acute cholecystitis or treatment of arthritis of the hip without mentioning surgery?

          Surely, articles which arguably carry so much weight and may be responsible for change of practice should be coauthored by a contributor from the relevant hospital specialty as well as a general practitioner? This would allow for more than one point of observation on a topic.

          References

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          Author's reply

          1. Paddy O'Neill, general practitioner
          1. Department of General Practice, University of Oslo, PO Box 1130, N-0317 Oslo, Norway
          2. Royal National Throat, Nose and Ear Hospital, London WC1X 8DA.
          3. Department of Otolaryngology-Head and Neck Surgery, St Michael's Hospital, Bristol BS2 8EG
          4. Royal Berkshire Hospital, Reading RGI 5AN
          5. Norton Medical Centre, Stockton on Tees TS20 1AN

            EDITOR—As Clinical Evidence is an evolving project to be updated every six months, comments are welcome. The management of acute otitis media and recurrent acute otitis media clearly remains controversial, and further studies are needed to resolve some important questions.

            Lindbaek highlights the difference between what clinical guidelines suggest and what practising clinicians do. Damoiseaux et al also explored prescribing behaviour in managing acute otitis media.1 Around three quarters of the antibiotic prescriptions in their study did not follow nationally recognised guidelines. Medical reasons for prescribing antibiotics were mentioned most often for antibiotic prescriptions that had not been based on guidelines, but in many cases doctors gave non-medical reasons as well. They concluded that appropriate use of antibiotics might not be reached by focusing only on the efficacy of these drugs and that the impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further.

            Sandhu et al point out that there are no stated guidelines on the management of acute otitis media in the article. This is because Clinical Evidence specifically aims not to make recommendations for reasons made clear in the introduction to the first edition.2

            Sandhu et al and Williamson and Patel express concerns about complications, particularly mastoiditis, arising from acute otitis media being treated symptomatically rather than with antibiotics. We found no controlled studies that looked at this question. Van Buchem reported that two out of 4860 children treated symptomatically without antibiotics developed mastoiditis.3 The recommendations of Sandhu et al are similar to those of the Dutch College of General Practitioners, and at least one report has suggested that outcomes for Dutch patients are as good as for patients treated in countries where antibiotic treatment is almost universal.4 This may not be the case in severe infections and in the developing world.

            Williamson and Patel and Herdman note that surgical interventions in the management of acute otitis media were conspicuously absent from this, the first, edition of Clinical Evidence. Later editions will present evidence on myringotomy, adenoidectomy, and adenotonsillectomy. This fact was not made clear in the opening paragraph of the article and was an error. Future editions will differentiate surgical and non-surgical interventions and look more closely at evidence on managing acute otitis media in children under the age of 2 years.

            References

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