Recommendations for clinical care guidelines on the management of Otitis Media in Aboriginal and Torres Strait Islander Populations

Section D: Medical Management of Otitis Media

Facilitate resolution or prevent progression of otitis media and hearing loss to minimise possible adverse effects

Page last updated: 14 October 2011

Facilitate resolution or prevent progression of otitis media and hearing loss to minimise possible adverse effects

Management of Episodic Otitis Media with Effusion (OME)

(Unilateral OME or bilateral OME for <3 months)
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Patient and Family EducationGrade B: Tell families/caregivers that episodic OME is very common in all populations. No investigation or treatment is required for episodic OME.

If the bilateral OME is present, check the medical records to make sure it has not been persistent.
II8;5;6;29I~A17;19;14
Medical Review GPP: Repeat the ear examination in 3 months to ensure resolution.III66;30I~A17;19;14

Management of Persistent Otitis Media with Effusion (OME)

(Persistent bilateral OME for >3 months)
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Treatment
Antibiotics
Grade A: Antibiotics are not recommended routinely for OME.
However, long term antibiotics (e.g. amoxycillin 25-50mg/kg 1-2 times daily for 3-6 months) are an option for infants who are at high risk of developing CSOM.

Antibiotics (e.g. amoxycillin) are an option prior to surgical treatment.
I110;8;5;6;25;60;29I~A18;14
I~B23
Other Medical TherapyGrade A: Topical or systemic steroids are not recommended.I50;5;6;30;29;111I~A16-18;14
Grade A: Antihistamines and decongestants are not recommended.I36;5;6;30;29I~A17;18;14
AutoinflationGrade B: Autoinflation devices are not recommended routinely.I46;5;6;29I~A18;14
Patient and Family EducationGPP: Tell the families/caregivers to:
  • provide a high level of language stimulation to babies and toddlers
  • encourage early attempts at speaking
  • encourage early attempts at writing
  • tell stories and read to young children
  • participate in their children’s early learning at child care centre and pre-school.
IV67;112;113;114I~A17-19
GPP: If talking to a hearing impaired person, make sure you speak slowly (and clearly) after gaining their attention in well-lit conditions. Health educators should use visual prompts. IV115;116I~A15
I~B22
Medical Review GPP: Refer children with persistent bilateral OME plus speech, language or behavioural problems for hearing evaluation within 3 months.IV67I~A13
Audiology ReferralGPP: Refer children for hearing tests when bilateral OME persists for 3 months or longer or at any time if there is concern about a child’s hearing. Referral to ENT specialist and/or paediatrician can be made at the same time.

Refer to Section E: ‘Audiological Assessment and Management’ for further guidance on:
  • signs of hearing loss
  • when to refer for hearing help including aids and devices.
IV5;6;25I~A13;14;17
Speech Therapy Referral GPP: Refer all the children with language, learning or behavioural problems for speech therapy.IV67;112I~A18;14
ENT ReferralGrade A: Consider an ENT assessment if OME with bilateral hearing loss (>25dB) has been present for 3 months. I42;8;57;25I~A16-18;14
GPP: Tell families/caregivers about potential benefits (short-term improvement on hearing) and potential risks of ENT surgery (ear discharge, tube extrusion and structural changes with TM).IV57;6;117I~A16;17
I~B23
The potential complications of grommet (tympanostomy tube) surgery are much more common in children at high risk of CSOM.IV29
Grade A: Refer the child (who is not at high risk for CSOM) for grommet insertion if:
  • the child has a persistent hearing loss >20dB
  • the parents understand that the operation will provide a modest improvement in hearing for 6-9 months
  • surgery is consistent with the parents’ preferences.

The likelihood of benefit from grommets increases with greater levels of hearing loss.
I42;53;57;5;6;30;25;29I~A17
ENT Referral
continued
GPP: Refer the child (who is at high risk for CSOM) for grommet insertion if:
  • the child is >3 years old
  • the child has persistent hearing loss >35dB
  • the child has failed medical treatment despite good compliance
  • the family agrees to attend for treatment if ear discharge occurs
  • surgery is consistent with the parents’ preferences.
IV29
Grade B: Adenoidectomy plus myringotomy is not recommended routinely.I118;119;8;5;6I~A17;13;14
Grade A: Tonsillectomy or myringotomy alone is not recommended routinely.II119;8;5;6I~A13;14
Grade B: Consider referral for adenoidectomy if bilateral OME has occurred despite previous grommet (tympanostomy tube) insertion or if the child is at high risk of CSOM. I52;119;29I~A17;13;14
Grommets plus adenoidectomy can be an option for children >3 years who have recurrent persistent OME and hearing loss after previous grommet insertion, severe nasal obstruction, or chronic adenoiditis.I~A13
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Management of Acute Otitis Media without Perforation (AOMwoP)

(AOM without middle ear discharge)
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Treatment
Pain Relief
Grade B: Treat with analgesics (e.g. paracetamol or ibuprofen) if ear pain is present. II120;5;28;25;121I~A16;24
I~B23
Antibiotics for populations not at high risk of CSOMGrade A: Antibiotic treatment should be considered. Treat with antibiotics if <2 years of age with bilateral disease, and those with a history of AOM with ear discharge.

Antibiotics will only provide a modest benefit for other children in populations not at high risk of CSOM. As most cases will resolve spontaneously, a ‘Watch and Wait’ strategy should be applied if adequate follow-up can be assured.

Alternatively, give the family an antibiotic script that can be filled if the child does not improve within 24-48 hours.
I35;48;49;54;122;5;28;25;29I~A15;16;18;24
I~B23
Antibiotics for populations at high risk of CSOMGrade A: Treat with antibiotics – especially all children <2 years of age with bilateral disease, and those with a history of AOM with ear discharge.I35;49;54;5;25;28;29I~A15;19
Grade A: Treat with antibiotics (e.g. amoxycillin 50mg/kg 2-3 times daily for 7 days) to reduce the likelihood of prolonged pain or persistent discharge and/or disease. I49;53;54;5;28;29I~A16;18
I~B23
GPP: Treat with high doses (e.g. amoxycillin 90mg/kg) if:
  • recent antibiotic use within 1 month
  • failure to respond to standard treatment within one week
  • regions with known penicillin resistance.
IV5;28;25;123I~A19;14;24
I~B23
Treatment
Antibiotics for populations at high risk of CSOM continued
Grade B: Treat with azithromycin (30 mg/kg stat) as a second line option if there are other indications for the use of this antibiotic (e.g. presence of trachoma). It should be noted that azithromycin is not currently licensed for use in children under six months of age.II65;28;25I~A15;19;23
Other TherapiesGrade A: Decongestants and antihistamines are not recommended routinely.I33;53;5;28;29I~A15 24 I~B23
GPP: Alternative medical therapies (insertion of oils, homeopathy etc) are not recommended.I~A18;14
Medical Review GPP: Review all children with AOM after 4-7 days or earlier if there is any deterioration. A further review should take place after completion of therapy.

Up to 50% of children will have effusion 1 month post AOM. Further antibiotic therapy is required if children are symptomatic or if there are signs of TM inflammation (i.e. bulging or recent discharge).
I~A15
I~B23
Audiology ReferralGPP: Audiometry is not recommended for episodic AOMwoP.I~A18
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Management of Acute Otitis Media with Perforation (AOMwiP)

(AOM with middle ear discharge)
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Accurate DiagnosisGPP: Document the duration of ear discharge. Consideration to be given for documenting the size and position of the TM perforation. This allows the assessment of progression of the disease and to guide the use of topical and systemic antibiotics. A video, photograph or drawing is the best way to record size of the perforation.IV7I~A13
Treatment
Oral Antibiotics
Grade A: Treat with longer course of antibiotics (e.g. amoxycillin 50-90mg/kg 2-3 times daily for 14 days).I49;53;54;5;28;25I~A15;19;14
I~B23
GPP: Treat with high dose antibiotics (amoxycillin 90mg/kg) or combination therapies (e.g. amoxycillin-clavulanate) if AOM with perforation persists for >7 days. IV5;25;25
GPP: Continue treatment with high doses of antibiotics in all children with persistent signs of AOM (with or without persistent perforation).IV5;25I~A19
Topical Antibiotics GPP: Add ear cleaning plus topical antibiotics in children with persistent discharge (despite 7 days oral antibiotics). IV5
Patient and Family EducationGPP: Show the families/caregivers how to clean/dry mop the ears with correctly prepared tissue spears, and also how to maximise effects of ear drops by ‘tragal pumping’.
Medical ReviewGPP: Review weekly until the signs of AOM have resolved. Also review within 4 weeks after resolution for children at high risk of CSOM. I~A15
I~B23
GPP: Commence management for CSOM if persistent discharge through an easily visible perforation continues despite treatment (oral antibiotics should be ceased unless recommended by a specialist).IV27;124I~A16
I~B23
Audiology ReferralGPP: Audiometry is not recommended for episodic AOMwiP.
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Management of recurrent Acute Otitis Media (rAOM)

(3 episodes of AOM within a 6 months period / 4 episodes within 12 months)
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Prophylaxis Grade A: Consider treatment with long-term antibiotics (e.g. amoxycillin 25-50mg/kg 1-2 times daily) for 3-6 months in children <2 years of age who are at risk of developing CSOM.

The decision to prescribe long-term antibiotics should be discussed with the families.
I41;110;125;8;126;5;28I~A15;16
GPP: Long-term antibiotics are not recommended routinely. Long-term antibiotic treatment has been associated with increasing antibiotic resistance.IV28I~B23
ENT ReferralGrade B: Refer for consideration of grommet surgery if:
  • The child is at low risk of developing CSOM
  • rAOM fails to improve on antibiotic prophylaxis (>3 episodes in 6 months or >4 episodes in 1 year).
I45;5;28;1271~A16;18;14
Grade B: Adenoidectomy is not recommended.I52;118;119;8
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Management of Chronic Suppurative Otitis Media (CSOM)

(OM with persistent middle ear discharge and easily visible eardrum perforation
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Accurate DiagnosisGPP: Only diagnose CSOM in children who have persistent ear discharge over 2-6 weeks and a visible eardrum perforation that allows discharge to pass through easily.IV7;27;29;124~B23
GPP: If the eardrum has only recently perforated, treatment should follow the AOMwiP recommendations. AOMwiP occurs most commonly in the first 18 months of life. Effective treatment will dramatically reduce the incidence of CSOM.IV7;5;61
GPP: Document the duration of ear discharge and size (and position) of any perforation.

This allows AOMwiP to be distinguished from CSOM and any progression of severe disease to be monitored. A drawing of the eardrum is often the best way to record size of perforation.
IV7I~A13
Treatment
Cleaning
GPP: Clean the ear canal by using twisted tissue paper (dry mopping) or syringing with dilute betadine (1:20). Syringing should be the initial treatment if the pus is thick or if the TM cannot be seen. Cleaning must be combined with antibiotic drops in order to reduce the production of more pus.IV5;30;25;124;128
Grade A: Treatment with disinfectant (such as betadine and acetic acid) alone is not recommended. Disinfectants alone are not as effective as topical antibiotics.I32;44;7;27;124
GPP: Consider referral for suctioning under direct vision if cleaning and syringing have not been effective.
Topical AntibioticsGrade A: Treat with topical antibiotics (e.g. ciprofloxacin 2-5 drops 2-4 times a day after cleaning) until ear has been dry for at least 3 days. This may require prolonged periods of treatment.I44;129;7;5;27;29;124;128
Systemic AntibioticsGrade A: Treatment with oral antibiotics (e.g. quinolones) is not recommended routinely. Oral antibiotics are usually less effective than topical treatment.I32;27;101;124
Grade B: Consider referral (after 3 months of treatment) for intravenous or intramuscular antibiotics (e.g. ceftazidime twice daily). This will usually require hospitalisation for 2-3 weeks and should be discussed with the local doctor. I32;7;124
Patient and Family EducationGPP: Show families/caregivers how to do ‘tragal pumping’ (pressing several times on the flap of skin in front of the ear canal). This should always be used after the antibiotics drops are inserted into the ear canal. The topical antibiotic treatment will only work if it can be pushed through the perforation.
GPP: Tell families/caregivers to:
  • provide a high level of language stimulation to babies and toddlers
  • encourage early attempts at speaking
  • encourage early attempts at writing
  • tell stories and read to young children
  • participate in their children’s early learning at child care centre and pre-school.
IV67;112;113;114I~A17-19
GPP: If talking to a hearing impaired person, make sure that you speak slowly and clearly after gaining their attention in well-lit conditions. Health educators should use visual prompts.IV115;116I~A15
I~B22
Medical Review GPP: Review 1-2 weekly until the signs of CSOM have resolved. A further review 4 weeks after resolution is recommended.
Audiology ReferralGPP: Refer the patient for audiological management when unilateral or bilateral CSOM persists for 3 months or longer.IV27;124
Audiology Referral continuedGPP: Audiometry referral is also recommended at completion of treatment to inform further referral pathways, or at any time when families or others are concerned about a child’s hearing.

Refer to Section E: Audiological Assessment and Management for further guidance on:
  • signs of hearing loss
  • when to refer for hearing help including aids and devices.
Speech Therapy Referral GPP: Refer all the children with language, learning or behavioural problems for speech therapy. IV67;112
ENT ReferralGPP: Refer to an ENT specialist anyone who fails prolonged medical therapy (e.g. ciprofloxacin 2-5 drops 2-4 times a day after cleaning for 4 months). The ENT specialist is able to confirm the diagnosis, exclude the possibility of a cholesteatoma, and consider the options of tympanoplasty and/or mastoidectomy.

Anyone with an attic perforation should be referred to an ENT surgeon immediately to exclude cholesteatoma.
IV7;130;27;131I~A16
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Management of Dry Perforation

(Presence of a perforation in the eardrum without any discharge)
StrategyRecommendation and GradingEvidence StudiesEvidence -Based Guidelines
Patient and Family EducationGPP: Tell people with dry perforations to attend the clinic for oral and topical antibiotics as soon as any new episodes of discharge occur.
GPP: Tell families/caregivers to:
  • provide a high level of language stimulation to babies and toddlers
  • encourage early attempts at speaking
  • encourage early attempts at writing
  • read to young children
  • participate in their children’s early learning at child care centre and pre-school.
IV67;112;113;114I~A17-19
GPP: If talking to a hearing impaired person, make sure that you speak slowly and clearly after gaining their attention in well-lit conditions. Health educators should use visual prompts. IV115;116I~A15
I~B22
Audiology ReferralGPP: Refer for hearing test when dry perforation persists for 3 months or more (or to monitor effects of any surgical interventions).
Speech Therapy Referral GPP: Refer all the children with language, learning or behavioural problems for speech therapy.IV67;112
ENT ReferralGrade C: Refer to an ENT specialist:
  • all children >6 years with a dry perforation persisting for >6-12 months
  • those with significant conductive hearing loss (>20dB) or recurrent infections.
III130;5;131;132
GPP: Tell teenagers and adults with persistent dry perforation about possible tympanoplasty and potential restoration of hearing after this operation.IV7;27I~A19
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