Created by: Felix Huber, Uwe Beise | Last revised: 01/2014, last modified 10/2018
table of contents
Short version (-> WebApp GL Otitis media)
3. clinic and diagnostics
Update 10/2018:New recommendations on antibiotic therapy
- Up to the third month of life, every tenth child has suffered an episode of acute otitis media (AOM), the peak age lies between the 6th and 15th month of life (1).
- Up to the age of 10 almost 40 % of all children suffer at least one AOM (1)
- The prospective LISA study (2) showed a cumulative AOM prevalence of 61.4% during the first six years of life. The mean number of otitis media episodes during the first two years of life was 2.2 per child.
- AOM is rather rare in adulthood.
- OM is a painful, mostly bacterial inflammation of the mucous membranes of the middle ear, usually by ascending infection via the tuba Eustachii with existing or previous upper airway infection. Viral infections are often pioneers. Due to the swelling of the tube, drainage is impeded, so that a breakthrough through the eardrum to the outside can occur.
- Pathogen: Haemophilus influenzae, Moraxella catarrhalis, Pneumococcus, Streptococcus pyogenes.
3. clinic and diagnostics
- Symptoms: suddenly occurring earache, hearing loss, fever, loss of appetite, irritability, crying, reduced AZ
- Diagnosis: Red, yellowish or cloudy eardrum (TF) during otoscopy. The diagnosis is likely if the TF is curved outwards and de-differentiated, if a fluid level is visible behind the eardrum, or if there is a perforated TF and/or otorrhoea. Exclusive redness of the TF is not a reliable sign of AOM.
- Complications (rare): Mastoiditis**, hearing loss (passages or persistent), meningitis, sinus thrombosis, recurrenceBeach: chills may indicate sepsis or sinus thrombosis** Mastoiditis signs: typically, ear pain suddenly recurs and fever increases. The tissue above the mastoid is swollen, reddened and sensitive to pressure. In addition, the auricle protrudes due to swelling and the external auditory canal is narrowed. The children are usually seriously ill. Note: Sensitivity to pressure due to swollen auricular lymph nodes also occurs in diseases of the upper respiratory tract.
Objective: To shorten and relieve pain and other symptoms and prevent complications.
4.1 Symptomatic therapy (analgesics) (4)
Paracetamol and NSAIDs are the remedies of choice for pain relief.
- Paracetamol (e.g. Dafalgan ® syrup, Ben-u-ron ® juice) Dosage: in children daily total dose max. 50 mg/kgKG. Duration of effect: approx. 6 h
- Infants 3-6 months (4-6 kg): 4 suppositories of 60 mg each (= 240 mg)
- Infants 6-12 months (7-10 kg): 4 suppositories 125 mg each (= 500 mg)
- Infants 1-3 years (10-15 kg): 5 suppositories 125 mg each (= 625 mg)
- Children 3-6 years (15-22 kg): 4 suppositories of 250 mg each (= 1,000 mg)
- NSAR dosage
- Ibuprofen (Algifor ® Junior, Algifor ® Dolo Junior) 20-30 mg/kgKG per day, divided into three to four individual doses (duration of action: approx. 8 h), or
- Diclofenac (Voltaren ® drops) 2-3 mg/kgKG per day (but not for infants!).
Local (nasal spray or NaCl) or systemic decongestant (Rhinopront ® ) – without Ev >mediX recommends: In patients without risk factors with uncomplicated acute otitis media, a waiting period of 24-48 h is appropriate (see also figure in appendix). Rules of thumb apply:
- sec. AB
- ≥ 2 years: With intact TF analgesia and re-evaluation after 48 h, with persistence or deterioration -> sec. AB
- Possible reserve supply of antibiotics to parents.
Primary antibiotic therapy may be recommended in the following situations
- Purulent otorrhoea (TF perforation, poor AZ)
- Intact TF, but bds. AOM, only hearing ear, otitis pronone child, anatomical malformation, immune deficiency.
- The prevention of mastoiditis is not a meaningful indication for primary AB therapy as this complication is too rare. NNT: > 4’000 (13)
- A persistent serous tympanic cavity effusion is usually not an indication for antibiotics and mucosal decongestant nasal drops (16).
Choice of antibiotic
- 1st choice: Amoxicillin 25 mg/kgKG 2 x/d p.o. for 5(-10) d
- 2nd choice: Clarithromycin for penicillin allergy 7.5 mg/kgKG 2 x/d for 5 d, cefuroxime 15 mg/kgKG in 2 doses/d for 5(-10) d (see note)
- With fever persistence > 72 h, relapse within 4 weeks: Amoxicillin clavulanate 40-45 mg/kgKG 2 x/d p.o. for 5(-10) d (17, 18) (see note).
Note: For children 2 episodes/6 months or 4 episodes/year) a 10-day therapy is recommended (see www.pigs.ch); this is slightly more effective than the 5-day short therapy (17).
- Primarily decongestant nasal drops and antiphlogistic and analgesic drugs, antibiotics only in case of persistence of pain above 3 d under symptomatic therapy!