3.03 Otitis Media
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agk's Library of Common Simple Emergencies

Presentation
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Adults and older children will complain of ear 
pain. There may or may not be accompanying 
symptoms of upper respiratory infection. In 
younger children and infants, parents may 
report that their child is irritable and 
sleepless, with or without fever, and possibly 
pulling at his ears. The tympanic menbrane is 
inflammed and may be bulging with loss of 
landmarks. It may be dull or opacified with 
reduced mobility on pneumatic otoscopy. and may 
or may not be accompanied by otorrhea.

What to do:
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- Investigate for any other underlying illness.
- Inquire as to whether or not the patient has 
   had a recent or unresponsive ear infection, 
   and whether or not the patient has recently 
   been on an antibiotic.
- If the patient has no recent histoy of otitis 
   media or antibiotic use, then prescribe an 
   appropriate dose of amoxicillin for ten 
   days. Trimethoprim plus sulfamethoxazole may 
   be substituted in the penicillin-allergic 
   patient.
- More expensive antibiotics such as amoxi- 
   cillin plus clavulinate, erythromycin plus 
   sulfamethoxazole, and cephalosporins should 
   be reserved for treatment failures and where 
   there is associated illness requiring a 
   beta-lactamase-stable antimicrobial
- Provide pain and fever control with 
   acetaminophen or ibuprofen elixir.
- Recommend a ten-day follow-up examination on 
   all patients under two years of age and in 
   those cases where the parents do not feel 
   the infection has resolved or where a 
   child's symptoms persist, there is a family 
   history of recurrent otitis or the accuracy 
   of the parental observations may be in 
   doubt.

What not to do:
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- Do not overlook serious underlying illness 
   such as meningitis.
- Do not prescribe antihistamines or decongest- 
   ants. These drugs do not decrease the 
   incidence nor hasten the resolution of 
   otitis media. Antihistamines can make 
   children drowsy and decongestants can cause 
   irritability.

Discussion
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Most otitis is caused by a viral infection, and 
most patients do well regardless of the 
antibiotic chosen. Despite the increase in 
antimicrobial resistance of community-acquired 
Streptococcus pneumoniae, Haemophilus 
influenzae and Moraxella catarrhalis and the 
plethora of alternative antibiotics available, 
amoxicillin remains the drug of choice, because 
it concentrates in middle ear fluid.

References:
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- Niemela M, Uhari M, Jounio-Ervasti K et al: 
   Lack of specific symptomology in children 
   with acute otitis media. *Pediatr Infect Dis 
   J* 1994;13:765-768.
- Rosenfeld RM, Vertrees JE, Carr J et al: 
   Clinical efficacy of antimicrobial drugs for 
   acute otitis media: metaanalysis of 5400 
   children from thirty-three randomized 
   trials. *J Pediatr* 1994;124:355-367.

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