28 HOW TO TREAT: OTITIS MEDIA IN CHILDREN
28 HOW TO TREAT: OTITIS MEDIA IN CHILDREN
18 JULY 2025 ausdoc. com. au
PAGE 25( eg, amoxicillin – clavulanate). Amoxicillin remains the first line in almost all international OM guidelines when antibiotics are used, although watchful waiting remains the recommendation in uncomplicated cases. 43 Cefaclor, although often used, is not recommended given it is one of the most common causes of serum sickness reactions in children( 80 % or greater). 44
Vaccination
S. pneumoniae immunisation has not proven to be very effective in preventing OM but is recommended for other reasons( eg, marked reduction in invasive pneumococcal disease, such as sepsis). The H. influenzae type B vaccine has nearly eradicated epiglottitis and contributed to the large reduction in meningitis, but it is ineffective for the non-typeable strains that cause OM. New conjugate vaccines using H. influenzae protein D show promise but require more research. Influenza vaccines have been shown to reduce OM incidence by 30 %, highlighting the role of viral infections in OM, but this protective effect is short term( a few
45, 46 months).
Unsubstantiated treatments
Recent trials have indicated that xylitol likely does not reduce OM incidence in children. 47 Similarly, vitamin D supplementation has been evaluated for its potential to support immune function and reduce OM episodes, but trials have shown no substantial benefit in preventing or reducing OM. 48, 49 Level I evidence shows that antihistamine drops do not work and can cause harm. 50
MANAGEMENT
GENERAL comments regarding management appear in box 2.
Otitis media with effusion
The clinical management of OME or‘ glue ear’ involves regular monitoring and informing families about its potential impact on hearing and speech – language development. If OME persists for more than three
S. pneumoniae immunisation has not proven to be very effective in preventing OM but is recommended for other reasons.
months, a hearing assessment is recommended. 3, 43 Treatment may include a 2 – 4-week course of amoxicillin. In cases of significant hearing loss or speech – language delay, surgical intervention, such as tympanostomy tube insertion, may be considered. 3, 43 Autoinflation therapy could benefit some children, but the evidence is not yet conclusive.
Ongoing audiological and educational support is essential to manage any hearing loss and its effects on speech and learning. 3 In children with long-lasting effusions and hearing impairment of greater than 20dB, ventilation tubes( grommets) can be helpful in the short term( while patent) and adenoidectomy
Table 2. Hearing-related developmental milestones Age Developmental milestone
3-6 months Vocalising, eye gaze and babbling 9 months Feeding and oral co-ordination, gesturing and complex babbling 12 months Babbling and mimicking talk-like phrases 20 months Talking / speaking with mostly clear words and following simple instructions 24 months Knowing more than 50 words, clearly understood and connecting words together 30 months Using two-plus word combinations in simple sentences 36 months Clearly understood and speaking in simple but increasingly complex sentences 48 months Following multi-step instructions 60 months Expressing desires clearly, clearly responding and understanding simple conversation
Based on information in Menzies School of Health Research 2020 3 may be indicated in some. However, consider the risks of surgery and anaesthetics( very low in paediatric specialty centres).
Inform parents that, while their child has middle ear effusions, hearing will be compromised, which may lead to frustration and behavioural issues. Regular follow-up( ie, monthly) is crucial to monitor the condition and adjust treatment as
Discharge in the ear canal or next to the eardrum
Tympanostomy tube?
Yes
Tympanostomy tube otorrhoea
CSOM
Perforation?
Yes
needed. The evidence shows those with prolonged OME( more than 6-9 months) are the ones who benefit from interventions. 3, 43
Box 3 lists additional options that may help the child’ s ability to hear.
Acute otitis media
The clinical management of AOM focuses on accurate diagnosis and appropriate treatment,
No
Discharge through perforation present for minimum two weeks?
Perforation large enough for topical antibiotic drop(> 2 % of eardrum)?
Yes
No
Yes or unknown
No or unknown
Ear canal swollen and sore?
Management: CSOM and AOM with perforation
CSOM
AOM with perforation
No
No
AOM with perforation
Yes
Otitis externa
• Dry mopping
• Ciprofloxacin three drops tds
• ENT and hearing referral
• Amoxicillin 50-90mg / kg / day as tds dosing for two weeks
• Review after one week
If middle ear discharge or bulging persists, refer to 2020 OM guidelines for further management
Figure 6. Algorithm for otitis media diagnosis and management when discharge is present.
particularly based on the presence of perforation.
AOM WITHOUT PERFORATION In AOM without perforation, children at high risk( eg, younger than two, bilateral disease, severe symptoms or at-risk groups) are more likely to benefit from immediate antibiotics. 3, 43 Most children can be managed with watchful waiting and
Box 2. Management comments
• See otitismediaguidelines. com for up-to-date recommendations.— NB: These guidelines are designed for First Nations children but are based on international evidence for all children and applicable across Australia.
• Refer all children with any OM lasting longer than three months for audiology and ENT review.
• Children with a recurrent / persistent OM, or a strong past history or family history of OM, are considered at higher risk( or‘ otitis prone’) and warrant more aggressive therapy( eg, antibiotics for AOM rather than watchful waiting).
• Recurrent OM is defined as:— At least three episodes in the past six months.
— At least four episodes in the past 12 months( with one in the past six).
Box 3. Additional options that may help the child’ s ability to hear
• Encouraging teachers to seat the child closer to the front of the class.
• Advising parents and teachers to speak directly( face to face) with the child.
• Considering temporary hearing aids in more severe cases or having the teacher wear voice amplifiers when many children in the class are affected.
analgesics. 3, 43 Antibiotics are associated with more rash and diarrhoea, whereas watchful waiting is associated with slightly lower resolution and very slightly higher rates of perforations, which are usually small and not consequential. 43 In either case, follow-up is essential, and if no improvement is seen, treatment should be escalated( watchful waiting does not mean no antibiotics ever, just no antibiotics at presentation).
ACUTE OTITIS MEDIA WITH PERFORATION Initial treatment involves antibiotics and regular review, with adjustments based on the child’ s response rather than watchful waiting. Persistent cases may require the addition of topical antibiotics and continued monitoring. Recurrent AOM necessitates audiometry and referral to an ENT specialist as the child may need long-term antibiotic prophylaxis or surgery, as well as regular follow-up. 3, 43
In different countries, approaches to AOM vary. For instance, clinicians in Israel often perform tympanocentesis and treat with antibiotics. 51 In the Netherlands, most practise watchful waiting. 52 International guidelines recommend watchful waiting in almost all uncomplicated cases and recommend amoxicillin( not amoxicillin – clavulanate) when antibiotic therapy is used. In Australia and the US, most children receive antibiotics at the initial visit despite guidelines recommending watchful waiting. 3, 53
WHAT DOES RECENT EVIDENCE SHOW? A 2024 Australian qualitative study