1. Organism

   Streptococcus pneumonia Hemophilus influenzae B. catarrhalis Streptococcus pyogenes (Grp. A) Staphylococcus aureus Others Mixed infections No growth

   25% 25% 20% 2% 1% 20% 5% Remainder

   
   

   From: Pocketguide to Antimicrobial Therapy in Otolaryngology-Head & Neck Surgery 9th Edition by Fairbanks, D.A.
   
   

2. Antibiotics
   There is a high incidence of penicillin resistant Haemophilus in individuals exposed to antibiotics e.g. day care center, etc. For these individuals, begin with second line drugs. For all others begin with first line therapy.
   
   
   1. 1st line:
      1. Amoxicillin 500 mg p.o. tid x 7-10 days
   2. 2nd line:
      1. Augmentin 875 mg p.o. bid x 7-10 days
      2. Ceftin 500 mg p.o. bic x 7-10 days
      3. Pediazole
   3. Penicillin allergic patients
      1. E-Mycin 333 mg p.o. tid x 7-10 days
      2. Septra DS i p.o bid x 7-10 days
      3. Erythromycin and Septra

Overview of Acute Otitis Media

Otitis media is an incredibly common malady. The middle ear and mastoid are all part of the upper respiratory tract system and are aerated through the eustachian tube. Secretions drain through the same tube. At birth and through childhood the eustachian tube is short and often functions poorly. There appears to be growth periods or maturation periods for the eustachian tube and growth occurs around the age of four, again around the age of seven and the last around puberty.

Illness and conditions predisposing to acute otitis media are upper respiratory tract viral infections, allergic rhinitis, chronic sinusitis, nasal pharyngeal tumors and congenital or anatomic eustachian tube abnormalities. The end result is the same. If the eustachian tube is dysfunctional, the ear fails to aerate, secretions are not drained and infections ensue.

Virtually every child will have at least one ear infection by the age of 3 or 4. Those in day care environments, where the exchange of upper respiratory tract virus is an every day occurrence, may have 3-10 episodes of otitis media annually.

Although the same disease occurs in adolescents and adults, the frequency is less. The signs, symptoms, diagnostic workup and treatment are basically the same.

The following is a simplified treatment paradigm.

Acute otitis media is treated with antibiotics. Our recommendation is to begin simple. Amoxicillin is the first line drug of choice. If this fails, it can be presumed that the patient has a beta lactam resistant bacteria and second line antibiotics are indicated. There are many who argue that the high frequency of beta lactam resistant organisms warrants beginning therapy with second line drugs. I disagree. This practice promotes bacterial resistance, both for the individual and for the world. It wastes money and even in the short term has no proven benefit.

The use of ancillary treatments belongs to the art of medicine and is based upon other contributing illness. The antihistamines and the decongestants once considered the standard of care, are now thought to be of no benefit. Nose drops, both saline and decongestants, have no proven benefit. The only scientifically proven treatment for acute otitis is antibiotics and followup.

If the otitis media fails to improve or if it should worsen, second and even third line antibiotics can be given. Assuming the infection resolves, all patients warrant followup to be certain that the residual fluid (serous otitis media a.k.a. chronic otitis media with effusion) fully resolves. Whether you follow at 2, 3 or 4 weeks, makes no difference; but you must follow to guarantee resolution of the fluid and restoration of hearing.

Recurrent or persistent acute otitis media is sometimes controlled with low dose prophylactic antibiotics. Myringotomies and middle ear ventilation tubes are also effective and may be used for cases of antibiotic failure or antibiotic intolerance.

Never, absolutely never, forget that the complications of acute or chronic otitis media can be fatal. These include acute and chronic mastoiditis, meningitis, brain abscess, labyrinthitis, sigmoid sinus thrombosis, facial paralysis and other serious illnesses. Chronic untreated ear infections can also cause scarring and destruction of the middle ear ossicles and the tympanic membrane and may impair sensorineural hearing. Patients can be left with a serious, permanent hearing impairment.

Lastly, the tympanic membrane can be difficult to visualize and otitis media difficult to diagnose. If one cannot see the ear drum or cannot see it sufficiently well to make a diagnosis with some certainty, consultation with a colleague is appropriate. It is far too easy to assume that the febrile, sick child whose ear canal is obstructed by wax or whose ear drum is reddened by screaming, has acute otitis media and to treat with a course of amoxicillin or "spectaculocillin."

Consultation with an otolaryngologist is not dishonorable.