Almost all children have at least one episode of acute otitis media (AOM), but many are plagued by recurrent infections throughout infancy and childhood. In one study of children living in the greater Boston area, approximately one child in five had experienced three or more episodes by his or her first birthday. By the third birthday, this figure had risen to more than 40%.1
Children who have experienced five or six episodes of AOM pose difficult problems for the physician. Children with middle ear effusion (MEE) experience hearing loss of varying severity; the average loss is about 25 dB (PTA). Because speech and language development occurs in infancy, any impediment to reception or interpretation of auditory stimuli may place the child at risk for late sequelae, including problems in speech, language, cognition, and achievement in school. Particularly in countries with inadequate medical care, recurrent infections lead to permanent anatomic damage and loss of hearing. Some children develop pyogenic complications such as mastoiditis, bacteremia, and meningitis.
From a more practical perspective, recurrent ear infections are costly and may cause severe pain and discomfort. Children with recurrent otitis media are frustrating to both parent and doctor. To the parent, the child always seems to be ill, often at night. To the doctor, the child seems to be always coming back to the office for yet another ear infection, and the physician feels unable to solve the problem.
This article, drawing from both clinical experience and the literature, describes an approach to recurrent acute otitis media that is suitable for the primary care physician.
Some understanding of the epidemiology of this disease is useful for both physician and parent. Parents are often relieved to know that their child's problem is common and, as a rule, will improve with time. Table 1 lists risk factors for recurrent AOM.
In modem studies in industrialized societies, the peak incidence of otitis media occurs in the first 2 years of Hie. In the most carefully performed studies, the peak incidence occurs in the second half of the first year of life. This epidemiologie clue is especially intriguing because it matches the incidence of more serious and life-threatening infections, notably meningitis. The most likely explanation is that this peak corresponds to the lowest levels of serum antibody (ie, after the disappearance of the passively transferred maternal antibody and before the development of natural immunity). Children in infancy (and to some extent, until age 5) are not as immunologically competent as older children and adults. They do not respond as well to nonprotein antigens (such as the polysaccharide capsule of the pneumococcus), and they have not yet encountered most of the common bacterial and viral pathogens. Other investigators in this area also have implicated anatomic changes in the eustachian tube. It seems likely that both anatomic and immunologie factors explain much of the susceptibility of infants.
Epidemiologie Risk Factors for Recurrent Acute Otitis Media
The age of onset also is important from a prognostic perspective. Children whose first infection occurs in the first 6 months of life are at greatest risk for severe, recurrent otitis media.
As with most bacterial infections, boys are more likely to have recurrent infections than are girls, but the difference is not striking.
Siblings and Sibling History
First-bom children generally are less likely to have recurrent otitis media than are younger siblings. Presumably this relative protection is due to the paucity of infections imported into a household. The contribution of sibling exposure to the increased risk for otitis media is important, but much less so than the family history.
Recurrent ear infections really do "run in the family." A child born into a family where the other children have had recurrent AOM is about three times more likely to develop recurrent AOM than a child born in an unaffected family.1 Although the reason for this familial susceptibility is not yet known, explaining this tendency to parents may provide some solace.
Many investigators have sought an association between the method of feeding and the risk for otitis media. The majority of studies, most of which have major flaws in study design, have suggested that breast-fed infants have fewer episodes of otitis media. The explanation for this apparent protection is currently unknown. It may be that breast milk is, by itself, protective. In an intriguing study, some children with cleft palate were fed human milk from a bottie. They had significantly less disease than others with clefts who were fed prepared formula.2 The available data, while they show human milk to have many immunologie additives, do not yet show that these are actually protective. It may ut chat constituents of prepared formulas are, by themselves, conducive to recurrent AOM.
Bottle Propping in Bed
As yet, this practice has not been eliminated as a risk factor above and beyond the feeding of prepared formulas. Infants fed when supine may reflux formula into the middle ear cavity. Prudence suggests this practice should be avoided.
A multitude of studies, one more than 50 years old, have documented the dramatically increased risk of recurrent AOM associated with day-care attendance. In a recently completed study of day care and otitis media in suburban Boston, enrollment in day care for 90 days or more in the first year of life almost tripled the risk for recurrent AOM by the first birthday.3 In some developed countries, more than half the mothers of infants are working outside the home; the implications of the added burden of increased rates of otitis media are immense. No effective strategies currently exist to reduce the risk that follows enrollment in day care.
Some studies have incriminated passive smoking as an additional risk factor for otitis media and other respiratory illnesses that may predispose to otitis media. For this reason, as well as the health of the parent, smoking should be discouraged. If parents must smoke, they should be encouraged to do so outside of the living environment.
In studies in temperate climates, otitis media is a strikingly seasonal disease, occurring predominantly during the cold weather months. Not only is this important for the parent to understand, but it also helps guide medical management, especially antimicrobial prophylaxis.
Effective Strategies for Controlling Recurrent Acute Otitis Media
HISTORY- KEY QUESTIONS
The following questions are important to ask when obtaining a medical history:
* At what age aid the problem begin?
An early onset, especially in the first 6 months of life, suggests increased probability of frequent recurrences. On the other hand, a child who has two infections, even two closely spaced ones, during the second winter of life will probably do well.
* Is there a family (sibling) history?
* How was the chiíd fed in infancy?
* Does the child attend day care?
* What prior interventions have been tried and with what success?
Parents frequently state that antimicrobial prophylaxis has been tried without success, but careful inquiry often reveals that the trial was much too short.
* What is the child's history of allergy?
The clinician must be aware of any drug allergies the child may have before starting treatment. The role of strategies to control manifestations of allergy to environmental allergens is less straightforward. To date, there are no convincing studies that demonstrate an important role for the allergist in reducing the severity of recurrent acute AOM.
* Asitie from the recurrent ear infections, is the child thriving?
Generally, children with recurrent AOM do well otherwise; they usually have good weight gain and do not suffer from other recurrent infections. Failure to thrive or recurrent infections in another organ should raise a red flag to the practitioner. Such children may have significant immunologie problems, which are discussed later.
* Have the child's speech and language stalls developed normally?
Subtle deficits in speech or language may be difficult to assess in children with recurrent AOM, especially young children. Any suggestion of impairment warrants a formal speech and language evaluation.
* What pattern has the disease followed?
Seasonally. The child with closely spaced infections all year round is distinctly unusual and presents a greater problem than the more common child whose disease is most severe during the fall, winter, and spring. Seasonal disease is often easily managed with extended antimicrobial prophylaxis, while nonseasonal disease may require ventilation tubes. With the child who has experienced multiple recurrences, most parents and clinicians are comfortable with several months of daily antimicrobial therapy, but few are comfortable with this intervention for years.
Laterality. The majority of afflicted children have disease that involves both ears, often one more than the other. Disease continuously and solely involving one ear suggests the possibility of an anatomic cause and warrants referral to an otolaryngologist for evaluation.
* How reliable is the history of recurrent AOM?
This is not so much an issue of the reliability of the parent as a historian, but rather one of the validity of the previous diagnoses. This may not be a problem for the practitioner who has followed a child continuously since birth, but it can be a problem with children whose past medical care has been delivered elsewhere.
In the latter circumstance, an ill child with a history of repeated ear infections is likely to have been treated, even if the tympanic membranes are not adequately visualized. Likewise, a young, highly febrile child may be treated for "an early otitis media" or "a touch of otitis media" or "incipient otitis media." In some circles, this entity is known as "acute, reassuring otitis media." Both parent and child feel better with the knowledge that antimicrobial therapy has been started.
If the validity of the past diagnoses seem suspect, a trial of observation is indicated. During this period, if otitis media is diagnosed elsewhere, the parent should be asked to bring the child for confirmation of the diagnosis within 24 to 48 hours. In these circumstances, it is remarkable how often the ears will be normal. While ears often become abnormal and filled with pus in less than 12 hours, they do not usually resolve as quickly.
* What is the child's breathing pattern?
A history of mouth breathing should suggest obstruction, usually due to enlarged adenoids, which are discussed later.
A complete physical examination should be performed. In addition to examining the ears, the clinician should pay particular attention to the nose, pharynx, and palate.
Examination of the tympanic membranes should include the position (neutral, retracted, or bulging), color, opacity, mobility to both positive and negative pressure, and the presence of other findings such as retraction pockets or tympanosclerosis. Results of the examination should be systematically recorded to allow comparison at future examinations.
The laboratory has a limited role in the evaluation of children with recurrent AOM who are otherwise thriving. A number of investigators have reported subtle immunologie defects (notably IgG2 sub-class deficiency),4 but the prevalence of identifiable immunologie conditions is probably less than 1%. This is not to imply that young children with recurrent AOM are immunologically the same as otitis-free children. To the contrary, evidence is accumulating that afflicted children probably lag in their immunologie maturity.5 However, no practical therapeutic intervention based on these ground is currently available for these children.
Monitoring blood counts is recommended by many who use extended antimicrobial prophylaxis, but past and current data do not show that surveillance of blood counts can warn of idiosyncratic and lifethreatening reactions, such as aplasia of the bone marrow. Nonetheless, many feel compelled to perform these counts as a prudent measure.
Formal audiologic assessment is most appropriate for children with MEE that persists for months, with or without superimposed episodes of AOM. Children with repeated infections that clear or begin to clear between episodes may not require an audiology consultation because it is not known how to use the audiologic data to guide the management of these patients. On the other hand, many authorities arbitrarily recommend audiologic assessment for children whose MEE has persisted for 3 months or longer.
EFFECTIVE STRATEGIES TO CONTROL RECURRENT OTITIS MEDIA
Over the past 20 years, more than 20 articles have been published on the efficacy of antimicrobial prophylaxis.6'15 Almost every potentially useful drug has been tried, and as a rule, all show some efficacy when compared to the use of a placebo or simple observation. In fact, the efficacy of these antibiotics is usually quite good. For some children, prophylaxis acts like a switch. As long as the drug is given, the child remains otitis free. For others, the incidence of episodes of AOM is markedly reduced. For a minority, prophylaxis appears totally ineffective. Some considerations on this strategy follow.
Selection of Drug. The largest body of supporting data exists for sulfisoxazole, which is usually given as a single daily dose. Other agents to consider, should sulfisoxazole fail, include amoxicillin (or ampicillin), trimethoprim/sulfamethoxazole, and (for the penicillinallergic child) erythromyctn. However, in the United States, package inserts for trimethoprim/sulfamethoxazole warn that trimethoprim-sulfamethoxazole is not indicated for prophylactic or prolonged administration in otitis media at any age. While trimethoprim/ sulfamethoxazole has been shown to be effective in published clinical trials and while clinical experience suggests its excellent activity as a prophylactic agent, prudence dictates another agent (at least in the United States).
Dosage and Scheduling of Drug. The optimal dose of antimicrobial therapy for prophylaxis of recurrent AOM is unclear. Most experienced clinicians choose about one half the usual total daily dose, given as a single dose. Equally unclear is the timing of administration. Many suggest giving the drug in the evening or at bedtime, but there are no data to confirm this as the best course of action. Other strategies that have been tried, with only limited success, including the use of the prophylactic drug only with colds or only on the weekends.
Duration of Therapy. Many clinicians will prescribe prophylaxis for 3 to 6 weeks. Others, including the author, begin with a minimum period of 3 months. This decision is based on the as yet untested impression that relapses seem to occur less frequently after a longer course. It is attractive to believe that the longer course permits the middle ear and eustachian tube to return to normal and so be more resistant to reinfection.
Toxicity. For those choosing courses longer than 6 weeks, it may be prudent to obtain periodic white blood counts, although no data exist to show that such monitoring will avoid the very rare and sometimes catastrophic adverse reactions. Parents must be told, of course, to discontinue the agent with onset of a rash or other potentially adverse reactions.
Management of AOM Episodes During Prophylaxis. The microbiology of such episodes has been studied for children receiving sulfisoxazole.16 Antimicrobial agents unrelated to the prophylactic antibiotic being given are likely to be most effective. For example, a penicillin or cephalosporin with proven efficacy for otitis media would be appropriate for a child who develops an episode while receiving a sulfa drug. Prophylaxis should be resumed as soon as therapy for the intercurrent episode is completed.
Determination That Prophylaxis Has Failed. This decision can only be made by comparing the pattern of disease on prophylaxis with that which preceded prophylaxis. A few children suddenly become otitis free, and some fail immediately with closely spaced recurrences; the majority have less disease overall. Some children may remain well, but have persistent MEE. Thus, periodic reexamination is needed, regardless of the appearance of well-being.
Counseling Apprehensive Parents. Many parents are at first reluctant to consider daily administration of an antimicrobial agent for a period of several months. Parents must be reminded that should prophylaxis not be started, their child will likely be exposed to many different drugs to treat the multiple additional episodes.
Myringotomy/Tympanostomy Tube Insertion
Despite their frequent use in children who have suffered from recurrent AOM, tympanostomy tubes have been subjected to only a limited number of studies. In 1979, Samuel et al reported that 25 of 30 children improved after the insertion of tubes.17 In 1981, Gebhart reported that 46% of children who had had tubes inserted remained free of otitis media; this compared favorably with 5% of the controls.18 Gonzalez et al later reported similar results.19
Both clinicians and investigators note that the efficacy of tympanostomy tubes appears to be largely confined to the period when the tube is in place and patent. Tubes themselves may have some long-term morbidity, if only in the changes they may cause in the tympanic membrane, and they are costly. Hence, they should be reserved only for children with established recurrent AOM who have failed to respond to prophylaxis.
Adenoidectomy has been studied over many years for children with both recurrent AOM and established persistent MEE. Gates et al demonstrated limited effectiveness of adenoidectomy for highly selected children.20 The benefits appeared to be greater for MEE than for recurrent AOM, More recently, Paradise et al published their study of adenoidectomy for children with recurrent AOM who had already foiled management with tubes alone.21 They concluded that adenoidectomy is probably indicated for a limited population of children who have unrelenting recurrent AOM despite tympanostomy tube insertion.
Among licensed bacterial vaccines, only the pneumococcal vaccine has been shown to be of any benefit to children with recurrent AOM.22·23 Several studies have shown either no or minimal protection in children under the age of 2. Over the age of 2, type-specific protection has been shown to develop, but the overall incidence of AOM was not significantly reduced in these studies. Furthermore, 2 years of age may be too late to institute this treatment since it is beyond the peak incidence of the disease and beyond the period of maximal concern for adverse influence on development.
The relationship of influenza A vaccine to recurrent AOM has been studied in Scandinavia.24 When this agent was prevalent in the community (only a short period of time in any given year), vaccinated children had a reduced attack rate of AOM. These studies are intriguing because they suggest that any intervention to reduce the rates of infection by respiratory viruses also might reduce the rates of AOM.
Currently, pneumococcal and influenza A vaccines should be considered only for the occasional older child who continues to have severe, recurrent AOM.
Immune Serum Globulin
This agent has had limited use in children with documented deficiency of an IgG subclass.4 Should the practitioner identify such a child, consultation with an experienced immunologist is warranted before beginning treatment with any form of immunoglobulin.
Recurrent AOM is a plague in many societies. The considerable attendant morbidity is best reduced through extended periods of antimicrobial prophylaxis. Children who are not helped by this intervention and who are experiencing sufficiently severe disease become candidates for surgical management with tympanostomy tubes. Should both strategies fail, then an adenoidectomy should be considered. In every case, the practitioner must weigh the severity of the recurrent illness against the real costs and risks of surgery.
1. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J In/ici DH. 1989:160:83-94.
2. Paradise JL, Elster BA- Breast milk protects against otitis media with effusion. Pediotr Bts. 1984;18:283A. Abstract.
3. Teele DW1 Klein JQ Rosner BA, et al. Daycare and risk for recurrent acute othis media in infancy. Presented at ihe 5th Internationa! Recent Advances in Otitis Media Symposium; May 20-24. 1991.
4. Silk HF, Ambrosino E^ GeKa RS. Effect of intravenous gamma globulin therapy in IgG 2 deficient and IgG2 sufficient children with recurrent infections and poor response to immunization with Hemopfiilui influenzae type b capsular polysaccharide antigen. Ann Allergy. 1990:64:21-25.
5. Ambrosino D, Umelsu U Siber OR, et al. Selective defect in the antibody response to Haemaphitta influenzas type b in children with recurrent Infections and normal serum [gG subclass levels. J Allergy CUn immnnof. 1988;81:1175-1179.
6. Leonini JP, Stankiewlei JA. Antimicrobial prophylaxis for recurrent otitis media. Otolarynsoi Head Neck Surg. 1988:99:81-82.
7. Lampe SM, "(Weir MR· Erythromycin prophylaxis for recurrent otitis media. CIm ffefioff (PWIa). 1986:25:510-515.
8. Varsano E, Volnvitz B, Mimouni H Sulfisoxazole prophylaxis of middle ear effusion and recurrent acute otitis media. Am J Dis Child. 1985; 139:63 2 -635.
9. Liston TE, rbshee WS. Pierson WD. Sulfisoxazole cheraoprophylaxis for frequent otitis media. Pedüma. 1 983 ;7 1:524-530.
10. Schuller DE- Prophylaxis of otitis media in asthmatic children. Pediacr Infect Dis J, 1983:2:280-283.
11. Paradise JL. Antimicrobial prophylaxis for recurrent acute otitis media. Ann Oíd Ritmo! LorjngotSafjpl. l981;90:53-57.
12. Coulthard SM. Chemoprophflaxis of recurrent otitis media. Otolaryngvi Head Neck Surg. 1979;87:706.
13. Perrin JM. Chamey E, MacWhinney JB Jr, Mdnemy TK, Miller RL, Nazarian LF. Sulfisoxaaote. as chemoprophvìaxis fat recurrent otitis media. A double-blind crossover study in pediatrie practice. N EnglJ MoJ. 1974:291:664-667.
14. Principi N, Marchisio P, Massironi E, Grasso RM, Filiberti G. Prophylaxis of recurrent acute otitis media and middle-ear effusion. Comparison of amoxidllin with sulfamethoxazole and trimethoprim. AmJ Du CMd. 1989:143:1414-1418.
15. Maynard JE, Reshman JK, Tschopp CF. Otitis media in Alaskan Eskimo children. Prospective evaluation of chemoprophylaxis. MMA. 1 97 2;2 19:597 -599.
16. Liston TE, Foshee WS, McCleskey FK. The bacteriology of recurrent otitis media and die effect of su Ifisoxaiole chemoprophytaxis. Pediatr Inject Dif}. 1 984 J: 20- 24.
17. Samuel J, Rosen G, Vered Y. Use of middle ear ventilation tubes in recurren! acure otitis media. J Lrnyn&t Owl. 1979;93:979-981.
18. Gebhart DE. Tympanostomy tubes in the otitis media prone child. Laryngoscope. 1981:91:849-866.
19. Gonzalez C, Arnold JE, Woody EA. et al. Prevention of recurrent acute otitis media: chemoprophylaxis versus tympanostomy tubes. Laryngoscope. 1986:96:1330-1334.
20. Gates GA, Avery CA, PrihodaTLCooperJCJr-Effeetivenessof adenoidectomy and tympanostomy tubes in die treatment of chronic oliti« media with emisión. N Engí ) Meí. 1987317:1444-1451.
21. Paradise JL, Bluestone CD, Rogers KD, el al. Efficacy of adenoidectomy for recurrent otiti« media in children previously treated with tympanostomy-tube placement. JAMA. I990;263:2066-2073.
22. Makela PH, Leinonen M, Pukander J, Karma P A study of die pneumococcal vaccine in prevention of clinically acute attacks of recurrent otitis media. Rev Infecí Dis. 1981:3:5124-5132.
23. Slayer JL Jt, Ptoussard JH, Howie VM. Efficacy of pneumococcal polysaccharide vaccine in preventing acute otitis medía in infants in Huntsville, Alabama. Rev lnfea Dis. 1981:3:51 19-S123.
24. Heikkineti T, Ruuskanen O, "Wans M. Zieglei T. Aiolà M, Hakmen P. Influenza vaccination in die prevention of acute otitis media in children. ?p J Dis OuU. 1991; 145:445-448.
Epidemiologie Risk Factors for Recurrent Acute Otitis Media
Effective Strategies for Controlling Recurrent Acute Otitis Media