It is likely that many pediatrie health care providers begin their professional careers assuming that the diagnosis and management of otitis media must be straightforward. After all, this is bread-and-butter pediatrics and otitis media is so prevalent. Subsequently they experience the difficulties of diagnosing it accurately, classifying it correctly, and managing it appropriately. A new appreciation for this clinical problem develops. It is my hope, and my expectation, that the contributions in this issue of Pediatrie Annals will enhance clinicians' knowledge and skills regarding otitis media and will enrich that appreciation.
What do we know about otitis media at the start of the new millennium? To provide clarity on the subject, a group of experts in otitis media have addressed the following topics: acute otitis media, otitis media with effusion, complications of otitis media, referral to the otolaryngologist, and vaccines ie, prevention). Each shares expertise and experience on his or her respective topic.
Drs. Hoberman and Paradise comprehensively review the most current information on the subject of acute otitis media. They propose an algorithm for distinguishing acute otitis media from otitis media with effusion. Importantly, they also address the topic of bacterial resistance and related therapeutic recommendations.
Drs. Roddey and Hoover provide unique perspectives from private practice and share their approach to the diagnosis and management of otitis media with effusion (synonyms include secretory otitis media, serous otitis media, and nonsuppurative otitis media). In addition, they comment on the U.S. Agency for Health Care Policy and Research's Clinical Practice Guideline on Otitis Media with Effusion in Young Children.
Drs. Roddey and Hoover also offer a provocative, although probably somewhat controversial, aspect of management. In an attempt to decrease antibiotic use in his practice, Dr. Roddey has recruited parents (those whom he considers to be reliable) to assist in making decisions about the filling of antibiotic prescriptions for cases of possible acute otitis media that are not clear-cut (even in the hands of such an experienced clinician). Obviously, this approach requires, at the minimum, skilled otoscopists working closely with a select population of parents who can first comply as directed and then recognize and respond when difficulties arise. Clearly, Drs. Roddey and Hoover stimulate us to think about new ways to decrease antimicrobial use, and additional research could prove helpful in evaluating this approach.
Dr. Kenna tackles the topic of referral to the otolaryngologist. Clearly, pediatricians and otolaryngologists work together in treating children with difficult cases of otitis media. Dr. Kenna discusses when to refer such children to an otolaryngologist and the role of surgical intervention. In addition, her discussion of audiologic assessment of children provides a review for pediatrie health care providers. It is important to reiterate that, when concerns about hearing are raised, assessment of the audiologic system can be performed at any age, although referral to a tertiary facility may be necessary.
Dr. Wetmore addresses the topic of intratemporal and intracranial complications of otitis media. He discusses pathogenesis, clinical presentation, and current management. Although some of these complications occur infrequently, the general pediatrician and other pediatrie health care providers must be able to identify them when present.
Drs. Black and Shinefield provide the most recent information on prevention of otitis media using vaccines. The idea of using vaccines is not new. However, implementation has been slowed by significant biological challenges. Drs. Black and Shinefield provide a state-of-the-art review of vaccines related to otitis media and offer their recommendations.
In the resident's column, Dr. Baum offers her insights on otitis media, starting with her view on the subject when she was a medical student and ending with her view as an accomplished pediatrie chief resident. Dr. Baum has learned what those of us with a long-standing interest in otitis media have also had to learn: accurate diagnosis of otitis media is often challenging (in part because of the dynamic nature of this condition), the ideal classification scheme and definitions are still being worked out, and optimal management continues to evolve. This is not comforting news for those newly interested in the subject or for those who have felt challenged for some time by this condition.
I would like to conclude with a few observations of my own about otitis media. First, accurate diagnosis of otitis media and differentiation of acute otitis media from otitis media with effusion are essential. Before one can contemplate therapy, he or she should be confident that disease is even present. Routine use of pneumatic otoscopy greatly facilitates accurate detection of middle ear effusion. Skillful instruction of clinicians, particularly of trainees, in the identification of otitis media and in the use of pneumatic otoscopy should enhance diagnostic acumen.
Second, appropriate management is key. Pediatricians have typically been cognizant in practice of the potential for overuse of antibiotics, especially in otitis media. Currently, because of developments regarding resistant bacteria, such caution is warranted even more. For example, this concern and others would seem to limit consideration of prolonged courses of antimicrobial prophylaxis for recurrent acute otitis media to relatively small numbers of selected cases.
Finally, pediatrie health care providers should continue to work closely with parents and otolaryngologists in the decisionmaking process. Optimal decision making will be enhanced by ongoing attention to clinical experience and by clinical research.
In asking this group of authors to contribute to this issue of Pediatrìe Annals, I have attempted to collate the most current views on otitis media from experts in different regions of the country, in different specialties (pediatrics and pediatrie otolaryngology), and in both academic medicine and private practice. Clearly, we need to learn even more about otitis media so as to instruct trainees in the most effective ways of detecting it and to ascertain the most appropriate prevention strategies and management plans over time. It is hoped that the articles in this issue of Pediatrie Annals will assist in accomplishing these goals.