Correspondence
Otitis Media in Children
N Engl J Med 1995; 333:1151-1152October 26, 1995
- Article
To the Editor:
The review of otitis media by Berman (June 8 issue)1 makes clear that the number of cases of mastoiditis has decreased drastically in the past 40 years. Those who treated acute otitis media with antibiotics may regard antibiotics as the cause of this decrease. In the Netherlands, this decrease was initially attributed to treatment with paracentesis. However, since the 1980s the use of paracentesis and antibiotics has been virtually abandoned in the Netherlands. Watchful waiting is the approach of choice for all patients older than one year. The combination of analgesics and local decongestants is now the preferred symptomatic treatment. This new approach was tested over a period of 17 months in some 5000 children (age, 2 to 12 years) with acute otitis media from a Dutch population of approximately 150,000.2 Mastoiditis developed in only two children (0.04 percent), and both then responded well to antibiotic therapy.
The decrease in the frequency of mastoiditis is probably not the result of treatment with either antibiotics or paracentesis. There must be other causes. One must consider the overall improvement in our physical health and environmental conditions and the variation in the pathogenicity and epidemiology of the causative bacteria. Thus, the decrease in mastoiditis over the past 40 years cannot be an argument for the routine antibiotic treatment of all cases of acute otitis media.
2 ReferencesF.L. van Buchem, M.D., Ph.D.
J.A. Knottnerus, M.D., Ph.D.
M.F. Peeters, M.D., Ph.D.
St. Elisabethziekenhuis, 5000 LC Tilburg, the Netherlands1
Berman S . Otitis media in children. N Engl J Med 1995;332:1560-1565
Full Text | Web of Science | Medline2
van Buchem FL ,Peeters MF ,van 't Hof MA . Acute otitis media: a new treatment strategy. BMJ 1985;290:1033-1037
CrossRef | Web of Science | Medline
To the Editor:
Berman states that “third-generation cephalosporins and amoxicillin plus clavulanate are mainly useful as antibiotics for children who are allergic either to amoxicillin or to antibiotics containing sulfa.” Clavulanate is a β-lactamase inhibitor that extends the activity of amoxicillin to include β-lactamase–producing strains of bacteria.1,2 In no way does it alter a patient's allergic response to amoxicillin: if a patient is allergic to amoxicillin, he or she is allergic to amoxicillin plus clavulanate.
2 ReferencesCheryl Mokry, Pharm.D.
Managed Prescription Services, St. Louis, MO 63101To the Editor:
Ten percent of children with recurrent otitis media have underlying allergic rhinitis that could be contributing to these recurrent infections.1-3 Children with allergic rhinitis may have swollen, boggy turbinates with enlarged adenoids capable of obstructing the eustachian tube, which opens into the posterior nasopharynx. A carefully obtained family history usually reveals that one or more parents have a history of allergic rhinitis.3 A convincing history of atopy in a child with recurrent otitis media warrants an evaluation for allergies to identify environmental triggers and a trial of pharmacologic therapy consisting of antihistamines, decongestants, and intranasal cromolyn sodium or intranasal corticosteroids to reduce airway secretions, congestion, and inflammation.3
3 ReferencesJonathan A. Bernstein, M.D.
University of Cincinnati College of Medicine, Cincinnati, OH 45267-05631
Bernstein JM ,Lee J ,Conboy K ,Ellis E ,Li P . The role of IgE mediated hypersensitivity in recurrent otitis media with effusion. Am J Otolaryngol 1983;5:66-69
Web of Science2
Bluestone CD . Eustachian tube function: physiology, pathophysiology, and role of allergy in pathogenesis of otitis media. J Allergy Clin Immunol 1983;72:242-251
CrossRef | Web of Science | Medline3
Lieberman PL, Crawford LV. Allergic diseases of the eye and ear. In: Patterson R, Zeiss CR Jr, Grammer LC, Greenberger PA, eds. Allergic diseases: diagnosis and management. Philadelphia: J.B. Lippincott, 1993:297-315.
Author/Editor Response
Dr. Berman replies:
To the Editor: In response to van Buchem et al.: clinical trials carried out during the 1940s and 1950s document a causal relation between antibiotic treatment in groups with high rates of mastoiditis and a reduction in subsequent occurrences of mastoiditis and chronic suppurative otitis media.1 I am unaware of published data documenting the efficacy of paracentesis alone.
Although mastoiditis is now rare regardless of whether antibiotic treatment is given for acute otitis media, the issue of routine antibiotic treatment of patients older than one year of age remains controversial. In a meta-analysis of 33 randomized, controlled clinical trials of antibiotic treatment for acute otitis media,2 treatment improved the resolution rate by 13.7 percent. Most clinicians prefer either routinely to treat the infection with antibiotics or (as in the Netherlands) not to treat with antibiotics. The remainder try to individualize this decision on the basis of an assessment of the risks and benefits for a specific patient and to involve the family in the decision-making process. Some advocates of nontreatment would treat children younger than one year of age with antibiotics and administer antibiotics to other untreated patients whose condition fails to improve in 48 to 72 hours. It is best to avoid the issue of whether to institute antibiotic treatment as much as possible by not overdiagnosing acute otitis media.
Mokry correctly points out that patients who are allergic to amoxicillin will also be allergic to amoxicillin plus clavulanate. If a child is allergic to amoxicillin but not cephalosporins, I recommend using a third-generation cephalosporin or clarithromycin to treat acute otitis media that has not responded to erythromycin plus sulfisoxazole or trimethoprim plus sulfisoxazole. If a child is allergic to an antibiotic containing sulfa, I recommend using amoxicillin plus clavulanate, a third-generation cephalosporin, or clarithromycin when the otitis has not responded to amoxicillin.
Bernstein comments on the role of underlying allergic rhinitis as a risk factor for recurrent acute otitis media. Allergic rhinitis is rarely identified in children younger than 18 months of age. Among 349 children followed in my otitis clinic, only 4.9 percent had symptoms of allergic rhinitis. However, the mothers of 30.5 percent of these children had a history compatible with allergic rhinitis. Bernstein et al. studied children (age, 2 to 18 years) with recurrent otitis who had at least two sets of tympanostomy tubes placed.3 The findings from this group cannot be generalized to younger children with recurrent otitis, the group usually seen by primary care physicians. Because of conflicting findings and the lack of randomized clinical trials, the Agency for Health Care Policy and Research Guideline Panel did not make a recommendation on the management of allergy.4 However, I agree that older patients with a “convincing history” of allergic rhinitis should have a trial of pharmacologic therapy in an attempt to reduce the symptoms of allergic rhinitis.
4 ReferencesStephen Berman, M.D.
University of Colorado School of Medicine, Denver, CO 802621
Berman S . Otitis media in developing countries. Pediatrics 1995;96:126-131
Web of Science | Medline2
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
CrossRef | Web of Science | Medline3
Bernstein JM ,Lee J ,Conboy K ,Ellis E ,Li P . The role of IgE mediated hypersensitivity in recurrent otitis media with effusion. Am J Otolaryngol 1983;5:66-69
Web of Science4
Stool SE, Berg AO, Berman S, et al. Otitis media with effusion in young children. Clinical practice guideline no. 12. Rockville, Md.: Department of Health and Human Services, 1994. (AHCPR publication no. 94-0622.)
- Citing Articles (2)
Citing Articles
1
R. G. Finch, D. E. Low. (2002) A critical assessment of published guidelines and other decision-support systems for the antibiotic treatment of community-acquired respiratory tract infections. Clinical Microbiology and Infection 8, 69-91
CrossRef2
Matthew D. Curry, Alta W. Andrews, Hal J. Daniel. (1997) A Community-Based Nursing Approach to the Prevention of Otitis Media. Journal of Community Health Nursing 14:2, 81-110
CrossRef
