A parent brings her two year old son to your office because of a chief complaint of fussiness and tugging at his right ear for the past two days. He has had coughing and a runny nose for about 5 days that has been treated with saline nose sprays and a humidifier. He has a low-grade fever of about 101 degrees F (38.3 degrees C) axillary for the past two days. Both parents smoke cigarettes. He attends daycare. His past medical history is significant for ear infections in the past, with his last otitis media episode 5 months ago, treated with amoxicillin. His immunizations are up to date, including 13-valent pneumococcal conjugate vaccine.
Exam: VS T 38.4, P 100, RR 28, BP 100/65. He is active, alert to his surroundings and otherwise in no distress. HEENT: Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic otoscopy. Left TM is clear with good mobility. Throat is non-erythematous. There are small cervical lymph nodes. Lungs are clear to auscultation. The rest of the examination is normal.
He is diagnosed with acute right otitis media. He is prescribed amoxicillin and acetaminophen. His parent is told to follow up in 2 to 3 days if he is not better, and warned against the dangers of their child to second-hand cigarette smoke.
Otitis media (OM) is one of the most common diagnoses that pediatricians encounter. It is estimated that otitis media comprises about 25% of all office visits in the first eighteen years of life, with most occurring in children younger than 3 years of age (1). In the United States, OM was the most frequent diagnosis in office settings, and accounted for 25 million visits in 2000 and more than 20 million prescriptions written that year. The estimated direct cost is $1.96 billion in 2005 (2).
The middle ear is a gas filled cavity in the petrous part of the temporal bone between the external auditory canal and the inner ear. It contains three ossicles called the malleus, incus, and stapes. These ossicles conduct sound from the external auditory meatus to the inner ear. Therefore, factors hindering the movement of these ossicles, such as pus or fluid in the middle ear, will adversely affect hearing. The middle ear is connected to the nasopharynx by the eustachian tube. The eustachian tube allows for ventilation and clearance of fluid from the middle ear. The tympanic membrane (TM) or eardrum is normally slightly convex, clear, and mobile. When there is an ear infection, the middle ear becomes pus filled, with subsequent bulging of the TM with the color being yellow, opaque, or red, in addition to being immobile. (3)
Otitis media is common in infants and young children with the peak age being between 6 to 18 months of age. This is due not only to anatomical factors, but immunologic as well, since these children still lack many protective antibodies against viral and bacterial organisms. The incidence of OM decreases after the first year of life and then increases again when the child enters school. It becomes less common after 7 years of age. Factors that increase the risk for OM are attendance in day care, second hand cigarette smoke exposure, craniofacial abnormalities such as cleft palate, immunologic deficiencies, family history, race (Native Americans, Alaskan and Canadian Eskimos, and indigenous Australians), and a slight increase with pacifier use. However, the most important risk factor is age. A protective factor is breastfeeding, which may be due to immune factors (e.g., secretory IgA and IgG), non-immune factors (e.g., interferon, glycoproteins, lactadherin), and anti-inflammatory factors (e.g., antioxidants, TNF-alpha, lactoferrin). Also, babies are breast-fed while in a vertical or semi-reclining position, compared to some babies who may be bottle fed while in a horizontal position. The practice of bottle feeding in the supine position (i.e., bottle-propping) is thought to increase OM by reflux of fluids from the nasopharynx into the middle ear (4,5).
The diagnosis of otitis media is a challenging one for pediatricians because of difficulty obtaining an adequate examination of the tympanic membrane (TM). The presence of cerumen and uncooperative and frightened patients complicate this. A common symptom of OM is otalgia, but otorrhea and hearing loss can also occur. Infants may only manifest otalgia by fussiness in the presence of fever. Other less common symptoms of OM and its complications are vertigo, nystagmus (unidirectional, horizontal, jerk type), tinnitus, swelling in the posterior auricular area (associated with mastoiditis), facial paralysis (due to disease within the temporal bone), and purulent conjunctivitis (which is associated with non-typable Haemophilus influenzae) The best tool for the diagnosis of OM is the pneumatic otoscope. Inspection of the TM should include four characteristics: position, color, degree of translucency, and mobility. Also by visualizing the TM, one notices several landmarks such as the malleus which is divided into the short process, manubrium, and umbo; the long process of the incus; and the pars flaccida on the superior aspect and the pars tensa on the inferior aspect (6). It should be noted, although controversial, that a tympanic membrane may become red in a crying child. Other methods of diagnosing OM include tympanometry, tympanocentesis, and acoustic reflectometry (2). This chapter will focus on two types of otitis media, namely acute otitis media and otitis media with effusion.
Acute otitis media (AOM) typically presents as a sudden onset of otalgia, fever, and hearing loss, which are preceded by an upper respiratory tract infection lasting for several days. Fever occurs in about 30-50% of patients of AOM, and is usually less than 40 degrees C. Fever over 40 dgrees C suggests bacteremia or a different etiology of the fever (8). Pneumatic otoscopy reveals an opaque TM that is bulging with poor mobility. Erythema is a characteristic finding, but it may be absent. There may be perforation. Otitis media with effusion (OME), on the other hand, is asymptomatic in most children. Some may complain of hearing loss and less commonly tinnitus and vertigo. Older children may complain of a "plugged" feeling or "popping" in their ears, which is usually bilateral. The TM commonly appears opaque, but may be retracted or full. An air fluid level or bubbles may be seen. Mobility is also decreased. It is important to distinguish between the two diseases because the management of each is different; however, it is not easily done. Some key points would be that fever, irritability, definite redness and otalgia, and a bulging and opaque eardrum are associated with AOM, whereas absence of symptoms except for hearing loss, and a retracted eardrum are associated with OME. Both can present with middle ear effusion and decreased mobility of the TM (9).
If severe otalgia is present, then analgesia becomes a major therapeutic consideration. Minor pain can be treated with acetaminophen or ibuprofen in most instances. For more severe pain, topical anesthesia with benzocaine containing ear drops (e.g., Auralgan otic) can be administered in the office to see if satisfactory analgesia is achieved. If not, a stronger analgesic such as acetaminophen with hydrocodone may be necessary. Although benzocaine containing ear drops are used for pain relief, one should be aware of allergic reactions and to be certain that there is no perforation of the TM.
Due to the overprescribing of antibiotics and emergence of antibiotic-resistant strains of bacteria, the guideline for the management of otitis media has changed, in that observation without antibiotics is an option that is dependent on age, severity, and assurance of follow-up (2,10,11,17).
Children with AOM should be given antibiotics for the following conditions:
. . . . . Children 6 months and older with otorrhea with AOM.
. . . . . Children 6 months and older with severe signs or symptoms, regardless whether unilateral or bilateral.
. . . . . Children younger than 24 months with non-severe signs and symptoms, with BILATERAL AOM, and otorrhea.
Children with AOM can be either be prescribed antibiotics OR observed without antibiotics for 48 to 72 hours if the following criteria are met:
. . . . . Children 6 to 23 months with non-severe signs and symptoms, with UNILATERAL AOM, and no otorrhea.
. . . . . Children 24 months and older with non-severe signs and symptoms, regardless whether unilateral or bilateral, and no otorrhea.
If the decision is made not to administer antibiotics but to observe instead, then a “wait and see” approach can be used in which the caregiver is given a prescription for antibiotics, and to use it if the child is not better in 48 to 72 hours, or if the caregiver is not given a prescription for antibiotics, the caregiver can call or follow up with doctor if the child is not better in 48 to 72 hours to receive antibiotic treatment.
Severe illness is defined as moderate to severe otalgia, or otalgia for at least 48 hours, or fever greater than 39 degrees C (102.2 degrees F). Non-severe illness is defined a mild otalgia less than 48 hours, with fever less than 39 degrees C (102.2 degrees F) (2,9,10). For OME, antibiotics have not been shown to be efficacious in treatment of this problem unless it becomes chronic, at which time, a 10-14 day course of antibiotics may be considered (9). The three most common organisms are Streptococcus pneumoniae, non-typable Haemophilus influenzae, and Moraxella catarrhalis. Other less common organisms are Streptococcus pyogenes, Staphylococcus aureus, and anaerobes (7). AOM caused by gram negative enteric bacteria such as Escherichia coli can occur in young infants in the first few months of life (4). The choice of antibiotic is dependent on efficacy, palatability, side effects, convenience of dosing, drug allergies, resistance patterns in the community, and cost. The drug of choice against AOM remains amoxicillin, although bacterial resistance continues to be a problem. For this reason, it is recommended that the dose of amoxicillin be increased from 40-50 mg/kg/day to 80-90 mg/kg/day in two to three divided doses, up to a maximum of 3 grams per day (4,8). Amoxicillin should be given if the child did not receive amoxicillin in the past 30 days, does not have concurrent purulent conjunctivitis, and is not allergic to amoxicillin (or penicillins). If there is concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome), an antibiotic with more beta-lactamase coverage such as amoxicillin-clavulanate (Augmentin) should be used. For those with a penicillin allergy, it depends whether the reaction was immediate (e.g., hives or anaphylaxis) or delayed (e.g., rash). For those with an immediate reaction, choices are macrolide or lincosamide antibiotics such as azithromycin and clindamycin. However, one should keep in mind that resistance is common with these antibiotics to S. pneumoniae and they are not effective against H. influenzae (8). For delayed allergic reactions, choices are cefdinir (Omnicef), cefpodoxime, and cefuroxime. An alternative is one intramuscular dose of ceftriaxone at 50 mg/kg, although if there is no response, 2 to 3 doses can be given. There should be clinical improvement in 48-72 hours, but if not, treatment failure must be considered with treatment changed to second-line therapy (8,10). The AAP (American Academy of Pediatrics) guideline recommends amoxicillin-clavulanate (with the amoxicillin component of 80-90 mg/kg/day) or ceftriaxone (50 mg/kg) be used for 3 days as second line therapy. If there is failure with second-line therapy, then the third-line therapy is clindamycin (30-40 mg/kg/day in 3 divided doses) with a third-generation cephalosporin, or tympanocentesis with a culture taken. If the culture shows multi-drug resistant bacteria, a consultation with an infectious disease specialist should be obtained (10). The optimal duration of treatment is not known, but generally is 10 days, especially in children less than 2 years of age or any age with severe symptoms. However, shorter courses can be used for older children with mild to moderate symptoms. For those between 2 to 6 years of age, a 7 day course of oral antibiotics can be used, and those over 6 years of age, a 5 to 7 day course. An exception is intramuscular ceftriaxone which is given for 1 to 3 days (10).
A follow-up visit is recommended in two cases. The first case is if the child does not improve in 48-72 hours, which could suggest a treatment failure. The second case is when symptoms resolve, a reexamination should be done in 8-12 weeks for children younger than age 2 years and for children older than age 2 with language or learning problems, since that is when 80%-90% of middle ear effusion should be resolved (8). In children with acute otitis media with tympanostomy tubes or with chronic suppurative otitis media, quinolone otic drops such as ofloxacin or ciprofloxacin can be used for well-appearing children over age 2 years (8).
Not only do we treat otitis media for symptomatic relief, but also to prevent its complications. The complications of OM include conductive and sensorineural hearing loss, mastoiditis, cholesteatoma, labyrinthitis, facial paralysis, meningitis, brain abscess, and lateral sinus thrombosis (4). Fortunately, because we live in the antibiotic and vaccine era, these complications are rarely seen.
The prognosis for otitis media is excellent. In most children, otitis media resolves after antibiotic therapy. Only in a few children does medical therapy fail, and more aggressive measures are needed, such as myringotomy and tympanostomy tubes. Recently, a 13-valent pneumococcal conjugate vaccine (Prevnar-13) has been FDA approved and is a recommended childhood immunization by the AAP, AAFP (American Academy of Family Physicians), and CDC (Centers For Disease Control and Prevention). This vaccine has been shown to reduce otitis media caused by pneumococcus; however, its greatest efficacy is in those patients with recurrent OM.
There are times that children may need to be referred to an otolaryngologist to have placement of tympanostomy tubes (also called PE or pressure equalization tubes). Indications for this would be if a child is considered to have recurrent ear infections; which are defined as having 3 AOM infections in 6 months or 4 AOM infections in 1 year. This is especially important in young children as recurrent and chronic ear infections could affect hearing, which would then have an impact on speech development. Per the new 2013 guidelines, the need for tympanostomy tubes is an option, since there is a risk involved with surgery such as anesthesia with potential long-term complications such as focal atrophy, tympanosclerosis, retraction pockets, and chronic perforation. It should be noted that long-term, low-dose antibiotic prophylaxis is not recommended due to the possibility of antibiotic resistance and side effects of taking the medications, with the protection of long-term antibiotic use being modest (10).
After tympanostomy tube placement, one of the problems that can occur is otorrhea. One needs to determine if it is acute (less than 6-8 weeks) or chronic (over 6-8 weeks). The causes of acute otorrhea are due to either an acute otitis media or contaminated water entering into the middle ear. The organisms involved in AOM with PE tubes are the same as those without PE tubes, namely Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae for those less than 2 years of age. For otorrhea in older children who may have contaminated water entering the middle ear or those having AOM not improved with oral antibiotics, the organisms are the same as otitis externa, that being Pseudomonas aeruginosa and Staphylococcus aureus. Therefore, the choice of medication is dependent on the age of the child and whether there is systemic symptoms or cellulitis. For infants and children without systemic symptoms or cellulitis, topical treatment such as fluoroquinolones can be used. For children with systemic symptoms or severe ear symptoms such as copious ear discharge, ear pain, high-dose amoxicillin (80-90 mg/kg) or amoxicillin-clavulanate can be used. If oral antibiotics are not working after 5 days, antibiotic ear drops effective against Pseudomonas aeruginosa and Staphylococcus aureus should be given. Finally, if there is cellulitis, the child should be treated with both oral antibiotics against S. aureus and S. pneumoniae, and topical antibiotics with a culture of the discharge taken. Because acute otorrhea after PE tube placement can be caused by contaminated water entering the middle ear, ear plugs can be used to prevent this during water activities, although there is a lack of consensus among otolaryngologists regarding water precautions. Therefore, the parents need to discuss water precautions and the need for ear plugs with their specialist (11).
Chronic otorrhea after tympanostomy tube placement is usually due to inadequate treatment of an acute cause of otorrhea such as debris in ear canal. This can be remedied by suctioning the debris and using a steroid-antibiotic ear drop for 5-7 days. One of the problems with chronic use of antibiotic ear drops may be the emergence of unusual pathogens such as aspergillus, actinomyces, and Candida albicans. Also, granulation tissue and cholesteatoma could also cause chronic otorrhea. Therefore, any chronic otorrhea should be referred to an otolaryngologist (11).
One of the questions parents may have is how long tympanostomy tubes remain in the tympanic membrane. It depends on the type of tube placed. Short-term tubes last for 6-18 months and are the most commonly ones used. Long-term tubes last for over 15 months, and are used less frequently due to complications such as higher risk of otorrhea and persistent perforation of the ear drum. Tubes normally extrude out of the TM spontaneously and naturally come out of the ear canal with time; however, occasionally ear tubes can be retained and need to be removed surgically depending on the type of tube it is. For a short-term tube, the time to remove is 2-3 years, and a long-term tube is over 3 years. Failure to remove a tube at this time could increase the rate of a persistent TM perforation (12).
Otitis externa is another condition that is often seen in pediatrics. Four factors that can lead to the development of otitis externa are excessive wetness (e.g., swimming), dryness (e.g., lack of cerumen and dry ear skin), other skin diseases (e.g., dermatitis, previous infection), and trauma (e.g., using cotton tipped applicators). It is also called swimmer's ear, although it can occur without swimming (13). The pathophysiology of otitis externa is the following. As the humidity in the outer ear increases, the stratum corneum in the cartilaginous portion of the ear absorbs water, which results in edema. Edema blocks the pilosebaceous units in the ear, thereby decreasing the excretion of cerumen. A decrease in cerumen causes an increase in the pH of the external ear, in addition to decreasing its water repelling covering. The exposed skin becomes susceptible to maceration and the higher pH becomes a favorable environment for bacteria such as Pseudomonas. Bacteria can then penetrate through the dermis after superficial breakdown or through minor trauma such as with cotton applicators. Inflammation and infection result. The most common organisms cultured in otitis externa are Pseudomonas and Staphylococcus aureus. Other organisms that can be cultured are Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, streptococci, coagulase-negative staphylococci, diphtheroids, and fungi/yeast such as Aspergillus and Candida. Symptoms initially include pruritus and aural fullness, which then progresses to ear pain that may be severe and out of proportion to its appearance. Purulent otorrhea and hearing loss from edema of the canal may be present as well. Examination shows an inflamed and erythematous cartilaginous canal, with variable involvement of the bony canal. Manipulation of the pinna and pressure on the tragus elicits pain. Although the tympanic membrane is not affected, it and the medial portion of the canal can become involved and often look granular. When this happens, pneumatic otoscopy is needed to rule out concomitant otitis media. Tender and palpable lymph nodes may be present in the periauricular and preauricular areas. Treatment includes the use of ototopical antibiotic drops, those being fluoroquinolones (e.g., ofloxacin [Floxin Otic] and ciprofloxacin [Cipro HC Otic, Ciprodex Otic]), polymyxin B and neomycin combinations (e.g., Cortisporin Otic), and aminoglycosides (e.g., tobramycin and gentamicin) (14). Many otic drops also contain corticosteroids to reduce inflammation and edema. If there is a lot of fluid drainage, it may be preferable to wick out most of the fluid prior to instilling the drops. If there is severe edema preventing effective instillation of drops, a wick can be placed in the membranous canal with otic drops applied several times a day, the wick can be replaced every 48 to 72 hours until the edema resolves (15). After 2-3 days, the edema of the ear canal is usually markedly improved. Analgesics such as acetaminophen, ibuprofen and hydrocodone can be used to treat severe pain. Cleaning the ear canal such as irrigating with 2% acetic acid to remove debris can be a useful adjunct to therapy. Prevention may be necessary for those patients who suffer from recurrences. Dilute alcohol or acetic acid (2%) can be instilled immediately after swimming or bathing. A preparation of 50% white vinegar and 50% rubbing alcohol works well for this. Patients should protect their ears from water when bathing (by placing a cotton ball with petrolatum jelly into the ear canal) and should avoid swimming until their otitis externa resolves. Other preventative methods include wearing ear plugs, shaking the ears dry after swimming, and using a blow dryer (14).
1. What is the peak age of otitis media?
2. What are some risk factors for otitis media?
3. What is the BEST tool for diagnosing otitis media (not gold standard)?
4. What is the difference between acute otitis media and otitis media with effusion?
5. What are the three most common organisms that cause otitis media?
6. What antibiotic is the drug of choice against otitis media?
7. What are the two second-line antibiotics recommended by the AAP if amoxicillin fails and there is no amoxicillin allergy?
8. What antibiotics can be used to treat otitis media in a child who has had an immediate allergic reaction to amoxicillin in the past (for example, hives or anaphylaxis)?
9. What are some complications of otitis media?
10. What are the most common organisms cultured in otitis externa?
11. What are four factors that can predispose a patient to develop otitis externa?
12. What can be instilled in the ear to prevent otitis externa in an otitis externa prone child?
13. Per new AAP/AAFP/CDC guidelines, would antibiotics be started in the patients below?
. . . . . a. 8 month old boy with URI symptoms, and slightly fussy. Has a fever of 38 degrees C which is controlled with acetaminophen. Right TM shows a full, moderately red TM with poor mobility.
. . . . . b. 5 year old girl with URI symptoms and slight right ear pain that is controlled with acetaminophen. Has a fever of 38 degrees C. Right TM shows a full, moderately red TM with poor mobility.
. . . . . c. 18 month old healthy boy seen for well-baby checkup. No fever, but has a little rhinorrhea for few days. Both TM’s are flat, dull, with poor mobility. Does not say any words on developmental screening.
14. When should a child be considered to be referred to an otolaryngologist for possible PE tube placement?
1. Ambulatory Care Visits with a Diagnosis of Otitis Media. (n.d.)From National Institute on Deafness and Other Communication Disorders.Retrieved from http://www.nidcd.nih.gov/health/statistics/Pages/officevisits.aspx
2. Subcommittee on Management of Acute Otitis Media. Diagnosis and Management of Acute Otitis Media. Pediatrics 2004;113:1451-1465.
3. Wald ER. Acute otitis media in children: diagnosis. In: Up-to-Date. March 1, 2013, Amsterdam: Wolters Kluwer.
4. Klein JO, Pelton S. Acute Otitis Media in Children: Epidemiology, microbiology, clinical manifestations, and complications. In: Up-to-Date. April 25, 2013, Amsterdam: Wolters Kluwer.
5. Schanler RJ. Infant benefits of breastfeeding. In: Up-to-Date. July 11, 2013, Amsterdam: Wolters Kluwer.
6. Kerschner JE. Chapter 632-Otitis Media. In: Kliegman RM, et al. Nelson Textbook of Pediatrics, 19th edition. 2011, Philadelphia: W.B. Saunders Company, pp. e2199-2213 e1.
7. Haddad J. Chapter 628-General Considerations and Evaluation. In: Kliegman RM, et al. Nelson Textbook of Pediatrics, 19th edition. 2011, Philadelphia: W.B. Saunders Company, pp. e2188 e1.
8. Klein JO, Pelton S. Acute Otitis Media in Children: Treatment. In: Up-to-Date. November 29, 2012, Amsterdam: Wolters Kluwer.
9. Careful Antibiotic Use, Otitis media with effusion does not require antibiotic treatment, Acute otitis media does not always require antibiotic treatment. (n.d.) From Center from Disease Control and Prevention. Retrieved from http://www.cdc.gov/getsmart/campaign-materials/info-sheets/child-otitismedia.html
10. Liberthal AS, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics 2013;131(3):e964-e999.
11. Isaacson, GC. Prevention and management of tympanostomy tube otorrhea in children. In: Up-to-Date. February 19, 2013, Amsterdam: Wolters Kluwer.
12. Isaacson, GC. Overview of tympanostomy tube placement and medical care of children with tympanostomy tubes. In: Up-to-Date. May 9, 2012, Amsterdam: Wolters Kluwer.
13. Goguen LA. External otitis: Pathogenesis, clinical features, and diagnosis. In: Up-to-Date. August 19, 2013, Amsterdam: Wolters Kluwer.
14. Goguen LA. External otitis: Treatment. In: Up-to-Date. April 12, 2012, Amsterdam: Wolters Kluwer.
15. Kryzer TC, Lambert PR. Chapter 20-Diseases of the External Auditory Canal. In: Canalis RF, Lambert PR. The Ear. 2000, Philadelphia: Lippincott Williams & Wilkins, pp. 341-357.
Answers to questions
1. 6 to 18 months of age.
2. Age (6-18 months of age), attendance in day-care, second-hand cigarette smoke exposure, craniofacial abnormalities, bottle-feeding in the horizontal position, family history, race (Native Americans, Alaskan and Canadian Eskimos, and indigenous Australians), and a slight increase with pacifier use.
3. Pneumatic otoscopy (myringotomy/tympanocentesis is the gold standard, but not the best diagnostic tool because of its invasiveness).
4. AOM: otalgia, fever, hearing loss, associated with upper respiratory tract infection; TM that is opaque or erythematous and bulging with poor mobility, perforation. OME: commonly asymptomatic but may have hearing loss; retracted TM (but could be full).
5. Streptococcus pneumoniae, non-typable Haemophilus influenzae, Moraxella catarrhalis.
7. Amoxicillin-clavulanic acid, intramuscular ceftriaxone
8. Azithromycin and clindamycin. Clarithromycin, erythromycin-sulfisoxazole can also be used, but these two choices were not mentioned in the chapter. One should keep in mind that there can be resistance to these antibiotics for S. pneumoniae, and that these antibiotics will not be effective against H. influenzae.
9. Conductive and sensorineural hearing loss, mastoiditis, cholesteatoma, labyrinthitis, facial paralysis, meningitis, brain abscess, and lateral sinus thrombosis.
10. Pseudomonas aeruginosa and Staphylococcus aureus.
11. Excessive wetness, lack of cerumen, preexisting skin problems, and trauma.
12. 2% acetic acid or dilute alcohol (i.e. white vinegar and rubbing alcohol mixture).
13a. Yes. Patient is between 6 months to 2 years of age with a certain diagnosis. Antibiotics should be started regardless of disease severity.
13b. No. Patient is over 2 years of age with a certain diagnosis, but does not have severe illness. Pain is controlled with medications. If one chooses not to treat with antibiotics, follow up is needed if there is no improvement in 48-72 hours, at which time antibiotics should be started. If follow up is not ensured, patient should be started on antibiotics.
13c. Yes and no. Patient likely has OME and not AOM. Although antibiotics have not been demonstrated to be effective, a single course of antibiotics for 10-14 days may be used if tympanostomy tubes are required, especially if there is conductive hearing loss with speech delay. Due to developmental delay, patient should be referred to early intervention and a formal audiological evaluation should be done.
14. If the child has 3 AOM in previous 6 month period, or 4 AOM in previous 12 month period.