The diagnosis and managementof acute otitis media:American Academy of PediatricsGuidelines 2013

Joe Grainger, Somiah Siddiq

Department of ENT, BirminghamChildrens Hospital NHSFoundation Trust, Birmingham,UK

Correspondence toSomiah Siddiq, Department ofENT, Birmingham ChildrensHospital NHS Foundation Trust,Steelhouse Lane, Birmingham B46NH, UK;somiah.siddiq@nhs.net

Received 2 December 2013Revised 23 September 2014Accepted 1 October 2014

To cite: Grainger J, Siddiq S.Arch Dis Child Educ Pract EdPublished Online First: [pleaseinclude Day Month Year]doi:10.1136/archdischild-2013-305550

INFORMATION ABOUT THE CURRENTGUIDELINEIn February 2013, the American Academyof Pediatrics (AAP) published a revisedclinical guideline on The Diagnosis andManagement of Acute Otitis Media in chil-dren aged 6 months to 12 years.1 Thisguideline review summarises this guidanceand compares it with UK guidance onacute otitis media (AOM).The AAP guidance is specific to

uncomplicated AOM (see box 2) in anotherwise healthy child. The guidancedoes not apply to children with under-lying conditions that may alter thenatural course of AOM, for example, thepresence of grommets, cleft palate,immune deficiencies and craniofacialabnormalities.The revised 35-page AAP guidance cul-

minates into 17 action statements and, ofparticular note, clearer diagnostic guide-lines and definitions for AOM and guid-ance on the management of recurrentAOM. Furthermore, there have beensome changes in guidance in the use ofantibiotics. It was previously recom-mended that all children between6 months and 2 years of age with acertain diagnosis received antibiotics.Now the guidance offers a choice ofeither antibiotic therapy or initial obser-vation for children with unilateral AOMand mild symptoms. The intended audi-ence for the guideline includes primarycare clinicians, paediatricians and familyphysicians, emergency department physi-cians, otolaryngologists, physician assis-tants and nurse practitioners.

UK GUIDELINESThe National Institute of Health andCare Excellence (NICE) as part of its

Clinical Knowledge Summaries (CKS)service to primary care practitioners inthe UK has published an AOM CKS2 3

(see box 1). Of note, the AAP guidelinesare specific to uncomplicated AOM (seebox 2). However, NICE CKS does notmake this distinction—all children withAOM are considered, as is their manage-ment (see figure 1). This includes poten-tial admission in children <3 months ofage, and when to refer for specialistassessment in cases of associated fever(see box 3).The Scottish Intercollegiate Guidance

Network (SIGN) published national guid-ance entitled ‘Diagnosis and managementof childhood otitis media in primarycare’ in 20034 (see box 1). Both, NICEand SIGN guidance recommend that chil-dren diagnosed with AOM should notroutinely be prescribed antibiotics asinitial treatment with emphasis on appro-priate analgesia.

DIAGNOSIS OF AOM▸ Accurate diagnosis of AOM is essential for

appropriate management and high qualityresearch.

▸ The most useful examination finding is theposition of the tympanic membrane (TM)to distinguish AOM from glue ear/otitismedia with effusion (OME) (see figure 2).

▸ Children have AOM if they present with amoderate to severe bulging of the TM ornew onset ottorhoea not due to acuteotitis externa. Evidence quality: GradeB. Strength: Recommendation.

▸ Children may have AOM if they presentwith mild bulging of the TM and <48 honset of ear pain (tugging, holding orrubbing the ear in a non-verbal child) orintense erythema of TM. Evidence quality:Grade C. Strength: Recommendation.

GUIDELINE REVIEW

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▸ A diagnosis of AOM cannot be made in the absence of amiddle ear effusion based upon pneumatic otoscopy and/or tympanometry (see box 2). Evidence Quality: GradeB. Strength: Recommendation.

ANALGESIA▸ An assessment of pain should be made in all patients

with AOM and appropriate analgesia recommendedregardless of antibiotic use. Evidence quality: GradeB. Strength: Strong recommendation.

▸ Antibiotic therapy alone does not provide symptomaticrelief in the first 24 h.

▸ The mainstay of analgesia in AOM is ibuprofen and/orparacetamol.

ANTIBIOTICS▸ Antibiotics should be prescribed in AOM (bilateral or

unilateral) in children 6 months and older with severeAOM. Evidence quality: Grade B. Strength: Strongrecommendation.

▸ Antibiotics should be prescribed in non-severe bilateralAOM in children aged 6 to 23 months. Evidence quality:Grade B. Strength: Recommendation.

▸ Antibiotic therapy or close observation may be consid-ered in non-severe unilateral AOM in younger children(6–23 months), and in bilateral or unilateral non-severeAOM in older children (over 24 months). Appropriatearrangements should be in place to start antibiotics ifthere is no improvement, or the child worsens within48–72 h following onset of symptoms. Evidence quality:Grade B. Strength: Recommendation.

▸ First-line antibiotic choice remains high-dose amoxicillin.Evidence quality: Grade B. Strength: Recommendation.NICE guidance suggests a dose of 40 mg/kg per day in 3divided doses compared with the higher doses recom-mended in the AAP guidance with the rise of penicillin-resistant Streptococcus pneumoniae (see Table 5 in fullguidance1). NICE guidance suggests either erythromycinor clarithromycin in penicillin allergy.

▸ Additional β lactamase cover may be required in concur-rent conjunctivitis, history of recurrent AOM or recenttreatment with amoxicillin in the last month. Evidencequality: Grade C. Strength: Recommendation.

▸ Consider changing antibiotics if persistent, severe symp-toms and signs beyond 48–72 h of initial antibacterialtherapy. Evidence quality: Grade B. Strength:Recommendation.

▸ In failure of initial therapy, amoxicillin–clavulanate isrecommended, or a second-generation or third-generation cephalosporin in penicillin allergy.

▸ The optimal duration of treatment is unclear with rec-ommendation for 10 days in children under 2 years ofage or with severe symptoms and a 5-day to 7-daycourse in children above 2 years of age with mild tomoderate symptoms. NICE guidance suggests a durationof 5 days initially, increased in duration if symptoms aresevere.

RECURRENT AOM▸ Current guidance does not recommend long-term

prophylactic antibiotics as only modest benefits areachieved while on treatment with no longer-lastingbenefit after cessation of antibiotics. Evidence quality:Grade B. Strength: Recommendation.

▸ The small reduction in frequency of AOM episodeswhile on long-term antibiotics must be balanced againstthe increased risk of adverse effects from antibiotics, costand bacterial resistance.

▸ Controversy still exists around the use of grommets forAOM due to limited data, but grommet insertion hasbeen shown to improve disease-specific quality-of-lifemeasures in children, such as hearing loss, speech impair-ment, emotional distress and activity limitations.Evidence quality: Grade B. Strength: Option.

PREVENTION OF AOM▸ The guidance recommends pneumococcal conjugate

vaccine (Evidence quality: Grade B. Strength: Strong

Box 1 Resources

Link to full AAP Guidance: The Diagnosis andManagement of Acute Otitis Mediahttp://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3448

Link to NICE, AOM, Clinical Knowledge Summaryhttp://cks.nice.org.uk/otitis-media-acute#!topicsummary

Link to SIGN guidelineshttp://www.sign.ac.uk/pdf/sign66.pdf

NICE, National Institute of Health and Care Excellence;AAP, American Academy of Paediatrics; AMO, acuteotitis media; SIGN, Scottish Intercollegiate GuidelinesNetwork.

Box 2 Definition of terms1

▸ Uncomplicated AOM: AOM without ottorhoea.▸ Severe AOM: AOM with moderate to severe otalgia, or

fever ≥39°C.▸ Non-severe AOM: AOM with mild otalgia and a tem-

perature below 39°C.▸ Recurrent AOM: Three or more documented episodes

in the preceding 6 months, or 4 or more episodes inthe preceding 12 months, with at least 1 episode inthe past 6 months.

▸ Tympanometry: Measuring transfer of acoustic energyof the ear as a function of ear canal air pressure.

▸ Pneumatic otoscopy: Standard tool used in diagnosingotitis media by applying negative and positive pres-sure to assess mobility of the eardrum.

AOM, acute otitis media.

Guideline review

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recommendation) and annual influenza vaccine to allchildren (Evidence quality: Grade B. Strength:Recommendation).

▸ Breast feeding should be encouraged for a minimum of6 months, but ideally should continue for the first year.

▸ Continue to encourage avoidance of tobacco smokeexposure.

UNDERLYING EVIDENCE BASE/METHODOLOGYThe AAP guidance literature review involved searchesfrom 1998 through June 2010 of PubMed, CochraneDatabase of Systematic Reviews, Cochrane CentralRegister of Controlled Trials and Education ResourcesInformation Centre. Seventy-two articles were

included, which were quality rated against establishedcriteria ( Jadad, QUADAS and GRADE). Decisionswere made on the basis of systematic grading of thequality of evidence and strength of recommendationsas well as expert consensus when definitive data wasnot available (see figure 1 and Table 1 in full guid-ance1 for definitions of evidence quality and recom-mendation outcome and evidence-based statements).

WHAT DO I NEED TO KNOW?What should I stop doing?▸ Routine use of antibiotics is not warranted in non-severe

AOM.

Figure 1 Comparison of NICE, CKS and AAP guidelines (for details regarding dosing and duration of antibiotics refer to originalguidelines in box 1). NICE, National Institute of Health and Care Excellence; CKS, Clinical Knowledge Summaries; AAP, AmericanAcademy of Paediatrics; AMO, acute otitis media.

Guideline review

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What should I start doing?▸ Review young children with non-severe AOM at 48–

72 h, as some may require the initiation of antibiotics ifsymptoms do not resolve, or worsen.

▸ Ensure adequate assessment and management of pain,particularly in children under 2 years of age.

▸ Familiarise yourself with the new immunisation schedulein England, particularly changes to flu vaccination inter-vals in children.5

What can I continue to do as before?▸ Amoxicillin should be considered the first-line antibiotic

in the absence of penicillin allergy.▸ Refer children with recurrent AOM for further otolaryn-

gology assessment.▸ Encourage breast feeding during the first year and offer

smoking cessation advice and support.

What should I do differently?▸ Assess more closely the extent of the bulging of the TM

to accurately diagnose AOM.

UNRESOLVED CONTROVERSIESA gold standard for the diagnosis of AOM is a chal-lenging goal, in part, because OME often precedesand follows AOM. Also, in children where waxobscures the TM and removal is not possible, theremay be further diagnostic uncertainty. Pneumotoscopyis not widely used or taught in UK clinical practice,

and tympanometry is not always available.Furthermore, attempting such techniques in a dis-tressed infant is challenging and may give false results.The development of cost effective, easy-to-use videopneumatic otoscopes may help this issue and is dis-cussed within the guideline.Both, training and the use of a high-quality, well-

illuminated otoscope is crucial to obtain an accuratediagnosis of AOM, particularly in observing the lossof normal landmarks and in identifying the character-istic bagel or doughnut-shaped appearance4 (seefigure 2).The effectiveness of more recently licensed

pneumococcal (PCV13) and influenza vaccines onAOM remains to be ascertained.5 Of interest is theseries of changes to England’s national immunisationprogramme6 to be introduced over the course of2013/2014, including annual flu vaccination for allchildren aged 2–16 years, and the impact this mayhave on the incidence of AOM.The revised guidelines do not address management

of AOM in children under 6 months of age and neo-nates7 which is further compounded by limited clin-ical evidence and potentially outdated practice. NICEguidance provides limited extrapolated advice in chil-dren under 6 months of age.2

Clinical bottom line

▸ The AAP guidance provides the most recent evidence-based guidelines in the management of acute otitismedia. It is intended to provide a framework for themanagement of children with AOM but must betaken in context with previous national guidance inthe UK.

▸ Greater clarity is provided on the physical diagnosticcriteria for AOM on otoscopy, in particular, the pos-ition of the normal versus the bulging tympanicmembrane. The three-criteria approach for the diag-nosis of AOM: position, opacification and discolour-ation, has been previously suggested as a simple andrapid approach when examining the tympanic mem-branes of young children.8

Box 3 Referral for admission NICE CKS2

Admit for immediate specialist assessment:▸ Children younger than 3 months with a temperature

of 38°C or more.▸ Children 3–6 months of age, with a temperature of

39°C or more.Consider admitting:▸ Children younger than 3 months of age with sus-

pected AOM.AOM, acute otitis media; CKS, clinical knowledge sum-maries; NICE, National Institute of Health and CareExcellence.

Figure 2 (A) Normal tympanic membrane (TM). (B) TM with mild bulging. (C) TM with moderate bulging. (D) TM with severebulging. Courtesy of Alejandro Hoberman MD.

Guideline review

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Competing interests None.

Provenance and peer review Commissioned; externally peerreviewed.

REFERENCES1 Lieberthal AS, Chonmaitree T, Ganiats TG, et al. The diagnosis

and management of acute otitis media. Pediatrics 2013;131:e964–99.

2 NICE Clinical Knowledge Summaries (CKS)—Otitis media—Acute. http://cks.nice.org.uk/otitis-media-acute#!topicsummary

3 NICE. Respiratory tract infections: antibiotic prescribing.Prescribing of antibiotics for self-limiting respiratory tractinfections in adults and children in primary care (NICE

guideline). Clinical guideline 69. National Institute for Healthand Clinical Excellence. 2008a. http://www.nice.org.uk

4 SIGN. Diagnosis and management of childhood otitis media inprimary care. A national clinical guidance. February 2013.

5 Principi N, Baggi E, Esposito S. Prevention of acute otitismedia using currently available vaccines. Future Microbiol2012;7:457–65.

6 Department of Health. Gateway reference 00157. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/207008/130613_Flu_Letter_v_29_Gateway_GW_signed.pdf

7 San LB. Management of acute otitis media in afebrile neonates.Pediatr Ann 2012;41:225–8.

8 Block SL. Improving the diagnosis of acute otitis media:“Seeing is believing”. Pediatr Ann 2013;42:485–90.

American Academy of Otolaryngology: head and neck surgeryfoundation clinical practice guideline on acute otitis externa 2014

This American guideline updates previous 2006recommendations providing guidance for primarycare and specialist clinicians for treating children of2 years and older with acute otitis externa (AOE): adiffuse inflammation of the external ear canal±pinna and tympanic membrane.1 2

KEY POINTS: WHAT SHOULD I BE DOING?▸ Distinguish diffuse AOE from other causes of otalgia

and otorrhoea, for example, dermatitis (inflammatory,contact, allergic), viral infections, furunculosis andreferred pain from other sites

▸ Appropriately assess pain and treat with analgesia suchas non-steroidal anti-inflammatories. There are no spe-cific indications for using anaesthetic ear drops, whichmay mask disease progression

▸ Prescribe topical ear drops for uncomplicated AOE forat least 7 days. Topical preparations include antibiotics(aminoglycosides, polymyxin B, quinolones), steroids(hydrocortisone, dexamethasone) and low-pH antisep-tics, for example, acetic acid. There is no good evi-dence to recommend one topical ear drop fromanother or monotherapy versus combination treatment

▸ If there is perforation of the tympanic membrane (iat-rogenic or disease related), prescribe non-ototoxic eardrops

▸ Provide education to patients and families to helpdelivery of drops and maximise adherence

▸ Do not prescribe systemic antibiotics as initial therapy,although these may be needed in patients with

underlying disease, for example, diabetes, HIV andother immunosuppression, where there is a risk ofnecrotising otitis externa

▸ Reassess after 48–72 h if there is no response to initialtreatment.

Philippa Prentice

Correspondence toDr Philippa Prentice, Department of Paediatrics, University of Cambridge,Box 116, Level 8, Addenbrookes Hospital, Hills Road, Cambridge CB20QQ, UK; pmp24@medschl.cam.ac.uk

Competing interests None.

Provenance and peer review Not commissioned; internallypeer reviewed.

To cite Prentice P. Arch Dis Child Educ Pract Ed Published Online First:[please include Day Month Year] doi:10.1136/archdischild-2014-307676

Received 7 October 2014Accepted 8 October 2014

REFERENCES1 Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical

practice guideline: acute otitis externa executive summary.Otolaryngol Head Neck Surg 2014;150:161–8.

2 Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinicalpractice guideline: acute otitis externa. Otolaryngol HeadNeck Surg 2014;150(1 Suppl):S1–24.

Guideline review

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Guidelines 2013Pediatricsotitis media: American Academy of

The diagnosis and management of acute

Joe Grainger and Somiah Siddiq

published online November 12, 2014Arch Dis Child Educ Pract Ed 

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