Otitis media is one of the most common ailments of childhood and is the most common complaint that brings a child to the health care provider.¹ Approximately 70% of children below the age of 3 will develop an episode of otitis media² and by the age of 7 years, 65 to 95% of children will experience one or more episodes of acute otitis media. Approximately $3.5 billion per year is spent on the management of otitis media in the United States.³ A large portion of this is spent on antimicrobial therapy. With such a significant impact on our health care system, it is not surprising that numerous controversies exist regarding the medical and surgical management of otitis media.

It is apparent from review of the literature regarding otitis media that a clear, descriptive classification system does not exist. Otitis media is a multifactorial disease process involving immunology, infectious disease, anatomic considerations, social and socioeconomic issues, and genetics, among other factors. Before physicians can attain a clear understanding of otitis media, a clear universally accepted classification system will need to be developed.

Although it is clear that serious bacterial infections should be treated with antibiotics, it is not clear that all otitis media is an infectious process necessitating treatment with antimicrobial therapy. In addition, evidence is emerging that the traditional 10-day treatment course for treatment for acute otitis media may not be necessary and that shorter treatment courses may be satisfactory. The role of antibiotic prophylaxis for recurrent acute otitis media has also come under criticism due to the emergence of resistant strains of Streptococcus pneumoniae, which may be related to the overutilization of antimicrobial therapy for children with upper respiratory tract infections.⁴

In addition to the controversy surrounding antimicrobial therapy for otitis media, numerous other medical therapeutic options have been described in the literature that also tend to complicate a clear understanding of the management of this disease process. Some of these treatment options include anti-histamine/decongestants, inhalation or systemic corticosteroids, desensitization for inhalation or food allergies, and alternative medicine treatment modalities. The role of vaccinations is gaining significant exposure in both the medical literature and lay press.

Surgical treatment options for otitis media are also not without controversy. The standard surgical treatment modality of myringotomy with placement of tympanostomy tubes has recently⁵ been called into question and the role of alternative surgical options (i.e., the role of adenoidectomy as well as laser myringotomy) has also been examined in recent years. An attempt will be made to address some of these controversial issues and to make recommendations regarding the appropriate treatment for otitis media.

Classification of Otitis Media

The terminology in the literature associated with otitis media is complex and quite variable. Most classification systems for otitis media attempt to describe the disease process on the basis of the duration of the process, the type of inflammatory fluid involved, the presence of tympanic membrane perforation, the presence of suppurative or nonsuppurative disease and other criteria.⁶ The confusion in the literature regarding classification impedes our ability to describe the disease process and thus complicates clinical research and our ability to communicate effectively about otitis media.⁷

For the purposes of this chapter, the following terminology is used:

1. 
   

   Acute otitis media: Suppurative or purulent middle ear process associated with purulent middle ear effusion with one or more of the following signs: otalgia, otorrhea, fever, and acute onset of irritability. Otoscopic findings demonstrate purulent middle ear effusion and a bulging tympanic membrane with loss of tympanic landmarks; possibly with the presence of an acute draining perforation.

   
   
2. 
   

   Recurrent acute otitis media: Repetitive bouts of acute otitis media, separated by asymptomatic periods and clearing of middle ear effusion.

   
   
3. 
   

   Chronic otitis media with effusion: The presence of middle ear effusion, regardless of symptomatology, that has been present for 90 days or longer. The fluid may be categorized into serous, purulent, or mucoid middle ear effusion.

Microbiology of Otitis Media

The microbiology of otitis media has been carefully elucidated by numerous studies.^8–12 However, with the increased use of antimicrobial agents, the emergence of resistant bacteria has become a significant problem related to otitis media. Data from studies performed by Bluestone and Klein⁹ demonstrate that Streptococcus pneumoniae remains the primary bacterial cause of otitis media, followed by Haemophilus (38%), Haemophilus influenzae (27%), and Moraxella caterrhalis (10%). In this same study, 28% demonstrated no bacteria or nonpathogenic bacteria. Approximately 30 to 40% of patients with acute otitis media demonstrate respiratory viruses that may be present in combination with bacterial pathogens.¹³ Respiratory syncytial virus has recently been implicated as a major viral pathogen in otitis media.¹⁴ In recent years, the incidence of resistant bacteria has increased in cases of otitis media. First noted was the advent of β-lactamase-producing Haemophilus influenzae and Moraxella caterrhalis. More recently, the incidence of penicillin-resistant pneumococci has increased.15 The resistance mechanism for each of these resistance types is quite different. Studies performed throughout the 1990_s have demonstrated increased incidence of resistance by both β-lactamase-producing bacteria and Streptococcus pneumonia.^15–20 The increased prevalence of bacterial resistance may alter the way we treat otitis media in children, with respect to both antimicrobial therapy and surgical intervention.

Treatment Options for Otitis Media

To understand fully when it is appropriate to treat otitis media in children, the pathophysiology of the various subtypes of otitis media should be understood and the appropriate diagnosis must be made. In addition, various treatment modalities for otitis media—both medical and surgical—may benefit a particular patient. The importance of individualization of treatment for every patient with otitis media must be emphasized. Otitis media is a multifactorial process. Different treatment modalities may be warranted in patients based on their particular social situation, immunologic status, age, associated medical problems, or other factors. Various treatment modalities for otitis media will be briefly discussed to help the practitioner decide which patient should be treated, and by what particular treatment strategy.

Medical Management Options for Otitis Media

ANTIBIOTICS

Antimicrobial therapy has continued to be a mainstay of therapy for patients with otitis media. Recently, there has been evidence that over usage of antimicrobial therapy has led to an increased incidence of bacterial resistance in common pathogens related to otitis media. Most notably, St. pneumoniae, H. influenzae, and M. caterrhalis.¹⁵ Children frequently presenting to primary physicians with viral upper respiratory tract infections may be treated with antimicrobials, whether or not the patient has simultaneously developed otitis media.⁴ We know from prior microbiologic studies^{13, 14} that a significant number of middle ear effusion cultures contain predominantly viruses that would not benefit from antimicrobial therapy. It is apparent from these prior studies that many children with otitis media may not benefit from antimicrobial agents, as the cause of otitis media in many cases is nonbacterial, or some cases of bacterial otitis media may resolve without pharmacologic therapy. Approximately 60% of cases of acute otitis media may resolve spontaneously; however, spontaneous resolution is less common in cases of S. pneumoniae , approximately 20%.^{21, 22} Although there are advocates of withholding antimicrobial therapy in cases of otitis media,¹⁷ this management strategy is not recommended because of the 20 to 40% incidence of persistent otitis, often caused by S. pneumoniae in nontreated cases. In addition, in cases of untreated otitis media, there is a risk of development of intratemporal or intracranial complications.

Currently, approximately 16 approved antimicrobials may be used for the treatment of otitis media.²³ The recommended first line antibiotic for treatment of otitis media continues to be amoxicillin.^{24, 25} In situations of treatment failures or drug allergy to amoxicillin, other antimicrobials should be considered. In cases where agents which have high activity against β-lactamase-producing H. influenzae and M. caterrhalis

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