HASH(0x21d84d80)

BACKGROUND Individual trials to test effectiveness of antibiotics in children with acute otitis media have been too small for valid subgroup analyses. We aimed to identify subgroups of children who would and would not benefit more than others from treatment with antibiotics. METHODS We did a meta-analysis of data from six randomised trials of the effects of antibiotics in children with acute otitis media. Individual patient data from 1643 children aged from 6 months to 12 years were validated and re-analysed. We defined the primary outcome as an extended course of acute otitis media, consisting of pain, fever, or both at 3-7 days. FINDINGS Significant effect modifications were noted for otorrhoea, and for age and bilateral acute otitis media. In children younger than 2 years of age with bilateral acute otitis media, 55% of controls and 30% on antibiotics still had pain, fever, or both at 3-7 days, with a rate difference between these groups of -25%(95% CI -36% to -14%), resulting in a number-needed-to-treat (NNT) of four children. We identified no significant differences for age alone. In children with otorrhoea the rate difference and NNT, respectively, were -36%(-53% to -19%) and three, whereas in children without otorrhoea the equivalent values were -14%(-23% to -5%) and eight. INTERPRETATION Antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea. For most other children with mild disease an observational policy seems justified.

A review of 800 pathological temporal bones collected from autopsy cases revealed 333 ((41.6%) to have some type of otitis media; purulent otitis media (52.5%), serous otitis media (6%), mucoid otitis media (4.5%), and chronic otitis media (36.9%). The 123 temporal bones with chronic otitis media were further studied and found to have granulation tissue, cholesteatoma, cholesterin granuloma, bone changes, and fibrosis. Other findings included tympanic membrane perforation, tympanosclerosis, metaplasia of the epithelium with subepithelial glandular formation, suppuration, labyrinthitis, and evidence of complications of chronic otitis media (meningitis, subdural abscess, brain abscess, petrositis, and endolymphatic hydrops). From this study it was concluded: 1) chronic otitis media occurred quite frequently, from a histological standpoint, in the absence of tympanic membrane perforation; 2) granulation tissue in temporal bones was found much more frequently in chronic otitis media than was cholesteatoma; and 3) complications and sequelae of otitis media tended to occur more commonly secondary to granulation tissue than to cholesteatoma.

BACKGROUND Middle ear disease (otitis media) is common and frequently severe in Australian Aboriginal children. There have not been any recent large-scale surveys using clear definitions and a standardised middle ear assessment. The aim of the study was to determine the prevalence of middle ear disease (otitis media) in a high-risk population of young Aboriginal children from remote communities in Northern and Central Australia. METHODS 709 Aboriginal children aged 6-30 months living in 29 communities from 4 health regions participated in the study between May and November 2001. Otitis media (OM) and perforation of the tympanic membrane (TM) were diagnosed by tympanometry, pneumatic otoscopy, and video-otoscopy. We used otoscopic criteria (bulging TM or recent perforation) to diagnose acute otitis media. RESULTS 914 children were eligible to participate in the study and 709 were assessed (78%). Otitis media affected nearly all children (91%, 95%CI 88, 94). Overall prevalence estimates adjusted for clustering by community were: 10%(95%CI 8, 12) for unilateral otitis media with effusion (OME); 31%(95%CI 27, 34) for bilateral OME; 26%(95%CI 23, 30) for acute otitis media without perforation (AOM/woP); 7%(95%CI 4, 9) for AOM with perforation (AOM/wiP); 2%(95%CI 1, 3) for dry perforation; and 15%(95%CI 11, 19) for chronic suppurative otitis media (CSOM). The perforation prevalence ranged from 0-60% between communities and from 19-33% between regions. Perforations of the tympanic membrane affected 40% of children in their first 18 months of life. These were not always persistent. CONCLUSION Overall, 1 in every 2 children examined had otoscopic signs consistent with suppurative ear disease and 1 in 4 children had a perforated tympanic membrane. Some of the children with intact tympanic membranes had experienced a perforation that healed before the survey. In this high-risk population, high rates of tympanic perforation were associated with high rates of bulging of the tympanic membrane.

More than 20 years ago, a shrewd clinician remarked,"There is little evidence that those antimicrobial agents which hypothetically or in vitro are more effective ... are superior in the treatment of otitis when compared to penicillin alone." Several hundred clinical trials later, the advantages of broad spectrum drugs remain unproved, and questions remains as to whether antibiotics are required for most episodes of AOM. Further, antibiotics have been demoted to the status of optional therapy for OME. This situation is unlikely to change as new studies with new antibiotics proliferate. What is clear, however, is that accelerated patterns of bacterial resistance mandate an evidence-based approach to managing otitis media. Bacteria have an uncanny ability to learn new mechanisms of antibiotic resistance. A large part of bacterial "education" has undoubtedly been fueled by antibiotic prescriptions from well-intentioned physicians, with unrealistic expectations of drug efficacy. A judicious approach to antibiotic treatment of otitis media can result only from knowing the spontaneous course of the disorder and incremental effect of antibiotics on clinical outcomes. In this article, a series of unifying concepts are developed to help practicing clinicians with an evidence-based approach to managing otitis media. Critical review of the published evidence suggests that the most favorable outcomes from medical treatment will occur if practitioners: appreciate the favorable natural history of untreated otitis media realize that OME may take months to resolve following a single AOM episode modify risk factors to improve the odds of spontaneous resolution use pneumatic otoscopy and confirmatory tympanometry to diagnose OME recognize the limited impact of antibiotic therapy on treatment and prevention balance the benefits of antibiotics against the risk of accelerated bacterial resistance avoid repetitive, prolonged, or prophylactic antibiotic treatment of chronic OME avoid ineffective therapy, such as antihistamine/decongestant preparations An important aspect of management is helping caregivers understand the natural history of otitis media and the impact of medical treatment on shortterm and long-term outcomes. Realistic expectations on the part of all involved parties should facilitate rational decisions about watchful waiting, medical therapy, and the need for surgical intervention.

Bacterial pathogens are isolated from middle ear fluid in up to 90% of children with acute otitis media (OM). Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis predominate. Acute OM can be classified as uncomplicated, persistent, recurrent or chronic. Patient age, symptom severity, prior treatment history and exposure through day-care attendance in children influences pathogen distribution, antimicrobial susceptibility and anticipated clinical and microbiological responses to empirical and pathogen-directed therapies. The natural history of acute OM without intervention is favourable. However, meta-analysis of clinical trials shows an improvement in symptom and middle ear effusion resolution with antimicrobials. Aminopenicillins, cephalosporins and macrolides are often selected as therapy for acute OM. The various agents have differing activity against acute OM pathogens, particularly organisms with resistance mechanisms and they differ in dosing schedule, side effects and compliance enhancing factors. Consideration should be given to pharmacokinetic and pharmacodynamic principles in antibiotic selection. Selection criteria include antibiotic activity against drug-resistant S. pneumoniae and efficacy against beta-lactamase-producing Gram-negative organisms. The necessary duration of treatment for acute OM varies according to multiple factors, including local preferences, but there is growing, compelling data to support short-course therapy. Tympanocentesis has been endorsed in various guidelines as a diagnostic and therapeutic procedure. Best-practice for management of acute OM continues to advocate antibiotic therapy with careful, accurate diagnosis and consideration of the major pathogens and their mechanisms of resistance.

OBJECTIVE To assess the time needed to perform tympanometry, the success rate and the importance of the child's cooperation for the accuracy of minitympanometry in detecting middle ear fluid, and the relation between the static admittance of the tympanogram and the weight of the middle ear fluid. STUDY DESIGN Two series of patients were enrolled. The first consisted of 206 consecutive children (mean age 4.7 years, range 1 month to 16 years) from the Outpatient Emergency Department of Pediatrics in the University of Oulu; the second group consisted of 162 children (age range 7 months to 8 years) who were referred to the Department of Otolaryngology for adenoidectomy, tympanostomy, or both procedures. In the first series the success rate and the time needed to complete a minitympanometric examination on each ear were recorded. In the second series, the tympanograms were evaluated according to the cooperation of the children at the time of the tympanometric examination, and the weight of the middle ear fluid was measured and compared with the static admittance of the minitympanometric curve. Sensitivity and specificity values were calculated separately for cooperative and uncooperative patients. RESULTS In the first series, the mean time needed for tympanometry was 2.1 minutes (range 0.5 to 10 minutes), and 179 (86.9%) of the patients were cooperative. In the second series, the sensitivity and specificity calculated for tympanometry in detecting middle ear fluid were 79% and 93% among the cooperative children. In the uncooperative group, sensitivity and specificity were 71% and 38%, respectively. The weight of the middle ear fluid varied from 5 mg to 695 mg. There was a significant negative correlation (r =-0.66, p < 0.001) between the static admittance in minitympanometry and the weight of the middle ear fluid. CONCLUSION Minitympanometry can be done quickly, it fails rarely, and in cooperative patients it is a better tool than has been earlier suggested, but it is useless in uncooperative children. The amount of middle ear fluid varies notably even among young children.

The anamnestic and clinical data on all of the 2254 attacks of acute otitis media (AOM) registered among 14200 children (less than 16 years) at risk during a one-year period were analysed. On the basis of otoscopic findings AOM was classified into three grades: 25.0% of the cases were considered mild, 39.0% moderate and 36.0% severe. Spontaneous perforation was found in 4.6% of the cases. 76.2% of the attacks were preceded by a respiratory infection, but only 1.4% were sequelae of some epidemic childhood disease. Earache was present in 73.5% of the attacks; in 81.0% of these it had lasted less than 24 hours. 39.4% of all the attacks were bilateral; during the first 2 years of life the proportion was 53.7%, decreasing thereafter with increasing age, and being only 18.7% among those 10-15 years old. In unilateral attacks the right ear was affected slightly, but not significantly, more often.