Development of a practical tool for assessing the severity of acute otitis media

The Development, Implementation, and Evaluation of an Acute Otitis Media Education Website

OBJECTIVE

To develop, implement, and evaluate an acute otitis media (AOM) education website for clinician-educators.

METHODS

We developed an education website following Kern's curriculum model.

RESULTS

The website contained peer-reviewed content, educational objectives, library search pages to identify evidence-based resources, and a faculty toolbox with instructional and evaluation instruments. Pediatric clinician-educators were purposefully sampled from different clinic sites to evaluate the website. Semistructured interviews explored key website components for content and usability in clinical teaching. In grounded theory tradition, investigators used the constant comparative method with qualitative analysis software to identify themes and representative quotations. Eleven faculty members (9 females and 2 males with teaching experience from 6 to 26 years) participated in the study. Identified themes were: 1) value of visual impact for learning specific topics, 2) promotion of efficiency in teaching clinical topics, 3) varying approaches for using website, and 4) faculty's self-report of knowledge and self-efficacy needs.

CONCLUSIONS

An education website may enhance the teaching of AOM, accommodate different teaching preferences, promote efficiency in teaching, and advance clinician-educator knowledge and skills. Next steps include evaluation of learners' perspectives, generalizability in varied teaching settings, and assessment of higher learning outcomes including impact on knowledge, skills, and patient outcomes.

Clinical practice guidelines for the diagnosis and management of acute otitis media in children-2018 update

OBJECTIVE

"Clinical Practice Guidelines for the Diagnosis and Management of Acute Otitis Media in Children-2018 update (2018 Guidelines)" aim to provide appropriate recommendations about the diagnosis and management of children with acute otitis media (AOM), including recurrent acute otitis media (recurrent AOM), in children under 15 years of age. These evidence-based recommendations were created with the consensus of the subcommittee members, taking into consideration unique characteristics of bacteriology and antimicrobial susceptibilities of AOM pathogens in Japan, as well as global advances in vaccines.

METHODS

The subcommittee re-evaluated key clinical issues based on SCOPE (a master plan of the guidelines) and created clinical questions (CQ) about the diagnosis and management of AOM patients. A literature search of the publications from 2013 to 2016 were added to the Guidelines 2013, not only to assess the evidence on the effectiveness of vaccines, but also to provide up to date information of the bacteriology and antimicrobial susceptibilities of AOM causative pathogens in Japan.

RESULTS

We have proposed guidelines for disease severity-based management of AOM patients, after classifying AOM severity into mild, moderate, and severe, based on age, clinical manifestations, and otoscopic findings.

CONCLUSIONS

Precise otoscopic findings are essential for judging AOM severity, which can lead to appropriate management of AOM patients.

Current management and referral patterns of pediatricians for acute otitis media

OBJECTIVE

The American Academy of Pediatrics (AAP) has published an evidence-based clinical practice guideline for the management of acute otitis media (AOM), most recently revised in 2013. This study aims to assess current practice patterns and how they compare to the published guideline.

METHODS

An 11 question survey addressing topics included in the 2013 AAP AOM guidelines was mailed to 196 practicing pediatricians. Statistical analysis was performed using Chi-square and ANOVA testing.

RESULTS

76 (38%) completed surveys were returned. 75% of respondents were in group practice (non-academic) and 83% were in practice 11 years or more. 93% were members of the AAP. 46% of responding pediatricians use pneumatic otoscopy and/or tympanometry at least once a day to aid in the diagnosis of AOM, while 28% never do. 15% of respondents would choose close observation over antibiotics in a child under the age of 2 years with unilateral non-severe AOM while 50% would choose close observation in a child over age 2. 75% would make a referral to Otolaryngology for recurrent AOM. No significant differences were noted in responses based on practice type, years in practice, or Otolaryngology experience during residency training.

CONCLUSIONS

Current pediatrician practice and referral patterns for AOM are not consistent with 2013 Guidelines from the AAP. As consulting surgeons, Otolaryngologists should have knowledge of management protocols in related specialties that can have an impact on their practice.

Grommets (ventilation tubes) for recurrent acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is one of the most common childhood illnesses. While many children experience sporadic AOM episodes, an important group suffer from recurrent AOM (rAOM), defined as three or more episodes in six months, or four or more in one year. In this subset of children AOM poses a true burden through frequent episodes of ear pain, general illness, sleepless nights and time lost from nursery or school. Grommets, also called ventilation or tympanostomy tubes, can be offered for rAOM.

OBJECTIVES

To assess the benefits and harms of bilateral grommet insertion with or without concurrent adenoidectomy in children with rAOM.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; CENTRAL; MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 4 December 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing bilateral grommet insertion with or without concurrent adenoidectomy and no ear surgery in children up to age 16 years with rAOM. We planned to apply two main scenarios: grommets as a single surgical intervention and grommets as concurrent treatment with adenoidectomy (i.e. children in both the intervention and comparator groups underwent adenoidectomy). The comparators included active monitoring, antibiotic prophylaxis and placebo medication.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Primary outcomes were: proportion of children who have no AOM recurrences at three to six months follow-up (intermediate-term) and persistent tympanic membrane perforation (significant adverse event). Secondary outcomes were: proportion of children who have no AOM recurrences at six to 12 months follow-up (long-term); total number of AOM recurrences, disease-specific and generic health-related quality of life, presence of middle ear effusion and other adverse events at short-term, intermediate-term and long-term follow-up. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

Five RCTs (805 children) with unclear or high risk of bias were included. All studies were conducted prior to the introduction of pneumococcal vaccination in the countries' national immunisation programmes. In none of the trials was adenoidectomy performed concurrently in both groups.Grommets versus active monitoringGrommets were more effective than active monitoring in terms of:- proportion of children who had no AOM recurrence at six months (one study, 95 children, 46% versus 5%; risk ratio (RR) 9.49, 95% confidence interval (CI) 2.38 to 37.80, number needed to treat to benefit (NNTB) 3; low-quality evidence);- proportion of children who had no AOM recurrence at 12 months (one study, 200 children, 48% versus 34%; RR 1.41, 95% CI 1.00 to 1.99, NNTB 8; low-quality evidence);- number of AOM recurrences at six months (one study, 95 children, mean number of AOM recurrences per child: 0.67 versus 2.17, mean difference (MD) -1.50, 95% CI -1.99 to -1.01; low-quality evidence);- number of AOM recurrences at 12 months (one study, 200 children, one-year AOM incidence rate: 1.15 versus 1.70, incidence rate difference -0.55, 95% -0.17 to -0.93; low-quality evidence).Children receiving grommets did not have better disease-specific health-related quality of life (Otitis Media-6 questionnaire) at four (one study, 85 children) or 12 months (one study, 81 children) than those managed by active monitoring (low-quality evidence).One study reported no persistent tympanic membrane perforations among 54 children receiving grommets (low-quality evidence).Grommets versus antibiotic prophylaxisIt is uncertain whether or not grommets are more effective than antibiotic prophylaxis in terms of:- proportion of children who had no AOM recurrence at six months (two studies, 96 children, 60% versus 35%; RR 1.68, 95% CI 1.07 to 2.65, I2 = 0%, fixed-effect model, NNTB 5; very low-quality evidence);- number of AOM recurrences at six months (one study, 43 children, mean number of AOM recurrences per child: 0.86 versus 1.38, MD -0.52, 95% CI -1.37 to 0.33; very low-quality evidence).Grommets versus placebo medicationGrommets were more effective than placebo medication in terms of:- proportion of children who had no AOM recurrence at six months (one study, 42 children, 55% versus 15%; RR 3.64, 95% CI 1.20 to 11.04, NNTB 3; very low-quality evidence);- number of AOM recurrences at six months (one study, 42 children, mean number of AOM recurrences per child: 0.86 versus 2.0, MD -1.14, 95% CI -2.06 to -0.22; very low-quality evidence).One study reported persistent tympanic membrane perforations in 3 of 76 children (4%) receiving grommets (low-quality evidence).Subgroup analysisThere were insufficient data to determine whether presence of middle ear effusion at randomisation, type of grommet or age modified the effectiveness of grommets.

AUTHORS' CONCLUSIONS

Current evidence on the effectiveness of grommets in children with rAOM is limited to five RCTs with unclear or high risk of bias, which were conducted prior to the introduction of pneumococcal vaccination. Low to very low-quality evidence suggests that children receiving grommets are less likely to have AOM recurrences compared to those managed by active monitoring and placebo medication, but the magnitude of the effect is modest with around one fewer episode at six months and a less noticeable effect by 12 months. The low to very low quality of the evidence means that these numbers need to be interpreted with caution since the true effects may be substantially different. It is uncertain whether or not grommets are more effective than antibiotic prophylaxis. The risk of persistent tympanic membrane perforation after grommet insertion was low.Widespread use of pneumococcal vaccination has changed the bacteriology and epidemiology of AOM, and how this might impact the results of prior trials is unknown. New and high-quality RCTs of grommet insertion in children with rAOM are therefore needed. These trials should not only focus on the frequency of AOM recurrences, but also collect data on the severity of AOM episodes, antibiotic consumption and adverse effects of both surgery and antibiotics. This is particularly important since grommets may reduce the severity of AOM recurrences and allow for topical rather than oral antibiotic treatment.

Efficacy of 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine against acute otitis media and nasopharyngeal carriage in Panamanian children - A randomized controlled trial

We previously reported 10-valent pneumococcal non-typeable Haemophilus influenzae (NTHi) protein D conjugate vaccine (PHiD-CV) efficacy in a double-blind randomized trial (ClinicalTrials.gov: NCT00466947) against various diseases, including acute otitis media (AOM). Here, we provide further analyses. In the Panamanian subset, 7,359 children were randomized (1:1) to receive PHiD-CV or control vaccine at age 2/4/6 and 15–18 months. Of these, 2,000 had nasopharyngeal swabs collected. AOM cases were captured when parents sought medical attention for children with AOM symptoms; surveillance was enhanced approximately 2 y into the study through regular telephone calls or home visits by study personnel, who advised parents to visit the clinic if their child had AOM symptoms. Mean follow-up was 31.4 months. Clinical AOM (C-AOM) cases were assessed by physicians and confirmed by otorhinolaryngologists. Middle ear fluid samples, taken from children with C-AOM after specific informed consent, and nasopharyngeal samples were cultured for pathogen identification. For 7,359 children, 2,574 suspected AOM cases were assessed by a primary healthcare physician; 649 cases were C-AOM cases as per protocol definition. From the 503 MEF samples collected, 158 resulted in a positive culture. In the intent-to-treat cohort (7,214 children), PHiD-CV showed VE against first C-AOM (24.0% [95% CI: 8.7, 36.7]) and bacterial (B-AOM) episodes (48.0% [20.3, 66.1]) in children <24 months, which declined thereafter with age. Pre-booster VE against C-AOM was 30.7% [12.9, 44.9]; post-booster, −6.7% [−36.4, 16.6]. PHiD-CV VE was 17.7% [−6.1, 36.2] against moderate and 32.7% [−20.5, 62.4] against severe C-AOM. VE against vaccine-serotype pneumococcal NPC was 31.2% [5.3, 50.3] 3 months post-booster, and 25.6% [12.7, 36.7] across all visits. NTHi colonization rates were low and no significant reduction was observed. PHiD-CV showed efficacy against C-AOM and B-AOM in children younger than 24 months, and reduced vaccine-serotype NPC.

Otitis media

Otitis media (OM) or middle ear inflammation is a spectrum of diseases, including acute otitis media (AOM), otitis media with effusion (OME; 'glue ear') and chronic suppurative otitis media (CSOM). OM is among the most common diseases in young children worldwide. Although OM may resolve spontaneously without complications, it can be associated with hearing loss and life-long sequelae. In developing countries, CSOM is a leading cause of hearing loss. OM can be of bacterial or viral origin; during 'colds', viruses can ascend through the Eustachian tube to the middle ear and pave the way for bacterial otopathogens that reside in the nasopharynx. Diagnosis depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane (eardrum) for AOM and hearing loss for OME; diagnostic modalities include (pneumatic) otoscopy, tympanometry and audiometry. Symptomatic management of ear pain and fever is the mainstay of AOM treatment, reserving antibiotics for children with severe, persistent or recurrent infections. Management of OME largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays or learning difficulties. The role of hearing aids to alleviate symptoms of hearing loss in the management of OME needs further study. Insertion of ventilation tubes and adenoidectomy are common operations for recurrent AOM to prevent recurrences, but their effectiveness is still debated. Despite reports of a decline in the incidence of OM over the past decade, attributed to the implementation of clinical guidelines that promote accurate diagnosis and judicious use of antibiotics and to pneumococcal conjugate vaccination, OM continues to be a leading cause for medical consultation, antibiotic prescription and surgery in high-income countries.

Xylitol for preventing acute otitis media in children up to 12 years of age

BACKGROUND

Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae (S pneumoniae) and Haemophilus influenzae (H influenzae) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011.

OBJECTIVES

To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years.

SEARCH METHODS

We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI).

MAIN RESULTS

We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta-analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis-prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low-quality evidence).

AUTHORS' CONCLUSIONS

There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis-prone children. The meta-analysis was limited because data came from a small number of studies, and most were from the same research group.

Incidence of acute otitis media in children below 6 years of age seen in medical practices in five East European countries

Background

Although acute otitis media (AOM) remains a major public health problem worldwide and brings economic burden on health care system and caregivers, little information is available about its epidemiology in Eastern Europe.

Methods

We conducted an epidemiological, prospective, observational, multi-centre cohort study (NCT01365390) in five East European countries (Estonia, Lithuania, Poland, Romania and Slovenia) between June 2011 and January 2013 to determine the incidence and clinical characteristics of AOM among children aged < 6 years during 1 year.

Results

AOM incidence was 160.7 cases (95 % confidence interval [CI]: 144.7–177.9) per 1000 person-years (PY) being the lowest in the < 1 year age group (92.3 cases [95 % CI: 59.7–136.2] per 1000 PY) and the highest in the 3– < 4 years age group (208.9 cases [95 % CI: 165.1–260.7] per 1000 PY). AOM incidence was similar across the countries, with the exception of Slovenia (340.3 cases [95 % CI: 278.3–412.0] per 1000 PY). There was a lower risk in breastfed children and a higher risk in those attending school/childcare or with allergies. AOM required 521 visits to the doctor. Antibiotics were prescribed for 276 (74.8 %) episodes with the lowest prescription rate in Estonia (51.4 %) and the highest in Romania (83.7 %). Complications were rare and hospitalisations occurred in 2 % of the cases.

Conclusions

The disease burden of AOM in Eastern Europe is relevant and public health initiatives to reduce it should be considered.

Trial registration

ClinicalTrial.gov NCT01365390.

The Impact of Childhood Acute Otitis Media on Parental Quality of Life in a Prospective Observational Cohort Study

Background and Objectives

Acute otitis media (AOM) not only affects childhood quality of life (QoL), but can also affect parental QoL. We adapted a previously published questionnaire on the effect of childhood recurrent ear, nose and throat infections on parental QoL for use with AOM and used it in an observational, multicentre, prospective study of children with AOM.

Methods

The AOM-specific parental QoL questionnaire grouped 15 items into emotional, daily disturbance, total and overall parental QoL impact scores. The questionnaire was assessed using item-convergent and item-discriminant validity criteria and internal consistency reliability; and then used with parents of children aged <6 years diagnosed with AOM at 73 practices in Germany, Italy, Spain, Sweden and the UK. Bivariate analyses explored the differences in mean parental QoL impact scores by various characteristics.

Results

The questionnaire demonstrated good to excellent internal consistency reliability for the various components (Cronbach’s α 0.82–0.97). There were 1419 AOM episodes among 5882 healthy children over 1 year, of which 1063 episodes (74.9 %) among 852 children had a questionnaire. Parents reported interrupted sleep (68.4 %), worry (51.0 %), altered daily schedule (44.6 %) and less leisure time (41.5 %) with a score ≥3 (1 = least to 5 = most impact). Factors that adversely affected parental QoL included: increased parental perception of AOM severity, younger child age and multiple AOM episodes.

Conclusions

The AOM-specific parental QoL questionnaire demonstrated good performance across five European countries. Parental QoL was affected by childhood AOM proportionally to severity, number of episodes and younger child age.

Electronic supplementary material

The online version of this article (doi:10.1007/s40261-015-0319-1) contains supplementary material, which is available to authorized users.

Management of acute otitis media in children six months of age and older

Acute otitis media (AOM) continues to be a common infection in young children. Milder disease, usually due to viruses or less virulent bacteria, resolves equally quickly with or without antibiotics. A bulging tympanic membrane, especially if yellow or hemorrhagic, has a high sensitivity for AOM that is likely to be bacterial in origin and is a major diagnostic criterion for AOM. Perforation of the tympanic membrane with purulent discharge similarly indicates a bacterial cause. Immediate antibiotic treatment is recommended for children who are highly febrile (≥39°C), moderately to severely systemically ill or who have very severe otalgia, or have already been significantly ill for 48 h. For all other cases, parents can be provided with a prescription for antibiotics to fill if the child does not improve in 48 h or the child can be reassessed if this occurs. Amoxicillin remains the clear drug of choice. Ten days of therapy is appropriate for children <2 years of age, whereas older children can be treated for five days.

A multi-centre open-label randomised non-inferiority trial comparing watchful waiting to antibiotic treatment for acute otitis media without perforation in low-risk urban Aboriginal and Torres Strait Islander children (the WATCH trial): study protocol for a randomised controlled trial

Background

Treatment guidelines recommend watchful waiting for children older than 2 years with acute otitis media (AOM) without perforation, unless they are at high risk of complications. The high prevalence of chronic suppurative otitis media (CSOM) in remote Aboriginal and Torres Strait Islander communities leads these children to be classified as high risk. Urban Aboriginal and Torres Strait Islander children are at lower risk of complications, but evidence to support the subsequent recommendation for watchful waiting in this population is lacking.

Methods/Design

This non-inferiority multi-centre randomised controlled trial will determine whether watchful waiting is non-inferior to immediate antibiotics for urban Aboriginal and Torres Strait Islander children with AOM without perforation. Children aged 2 − 16 years with AOM who are considered at low risk for complications will be recruited from six participating urban primary health care services across Australia. We will obtain informed consent from each participant or their guardian. The primary outcome is clinical resolution on day 7 (no pain, no fever of at least 38 °C, no bulging eardrum and no complications of AOM such as perforation or mastoiditis) as assessed by general practitioners or nurse practitioners. Participants and outcome assessors will not be blinded to treatment. With a sample size of 198 children in each arm, we have 80 % power to detect a non-inferiority margin of up to 10 % at a significance level of 5 %, assuming clinical improvement of at least 80 % in both groups. Allowing for a 20 % dropout rate, we aim to recruit 495 children.

We will analyse both by intention-to-treat and per protocol. We will assess the cost- effectiveness of watchful waiting compared to immediate antibiotic prescription. We will also report on the implementation of the trial from the perspectives of parents/carers, health professionals and researchers.

Discussion

The trial will provide evidence for the safety and effectiveness of watchful waiting for the management of AOM in Aboriginal and Torres Strait Islander children living in urban settings who are considered to be at low risk of complications.

Trial registration

The trial is registered with Australia New Zealand Clinical Trials Registry (ACTRN12613001068752). Date of registration: 24 September 2013.

Use of symptoms and risk factors to predict acute otitis media in infants

OBJECTIVES

Infants and children with upper respiratory tract infection (URI) often have concurrent acute otitis media (AOM). Young infants have fewer specific symptoms than older children. The purpose of this study was to evaluate the usefulness of symptoms and other risk factors in predicting the presence of AOM in infants.

METHODS

Healthy infants, age less than four weeks, were enrolled and followed prospectively for up to age one year. Infants were scheduled for a research visit when their parents noted the onset of symptoms. At each URI visit, parents first reported the severity of symptoms. An investigator then diagnosed the presence or absence of concurrent AOM. Risk factors and symptom scores for infants with and without AOM were studied.

RESULTS

Infants (N=193, mean age at first URI 3.9±2.5 months) experienced 360 URI episodes and 63 AOM events. Symptoms consisting of fever, earache, poor feeding, restless sleep, and irritability together (ETG-5) were statistically associated with the prediction of AOM (P=0.006). A multiple variable statistical model (J-Score) that included day care attendance, age, severity of cough and earache best predicted AOM (P<0.001), with 95% specificity. Both ETG-5 and J-score yielded relatively low sensitivity for AOM prediction.

CONCLUSIONS

In infants with URI in the first year of life, severity of symptoms was significantly associated with concurrent AOM. Daycare attendance, presence and severity of earache and cough added to better correlation. These observations may have clinical application in identification of infants at risk for AOM.

Role of Nasopharyngeal Bacteria and Respiratory Viruses in Acute Symptoms of Young Children

BACKGROUND

The spectrum of acute symptoms in young outpatient children with respiratory tract infection (RTI) is variable, and it cannot be explained by the diagnosis of acute otitis media (AOM) versus uncomplicated RTI. We studied that the variation of symptoms is explained by the nasopharyngeal bacteria and/or respiratory viruses.

METHODS

Children aged 6-35 months with acute symptoms with AOM (n = 201) or without AOM (n = 225) were eligible in this cross-sectional study. We analyzed their nasopharyngeal samples for pathogenic bacteria by culture and for respiratory viruses by polymerase chain reaction. We surveyed 17 symptoms (fever, respiratory, ear related, nonspecific, gastrointestinal) with a structured questionnaire.

RESULTS

Fever had a positive association with influenza viruses [odds ratio (OR): 6.61; 95% confidence interval (CI): 1.66-26.27], human metapneumovirus (OR: 3.84; 95% CI: 1.25-11.77), coronaviruses (OR: 3.45; 95% CI: 1.53-7.75) and parainfluenza viruses (OR: 2.18; 95% CI: 1.07-4.47). Rhinitis (OR: 5.07; 95% CI: 1.93-13.36), nasal congestion (OR: 2.03; 95% CI: 1.25-3.31) and cough (OR: 1.91; 95% CI: 1.15-3.17) had positive associations with Moraxella catarrhalis. Furthermore, cough had a positive association with respiratory syncytial virus (OR: 7.20; 95% CI: 1.59-32.71) and parainfluenza viruses (OR: 2.79; 95% CI: 1.02-7.69).

CONCLUSIONS

The variation of acute symptoms in young children may be influenced by both nasopharyngeal bacteria and respiratory viruses. Our results showed a strong association between fever and respiratory viruses; rhinitis, nasal congestion and cough were associated with M. catarrhalis in the presence of viruses. Further studies are required to determine the possible synergistic role of M. catarrhalis in symptoms of RTI.

Homeopathic Ear Drops as an Adjunct in Reducing Antibiotic Usage in Children With Acute Otitis Media

Objective. To determine if use of a homeopathic ear drop preparation reduces antibiotic use in children diagnosed with acute otitis media (AOM). Methods. Children 6 months to 11 years old, diagnosed with AOM and managed with a delayed antibiotic approach, were randomized to standard therapy alone or standard therapy plus a homeopathic ear drop preparation. The primary outcome was whether or not the antibiotic prescription given at the index visit was filled during a 12- to 15-day follow-up period. Results. Among 210 enrolled children, follow-up antibiotic data were collected on 206. During the 12- to 15-day follow-up period, fewer parents of children randomized to the homeopathic ear drops group filled the antibiotic prescription compared with those of children receiving standard therapy alone (26.9% and 41.2%, respectively, P = .032). Conclusion. Homeopathic ear drops may be effective in reducing the use of antibiotics in children with AOM managed with a delayed antibiotic approach.

Efficacy of pneumococcal nontypable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) in young Latin American children: A double-blind randomized controlled trial

BACKGROUND

The relationship between pneumococcal conjugate vaccine-induced antibody responses and protection against community-acquired pneumonia (CAP) and acute otitis media (AOM) is unclear. This study assessed the impact of the ten-valent pneumococcal nontypable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) on these end points. The primary objective was to demonstrate vaccine efficacy (VE) in a per-protocol analysis against likely bacterial CAP (B-CAP: radiologically confirmed CAP with alveolar consolidation/pleural effusion on chest X-ray, or non-alveolar infiltrates and C-reactive protein ≥ 40 µg/ml); other protocol-specified outcomes were also assessed.

METHODS AND FINDINGS

This phase III double-blind randomized controlled study was conducted between 28 June 2007 and 28 July 2011 in Argentine, Panamanian, and Colombian populations with good access to health care. Approximately 24,000 infants received PHiD-CV or hepatitis control vaccine (hepatitis B for primary vaccination, hepatitis A at booster) at 2, 4, 6, and 15-18 mo of age. Interim analysis of the primary end point was planned when 535 first B-CAP episodes, occurring ≥2 wk after dose 3, were identified in the per-protocol cohort. After a mean follow-up of 23 mo (PHiD-CV, n = 10,295; control, n = 10,201), per-protocol VE was 22.0% (95% CI: 7.7, 34.2; one-sided p = 0.002) against B-CAP (conclusive for primary objective) and 25.7% (95% CI: 8.4%, 39.6%) against World Health Organization-defined consolidated CAP. Intent-to-treat VE was 18.2% (95% CI: 5.5%, 29.1%) against B-CAP and 23.4% (95% CI: 8.8%, 35.7%) against consolidated CAP. End-of-study per-protocol analyses were performed after a mean follow-up of 28-30 mo for CAP and invasive pneumococcal disease (IPD) (PHiD-CV, n = 10,211; control, n = 10,140) and AOM (n = 3,010 and 2,979, respectively). Per-protocol VE was 16.1% (95% CI: -1.1%, 30.4%; one-sided p = 0.032) against clinically confirmed AOM, 67.1% (95% CI: 17.0%, 86.9%) against vaccine serotype clinically confirmed AOM, 100% (95% CI: 74.3%, 100%) against vaccine serotype IPD, and 65.0% (95% CI: 11.1%, 86.2%) against any IPD. Results were consistent between intent-to-treat and per-protocol analyses. Serious adverse events were reported for 21.5% (95% CI: 20.7%, 22.2%) and 22.6% (95% CI: 21.9%, 23.4%) of PHiD-CV and control recipients, respectively. There were 19 deaths (n = 11,798; 0.16%) in the PHiD-CV group and 26 deaths (n = 11,799; 0.22%) in the control group. A significant study limitation was the lower than expected number of captured AOM cases.

CONCLUSIONS

Efficacy was demonstrated against a broad range of pneumococcal diseases commonly encountered in young children in clinical practice.

TRIAL REGISTRATION

www.ClinicalTrials.gov NCT00466947.

Development and validation of a new grading scale for otitis media

BACKGROUND

Grading of acute otitis media (AOM) is important in clinical situations as well as in research. Current grading scales for AOM have used a 6 to 9 point scoring system primarily based on variation of redness and bulging of the tympanic membrane (TM). This study aimed to develop and validate a new scale for grading AOM.

METHOD

The scale was developed in 3 stages based on 32 patients with images taken of the TM when a child attended healthcare centre with othalgia and at follow-up visits. Content validity was used as the method for the first 2 stages. An expert panel reviewed the scale and repeated the process on a revised scale. Reliability was tested with a different expert panel that used the final scale on a sample of TM images in a test-retest and inter-rater and intra-rater agreements were calculated.

RESULTS

The scale was developed in 3 steps using expert committees. During the process the description of vascularization was judged to be of insufficient importance for our scale. Inter-rater agreement was moderate (κ = 0.52) and intra-rater agreement was good (κ = 0.66 to 0.89) in the test-retest of the final scale.

CONCLUSIONS

The developed AOM image-based grading scale demonstrates substantial inter- and intra-rater reliability with potential use in clinical research and telemedicine applications. Furthermore, the parameter "redness of TM" is of less importance in our scale as compared with other available grading systems.

The diagnosis and management of acute otitis media

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Symptoms and otoscopic signs in bilateral and unilateral acute otitis media

OBJECTIVE

Bilateral acute otitis media (AOM) is considered more severe than unilateral AOM, and several guidelines recommend more active treatment and/or follow-up of bilateral AOM. We studied whether bilateral AOM is a clinically more severe illness than unilateral AOM by comparing symptoms and otoscopic signs between bilateral and unilateral AOM.

METHODS

Two hundred thirty-two children aged 6 to 35 months diagnosed with AOM were eligible. We surveyed the symptoms with a structured questionnaire and recorded the otoscopic signs systematically.

RESULTS

Ninety-eight children had bilateral and 134 children unilateral AOM. Children with bilateral AOM were more often <24 months than children with unilateral AOM (87% vs 75%; P = .032). Fever (≥38°C) occurred in 54% and 36% (P = .006) and severe conjunctivitis in 16% and 44% (P = .047) of children with bilateral and unilateral AOM, respectively. In 15 other symptoms, we found no overall differences even when adjusted with age. We observed the following severe otoscopic signs in the bilateral and unilateral AOM group, respectively: moderate/marked bulging of tympanic membrane (63% and 40%; P = .001), purulent effusion (89% and 71%; P = .001), bulla formation (11% and 10%; P = .707), and hemorrhagic redness of tympanic membrane (7% and 10%; P = .386).

CONCLUSIONS

Bilateral AOM seems to be a clinically only slightly more severe illness than unilateral AOM. Therefore, when assessing AOM severity, bilaterality should not be used as a determining criterion; instead, the child's symptomatic condition together with otoscopic signs should also be taken into consideration.

Acute Otitis Media in Infants

Acute otitis media has changed conceptually from being a feared infection with severe complications to a modest disease that should be treated for symptomatic relief but often without immediate antimicrobials. This holds true for infants and children with nonsevere forms of the illness if the parents and the clinician agree to a strategy of watchful waiting with easy access for follow-up. Accurate otologic examination is critical for disease recognition, but the initial choice of treatment must also consider the general impact that the disease produces in each individual patient. The appraisal of the symptoms that characterize the illness in a child, matched with the otoscopic intensity of the disease, provide a comprehensive estimation of overall severity that many experts have used for research. The perspectives examined in this article and the schematic construct that proposes considering disease and illness independently may help to bring the current paradigm of acute otitis media into everyday pediatric practice as a model for a more rational and personalized management of each patient.

Homeopathic ear drops as an adjunct to standard therapy in children with acute otitis media

OBJECTIVE

To assess the effectiveness of a homeopathic ear drop for treatment of otalgia in children with acute otitis media (AOM).

METHODS

Children with AOM were enrolled in the study at the time of diagnosis and randomized to receive either standard therapy alone or standard therapy plus a homeopathic ear drop solution that was to be used on as needed basis for up to 5 days. Parents of children in both treatment groups rated the severity of 5 AOM symptoms twice daily for 5 days in a symptom diary. A symptom score was computed for each assessment with lower scores denoting less severe symptoms. Parents of children randomized to receive ear drops also recorded information regarding symptoms being treated and response to treatment.

RESULTS

A total of 119 eligible children were enrolled in the study; symptom diaries were received from 94 (79%). Symptom scores tended to be lower in the group of children receiving ear drops than in those receiving standard therapy alone; these differences were significant at the second and third assessments (P = 0.04 and P = 0.003, respectively). In addition, the rate of symptom improvement was faster in children in the ear drop group compared with children in standard therapy alone group (P = 0.002). The most common reason for administration of ear drops was ear pain, recorded for 93 doses; improvement was noted after 78.4% of doses for this indication. There were no significant side effects related to use of the ear drops.

CONCLUSIONS

This study suggests that homeopathic ear drops were moderately effective in treating otalgia in children with AOM and may be most effective in the early period after a diagnosis of AOM. Pediatricians and other primary health care providers should consider homeopathic ear drops a useful adjunct to standard therapy.

Xylitol for preventing acute otitis media in children up to 12 years of age

BACKGROUND

Acute otitis media (AOM) is the most common bacterial infection among young children in the United States with limitations and concerns over its treatment with antibiotics and surgery. Therefore, effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk for dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae (S. pneumoniae) and Haemophilus influenzae (H. influenzae) to nasopharyngeal cells in vitro.

OBJECTIVES

To assess the efficacy and safety of xylitol to prevent AOM in children up to 12 years old.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August Week 1, 2011), EMBASE (1974 to August 2011), CINAHL (1982 to August 2011), Health and Psychosocial Instruments (1985 to August 2011), Healthstar (OVID) (1966 to August 2011) and International Pharmaceutical Abstracts (2000 to August 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of children aged 12 years or younger where xylitol supplementation was compared to placebo or no treatment to prevent AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI).

MAIN RESULTS

We identified four studies of adequate methodological quality that met our eligibility criteria. In three RCTs with a total of 1826 healthy Finnish children attending day care, there was a reduced risk of occurrence of AOM in the xylitol group (in any form) compared to the control group (RR 0.75; 95% CI 0.65 to 0.88). The fourth RCT included 1277 Finnish day care children with a respiratory infection and found no effect of xylitol on reducing the occurrence of AOM (RR 1.13; 95% CI 0.83 to 1.53). Xylitol chewing gum was superior to xylitol syrup in preventing AOM among healthy children (RR 0.59; 95% CI 0.39 to 0.89) but not during respiratory infection (RR 0.68; 95% CI 0.43 to 1.07). There was no difference between xylitol lozenges and xylitol syrups in preventing AOM among healthy children (RR 0.77; 95% CI 0.53 to 1.11) or among children during respiratory infection (RR 0.74; 95% CI 0.47 to 1.14). Similarly, no difference was noted between xylitol chewing gum and xylitol lozenges in preventing AOM among healthy children (RR 0.73; 95% CI 0.47 to 1.13) or among children during respiratory infection (RR 0.92; 95% CI 0.59 to 1.46). Among the reasons for drop-outs, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups.

AUTHORS' CONCLUSIONS

There is fair evidence that the prophylactic administration of xylitol among healthy children attending day care centres reduces the occurrence of AOM by 25%. This meta-analysis is limited since the data arise from a small number of studies, mainly from the same research group.

A simple scoring system to improve clinical assessment of acute otitis media

OBJECTIVE

To evaluate an easy to use 10-point scoring system in clinical assessment of acute otitis media (AOM). Study design. Symptoms of AOM observed by validated otoscopists were tabulated and scored with a 10-point and a 30-point system at acute onset of illness and at the test-of-cure (TOC) 3 weeks later.

RESULTS

A total of 330 children (mean age = 13.1 months) with AOM were studied. At AOM onset, the mean 10-point and 30-point scores; were highly correlated (P < .001). At TOC, 256 children were cured, 69 failed, and 5 were lost to follow-up. The 10-point scores were 0.5 and 4.4 for children with cure and failure. The 10-point score had a sensitivity of 87%, specificity of 98%, positive predictive value of 91%, and negative predictive value of 97% compared with the diagnosis by validated otoscopists.

CONCLUSION

A simple, easy-to-use 10-point AOM scoring system was shown to discriminate AOM cure and failure at TOC.

Acute otitis media severity: association with cytokine gene polymorphisms and other risk factors

BACKGROUND

We have previously shown an association between polymorphisms of proinflammatory cytokine genes and susceptibility to upper respiratory tract infection and acute otitis media. It has not been known whether polymorphisms or risk factors are associated with the severity of acute otitis media.

OBJECTIVE

To evaluate the influences of proinflammatory cytokine gene polymorphisms and other risk factors on severity of acute otitis media following upper respiratory tract infection.

METHODS

In a prospective, longitudinal study, children aged 6-35 months were followed for one year for occurrences of upper respiratory tract infection and acute otitis media. Children were studied for TNFα(-308), interleukin (IL)-6(-174) and IL-1β(+3953) polymorphisms, taking into account age, gender, race, family history of otitis, tobacco smoke exposure, breast feeding, day of upper respiratory tract infection at the time of diagnosis and pneumococcal vaccine status. Symptoms and signs of acute otitis media were graded according to a validated scale. The association between acute otitis media clinical severity, polymorphic genotypes, and risk factors were analyzed using statistical models that account for multiple episodes of acute otitis media per child.

RESULTS

A total of 295 episodes of acute otitis media in 128 subjects was included. More severe acute otitis media symptoms were associated with young age (P=0.01), family history of acute otitis media (P=0.002), tobacco smoke exposure (P=0.008), and early diagnosis of otitis after onset of upper respiratory tract infection (P=0.02). Among children with a bulging or perforated tympanic membrane (206 episodes, 104 subjects), those who had the IL-1 β(+3953) polymorphism, experienced higher symptom scores (P<0.02).

CONCLUSION

This is the first report of the association between risk factors and acute otitis media severity. Risk factors such as tobacco smoke exposure and a positive family history appear to be more significantly associated with acute otitis media severity than proinflammatory gene polymorphisms. Clinical severity may be an important factor contributing to the incidence and costs of acute otitis media, because children with more severe symptoms might be more likely to be brought for a medical visit, receive a diagnosis of acute otitis media, and be prescribed an antibiotic.

Clinical spectrum of acute otitis media complicating upper respiratory tract viral infection

BACKGROUND

acute otitis media (AOM) often occurs as a complication of upper respiratory tract infection (URI).

OBJECTIVE

to describe otoscopic findings during URI, the full clinical spectrum of AOM, and outcome of cases managed with watchful waiting.

METHODS

: In a prospective study of 294 healthy children (6 months-3 years), characteristics of AOM complicating URI were studied. Otoscopic findings were categorized by tympanic membrane (TM) position, color, translucency, and mobility. Otoscopic score was assigned based on McCormick otoscopy scale (OS)-8 scale.

RESULTS

during days 1 to 7 of URI, otoscopic findings at 1114 visits were consistent with AOM in 22%; myringitis (inflamed TM, no fluid) was diagnosed in 7%. In AOM episodes diagnosed within 28 days of URI onset, TM position was described as: nonbulging (19%), mild bulging (45%), bulging (29%), and TM perforation occurred in (6%). OS-8 scale showed mild TM inflammation (OS, 2-3) in 6%, moderate (OS, 4-5) in 59%, and severe (OS, 6-8) in 35%. In 54% of 126 bilateral AOM episodes, inflammation of both TMs was at different stages. Of 28 cases of nonsevere AOM managed with watchful waiting, 4 progressed and 3 later required an antibiotic.

CONCLUSIONS

AOM is a spectrum of infection that may present at various stages, even in the same child with bilateral disease. During URI, otoscopic changes are observed from the first day of onset. Understanding the wide clinical spectrum of AOM is needed to help with future clinical trial design and development of a scoring system to establish treatment criteria that will minimize antibiotic use.

Acute otitis media: From diagnosis to prevention. Summary of the Italian guideline

Acute otitis media (AOM) is the most common disease occurring in infants and children and has major medical, social and economic effects. If we consider the Italian pediatric population and the incidence rates in different age ranges it can be calculated that almost one million cases of AOM are diagnosed in Italy every year. Various attempts have been made internationally to clarify the most appropriate ways in which AOM should be managed. In Italy, this has been done at local or regional level but there have so far been no national initiatives. The objective of this guideline is to provide recommendations to pediatricians, general practitioners and otolaryngologists involved in the clinical management of acute otitis media in healthy children aged 2 months to 12 years. After a systematic review and grading of evidences from the literature, the document was drafted by a multidisciplinary panel with identified key clinical questions related to diagnosis, treatment of the acute episode, management of complications and prevention.

Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age

OBJECTIVE

Acute symptoms are used to diagnose and manage acute otitis media (AOM). We studied whether AOM could be predicted by the reason for parental suspicion of AOM or by the occurrence, duration, and/or severity of symptoms. We also compared scores including or excluding tympanic-membrane examination of children with and without AOM.

PATIENTS AND METHODS

Children aged 6 to 35 months with parental suspicion of AOM were eligible. Before tympanic-membrane examination, we registered on a structured questionnaire the reason for parental suspicion of AOM, symptoms, and score components.

RESULTS

Of 469 children studied, 237 had AOM and 232 had respiratory tract infection without AOM. The most common reason for parental suspicion of AOM, restless sleep, was not predictive for AOM (RR: 1.0 [95% CI: 0.8-1.2]), nor was ear-rubbing (relative risk [RR]: 0.7 [95% confidence interval (CI): 0.5-1.0]). Neither the occurrence of fever (RR: 1.2 [95% CI: 1.0-1.4]) nor the highest mean temperature within 24 hours predicted AOM, nor did the occurrences of ear-related, nonspecific, respiratory, or gastrointestinal symptoms. The duration and severity of symptoms were not predictive for AOM, although rhinitis lasted longer and conjunctivitis was more severe in children with AOM. The clinical/otologic score (median: 4.0 vs 2.0; P = .000) and the AOM total-severity index (11.0 vs 6.0; P = .000), both including symptoms and tympanic-membrane examination, were higher in those with AOM. The AOM severity-of-symptom scale, based solely on symptoms, was equal in children with and without AOM (6.0 vs 6.0; P = .917).

CONCLUSIONS

AOM cannot be predicted by the occurrence, duration, or severity of symptoms at otitis-prone age. Likewise, solely symptom-based scores do not differentiate between respiratory tract infections with or without AOM. Thus, tympanic-membrane examination is crucial in the diagnosis and severity classification of AOM in clinical practice and research settings.

Development and preliminary evaluation of a parent-reported outcome instrument for clinical trials in acute otitis media

BACKGROUND

Acute otitis media (AOM) is the most common childhood diagnosis, leading to prescription of an antibiotic in the United States. Although antibiotics are used in children with AOM, in part, to shorten the duration of symptoms, no instruments have been developed to track early changes in symptoms from the parent's point of view. The goal of the present study was to develop and evaluate a parent-reported symptom scale for children with AOM (AOM-SOS) for use as an outcome measure in AOM treatment trials.

METHODS

From a pool of 28 potential symptoms, we selected 7 on the basis of parent questionnaire, expert interviews, and review of the literature for inclusion in the AOM-SOS. We administered the AOM-SOS to a primary-care sample of children aged 6-25 months enrolled in a study of nasopharyngeal bacterial colonization. Children were seen for well visits, illness visits, and AOM follow-up visits. At each visit, parents completed the AOM-SOS and their children were examined by trained otoscopists. As part of the evaluation of the AOM-SOS, we examined the association between each item on the questionnaire and the clinical diagnosis of AOM while adjusting for the presence of upper respiratory tract infection. To assess responsiveness, we examined the change in AOM-SOS scores in patients with AOM who were seen for follow-up within 3 weeks of diagnosis.

RESULTS

We evaluated 264 children (mean age, 12.5 months at entry) at a total of 642 visits. We diagnosed AOM at 24% of the visits. Each item on the questionnaire was significantly associated with the clinical diagnosis of AOM (P < 0.001 for each), before and after adjusting for the presence or absence of upper respiratory infection. The mean AOM-SOS score at visits when AOM was diagnosed was 3.71, compared with 0.96 at visits when AOM was not diagnosed (P < 0.001). Internal reliability of the scale as measured by Cronbach's alpha was 0.84. AOM-SOS scores in children with AOM who were otoscopically improved decreased by an average of 2.81 points (standardized response mean = 0.73).

CONCLUSIONS

We have developed a short symptom scale for children with AOM. This study provides preliminary data on the performance of the AOM-SOS in a primary care sample of children.

Laterality of acute otitis media: different clinical and microbiologic characteristics

BACKGROUND

A large individual patient data meta-analysis recently showed that children aged less than 2 years with bilateral, as compared with unilateral, acute otitis media (AOM) were at higher risk for persistent symptoms without antibiotic treatment. Prior studies have shown a propensity for children with bilateral AOM to be infected with bacterial pathogens, specifically Haemophilus influenzae. The objectives of this study were to further characterize risk factors for bilateral AOM and to assess the propensity for specific viral and bacterial pathogens to predispose to bilateral versus unilateral AOM.

METHODS

We performed a secondary data analysis on 1216 cases of AOM diagnosed and treated at our institution: 566 subjects underwent tympanocentesis and middle ear fluid (MEF) culture. We compared subjects with bilateral and unilateral AOM for demographic characteristics, clinical findings, parent/clinician perception of AOM severity, and MEF study results for bacteria and viruses.

RESULTS

When compared with children who have unilateral AOM, children with bilateral AOM were more likely to be younger (P < 0.001), have H. influenzae isolated from one or both MEFs (P < 0.0001), and have more severe inflammation of the tympanic membrane on otoscopic examination (P < 0.0001).

CONCLUSION

Compared with children who have unilateral AOM, children with bilateral AOM are more likely to have bacteria in the MEF and have more severe inflammation of the tympanic membrane. This may help explain why children with bilateral AOM are more likely to experience persistent symptoms without antibiotic treatment. Laterality of AOM should be considered when discussing treatment options with parents.