Otitis

2.
3 Patofisiologi
Otitis media dengan efusi (OME) dapat terjadi selama resolusi otitis media akut (OMA) sekali peradangan akut telah teratasi. Di antara anak-anak yang telah memiliki sebuah episode dari otitis media akut, sebanyak 45% memiliki efusi persisten setelah 1 bulan, tetapi jumlah ini menurun menjadi 10% setelah 3 bulan(11).
Hampir keseluruhan otitis media efusi disebabkan gangguan fungsi tuba Eustachius, yaitu ventilasi untuk menjaga agar tekanan udara antara telinga tengah dan telinga luar selalu sama, pembersihan sekret dari telinga tengah yang dialirkan ke nasofaring, dan sebagai proteksi pada telinga tengah. Kegagalan pada fungsi ventilasi menyebabkan tekanan negatif berkembang dalam telinga tengah sehingga terjadi transudasi dari mukosa yang menyebabkan terjadinya akumulasi serosa dengan dasar efusi yang steril. Kegagalan pada fungsi pembersihan sekret menyebabkan OME dengan sekret mukoid. Terdapat 3 fungsi utama tuba Eustachius yaitu ventilasi untuk menjaga agar tekanan udara antara telinga tengah dan telinga luar selalu sama, pembersihan sekret, dan sebagai proteksi pada telinga tengah. Gangguan fungsi yang dapat disebabkan oleh sejumlah keadaan dari penyumbatan anatomi peradangan sekunder terhadap alergi, infeksi saluran pernapasan atas (ISPA), atau trauma. Jika gangguan fungsi tuba Eustachius berlangsung terus-menerus, tekanan negatif berkembang dalam telinga tengah dari penyerapan dan/atau penyebaran nitrogen serta oksigen ke dalam sel mukosa telinga tengah. Jika berlangsung cukup lama dengan sejumlah besar yang sesuai, terjadi transudasi dari mukosa akibat tekanan negatif, yang menyebabkan terjadinya akumulasi serosa dengan dasar efusi yang steril. Disebabkan gangguan fungsi dari tuba Estachius, efusi menjadi media yang baik untuk perkembangbiakan bakteri dan bisa mengakibatkan terjadinya otitis media akut.5 Teori terbaru menjelaskan kejadian utama sebagai peradangan pada mukosa telinga tengah disebabkan oleh reaksi terhadap bakteri sudah ada dalam telinga tengah. Bluestone dkk menunjukkan (menggunakan bukti radiografi) refluks sampai tuba Eustachius dapat dibuktikan pada anakanak rentan terhadap otitis media. Selanjutnya, Crapko dkk menunjukkan adanya pepsin dalam ruang telinga tengah pada 60% anak dengan otitis media efusi. Refluks ini tentu juga dapat terjadi pada individu yang sehat. Mediator-mediator inflamasi dilepaskan sebagai akibat dari antigen bakteri
menyebabkan produksi gen musin. Produksi efusi musin berlebihan akan menjadi media yang cukup untuk perkembangbiakan bakteri dan mengakibatkan otitis media akut.5 Hampir keseluruhan otitis media efusi disebabkan gangguan fungsi tuba Eustachius. Apabila peradangan dan infeksi bakteri akut telah jelas, kegagalan dari mekanisme pembersihan telinga tengah memungkinkan tejadi efusi pada telinga tengah. Banyak faktor yang telah terlibat dalam kegagalan dari mekanisme pembersihan, termasuk gangguan fungsi siliar, edema mukosa, hiperviskositas efusi, dan tekanan udara antara telinga tengah dan telinga luar yang tidak baik.5 2.5 Penatalaksanaan Dokter umum harus merujuk ke ahli THT setiap kali curiga terdapat gangguan tuli konduktif persisten pada anak-anak, terutama mereka dengan tanda-tanda keterlambatan perkembangan bahasa. Selain itu, harus dirujuk ke ahli THT jika penyakit ini berulang, jika terapi medis tersedia yang sesuai yang diberikan dokter umum tidak membaik, dan/atau jika ditemukan kriteria untuk intervensi operasi. Sejumlah besar bukti epidemiologi menunjukkan bahwa pantas dilakukan modifikasi faktor risiko pada intervensi pelayanan primer. Modifikasi berikut ini mungkin membantu:

Menghindari asap rokok Menyusui bila memungkinkan Menghindari makan, baik dengan payudara atau botol ketika terlentang Menghindari berada ditempat yang terdapat sejumlah besar anak, terutama di pusat-pusat penitipan anak Menghindari paparan dari anak yang diketahui menderita OME Menghindari alergen dikenal6
Penelitian dari Kouwen dan Dejonckere menunjukkan penurunan prevalensi 40% pada anak-anak dari Belanda dengan otitis media efusi yang secara rutin (setidaknya mingguan) mengunyah permen karet.6 Terapi medikamentosa dari otitis media efusi (OME) termasuk penggunaan antibiotik, steroid, antihistamin dan dekongestan, serta mukolitik. Karena otitis media efusi menunjukkan terdapatnya bakteri patogen, diperlukan pengobatan dengan antibiotik yang tepat, meskipun bukti yang menunjukkan hanya bermanfaat untuk jangka masa pendek. Penelitian eritromisin, sulfisoxazole, amoksisilin, amoksisilin-klavulanat,
dan trimetoprim-sulfametoksazol telah menunjukkan tingkat kesembuhan lebih cepat dibandingkan dengan plasebo, meskipun perbedaannya hampir tidak signifikan secara statistik di sebagian besar uji coba ini.6 Apabila otitis media efusi menjadi kronis (3 bulan), efektivitas antibiotik berkurang, meskipun temuan ini masih kontroversial. Studi yang diterbitkan antara 2002 dan 2004 dan dikutip oleh pedoman praktek klinis untuk otitis media efusi juga menunjukkan kesembuhan efusi telinga tengah dengan antibiotik, namun mereka juga menunjukkan cepat dan sering terjadinya rekuren. Dalam 3 uji klinis plasebo terkontrol secara acak,
otitis media efusi tidak membaik dengan hanya steroid oral dalam waktu 2 minggu pengobatan. Ketika steroid oral dikombinasikan dengan antibiotik, tingkat kesembuhan efusi telinga tengah tidak ada peningkatan dibandingkan dengan hanya memakai antibiotik. Studi
lain menemukan bahwa steroid topikal intranasal saja atau kombinasi dengan antibiotik tidak memiliki manfaat jangka pendek maupun jangka panjang dalam pengelolaan anak-anak dengan otitis media efusi.6 Hidung tersumbat, rinore, dan sinusitis sering menyertai otitis media, antihistamin dan dekongestan dapat dipertimbangkan untuk menghilangkan gejala-gejala yang terkait terutama jika disebabkan oleh alergi. Antihistamin mencegah degranulasi sel mast dan pelepasan histamin yang dapat menyebabkan peradangan mukosa akibat peningkatan obstruksi hidung dan peningkatan produksi lendir. Studi besar terkontrol secara acak dari 430 anak-anak mengungkapkan bahwa tingkat penyembuhan otitis media efusi tidak meningkat secara signifikan dengan mukolitik dibandingkan plasebo. Temuan 2 uji lebih kecil lainnya mengkonfirmasi hasil ini. Operasi menjadi terapi yang paling banyak diterima untuk otitis media efusi persisten (OME), dan ini jelas efektif. Intervensi termasuk miringotomi dengan atau tanpa penempatan tuba, adenoidektomi, atau keduanya. Tonsilektomi telah terbukti sedikit bermanfaat sebagai pengobatan primer dari otitis media efusi. Rekomendasi pedoman klinis bagi intervensi operasi dari The American Academy of Family Physicians
(AAFP), American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), dan American Academy of Pediatrics (AAP) :

Ketika terdapat indikasi operasi pada seorang anak, penempatan tuba tympanostomy adalah prosedur awal yang sering dipakai Adenoidektomi tidak boleh dilakukan, kecuali ada terdapat indikasi misalnya, sumbatan hidung, dan adenoiditis kronis Operasi ulang terdiri dari adenoidektomi ditambah miringotomi, dengan atau tanpa penembatan tuba Tonsilektomi atau miringotomi saja tidak berguna untuk mengobati otitis media efusi.6
Pada pasien otitis media efusi dengan gangguan pendengaran, hilangnya 40 dB atau lebih besar menjadi indikasi absolut untuk dimasukkan tabung pemerataan tekanan sedangkan kehilangan sekitar 21-40 dB adalah indikasi relatif. Selain itu, pedoman klinis menyarankan terapi lebih agresif untuk anakanak beresiko terjadinya keterlambatan perkembangan khususnya dalam perkembangan bicara dan bahasa. Anak-anak yang mungkin berisiko termasuk salah satu dari berikut:

Anak-anak dengan kehilangan pendengaran permanen independen akibat otitis media efusi Mereka dicurigai atau didiagnosis dengan gangguan atau keterlambatan bicara dan bahasa Mereka dengan gangguan autisme atau gangguan perkembangan terkait lainnya Anak-anak dengan sindrom (misalnya sindrom Down) atau kelainan kraniofasial yang meliputi keterlambatan kognitif, bicara, dan bahasa Mereka yang buta atau memiliki gangguan penglihatan yang tidak bisa diperbaiki Anak-anak dengan labiopalatoskisis, dengan atau tanpa sindrom terkait Anak-anak dengan keterlambatan perkembangan6
Ketika dilakukan miringotomi dan aspirasi efusi tanpa penempatan tabung pemerataan tekanan, prosedur ini telah terbukti mengecewakan dalam tindak lanjut jangka panjang pada anak. Gates dkk telah menunjukkan bahwa ketika miringotomi dilakukan dengan penempatan tabung pemerataan tekanan terdapat perbaikan pendengaran, durasi efusi telinga tengah, waktu untuk kambuh, dan perlunya prosedur ulang. Miringotomi dan aspirasi berguna untuk mengobati pasien dengan gangguan
pendengaran sedang sampai berat dengan pemulihan fungsi normal telinga tengah.6 Tingkat komplikasi secara keseluruhan setelah penempatan tabung pemerataan tekanan adalah sekitar 11%. Otorrhea Persistent adalah komplikasi yang paling umum, terjadi pada 15% pasien dan bertahan selama 1 tahun sebanyak 5%. Komplikasi kedua tersering adalah timpanosklerosis, yang tidak mungkin secara klinis signifikan kecuali terjadinya perluasan. Perforasi persisten adalah komplikasi paling umum yang ketiga. Meskipun frekuensi yang tepat tidak diketahui (kira-kira 2%), perforasi persisten meningkat dengan nyata jika tabung tekanan pemerataan ditempatkan lebih dari 18 bulan. Komplikasi ini juga diketahui meningkat dengan penempatan tabung tympanostomy (T-tubes) yang dirancang untuk tinggal di membran timpani lebih lama dari Grommettube tipikal. Umumnya digunakan untuk pasien dengan otitis media berulang atau kronis yang gagal dengan penempatan Grommet-tube. Komplikasi potensial lainnya termasuk pembentukan jaringan granulasi, kolesteatom, dan tuli sensorineural.6 Meskipun adenoidektomi pernah menjadi pengobatan utama untuk otitis media efusi (OME), penempatan tabung pemerataan tekanan (PETs) kini disukai karena mudah dan resiko rendah. Pengobatan dengan hanya adenoidektomi ditemukan hampir sama efektifnya dengan penempatan tabung pemerataan tekanan untuk pengobatan otitis media efusi. Apabila adenoidektomi dilakukan dengan penempatan tabung pemerataan tekanan, frekuensi penyakit berulang, interval bebas penyakit, dan durasi penyakit semua membaik, dibandingkan dengan penggunaan hanya salah satu prosedur.6 Terdapat 3 alasan dilakukan adenoidektomi. Alasan pertama adalah pengangkatan karena pembesaran kelenjar gondok menutup jalan nasofaring dan koana sehingga menyebabkan tekanan yang berlebihan selama nasofaring menelan. Ini berpontensi terjadinya refluks tuba Eustachius. Namun, berbagai penelitian telah mengungkapkan bahwa hasil adenoidektomi tidak tergantung dari ukuran adenoid. Temuan ini menunjukkan bahwa proses-proses lain dari massa adenoid sederhana yang terlibat. Alasan kedua pengangkatan untuk perbaikan fungsi tuba Eustachius, kelenjar gondok yang sangat besar secara fisik mungkin menutup muara tuba Eustachius, meskipun Bluestone dkk telah menunjukkan bahwa ini jarang terjadi. Alasan ketiga untuk adenoidektomi
adalah untuk menghapus sumber inflamasi potensial dan terdapatnya infeksi pada muara tuba Eustachius. Ketika dilakukan dengan benar, adenoidektomi dapat digunakan untuk membuat mukosa nasofaring licin, yang menurunkan kolonisasi bakteri yang dapat terjadi di kriptus jaringan adenoid.6 Pasien dinasehatkan bahwa jika terjadi lebih dari 2 episode otorrhea sebelum 6 bulan follow-up yang dijadwalkan, mereka harus kontrol ke ahli THT di samping dokter umumnya. Disarankan pengangkatan tabung pemerataan tekanan yang belum secara spontan diekstrusi antara 18-24 bulan setelah penempatan karena meningkatnya risiko perforasi membran timpani persisten. Peraturan itu umumnya dilakukan pada set pertama gaya Grommet-tube. Sebuah tim multidisiplin harus mengikuti ketat dan mengobati dengan cepat terkait keterlambatan perkembangan bahasa. Intervensi harus termasuk penggunaan alat bantu dengar, jika diperlukan.6BAB IV KESIMPULAN Otitis media efusi (OME) adalah terdapatnya cairan dalam telinga tengah tanpa tanda-tanda atau gejala infeksi telinga akut. OME merupakah salah satu penyakit paling umum ditemukan pada anak. Sekitar 90% anak memiliki otitis media efusi (OME) pada beberapa waktu sebelum usia sekolah OME menjadi perhatian klinis karena dapat menyebabkan terjadinya gangguan pendengaran dan keterlambatan perkembangan bahasa. Diagnosis yang tepat dari OME mendasari penatalaksanaan yang benar.7 (Jurnal 3 halaman) Seringkali pada OME terdapat hipertrofi adenoid, terutama pada anakanak dengan OME lama atau berulang. Kadang-kadang hipertrofi tonsil dapat ditemukan. Temuan tambahan mungkin ditemukan termasuk hidung tersumbat, rinore, postnasal drip dan tanda-tanda alergi seperti mata merah dan/atau berair. Pemeriksaan audiometri dianjurkan ketika OME persisten untuk jangka waktu yang lebih lama, atau jika terdapat keterlambatan bahasa, gangguan belajar, atau gangguan pendengaran yang signifikan terjadi.7 .(Jurnal 3 halaman) Sejumlah besar bukti epidemiologi menunjukkan bahwa pantas dilakukan modifikasi faktor risiko pada intervensi pelayanan primer. Terapi medikamentosa dari otitis media efusi (OME) termasuk penggunaan antibiotik, steroid, antihistamin dan dekongestan, serta mukolitik. Karena
otitis media efusi menunjukkan terdapatnya bakteri patogen, diperlukan pengobatan dengan antibiotik yang tepat, meskipun bukti yang menunjukkan hanya bermanfaat untuk jangka masa pendek. Penelitian eritromisin, sulfisoxazole, amoksisilin, amoksisilin-klavulanat, dan trimetoprim-sulfametoksazol telah menunjukkan tingkat kesembuhan lebih cepat dibandingkan dengan placebo. Antihistamin dan dekongestan dapat dipertimbangkan untuk menghilangkan gejala-gejala seperti hidung tersumbat, rinore, dan sinusitis sering menyertai otitis media. Operasi menjadi terapi yang paling banyak diterima untuk otitis media efusi (OME), dan ini jelas efektif. Intervensi operasi termasuk miringotomi dengan atau tanpa penempatan tuba, adenoidektomi, atau keduanya.6 DAFTAR PUSTAKA 5. Thrasher RD. Otitis Media With Effusion. Diunduh dari http://emedicine.medscape.com/article/858990overview#a0104. Updated: Oct 7, 2011 6. Thrasher RD. Otitis Media With Effusion Treatment & Management. http://emedicine.medscape.com/article/858990-treatment#showall. Updated: Oct 7, 2011 7. Burkert S, Rasinski Ch, Burkert R. Otitis Media With Effusion Current Management In Children. Achive Of Perinatal Medicine. Ent-Hospital, Head & Neck Surgery, University Hospital Martin-Luther- University Halle-Witten Berg. Germany: 2007
A large meta-analysis of findings from 10 blinded, randomized controlled trials involving 1041 children with otitis media with effusion revealed that resolution of middle ear effusion (MEE) was significantly more likely in the patients treated with antimicrobials than in those treated with placebo or those receiving no treatment. The difference was noted at short-term (2- to 5-wk) follow-up. The findings of 2 other meta-analyses did not demonstrate a difference between antimicrobials and placebo with 6- to 11-week follow-up period. http://emedicine.medscape.com/article/858990-
treatment#aw2aab6b6b3
The 2004 clinical guidelines recommended avoiding the use of antibiotics, decongestants, oral steroids, and antihistamines for the treatment of otitis media with effusion due to evidence that cites [5, 20] their lack of effectiveness. The guidelines did not make a recommendation for or against the use of intranasal steroids, nor were any recommendations made for alternative medicine treatments.
Rosenfeld RM, Culpepper L, Doyle KJ, Grundfast KM, Hoberman A, Kenna MA. Clinical practice guideline: Otitis media with effusion. Otolaryngol Head Neck Surg. May 2004;130(5 Suppl):S95-118. Rosenfeld RM, Culpepper L, Doyle KJ. Clinical practice guideline: Otitis media with effusion. Am Fam Physician. Jun 15 2004;69(12):2776, 2778-9
November 22, 2011 (Boston, Massachusetts) The nasal corticosteroid spray ciclesonide is more effective than a broad-spectrum oral antibiotic for the treatment of children with otitis media with effusion, according to a small study presented in an oral session here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting. A resolution of otitis media with effusion occurred after 8 days of treatment with the aqueous nasal spray, but it took 14 days for a resolution in children treated with amoxicillin and clavulanate, Safa Nsouli, MD, director of the Danville Asthma and Allergy Clinic in California, reported. In an open-label study, Dr. Nsouli and colleagues randomized 40 atopic children, 6 to 11 years of age, with otitis media with effusion to 1 of 2 groups: 2 sprays of ciclesonide 50 g per nostril daily (n = 20); or amoxicillin and clavulanate potassium 90 mg/kg per day in 2 divided doses every 12 hours (n = 20). Both treatments were given for a 2-week period. The effectiveness of the 2 treatments was assessed objectively using pneumatic otoscopy, impedance tympanometry, and audiometry. "There is a nasal obstruction that occurs with otitis media. If we eliminate the nasal obstruction with ciclesonide, we decrease the aspiration reflex of the nasopharyngeal secretions into the middle ear that occur via the eustacian tube," Dr. Nsouli told Medscape Medical News. "We also reduce the allergic inflammatory obstruction of the eustacian tube. Ciclesonide decreases those mechanisms, which helps clear the otitis media much faster than a plain antibiotic treatment that works only on the bacteria," he said. "It's like having a clogged sink. You can try to clean the sink but it is impossible unless the sink is unplugged and drained." In addition to resolving otitis media symptoms more rapidly, ciclesonide is a safer option, Dr. Nsouli said. "I am sure many doctors and parents have noticed that their pediatric patients with otitis media can be on several antibiotic courses, sometimes for 6 to 8 months, with no results. They have even inserted an ear tube for drainage of the secretions. Our study shows that we can eliminate the long-term course of antibiotics," Dr. Nsouli said. Heartening Results Medscape Medical News invited Chitra Dinakar, MD, professor of pediatrics at the University of Missouri at Kansas City, for her views on this study. "Studies have shown that only about 1 in 3 children with middle-ear effusion who undergo myringotomy and placement of ventilation tubes have a bacterial pathogen identified; in general, qualitative studies suggest low bacterial densities in such effusions," Dr. Dinakar noted. "Additionally, inflammatory exudates or infiltration of neutrophils in the fluid is typically not found.
Despite this, pediatricians encounter patients with "fluid in the ear" who are given multiple course of antibiotics, raising concerns about "the development of multidrug-resistant pathogens and the effects of antibiotics on a young child's natural flora and immune system," she said. "It is heartening to note that this small open-label study showed more rapid resolution of symptoms with a nasal steroid, compared to a course of an appropriate antibiotic, at least in the short-term assessment period of 2 weeks," Dr. Dinakar said. Dr. Nsouli has disclosed no relevant financial relationships. Dr. Dinakar reports financial relationships with AstraZeneca and GlaxoSmithKline. American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 62. Presented November 6, 2011.
http://www.medscape.com/viewarticle/754040
Antihistamine-Antibiotic Combo Speeds Resolution of Otitis Media

Fran Lowry Authors and Disclosures
Print This Email this Share November 23, 2010 (Phoenix, Arizona) Adding the nasal antihistamine olopatadine to oral antibiotic therapy hastens the resolution of serous otitis media in children, according to a study presented here at the American College of Asthma, Allergy & Immunology (ACAAI) 2010 Annual Scientific Meeting. "Otitis media with effusion is a very important problem," Safa M. Nsouli, MD, director of the Danville Asthma and Allergy Clinic and the Castro Valley Asthma and Allergy Clinic in Danville, California, told Medscape Medical News. "It is very frequent, and the reason for the most visits to the paediatrician. We want to treat these children quickly so that any damage to the middle ear is lessened." Chronic inflammation is the histopathologic landmark of otitis media with effusion, and past observations have led Dr. Nsouli to believe that adding an antihistamine to antibiotic therapy would be more effective in this setting. "The advantage of olopatidine is that it is a very gentle antihistamine and does not contain steroids," he noted. "It is so safe it was used as eye drops, and the fact that it does not contain steroids is reassuring to parents." In his study, which was randomized and open labeled, Dr. Nsouli compared the efficacy of nasal olopatadine (665 g per nostril twice daily) together with oral amoxicillin/clavul anate potassium (90 mg/kg daily given in 2 divided doses every 12 hours) with that of the antibiotic alone in 40 pediatric patients (20 patients in each group) aged 6 to 11 years. The duration of the study was 2 weeks.
Efficacy was assessed with pneumatic otoscopy, impedance tympanometry, and audiometry on day 7 and day 14 of the study. Using impedance tympanometry was the key to assessing the effect of adding the antihistamine, Dr. Nsouli said. "These are little children, and sometimes they cannot describe in words very accurately what they are feeling. Tympanometry is an objective way to measure improvement." At day 7, the children who were receiving both medications showed a complete resolution of their otitis media with effusion. In contrast, the group treated with antibiotics alone showed no improvement until day 14, Dr. Nsouli said. "It is very important to think of the middle ear as a sinus cavity, and to treat it as such," he said. "That is why it is logical to combine treatments. Rather than thinking of the ear as one target, and the sinus as another, we should be giving a treatment that targets both at once." Comments: Combination a Novel Idea Marianne Frieri, MD, PhD, chief of allergy and immunology at Nassau University Medical Center, East Meadow, New York, commented that adding a nasal antihistamine along with an antibiotic seems like a good idea. "We know that olopatadine has many effects on various inflammatory cells, so adding it to an antibiotic sounds like a smart thing to do," Dr. Frieri, who comoderated the session, told Medscape Medical News. "I thought this study was very interesting. It is quite novel to add a nasal antihistamine because of histamine in the ear fluid, to an antibiotic. It makes the time to treat shorter. It was a wise thing to do," she said. Dr. Frieri's comoderator, Joseph A. Bellanti, MD, professor of pediatrics and microbiology and immunology at Georgetown University Medical Center, Washington, DC, agreed. "The study suggests that the serous otitis media may be due to an infection, so adding the antibiotic to the histamine makes sense. You get a double effect." For his part, Dr. Nsouli added: "We don't want to use too many antibiotics, and we don't want children to suffer the ill effects of not being able to hear because this can cause learning difficulties, which can be irreversible. Also, the ear infection can cause lasting damage. This is a safe treatment that gets the children better faster." Drs. Nsouli, Frieri, and Bellanti have disclosed no relevant financial relationships. American College of Asthma, Allergy & Immunology (ACAAI) 2010 Annual Scientific Meeting: Abstract 22: Presented November 14, 2010
Nasal Steroid Spray May Not Help Eustachian Tube Dysfunction

May 18, 2011 (UPDATED June 7, 2011) The use of intranasal steroid sprays may not alleviate the manifestations of eustachian tube dysfunction (ETD), according to the results of a randomized,
placebo-controlled, double-blind, prospective clinical trial reported in the May issue of Archives of OtolaryngologyHead & Neck Surgery. "Although many interventions have been recommended to treat ETD, no single therapy has gained universal acceptance and been shown to be efficacious," write Michael B. Gluth, MD, formerly of the Mayo Clinic in Rochester, Minnesota (now with University of Arkansas for Medical Sciences in Little Rock), and colleagues. "Given the potential for inflammatory processes within the nasal cavity and nasopharynx to play a role in the acute development of ETD, it has been hypothesized that intranasal administration of topical corticosteroid medications may contribute to the management of this condition. Previous attempts to prospectively study the effectiveness of nasal steroids to treat ETD have been limited to the pediatric population." Efficacy of Therapy The goal of the study was to assess the efficacy of intranasal aqueous triamcinolone acetonide in reducing otitis media with effusion, negative middle ear pressure, and other tympanometric signs and symptoms of ETD. At a tertiary referral clinic, adults at least 18 years old and children 6 to 17 years old seen for otitis media with effusion and/or negative middle ear pressure were randomly assigned to receive aqueous triamcinolone or matching placebo administered once daily intranasally for 6 weeks. Before and after treatment, all participants underwent tympanometry and otologic examination, and completed a symptom questionnaire. The main study endpoints consisted of resolution of abnormal tympanometry and change in severity and frequency of symptom scores. From September 1, 2005, through December 31, 2008, a total of 91 patients were enrolled. Compared with the placebo group, the active treatment group had no statistically significant difference in normalization of abnormal tympanometric signs, either on a per-patient basis (19% vs 32%; P = .18) or a per-ear basis (22% vs 35%; P = .15). In an analysis of covariance model, the 2 groups did not differ significantly in the overall poststudy symptom score, after adjustment for the overall symptom score before the study (P = .27). Do Not Overprescribe "Readers should take away from these results that there is no evidence supporting the use of intranasal steroid spray just in case it may work or help normalize negative middle pressure or for relieving middle ear fluid," Julie L. Wei, MD, associate professor of pediatric otolaryngology, Department of Otolaryngology-Head Neck Surgery at the University of Kansas School of Medicine, told Medscape Medical News in an independent comment. "This is important so that we do not overprescribe a therapy that is not proven to be effective." "While the treatment was not associated with adverse events, by not overprescribing we are saving unnecessary costs and medication use in adults and children," Dr. Wei said. "Also, since it would appear that not much improvement occurs after 6 weeks, physicians may want to reassess patients after a longer period of time than 6 weeks to see if fluid clears or middle ear negative pressure goes away." Study Limitations, Strengths Limitations of this study include slow rate of participant recruitment, resulting in enrollment of 91 rather than the targeted 146 participants; use of a nonvalidated eustachian tube symptom questionnaire; and lack of data on nasal septal deviation, turbinate hypertrophy, and adenoid hypertrophy. Patients with allergic rhinitis were not specifically included or excluded.
"Also, this study did not include children younger than age 6, and often physicians are treating this condition in preschool aged children," Dr. Wei said. "The strengths of this study include the fact that it is a well-designed clinical trial, described as prospective, randomized, placebo-controlled, doubleblinded design. A second strength is the fact that this clinical trial included both adults and children (older than age 6), [reflecting] the general population with negative middle ear pressure and/or middle ear fluid that are seen and treated in the clinical setting by all physicians." A third strength noted by Dr. Wei is use of both objective and subjective outcome measures, namely tympanometry to measure whether the pressure was normal or negative, and a questionnaire to assess subjective outcome self-reported by the patient or reported by the parents regarding symptoms of ETD. "Finally, for the placebo group, this study showed that in general, even after waiting 6 weeks most patients did not get better," Dr. Wei said. In future research, she suggested use of a validated subjective ETD-related questionnaire, and studying this issue in children younger than 6 years, although a few such studies have already been done. "[O]ur data portray a natural history of [otitis media with effusion and negative middle ear pressure] in this population that undergoes spontaneous resolution by 6 weeks in only approximately one-third of subjects," the study authors conclude. "The study medication was well tolerated without any unexpected adverse effects or serious adverse events reported."
Antibiotics for otitis media with effusion.

Minerva Pediatr. 2004; 56(5):481-95 (ISSN: 0026-4946)
Mandel EM; Casselbrant ML ENT Research Center, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA. mandele@pitt.edu Otitis media with effusion (OME) is defined as asymptomatic middle-ear effusion, that is, without the signs and symptoms of acute otitis media (AOM), such as fever, otalgia, or otorrhea. OME can occur after an episode of AOM or may occur without any prior or concurrent symptoms and is often noted on a routine physical examination or screening. Because children with OME are usually not ill, there is a question of whether treatment is warranted for this condition. Also adding to the complexity of this problem is the high spontaneous cure rate of OME. This paper will review the many clinical trials of the efficacy of antimicrobial therapy for OME. We have grouped the studies into 4 major categories: antibiotic vs no treatment, antibiotic vs placebo, antibiotic vs antibiotic, and antibiotic prophylaxis. While study designs, definitions, and quality vary widely, these studies show a trend toward shortterm efficacy of antimicrobial treatment, but long-term efficacy is doubtful. In this age of antimicrobial resistance, coupled with the high natural cure rate, routine antimicrobial treatment of OME is not warranted. It may be useful in selected patients, particularly those with chronic OME (3 months or longer of bilateral effusion or 6 months or longer of unilateral effusion) for whom surgery is being considered: a 1-time short course of antibiotic may allow cancellation or at least postponement of a surgical procedure, particularly in spring/summer when one would like to avoid placing tubes in the ears and placing the child at risk for otorrhea due to water exposure. Also, antimicrobial therapy may provide at least short-term relief for symptomatic children (hearing loss, developmental delay, etc.) for whom surgery must be postponed or is contraindicated
http://reference.medscape.com/medline/abstract/15459573
Current bacteriology of chronic otitis media with effusion: high rate of nosocomial infection and decreased antibiotic sensitivity.
J Infect. 2009; 59(5):308-16 (ISSN: 1532-2742)
Jung H; Lee SK; Cha SH; Byun JY; Park MS; Yeo SG Department of Otolaryngology, College of Medicine, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul, Republic of Korea. OBJECTIVES: Otitis media with effusion is a common disease entity in children, which is frequently managed surgically by insertion of a tympanostomy tube. Children who develop posttympanostomy tube otorrhea (PTTO) can be treated by administration of antibiotics. The abuse and misuse of antibiotics, however, has led to the emergence of resistant bacterial strains. We therefore examined the antibiotic sensitivity of bacterial strains collected from middle ear effusion fluid (MEEF) and PTTO. We also evaluated treatment outcomes in these patients. METHODS: This study was conducted in 289 patients who underwent tympanostomy tube insertion for chronic otitis media with effusion between March 2004 and February 2008. RESULTS: Bacterial culture tests during the insertion of tympanostomy tubes showed a high frequency of coagulase(-) Staphylococcus (CNS), followed by Pseudomonas, methicillin resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA). Patients with PTTO had a high frequency of CNS and MRSA, followed by MSSA and Streptococcus pneumoniae. Overall antibiotic sensitivity was lower in postoperatively collected than in intraoperatively collected bacterial strains. CONCLUSIONS: The bacterial strains detected in MEEF, and their antibiotic sensitivity profiles, differed somewhat from those of PTTO. Antibiotic sensitivity was decreased in bacteria from PTTO compared with those in MEEF.
5. Current bacteriology of chronic otitis media with effusion: high rate of nosocomial infection and decreased antibiotic sensitivity.
J Infect. 2009; 59(5):308-16 (ISSN: 1532-2742)
Jung H; Lee SK; Cha SH; Byun JY; Park MS; Yeo SG Department of Otolaryngology, College of Medicine, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul, Republic of Korea. OBJECTIVES: Otitis media with effusion is a common disease entity in children, which is frequently managed surgically by insertion of a tympanostomy tube. Children who develop posttympanostomy tube otorrhea (PTTO) can be treated by administration of antibiotics. The abuse and misuse of antibiotics, however, has led to the emergence of resistant bacterial strains. We therefore examined the antibiotic sensitivity of bacterial strains collected from middle ear effusion fluid (MEEF) and PTTO. We also evaluated treatment outcomes in these patients.
METHODS: This study was conducted in 289 patients who underwent tympanostomy tube insertion for chronic otitis media with effusion between March 2004 and February 2008. RESULTS: Bacterial culture tests during the insertion of tympanostomy tubes showed a high frequency of coagulase(-) Staphylococcus (CNS), followed by Pseudomonas, methicillin resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA). Patients with PTTO had a high frequency of CNS and MRSA, followed by MSSA and Streptococcus pneumoniae. Overall antibiotic sensitivity was lower in postoperatively collected than in intraoperatively collected bacterial strains. CONCLUSIONS: The bacterial strains detected in MEEF, and their antibiotic sensitivity profiles, differed somewhat from those of PTTO. Antibiotic sensitivity was decreased in bacteria from PTTO compared with those in MEEF.
Impact of antibiotics on pathogens associated with otitis media with effusion.

J Laryngol Otol. 2005; 119(11):862-5 (ISSN: 0022-2151)
Hamamoto Y; Gotoh Y; Nakajo Y; Shimoya S; Kayama C; Hasegawa S; Nibu K Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan. OBJECTIVE: To further understand the roles of bacteria and antibiotics in the development of otitis media with effusion (OME). METHODS: Samples of middle-ear effusion (MEE) were collected during the placement of ventilation tubes to treat chronic OME. Children with acute otitis media within the past three months were excluded from this study. We used polymerase chain reaction (PCR) to detect pathogens and to test the susceptibility of Streptococcus pneumoniae to penicillin. RESULTS: Among MEE samples from 52 children, PCR detected bacterial DNA in 32 per cent (24/75) of them. S. pneumoniae was detected more frequently in middle ears that required ventilation tube insertion at least twice compared with those requiring ventilation tube insertion only once (5/15 versus 4/60; p = 0.013). Higher levels of S. pneumoniae were detected in MEE from children with, than without, a long history of antibiotic administration (7/10 versus 2/14; p = 0.0187). The pbp genes of all isolated S. pneumoniae contained mutations. CONCLUSIONS: Long exposure to antibiotics might significantly influence the bacterial genome in MEE
A consensus statement published in August 2000 defined an appropriate logarithm for the medical treatment of acute otitis media (AOM) and recurrent acute otitis media (RAOM).[19] Antimicrobials are the only medications that have been shown to increase the rate of clearance of otitis media with effusion (OME) in randomized controlled trials. However, these benefits are temporary at best. The 2004 clinical guidelines recommended avoiding the use of antibiotics, decongestants, oral steroids, and antihistamines for the treatment of otitis media with effusion due to evidence that cites their lack of effectiveness.[5, 20] The guidelines did not make a recommendation for or against the use of intranasal steroids, nor were any recommendations made for alternative medicine treatments.
http://emedicine.medscape.com/article/858990-medication
Topical intranasal corticosteroids in 4-11 year old children with persistent bilateral otitis media with effusion in primary care: double blind randomised placebo controlled trial.
BMJ. 2009; 339:b4984 (ISSN: 1756-1833)
Williamson I; Benge S; Barton S; Petrou S; Letley L; Fasey N; Haggard M; Little P Primary Medical Care, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST. igw@soton.ac.uk Topical steroids are unlikely to be an effective treatment for otitis media with effusion in general practice. High rates of natural resolution occurred by 1-3 months
Clinical practice guideline: Otitis media with effusion.

Otolaryngol Head Neck Surg. 2004; 130(5 Suppl):S95-118 (ISSN: 0194-5998)
Rosenfeld RM; Culpepper L; Doyle KJ; Grundfast KM; Hoberman A; Kenna MA; Lieberthal AS; Mahoney M; Wahl RA; Woods CR; Yawn B; ; ; SUNY-HSC Brooklyn, Department of Pediatric Otolaryngology, NY 11201, USA. richrosenfeld@msn.com The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM). The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy,
with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.
Otitis media with effusion.

Pediatrics. 2004; 113(5):1412-29 (ISSN: 1098-4275)
because antihistamines and decongestants are ineffective for OME, they should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.
The link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids.
Pediatr Allergy Immunol. 2011; 22(3):258-66 (ISSN: 1399-3038)
Lack G; Caulfield H; Penagos M Children's Allergy Department, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, UK. gideon.lack@kcl.ac.uk
We reviewed the evidence linking otitis media with effusion (OME) and atopy, with the goal of clarifying the possible role of intranasal corticosteroids (INSs) in OME treatment. In August 2009, the MEDLINE database was searched for primary studies on OME epidemiology, pathophysiology, and treatment. Relevant clinical guidelines were obtained. Interpreting OME research is complicated by variable disease definitions, patient populations, methodologies, and outcomes assessments, along with the possibility of spontaneous resolution. However, evidence links OME with atopic conditions including allergic rhinitis; observed prevalence of allergic rhinitis in patients with chronic or recurrent OME ranges from 24% to 89%. Such findings have prompted evaluations of common allergy medications for OME treatment. While short-term use of INSs alone or combined with antibiotics has shown benefit in some studies, more prolonged treatment protocols and long-term clinical outcomes will require critical assessment. Evidence suggesting epidemiologic and pathophysiologic links between allergy and OME has prompted investigation into a potential role for INSs in OME management, with promising initial results. Benefits of considering medical treatment in patients with OME prior to surgery include both the potential reductions in allergic inflammation and the naturally occurring spontaneous resolution of OME in these patients
Relationship between effusion bacteria and concentrations of immunoglobulin in serum and effusion fluid in otitis media with effusion patients.
Int J Pediatr Otorhinolaryngol. 2008; 72(3):337-42 (ISSN: 01655876)
Yeo SG; Park DC; Lee SK; Cha CI Department of Otolaryngology, College of Medicine, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Republic of Korea. OBJECTIVE: Bacterial infection and immunity are important in the development of otitis media with effusion (OME) in children who have not developed Eustachian tube function. We evaluated the relationship between the presence of bacteria in effusion fluid and immunoglobulin (Ig) concentrations in effusion fluid and serum. METHODS: Middle ear effusion and blood samples were collected from 58 OME patients who had undergone ventilation tube insertion. Bacteria in effusion fluid were detected by standard bacterial culture and polymerase chain reaction (PCR). Serum and middle ear fluid Ig concentrations in OME patients and serum Ig concentrations in 64 control children were evaluated. RESULTS: Bacteria were detected in 24/58 (41.4%) effusion fluid samples by PCR and in 12/58 (20.6%) by standard culture. There was no correlation between effusion Ig concentration and the presence of bacteria or between serum and effusion Ig concentrations, but serum Ig concentration was related to the presence of effusion bacteria (p<0.05). Serum IgG, IgA and IgM in patients with OME were lower than in control patients (p<0.05). CONCLUSIONS: These results suggest that the presence of effusion bacteria in OME may be related to systemic immunity, but that the concentration of Ig in effusion fluid may not be affected by the presence of effusion bacteria.
Frequency of Alloicoccus otitidis, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae in children with otitis media with effusion (OME) in Iranian patients.
Auris Nasus Larynx. 2012; 39(4):369-73 (ISSN: 1879-1476)
Khoramrooz SS; Mirsalehian A; Emaneini M; Jabalameli F; Aligholi M; Saedi B; Bazargani A; Taherikalani M; Borghaei P; Razmpa E Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. OBJECTIVE: To determine the presence of common bacterial agents of otitis media with effusion (OME), together with investigation these agent in the adenoid tissue and antimicrobial susceptibility pattern of isolated bacteria in Iranian children with OME. METHODS: Polymerase chain reaction (PCR) and bacterial culture methods were used for detection and isolation of Alloicoccus otitidis, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae in 63 middle ear fluid samples and 48 adenoid tissues from 48 OME patients. Fifteen patients were bilaterally affected. Antimicrobial susceptibility of all bacterial isolates were determined by disk agar diffusion (DAD) method. RESULTS: Bacteria were isolated from 47% (n=30) of the middle ear fluid samples and 79% (n=38) of the adenoid tissue specimens in OME patients. A. otitidis was the most common bacterial isolated v S. pneumoniae was the most prevalent pathogen (35.5% and 31.2% by culture and PCR) in the adenoid tissues. In 10 patients the same organisms were isolated from the middle ear fluid and adenoid tissue. Antimicrobial susceptibility pattern showed taht most isolates of bacteria were sensitive to ampicillin, Amoxicillin/Clavulanate and fluoroquinolones. CONCLUSION: The present study, being the first report on the isolation of A. otitidis by culture method in Iran and Asian countries, shows that A. otitidis is the most frequently isolated bacterium in Iranian children having otitis media with effusion. In this study A. otitidis, S. pneumoniae, H. influenzae and M. catarrhalis are the major bacterial pathogens in patients with OME and we found that ampicillin and Amoxicillin/Clavulanate have the excellent activity against bacterial agents in Iranian children with OME.
What is new in otitis media?

Eur J Pediatr. 2007; 166(6):511-9 (ISSN: 0340-6199)
Corbeel L Department of Pediatrics, University Hospital, Herestraat 49, Leuven, Belgium. lucien.corbeel@med.kuleuven.be OME needs a watchful waiting approach. When associated with deafness for 2-3 months in children over 2 years of age, an antibiotic should be given according to the results of the bacterial resistance in the nasopharyngeal aspirate.
1.
Compared to placebo, long-term antibiotics resolve otitis media with effusion (OME) and prevent acute otitis media with perforation (AOMwiP) in a high-risk population: a randomized controlled trial.
BMC Pediatr. 2008; 8:23 (ISSN: 1471-2431)

Leach AJ; Morris PS; Mathews JD; Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia. amanda@menzies.edu.au BACKGROUND: For children at high risk of chronic suppurative otitis media (CSOM), strategies to prevent acute otitis media with perforation (AOMwiP) may reduce progression to CSOM. METHODS: In a double blind study in northern Australia, 103 Aboriginal infants with first detection of OME were randomised to receive either amoxicillin (50 mg/kg/d BD) or placebo for 24 weeks, or until bilateral aerated middle ears were diagnosed at two successive monthly examinations (success). Standardised clinical assessments and international standards for microbiology were used. RESULTS: Five of 52 infants in the amoxicillin group and none of 51 infants in the placebo group achieved success at the end of therapy (Risk Difference = 9.6% [95% confidence interval 1.6,17.6]). Amoxicillin significantly reduced the proportion of children with i) perforation at the end of therapy (27% to 12% RD = -16% [-31,-1]), ii) recurrent perforation during therapy (18% to 4% RD = -14% [25,-2]), and iii) reduced the proportion of examinations with a diagnosis of perforation during therapy (20% to 8% adjusted risk ratio 0.36 [0.15,0.83] p = 0.017). During therapy, the proportion of examinations with penicillin non-susceptible (MIC > 0.1 microg/ml) pneumococci was not significantly different between the amoxicillin group (34%) and the placebo group (40%). Beta-lactamase positive non-capsular H. influenzae (NCHi) were uncommon during therapy but more frequent in the amoxicillin group (10%) than placebo (5%). CONCLUSION: Aboriginal infants receiving continuous amoxicillin had more normal ears, fewer perforations, and less pneumococcal carriage. There was no statistically significant increase in resistant pneumococci or NCHi in amoxicillin children compared to placebo children who received regular paediatric care and antibiotic treatment for symptomatic illnesses
2.
Prevalence and risk factors of otitis media with effusion in Trabzon, a city in northeastern Turkey, with an emphasis on the recommendation of OME screening.
Eur Arch Otorhinolaryngol. 2006; 263(5):404-8 (ISSN: 0937-4477)

Caylan R; Bektas D; Atalay C; Korkmaz O Department of Otolaryngology, Black Sea Technical University School of Medicine, Trabzon, Turkey. refikcaylan@yahoo.com This cross-sectional study was undertaken to assess the prevalence and risk factors for otitis media with effusion (OME) in Trabzon, a city in northeastern Turkey, and evaluate the need for screening for OME in the normal population. In kindergartens, daycare centers, public and private schools in the rural and central areas of Trabzon, 1,077 children aged between 5 and 12 years were examined.
OME prevalence was 11.14% (120/1,077). Young age, attendance at kindergarten/daycare, low economical status, the mother's working status (housewife), history of snoring and acute otitis media, antibiotic use in the previous 3 months and active upper respiratory tract infection (URTI) were found to be the risk factors for OME. A history of hearing loss reported by the parents and teachers was found significant in the diagnosis of OME despite the low predictive value. When the parents suspected that their child had experienced hearing loss (in 36 cases), they did not refer them to a healthcare facility. To conclude, the approach to OME in developing countries should be more interventional as healthcare coverage is usually low and behavioral factors such as the demand for healthcare is poor
3.
Management for the children with otitis media with effusion in the tertiary hospital.
Clin Exp Otorhinolaryngol. 2008; 1(4):201-5 (ISSN: 1976-8710)

Choung YH; Shin YR; Choi SJ; Park K; Park HY; Lee JB; Han DH; Kahng H Department of Otolaryngology, Ajou University School of Medicine, Yeongtong-gu, Suwon, Korea. yhc@ajou.ac.kr OBJECTIVES: Recently, new evidence-based recommendations have been introduced for diagnosing and managing otitis media with effusion (OME) in children. However, there are some difficulties to follow the general guidelines in the tertiary hospitals. The purpose is to evaluate the efficiency of antibiotics or antihistamines for treatment of children with OME in the tertiary hospital with a randomized prospective clinical study. METHODS: Eighty-four children with OME who had been diagnosed in the tertiary hospital were randomized to receive 5 different medications for 2 weeks. We prescribed antibiotics (amoxicillin-clavulanate syrup) in Group I (n=16), antibiotics/steroids (prednisolone) in Group II (n=18), antibiotics/antihistamines (ebastine) in Group III (n=15), antibiotics/steroids/antihistamines in Group IV (n=17), and mucolytics (ivy leaf extract) in Group V (n=17) for control. We followed-up children every 2 weeks and evaluated the state of OME at 3 months. RESULTS: Thirty six (42.9%) of 84 children were resolved within average 6.9 weeks after the treatments. Thirty-six (42.9%) were treated with ventilation tube insertion and 12 patients (14.3%) were observed. There was no difference in the resolution rates of OME among the five different protocols (P>0.05). There was no difference in the resolution rates among groups who used steroids, antihistamines, steroids and antihistamines, or other medications to manage 42 children with allergies (P>0.05). CONCLUSION: In the tertiary hospital, the cure rate of children with OME was not as high as well-known, and antibiotics or anti-allergic medications were not more effective than control. We may, therefore, need any other guidelines which are different from the previous evidence-based recommendations, including early operation in the tertiary hospitals
4.
Otitis media and antihistamines.
Curr Allergy Asthma Rep. 2009; 9(6):456-9 (ISSN: 1534-6315)

Goodrich T; Rubio F; Cutler JL Otitis media with effusion (OME) and acute otitis media (AOM) continue to be a significant source of morbidity in the United States, as they account for more than 3.5 billion dollars in annual costs, and OME is the sixth most common reason for an emergency department visit. The efficacy of
antihistamines in the treatment of OME/AOM has been thoroughly refuted in the literature during the past three decades. However, most studies to date have used first-generation antihistamines with or without decongestants. We propose that second-generation antihistamines may have increased efficacy in the treatment of OME/AOM because of their greater selectivity for histamine receptors and lack of anticholinergic activity. Further clinical trials may be warranted, as medical treatment with second-generation antihistamines, if proven more efficacious, may reduce the need for antibiotic treatment and surgical intervention.
5.
A review of the burden of disease due to otitis media in the Asia-Pacific.
Int J Pediatr Otorhinolaryngol. 2012; 76(5):623-35 (ISSN: 18728464)

Mahadevan M; Navarro-Locsin G; Tan HK; Yamanaka N; Sonsuwan N; Wang PC; Dung NT; Restuti RD; Hashim SS; Vijayasekaran S Starship Children's Hospital, Auckland, New Zealand. OBJECTIVE: The burden of disease due to otitis media (OM) in Asia Pacific countries was reviewed to increase awareness and raise understanding within the region. METHODS: Published literature and unpublished studies were reviewed. RESULTS: In school-age children, OM prevalence varied between 3.25% (Thailand) and 12.23% (Philippines) being highest (42%) in Aboriginal Australian children. OME prevalence at school age varied between 1.14% (Thailand) and 13.8% (Malaysia). Higher prevalence was reported in children with hearing impairment, HIV, pneumonia and rhinitis. CSOM prevalence was 5.4% in Indonesia (all ages), 15% in Aboriginal Australian children and 2-4% in Thailand, Philippines, Malaysia and Vietnam (WHO estimate). OM prevalence/incidence and service utilisation were highest in children 2-5 years of age. The disease burden was substantially higher in Pacific Island children living in New Zealand (25.4% with OME), and was highest in indigenous Australians (>90% with any OM). Streptococcus pneumoniae and Haemophilus influenzae dominated as primary causes of AOM in all studies. Few studies examined pneumococcal serotype distribution. Health-related cost estimates for OM, when available, were substantial. In developing countries, significant investment is needed to provide facilities for detection and treatment of ear disease in children, if long term hearing deficits and other sequelae are to be prevented. CONCLUSION: The available evidence suggests an important burden of disease and economic cost associated with OM in most Asia Pacific countries and a potential benefit of prevention through vaccination. Large, prospective community-based studies are needed to better define the prevalence of ear disease in children, and to predict and track pneumococcal conjugate vaccine impacts. AOM prevention through vaccination may also provide a means of reducing antibiotic use and controlling antibiotic-resistant disease in children. This review highlights the need for additional research, and provides a basis on which to build and develop regional guidelines for OM management.
6.
The role of chronic infection in children with otitis media with effusion: evidence for intracellular persistence of bacteria.
Otolaryngol Head Neck Surg. 2008; 138(6):778-81 (ISSN: 01945998)

Coates H; Thornton R; Langlands J; Filion P; Keil AD; Vijayasekaran S; Richmond P Department of ENT Surgery, Princess Margaret Hospital for Children, Perth, Western Australia. harveyc@cyllene.uwa.edu.au OBJECTIVE: Demonstrate mucosal bacterial infection in children with otitis media with effusion (OME). STUDY DESIGN AND SETTING: Middle ear mucosal biopsies from 11 children with OME were examined for bacteria utilizing transmission electron microscopy. This was correlated with standard culture and polymerase chain reaction (PCR) of middle ear effusions. RESULTS: Grampositive coccal bacteria were demonstrated in middle ear mucosal epithelial cells of 4 of 11 (36%) children. Morphological appearance of bacteria and detection of pneumolysin DNA by PCR in middle ear fluid suggests a role for persistent intracellular infection with Streptococcus pneumoniae and other gram-positive cocci in some cases of OME. CONCLUSION: Intracellular bacterial infection of middle ear mucosal epithelial cells in children with OME may be an important mechanism for bacterial persistence, and contribute to inflammation and mucus production in the pathogenesis of this condition. SIGNIFICANCE: Persistent intracellular infection is a novel paradigm for OME pathogenesis in children and may influence antibiotic effectiveness in treatment of this condition.
7.
Medical management of middle ear disease in children less than 2 years of age with sensorineural hearing loss.
J Otolaryngol. 2005; 34 Suppl 2:S64-9 (ISSN: 0381-6605)

Westerberg BD; Morzaria S; Kozak FK; Price D Division of Otolaryngology, University of British Columbia, Vancouver, BC, Canada. BWesterberg@providencehealth.bc.ca OBJECTIVE: With emerging early hearing detection and communication development programs, physicians are increasingly requested to review young children with sensorineural hearing loss (SNHL) and associated conductive hearing loss (CHL). The purpose of this critical review is to develop an evidence-based approach to the management of the child less than 2 years of age with fluctuating CHL and coexisting SNHL. METHODS: A critical review of the 1966-2002 MEDLINE database was performed to address the diagnosis, natural history, and management of otitis media with effusion (OME) and the management of acute otitis media (AOM) in the child under 2 years of age with underlying SNHL. RESULTS: Pneumatic otoscopy should be used to diagnose middle ear effusion. Clearance of OME may be prolonged in children with craniofacial abnormalities. Antibiotics provide a small short-term increase in the resolution of OME and may be warranted in children with coexisting SNHL and OME for 4 to 6 weeks. If OME persists for 8 to 12 weeks, bilateral myringotomy and tube placement (BM&T) with short-term tubes will improve hearing and help resolve OME. AOM in children less than 2 years of age should be treated with a 10-day course of antibiotics. Prophylactic antibiotics may be useful in avoiding tube placement in children less than 2 years of age with recurrent AOM. BM&T with short-term tubes are recommended if recurrent AOM persists. Pneumococcal vaccination can decrease episodes of AOM by 6 to 7%. CONCLUSIONS: An
evidence-based algorithm for the management of fluctuating CHL in children less than 2 years of age with an underlying SNHL is presented
8.
Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children.
Cochrane Database Syst Rev. 2005; (1):CD001801 (ISSN: 1469493X)

Lous J; Burton MJ; Felding JU; Ovesen T; Rovers MM; Williamson I Institute of Public Health, General Practice, University of Southern Denmark, Winslwparken 19, 3, DK-5000 Odense C, Denmark. jlous@health.sdu.dk BACKGROUND: Otitis media with effusion (OME), or 'glue ear', is very common in children, especially between the ages of one and three years with a prevalence of 10% to 30% and a cumulative incidence of 80% at the age of four years. OME is defined as middle ear effusion without signs or symptoms of an acute infection. OME may occur as a primary disorder or as a sequel to acute otitis media. The functional effect of OME is a conductive hearing level of about 25 to 30 dB associated with fluid in the middle ear. Both the high incidence and the high rate of spontaneous resolution suggest that the presence of OME is a natural phenomenon, its presence at some stage in childhood being a normal finding. Notwithstanding this, some children with OME may go on to develop chronic otitis media with structural changes (tympanic membrane retraction pockets, erosion of portions of the ossicular chain and cholesteatoma), language delays and behavioural problems. It remains uncertain whether or not any of these findings are direct consequences of OME. The most common medical treatment options include the use of decongestants, mucolytics, steroids, antihistamines and antibiotics. The effectiveness of these therapies has not been established. Surgical treatment options include grommet (ventilation or tympanostomy tube) insertion, adenoidectomy or both. Opinions regarding the risks and benefits of grommet insertion vary greatly. The management of OME therefore remains controversial. OBJECTIVES: To assess the effectiveness of grommet insertion compared with myringotomy or non-surgical treatment in children with OME. The outcomes studied were (i) hearing level, (ii) duration of middle ear effusion, (iii) well-being (quality of life) and (iv) prevention of developmental sequelae possibly attributable to the hearing loss (for example, impairment in impressive and expressive language development (measured using standardised tests), verbal intelligence, and behaviour). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2003), MEDLINE (1966 to 2003), EMBASE (1973 to 2003) and reference lists of all identified studies. The date of the last systematic search was March 2003, and personal non-systematic searches have been performed up to August 2004. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the effect of grommets on hearing, duration of effusion, development of language, cognition, behaviour or quality of life. Only studies using common types of grommets (mean function time of 6 to 12 months) were included. DATA COLLECTION AND ANALYSIS: Data from studies were extracted by two reviewers and checked by the other reviewers. MAIN RESULTS: Children treated with grommets spent 32% less time (95% confidence interval (CI) 17% to 48%) with effusion during the first year of follow-up. Treatment with grommets improved hearing levels, especially during the first six months. In the randomised controlled trials that studied the effect of grommet insertion alone, the mean hearing levels improved by around 9 dB (95% CI 4 dB to 14 dB) after the first six months, and 6 dB (95% CI 3 dB to 9 dB) after 12 months. In the randomised controlled trials that studied the combined effect of grommets and adenoidectomy, the additional effect of the grommets on hearing levels was improvement by 3 to 4 dB (95% CI 2 dB to 5 dB) at six months and about 1 to 2 dB (95% CI 0 dB to 3
dB) at 12 months. Ears treated with grommets had an additional risk for tympanosclerosis of 0.33 (95% CI 0.21 to 0.45) one to five years later. In otherwise healthy children with long-standing OME and hearing loss, early insertion of grommets had no effect on language development or cognition. One randomised controlled trial in children with OME more than nine months, hearing loss and disruptions to speech, language, learning or behaviour showed a very marginal effect of grommets on comprehensive language. AUTHORS' CONCLUSIONS: The benefits of grommets in children appear small. The effect of grommets on hearing diminished during the first year. Potentially adverse effects on the tympanic membrane are common after grommet insertion. Therefore an initial period of watchful waiting seems to be an appropriate management strategy for most children with OME. As no evidence is yet available for the subgroups of children with speech or language delays, behavioural and learning problems or children with defined clinical syndromes (generally excluded from the primary studies included in this review), the clinician will need to make decisions regarding treatment for such children based on other evidence and indications of disability related to hearing impairment. This review does not resolve the discrepancy between parental and clinical observation of a beneficial treatment effect and the results in the reviewed RCT showing only a short-term effect on hearing and virtually no effect on development. Is the perceived, often dramatic, effect of grommets only a shortterm one? Are some children more sensitive to OME-related hearing loss than others? If so, how do we identify them?Further research should focus upon indications. Studies should use sufficiently large sample sizes to show significant interactions. There is a need to determine the most suitable variables and appropriate "softer" outcomes to be the subject of these interaction tests. Interesting options include measures of speech-in-noise and binaural hearing. The generally modest results in the trials which are included in this review should make it easier to justify randomisation of more severely affected and higher-risk children in appropriately constructed trials. Randomised controlled trials are necessary in these children before more detailed conclusions about the effectiveness of grommets can be drawn.
9.
Otitis media with effusion in children. X
Clin Evid (Online). 2011; 2011 (ISSN: 1752-8526)

Williamson I The University of Southampton, Southampton, UK. INTRODUCTION: Up to 80% of children have been affected by otitis media with effusion (OME) by the age of 4 years, but prevalence declines beyond 6 years of age. Non-purulent middle-ear infections can occur in children or adults after upper respiratory tract infection or acute otitis media. Half or more of cases resolve within 3 months and 95% within 1 year, but complications such as tympanic membrane perforation, tympanosclerosis, otorrhoea, and cholesteatoma can occur. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent otitis media with effusion in children? What are the effects of pharmacological, mechanical, and surgical interventions to treat otitis media with effusion in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found one systematic review and one RCT that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: adenoidectomy, antibiotics, antihistamines, autoinflation, bottle feeding, decongestants, exposure to other children, intranasal corticosteroids, mucolytics, oral corticosteroids, passive smoking, and ventilation tubes.
http://reference.medscape.com/medline/abstract/21477396 10.
Otitis Media With Effusion Treatment & Management
Surgery has become the most widely accepted therapeutic intervention for persistent otitis media with effusion (OME), and it is clearly effective. The interventions include myringotomy with or without tube insertion, adenoidectomy, or both. Tonsillectomy has been shown to be of little benefit as a primary treatment of otitis media with effusion. The indications for surgical intervention remain controversial but have changed with the practice guidelines published in 2004.[5] As with all surgery, the benefits of intervention must outweigh the risks. Previously, surgical intervention was advocated if fluid persisted beyond 3 months. However, 2 wellconducted long-term studies showed that in the absence of a significant hearing loss, children who were only observed compared with those children who received pressure equalization tubes (PETs) had no difference in quality of life or overall hearing, speech, and language abilities. Therefore, in the presence of hearing thresholds better than 20 dB, observation is an option. However, only 30% of patients who have otitis media with effusion after 3 months duration will clear that effusion over the next 12 months; therefore, ongoing monitoring of hearing levels is required. Again, most cases of otitis media with effusion resolve spontaneously, and such spontaneous resolution is more common in the spring and summer. Thus, a conservative approach is often warranted at these times of the year; whereas, in fall and winter, exacerbations are more common, and surgical intervention is likely to yield better control.
Clinical guidelines
According to clinical guidelines on otitis media with effusion, certain changes to the tympanic membrane may mandate pressure equalization tube insertion despite normal hearing. These conditions include posterosuperior retraction pockets, ossicular erosion, adhesive atelectasis, and retraction pockets that accumulate keratin debris. Ongoing surveillance is mandatory, because the frequency of structural damage increases with effusion duration. For patients with hearing loss and otitis media with effusion, a loss of 40 dB or greater is felt to be an absolute indication for pressure equalization tube insertion. A loss in the range of 21-40 dB is a relative indication with a very low threshold for placement. Moreover, the clinical guidelines suggest more aggressive therapy for children at risk for developmental delays, particularly in the areas of speech and language development. Children who may be at risk include any of the following: Children with permanent hearing loss independent of otitis media with effusion Those with suspected or diagnosed speech and language delay or disorder Those with autism spectrum disorder or other pervasive developmental disorders Children with syndromes (eg, Down syndrome) or craniofacial disorders that include cognitive, speech, and language delays Those who are blind or have uncorrectable visual impairment Children with cleft palate, with or without an associated syndrome Children with developmental delay
Pharmacotherapy
Pharmacologic management of otitis media with effusion (OME) includes administration of antimicrobial agents, steroids, antihistamines and decongestants, and mucolytics.
Antimicrobial agents
Because otitis media with effusion demonstrates viable pathogenic bacteria, treatment with appropriate antibiotics is reasonable, albeit with evidence showing only short-term benefit.[9] Studies of erythromycin, sulfisoxazole, amoxicillin, amoxicillin-clavulanate, and trimethoprimsulfamethoxazole have demonstrated clearance rates faster than those of a placebo, although the difference is barely statistically significant in most of these trials. A large meta-analysis of findings from 10 blinded, randomized controlled trials involving 1041 children with otitis media with effusion revealed that resolution of middle ear effusion (MEE) was significantly more likely in the patients treated with antimicrobials than in those treated with placebo or those receiving no treatment. The difference was noted at short-term (2- to 5-wk) follow-up. The findings of 2 other meta-analyses did not demonstrate a difference between antimicrobials and placebo with 6- to 11-week follow-up period. When the otitis media with effusion becomes chronic (3 mo), the effectiveness of antimicrobials diminishes, although this finding is controversial. Studies published between 2002 and 2004 and cited by the clinical practice guidelines for otitis media with effusion also demonstrate clearance of middle ear effusion with antibiotics; however, they also show rapid and frequent recurrence.
Steroids
In 3 placebo-controlled randomized clinical trials, oral steroids alone did not improve otitis media with effusion clearance within 2 weeks of treatment. When oral steroids are combined with antibiotics, the rate of clearance of middle ear effusion does not improve compared with the rate with antibiotics alone. A couple of small studies of topical nasal steroid sprays (vs placebo) have demonstrated fewer effusions at 4 and 8 weeks, as well as improved middle ear pressure at 12 weeks. Empirical evidence indicates that these medications show promise. To the author's knowledge, only one randomized study has been published comparing intranasal steroids (beclomethasone) and antibiotics to antibiotics alone.[10] This study demonstrated no statistically significant difference between the 2 arms. A 2011 meta-analysis confirmed these findings.[11] Another study found that topical intranasal steroids, alone or in combination with antibiotics, have no long- or short-term benefit in the management of children with otitis media with effusion.[12] Williamson et al found that topical intranasal corticosteroids are very unlikely to be effective for treating otitis media with effusion.[13] In a double-blind, randomized, placebo-controlled trial in 207 children aged 4-11 years with persistent bilateral otitis media with effusion, children received either mometasone, 50 mcg in each nostril, or placebo spray once daily for 3 months. Tympanometric clearance in one or both ears at 1, 3, and 9 months was 40.6%, 58.1%, and 55.6%, respectively, in the steroid group; in the placebo group, it was 44.9%, 52.3%, and 65.3%, respectively.[13] Absolute risk reduction at 1 month was -4.3.
Antihistamines and decongestants

In the largest study to date, Cantekin and others randomly assigned 553 children with chronic otitis media with effusion (COME) to receive an antihistamine/decongestant or placebo and found no difference in the clearance rates of the effusion.[14] A 2011 meta-analysis confirmed these findings.[15] That antihistamines increase the viscosity of secretions may account for this finding. The viscosity of chronic otitis media with effusion is often substantial; thus, it is aptly termed glue ear in these cases. This condition can also manifest as a serous effusion. However, nasal obstruction, rhinorrhea, and sinusitis often accompany otitis media, and antihistamines and decongestants may be considered for the relief of these associated symptoms. This is particularly true if the inciting cause is allergies. Antihistamines, as the name suggests, prevent the degranulation of mast cells and subsequent release of histamine, which can lead to mucosal engorgement with resultant increase in nasal obstruction and an increase in the production of mucus.
Mucolytics
A large, randomized, controlled study of 430 children revealed that clearance rates for otitis media with effusion did not significantly improve with mucolytics versus placebo. Findings of 2 smaller trials of other mucolytics confirmed this result.
http://emedicine.medscape.com/article/858990-treatment#aw2aab6b6b3
11. Topical Nasal Steroids

Class Summary
Results of small trials have shown that nasal steroids speed the clearance of otitis media with effusion (OME) and prevent its recurrence. A 2011 meta-analysis confirmed these findings.[11] However, to the author's knowledge, no large randomized trials have been performed to confirm this finding.
http://emedicine.medscape.com/article/858990-medication#2
12. Otitis Media Treatment & Management
Author: Muhammad Waseem, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP
http://emedicine.medscape.com/article/994656-treatment
Patients in whom OME is unresponsive to medical therapy and with an MEE that persists more than 12 weeks should be referred to an otolaryngologist to discuss surgical options in conjunction with further medical therapies. o o o o o Antimicrobial therapy No clinical guidelines or consensus recommendations suggest which antimicrobials to use as firstline agents for OME. In this era of increasing antibiotic resistance, selection of an antibiotic agent should be individualized to the patient. In each patient, consider prior experience with antibiotics, age, sex, and daycare attendance. If penicillin allergy is not a concern and if the patient has no recent exposure to antibiotics, a reasonable choice for initial therapy is amoxicillin, administered at the same high dose recommended by the CDC for AOM (ie, 80-90 mg/kg/d). A reasonable first choice in a patient with antibiotic exposure during the prior month is trial administration of a beta-lactamasestable agent (eg, amoxicillin/clavulanate) or a second- or thirdgeneration cephalosporin. As with antimicrobial selection, no recommendations have been made regarding duration of therapy; 10 days is reasonable for amoxicillin, amoxicillin/clavulanate, and cephalosporins. Studies of prolonged treatment in patients with OME show no advantage in therapies that last longer than 10 days. Steroid therapy The literature on steroid treatment is inconclusive. In 1994, the Agency for Health Care Policy and Research (AHCPR) reviewed more than 5000 articles concerning the management of OME and published a clinical practice guideline on the topic.[22] The review reported that a combination of steroids plus antibiotics improved clearance of MEE in 25.1% of patients. This difference did not meet statistical significance standards, and the panel felt the risks of steroid administration outweighed potential benefits. The final guideline states, "steroid medications are not recommended for treatment of OME in a child of any age." Since publication of the AHCPR guideline, another investigation of steroids plus antibiotics to treat OME has been published by Rosenfeld.[23] Rosenfeld reported that surgery was avoided or postponed for 6 months in 1 of 4 children treated with steroids. Therefore, steroid administration may have a role in patients who are not good surgical candidates. The steroid regimen should be oral prednisone or prednisolone at a dose of 1 mg/kg/d for 5-7 days, administered in combination with a beta-lactam antibiotic. Steroids are contraindicated in patients with exposure to varicella who have not received the varicella vaccine because of the possibility of life-threatening disseminated disease.
o o
Controversy continues over the optimal management of OME. The AHCPR guideline, although criticized for having a narrow scope, for favoring medical rather than surgical management of OME, and for minimizing the problem of drug-resistant bacteria, provides a framework with which to consider management options.
Controversy regarding the need for treatment of otitis media has been found in recent literature, but most physicians agree on its benets (15). A. otitis is resistant to sulfamethoxazole-trimethoprim and often to erythromycin (3), but it does not have a beta-lactamase.

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2.

Antihistamine-Antibiotic Combo Speeds Resolution of Otitis Media

Nasal Steroid Spray May Not Help Eustachian Tube Dysfunction

Antibiotics for otitis media with effusion.

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Otitis media with effusion.

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Int J Pediatr Otorhinolaryngol. 2012; 76(5):623-35 (ISSN: 18728464)

Otolaryngol Head Neck Surg. 2008; 138(6):778-81 (ISSN: 01945998)

J Otolaryngol. 2005; 34 Suppl 2:S64-9 (ISSN: 0381-6605)

Cochrane Database Syst Rev. 2005; (1):CD001801 (ISSN: 1469493X)

Otitis media with effusion in children. X

Clin Evid (Online). 2011; 2011 (ISSN: 1752-8526)

Otitis Media With Effusion Treatment & Management

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12. Otitis Media Treatment & Management

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