Debu Mukhopadhyay wrote: > > Dear Doctor Friends and Colleagues, 12 June 1997 > > I am writing to seek your guidance regarding the medical problem > 'paediatric otitis media'. Although I am a doctor (with specialisation > in anaethesiology) and also the mother of the child concerned, we live > in a third world country and have certain constraints in obtaining the > latest medical wisdom here. My husband got your address by searching the > internet, a relatively new technology for us and I am using his email. > The brief case report is as follows. > > My infant son, born on 4 April 1996, suffers from frequent attacks of > otitis media. He is a full-term, vaginally delivered mature baby of > Apgar score 10. For the first four months he had only breast milk, no > supplementary food was given. He preferred breast feeding in lying > position. From the very first month watering from nose and sneezing were > of common occurrence. When he was about five months, a purulent > discharge was noticed for the first time from his left ear. Amoxycillin > suspension was started immediately (125 mg tab, 1/2 tab thrice daily) > but two days later purulent discharge from right ear also began. > Amoxycillin was continued but the clinical response was unsatisfactory. > > A culture test showed the growth of staphylococcus aureus, sensitive to > ampicillin and erythromycine etc. Augmentine (amoxycillin + clavulanic > acid - 5 ml thrice daily) was administered and continued for a course of > five days. Discharge from both ears diminished. About a month later he > had cough and cold. Antihistaminic drug and nasal drop were used right > away, but within two days purulent discharge from right ear occurred. > Augmentine was once more given for a period of seven days. Local > toiletting with rectified spirit was performed two to three times daily. > After doing otoscopy, the concerned ENT surgeon diagnosed central > perforation in both ears. Since October '96 till date my son has had > several attacks of otitis media, necessitating the use of antibiotics. > > During March '97 he was given Keflor (cefaclor) for two weeks. Since > then, he has had no aural discharge, but with changes of temperature and > humidity he becomes restless and sticks a finger into one of his ears, > as if in discomfort. I am afraid of perforation again. Our ENT surgeon > advises us to avoid cold and coughing, but, for a baby, specially having > a suspected allergic background, that's difficult to do. Frequent use of > antibiotics may affect his growth, immunity etc, I am afraid. He does > not seem to have a hearing problem. > > I seek advice on what the latest effective treatment is. How can future > complications best avoided? What all can be done to prevent the child > catching a cold? What should be done if purulent discharge comes out > through the ears again? Is local toiletting along with systemic anti- > histamine and nasal decongestant sufficient for therapy? Is the use of > antibiotics mandatory? Should we perform any special tests? > > With best regards, > > Dr Chandra Mukhopadhyay E-mail: > Department of Anaesthesiology Phone: 091-033-3375345 (extn 349) > SSKM Hospital Telefax: 091-033-3374637 > Calcutta 700 020 INDIA Home Phone: 091-033-4664299 > We just had a conference on otitis media through international pediatric chat, as our Sun. afternoon CME session where people from all over the world meet with a moderator who leads discussion. I think you would have enjoyed it. As far as prevention, that is hard to do. O.M. is often associated with URI's or allergic rhinitis but may occur separately. Colds are difficult to prevent but occur more frequently in daycare or crowded facilities with a coinciding increase in otitis media. I am not aware of cold air or winds contributing. Breast feeding helps but you're already doing that. Smoking should be avoided. Spontaneous perforations generally resolve quickly after an acute otitis. I understand the last om was in March. Things are presumably stable now so i do not think further intervention is required, if there is not a persisting bil effusion. If there are recurrent draining ears or a bilateral MEE persisting for longer than 3-4 months, t-tubes would be considered. For a persistent bilat effusion, I am interested in language development, which will give me further info as to how aggressive I should be. If language is delayed, (not relevant so much during infancy) I arrange for audiology to assess. More recent literature refutes the use of anti-histamines and decongestants to treat om and colds. No better than placebo. Anti-histamines may help if allergic rhinitis component but i think that as well may be controversial. I often use amoxil and topical otic drops like garasone (latter for 5 days). Amoxil has relatively low mic's against pneumococcus, the more virulent organism, and hence is recognized as the drug of choice. If things are not improving after 48-72 hrs, I would try a p.o. antibiotic that is b-lacatamase resistant and effective against the more benign non-typable h. flu and moraxella catarrhalis, like clavulon (but high incidence of diarrhea), cefuroxime, pediazole or biaxin. Randomized trials have not shown significant clinical advantage of the more expensive antibiotics over amoxil. This may be related however to the fact that 80-85 % of om gets better without antibiotics, so a very large sample size is required. If one's child is quite sick, tympanocentesis conducted by ent is not unreasonable, with cultures and sensitivities to be followed. Over the last 5 years, I have never had to proceed that way. I don't normally swab otic d/c for c and s unless not responding as was in your case. I wonder if the s. aureus was colonizing the canal as opposed to being a pathogen, as staph is considered to rarely cause om (? 1-2%) As far as duration, some now are suggesting 5 days instead of the traditional 10 day emperically established course. I use the 10 days for 6 months and under, 7-10 days for 2 yo and under and 5 day courses thereafter, with some variation but this is my preference and not CDC consensus. follow up of otitis media is changing. Some argue f/u at 3 months when less than 3 yo, and no f/u after 3 if language is ok and asymptomatic. I've been seeing them at 6 weeks, just to document if an effusion is present. If so, and asymptomatic, I would not tx. but rather see them again in another 6 weeks if bilateral, and later if unilateral. If persisting bilateral effusion i would refer to ent. If unilateral effusion and language and hearing is not problematic, I may wait 6 months to 1 year of persisting effusion before consulting ent. In the past, we have been following up asymptomatic pts. in 10-21 days. This has led often to the cyclical use of unnecessary antibiotics to treat middle ear effusions that is normally present for up to 3 months. Sticking fingers in ears may not have anything to do with o.m. but do warrant an assessment. As far as recurrent otitis media, is concerned, I do not generally proceed with an immunological work up in a thriving child who is otherwise well. Otitis media is a tremendously controversial topic with management strategies changing quickly. I'm sure others will have lots to say as well from a different perspective. Brad