What is the most modern strategy for treating middle ear infections in children?

Question

I am trying to wrap my head around the treatment of middle ear infections in children, since my toddler is having a lot of these, and there doesn't seem to be a clear cut solution.

So far I have learned the following:

• There was a time when acute middle ear infection (the type you don't expect will heal on its own) was mostly treated surgically by an incision in the eardrum and optionally tubes in addition.
• In more modern times, antibiotics have gained popularity as a first-line treatment and surgery is reserved for cases, where antibiotics fail.
• The main worry about middle ear infections, is permanent damage to the ear and hearing loss. However, data seems to suggest, that antibiotics treatment does not appear to statistically reduce this type of complication (I am not sure if this is actually true).
• The second most important urgency factor is temporary hearing loss, which may hinder speech development.
• Some data seems to suggest, that the "tubes" solution, doesn't appear to be very effective.
• Antibiotics can be applied intranasally, via a cream or internally. Some doctors prescribe anti-viral nasal drops, while others don't. Some prescribe ear drops, others don't.
• Some people believe, that using a ultra-red lamp may help with this condition.
• Surgery is not a permanent solution, but only a solution to drain the ear. Future infections may require repeat surgical procedures.

I have visited a bunch of doctors, and have anecdotally observed the following patterns:

• Old Scool doctors in economically underdeveloped neighborhoods seem to be quick on the surgery trigger.
• Less old school, but in no way very forward thinking doctors seem to rely on internal antibiotics.
• Private doctors, or doctors, who are on the "cutting edge" are more likely to prescribe an antibiotic cream and or ear/nose drops over internal antibiotics.

So in conclusion, the therapy seems to have changed from routine surgery to heavy-handed use of antibiotics, to less heavy-handed use of antibiotics in combination with other remedies.

Since I am not a doctor, I may be completely wrong, and of course, every tool has its purpose, but I am asking about the general trend here.

What is the most current understanding, about how such infections should be tackled by physicians? What is the most "cutting edge" idea at the moment?

Am I correct in thinking, that over time, the approach has become more "hands-off", than in the past?

Please feel free to make suggestions on how to make this question better. I am trying to find out, what the most modern approach here is. Please also feel free to correct me on my list of assumptions.

Answer 1

Thank you for this most interesting question. Happy to have a fresh look on these things.

The main question is if you give or do not give medication, mainly antibiotics, steroids, antihistamines or painkillers.

Luckily there is a cochrane [1] review of studies, I think the best answer is already in just sharing the conclusion:

Authors’ conclusions: This review reveals that antibiotics have no early effect on pain, a slight effect on pain in the days following and only a modest effecton the number of children with tympanic perforations, contralateral otitis episodes and abnormal tympanometry findings at two tofour weeks and at six to eight weeks compared with placebo in children with AOM. In high-income countries, most cases of AOMspontaneously remit without complications. The benefits of antibiotics must be weighed against the possible harms: for every 14 childrentreated with antibiotics one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred ifantibiotics were withheld. Therefore clinical management should emphasise advice about adequate analgesia and the limited role forantibiotics. Antibiotics are most useful in children under twoyears of age with bilateral AOM, or with both AOM and otorrhoea. Formost other children with mild disease in high-income countries,an expectant observational approach seems justified

To be honest, Antibiotics need to be strictly reserved to really serious cases, everything else is non evidence bad practice.

I also like to highlight a review more concentrated on otitis media with effusion (fluid behind the ear drum) [2] - have a look at table 6 on page 9). Please remember it is targeted at the otitis media with effusion, still there are some really nice findings in it.

They also check on steroids and antihistamines, these are also out and are in no current guideline I know of mentioned at all. Also antiviral medication, as mentioned by you, is just something that is highly questionable in all cases and have a very limited use - for sure they are straightforward useless in infections of the ear (No Data for that, but given the limited use in general I think that is a fair assumption).

Draining is done to relief pain by draining effusion and there are in the second study some guidelines when to do it (page 33)

In [3] there is mentioned that ear drops are not studied yet, so there is no way to tell if they are working. Also they refer to nose sprays that they are having no effect on the length of the infection and outcome, but may make the feeling better if they have a blocked nose.

So in general the summary is:

-Give painkillers -Surgical could be done in more severe cases -Give antibiotics only if really neccessary as the risks outweight the benefit -Anything helping the patient to feel good is in general okay but does not change outcome

[1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000219.pub4/epdf/full Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM.Antibiotics for acute otitis media in children.Cochrane Database of Systematic Reviews2015, Issue 6. Art. No.: CD000219.DOI: 10.1002/14651858.CD000219.pub4

[2] http://www.rcot.org/pdf/ClinicalPracticeGuideline-OtitisMediawithEffusion(Update)-27-06-59.pdf Otolaryngology– Head and Neck Surgery 2016, Vol. 154(1S) S1–S41 ! American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815623467

[3] https://www.ncbi.nlm.nih.gov/books/NBK279380/