Primary care management of otitis media among Australian children

Hasantha Gunasekera, Tony E O’Connor, Shyan Vijayasekaran and Christopher B Del Mar
Med J Aust 2009; 191 (9): S55. || doi: 10.5694/j.1326-5377.2009.tb02928.x
Published online: 2 November 2009
Management of acute otitis media

Box 1 provides a summary of treatment options for AOM among Indigenous and non-Indigenous patients.

Antibiotic therapy

The microbiological pathophysiology of AOM suggests that antibiotic therapy should be effective by treating any bacteria underlying the inflammation. However, middle ear inflammation is not always accompanied by bacterial infection. Often, only viruses, and no potential pathogens, are found.10 Randomised trials comparing antibiotic therapy with controls yield very disappointing results. In most cases, antibiotic therapy makes no difference to the resolution of the pain within 24 hours, and over the following few days, most (15 out of 16 patients) gain no reduction of pain.11 Antibiotic therapy makes no difference to persistent conductive hearing loss caused by middle ear effusion. Its marginal benefits are offset by the common (although usually mild) adverse effects of antibiotics, such as diarrhoea, rashes and abdominal pain (in one in 24).11

A search for subgroups of children who might benefit from antibiotics using meta-analysis of individual patients (rather than of the different trials) found that antibiotic therapy was more likely to be successful among children under 2 years of age with bilateral otitis media and those with discharging ears.11 However, 85% of cases of AOM resolve within a week with no treatment (Box 2). Indigenous Australian children are an exception: the Office for Aboriginal and Torres Strait Islander Health national guidelines recommend treatment of all Indigenous children with AOM with antibiotics at the initial visit.7

The unimpressive benefits of antibiotic therapy, combined with increasing anxiety about antibiotic resistance in the community, have led to decreasing antibiotic prescribing among many general practitioners.13 But there is now a void in the options for the management of AOM.


Xylitol is a low-kilojoule sugar alternative with antibacterial activity used in some chewing gums to reduce dental caries.20 It has been trialled as a preventive for AOM (with the thinking that the chewing action and xylitol would both help) and shown to be effective.21 However, evidence from more studies will be required before this can become standard practice, and chewing gum is not possible for young infants.

Tympanostomy tubes

Tympanostomy tubes (also known as ventilation tubes or “grommets”) are recommended for the treatment of recurrent AOM.22 Tympanostomy tube placement for AOM reduces recurrence rates in comparison to a course of antibiotic therapy. However, consensus has not been achieved regarding the number of episodes that constitutes clinically significant recurrent AOM. The current recommendation for tympanostomy tube placement is three or more separate episodes of AOM in 6 months, or four or more episodes in 12 months.23

Management of otitis media with effusion (glue ear)

Most new middle ear effusions clear spontaneously within 3 months, and there is no evidence to support the immediate use of antibiotic therapy following a new diagnosis of otitis media with effusion (OME).24 For these reasons, the Australian Therapeutic guidelines: antibiotic8 and American Academy of Pediatrics guidelines25 recommend observation for children with OME who do not have other risk factors, such as speech and language delays (Box 3). There is no evidence of sustained benefit from oral or topical steroids.26 Similarly, decongestants and antihistamines are of no benefit, can cause gastrointestinal or central nervous system side effects, and are not recommended. It is therefore not surprising that screening for OME has not been shown to provide any tangible benefits in the developed world.27

For children with effusions persisting for 3 months, the rate of spontaneous resolution is only about 20% over the next 3 months. In this situation, long-term oral antibiotics (2–4 weeks) may have a modest benefit.28,29 An alternative therapy with low cost, low risk of harm and with potential benefit is auto-inflation. This is essentially any action that reproduces a Valsalva manoeuvre, such as forced exhalation with closed mouth and nose, or blowing up a balloon through each nostril, to force air into the middle ear through the eustachian tube. Some trials showed impressive results, but the trials were too small to be certain of a consistent effect.30

Audiological evaluation is important to help guide further management. Children with middle ear effusions persisting longer than 3 months, those with effusions associated with bilateral hearing impairment greater than 30 dB on audiometry, and those with significant retraction pockets in the tympanic membranes should be referred to an ear, nose and throat specialist for consideration of tympanostomy tubes, and possible adenoidectomy in recurrent cases.

Tympanostomy tubes reduce the mean time with effusion by 32% over the next year and improve hearing, particularly during the first 6 months after surgery.31 Despite these clear short-term benefits, the long-term effects of tympanostomy tubes in otherwise well children with mild hearing impairments (< 30 dB) on speech, language, cognition and school performance are disappointing.32 However, these data were obtained from the developed world, where populations have lower otitis media burdens than do disadvantaged populations, such as Australian Aboriginal children; this makes generalisation to the Indigenous Australian setting problematic.

The critical period for tympanostomy tubes is when children are young, before school entry and when language skills are being developed. Recurrent and prolonged otitis media may result in poorer receptive and expressive language skills,6 and surgical intervention may improve these children’s quality of life.33,34 The benefits need to be balanced against the risks, which include the risks associated with anaesthesia,25 tympanosclerosis, and persistent perforation with or without otorrhoea. Chronic perforations occur in 2% of children after short-term tympanostomy tubes and in up to 17% of children with long-term tubes.25 Tympanostomy tubes are a common cause of chronic ear discharge.

In addition to tympanostomy tubes and the other management options described above, the parents, carers and teachers of children with OME must be made aware of the likely hearing impairment and the potential impact on behaviour. This can be ameliorated by preferential seating, non-verbal cues, and reduced background noise.25 Amplification devices are an option for children with severe and prolonged hearing impairment. These devices can be obtained from Australian Hearing following review by an otolaryngologist.

Management of chronic suppurative otitis media

Chronic suppurative otitis media should be treated with ear cleaning (“ear toilet”) and topical antibiotics.35 Ear cleaning can be achieved using tissue spears (dry mopping) or with povidone–iodine (Betadine) washouts. Ciprofloxacin drops are listed on the Pharmaceutical Benefits Scheme for Aboriginal and Torres Strait Islander children with chronic suppurative otitis media, but are not currently listed for non-Indigenous children. Ciprofloxacin drops have an advantage over dexamethasone–framycetin–gramicidin (Sofradex) drops as they are not ototoxic. If it is not clear whether the discharge is acute or chronic, the best option is to treat as for AOM with perforation — ear cleaning, topical antibiotic therapy and 14 days of oral amoxycillin. If the discharge has been present for over 2 weeks, the evidence for oral antibiotic therapy is weak. Trimethoprim–sulfamethoxazole has been shown to increase resolution rates in the short term, but by 6 weeks there was no difference between those treated with topical therapy plus oral antibiotics compared with topical therapy alone.36


Streptococcus pneumoniae and Haemophilus influenzae are two of the commonest bacterial pathogens involved in otitis media. Pneumococcal vaccination has been shown to reduce the rates of otitis media and tympanostomy tube insertion.37 However, these results were not as dramatic as expected, possibly due to infection by non-vaccine serotypes of pneumococci (“serotype replacement”) or non-typeable H. influenzae (not covered by the H. influenzae vaccination). A new second-generation pneumococcal conjugate vaccine, using the protein D of H. influenzae as a protein carrier, is more encouraging for otitis media prevention.38 Influenza infection can precede AOM, but trials examining whether influenza vaccination decreases AOM rates have shown conflicting results. A Cochrane meta-analysis is currently underway.39

Indications for specialist referral in otitis media

The sequelae of otitis media include language and learning delay and, less commonly, mastoiditis, facial nerve paralysis, meningitis, intracranial abscess, and lateral sinus thrombosis. Any illness not progressing towards resolution as expected, even when the child is taking a course of antibiotics, should be a trigger for considering specialist referral (Box 4).

  • Hasantha Gunasekera1,2
  • Tony E O’Connor3
  • Shyan Vijayasekaran3,4
  • Christopher B Del Mar5

  • 1 General Medicine, Children’s Hospital at Westmead, Sydney, NSW.
  • 2 School of Public Health, University of Sydney, Sydney, NSW.
  • 3 Princess Margaret Hospital for Children, Perth, WA.
  • 4 School of Surgery, University of Western Australia, Perth, WA.
  • 5 Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD.


Competing interests:

None identified.

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