• University of Michigan Health System (UMHS). Otitis media. Ann Arbor (MI): University of Michigan Health System (UMHS); 2007 July. 12 p. [13 references]

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Otitis media. Ann Arbor (MI): University of Michigan Health System; 2002 May. 12 p. [7 references]

Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text of the original guideline document for additional information, including detailed information on dosing, possible side effects, and cost of medications; risk factors; subspecialty referrals; and considerations for special circumstances. Definitions for the levels of evidence (A, B, C, D) are provided at the end of the "Major Recommendations" field.

Diagnosis

• Distinguish between acute otitis media (AOM) and otitis media with effusion (OME) in making therapeutic decisions. Symptoms of pain or fever, together with an inflammatory middle ear effusion, are required to make a diagnosis of AOM. (Refer to Table 1 in original guideline document for details.) [D]
• The presence of middle ear effusion should be determined by the combined use of otoscopy, pneumatic otoscopy, and tympanometry when necessary [D].

Therapy of Acute Otitis Media

• Recommend adequate analgesia for all children with AOM [D].
• Consider deferring antibiotic therapy for lower risk children with AOM [A].
• When antibiotic therapy is deferred, facilitate patient access to antibiotics if symptoms worsen (e.g., a "back-up" prescription given at visit or a convenient system for subsequent call-in) [D].
• Amoxicillin is the first choice of antibiotic therapy for all cases of AOM. For children under 4 years of age, amoxicillin should be dosed at 80 mg/kg/day divided twice a day (BID) for 5 to 10 days. Children 4 years of age or older can probably be treated at 40-60 mg/kg/day [C]. In the event of allergy to amoxicillin, azithromycin dosed at 30 mg/kg for one dose is the appropriate first line therapy.
• Treat AOM that is clinically unresponsive to amoxicillin after 72 hours of therapy with amoxicillin/clavulanate (amoxicillin component 80 mg/kg/day divided twice a day) for 10 days or with azithromycin 20 mg/kg daily for 3 days [C].
• Patients with significant, persistent symptoms on high-dose amoxicillin/clavulanate or azithromycin should receive 1-3 doses of intramuscular (IM) ceftriaxone [C]. The decision to use ceftriaxone should take into account the possible impact of this antibiotic on patterns of antibiotic resistance.

Therapy of Otitis Media with Effusion

• Children with middle ear effusions should be examined at 3 month intervals for clearance of the effusion [D].
• Children with evidence of mucoid effusions or anatomic damage to the middle ear should be referred to otolaryngology if effusion or abnormal physical findings persist for 3 months [D].
• Children with apparent serous effusions should be referred to otolaryngology if effusion persists for 6 months and there is evidence of hearing loss or language delay [D].
• Children with an asymptomatic middle ear effusion (no apparent developmental or behavioral problems) can be followed without referral [D].
• Parents of all children with otitis media with effusion should be informed about approaches to maximize language development in a child with a possible hearing loss [C].

Definitions:

Levels of Evidence:

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

None provided

The type of supporting evidence is identified and graded for the most significant recommendations (see "Major Recommendations").

Conclusions were based on prospective randomized clinical trials if available, to the exclusion of other data; if randomized controlled trials were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size. Expert consensus was used to formulate recommendations based on the available evidence.

• University of Michigan Health System (UMHS). Otitis media. Ann Arbor (MI): University of Michigan Health System (UMHS); 2007 July. 12 p. [13 references]

Not applicable: The guideline was not adapted from another source.

1997 Nov (revised 2007 Jul)

University of Michigan Health System - Academic Institution

University of Michigan Health System

Otitis Media Guideline Team

Team Leader: Richard Linsk, MD, PhD, General Pediatrics

Team Members: R. Alexander Blackwood, MD, PhD, Pediatric Infectious Diseases; James M. Cooke, MD, Family Medicine; R. Van Harrison, PhD, Medical Education; Peter P. Passamani, MD, Pediatric Otolaryngology

Guidelines Oversight Team: Connie Standiford, MD; William E. Chavey, MD; R. Van Harrison, PhD

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

Team Member; Company; Relationship

Alexander Blackwood, MD, PhD (None)

James Cooke, MD (None)

R. Van Harrison, PhD (None)

Richard Linsk, MD, PhD (None)

Peter P. Passamani, MD (None)

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Otitis media. Ann Arbor (MI): University of Michigan Health System; 2002 May. 12 p. [7 references]

This NGC summary was completed by ECRI on January 7, 2003. The information was verified by the guideline developer on February 4, 2003. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This NGC summary updated by ECRI Institute on January 22, 2008. The updated information was verified by the guideline developer on February 11, 2008.

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).