Acute otitis media affects two thirds of American children by 2 years of age, and chronic otitis media affects two thirds of children younger than the age of 6.¹ Otitis media is the most common diagnosis in children and is the leading cause of all visits to pediatricians. It is the main reason for antibiotic and surgical interventions in kids. Children diagnosed with otitis media during infancy are also at greater risk for developing late-onset atopy, such as allergic eczema and asthma during the school-age years. The more frequent the otitis, the stronger these associations.² A conservative estimate is that approximately $4 billion to $8 billion is spent annually on the medical and surgical treatment of earache in the United States.

Standard Medical Treatment

The standard medical approach to otitis media in children is to administer antibiotics, analgesics (e.g., acetaminophen), or antihistamines. If the ear infection is long standing and unresponsive to the drugs, surgery is performed. The surgery involves the placement of a tiny plastic myringotomy tube through the eardrum to facilitate the normal drainage of fluid into the throat via the eustachian tube. It is not a curative procedure, since children with myringotomy tubes in their ears are in fact more likely to have further problems with otitis media.

Myringotomies are currently being performed in nearly 1 million American children each year. It appears that the unnecessary surgery of the past, the tonsillectomy, has been replaced by this new procedure. In fact, there is a direct correlation between the decline of the tonsillectomy and the rise of the myringotomy. More than 2 million myringotomy tubes are inserted into children’s ears each year in addition, there are also 600,000 tonsillectomies and adenoidectomies. These surgeries are unnecessary for most children.

A 1994 evaluation of the appropriateness of myringotomy tubes in children younger than 16 years of age in the United States found that only 42% were judged to have been appropriate.³ These results mean that several hundred thousand children are subjected to a procedure that will do them little good and possibly significant harm.

A number of well-designed studies have demonstrated that there were no significant differences in the clinical course of acute otitis media when conventional treatments were compared with placebo. Specifically, no differences were found between nonantibiotic treatment, ear tubes, ear tubes with antibiotics, and antibiotics alone.⁴^–⁸ Interestingly, in some studies children not receiving antibiotics did have fewer recurrences than those receiving antibiotics. This reduced recurrence rate is undoubtedly a reflection of the suppressive effects antibiotics have on the immune system while also disturbing the normal flora of the upper respiratory tract.⁹

Because most children with acute otitis media (70%-90%) have spontaneous resolution within 7 to 14 days, antibiotics should not initially be routinely prescribed for all children.^8,¹⁰ Extensive reviews of the scientific literature on the value of antibiotics in the treatment of otitis media over the past 30 years have led to the following conclusions:

• The benefit of routine antimicrobial use for otitis media, judged by either short- or long-term outcomes, is unproved.

• Existing research offers no compelling evidence that children with acute otitis media routinely given antimicrobials have a shorter duration of symptoms, fewer recurrences, or better long-term outcomes than those who do not receive them.

• Although the prevention of mastoiditis and meningitis is a rationale for antimicrobial treatment, little evidence exists that routine treatment is effective for this purpose.

• Antimicrobials did not improve outcome at 2 months, and no differences in rates of recovery were found for either antimicrobial type or duration.

Whereas these results have been accepted by some U.S. pediatricians, others still rely heavily on antibiotics to treat otitis media. Instead of antibiotics, the recommendation from this group of experts was to use analgesics (e.g., acetaminophen) and for the caregiver to keep a close watch. Results of clinical trials have shown that more than 80% of children with acute otitis media respond to a placebo within 48 hours. Although analgesics may be of use to limit the child’s pain, they have their own toxicity profile. We therefore recommend other proved pain-relieving options like botanical eardrops as a replacement analgesic (see later).

Apart from the fact that antibiotics are not very effective in otitis media, their widespread use and abuse is becoming increasingly alarming. Risks of antibiotics include allergic reactions, gastric upset, accelerated bacterial resistance, and unfavorable changes in nasopharyngeal bacterial flora. Antibiotics not only fail to eradicate the organisms but can induce middle-ear superinfection. Moreover, antibiotic prescribing can increase the rate of return office visits and the likelihood of seeking medical care for future illness.¹¹ Additionally, studies on concomitant antibiotic and steroid treatment have revealed poor results on long-term efficacy for chronic otitis media.¹²

Antibiotics are encouraging the near-epidemic proportion of chronic candidiasis sufferers as well as the development of “superbugs” that are resistant to currently available antibiotics. The position of the American Academy of Otolaryngology–Head and Neck Surgery states that there is no evidence indicating that systemic antibiotics alone can improve treatment outcome and that these agents should not be used save the situation of an underlying systemic infection.¹³ According to many experts as well as the World Health Organization, we are coming dangerously close to arriving at a “postantibiotic era” in which many infectious diseases will once again become almost impossible to treat because of an overreliance on antibiotics (see Chapter 56 for further information).¹⁴

The bottom line is that otitis media is normally a self-limited disease. It normally remits on its own regardless of treatment. High rates of spontaneous resolution have been well documented in the medical literature. Three meta-analyses independently found that approximately 80% of children with acute otitis media had spontaneous clinical relief within 2 to 14 days. Some studies of children younger than 2 years of age do suggest a lower spontaneous resolution of about 30% after a few days.¹¹

The risks and failure with antibiotics, when coupled with the high rate of spontaneous resolution and the high recurrence rate of otitis media following the insertion of ear tubes, suggest that conservative (nonantibiotic, nonsurgical) treatment alone would reduce the incidence of otitis media and decrease the associated yearly financial costs. To examine this concept, the authors of one clever study gave the caregivers of children with nonsevere acute otitis media a “safety prescription” of antibiotics to be filled only if there was no improvement within 2 days. This method of “wait and see” reduced median antibiotic prescriptions by 31%, compared with 12% in a control practice.¹⁵

Although standard antibiotic and surgical procedures may not be statistically effective, each child must be evaluated individually and appropriate follow-up including physician-family communication should be devised and assured before a decision not to use these procedures is made. Special circumstances in the interest of preventing hearing loss–induced developmental delays would suggest a more appropriate use of ear tubes.

Finally, pneumococcal and viral vaccines have been designed but have also shown little benefit, probably due to the multifactorial nature of this condition.¹¹ Given the inherent risks and complications, vaccinations do not appear to be warranted at this time.

Causes

The primary risk factors for otitis media are as follows ¹:

All of these factors share a common mechanism—abnormal eustachian tube function, the underlying cause in virtually all cases of otitis media. The eustachian tube regulates gas pressure in the middle ear, protects the middle ear from nose and throat secretions and bacteria, and clears fluids from the middle ear. Swallowing causes active opening of the eustachian tube owing to the action of the surrounding muscles. Infants and small children are particularly susceptible to eustachian tube problems because in them the tube is smaller in diameter and more horizontal.

Obstruction of the eustachian tube leads first to fluid buildup and then, if the bacteria present are pathogenic and the immune system is impaired, to bacterial infection. Obstruction results from collapse of the tube (due to weak tissues holding the tube in place, an abnormal opening mechanism, or both), blockage with mucus in response to allergy or irritation, swelling of the mucous membrane, or infection.

Otitis media may also have a genetic component; in twin studies, monozygotic twins tend to have a higher concordance rate in otitis media histories than dizygotic twins.¹¹ Although immunoglobulin markers¹⁶ and human leukocyte antigen (HLA)¹⁷ have also been a focus of research, no specific genetic associations have been elucidated thus far. Research has also shown that children with blood type A have about a 50% higher rate of infection and are susceptible to more severe and repeated bouts of ear infection. Children whose mothers are blood type A who have ear infections before 1 year of age have a relatively greater risk of having recurrent ear infections of an astounding 2677%.¹⁸