Watchful waiting works for non-severe otitis media

Pediatricians have been waiting for solid data on the effect of watchful waiting on acute otitis media for two years. That's how long it has been since the American Academy of Pediatrics and the American Academy of Family Physicians issued new guidelines offering observation as a treatment choice for non-severe AOM.

Early reports are in,and watchful waiting works for 66% of non-acute otitis media patients, said David McCormick, MD, University of Texas Medical Branch in Galveston, at the PAS Annual Meeting today in San Francisco.

"The old model was to treat all AOM patients with antimicrobials," he said. "The new model is to treat non-severe cases with watchful waiting and a safety net prescription."

Dr. McCormick reported results from a randomized trial with 226 AOM patients in 2005. In patients older than 2 years, the cure rate for watchful waiting was 66%, versus 77% for antibiotic. The recurrence rate was 13% for watchful waiting, compared to 18% for amoxicillin.

Patients younger than 2 years old fared less well, with a 56% cure rate on watchful waiting, compared to 77% on antibiotic and a recurrence rate of 44% with watchful waiting, versus 23% for antibiotic. Despite the clinical difference, however, there was no subjective advantage to antibiotic treatment. "Patient and parent satisfaction and quality of life scores were the same for the watchful waiting and antimicrobial treatment groups," Dr. McCormick said. "If we translate this study to the larger population, we have the potential to decrease antibiotic prescribing by 30% to 35% in AOM."

Current treatment guidelines separate AOM patients into severe and non-severe groups, noted Jerome Klein, MD, Boston University School of Medicine. Patients with severe AOM should be treated immediately with amoxicillin-clavulanate or, for penicillin-allergic patients, ceftriaxone. Non-severe patients can receive either amoxicillin, a cephalosporin, or observation.

The key, Dr. Klein said, is accurate diagnosis to separate non-severe and severe AOM patients. The typical pediatrician looks at 8,000 ears annually, he said. Many are using outdated equipment in their exam rooms.

"Using the same otoscope for 20 or 30 years, like using the same stethoscope, leaves you well behind the technology," he said. Modern otoscopes offer better illumination; a larger, clearer field of view; and better resolution of the typmpanic membrane.

A double-headed otosocope usually used for training is particularly useful, he said. Two eyepieces give parents a view of the tympanic membrane, which can be helpful in explaining AOM and the treatment options.

Three options pediatricians do not have are antihistamines, decongestants, and corticosteroids. Recent trials with ceftriaxone, chlorphenamine, and prednisolone show no difference in clinical outcome with the antihistamine or steroid, reported Tasnee Chonmaitree, MD, University of Texas Medical Branch in Galveston. But the use of an antihistamine prolonged middle-ear effusion from a mean of 25 days to 73 days. A 2005 Cochrane Review also found no clinical advantage to the use of antihistamines, corticosteroids, or decongestants and a similar prolongation of MEE with antihistamines.