To treat or not to treat otitis media--that's just one of the questions.

Acute otitis media (AOM) is a middle ear infection with rapid onset of symptoms and an abnormalappearing, immobile tympanic membrane. Accounting for more than 20 million office visits a year in the United States, AOM is one of the most common reasons a child sees a family physician. By their first birthday, nearly two thirds of children will have at least one episode of AOM, and more than 90% will have one episode by age 2 years. A diagnosis of AOM is the most common reason children receive a prescription for antibiotics. Nearly $5 billion is spent each year in the United States in managing AOM; this expenditure does not take into account the disruption of child-care arrangements and work schedules. Despite the frequency and enormous associated costs of AOM, recent evidence from the medical literature has created controversy in nearly every aspect of its management. We, as family physicians, overdiagnose AOM in the United States. A busy clinician examining a squirming, uncooperative toddler with an ear canal occluded with cerumen often will err on the side of making a diagnosis of AOM to please anxious parents. Diagnostic uncertainty by primary care physicians is as high as 33% to 42%. Because symptoms and signs (eg, fever, earache, tugging of the ear, irritability, etc) are nonspecific and not always present, an accurate diagnosis of AOM requires a clear and well-illuminated view of the tympanic membrane. The light of the otoscope should work well; bulbs for most otoscopes should be changed every 2 years. Pneumatic otoscopy and tympanometry are tools useful in confirming middle ear effusion. A bulging or cloudy tympanic membrane, with or without erythema, middle ear effusion, and marked decrease or absence of tympanic membrane mobility, is nearly 100% predictive of AOM. Perforation of the tympanic membrane with purulent drainage is also diagnostic of AOM. Recent evidence has thrown into question the use of antibiotics and the length of treatment, if prescribed. The growing worldwide development of multidrug-resistant bacteria, the uncertainty of diagnosis, and that up to one third of cases of AOM are viral in origin have made popular a wait-andsee approach to the initial prescription of antibiotics, especially in many European countries. In several randomized clinical trials, antibiotics provided only a small benefit. In a meta-analysis of more than 2000 children with AOM, ear pain resolved spontaneously without antibiotics in two thirds by 24 hours and in 80% by day 7. This study estimated that 17 children would need to be given antibiotics to prevent 1 child from having some pain after 2 days, at the cost of a twofold increase in adverse reactions, such as skin rash, vomiting, or diarrhea. Minimizing the use of antibiotics in children with AOM does not increase the risks of perforation of the tympanic membrane, hearing loss, contralateral or recurrent AOM, or development of mastoiditis. In summary, the immediate prescription of antibiotics offers some benefits, but these benefits are offset by the disadvantages of increased cost, drug resistance, and adverse reactions. Watchful waiting is feasible and acceptable to most parents, with a 76% reduction in the use of antibiotics. If antibiotics are used, amoxicillin remains the drug of choice for most children. Although there are more than 1 dozen other clinically effective antibiotics approved by the Food and Drug Administration for treating AOM, none of these more expensive options has been shown to be more Submitted 28 September 2001. From the Department of Family Medicine, The Ohio State University College of Medicine and Public Health, Columbus. Address reprint requests to William F. Miser, MD, MA, Department of Family Medicine, The Ohio State University College of Medicine and Public Health, 2231 North High St, Columbus, OH 43201.