Is acute otitis media a treatable disease?

In this issue of the Journal, investigators in Pittsburgh and in Turku, Finland, respond to the question of whether infants and young children with acute otitis media benefit from amoxicillin– clavulanate therapy initiated at the time of diagnosis.1,2 Physicians who cared for children 50 years ago would be surprised — more likely shocked — that the question is being asked. Before antimicrobial agents were introduced, acute otitis media was a severe event in infants. In 1932, acute otitis media and its suppurative complications accounted for 27% of all pediatric admissions to Bellevue Hospital.3 Mastoiditis and suppurative intracranial complications were common. The introduction of effective antimicrobial agents reduced the severity of acute otitis media, and the use of an appropriate antimicrobial agent soon became the standard of care. Today, severe acute otitis media and its complications still occur, but mostly in children who live in regions with limited access to medical care. Beginning in the 1980s, investigators in Western Europe suggested that children with acute otitis media could initially be observed rather than treated immediately with an antimicrobial agent. Van Buchem and colleagues in the Netherlands found that infants could initially be given an analgesic agent and nose drops; antimicrobial agents were administered only if the illness persisted for 3 days or longer.4 Other studies from centers in Western Europe, Britain, and the United States appeared to corroborate the Dutch observations. However, each of the studies had substantial flaws in study design, including the lack of precise criteria for the diagnosis of acute otitis media, participation of physicians who were not validated otoscopists, inadequate sample size, inclusion of older children, inclusion of children who had minimal or uncertain signs of disease, and ambiguous end points for cure or failure. Wald pointed out that the evidence from these studies was insufficient to conclude that acute otitis media in children could be safely managed without antimicrobial agents.5 Nevertheless, in 2004, the American Academy of Pediatrics and the American Academy of Family Physicians endorsed a guideline that recommended initial observation rather than immediate antimicrobial therapy for the management of acute otitis media in selected children.6 How did the perception of acute otitis media change from a severe disease with suppurative complications in the pre-antibiotic era to a modest illness that could be considered for management by observation alone in the 1980s? Four factors probably contributed to this change: First, access to medical care has changed. In the pre-antibiotic era it is probable that only children with severe acute otitis media were brought to a doctor for medical attention. Since there was no effective therapy, and medical care was expensive, most children with earaches were given hot compresses at home instead of being brought to the doctor. Today there are more appointments with physicians for sick and well visits and more opportunities for the diagnosis of mild acute otitis media. Second, the method of diagnosis has changed. In the pre-antibiotic era, the diagnosis of acute otitis media was often made when the tympanic membrane was perforated or when myringotomy was performed for incision and drainage of the middle-ear abscess. Today, myringotomy is almost never performed in the office setting. The diagnosis of acute otitis media is based on otoscopic