Treatment of acute otitis media

The main thing in the treatment of acute otitis media is the restoration of the patency of the auditory tube, which is easily achieved by the use of vasoconstrictive drops in the nose and by usual physiotherapeutic procedures. Sometimes, if this does not help, apply a simple blowing of the ears through the nose (according to Politzer). Beginning with 3-4 years, and in older children with a unilateral process - catheterization of the auditory tube. Antibiotics for acute catarrhal otitis media do not apply.

Indications for consultation of other specialists

Given the association of acute otitis media with respiratory and other childhood infections, infectious disease counseling can be indicated, with the appearance of symptoms of refractory intracranial complications, the neurologist and the neurosurgeon.

Medication for acute otitis media

Principles of choosing antibiotics for acute otitis media:

• activity against the most likely pathogens (pneumococcus, haemophilus rod);
• the ability to overcome the resistance of these pathogens to an antibiotic if it is prevalent in a given region or population;
• the concentration of antibiotic in the middle ear fluid and serum is above the minimum inhibitory concentration for this pathogen and the concentration in the serum is maintained above the minimum inhibitory concentration within 40-50% of the time between drug intake.

If a decision is made to prescribe an antibiotic, amoxicillin should be the drug of choice. Of all available oral penicillins and cephalosporins, including cephalosporins II-III generation, amoxicillin is the most active against penicillin-resistant pneumococci.

As is known, amoxicillin was obtained as a result of some modification of the ampicillin molecule. However, this had a significant effect on its pharmacokinetics: twice as high as in ampicillin, the blood level, which is much lower than the frequency of undesirable reactions from the digestive tract and the convenience of admission. Amoxicillin is taken 3 times a day, regardless of the time of reception of food, whereas ampicillin should be taken 4 times a day for 1 hour before or 2 hours after a meal, because the food reduces the bioavailability of this antibiotic in 2 times.

However, amoxicillin, like ampicillin, is destroyed by beta-lactamases, which can produce a hemophilic rod and moraxella. That is why the combination of amoxicillin with the beta-lactamase inhibitor-clavulanic acid, known generically as amoxicillin / clavunate or co-amoxiclav, was deservedly widespread in the treatment of OSO. To the action of beta-lactamases, cefuroxime and ceftriaxone are stable. That is why an alternative to amoxicillin, especially with relapses of otitis or inefficiency of treatment, can be amoxicillin / clavulanate, cefuroxime (axetil) for ingestion or intramuscularly ceftriaxone for one injection per day for 3 days.

Macrolides are currently considered as second-line antibiotics, mainly used for allergy to beta-lactams. Unfortunately, macrolides in otitis use mainly erythromycin, but it does not have activity against the hemophilic rod, it is very bitter, it causes a lot of undesirable reactions from the digestive tract, etc. New macrolides (azithromycin, clarithromycin) have a higher activity against the hemophilic rod, compared with erythromycin. However, eradication of pneumococcus and hemophilic rod using this group of antibiotics is much lower than with the administration of amoxicillin. Their advantage is undeniable in children with allergies to beta-lactams. Perhaps in the future the use of macrolides will expand (after clarifying the role of atypical pathogens), primarily Chlamydia pneumoniae, with acute otitis.

Especially it should be said about the attitude to such a common drug as co-trimoxazole (biseptol, septrin, etc.). According to pharmacoepidemiological data, it is prescribed in more than 1/3 of cases of otitis media in children. This practice can not be considered correct, since co-trimoxazole is marked by a high level of resistance of pneumococcus and hemophilic rod. In addition, in general, the use of co-trimoxazole should be drastically reduced due to the possibility of developing severe unwanted reactions from the skin (Stevens-Johnson and Lyell syndromes). The risk of developing these syndromes with co-trimoxazole is 20-30 times higher than when using penicillins or cephalosporins.

As for the appointment of antibiotics in acute otitis media, there is no unanimous opinion among specialists, as in 60% of cases, recovery comes without their application. In antibiotics, in fact, only 1/3 of children with acute otitis media are needed, in which the eradication of the pathogen leads to a faster recovery, but it is difficult and sometimes impossible to identify such patients. That is why the answer to the question of the prescription or non-assignment of an antibiotic depends on such factors as age of the child, accompanying and background diseases, ENT history, socio-cultural level of parents, availability of qualified medical care, and most importantly - severity of the disease course.

In children under two years old at a temperature above 38 ° C, symptoms of intoxication should immediately be prescribed antibiotics due to the danger of rapid development of complications. At an older age in the first day with mild general symptoms, you can restrict analgesics (paracetamol, ibuprofen) and local treatment (vasoconstrictor drugs in the nose, etc.). If the condition does not improve within 24 hours, antibiotics are prescribed.

After the appointment of an antibiotic 48-72 hours, the general condition is re-evaluated. If it has not improved, it is necessary to change the antibiotic, for example, instead of amoxicillin, use amoxicillin / clavulanate or cefuroxime. It is highly desirable to carry out a paracentesis (or tympanopuncture) with a bacteriological study of the material obtained. The duration of the antibacterial course is 7 days, by this time the exudate in the tympanum and, consequently, the hearing loss usually still persist.

The route of administration of antibiotics

In the vast majority of cases, antibiotics should be administered orally. Parenteral administration should be an exception, especially in outpatient practice. It is very important that the antibiotic has good organoleptic qualities (taste, aftertaste, odor, consistency and others), since with an unpleasant taste it will be very difficult to get a child to take the drug. That is why we should strive to ensure that children of preschool age do not receive "adult" tablets, but suspensions and syrups.

Of course, if there is a suspicion of complications of acute otitis media or a withdrawal from ingestion, parenteral administration of antibiotics in a hospital setting should be used.

The local use of antibiotics is to use ear drops with antibacterial drugs. The effectiveness of such treatment is more than doubtful. Antibiotics, which are part of these drops, simply do not penetrate through the perforated tympanic membrane. If the perforation exists and pus is released, their concentration in the exudate of the tympanic cavity is very small and does not reach the therapeutic one. In addition, care should be taken with the use of ear drops containing ototoxic antibiotics (neomycin, gentamicin, polymyxin B), especially with perforated otitis media.

Systemic antibiotic therapy is the main method of treating OSO in children, but it must necessarily be combined with rational local treatment conducted by the otorhinolaryngologist (paracentesis, tympanopuncture, anemia of the auditory tube, vasoconstrictor drugs in the nose, active therapy of concomitant acute ENT diseases), its goal is complete recovery auditory function, serving as the main criterion for curing acute otitis media.

Treatment of recurrent otitis media should be done in two stages. At the first stage, the treatment is aimed at eliminating the current exacerbation. They produce the toilet of the ear, simultaneously prescribe conservative treatment of concomitant inflammatory diseases of the ENT organs. Antibiotics are rarely used at this stage. However, the second stage is considered the main thing, its goal is the prevention of subsequent relapses. Treatment at this stage must necessarily be comprehensive, it should be conducted in conjunction with the pediatrician. Of great importance is the identification of causes of a general nature. For example, in infants, sometimes only changes in the feeding regimen of nursing mothers lead to the cessation of recurrence of otitis media. There are data that in children with recurrent otitis media there are immune disorders. In connection with this, various drugs with immunomodulating activity are introduced into the treatment regimen. However, there is no convincing data on the effectiveness of such drugs as dibazol, Y-globulins, and many others.

During the remission period, active local conservative and surgical treatment is carried out aimed at restoring the ventilation function of the auditory tube. They produce pneumo- and vibromassage of the tympanic membrane, purging, use vasoconstrictive drops, unsweetened chewing gum, if necessary - treatment of sinusitis, adenotomy and tonsillotomy. It should be remembered, in some cases, one removal of adenoids does not lead to restoration of patency of the auditory tube, but should be combined in the future with gymnastics for the development of its muscles, electroreflexotherapy, vibro- and pneumomassage of tympanic membranes.

In most cases, this complex conservative treatment leads to the cessation of recurrence of otitis media. However, there is a persistent current, when, in spite of the restored function of the auditory tube, targeted antibiotic therapy and the use of all measures of general influence on the child's organism, the recurrences of the disease continue. They are explained more often by destructive bone changes in the mastoid process, so in such cases it is necessary to resort to surgical treatment.

Forecast

In most cases, acute otitis media is favorable.

The danger of recurrent middle otitis media is, first, in a persistent hearing loss in young children, this largely affects the overall intellectual development and the formation of speech. If suspected of such persistent deafness, the child should be examined by a specialist, since at present there are all possibilities for an accurate audiological diagnosis. Secondly, recurrent middle otitis media can lead to the formation of a stable perforation of the tympanic membrane, that is, chronic otitis media.

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Prevention of acute otitis media

Breastfeeding for 3 months significantly reduces the risk of acute otitis media during the first year. Given the relationship of acute otitis media with a seasonal surge in incidence, it is recommended that prevention of cold infections should be carried out according to generally accepted protocols.