Treatment of acute otitis media

The main thing in the treatment of acute otitis media is to restore the patency of the auditory tube, which is easily achieved by using vasoconstrictor drops in the nose and regular physiotherapy procedures. Sometimes, if this does not help, simple blowing of the ears through the nose is used (according to Politzer). starting from 3-4 years, and in older children with a unilateral process - catheterization of the auditory tube. Antibiotics are not used for acute catarrhal otitis media.

Indications for consultation with other specialists

Given the connection between acute otitis media and respiratory and other childhood infections, a consultation with an infectious disease specialist may be indicated; if symptoms of otogenic intracranial complications appear, a neurologist and neurosurgeon may be indicated.

Drug treatment of acute otitis media

Principles for choosing antibiotics for acute otitis media:

• activity against the most likely pathogens (pneumococcus, Haemophilus influenzae);
• the ability to overcome the resistance of these pathogens to antibiotics if it is widespread in a given region or population;
• the concentration of the antibiotic in the middle ear fluid and blood serum is above the minimum inhibitory concentration for a given pathogen and the concentration in the blood serum is maintained above the minimum inhibitory concentration for 40-50% of the time between doses of the drug.

If a decision is made to prescribe an antibiotic, the drug of choice should be oral amoxicillin. Of all the available oral penicillins and cephalosporins, including second- and third-generation cephalosporins, 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 significantly affected its pharmacokinetics: a level in the blood that is twice as high as that of ampicillin, a significantly lower frequency of adverse reactions from the digestive tract and ease of administration are noted. Amoxicillin is taken 3 times a day, regardless of the time of food intake, while ampicillin should be taken 4 times a day 1 hour before or 2 hours after meals, since food reduces the bioavailability of this antibiotic by 2 times.

However, amoxicillin, like ampicillin, is destroyed by beta-lactamases, which can be produced by Haemophilus influenzae and Moraxella. That is why a combination of amoxicillin with a beta-lactamase inhibitor, clavulanic acid, known under the generic name amoxicillin/clavulanate or co-amoxiclav, has deservedly become widespread in the treatment of acute otitis media. Cefuroxime and ceftriaxone are resistant to beta-lactamases. That is why an alternative to amoxicillin, especially in case of recurrent otitis or treatment failure, can be amoxicillin/clavulanate, cefuroxime (axetil) for oral administration or intramuscular ceftriaxone, one injection per day for 3 days.

Macrolides are currently considered as second-line antibiotics, they are mainly used for allergies to beta-lactams. Unfortunately, erythromycin is mainly used among macrolides for otitis, but it is not active against Haemophilus influenzae, has a very bitter taste, causes a large number of undesirable reactions from the digestive tract, etc. New macrolides (azithromycin, clarithromycin) have a higher activity against Haemophilus influenzae, compared with erythromycin. However, the eradication of pneumococcus and Haemophilus influenzae when using this group of antibiotics is significantly lower than when taking amoxicillin. Their advantage becomes undeniable in children with an allergy to beta-lactams. Perhaps in the future, the use of macrolides will expand (after clarifying the role of atypical pathogens), primarily Chlamydia pneumoniae, in acute otitis.

It is especially important to mention the attitude towards 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 cannot be considered correct, since a high level of resistance of pneumococcus and Haemophilus influenzae to co-trimoxazole is noted. In addition, in general, the use of co-trimoxazole should be sharply reduced due to the possibility of developing severe adverse reactions from the skin (Stevens-Johnson and Lyell syndromes). The risk of developing these syndromes when using co-trimoxazole is 20-30 times higher than when using penicillins or cephalosporins.

There is no unanimous opinion among specialists regarding the prescription of antibiotics for acute otitis media, since in 60% of cases recovery occurs without their use. In fact, only 1/3 of children with acute otitis media need antibiotics, in whom the destruction (eradication) of the pathogen leads to a faster recovery, but it is difficult, and sometimes impossible, to identify such patients based on clinical data. That is why the answer to the question of whether or not to prescribe an antibiotic depends on such factors as the child's age, concomitant and background diseases, ENT history, the socio-cultural level of the parents, the availability of qualified medical care, and most importantly - the severity of the disease.

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

After the antibiotic is prescribed, the general condition is re-evaluated 48-72 hours later. If it has not improved, it is necessary to change the antibiotic, for example, to prescribe amoxicillin/clavulanate or cefuroxime instead of amoxicillin. It is highly desirable to perform paracentesis (or tympanopuncture) with bacteriological examination of the obtained material. The duration of the antibacterial course is 7 days, by which time the exudate in the tympanic cavity and, consequently, hearing loss usually still persist.

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, smell, consistency, etc.), since if the taste is unpleasant, it will be very difficult to get the child to take the drug. This is why it is necessary to ensure that preschool children receive suspensions and syrups rather than "adult" tablets.

Of course, if complications of acute otitis media are suspected or oral administration is refused, parenteral administration of antibiotics should be used in a hospital setting.

Local application of antibiotics consists of using ear drops with antibacterial drugs. The effectiveness of such treatment is more than doubtful. Antibiotics included in these drops simply do not penetrate through the perforated eardrum. If there is a perforation and pus is released, their concentration in the exudate of the tympanic cavity is very small and does not reach the therapeutic level. In addition, one should be very careful when using ear drops containing ototoxic antibiotics (neomycin, gentamicin, polymyxin B), especially in perforated otitis media.

Systemic antibiotic therapy is the main method of treating acute otitis media in children, but it must be combined with rational local treatment carried out by an otolaryngologist (paracentesis, tympanopuncture, anemia of the auditory tube, vasoconstrictor drugs in the nose, active therapy of concomitant acute ENT diseases), its goal is the complete restoration of auditory function, which serves as the main criterion for recovery from acute inflammation of the middle ear.

Treatment of recurrent otitis media should be carried out in two stages. At the first stage, treatment is aimed at eliminating the current exacerbation. They perform ear toilet, and 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 most important, its goal is to prevent subsequent relapses. Treatment at this stage must necessarily be comprehensive, it should be carried out together with a pediatrician. Identifying general causes is of great importance. For example, in infants, sometimes only changes in the diet of nursing mothers lead to the cessation of otitis relapses. There is evidence that children with recurrent otitis media have immune disorders. In this regard, various drugs with immunomodulatory activity are introduced into the treatment regimen. However, there is no convincing data on the effectiveness of drugs such 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. Pneumo- and vibration massage of the eardrum, blowing are performed, vasoconstrictor drops, unsweetened chewing gum are used according to indications, if necessary - treatment of sinusitis, adenotomy and tonsillotomy. It should be remembered that in some cases, one removal of the adenoids does not lead to restoration of the patency of the auditory tube, but should be combined subsequently with gymnastics for the development of its muscles, electroreflexotherapy, vibration and pneumatic massage of the eardrums.

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

Forecast

In most cases of acute otitis media - favorable.

The danger of recurrent otitis media is, firstly, in persistent hearing loss in young children, which significantly affects general intellectual development and speech formation. If such persistent hearing loss is suspected, the child should be examined by a specialist, since at present there are all the possibilities for an accurate audiological diagnosis. Secondly, recurrent otitis media can lead to the formation of persistent perforation of the eardrum, that is, to chronic otitis media.

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Prevention of acute otitis media

Breastfeeding for 3 months of life significantly reduces the risk of acute otitis media during the first year. Given the association of acute otitis media with a seasonal surge in morbidity, it is recommended to carry out prevention of colds according to generally accepted protocols.