218 / 280
Rosenfeld et al
especially
P aeruginosa
. One additional RCT assessed topical
antibiotics with and without concurrent oral antibiotics but did
not find any advantage to combination therapy.
126
Topical antibiotic therapy avoids adverse events associated
with systemic antibiotics including dermatitis,
123,124
allergic
reactions, gastrointestinal upset,
123,124
oral thrush,
124
and increased
antibiotic resistance.
121
Only topical drops approved for use
with tympanostomy tubes should be prescribed (eg, ofloxacin
or ciprofloxacin-dexamethasone) to avoid potential ototoxic-
ity from aminoglycoside-containing eardrops, which are often
used to treat acute otitis externa.
127
Otomycosis has not been
reported after topical therapy in RCTs of acute TTO,
123-125
but
prolonged or frequent use of quinolone eardrops may induce
fungal external otitis.
128,129
Caregivers should be advised to
limit topical therapy to a single course of no more than 10
days. Last, although systemic quinolone antibiotics are not
approved for children aged 14 years or younger, topical drops
are approved because they do not have significant systemic
absorption.
Acute TTO usually improves rapidly with topical antibiotic
therapy, provided that the drops can reach the middle ear
space.
18
This is most likely to occur if the ear canal is cleaned
of any debris or discharge before administering the drops, by
blotting the canal opening or using an infant nasal aspirator to
gently suction away any visible secretions.
3
Any dry crust or
adherent discharge can be cleaned using a cotton-tipped swab
and hydrogen peroxide, which can be used safely when a tym-
panostomy tube is present.
130
Persistent debris despite these
measures can often be removed by suctioning through an open
otoscope head or by using a binocular microscope for visual-
ization. In addition, having the child’s caregiver “pump” the
tragus several times after the drops have been instilled will aid
delivery to the middle ear.
116,131
Last, caregivers should be
advised to prevent water entry into the ear canal during peri-
ods of active TTO.
Systemic antibiotic therapy is not recommended for first-
line therapy of uncomplicated, acute TTO but is appropriate,
with or without concurrent topical antibiotic therapy, when:
1. Cellulitis of the pinna or adjacent skin is present
2. Concurrent bacterial infection (eg, sinusitis, pneu-
monia, or streptococcal pharyngitis) is present
3. Signs of severe infection exist (high fever, severe
otalgia, toxic appearance)
4. Acute TTO persists, or worsens, despite topical anti-
biotic therapy
81
1
Has the child had bilateral
COME and documented
hearing difficulty?
Offer tympanostomy
tube insertion
Educate caregivers and
proceed with
tympanostomy tube
placement
Clinician may perform
tympanostomy tube
insertion
Is the child
considered ‘at
risk’?
Reevaluate child until OME
resolves, persists 3 months or
longer, or is associated with a
type B (flat) tympanogram
Does the child have
unilateral or bilateral
chronic OME or a type B
(flat) tympanogram?
Does the parent or
guardian agree with
tympanostomy
tube insertion?
No
Yes
Yes
Yes
Yes
Yes
Yes
Has the child had
unilateral or bilateral
chronic OME and
symptoms that are likely
attributable to OME?
Reevaluate child every 3 to 6 months until effusion no
longer present, significant hearing loss detected, or
structural abnormalities suspected
No
No
No
No
No
Childage 6 months to
12 years with OME
Has the child had
persistent OME for 3
months or longer?
Obtain hearing
test
Clinician may perform
tympanostomy tube
insertion
Figure 9.
Algorithm of guideline’s key action statements for children with otitis media with effusion.
196