PEDIATRICS Vol. 115 No. 5 May 2005, pp. 1444-1445 (doi:10.1542/peds.2005-0284)
Thoughts on the American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline on Acute Otitis Media: A Different Perspective: In Reply
Allan S. Lieberthal, MD, FAAPKaiser Permanente
Panorama City, CA 91402
Theodore G. Ganiats, MD
Department of Family Medicine
University of California, San Diego
San Diego, CA 92093
We thank Dr Pellman for his comments on the clinical practice guideline "Diagnosis and Management of Acute Otitis Media."1 As he notes, accurate diagnosis is the key to appropriate management of this common condition. The debate as to the place of bulging in the diagnosis of acute otitis media (AOM) is important, and many commentators have stated that significant bulging is the most reliable sign of AOM.
Issues related to the articles by Halsted et al2 and Schwartz et al,3 as well as the studies by Karma et al4 that served as the basis for Pelton's review,5 have been addressed previously in a letter6 to the editor of Pediatrics and its reply.7 To summarize, each of the quoted studies has flaws that result in the true relationship of bulging in the diagnosis of AOM being inconclusive. A well-conducted study to clarify the situation would be welcome.
"Option," as defined by the American Academy of Pediatrics' Steering Committee on Quality Improvement and Management, "...means either that the evidence quality that exists is suspect or that well-designed, well-conducted studies have demonstrated little clear advantage to one approach versus another. Options offer clinicians flexibility in their decision-making regarding appropriate practice..."8
Observation (recommendation 3A) has been categorized as an option for the exact reasons stated by Dr Pellman. The studies on which it is based have limitations including a significant number of patients who do not have AOM. Despite these deficiencies the studies consistently show that observation in selected children is safe as demonstrated by the very low incidence of mastoiditis or other suppurative complications. Pain and fever may be present longer (1/2 and 1 day, respectively) in the observed child as opposed to one treated with antibacterial medication.9,10 Both symptoms are readily relieved with analgesic/antipyretic medicines. The potential to reduce the duration of symptoms must be weighed against the risk of adverse effects from antibiotics in 16% of patients11 and the concern for increasing resistance of common bacteria resulting from excessive antibiotic use.
The study by Kaleida et al12 showed greater likelihood of failure of observation in younger children and in those who were severely ill (defined in the study as moderate or severe pain or fever 
39°C [102.6°F]). Based on this study the clinical practice guideline states that the observation option should only be considered in children >24 months old with certain AOM or >6 months old if the diagnosis is uncertain and only if the child is not severely ill.
The observation option provides an alternative approach to the management of AOM and is not a mandated mode of therapy. The clinician and the parent should jointly decide if this option is appropriate for the individual child on the basis of diagnostic certainty, age, illness severity, assurance of follow-up, and personal preference.
REFERENCES
- American Academy of Pediatrics, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media.
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[Abstract/Free Full Text] - Halsted C, Lepow ML, Balassanian N, Emmerich J, Wolinsky E. Otitis media: clinical observations, microbiology, and evaluation of therapy.
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[Abstract/Free Full Text] - Schwartz RH, Stool SE, Rodriguez WJ, Grundfast KM. Acute otitis media: toward a more precise definition. Clin Pediatr (Phila). 1981;20 :549 –554
- Karma PH, Penttila MA, Sipila MM, Kataja MJ. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings. Int J Pediatr Otorhinolaryngol. 1989;17 :37 –49[CrossRef][Web of Science][Medline]
- Pelton SI. Otoscopy for the diagnosis of otitis media. Pediatr Infect Dis J. 1998;17 :540 –543[CrossRef][Web of Science][Medline]
- Hoover H, Roddey OF. The overlooked importance of tympanic membrane bulging [letter].
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[Free Full Text] - Lieberthal AS, Ganiats TG. The overlooked importance of tympanic membrane bulging: in reply [letter]. Pediatrics. 2005;115 :513 –514
- American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines.
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[Abstract/Free Full Text] - Damoiseaux RA, van Balen FA, Hoes AW, Vaerheij TJ, de Melker RA. Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.
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[Abstract/Free Full Text] - Burke P, Bain J, Robinson D, Dunleavey J. Acute red ear in children: controlled trial of non-antibiotic treatment in general practice. BMJ. 1991;303 :558 –562
- Ruben RJ. Sequelae of antibiotic therapy. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. Hamilton, ON, Canada: BC Decker Inc; 1999:303–314
- Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial.
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[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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Pediatrics 2005 115: 1443.[Extract] [Full Text]
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