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Paper Chase 5: Acute Otitis Media Initially Managed Without Antimicrobials

Roy Benaroch, MD and Geoff Simon, MD
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Discuss current literature that impacts pediatric practice.

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Beezer M. -

There was still 3% of children among the ones who appeared to be getting better by parental report but who appeared to actually be worse on physcial exam. This report makes it appear that the parents were correct and the otoscopy wrong in these cases, or that the 3% is very small statistically. But imagine if, among the kids with ear infections that you employ watchful waiting on and send home and do not follow up on, that 3% of these kids get worse but asymptomatically so. These asymptomatic worsening ear infections are what leads to mastoiditis, abscesses, or other complications. Imagine seeing 3 or 4 cases of mastoiditis a year and one case of cerebral abscess every year in a busy practice of 1000 kids on the panel. This is what ignoring 3% means. This is my biggest fear, that an ear infection will actually stop hurting once it gets WORSE, such as if the TM ruptures (best case scenario) or there is actual nerve damage to the sensory pain nerves in the ear as the ear infection spreads inward (worst case scenario), or even if the infection just "settles" and then later gets superinfected with Staph aureus, so now you are dealing with a chronic otitis media.

Watchful waiting is already not that commonly employed, so when you take it a step further and not even physically follow up with a patient, and if there is a bad outcome, it will be extremely hard to demonstrate that you were following "standard of care," even with studies like this out there. Also, 3% is a high number to just ignore and not do a simple follow up on a patient. We hospitalize patients for smaller numbers than this if there is a 3% mortality or other bad outcome, such as with neonatal fever, etc.

Solomon B., MD -

Hi Beezer-
we reached out to our Paper Chasers, and here was Geoff Simon's response:

Dear Beezer M.
Thanks for listening to the January Paper Chase and commenting on our review of Uitti JM et al. Close Follow-up in Children With Acute Otitis Media Initially Managed Without Antimicrobials. , appearing in JAMA Pediatrics 2016. You express concern that if there are patients with AOM who have progression of disease but without any symptoms, this could lead to significant morbidity and mortality, including mastoiditis and intracranial abscesses at a rate of 3-5 per year. While certainly a concern, I think you have to look at some background epidemiology re: mastoiditis. The incidence of mastoiditis in children in developed countries is most recently in the range of 1.2-6 cases per 100,000 children. In studies done in the US and in Israel, there appeared to be a significant drop in incidence of mastoiditis following introduction of PCV7, though this increased to baseline after 4 years. ( Kordeluk S, Kraus M, Leibovitz E. Challenges in the management of acute mastoiditis in children. Curr Infect Dis Rep. 2015 )
However, more recent data from the same populations in the US demonstrate a decrease again without rebound following introduction of PCV13 vaccine, suggesting the initial rebound was due to antibiotic resistance from non-vaccine strains that are now included in the PCV-13, particularly 19a. In order to see an incidence of mastoiditis of 3 per 1,000 patients per year, that would be a very special patient population, such as significant immunosuppression, whether SCIDS, HIV or significant anatomic abnormalities that would not really fit any normal clinical guidelines for AOM management. In that situation, you are correct in this not being useful.

Clinically, it would be unusual to have asymptomatic surgical mastoiditis – the characteristics are consistently fever, fussiness, and usually purulent otorrhea. I think the likelihood of having asymptomatic mastoiditis would be exceedingly rare. Let’s assume even 5% of acute surgical mastoiditis presents without any symptoms. This would be 5% of 6/100,000 children, which would be about 3/1,000,000 children. The likelihood of seeing such an entity over the course of a lifetime in practice with an 1000 patient panel would be pretty low. Additionally, the majority of mastoiditis occurs in children <2 years, with a mean age of 12 months. Currently guidelines do not recommend watchful waiting for ill appearing children under a year of age, so this would also make the possibility of having an asymptomatic mastoiditis occur in a watchful waiting scenario even lower, or even nonexistent if following the guidelines.

These studies are helpful in understanding the science and epidemiology to help us practice better medicine. However, the ultimate decision lies with the physician or practitioner with the patient in front of them being able to make the best choice for that child and family. That, we can all agree on, is the Art of Medicine.

Thanks again for listening.


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