Middle Ear, Eustachian Tube, Inflammation/Infection Treatment & Management
In the United States, acute otitis media (AOM) is typically treated with antibiotics. Treatment with amoxicillin for 10 days is the initial antibiotic selection, or Bactrim is substituted if the patient is allergic to penicillin. In Europe, a more conservative approach to treating acute otitis media (AOM) is used. Given the alarming increase in antibiotic resistance, the routine usage of antibiotics in the United States should be reconsidered.
A recent meta-analyses from 30 articles written in English and 3 articles written in a language other than English revealed that acute otitis media (AOM) achieved complete clinical resolution without treatment 81% of the time as compared with resolution 95% of the time with the use of antimicrobials. Criteria for withholding or delaying antibiotic therapy for acute otitis media (AOM) include (1) patient older than 2 years, (2) normal host, (3) intact tympanic membrane, (4) at least 3-6 months since last episode of otitis media (OM), (5) receptive parents, and (6) assurance of medical follow-up care.
A study by Tawfik et al indicated that since the introduction of pneumococcal vaccination, hospital admissions for pediatric acute otitis media (AOM)/complications of acute otitis media (AOM) in the United States have decreased in prevalence, as have admission rates for pneumococcal meningitis with acute otitis media (AOM)/complications of acute otitis media (AOM). Using information from the Kids’ Inpatient Database from between 2000 and 2012, the study found particularly sharp declines in admissions for children under age 1 years, from 22.647 to 8.715 per 100,000 persons, and for children aged 1-2 years, from 13.652 to 5.554 per 100,000 persons. 
In the United States, otitis media with effusion (OME) can be treated with observation, antibiotics, or tympanostomy tube placement. Meta-analysis of controlled studies revealed only a 14% increase in resolution rate when antibiotics are given. Antibiotic suppression is not indicated for otitis media with effusion (OME), and multiple courses of antibiotics have no proven benefit. Consider surgical intervention after 3-4 months of effusion with a 20 dB or greater hearing loss. 
Eustachian tube dysfunction (ETD) can be treated primarily with a combination of time, autoinsufflation (eg, an Otovent), and oral and nasal steroids (budesonide, mometasone, prednisone, methylprednisolone). The results of one study suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction. 
Decongestants (eg, pseudoephedrine, oxymetazoline, phenylephrine) are also helpful, but not as useful for chronic eustachian tube dysfunction (ETD). Consider the cardiovascular effects of oral decongestants and the early development of tachyphylaxis observed with the use of nasal decongestants; limit the use of the decongestant to short-term symptomatic relief (ie, no more than 3-5 d).
Nasal and oral antihistamines can also be beneficial in patients with allergic rhinitis. Leukotriene antagonists (eg, montelukast sodium [Singulair]) are helpful in some patients when oral steroids are not an option. Adequate control of laryngeal pharyngeal reflux helps to resolve eustachian tube dysfunction (ETD) in patients with an associated peritubal inflammation from reflux. Proton pump inhibitors (esomeprazole magnesium [Nexium], rabeprazole [Aciphex], omeprazole [Prilosec]) administered twice a day are often used. Myringotomy with tube insertion is reserved for the refractory patient with debilitating symptoms.
The primary surgical treatment of all types of otitis media (OM) is myringotomy with tube placement.  The typical ventilation tube stays in place for a period of 8-12 months with closure of the perforation occurring after tube extrusion. In a small percentage of patients with poor eustachian tube function or other complicating factors, the perforation may persist.
Consult with an otolaryngologist if the patient has any evidence of complications of otitis media (OM), if the effusion persists for longer than 3 months, if a 20 dB or greater hearing loss exists, or if a patient has more than 3 episodes of otitis media (OM) in 4 months or 6 episodes of otitis media (OM) in 1 year.
Neurosurgery consultation may be required for intracranial complications such as a brain abscess.
Patients with eustachian tube dysfunction (ETD) must be careful when flying or diving because of the risk of barotrauma. Instruct patients with significant eustachian tube dysfunction (ETD) to use oral and topical decongestants 30 minutes before landing. An Otovent may be used to assist with autoinsufflation in the treatment of eustachian tube dysfunction (ETD).
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Contributor Information and Disclosures
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Ari J Goldsmith, MD Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center