ACAAI Review for the Allergy and Immunology Boards - American ...

HYPERSENSITIVITY DISORDERS / 203TreatmentStandard treatment of AOM is AMOX 90 mg/kg divided bid x 10 days. Alternatives in PCNallergicpatients may include macrolides or TMP/SMX. Treatment failures should be treated witha broader spectrum agent such as amoxicillin-clavulanate or cefdinir (third generationcephalosporin). Should the infection fail to respond to this additional course of antibiotics, thenthe next step is a three-day course of ceftriaxone. Should the infection still fail to improve, thenthe physician should consider ENT consultation for tympanocentesis, culture, and pneumatictube insertion. An increasingly popular alternative for low-risk cases (eg, good likelihood ofadequate, reliable follow up, older than two years of age, mild cases) is supportive care (ie, paincontrol with acetaminophen) and observation for two to three days with follow up afterwards.This is an acceptable option in selected cases, because spontaneous resolution occurs in 80% ofpatients within two weeks; and the number needed to treat with antibiotics is between seven and20 for one improved outcome. Recurrent AOM may be managed medically with low dose, daily,prophylactic AMOX or TMP/SMX, or surgically with tympanostomy tubes.OTITIS MEDIA WITH EFFUSIONUnlike AOM, otitis media with effusion (OME) is a condition that does not warrant antibiotictreatment, as the effusion in this case is sterile. Most commonly, it occurs in children under twoyears of age, may occur in some children from two to six years of age, and very rarely occursafter the age of six. The only symptoms may be subtly-decreased hearing and the sensation offullness in the ear. Pneumatic otoscopy is sensitive (nearly 90%), but not as specific (50%-88%),while a tympanogram may be helpful to confirm uncertain cases or document hearing loss(Figure 7-1). This is a common, potentially incidental finding in children; but, a persistenteffusion in adults could indicate a structural abnormality such as a tumor. The most commoncause is recent AOM with lingering eustachian tube dysfunction. There is insufficient evidenceto suggest a causal link between atopy and OME, although there is a strong increased relativerisk of OME in atopic patients.After AOM, the majority will have an effusion at two weeks, nearly 50% at one month, 10%-25% at three months, and 5%-10% will last one year or longer. OME is the leading cause ofhearing loss in children (usually conductive), and it may be associated with language delay inchildren under 10 years of age. The average hearing loss from OME is 25 dB (mild=21 to 39 dBloss; moderate=40 dB or greater).