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AN EVIDENCE-BASED APPROACH TO TREATING OTITIS MEDIA
Pediatric Clinics of North America
- Volume 43, Issue 6 (December 1996) - Copyright 1996 W. B. Saunders Company
AN EVIDENCE-BASED APPROACH TO TREATING OTITIS MEDIA
Richard M. Rosenfeld MD, MPH
From the Department of Otolaryngology, State University of New York Health Science Center at Brooklyn; and the Division of Pediatric Otolaryngology, Department of Otolaryngology, University Hospital of Brooklyn and The Long Island College Hospital, Brooklyn, New York
Patient care is ideally based on evidence derived from the best available studies. The practitioner who treats children with otitis media is
fortunate in this regard, because a wealth of high quality clinical trials and epidemiologic studies have been published. Further, much of
this evidence has been synthesized into bottom-line efficacy estimates and treatment guidelines that deal specifically with the medical
management of otitis media.     
Otitis media implies the presence of a middle ear effusion (MEE), or fluid in the middle ear space (Table 1) . MEE accompanied by acute
symptoms is called acute otitis media (AOM). AOM is caused by ascent of viral or bacterial pathogens from the nasopharynx into the
middle ear during an upper respiratory infection. MEE without associated symptoms is called otitis media with effusion (OME). OME
may arise as a sequelae to AOM or spontaneously; the latter is also called silent otitis media when it occurs as an incidental finding during
physical examination or screening tests. The nonspecific term ear infection applies to AOM and OME, because pathogenic bacteria
generally are present in the middle ear with both conditions. 
This article presents an evidence-based approach to managing otitis media. Rational management begins by understanding the natural
history of untreated otitis media and knowing what to expect from medical therapy.  Next, a stepwise treatment plan is presented,
based on epidemiologic studies, systematic reviews of clinical trials, and personal experience as a pediatric otolaryngologist who has
successfully treated thousands of children with otitis media.
TABLE 1 -- OTITIS MEDIA DEFINITIONS AND EPIDEMIOLOGY
Fluid in the middle ear space,
Diagnosis requires assessment
regardless of cause; hearing loss
of middle ear function by
may be present depending on the
pneumatic otoscopy or
volume of fluid
Erythema of the tympanic membrane,
Most often viral but may be
without MEE; similar appearance
seen in early stages of AOM
occurs from dilation of tympanic
or during resolution; does
membrane vessels when crying
not require antibiotic
MEE with rapid onset of one or more
Most frequent diagnosis made
of the following: otalgia, ear pulling,
by pediatricians; affects
otorrhea, fever, irritability, anorexia,
about 50% of children by
vomiting, or diarrhea
age 1 year, 65% by age 2
years, and 70% by age 3
MEE without signs or symptoms of
Occurs in both healthy children
acute infection; chronic OME
and following an episode of
implies duration longer than 2 to 3
AOM; 15% prevalence with
At least three episodes of AOM in the
Affects about 15-30% of
past 6 months, or four episodes in
children; MEE may persist to
12 months; also called the otitis-prone condition
varying degrees between
AOM = acute otitis media, OME = otitis media with effusion.
Address reprint requests to
Richard M. Rosenfeld, MD, MPH Department of Otolaryngology Long Island College Hospital 340 Henry Street Brooklyn, NY 11201
Otitis media has a favorable natural history. Data from observational studies   and from control groups in randomized control trials  
  show that most cases of AOM and OME resolve without treatment (Table 2) . For example, in two recent well-designed clinical trials,
86% and 92% of placebo-treated children with AOM were clinical cures.   To appreciate the impact of natural history on perceptions of treatment efficacy, consider the following:
If 100 children with AOM caused by amoxicillin-resistant bacteria are nonetheless treated with amoxicillin, how many will have
complete clinical resolution in 7 to 14 days? About 70% to 90% will be "cured" as shown in Table 2 . The child's immune system cares little if the bacteria are resistant to the drug; it mounts an effective inflammatory response regardless.
If 100 children with persistent OME after AOM have chiropractic manipulation for 1 month, how many will resolve? About 60%,
assuming that chiropractic is no better than placebo. If "treatment" is continued for an additional 2 months, the "cure" rate will rise to 90%.
If 100 children with silent OME detected in a school screening program receive homeopathic treatment for 3 months, how many will
resolve? About 65%, assuming that homeopathy is no better than placebo. If "treatment" is continued for an additional 3 months, 85% will be "cured" of effusion.
If 100 children with recurrent AOM take garlic concentrate for 12 months,
how much will the frequency of AOM diminish? About 1.5 to 3.0 annual episodes will be "prevented," assuming that garlic is no better than placebo.
-- NATURAL HISTORY OF UNTREATED OTITIS MEDIA
antibiotic trials of initial empiric therapy
antibiotic trials, most with OME duration 4-8 weeks
* Resolution of asymptomatic middle ear effusion not required for cure.
The examples above are provided to illustrate the favorable natural history of otitis media, not to demean alternative medicine. Alternative medicine, however, is used by 11% of children,  most often for chronic disease (e.g., otitis media) and without the knowledge of the child's physician.  Because most cases of otitis media are self-limited, the efficacy of alternative medicine--or any intervention--can be judged only by prospective clinical trials with a parallel control group. Without a thorough appreciation of the spontaneous course of untreated otitis media, practitioners and caregivers can easily mistake natural history for treatment effects.
Short-term spontaneous resolution of AOM most likely reflects the host immune response and local inflammatory reaction. This phenomenon is appreciated in Denmark, Norway, Sweden, and the Netherlands, where most children 2 years of age and older with nonsevere AOM are not treated initially with antibiotics.   Unfortunately, the middle ear inflammation that accompanies AOM can result in lingering OME after symptom relief. Spontaneous clearance of residual OME, however, occurs in 90% of children within 3 months (Table 2) as inflammation subsides and the eustachian tube reopens. Because OME is so common following antibiotic treatment for AOM, clearance of the fluid is unnecessary for a successful outcome in efficacy trials. 
Long-term spontaneous resolution of recurrent AOM and chronic OME most likely reflects a gradual maturation in the child's immune system and eustachian tube function. Further, because most patients seek medical care when at their worst, the next event is often a change for the better, irrespective of treatment given (regression to the mean).  Children enter clinical trials for recurrent AOM with three to five annual episodes but average only one to two episodes during the next 12 months when treated with placebo.  A similar
pattern has been reported for children with recurrent sore throat after entering a tonsillectomy trial. 
More than 250 clinical trials have sought to define the impact of medical treatment on otitis media. Systematic literature reviews (meta-analysis) of published randomized control trials yield the mean estimates of treatment efficacy listed in Table 3 . These data have been summarized as follows  :
Antibiotics have a modest but statistically significant impact on the treatment of otitis media. About seven children with AOM or OME
must be treated to improve a single child, beyond what would occur from natural history alone. Despite this modest effect, some studies show faster symptom relief with antibiotics than with placebo.   
Antibiotics have a modest but statistically significant impact on the prevention of otitis media. Preventing a single episode of AOM
requires that prophylaxis be given to one child for 9 months, or to nine children for 1 month.
Subgroup analyses have not demonstrated a significant increase in clinical efficacy for newer, more expensive drugs over established
standards, such as amoxicillin, when treating AOM or OME.
Combining an antibiotic with an oral steroid seems promising, but the evidence is sparse, inconsistent, and just misses statistical
Antihistamine and decongestant preparations, alone or in combination, have comparable efficacy to placebo. Consequently, there is no
justification for their use when treating OME, unless they are consciously administered to achieve a placebo effect.
-- WHAT TO EXPECT FROM MEDICAL TREATMENT FOR OTITIS MEDIA
Impact of Therapy
Qualification of these comments is required. First, the results apply only to clinical efficacy; the ability of antibiotics to destroy middle ear pathogens-- bacterial efficacy--may exceed that suggested by clinical outcomes.  Second, bacterial resistance patterns are changing, with an increasing prevalence of multidrug-resistant Streptococcus pneumoniae
 and beta-lactamase-producing Haemophilus influenzae
and Moraxella catarrhalis
.  Older studies may have included children with bacteriology different than those encountered today, but the high rate of spontaneous otitis media resolution makes it unlikely that this would substantially alter results. Finally, because the results reflect mean treatment effects, individual patients may vary in their response to antibiotics.
The modest impact of antibiotics on otitis media argues for judicious treatment, not therapeutic nihilism. Although natural history--not antibiotics-- accounts for most clinical resolution of AOM, delayed suppurative complications (e.g., mastoiditis) are exceedingly rare compared with the preantibiotic era. For OME the modest short-term benefit of antibiotics makes it unlikely that prolonged or repetitive therapy will offer any advantage; therefore, treatment should be limited to one or two drugs spaced at least several weeks apart. For recurrent AOM, the modest benefits of antibiotic prophylaxis probably are exceeded by the risk of accelerated bacterial resistance, particularly in group day care, where horizontal transmission of resistant organisms is common.  Prophylaxis might be reserved for selected children not enrolled in day care, with frequent or severe infections.
SELECTING AN ANTIBIOTIC FOR OTITIS MEDIA
Recommended drugs for managing otitis media are listed in Table 4 . The most important decision concerns which class of antibiotic to use--prophylactic, first-line, second-line, or third-line--not which agent to administer within a class. Prophylactic antibiotics are indicated only for recurrent AOM as defined in Table 1 ; there is no benefit to long-term prophylaxis for OME.   First-line antibiotics are used for initial empiric therapy of uncomplicated AOM or OME. Second-line drugs are indicated for initial treatment failures, complicated infections, and children with ipsilateral conjunctivitis suggesting H. influenzae
infection.  Because no comparative differences in clinical outcomes have been reported among second-line antibiotics, drug choice should be based on cost, convenience, and tolerance.
If the prevalence of beta-lactamase-producing pathogens is rising,   how can amoxicillin still be the drug of choice for initial treatment of otitis media? It is because of a favorable natural history, which occurs independently of bacterial resistance patterns.  AOM treatment failures occur despite susceptible bacteria, and successes occur despite bacterial resistance.   For example, if 20% of children with uncomplicated AOM have beta-lactamase-producing bacteria, resistance will account for failure in only 4% of cases because spontaneous resolution is 80%. This theory assumes that 35% of AOM is caused by S. pneumoniae
, 30% by H. influenzae
, and 10% by M. catarrhalis
, of which approximately 0%, 35%, and 90% produce beta-lactamase. 
Penicillin-resistant S. pneumoniae
are rising in prevalence, particularly among children in group day care.  Recent use of a beta-lactam antibiotic is
-- RECOMMENDED DRUGS FOR MEDICAL MANAGEMENT OF OTITIS MEDIA
Category; Generic (Trade) Names
Still the drug of choice for initial therapy
1 tsp each 10 lb body When child is penicillin-allergic
ac = before meals, pc = after meals.
also a risk factor. Amoxicillin achieves MEE levels effective against 90% of pneumococci with intermediate penicillin resistance, contrasted with the inadequate levels achieved by most second-line drugs.   This helps explain reports of pneumococcal bacteremia and meningitis during initial treatment of AOM with cefixime  and clarithromycin.  For highly penicillin-resistant pneumococci, the only orally administered antibiotic with adequate MEE levels is clindamycin,   hence its listing as a third-line agent in Table 4 . Note that Clostridium difficile
colitis can occur with any broad-spectrum antibiotic and is no more common with clindamycin than with amoxicillin or the cephalosporins.  A pediatric suspension of clindamycin is available.
Single-dose intramuscular ceftriaxone is no "magic bullet" for AOM, and its impact on OME has not been studied. Recent trials show a mean 79% clinical improvement with single-dose ceftriaxone versus 84% improvement with 10 days of amoxicillin,  cefaclor,  or trimethoprim-sulfamethoxazole.   Although the difference is not statistically significant, we cannot conclude with certainty that 79% resolution offers any benefit beyond natural history. Further, liberal use of a potent, broad-spectrum antibiotic, such as ceftriaxone, may accelerate bacterial resistance.
 Consequently, the author suggests reserving ceftriaxone for third-line therapy (e.g., second-line treatment failures) and for AOM with
intracranial or intratemporal complications (e.g., meningitis).
The optimal duration and dosing of antibiotic therapy is uncertain. Amoxicillin-treated children with AOM had similar outcomes with 3-day versus 7-day,  3-day versus 10-day,  5-day versus 10-day,  and 10-day versus 20-day regimens.  Furthermore, clinical resolution is unaltered when amoxicillin is given once, twice, or thrice daily.   These negative findings are not surprising given that the majority of AOM clinical resolution occurs by natural history and that there is no worldwide consensus on whether antibiotics are necessary for most cases. Limited data are available for OME, but the findings for AOM most likely apply. Because efficacy estimates (see Table 3) are derived mostly from clinical trials using 10-day therapy and dosing schedules approved by the manufacturer, the author recommends that practitioners do the same. Individualized variations in duration and dosing, however, are unlikely to significantly alter results.
AOM remains the most common childhood disorder seen in physicians' offices and in hospital emergency departments. Annual visitation rates for AOM have more than doubled from 1975 to 1990, with a corresponding rise in antibiotic drug prescription rates. Although amoxicillin is currently prescribed twice as often as other drugs, a disturbing trend has occurred toward increased use of more expensive, broad-spectrum agents, such as cephalosporins. This trend may contribute to rising health care costs and the emergence of antibiotic resistance. 
Aggressive treatment for AOM with expensive, broad-spectrum antibiotics reflects unrealistic expectations on the part of practitioners and caregivers (Table 5) .  There is no benefit to initial empiric therapy with second-line drugs (see Table 4) over first-line agents, because 70% to 90% of AOM improves clinically without treatment. For the 90% to 95% of children who respond favorably to antibiotics, about 80% of cures are from spontaneous resolution and only 10% to 15% from drug therapy.  The primary benefit of antibiotic treatment on AOM is most likely to reduce the incidence of delayed suppurative complications,
-- STEPWISE APPROACH TO MANAGING ACUTE OTITIS MEDIA
Base decisions on cost, convenience, and tolerance, not bacterial spectrum; use a second-line antibiotic (see Table 4) if otitis-conjunctivitis syndrome or early relapse of prior AOM
About 90-95% symptom relief, excluding asymptomatic MEE, within 10-14 days (80% from spontaneous resolution, 10-15% from antibiotic); main purpose of antibiotic is to reduce chance of suppurative complications
Use a second-line antibiotic (see Table 4) if symptoms persist; retreatment with first-line drugs is less effective
Reserve for retreatment failures with severe symptoms, or those refractory to third-line antibiotics (see Table 4) ; no role for tympanocentesis earlier in therapy
Residual OME after AOM is the rule, not the exception, and may last for several months; consider reating with a second-line antibiotic (see Table 4) after 6-8 weeks
similar to the impact of antibiotics on group A streptococcal pharyngitis. For example, acute mastoiditis complicated more than 20% of cases of AOM in the preantibiotic era  but now has an incidence of less than 0.1%. 
Persistent AOM following treatment is most often secondary to middle ear inflammation after bacteria are killed, either by antibiotics or by the host immune response. Other causes of persistent AOM include bacterial resistance to the initial antibiotic  and viral pathogens or copathogens in the middle ear.  Because the cause of failure generally is not apparent, continued antibiotic therapy is indicated to cover any persistent bacteria that may predispose the child to suppurative complications. Retreatment with a second-line antibiotic is more effective (60-90% clinical resolution) than retreatment with amoxicillin or trimethoprim-sulfamethoxazole (25-40% clinical resolution). 
Penicillin-resistant S. pneumoniae
may cause persistent AOM, particularly in otitis-prone children fewer than 2 years of age who attend group day care.   Clindamycin is the most effective orally administered antibiotic for resistant pneumococcus; about two thirds of highly resistant
strains also may be susceptible to intramuscular ceftriaxone (not single-dose therapy).  High-dose amoxicillin (60-80 mg/kg/d) also has been proposed and may be appropriate first-line therapy for high-risk children in communities with endemic penicillin resistance.  Myringotomy should be reserved for cases refractory to second-line and third-line antibiotics and for children with immune dysfunction or multiple drug allergies. When used as initial therapy for severe AOM, however, myringotomy is no more effective than antibiotics alone. 
Residual OME after resolution of acute symptoms is a consequence--not a complication--of AOM. About 50% of children in clinical trials have anasymptomatic effusion following treatment for AOM, unrelated to the duration or bacterial spectrum of the initial antibiotic.   Fortunately, about 90% of episodes resolve spontaneously within 3 months unless acute reinfection occurs (see Table 2) . Treatment of residual OME with additional antibiotics has a modest impact
on short-term cures (see Table 3) , but the impact on long-term cure is uncertain.  Therefore, at most, one first-line antibiotic and one second-line antibiotic should be used for stubborn effusions following AOM.
The first step in managing OME is diagnosing its presence. Many children with OME have a normal-appearing tympanic membrane, making it easy to miss an effusion unless middle ear function is assessed. Tympanometry is used most often in this regard, although pneumatic otoscopy has comparable accuracy.  The positive predictive value for OME of a flat (type B) tympanogram (i.e., the likelihood that an effusion is present if the tympanogram is abnormal) is between 49% and 99%. A false-positive tympanometry result can be caused by impacted cerumen, a foreign body, tympanic membrane perforation, or improper placement of the instrument tip on the ear canal wall. Because of these limitations, pneumatic otoscopy is recommended for primary diagnosis of OME with tympanometry as a confirmatory test. 
Detecting OME does not imply a need for active treatment (Table 6) . About 90% of effusions less than 2 to 3 months' duration resolve without treatment within a few months (see Table 2) . OME of longer duration has cure rates of only 15% to 30% from watchful waiting (see Table 2) , even when observation is extended to 30 months.  Regardless of OME duration, the impact of antibiotic therapy is marginal (see Table 3) and short-lived; antibiotic-treated and placebo-treated children have comparable outcomes several weeks after completing therapy.  Aggressive antibiotic treatment of OME is therefore difficult to justify, especially because the incidence of delayed suppurative complications is near
-- STEPWISE APPROACH TO MANAGING OTITIS MEDIA WITH EFFUSION
Most cases resolve without treatment (see Table 1) , particularly when following a recent episode of AOM
Antibiotics boost short-term resolution by about 15% and therefore benefit only one child of every seven treated; do not use repetitive, prolonged, or prophylactic antibiotics
Limit passive smoke exposure; treat sinusitis; control food and inhalant allergies
Any child can be tested, regardless of age; tube insertion is recommended for bilateral effusions lasting 4 months or longer with an associated hearing loss
Most effective when hearing is normal and child is not otitis-prone; observe varicella precautions (see text)
Chronic effusions without hearing loss can be managed expectantly; consider surgery if accompanied by otalgia, recurrent AOM, retraction pockets, speech problems, or antibiotic intolerance
zero. Autoinflation of the eustachian tube, by means of a plastic nasal cannula and attached balloon, is a harmless adjunct to watchful waiting that may be tried in older children.   Prophylactic antibiotics and antihistamine-decongestant preparations offer no benefits beyond placebo therapy.
Clinicians can improve the odds of OME resolution by modifying risk factors and controlling concurrent illness. The risk of getting AOM or OMEis increased with passive smoke exposure, group day-care attendance, and bottle-feeding rather than breast-feeding infants.  The associations, however, are modest (relative risk about 2.0), and many breast-fed children cared for at home by nonsmokers still obtain otitis media. Nonetheless, efforts to limit smoke exposure seem prudent, particularly for children in group day care, in which 18% of cases of OME may be attributable to parental smoking.  Because allergy to milk proteins may cause middle ear inflammation,  the author recommends a milk-free diet for several weeks as a diagnostic trial in children fewer than 2 years of age. In older children with OME, concurrent illnesses, such as sinusitis and allergic rhinitis, should be brought under optimal control.
A child with bilateral OME for 3 months or longer should undergo hearing evaluation.  No child is too young to test, including infants fewer than 6 months of age. OME generally causes a mild conductive hearing loss (27 dB hearing level [HL]), but 20% of ears have a pure-tone average of more than 35 dB HL.  Although the relationship between early OME and language development is controversial, the literature supports a direct connection between hearing and language with middle ear effusion as an intermediate variable. 
Placement of tympanostomy tubes is recommended for children with 4 to 6 months of bilateral OME and hearing loss, defined as 20 dB HL or higher for the better ear.  Hearing levels obtained in a soundproof booth, however, may underestimate the auditory impact of OME on children in real-world listening environments. For example, the ability of children to recognize words presented at soft levels or with background noise deteriorates when OME is present, even when hearing levels are normal.  Difficulties in word recognition may cause behavioral problems, poor attention span, or poor school performance. Therefore, affected children with bilateral OME and normal hearing may still benefit from tympanostomy tubes on a selective basis. Finally, hearing levels fluctuate relative to the volume of middle ear fluid and should be periodically retested when deferring surgery because of normal hearing.
Steroid therapy is not recommended for children 3 years of age or younger with OME  but may be used selectively in older children as a last-resort medical alternative to surgery.  Oral prednisone or prednisilone (see Table 4) is given concurrently with a second-line antibiotic, provided that there has been no varicella exposure for 3 weeks and there is no coexisting AOM or sinusitis. Children who get varicella while taking steroids should discontinue the drug and be considered for oral acyclovir therapy to minimize the likelihood of severe disease.  Relapse of OME occurs in 40% of initial responders following steroid-antibiotic therapy, yielding a 6-month cure rate of about 25%. Children without hearing loss or recurrent AOM seem to have the most favorable outcomes. 
Decisions concerning the relative merits of ongoing medical therapy for OME versus surgical intervention (i.e., tympanostomy tubes) must be individualized (Table 7) . Children with asymptomatic OME who also have normal hearing, speech, school performance, and tympanic membrane appearance may be monitored with extended periods of watchful waiting. The key word in the preceding sentence is monitored
; implicit in a wait-and-see approach is interval otoscopy and audiometry every 3 to 4 months to detect changes in hearing status or the structural integrity of the tympanic membrane. In contrast, a hearing-impaired
-- FACTORS INFLUENCING DECISIONS FOR OR AGAINST SURGERY FOR OME
Favors Alternatives to
*Cleft palate, immunodeficiency, Down syndrome, craniofacial anomalies, Eskimos, Native Americans.
child with unilateral or bilateral OME and a baseline sensorineural loss would benefit from early tympanostomy tube insertion, not prolonged medical therapy. Adenoidectomy is effective for OME in older children    but is not recommended for those age 3 years or younger. 
A network of primary care doctors representing nine countries was asked to rate how certain they were when diagnosing AOM in young children. Survey results indicated a disconcerting 58% level of diagnostic certainty in patients aged 0 to 12 months, rising to 66% at 13 to 30 months, and 73% for children more than 30 months of age.  These results illustrate the difficulty of diagnosing AOM in young children, not the incompetence of the physicians surveyed. With recurrent AOM, the issue of diagnostic certainty is paramount because of a geometric increase in the potential consequences.
Even a skilled otoscopist can struggle to glimpse the tympanic membrane in an uncooperative child with small ear canals or obstructing cerumen. If obstructing cerumen cannot be removed easily, the child should be referred to an otolaryngologist for microscopic cleaning of the ear canal. When the tympanic membrane is visualized, a test of middle ear function is performed to verify that a MEE is present (tympanometry or pneumatic otoscopy). Unfortunately the severity of tympanic membrane inflammation predicts neither the presence of MEE nor the clinical course of recurrent AOM.  A red eardrum commonly
occurs during brisk crying and viral myringitis, which are self-limited conditions distinct from AOM.
Recognizing that problems with diagnostic certainty can never be completely avoided, the author recommends tailoring the treatment of recurrent AOM episodes accordingly. When certainty is high, treatment of the episode should proceed as outlined earlier (see Table 5) . Examples include purulent otorrhea, a bulging tympanic membrane, or acute symptoms with a documented MEE. When certainty is low, the caregiver may be given a prescription for a first-line antibiotic and told to treat the child only if acute symptoms do not subside after 24 to 48 hours of expectant therapy. This approach avoids unnecessarily treating viral myringitis and false-positive diagnoses of AOM. When certainty is moderate, judgment is required. Infants and young children with severe symptoms should probably be treated, but older children with nonsevere symptoms may be managed expectantly.
Primary prevention of recurrent AOM involves modifying risk factors and using vaccines (Table 8) . Children in group day care are at increased risk for recurrent AOM, but the size of the group--not day care per se--is responsible.   When the group size is six children or fewer, risk is not increased. Pacifiers should be discouraged in day care settings, because their use accounts for 25% of recurrent AOM in children less than 3 years of age.  Children in day care also benefit from an influenza A vaccine, which reduces the incidence of AOM by about 40% during the influenza season (January to February).   In contrast, the pneumococcal vaccine (children 2 years or more) does not decrease overall incidence of AOM but reduces vaccine-type pneumococcal AOM.  This may be beneficial given a rising prevalence of multidrug-resistant pneumococcus. Finally, breast-feeding (4 months or longer) has been shown to reduce AOM frequency in longitudinal studies.  
Enthusiasm for antibiotic prophylaxis of recurrent AOM must be tempered by reality: a child must be treated for 9 months, on average, to prevent one AOM episode beyond what would occur from natural history alone.  Although
-- STEPWISE APPROACH TO MANAGING RECURRENT ACUTE OTITIS MEDIA
Distinguish myringitis from true otitis media; confirm MEE by tympanometry or pneumatic otoscopy
Limit passive smoke exposure; consider group day- care alternatives; discourage pacifier use in day care
Encourage breast feeding; control allergies; consider pneumococcal vaccine (age 2 years or more) or influenza vaccine (day care)
Risk of acclerated bacterial resistance often outweighs minimal benefit of prolonged antibiotic prophylaxis
Antihistamine/decongestant combinations are of no benefit; chiropractic, homeopathy, and naturopathy are unproven
Recurrent AOM with minimal symptoms can be
managed expectantly; consider surgery if accompanied by febrile seizures, antibiotic intolerance, hearing loss, speech problems, or chronic OME
statistically significant, the clinical significance is questionable when balanced against risks of accelerated bacterial resistance. Particular caution applies to children in group day care, where bacterial resistance is already more common.  Intermittent prophylaxis during respiratory illness is appealing but may be less effective than continuous treatment.  Furthermore, when OME persists between episodes of recurrent AOM, prophylaxis does not increase resolution of the baseline effusion.   These findings argue for judicious use of antibiotic prophylaxis on a restrictive and individualized basis.
When medical options have been exhausted, surgery must be considered. Tympanostomy tubes are effective in controlling recurrent AOM, with or without intercurrent OME, because they effectively bypass the child's immature and poorly functioning eustachian tube.    Breakthrough episodes of AOM while on antibiotic prophylaxis are not a mandatory prerequisite to tube insertion because of the concerns about prophylaxis expressed earlier. What is important, however, is the frequency and severity of AOM episodes and the presence or absence of associated sequelae, such as hearing loss, speech problems, or multiple drug allergies. Adenoidectomy is effective for recurrent AOM in children who have had tympanostomy tube insertion at least once previously. 
More than 20 years ago, a shrewd clinician remarked, "There is little evidence that those antimicrobial agents which hypothetically or in vitro are more effective . . . are superior in the treatment of otitis when compared to penicillin alone."  Several hundred clinical trials later, the advantages of broad spectrum drugs remain unproved, and questions remain as to whether antibiotics are required for most episodes of AOM. Further, antibiotics have been demoted to the status of optional therapy for OME.  This situation is unlikely to change as new studies with new antibiotics proliferate.
What is clear, however, is that accelerated patterns of bacterial resistance mandate an evidence-based approach to managing otitis media. Bacteria have an uncanny ability to learn new mechanisms of antibiotic resistance.  A large part of bacterial "education" has undoubtedly been fueled by antibiotic prescriptions from well-intentioned physicians, with unrealistic expectations of drug efficacy. A judicious approach to antibiotic treatment of otitis media can result only from knowing the spontaneous course of the disorder and incremental effect of antibiotics on clinical outcomes.
In this article, a series of unifying concepts are developed to help practicing clinicians with an evidence-based approach to managing otitis media. Critical review of the published evidence suggests that the most favorable outcomes from medical treatment will occur if practitioners:
appreciate the favorable natural history of untreated otitis media realize that OME may take months to resolve following a single AOM episode modify risk factors to improve the odds of spontaneous resolution use pneumatic otoscopy and confirmatory tympanometry to diagnose OME
recognize the limited impact of antibiotic therapy on treatment and prevention balance the benefits of antibiotics against the risk of accelerated bacterial resistance
avoid repetitive, prolonged, or prophylactic antibiotic treatment of chronic OME avoid ineffective therapy, such as antihistamine/decongestant preparations
An important aspect of management is helping caregivers understand the natural history of otitis media and the impact of medical treatment on short-term and long-term outcomes. Realistic expectations on the part of all involved parties should facilitate rational decisions about watchful waiting, medical therapy, and the need for surgical intervention.
Special thanks to the countless investigators who conduct and publish clinical trials and epidemiologic studies on otitis media, without whom an evidence-based approach to treatment would be impossible. I am also indebted to Dr. Charles Bluestone for his insights and inspirations, which underlie many of the concepts explored herein.
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Security Sector Reform in Guatemala For 26 years, from 1960 until 1996 and the signing of the Accord for a “Firm andLasting Peace”, Guatemala was the setting of one of the bloodiest of LatinAmerica’s Cold War armed conflicts. During this period, a national security doctrinemilitarized the state. The last provision of the Peace Accord in Guatemala, the‘Agreement on the Strengthening of