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Expectant management is an acceptable treatment approach for selected children with acute otitis media (AOM) and avoids overuse of antibiotics (Journal Watch Emergency Medicine Oct 20 2006). In two recent studies, researchers hypothesized that bilateral and unilateral AOM might have different clinical, demographic, and microbiologic features. Such features might assist clinicians in determining which patients are likely to benefit from antimicrobial therapy.
A study from Texas included 1216 cases with clinical characteristics of AOM in children up to age 16 years; 566 underwent tympanocentesis and culture of middle ear fluid. Fifty-eight percent of the cohort had bilateral disease. Children younger than 2 years were significantly more likely to have bilateral than unilateral disease, but bilateral or unilateral disease was not associated with ethnicity, gender, history of prior AOM, fever, or day-care attendance. Age and severity of tympanic membrane inflammation were independent predictors of bilateral disease. Viruses did not show a significant relation to laterality, but bacterial pathogens, in particular Haemophilus influenzae, were significantly more likely to be isolated from subjects with bilateral disease.
A study from Israel included 1026 children aged 3 months to 3 years; all underwent tympanocentesis. Sixty-one percent had bilateral AOM. Patients with bilateral disease were younger than those with unilateral disease (mean age, 10.6 vs. 11.8 months), but no differences in gender, ethnicity, or history of previous AOM were noted. Bacteria were more commonly isolated from cultures of middle ear fluid in patients with bilateral AOM than in those with unilateral AOM (83% vs. 67%). The microbiologic spectrum was similar to that in the other study, and again, H. influenzae was more common in bilateral than unilateral disease (63% vs. 42%). Clinical/otologic scores used for determining disease severity were higher in patients with bilateral AOM, and bilateral disease was an independent risk factor for more-severe disease.
McCormick DP et al. Laterality of acute otitis media: Different clinical and microbiologic characteristics. Pediatr Infect Dis J 2007 Jul; 26:583-8.
Leibovitz E et al. Is bilateral acute otitis media clinical different than unilateral acute otitis media? Pediatr Infect Dis J 2007 Jul; 26:589-92.
Comment
These data provide no big surprises, but the consistency between the findings of the two studies strengthens the conclusions. Bilateral disease is strongly associated with age (<2 years) and degree of tympanic membrane inflammation/disease severity, two factors that clinicians already consider when deciding whether to start antimicrobial therapy. Based on these two studies, it is reasonable for clinicians to also consider bilateral ear involvement as indicative of more-severe disease that requires antimicrobial therapy.