Otitis Media 3 months–12 years

Please refer to our Otitis Media Guideline (see link below in Resources/References). If the TMs are red and have no mobility – then recommendation is to treat them as suggested by the primary care provider or ENT (Many ENTs prefer monitoring even if TMs are red and immobile). Our antibiotic recommendation include—first line high dose Amoxicillin, second line Augmentin, third line Omnicef, and lastly Rocephin x 3 days. Referral to audiology is always warranted and recommended if the child has history of ear infections. (ENT always wants an audiogram regardless of number of ear infections). Tube placement referral is very common and is performed in Anchorage.

In general, children should be referred to Audiology at YKHC for recurrent infections (>3 in 6 months or 4 in a year), persistent effusion >3 months (especially with hearing loss), or if there is a question of hearing loss/speech delay secondary to recurring infections. Audiologists routinely do telemedicine consults with the ANMC ENT’s using TM photos. Antibiotic prophylaxis for recurrent OM’s is not warranted as this has not been shown to be effective.

Many people have had acute otitis media complicated by mastoiditis requiring mastoidectomies in our population. We encourage ENT be consulted for these patients with treatment and follow up as ENT recommends.

All infants fewer than 3 months of age that are diagnosed by a CHA to have otitis media should be seen and evaluated in Bethel before being started on any antibiotic.

• Recurrent Acute Otitis Media that qualifies for ear tubes
  • Diagnostic Criteria:
    • 3+ separate episodes of AOM in 6 mo,
    • 4+ separate episodes of AOM in 12 mo, or
    • OME present for 3+ months
    • If these criteria are not met, but you have concerns about hearing or other complications associated with recurrent AOM, please place order for hearing screen through Audiology who can direct to ENT as needed.
  • Order: "Refer to Audiology Internal"

Tables from ANMC ENT Dr. Joshua Tokita

Condition	Ofloxacin (Floxin Otic)	Ciprodex (Ciprofloxacin/Dexamethasone)	Cortisporin (Neomycin/Polymyxin B/Hydrocortisone)
Acute Otitis Externa (AOE) (Swimmer’s Ear)	✅ Use if TM perforation or tubes present	✅ Preferred if significant inflammation	❌ Avoid if TM perforation (ototoxic)
Chronic Suppurative Otitis Media (CSOM) (with TM perforation)	✅ First-line treatment (non-ototoxic)	✅ Can be used, but no advantage over ofloxacin	❌ Avoid (ototoxic & can cause allergic reactions)
Otorrhea with Tympanostomy Tubes	✅ First-line (safe for perforated TM)	✅ Preferred if inflammation present	❌ Avoid (ototoxic, TM damage risk)
Post-Surgical Otorrhea (Tympanoplasty, Mastoidectomy, or Ear Surgery)	✅ Safe after ear surgery	✅ If inflammation is significant	❌ Avoid (ototoxic)
Bacterial Superinfection of Viral Myringitis	✅ If secondary bacterial infection develops	✅ If significant inflammation	❌ Avoid (ototoxic & potential allergy)
Severe Otitis Externa (AOE) with Canal Swelling	❌ Less effective alone due to lack of steroid	✅ Best choice due to steroid for swelling	✅ Can use if TM is intact and patient isn’t allergic
Mild to Moderate AOE (Swimmer’s Ear) with Intact TM	✅ Effective, but lacks steroid	✅ Preferred if inflammation present	✅ Use if patient tolerates neomycin (cheaper option)
Otomycosis (Fungal Ear Infection)	❌ Not effective	❌ Not effective	❌ Not effective
Cost Consideration	💲💲 Moderate	💲💲💲 Expensive	💲 Cheap

Condition	Vosol-HC (Acetic Acid + Hydrocortisone)	Clotrimazole (Antifungal)	Boric Acid (Antifungal & Antiseptic)	Gentian Violet (Antiseptic & Antifungal)
Acute Otitis Externa (AOE) (Swimmer’s Ear)	✅ Useful for mild cases; acidifies canal to inhibit bacterial growth	❌ Not effective	❌ Not effective	❌ Not effective
Chronic Suppurative Otitis Media (CSOM) (with TM perforation)	❌ Not effective	❌ Not effective	❌ Not effective	❌ Not effective
Otorrhea with Tympanostomy Tubes	❌ Not effective	❌ Not effective	❌ Not effective	❌ Not effective
Post-Surgical Otorrhea (Tympanoplasty, Mastoidectomy, or Ear Surgery)	❌ Not recommended	❌ Not recommended	❌ Not recommended	❌ Not recommended
Bacterial Superinfection of Viral Myringitis	❌ Not effective	❌ Not effective	❌ Not effective	❌ Not effective
Severe Otitis Externa (AOE) with Canal Swelling	✅ Can be used if mild and not purulent	❌ Not recommended	❌ Not recommended	❌ Not recommended
Mild to Moderate AOE (Swimmer’s Ear) with Intact TM	✅ Good for **mild, early infections**	❌ Not effective	❌ Not effective	❌ Not effective
Otomycosis (Fungal Ear Infection)	❌ Not effective	✅ **First-line for fungal infections** (Otomycosis)	✅ **Alternative for otomycosis** (not first-line)	✅ **Effective for fungal infections** but stains tissue
MRSA Otitis Externa or Otitis Media	❌ Not effective	❌ Not effective	✅ **Can help in MRSA infections** (acidifies environment)	✅ **Effective for MRSA** (antiseptic properties)
Fluoroquinolone-Refractory Otitis Media or Otitis Externa	❌ Not effective	❌ Not effective	✅ **Can be used in refractory cases**	✅ **Used for refractory bacterial & fungal cases**
Granular Myringitis	✅ Can help acidify the canal, but limited use	❌ Not effective	✅ Used as a powder for **granular myringitis**	✅ **Can be applied to affected areas for granular myringitis**
Cost Consideration	💲💲 Moderate	💲 Affordable	💲 Affordable	💲 Affordable

Condition	Ofloxacin (Floxin Otic)	Gentamicin (Aminoglycoside)	Sulfacetamide (Sulfonamide)
Acute Otitis Externa (AOE) (Swimmer’s Ear)	✅ Use if TM perforation or tubes present	❌ **Avoid** (Ototoxic)	❌ Not effective against typical otitis externa bacteria
Chronic Suppurative Otitis Media (CSOM) (with TM perforation)	✅ First-line treatment (non-ototoxic)	❌ **Avoid** (Ototoxic)	❌ Not effective
Otorrhea with Tympanostomy Tubes	✅ First-line (safe for perforated TM)	❌ **Avoid** (Ototoxic)	❌ Not effective
Post-Surgical Otorrhea (Tympanoplasty, Mastoidectomy, or Ear Surgery)	✅ Safe after ear surgery	❌ **Avoid** (Ototoxic)	❌ Not recommended
Bacterial Superinfection of Viral Myringitis	✅ If secondary bacterial infection develops	❌ **Not recommended**	❌ Not effective
Severe Otitis Externa (AOE) with Canal Swelling	❌ Less effective alone due to lack of steroid	✅ Can be used if TM is intact	❌ Not recommended
Mild to Moderate AOE (Swimmer’s Ear) with Intact TM	✅ Effective, but lacks steroid	✅ Use if TM is intact	❌ Not effective
Otomycosis (Fungal Ear Infection)	❌ Not effective	❌ Not effective	❌ Not effective
MRSA Otitis Externa or Otitis Media	❌ Poor MRSA coverage	❌ MRSA is usually resistant	✅ Effective
Fluoroquinolone-Refractory Otitis Media or Otitis Externa	❌ Not effective if already fluoroquinolone-resistant	❌ Not effective if resistance present	⚠️ Sometimes effective
Cost Consideration	💲💲 Moderate	💲 Affordable	💲 Affordable

Resources/References

• Lieberthal, A. et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. March 2013, 131(3)e964-e999; doi.org/10.1542/peds.2012-3488
• Singleton, R. et al. Trends in otitis media and myringtomy with tube placement among American Indian/Alaska native children and the US general population of children. Pediatr Infect Dis J. 2009 Feb;28(2):102-7. doi: 10.1097/INF.0b013e318188d079
• Ochi, J. et al. Chronic Otitis Media in Ancient American Indians. Pediatrics. 2018; 141(4):e20172308
• Coleman, A. et al. The unsolved problem of otitis media in indigenous populations: a systematic review of upper respiratory and middle ear microbiology in indigenous children with otitis media. Microbiome 6, 199 (2018). https://doi.org/10.1186/s40168-018-0577-2
• Otitis Media 2019 (PowerPoint Presentation)
• Otitis Media (Powerpoint presentation by Dr. Leslie Herrmann)
• The Draining Ear 2017 (Powerpoint Presentation)
• Otitis Media (PowerPoint Presentation)
• ENT Guidelines 2015 (Powerpoint Presentation)
• ANMC Pediatric Acute Otitis Media Clinical Guideline
• Acute Otitis Media (3 months to 12 years) YKHC Clinical Guideline

YKHC Clinical Guidelines
Common/Unique Medical Diagnoses