Acute Sinusitis
Epidemiology
Epidemiology
Anatomic Considerations Commonly, bacterial sinusitis arises after an acute viral
Etiology upper respiratory tract infection (80%) or allergic rhinitis
Pathogenesis (20%). Approximately 0.5% to 13% of viral upper respira-
Clinical Presentation tory tract infections (URTIs) may be complicated by
Differential Diagnosis bacterial sinus infection, while as many as 90% of viral
Laboratory Findings URTIs may result in sinus mucosal involvement without
Imaging bacterial disease and without differentiating clinical
Treatment and Expected Outcome symptoms. Infants younger than 1 year of age can de-
Education velop sinusitis, but there are few data from controlled
Prevention trials, partly because of the difculty of aspirating the si-
Complications nuses of young infants. Recurrent sinus infections com-
Acute Otitis Media monly occur in children with anatomic abnormalities
Epidemiology resulting from facial dysmorphism or trauma, immuno-
Etiology logic defects, or physiologic defects such as cystic bro-
Pathogenesis sis, immotile cilia syndrome, or Wegeners granulomato-
Diagnosis and Clinical Presentation sis. Nasogastric feeding tubes, gastroesophageal reux
Laboratory Studies and Noninvasive Tests disease, and asthma have also been associated with in-
Differential Diagnosis creased incidence of sinusitis.
Treatment and Expected Outcome
Prevention
Anatomic Considerations
The paranasal sinuses consist of four bilateral cavities:
maxillary, ethmoid, frontal, and sphenoid. The ethmoid
ACUTE SINUSITIS and maxillary sinuses develop in the third to fourth
month of pregnancy and are present at birth, although
Acute bacterial sinusitis is one of the most common they can continue to grow until early adolescence. The
infections seen by the general pediatrician. Convention- sphenoid sinuses typically begin to pneumatize by age
ally, the acute phase of sinusitis has been dened as dura- 5 years, and the frontal sinuses by age 8 years. However,
tion of symptoms for less than 1 month. Many episodes of the age at pneumatization of the sphenoid and frontal si-
acute bacterial sinusitis resolve without antibiotics, al- nuses varies widely and absence or hypoplasia of the
though life-threatening complications can arise. This re- frontal and sphenoid sinuses is common. The sphenoid
view provides the general pediatrician with a framework sinuses, while the least accessible on physical examina-
for evaluating the child who presents with acute sinusitis, tion and rarely infected in younger children because of
with emphasis on appropriate diagnosis and proper treat- their later pneumatization, carry a high rate of intracranial
ment. The role of infection in chronic sinusitis is contro- complications if infected because of their proximity to
versial and is not discussed extensively in this chapter. the optic nerve, cavernous sinus, and carotid artery. The
85
function of the sinuses is not conclusively understood; sinusitis in children but may be indicative if reproducible.
purported roles include protecting intracranial structures, Postnasal drainage may be noted. Periorbital edema sug-
improving voice resonance, and aiding olfaction. gests ethmoid sinusitis. The clinician should check that
extraocular movements are intact and that visual acuity is
preserved to exclude the possibility of complicating or-
Etiology bital cellulitis.A neurologic examination is recommended
Sinus aspiration studies indicate that Streptococcus in any patient presenting with symptoms and signs of si-
pneumoniae is recovered in 30% of children with sinus- nusitis.Transillumination of the maxillary sinus is difcult
itis. Haemophilus inuenzae and Moraxella catarrhalis to perform in children and may not be reliable, especially
are each recovered about 20% of the time.The other 30% in children younger than 10 years of age.
of children have sterile sinus aspirates. Staphylococcus
aureus, gram-negative enterics, and anaerobes are not
usually recovered and do not have to be empirically cov- Differential Diagnosis
ered when treating most children with acute sinusitis. The major diagnostic challenge in evaluating a patient
Respiratory viruses have been implicated as causes of with possible sinusitis is differentiating bacterial from vi-
protracted episodes of sinusitis but are expected to re- ral disease. Fever can result from viral infection, and the
solve without therapy in the immunocompetent host. height of the fever is not predictive of bacterial disease.
However, fever resulting from viral infections tends to oc-
cur early in an illness, often with other symptoms such as
Pathogenesis headache and myalgias. Purulent nasal discharge may not
Sinus cavities are air-lled paired spaces continuous appear for several days. Viral URTIs usually last for 7 days
with the nasopharynx but separated by tortuous pas- and, if persistent beyond that point, should at least have
sageways lined with pseudostratied, columnar epithe- begun to improve. Sinus infection is suspected if there is
lium and mucus-producing goblet cells. Mucus formed in no sign of improvement at the 10-day mark. It is particu-
response to bacterial or viral infection is swept by cilia larly difcult to distinguish whether a child who has
toward ostia, which if obstructed leads to decreased in- persistent URTI symptoms has had consecutive viral in-
ternal sinus pressure and local hypoxia, facilitating the fections, although a careful history of the time course of
growth of microorganisms. Like in acute otitis media, the illness and other sick contacts may aid the clinician in
spontaneous resolution may occur in as many as 40% of determining the presence of a second viral infection.
cases. On a related basis, allergic rhinitis can also lead to
congestion and obstruction with bacterial superinfec-
tion, although this usually results in a more chronic pre- Laboratory Findings
sentation. It has also been postulated that some allergens The gold standard of diagnosis is the recovery of a
can persist on the sinus mucosal surface and directly in- high density of bacteria from a sinus cavity obtained by
duce an inammatory response. There does seem to be sinus aspiration. However, this is invasive, technically dif-
an association between sinusitis and asthma exacerba- cult to perform, and not usually available in the primary
tion, although it is not clear whether it is mediated on an care setting. Nasopharyngeal cultures are not recom-
inammatory or allergic basis. mended, because the middle meatus of healthy children
is frequently colonized by sinusitis pathogens. Peripheral
white blood cell count, sedimentation rate, and C-reactive
Clinical Presentation protein may be elevated, but these ndings will not reli-
The American Academy of Pediatrics (AAP) recom- ably distinguish bacterial from viral infection. For this
mends diagnosing sinusitis based on clinical criteria, spe- reason, the AAP recommends that children be diagnosed
cically upper respiratory symptoms that are persistent based on clinical criteria.
or severe as dened by temperature of 102F, purulent Recurrent or chronic symptoms may warrant further
nasal discharge for 3 days, and ill but not toxic appear- laboratory diagnosis for an underlying condition. Al-
ance. Children may have severe headache, often described though recurrent symptoms are most commonly caused
as above or behind the eye. They may also experience by recurrent viral URTI, other disorders to consider are
coughing, vomiting, or gagging. Other nonspecic symp- cystic brosis, congenital or acquired immunode-
toms include nausea, malaise, fatigue, halitosis, and sore ciency, and ciliary dyskinesia. The extent of laboratory
throat. Younger children may simply be irritable. Physical workup is usually indicated by other risk factors be-
examination reveals erythematous and edematous nasal sides recurrence alone, such as need for intravenous
turbinates with surrounding mucus and purulent dis- antibiotics for resolution, recurrent otitis media or
charge; similar features are occasionally seen with viral pneumonia, nasal polyps before 10 years of age, or
infections. Facial tenderness is not a common feature of growth failure.
can be given if vomiting precludes compliance with an oral guided the physician to begin antimicrobial therapy and
regimen. that there is no harm in waiting for symptom resolution in
Macrolides and trimethoprim-sulfamethoxazole are the early stages of a viral infection to allow better differen-
probably not benecial if there has been an amoxicillin tiation between viral and bacterial disease. Advantages of
failure and may actually provide less coverage of the major antibiotic therapy once a diagnosis of bacterial sinusitis is
pathogens. Patients who have failed a second course suspected include more rapid resolution of symptoms,
of antibiotics can be referred to an otolaryngologist for prevention of complications, and tolerability of rst line
sinus aspiration or hospitalized to receive intravenous an- agents. Disadvantages mainly center on side effects of the
tibiotics. If a patient has failed high-dose amoxicillin and particular medication used. In patients with unclear diag-
amoxicillin-clavulanate or acceptable alternative, culture- nosis, parents should be reminded that side effects may be
based diagnosis is recommended instead of continued less acceptable for a disease that could resolve spontane-
empirical antibiotic changes. Recurrent episodes of sinus- ously and that indiscriminate use of antibiotics may lead
itis may warrant referral to an allergist-immunologist for to future resistance and fewer antibiotic choices when
further diagnostic workup. Endoscopic sinus surgery is true infection is diagnosed.
rarely necessary in children in the setting of acute sinusitis
and should be left to the discretion of an experienced
otolaryngologist. The duration of therapy for sinusitis var- Prevention
ies widely. Most experts agree that 10 days is a minimum Although the link between environmental factors is
course of therapy, with most cases expected to resolve not denitive, children with sinusitis should avoid expo-
with a 10- to 14-day course. Some would treat for as sure to triggers such as suspected allergens and cigarette
many as 3 to 4 weeks, whereas others treat for 7 days after smoke. Antibiotic prophylaxis for recurrent sinusitis is
symptom resolution. controversial and may foster antibiotic resistance. The
AAP does acknowledge that daily antibiotics may be use-
Adjuvant Therapy ful in a limited subset of patients who have frequent, se-
Adjuvant therapies such as saline nasal irrigation, anti- vere recurrences, although data are extrapolated from
histamines, decongestants, mucolytics, and intranasal ste- acute otitis media. One strategy in such situations is to
roids are of unclear benet and have not been studied prescribe amoxicillin 20 mg/kg as a nightly dose. Man-
extensively in children. Saline nose drops and sprays may agement of such situations should include a thorough
be helpful by liquefying secretions and facilitating nasal evaluation for predisposing medical conditions and oto-
drainage without affecting mucociliary activity. Saline laryngology referral.
may also act as a mild vasoconstrictor of nasal blood ow.
Saline irrigation is inexpensive, readily available, and de-
void of serious side effects. Whereas topical deconges- Complications
tants shrink nasal mucous membranes to improve ostial Complications of bacterial sinusitis are thought to be
drainage and transient symptomatic improvement, they rare but can be life threatening or vision impairing. Serious
also cause ciliary stasis, which may impair clearance of complications of bacterial sinusitis include meningitis,
infected material. Furthermore, by decreasing local blood brain abscess, epidural or subdural empyema, orbital cel-
ow to the mucosa, topical decongestants may also re- lulitis, cavernous or sagittal sinus thrombosis, and cranial
duce the diffusion of antimicrobial drugs into the si- osteomyelitis. The true incidence of these complications
nuses. Therefore routine use of topical decongestants is in untreated sinusitis in children is unknown. Ethmoid
discouraged. Intranasal steroids may be helpful for chil- sinusitis can lead to periorbital or intraorbital inamma-
dren with underlying allergic rhinitis. tion resulting in cellulitis or abscess formation or cavern-
ous sinus thrombosis. Unless very mild, these complica-
tions require intravenous antibiotics such as ceftriaxone
Education or ampicillin-sulbactam. If visual acuity or extraocular
Informing the parents of the nature of sinusitis is im- movements are compromised, a CT scan of the sinus and
portant to foster realistic expectations and to improve orbits is required, and consultation with an otolaryngolo-
adherence to therapy. Parents may need to be reassured by gist or ophthalmologist is recommended. Surgical drain-
their provider that sinusitis is a clinical diagnosis and that age may be necessary. If mental status is altered or nuchal
routine laboratory testing and radiologic imaging may not rigidity is present, a CT scan with contrast of the head is
be necessary or useful. Some parents may request antibiot- imperative to search for sinus thrombosis, frontal osteomy-
ics with the next viral URTI, pointing to the fact that the elitis, meningitis, or brain abscess. In one case series of
last time antibiotics were not started soon enough, the 16 children with intracranial complications of sinusitis,
URTI turned into sinusitis. The parent should be edu- the most common presenting features were headache
cated that the persistence or severity of symptoms is what (69%), vomiting (69%), and neurologic abnormalities
(56%); most of the complications occurred in male teen- from 2000 show a decline to 16 million ofce visits for
agers. Lumbar puncture should be considered, and the AOM each year. Despite this decline, AOM still accounts
patient should receive vancomycin and a third generation for an estimated $2 to $5 billion in direct health care
cephalosporin until culture results are available. Neurosur- costs with an additional $1 billion in indirect costs. Fur-
gical consultation may be warranted. thermore, some studies have suggested an increase in the
rate of early onset AOM (younger than 12 months of age
at rst diagnosis), and an increase in the number of chil-
dren suffering from repeated episodes of AOM (more
than three episodes by age 6 years).
MAJOR POINTS
Viruses alone cause 10% to 20% of all cases of AOM. of resistant organisms. Therefore it is essential for physi-
Viruses, with or without bacteria, have been isolated from cians to have a consistent approach for making the diag-
the middle ear uid in up to 40% of patients with AOM: nosis of AOM. The diagnosis is contingent on both symp-
most commonly respiratory syncytial virus (RSV), parain- toms identied by history and clinical signs identied by
uenza virus, and inuenza virus and less commonly en- a thorough physical examination, including pneumatic
terovirus and adenovirus. The question remains whether otoscopy. Children may present with a recent history of
the virus causes middle ear inammation directly or fever and acute onset of irritability (infants and toddlers)
whether it causes the URI that predisposes bacterial inva- or ear pain (older children). Other associated symptoms
sion of the middle ear. In 65% of cases when a virus is include cough and rhinorrhea.
isolated from the middle ear, it is accompanied by a posi- Unfortunately, these symptoms overlap considerably
tive culture for bacteria. Interestingly, inuenza virus is with those identied in an acute viral URI. Therefore the
most likely to be found with S. pneumoniae, RSV is most physician must then identify a middle ear effusion (MEE)
likely to be found with nontypeable H. inuenzae, and by physical examination. First, the external auditory ca-
parainuenza virus is equally associated with nontypeable nal needs to be cleaned of any existing cerumen that
H. inuenzae and M. catarrhalis. might block direct visualization of the TM. Removal of
cerumen can be attempted with curettes, suctioning, or
irrigation. In younger children this can be difcult be-
Pathogenesis cause they are less likely to be cooperative for the proce-
When at rest, the eustachian tube is a closed potential dure. Parental involvement is necessary to help restrain
space that protects the middle ear from unwanted sounds the child in a stable position so that the cerumen can be
or pressure changes. Swallowing causes contraction primar- removed with little trauma to the external canal or the
ily of the tensor veli palatini muscle, which opens the eusta- TM. In older, more cooperative children, irrigation can be
chian tube. This allows for ventilation and drainage of the performed in the upright position with warm saline or a
middle ear via mucociliary activity toward the nasophar- dilute hydrogen peroxide solution.
ynx. Disruption of the normal function of the eustachian Once the external canal is clear, the TM should be exam-
tube is typically caused by a viral URI. Less common ana- ined for presence of MEE. MEE is conrmed by the visual-
tomic abnormalities, seen in cleft palate and trisomy 21, can ization of air-uid levels,TM bulging, or decreased mobility
also impair the function of the eustachian tube. In these of the membrane.TM bulging or decreased mobility should
situations the middle ear is poorly ventilated, allowing for be conrmed with the use of pneumatic otoscopy on ev-
nasopharyngeal contents to enter. Bacteria and viruses are ery examination. When performing pneumatic otoscopy,
able to reach the middle ear where they replicate and cause the speculum needs to properly t into the canal to effect
inammation. In certain instances the infection produces an airtight seal. Once the seal is obtained, the operator
enough middle ear pressure to perforate the tympanic gently squeezes and releases the bulb while watching the
membrane (TM) with resultant spontaneous drainage into movement or lack of movement in the TM. Physician diag-
the external auditory canal referred to as otorrhea. Patients nosis of a MEE can be supported with the use of tympa-
often feel a relief of their pain after perforation. nometry or acoustic reectometry, but these tools should
not replace pneumatic otoscopy (see later).
After the presence of MEE is established, the physician
Diagnosis and Clinical Presentation needs to differentiate whether the MEE is from AOM or
It has been estimated that AOM is misdiagnosed up to otitis media with effusion (OME) (Table 102). AOM is as-
50% of the time. This results in unnecessary exposure of sociated with symptoms or signs of inammation that in-
children to antibiotics and potentiates the development clude the following: (1) redness, cloudiness, opacication
Table 10-2 Comparison of the Appearance of a Normal Ear, Acute Otitis Media,
and Otitis Media with Effusion
or bullous changes of the TM indicating edema; (2) bulg- to conrm the presence of MEE but not as the sole
ing of the TM; (3) otalgia in older children or irritability means for diagnosing AOM.
with ear pulling in younger children; (4) purulent otor-
rhea in the absence of otitis externa. This stepwise ap-
proach of history taking, pneumatic otoscopy to locate Differential Diagnosis
MEE, and identication of signs and symptoms of middle The primary challenge for pediatricians is to differenti-
ear inammation should help practitioners increase their ate viral URI, OME, and AOM. As previously discussed, a
accuracy in diagnosing AOM and thus limit the prescribing number of the symptoms seen with a viral URI are also
of unnecessary antibiotics. present in AOM. Pediatricians must resist the temptation
to overdiagnose AOM in the setting of a patient with fever,
irritability, cough, and congestion. Often there is pressure
Laboratory Studies and Noninvasive Tests from parents to prescribe an antibiotic in the absence of
As discussed earlier, the history and physical examina- true middle ear inammation. In these situations, educa-
tion are the most important parts for a correct diagnosis tion of parents on the ineffectiveness of antibiotics to
of AOM. Laboratory analysis is usually unnecessary unless treat a viral infection is necessary.
there is a concern for a more severe underlying illness Close follow-up is also important because a viral URI
such as mastoiditis or meningitis. In such patients, the can evolve into an episode of AOM.
clinical examination should dictate further studies that OME is similar to AOM in that both are associated with
might include CT scanning of the head or mastoids and presence of an MEE. However, OME lacks symptoms or
lumbar puncture. With the increasing availability of poly- signs of middle ear inammation seen with AOM. OME
merase chain reaction analysis of nasopharyngeal aspi- may precede or follow an episode of AOM or may pres-
rates for viruses, the cause of the preceding viral illness ent at the same time as viral URI. The most recent AOM
can sometimes be identied. However, such results would clinical practice guidelines recommend against antibiot-
not likely impact therapeutic decision making and should ics as a therapeutic intervention for OME. The ultimate
not be routinely performed. consequences of persistent OME is not fully known, but
Despite attempts to use other methods (e.g., naso- persistent OME has been associated with hearing loss.
pharyngeal swab cultures) as a surrogate for identifying Given this potential, close follow-up with serial monthly
middle ear pathogens, tympanocentesis remains the examinations should be done to document resolution of
gold standard. This procedure allows the physician to MEE. Persistence of OME beyond 3 months typically war-
drain the middle ear uid and to potentially identify the rants a hearing evaluation and possible referral to an ear,
bacteria to direct antibiotic therapy. Unfortunately, this nose, and throat specialist.
is a skill that is not readily taught in most residency pro-
grams, is invasive, and is not easily performed in a busy
pediatric clinic. As antibiotic resistance worsens for Treatment and Expected Outcome
AOM pathogens, this may become a more necessary The therapeutic recommendations for treatment of
procedure. AOM continue to evolve as resistance proles of the
Tympanometry and acoustic reectometry are two causative pathogens continue to change. The judicious
objective tools that can aid the physician in diagnosing use of antibiotics is necessary to slow this progression of
AOM.The tympanometer uses acoustic energy combined resistance. The following discussion is based on pub-
with production of positive and negative pressures in lished data as well as the most recent clinical practice
the ear canal to estimate the mobility of the tympanic guidelines supported by the AAP and the American Acad-
membrane. A tracing of the results can then be printed emy of Family Physicians. Local rates of AOM pathogens
for interpretation. A at curve output indicates a poorly and local pathogen resistance proles should be used
compliant membrane and suggests presence of a MEE. when deciding which antibiotic to prescribe.
The acoustic reectometer uses sound waves of variable
frequencies. Resonance of the sound frequencies from Antibiotics vs. Observation
the tympanic membrane is recorded and given a reec- Multiple randomized trials comparing oral amoxicillin
tivity value between 0 and 9 and a gradient angle mea- therapy with observation or delayed therapy have been
sured in degrees. A higher reectivity value (5) and a performed outside the United States. These studies have
lower gradient angle (50 degrees) is suggestive of an shown that a childs condition will improve without an-
MEE. Results of these studies can be compromised by tibiotic therapy 70% to 75% of the time. The studies did
cerumen in the external canal, by a perforated TM, or by nd that immediate antibiotic therapy reduces the dura-
inexperienced operators. Both tools may successfully tion of symptoms, such as fever and pain by as much as
identify MEE, but neither can differentiate between AOM 24 to 48 hours. The number needed to treat is seven
and OME.Therefore they should be used as supplements to eight patients in order to show improvement in one
patient. Based on these results, a number of countries Some pediatricians have incorporated a shared-decision
have adopted an observational approach to AOM in chil- component into their observational approach. This entails
dren older than 6 months of age. giving a prescription to the parent at the initial evaluation.
Treatment of AOM in the United States still favors im- Parents are then instructed to ll the prescription if
mediate antibiotic intervention for AOM in most situa- they deem that the childs symptoms are not improved after
tions. The recent AAP clinical practice guidelines should 48 to 72 hours. This approach has been shown to
be used as a guide for antibiotic vs. observational therapy signicantly reduce antibiotic use for AOM but relies heavily
decision making. All children younger than 6 months of on the parents ability to assess clinical improvement or
age with suspected or certain diagnosis of AOM should worsening. Certain parents may not be comfortable with this
receive immediate antibiotic therapy. Children between responsibility.The shared-decision model should be reserved
6 and 24 months of age with certain diagnosis should also for parents who have been educated on when to initiate
receive immediate antibiotic therapy. Observation is con- therapy and when they should seek further medical care.
sidered appropriate in children age 6 to 24 months with
uncertain diagnosis and in children older than 2 years of Antibiotic ChoiceFirst Line Therapy
age with a certain diagnosis of AOM.Any child with severe The decision of which antibiotic to initiate as primary
otalgia and temperature of 39C or greater should be pre- therapy will continue to be debated as the microbiology
scribed antibiotics at the time of presentation. Children and resistance prole of AOM pathogens continue to
with these symptoms at presentation are more likely to change. The AAP clinical practice guidelines for AOM ther-
have persistence of symptoms beyond 72 hours.The deci- apy are summarized in Table 103. Amoxicillin at a dose of
sion to observe a child with conrmed AOM or suspected 80 to 90 mg/kg/day remains the recommended rst line of
AOM should be made with the following assurances: therapy for uncomplicated AOM. This recommendation is
(1) parental understanding of the risk and benets of de- based on the acceptable taste, cost, and effectiveness of
laying therapy (i.e., potential prolongation of symptoms amoxicillin against sensitive and intermediately resistant
for up to 24 hours without antibiotics or potential in- S. pneumoniae. The rationale for the recommendation for
crease in diarrhea with antibiotic use); (2) ability to have high-dose amoxicillin is that antibiotic activity toward
reliable physician contact with the patient either by S. pneumoniae is affected by alterations in the penicillin-
phone or clinic follow-up within 48 to 72 hours; and binding proteins. As these alterations occur, the minimum
(3) conrmation of reliable adult supervision of the child inhibitory concentration (MIC) of the organism increases.
at home with a plan to bring the child for medical evalua- Thus as MICs to S. pneumoniae increase, concentrations
tion if symptoms worsen more acutely. of antibiotics in the middle ear uid must also increase to
Table 10-3 AP and AAFP Clinical Practice Guidelines for Antibiotic Regimens of Uncomplicated
and Complicated Acute Otitis Media
allow for adequate time above the MIC for effective bacte- Treatment Failure
rial killing.Also, pneumococcal AOM is less likely to resolve If the patient continues to be febrile, remain irritable,
spontaneously as compared to those cases caused by or sleeping and eating patterns do not return to normal,
H. inuenzae or M. catarrhalis; therefore, rst line therapy then the pediatrician should consider either antibiotic
should be directed at pneumococci. For complicated AOM, failure, poor adherence to the prescribed medication, or
dened as temperature 39C and/or severe otalgia, rst an alternative diagnosis. When presence of AOM and anti-
line therapy is amoxicillin-clavulanate at 90 mg/kg/day of biotic adherence are conrmed, then a switch to an alter-
the amoxicillin component (extra-strength formulations native antibiotic is prudent (see Table 103). Patients
that contain a higher amoxicillin to clavulanate ratio who were initially started on high-dose amoxicillin should
should be used, i.e., 600 mg amoxicillin and 42.9 mg clavu- be advanced to high-dose amoxicillin-clavulanate. Those
lanate per 5 mL).This recommendation is based on the re- with complicated AOM that were started on amoxicillin-
cent potential shift in AOM pathogen rates during the post clavulanate should be given a dose of intramuscular cef-
heptavalent pneumococcal conjugate vaccine era. While triaxone at 50 mg/kg/day. In nontype I penicillin-allergic
the vaccine may cause a shift toward more penicillin- patients, a similar 3-day course of ceftriaxone should be
sensitive pneumococci, there has likely been an overall in- prescribed. Those with a true type I allergy to penicillin
crease in -lactamaseproducing gram-negative pathogens that fail azithromycin have limited options. Clindamycin
(Table 104). at 30 to 40 mg/kg/day would be reasonable for patients
In penicillin-allergic patients, the options for antibiotic with suspected S. pneumoniae infection, but this would
therapy are altered depending on the type of allergy. Pa- be of no benet for infection with H. inuenzae or
tients with a nontype I allergy will oftentimes tolerate an M. catarrhalis. Trimethoprim-sulfamethoxazole is a less
oral cephalosporin. Three cephalosporin options exist attractive option in this setting because as many as 40%
in these patients who have uncomplicated AOM: one sec- of S. pneumoniae isolates are resistant to trimethoprim-
ond generation cephalosporin (cefuroxime at 30 mg/kg/ sulfamethoxazole.
day) and two third generation cephalosporins (cefdinir at Middle ear effusions commonly occur following effec-
14 mg/kg/day or cefpodoxime at 10 mg/kg/day). If the tive treatment of AOM. The presence of a middle ear effu-
child has a complicated AOM with a nontype I penicillin sion in the absence of signs of infection does not represent
allergy, then a single intramuscular dose of ceftriaxone treatment failure. The natural course of a middle ear effu-
50 mg/kg should be administered. Patients with type I al- sion after appropriately treated AOM is resolution over a
lergy to penicillin restrict therapeutic options even further. period of weeks to months. After an episode of AOM,
In such instances, azithromycin (10 mg/kg/day) and 30% to 40% of children will have an effusion at 1 month,
clarithromycin (15 mg/kg/day) are recommended (see 20% at 2 months, and less than 10% at 3 months.
Table 103). If it is not clear whether the patient has a type
I or nontype I allergy to penicillin, then a consultation Length of Therapy
with an allergist should be considered to conrm the al- Duration of therapy for AOM should be 10 days when
lergy type.This is important because S. pneumoniae and H. treating with an oral regimen. Shorter durations of ther-
inuenzae sensitivities to azithromycin only approach ap- apy have been studied, and a 5- to 7-day course may be
proximately 80% and 49%, respectively, and thus the use of considered only in children older than 5 years of age. In
azithromycin may signicantly reduce the chance of cure. children receiving intramuscular ceftriaxone therapy,
bacteriologic cure is achieved after a single dose in
nearly all cases when infection is caused by nontypeable
H. inuenzae or penicillin-susceptible S. pneumoniae.
Table 10-4 Resistance Proles of Common Acute When penicillin-nonsusceptible S. pneumoniae are iso-
Otitis Media Pathogens Before and After
lated, bacteriologic cure is accomplished in approxi-
Heptavalent Pneumococcal Conjugate
Vaccine (PCV-7)
mately 50% of cases after one dose of ceftriaxone and in
97% of cases after three doses of ceftriaxone. If this op-
tion is used, follow-up in 24 to 48 hours should be estab-
Organism Before PCV-7 After PCV-7 lished to document clinical improvement.
S. pneumoniae
Penicillin sensitive 48% to 58% 38% to 72% Pain Management
Penicillin intermediate 12% to 33% 14% to 42% Pain control in children with otalgia is an important
Penicillin resistant 19% to 34% 14% to 19% component in the management of AOM. Even when an-
H. inuenza
tibiotics are not prescribed, analgesics should still be
Beta-lactamase present 33% to 56% 55% to 64%
M. catarrhalis recommended. Ibuprofen (5 to 10 mg/kg/dose every
Beta-lactamase present 90% to 100% 90% to 100% 6 to 8 hours) and acetaminophen (10 to 15 mg/kg/dose
every 4 to 6 hours) continue to be the mainstay for the