Predicting Treatment Failure in Kids With AOM

William T. Basco, Jr., MD


November 27, 2017

In Whom Did Treatment Fail?

More than 300 children were evaluated (median age, 14 months), 57% of whom were boys and 99% of whom were white. Slightly more than half of the children attended daycare. At enrollment, 92% of the children had a full or bulging tympanic membrane, 76.5% had purulent fluid behind the tympanic membrane, and 9.7% had hemorrhagic erythema of the membrane.

Overall, 31.7% of the children experienced a treatment failure. Only 20% of the children aged 24-35 months experienced treatment failure compared with 34.4% of those aged 6-23 months. Children who had a peaked tympanogram had a lower risk for treatment failure. In regression analyses, age >23 months and the presence of a peak on tympanogram both were associated with a lower chance of failure. Stratified analyses revealed that severe bulging of the tympanic membrane was associated with a greater risk for treatment failure.

As a subgroup, among children with a bulging tympanic membrane, 11% of those who were treated with antibiotics experienced failure compared with 64.1% of children who initially received placebo, resulting in a number needed to treat of approximately two children to avoid one failed treatment. The study authors suggested that children with severe bulging of the tympanic membrane will benefit most from antimicrobial treatment, whereas children with a peak on tympanogram are good candidates for initial observation.


Some of the clinical findings in this study would be very beneficial in everyday practice. The study authors pointed out that the current treatment guidelines for AOM suggest that children with bilateral otitis media may be more likely to benefit from treatment. The data from this study suggest that it is the severity of infection in either ear that determines the risk for short-term treatment failure rather than the presence or absence of bilateral infection. Most practitioners would agree that they are more likely to treat a child with antibiotics when the tympanic membrane is bulging or very inflamed. However, the findings of this study reinforce the fact that a child with a bulging or severely inflamed tympanic membrane, even those over the age of 2 years, may not be a good candidate for initial observation. Similarly, the tympanogram (almost certainly underused in daily practice) appears to be a valuable adjunct in making the decision about who might be a good candidate for watchful waiting.


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