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INITIATINGDRUGTHERAPY
GoalsofDrugTherapy
ThegoalsoftherapyforAOMincludesymptomaticpainrelief,appropriateuseofantibioticstoprevent
complications,andjudicioususe ofantibioticsto preventfutureantimicrobialresistance.Symptomatic
painrelief can be achieved with over-the-counteranalgesics such as acetaminophen or anonsteroidal
antiinflammatorydrug (NSAID) such as ibuprofen, andshould be offered regardless of antibiotic use,
unless hypersensitivity exists. Local topical anesthetics containing benzocaine or procaine should be
reservedforchildrenover 5years ofageandmayprovidebriefadditionalpainrelief.Antibiotics are
utilized to eradicate the infectingorganism andpreventcomplicationssuch as mastoiditis and hearing
impairment. However, due to concerns of microbial resistance and adverse effects, clinicians should
avoidunnecessaryuseofantibiotics.
ObservationalTherapyversusAntibioticTherapy
ThedecisiontomanageAOMwithantibiotics isbased onpatient-specific characteristicssuchas age,
bilateralinvolvement,presenceofotorrhea,andseverityofillness(Lieberthaletal.,2013).Allpatients
withsuspectedAOMwhoareyoungerthanages6monthsshouldreceive antibioticsduetodiagnostic
difficultiesandhighriskofcomplications.Forpatientswithnon-severe,unilateralAOMwithoutotorrhea
who are older than age 6 months, the role of antibiotics is unclear, and the decision to provide
symptomaticreliefwithcloseobservationcanbemade.Thedecisiontoobserveandwithholdantibiotics
isbasedonthehighrateofspontaneousresolution(approximately80%)andoverlapofnonspecificAOM
symptomswithviralURIs(Hershetal.,2013).Observationtherapyrequiresimplementationoffollowupwithin48to72hourstoensureantibioticscanbeinitiatedifthechild’sconditionworsensorfailsto
improve.Thetechniqueforobservationaltherapyiscontroversial:observewithorwithoutaprescription
withinstructionstofillafter2to3daysifsymptomspersist(Chaoetal.,2008).Thisdecisionshouldbe
based on the prescriber’s discussionwith the caregiver andassessmentof likelihoodtoadhere to the
plan.
Patientswithotorrheaorseveresymptoms(i.e.,toxic-appearingchild,persistentotalgiamorethan48
hours,temperaturemorethanorequalto102.2°Finthepast48hours,oruncertainaccesstofollowup)
requireantibiotictherapyregardlessofage.IfAOMisidentifiedbilaterally,thedecisiontotreatisbased
on the patient’s age: AOM requires antibiotic therapy only if the patient is less than 2 years of age.
Patients2yearsoldorgreaterwithbilateralAOMwithoutotorrheaorseveresymptomsmayinitiallybe
managedwithobservationtherapyafteradiscussionwiththechild’sfamilytounderstandthedecision.
Penicillins
First-linetherapyforAOMishigh-doseamoxicillinforadequatemiddleearpenetrationandtoovercome
intermediate-resistantS.pneumoniae(Lieberthaletal.,2013;Figure17.1;Table17.3).Ifthechild has
receivedamoxicillininthepast30daysorhasconcurrentpurulentconjunctivitisorallergytopenicillin,
amoxicillin may not be appropriate. Recent receipt of amoxicillin or failure to improve while on
amoxicillinraises concernofresistantorganisms causingthe infection,suchasM.catarrhalis and H.
influenzae.Therefore,theadditionofbeta-lactamaseinhibitortoabeta-lactam or useofabeta-lactam
stablecephalosporin(seeCephalosporinssectionfollowing)isnecessary.Amoxicillin—clavulanateisa
combination productcommerciallyavailableintheUnitedStates invariousconcentrations oftheoral
suspension, chewables, tablets, and extended-release tablets. The major difference among these
formulationsistheratio ofclavulanatetoamoxicillinandthereforemaynotbeinterchanged.Themost
commonadverseeffectofantibioticsisdiarrhea,whichisevenmoresowithamoxicillin—clavulanate
when the dosage of clavulanate is too high (Hoberman et al., 2017). Since high-dose amoxicillin is
recommended for AOM treatment, use of amoxicillin—clavulanate standard ratio (clavu-lanate to
amoxicillin,1:7) would result inexcess exposure of clavulanate anddiarrhea. Therefore, theES oral
suspensionformulation(ratio1:14)orXRformulationfortablets(ratio1:16)shouldberecommendedto
limitexcessiveexposuretoclavulanateandthereforereducetheincidenceofdiarrhea.
Cephalosporins
Ifthepresenceofapenicillinallergyiselicitedfromthepatientorcaregiver,thetypeofreactionshould
beassessed.Fortunately,thecross-reactivitybetweenpenicillinsandmostsecond-generationandthirdgenerationcephalosporinsislowduetodistinctchemicalstructures(Nortonetal.,2018).Therefore,oral
formulations of cefdinir andcefpodoxime,whichare third-generationcephalosporins, andcefuroxime,
whichisasecond-generationcephalosporin,arerecommendedforpenicillin-allergicpatients,regardless
ofreactiontype(bothanaphylacticandurticarialreaction)(Table17.3).
FIGURE17-1Ireatmentalgorithmforacuteotitismedia.AOM,acuteotitis media;IM,intramuscular;
TM,tympanicmembrane.
TABLE17.3
OverviewofAntibioticsforAcuteOtitisMedia
*
Standardratioofclavulanatetoamoxicillinof1:7.
tESratioofclavulanatetoamoxicillinof1:14.
*Standard125mgofclavulanatepertablet.
§XRratioofclavulanatetoamoxicillinof1:16.
ES,extrastrength;GI,gastrointestinal;IM,intramuscular;TM,tympanicmembrane;XR,extendedrelease.
For patients who are persistently vomiting or cannot tolerate oral medication for other reasons,
ceftriaxone, a third-generation cephalosporin, administered as an intramuscular (IM) injection, is an
option as a single dose for initial treatment or daily dosing for a total of three for repeat antibiotic
treatmentduetotreatmentfailure.
Macrolides
Historically,macrolidesincludingazithromycinanderythromycinwererecommendedforpatientswitha
history of anaphylactic reaction to penicillins. Due to limited macrolide efficacy against both S.
pneumoniae and H. influenzae and realized lower rate of cross-sensitivity to cephalosporins among
penicillin-allergicpatientsthanpreviouslyreported,macrolidesarenolongerrecommendedbytheAAP
forAOM(Lieberthaletal.,2013).
Clindamycin
Similarto macrolides,clindamycinhistoricallywasanoptionfor patients whohadananaphylactic to
penicillin.Butagain,duetoconcernsofclindamycin’slackofactivityagainstgramnegativebacteria,such
asH.influenzaeorM.catarrhalis,itisnolongerrecommended.Clindamycinmaybeusedforsuspected
DRSP,butitmaynotbeeffectiveagainstmulti—drug-resistantstrains,suchasserotype19A(Kaplanet
al.,2015).
SelectingtheMostAppropriateAgent
Figure17.1outlinestheprocessforselectingthemostappropriateagent.
First-LineAntibioticTherapy
Oncethedecisiontoinitiateantibioticsismade,regardlessofwhetheranobservationperiodhaspassed
ornot,thesameantibioticdecisionalgorithmapplies(Figure17.1).Amoxicillinisconsideredthefirst-
line treatment for AOM in patients who show severe symptoms and who did not have a course of
amoxicillininthepast30daysorare notallergictopenicillin.Forthosepatientswhohadacourseof
amoxicillinintherecentpast,treatmentwiththecombinationamoxicillin—clavulanateis indicated.In
patientswithpenicillinallergy,oneofthecephalosporinsisindicatedasthefirst-linetreatment.
Second-LineAntibioticTherapy
Patientswho receive antibioticsfor morethan72 hours withpersistent,severe symptomsare deemed
treatmentfailure.Thismaybeduetothepresenceofaresistantorganism,aviralinfectionwhichwould
be unresponsive to antibiotic therapy, inadequate concentration of antibiotic in the middle ear, or
noncompliance with the prescribed regimen. Treatment failure requires escalation to the next step in
managementandishighlydependentontheinitialtherapy.Ifthepatient’s
condition does not improve with high-dose amoxicillin treatment, therapy should be switched to
amoxicillin—clavulanate.Forpatientswhofaileitheramoxicillin—clavulanateoranoralcephalosporin
(i.e., cefpodoxime,cefuroxime,cefdinir), escalationtoceftriaxoneasa single dailyIMor intravenous
injectionfora3-daycourseisrecommended(Leibovitzetal.,2000).Tympanocentesisforbacteriologic
diagnosisisanoptionforpatientswhohaverepeatedlyfailedtherapy.TheeffusionissentforGramstain,
culture,andantibioticsusceptibilitytestingtotailortherapytothecausativeorganism.
MonitoringPatientResponse
Thedurationofantibiotic therapyisdependentontheseverityandageofthepatient:severeAOMor
patientsyoungerthanage2yearsshouldreceivea10-daycourse,patientsofage2yearsoroldershould
be treated witha 7-daycourse, and those ofage6 years and oldermaybenefitfrom a shorter,5-day
course of therapy (Lieberthal et al., 2013). Reduced duration of 5 days was compared to a 10-day
durationofamoxicillin/clavulanateinchildrenof age6 to23 monthswithAOM;this wasassociated
withsignificantlyworseoutcomes(Hobermanetal.,2016).Symptomresolutionshouldoccurwithin2to
3 days, andthepatientshould achieve completeresolutionof AOM symptoms after 7 days;however,
asymptomatic MEE may persistifinspectedbypneumatic otoscope. The patientor caregiver mustbe
counseledtocontinueantibiotictherapyevenifsymptomsresolvebeforecompletionoftheentiretherapy
coursetopreventrecurrence.
RECURRENTACUTEOTITISMEDIA
RecurrentAOMisdefinedasmorethan3episodeswithin6monthsor4episodeswithin12months,with
1 episodeinthepreceding6 months.Recurrenceismostcommonlyduetorelapse (infectionwiththe
same organism) or reinfection (infection with a different organism). Management of recurrent AOM
remainscontroversial, but may includeepisodic antibiotic treatment,adenoidectomy, ortympanostomy
tubeinsertion.However,theeffectoftheseinterventionsonOMrecurrenceisinconsistent,andevidence
is contradictory. The American Academy of Otolaryngology: Head and Neck Surgery Foundation
published guidelines stating tympanostomy tube insertion should be offered to children with bilateral
OMEanddocumentedhearingdifficultiesfor3monthsorlonger(Rosenfeldetal.,2013).Anadditional
indicationisforchildrenatincreasedriskofspeech,language,orlearningproblemsfromOMEdueto
baselinesensory,physical,cognitive,orbehavioralfactors.Myringotomyandinsertionoftympa-nostomy
tubes improve AOM symptoms by allowing drainage of the effusion; however, reduction in OME
recurrence is not consistent. Complications of tube placement include otorrhea, myringosclerosis,
perforation,andtissuegranulationasseenonotoscopicexamination.
Prophylaxisand/orPrevention
Use of antibiotic prophylaxis for recurrentAOMis controversial due to lack of supporting evidence.
Cost, adverse effects, and contribution to bacterial resistance emergence do not outweigh the small
reductioninfrequencyofAOMwithlong-termantibioticprophylaxis.Therefore,antibioticprophylaxisis
nolongerrecommendedforchildrenwithrecurrentAOM.
TheCentersfor DiseaseControl andPrevention’s (CDC)childhoodvaccinationschedule should be
followed to reduce preventable diseases. The vaccines pertinent to the prevention of AOM are the
pneumococcal,H.influenzaetypeB(HiB),andinfluenzavaccine.Pleaserefertothepreventionsection
ofthischapterforadetaileddiscussionontargetedvaccinegroupsandcurrentrecommendations.
OTITISEXTERNA
DiagnosticCriteriaandClinicalPresentation
OE diagnosis requires all three criteria: symptoms of ear canal inflammation such as otalgia (often
severe),itching,orfullness;signsofearcanalinflammationsuchastendernessoftragusand/orpinna;and
anerythematousearcanalwithoccasionalotorrhea(Rosenfeldetal.,2014).Hearingisusuallyunaffected
unlesspressure andfullnessintheear exist,producingoccasionalconductiveor sensorineural hearing
loss. Jaw pain may also be present.Acute OE diagnosis requires rapid onsetofsigns and symptoms
within48hoursinthepast3weeks.Differentiationfromotherpossiblecausesofotalgia,otorrhea,and
inflammationof the ear canal, suchas AOM,isimportantdue tooverlapping pathologies thatrequire
differenttreatmentmanagement.
Patient evaluation should include history of symptoms, water exposure, local trauma, past medical
historyofinflammatoryskindisordersordiabetes,andhistoryofearsurgeriesorlocalradiotherapy.As
mentioned in the Diagnostic Criteria and Clinical Presentation section, otoscopic examination may
requirecerumenordebrisremoval.IftheTMisbulgingorerythematous,thepatientshouldbeworkedup
forOM.Examinationofpinnaandadjacentskinforregionallymphadenitisandcelluli-tisisincludedas
well. Otomycosis, thatis,fungalOE, presents withintensepruritus, aural fullness, clearotorrhea,and
fluffy, cotton-like debris in the external ear canal upon examination (Kesser, 2011). Necrotizing OE
diagnosis is confirmed with an elevated erythrocyte sedimentation rate and abnormal computed
tomographyor magnetic resonance imagingscanto detecta skull base osteomyelitis(Rosenfeld et al.,
2014).
INITIATINGDRUGTHERAPY
GoalsofDrugTherapy
ThegoalsofOEtreatmentaresimilartothoseofOM:decreasingtheaccompanyingpainanderadicating
thecausativeorganisms.
Thiscanbeaccomplishedwithsystemicanalgesicand/orantiin-flammatorydrugsanddirectototopical
applicationofantimicrobialagents,respectively.
Pain relief can be achieved with orally administered acetaminophen or NSAIDs given alone or in
combinationwithanopioidformildtomoderatepain(Rosenfeldetal.,2014).Topicalanestheticdrops,
suchas benzocaineotic solution,arenotrecommendedduetopotential maskingofunderlyingdisease
statesandlackofFoodandDrugAdministration(FDA)approvalforOEindication.
ManagementofOEbeginswithclearinganyobstructingdebrisorexcesscerumenfromthecanal(i.e.,
auraltoilet)andcheckingtheintegrityoftheTMtodetermineifextensionbeyondtheearcanalispresent.
Topical therapyis themainstayofOE treatment(i.e., antibiotics,steroids, or combinationtreatments).
Topicalantimicrobialsarepreferredoversystemicadministrationtoachievehighconcentrationatthesite
ofinfectionwhilereducingsystemicadverseeffectstothepatient.Selectionoftheappropriateproduct
mustincludeevaluationofthepatient’sinfection,predisposingfactors,adherence,andmedicationcosts
(Boyce&Balakrishnan,2018).Thedurationofototopicalantibiotictreatmentis7to10days.
OralantibioticsmayberecommendedforpatientswithacuteOEinfectionsextendingoutsidetheear
canalorcertainhostfactorssuchasdiabetes,immunedeficiency,orinabilitytoeffectivelydelivertopic
therapy. Systemic antibioticsshould also be considered for patients withrecurrentepisodes of OE or
clinical signs of necrotizing (i.e., malignant) OE, which is a serious and potentially life-threatening
complicationoftheinfectionextendingtothemastoidor temporalbone.Immunocompromisedpatients,
including the elderly with diabetes and human immunodeficiency virus, are at the highest risk of
necrotizingOE.ChronicOEisasingleepisodelastinglongerthan3monthsor4ormoreepisodesin1
year;itisoftentheresultofallergies,chronicdermatologicconditions,orinadequatelytreatedacuteOE
(Rosenfeldetal.,2014;Schaefer&
Baugh2012
)
AntibioticTherapy
Ifedemapreventsapplicationofthedrops,acompressedcelluloseearwickcanbeplacedintotheearto
facilitatedrugdelivery.Themedicationshouldbeappliedtothewickuntilinflammationsubsidesandthe
wick falls out or is removed as instructed by a clinician (usually within 24—48 hours). Ototopical
antimicrobials for OE include aminoglycosides, polymyxin B, and quinolones. Ototopical selection is
basedonseveralfactorsincludingTMcondition(e.g.,perforation,tympanostomytubes),riskofadverse
effect, adherence issues, cost, patient preference, and physician experience/preference (Table 17.4).
Systemicantimicrobials are notrecommendedforuncomplicated,acuteOE,buttheyarerecommended
forinfectionsextendingbeyondtheearcanal or whencertainfactorsarepresent,suchas uncontrolled
diabetes,immunocompromisedstatus,historyofradiotherapy,orinability todelivertopicalantibiotics.
Otomycosis requires debridement and topical antifungal therapy, such as a powdered mixture of
chloromycetin, sulfanilamide, amphotericin, and hydrocortisone (Kesser, 2011). Necrotizing OE is
managed with surgical debridement and systemic, prolonged antipseudomonal and antistaphylococcal
antibiotics.
Fluoroquinolones
The fluoroquinolone antibiotics, thatis, ciprofloxacin andofloxacin, are oftenused to treatinfections
associatedwithOE,duetoitsidealantipseudomonalactivity.Higherbacteriologicandclinicalcurerates
havebeenobservedwithquinolone-containingoticdropsthanwithnon-quinolonetherapy(Mösgesetal.,
2011). Inaddition,theseagentsmaybe more tolerable thanneomycin—polymyxinBduetoinfrequent
administration,lessadverseeffects(e.g.,stinging),andlowerriskofhypersensitivity.Thisinformation
mustbebalancedwiththehighcostofquinoloneoticpreparations.Ciprofloxacin0.3%—dexamethasone
0.1% (Ciprodex) and ofloxacin (Floxin Otic) are commercially available fluoroquinolone otic
formulations.(SeeTable17.4 for dosage andadverse effectinformation.) However, the additionofa
corticosteroid to the antibiotic formulation is controversial. The antiinflammatory effects of
corticosteroidspotentiallyincludereducedpain,swelling,anditching.Ciprofloxacinoticsolutionwas
foundto be non-inferior tothe corticosteroid plusantibiotic otic combinationsolution,polymixinB—
neomycin—hydrocortisone based on clinical cure (Drehobl et al., 2008). The risk of local
immunosuppression and potential hypersensitivity reactions should be studied before recommending
corticosteroid—fluoroquinoloneantibioticcombinationoticsolutionsfirstline.Ofnote,theFloxinOtic
preparationdoesnotcontainacorticosteroid.
TABLE17.4
OverviewofTreatmentforOtitisExterna
Generic(Trade)Nameand
Dosage
SelectedAdverseEvents Contraindications Special
Considerations
PolymyxinBsulfate,
neomycin,andhydrocortisone
Children:3dropsintoearcanal
TID-QIDformaximumof10
days
maximumof10daysAdults:4
dropsintoearcanalTID-QID
formaximumof10days
Superinfection,contact
dermatitis,ototoxicitywith
prolongeduse
Herpessimplex,fungal,
tubercular,orviralotic
infections
Perforatedeardrum
Prescribewithcautionin
pregnancy(categoryCdrug)
andinbreast-feedingpatients
Useoticdrops
foramaximum
of10days
Ofloxacin(Floxin)
Children6months-12years:5
dropsintoearcanaloncedaily
for10days
Children>12yearsandadults:
10dropsoncedailyfor10days
Pruritus,sitereaction,
dizziness,earache,vertigo,taste
perversion,paresthesia,rash
Perforatedeardrum
Prescribewithcautionin
pregnancy(categoryCdrug)
andinbreast-feedingpatients
Useoticdrops
foramaximum
of10days
AminoglycosideAntibiotics
The combination product neomycin sulfate—polymyxin B—hydrocortisone acetate (Cortisporin) has
historically been used for OE. The combination of the gram-positive coverage of the aminoglycoside
neomycinandtheantipseudomonalactivityofpolymyxinhasmadethiscombinationthegoldstandardof
treatmentinthepast.AsstatedintheFluoroquinolonessection,theadditionofacorticosteroidwiththis
combination remains controversial. Concerns associated with the side effect profile, particularly the
hypersensitivity reactions related to neomycin(and possibly the preservative), and frequency of dose
administrationmustbe weighedagainst thelowcostfor this generic product. Furthermore, ototoxicity
withneomycinhasbeenreported,althoughthenumberofreportsislowandthedataarespeculative.Due
toconcernsofototoxicity,aminoglycosides shouldnotbe usediftheTMisnotintactsincetheriskof
injuryoutweighsthebenefitandefficacious,non-ototoxicantibioticsareavailable(i.e.,quinolones).
SelectingtheMostAppropriateAgentFirst-LineTherapy
OEwithintactornon-intactTMistreatedinitiallywitha fluoroquinoloneantibiotic. Theselectionof
ciprofloxacinversusofloxacindependsontheformularystatusoftheagents,as well as theclinician’s
experiencewithaddedcorticosteroids(Table17.5).
Second-LineTherapy
Neomycin-polymyxinBcombinationsareconsideredsecond-lineagents,primarilyduetotheirsideeffect
profile and precaution against use for nonintact TM OE. The lower cost of these agents, however,
warrantsconsideration,particularlyinpatientswithoutinsuranceorothermeansofpayingforthemore
expensivefluoroquinolones.
Third-LineTherapy
Antifungals can be considered if a patient fails to respond to initial topical antibiotic therapy (e.g.,
clotrimazole,miconazole,bifonazole,ciclopiroxolamine,tolnaftate)(Vennewaldetal.,2010).Systemic
antibiotic therapywithP.aeruginosaandS.aureus coverageisrecommendedif ear canalobstruction
cannotberelievedorifinfectionextendsbeyondtheearcanal.
TABLE17.5
RecommendedOrderofTreatmentforOtitisExterna
Order Agents Comments
First
line
Fluoroquinolonedrops Floxinisnot
recommendedforpatients<6monthsUseallotic
dropsforamaximumof10days
Second
line
Combinationneomycin-polymyxinBdrops Alldropsarecontra-indicatedincasesofperforated
eardrum
Third
line
Antifungaldrops
Systemicantipseudomonalorantistaphylococcal
agent
Considerifapatientfailstorespondtoinitialtopical
antibiotictherapy
Considerifearcanalobstructioncannotberelievedorif
infectionextendsbeyondtheearcanal
SpecialPopulationConsiderations
Childrenwith tympanostomytubesplaced within1 year ofan acute OE episode are assumed tohave
nonintact TM and therefore should not receive an ototoxic antibiotic. Historical concerns of
fluoroquinoloneuseinchildrenarenotrelevantduetotheminimalsystemicabsorptionandsmalldose
administeredototopically.
MONITORINGPATIENTRESPONSE
Symptom improvement should occur within 48 to 72 hours after appropriate treatment initiation, but
completesymptomresolutionmaytakeupto2weeks.Reassessmentofpatientswhofail initialtherapy
mayincludeaddressingpatientadherencewiththerapy,re-examinationoftheearcanalandTM,aculture
of the ear canal to identify causes of infection and target therapy, and consideration of underlying
dermatologicdisorders.
PREVENTION
Preventionis thekeyandplaysasignificantroleinreducingtheoverall burdenofillness(e.g.,office
visits, antibiotic expenditures, severity of illness). Vaccination programs have been shown to have a
favorable outcome on decreasing the overall incidence of the AOM, namely, those caused by S.
pneumoniae,H.influenzae,andinfluenzavirus.
Theintroductionoftheheptavalentpneumococcalpolysaccharideconjugatevaccine(PCV-7,Prevnar7;serotypes4,6B,9V,14,18C,19F,and23F)decreasedtheoverallincidenceofinvasivepneumococcal
diseaseby69%inchildrenyoungerthanage2from1998to1999and2001(Pichichero&Casey,2007).
Specifically, reductions in OM office visits and severity of illness have been observed since the
introductionofthevaccine(Blacketal.,2000).Whenthe7-valentvaccinewasbroughttothemarketin
2000,theserotypesrepresentedapproximately70%oftheserotypesfoundinAOM.Unfortunately,after
the introduction of PCV-7, otopathogenic S. pneumoniae serotype 19A has been identified as being
resistant to all FDA-approved antibiotics for children withAOM(Pichichero & Casey,2007). A13valentpneumococcalconjugatevaccine(PCV-13,Prevnar-13)wasapprovedbytheU.S.FDAin2010to
containthe6serotypesresponsiblefor63%ofinvasivepneumococcaldisease(serotypes1,3,5,6A,7F,
and 19A, in addition to the 7 serotypes of PCV-7). PCV-13 has replaced PCV-7 in the childhood
vaccinationschedule(CentersforDiseaseControlandPrevention,2020).
In addition to the routine pneumococcal vaccination with PCV, the polysaccharide (PPSV) is
recommendedforchildrenolderthanage2yearswithcomorbidities.Itisnotindicatedininfantsyounger
thanage2yearsduetopoorimmunogenicitytoPPSV.PPSVcontains23pneumococcalserotypesandis
indicated for children withchronic diseases such as chronic lungdisease or congenital heartdisease,
cochlearimplant,andmore.Checkthemostup-to-daterecommendationsfromtheAdvisoryCommitteeon
ImmunizationPractices(ACIP).
The HiB and influenza vaccines are also routinely recommended in the childhood immunization
schedule.TheHiBvaccineisapolysaccharide,conjugatedproteincarrierindicatedforinfantsofage6
weeksandolder.Theinfluenzavaccineis recommendedfor allpersonsover 6 monthsofage,butthe
selectionofthecorrectformulationisdependentontheageofthepatient.Influenzavaccineisavailable
as a trivalentor quadrivalentinactivatedinfluenza vaccine (IIV)for IM injection, and live attenuated
vaccine(LAIV)asanintranasaladministration.TheIIVrequirestwodosesduringasinglefluseasonfor
childrenofage6 monthsthrough8 years ifit’stheir first vaccinatedseason,dependingonthecurrent
ACIP.TheminimumagetoreceivetheLAIVisage2years.Inaddition,theLAIVshouldnotbegivento
individualswhoarenotimmunocompromisedorpregnant.Currentrestrictionson
LAIVusemustbecheckedbeforerecommending(CentersforDiseaseControlandPrevention,2020).
For up-to-date ACIP vaccine administration schedules, check the CDC Web site at
www.cdc.gov/vaccines(CentersforDiseaseControlandPrevention,2020).
PATIENTEDUCATION
DrugInformation
Administrationofototopicalproductsrequirespatienteducationandpotentiallyanassistanttoadminister
the drops for them as self-administration may be difficult. Ototopicals should be warmed to body
temperaturebeforeinstillationtoavoiddizziness.Towarmtheoticsolution,thepatientshouldholdor
rollthebottleinthehandfor1to2minutes.Toinstilldrops,thepatientshouldliewiththeaffectedear
upward,administerenoughdropstofilltheearcanal(orsaturatetheearwickifinplace),gentlytugthe
auricletohelpexpeltrappedairandassistdrugdelivery,andremaininthispositionforabout5minutes
tohelpthesolutionpenetrateintotheearcanal.
Nutrition/LifestyleChanges
The use of hypoallergenic ear canal molds when swimming or showering is controversial for the
preventionofOE.Dryingtheearswithacoolhairdryertoaidremovaloffluidafterswimmingmaybe
beneficial.Thepatientshouldavoidtryingtoremoveearwaxmechanicallywithcotton-tippedswabsto
preventtrauma.Itisimportantforthepatienttoavoidwaterintheearuntiltheinfectionclears(usually5
—7days)andfor4to6weeksafterward.Toaccomplishthis,haircanbewashedinasinkinsteadofa
showerortub,andthepatientcanuseashowercapwhenbathing.
ComplementaryandAlternativeMedications
“Homeremedies”ofa1:1solutionofwhitevinegarandrubbingalcoholhaveneverbeenevaluatedor
substantiatedandthereforearenotrecommendedforOE.Inaddition,earcandlesarenotefficaciousand
maybeharmful(e.g.,hearingloss).
CASESTUDY1
C.J.,age17, isonhis highschool swimteam.Hepresentswithsuddenonsetofrightearpainthat
worsensatnight.Hesaysthatthepainintensifieswhenhetoucheshisearandthathehasafeelingof
fullnessintheear.Onexaminationofhisrightear,theauditorycanalisedematousanderythematous,
withyellowcrusting.Histemperatureis97.8°F,andhistympanicmembrane(TM)ispearlygraywith
landmarksintact.Hisleftearexamiswithinnormallimits(LearningObjectives1and3).
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