Parental experiences and opinions regarding the management of acute otitis media in Finland-a comparative questionnaire between 2006 and 2019.

BACKGROUND: Treatment guidelines for acute otitis media (AOM) have changed over the past 20 years. Watchful waiting is often recommended as an option for antibiotic treatment and the use of proper pain medication is emphasised. OBJECTIVE: To study parental experiences and opinions regarding the management of AOM and compare our findings with our previous questionnaire submitted in 2006. METHODS: We sent an online survey link through day-care centres and Facebook parental groups in Turku area. Children <4 years of age attending day care were included in the analysis. We asked about the child's history of AOM, parental opinions about AOM treatment, and antibiotic resistance. Results of 2019 were compared with those of 2006. RESULTS: Altogether 84% (320/381) and 83% (568/681) of children had had at least 1 episode of AOM in 2019 and 2006, respectively. In 2019, more children had been treated without antibiotics (30% vs. 13%, P < 0.001) and fewer parents thought that antibiotics are necessary for the treatment of AOM (70% vs. 85%, P < 0.001) compared with 2006. The use and knowledge of painkillers had increased over the past 13 years. Painkillers had been given at least once to 93% (296/320) of children in 2019 and 80% (441/552) of children in 2006 (P < 0.001). CONCLUSIONS: Today, more parents accept watchful waiting as a treatment option for AOM and give painkillers to their children, which indicates that the education about optimal management of AOM has reached parents.

Ear infection, or acute otitis media (AOM), is one of the most common infections in young children. Studies have shown that antibiotics are effective in treating AOM, but some children may recover well without antibiotics. Antibiotic use may cause adverse events and increase bacterial resistance. We asked Finnish parents for their experiences and opinions regarding AOM management. We sent the same questionnaire in 2006 and 2019 and compared the responses. We found that more children had been treated without antibiotics in 2019, which is in line with the changes in clinical practice guidelines. We also found that parents had given painkillers more often in 2019 than in 2006.

Rhinovirus C Is Associated With Severe Wheezing and Febrile Respiratory Illness in Young Children.

BACKGROUND: Rhinovirus is the most common virus causing respiratory tract illnesses in children. Rhinoviruses are classified into species A, B and C. We examined the associations between different rhinovirus species and respiratory illness severity. METHODS: This is a retrospective observational cohort study on confirmed rhinovirus infections in 134 children 3-23 months of age, who were enrolled in 2 prospective studies on bronchiolitis and acute otitis media, respectively, conducted simultaneously in Turku University Hospital, Turku, Finland, between September 2007 and December 2008. RESULTS: Rhinovirus C is the most prevalent species in our study, and it was associated with severe wheezing and febrile illness. We also noted that history of atopic eczema was associated with wheezing. CONCLUSIONS: Our understanding of rhinovirus C as the most pathogenic rhinovirus species was fortified. Existing research supports the idea that atopic characteristics are associated with the severity of the rhinovirus C-induced illness.

Smartphone Otoscopy Performed by Parents.

Introduction:Implementation of pediatric telemedicine has been emphasized. We examined whether parents could perform smartphone otoscopy for the diagnosis of otitis media.Materials and Methods:We included children (6-35 months) attending day care with at least one episode of acute otitis media (AOM) within 90 days of the study entry. The timing for a teaching intervention was randomized. In the immediate teaching group, parents were taught smartphone otoscopy and cerumen was removed at the first visit. The delayed teaching group received the teaching intervention after 1 week's independent use. During the 60 study days, parents performed home examinations. The main outcome, the diagnostic quality of the tympanic membrane videos to determine healthy ear, otitis media with effusion (OME) and AOM diagnoses was measured with a structured video analysis independently by three physicians. Parents' experience was measured with a questionnaire.Results:AOM could be detected or excluded in 87% (609/699) of the videos during acute symptoms. After the teaching intervention, healthy ear, OME, or AOM could be diagnosed in 40% (521/1,293) of the videos. During the first week's intervention, one of the three diagnoses was attained in 33% (50/153) and in 12% (22/179) of the videos in the immediate and delayed teaching group, respectively (p < 0.001). The performance of the smartphone otoscopy examination was easy in 85% (35/41) of families.Discussion:After been taught, parents are able to perform smartphone otoscopy for the remote detection or exclusion of AOM.Conclusions:Future studies should assess the clinical usefulness of parent-performed smartphone otoscopy.

Adaptation of pain scales for parent observation: are pain scales and symptoms useful in detecting pain of young children with the suspicion of acute otitis media?

BACKGROUND: The assessment of ear pain is challenging in young, mostly preverbal children. Our aim was to investigate whether pain scales are useful tools for parents to detect pain in their young children with the suspicion of acute otitis media (AOM), and to assess associations between 16 symptoms and the severity of pain. METHODS: This cross-sectional study included 426 children (6-35 months) with symptoms suggestive of AOM. We surveyed symptoms and pain via parental interview. As part of the interview, parents assessed their child's pain by using two pain scales: The Faces Pain Scale-Revised (FPS-R) and the Face, Legs, Activity, Cry, Consolability (FLACC) Scale. The outcome of interest was moderate/severe pain. We used the χ2 test or Fisher's test as applicable to compare the severity of pain between three parental pain assessment methods (the parental interview, the FPS-R and the FLACC Scale). We also used multivariable logistic regression models to study the association between the severity of pain and AOM and to study the association between symptoms and the severity of pain. RESULTS: In children with AOM (n = 201), pain was assessed by parents as moderate/severe in 65% via interview; 90% with the FPS-R; and 91% with the FLACC Scale (P < 0.001). In children without AOM (n = 225), the percentages were 56, 83 and 88%, respectively (P < 0.001). Between children with and without AOM, the occurrence of moderate/severe pain did not differ with any of the pain evaluation methods. Of symptoms, ear pain reported by child and restless sleep were significantly associated with moderate/severe pain, regardless of the pain evaluation method. CONCLUSIONS: It seems that nearly all the children with respiratory tract infection, either with or without AOM, might suffer from moderate/severe pain. Without pain scales, parents may underestimate their child's pain. Of symptoms, ear pain reported by child and restless sleep might indicate pain in children with respiratory tract infection. We suggest that the adaptation of pain scales for parent observation is a possibility in children with respiratory tract infection which, however, requires further studies. TRIAL REGISTRATION: www.clinicaltrials.gov , identifier NCT00299455 . Date of registration: March 3, 2006.

Impact of Antimicrobial Treatment for Acute Otitis Media on Carriage Dynamics of Penicillin-Susceptible and Penicillin-Nonsusceptible Streptococcus pneumoniae.

Background: Despite concerns that antimicrobial treatment of prevalent infections may select for drug-resistant bacteria, the effects of antimicrobial treatment on colonization dynamics have not been well quantified. Methods: We measured impacts of antimicrobial treatment on nasopharyngeal carriage of penicillin-susceptible Streptococcus pneumoniae (PSSP) and penicillin-nonsusceptible (PNSP) lineages at the end of treatment and 15, 30, and 60 days after treatment in a previously conducted randomized, double-blinded, placebo-controlled trial of amoxicillin-clavulanate for stringently defined acute otitis media. Results: In intention-to-treat analyses, immediate treatment with amoxicillin-clavulanate reduced PSSP carriage prevalence by 88% (95% confidence interval [CI], 76%-96%) at the end of treatment and by 27% (-3%-49%) after 60 days but did not alter PNSP carriage prevalence. By the end of treatment, 7% of children who carried PSSP at enrollment remained colonized in the amoxicillin-clavulanate arm, compared with 61% of PSSP carriers who received placebo; impacts of amoxicillin-clavulanate persisted at least 60 days after treatment among children who carried PSSP at enrollment. Amoxicillin-clavulanate therapy reduced PSSP acquisition by >80% over 15 days. Among children who carried PNSP at enrollment, no impacts on carriage prevalence of S. pneumoniae, PSSP, or PNSP were evident at follow-up visits. Conclusions: Although the absolute risk of carrying PNSP was unaffected by treatment, antimicrobial therapy conferred a selective impact on colonizing pneumococci by accelerating clearance and delaying acquisition of PSSP.

Effect of Antimicrobial Treatment on the Resolution of Middle-Ear Effusion After Acute Otitis Media.

BACKGROUND: Acute otitis media (AOM) induces middle-ear effusion (MEE), which affects hearing. The effect of antimicrobial treatment on the resolution of MEE is controversial, and the factors that affect resolution are unknown. METHODS: We studied the effect of antimicrobial treatment on the time to the resolution of MEE as a secondary objective in our randomized double-blind placebo-controlled trial. Children aged 6 to 35 months with stringently diagnosed AOM were allocated to receive amoxicillin-clavulanate (161 patients) or placebo (158 patients) for 7 days and closely followed for 3 months. This study was registered at ClinicalTrials.gov (identifier NCT00299455). RESULTS: The median times to resolution of MEE were 20 days (95% confidence interval [CI], 16-24 days) and 29 days (95% CI, 26-32 days) in the amoxicillin-clavulanate and placebo groups, respectively (P = .10). The resolution of MEE was confirmed in 138 (86%) of 161 and 132 (84%) of 158 patients in the amoxicillin-clavulanate and placebo groups, respectively (P = .59). In multivariable analysis, the resolution of MEE was prolonged most significantly by at least 1 recurrence of AOM during follow-up. MEE resolved in 65 (65%) of 100 patients with a recurrence of AOM during follow-up and in 205 (94%) of 219 of those without a recurrence (P < .001) (median times to resolution, 67 vs 15 days, respectively; P < .001). CONCLUSIONS: Immediate antimicrobial treatment of AOM does not significantly affect the resolution of MEE in young children. Subsequent recurrences of AOM are a major reason for the persistence of MEE.

Prognostic Factors for Treatment Failure in Acute Otitis Media.

BACKGROUND AND OBJECTIVES: Antimicrobial treatment is effective in the management of acute otitis media (AOM), but approximately half of the children may recover without antimicrobial agents. By identifying patients who may not require antimicrobial treatment for the management of AOM, the use of antimicrobial agents could be substantially reduced. Our aim was to identify subgroups of children with AOM who would benefit most from antimicrobial treatment and children who could be suitable for initial observation. METHODS: This is a secondary analysis of randomized, double-blind, placebo-controlled trial. Children 6 to 35 months of age with AOM (N = 319) were randomly allocated to receive amoxicillin-clavulanate (40/5.7 mg/kg per day) or placebo for 7 days. Our primary outcome was time until treatment failure. RESULTS: Treatment failure occurred in 31.7% of all children. Older age (24-35 months) and peaked tympanogram at entry decreased the hazard for treatment failure (hazard ratio, 0.53; 95% confidence interval [CI], 0.29 to 0.96; P = .04; and hazard ratio, 0.43; 95% CI, 0.21 to 0.88; P = .02, respectively). The rate difference for treatment failure between antimicrobial treatment and placebo groups was highest among children with severe bulging of the tympanic membrane (11.1% vs 64.1%; rate difference -53.0%; 95% CI, -73.5% to -32.4%), resulting in a number needed to treat of 1.9. CONCLUSIONS: Children with severe bulging of the tympanic membrane seem to benefit most from antimicrobial treatment of AOM. On the other hand, children with peaked tympanogram (A and C curves) may be optimal candidates for initial observation.

Can changes in parentally measured acoustic reflectometry levels predict the middle ear status?

OBJECTIVE: Spectral gradient acoustic reflectometry (SG-AR) may be used to detect middle ear effusion. Our aim was to investigate whether increasing SG-AR levels between two SG-AR examinations indicate deterioration from a healthy middle ear to acute otitis media (AOM). METHODS: We enrolled 185 children (age 6-35 months) whose parents were willing to use the SG-AR at home daily. Measurement pairs of parental home SG-AR examination results were generated and analyzed. There was one SG-AR examination result obtained within ±1 day of the reference visit and another result within ±1 day of the subsequent visit. We defined the SG-AR level as increasing when the difference between two measurements was ≥2 levels from a lower to a higher level, suggesting development of AOM. When the SG-AR level difference was ≤1, we defined this no change of the SG-AR level. The middle ear diagnosis was determined by pneumatic otoscopy at the study clinic. RESULTS: 361 paired SG-AR home measurements were obtained. The reference measurement was related to a healthy middle ear as determined by pneumatic otoscopy. Increasing SG-AR levels (59/361), were 63% (95% CI 50%-74%) sensitive and 94% (91%-97%) specific for deterioration of a healthy middle ear to AOM. The positive predictive value was 71% (58%-82%) and the negative predictive value was 92% (88%-95%). When there was no SG-AR level difference between the SG-AR examinations, the corresponding figures were 88% (95% CI 84%-92%), 69% (56%-79%), 93% (89%-95%) and 57% (45%-68%), respectively. CONCLUSIONS: This study shows that increasing SG-AR levels might not be sufficiently sensitive to detect deterioration of the middle ear status from healthy middle ear to AOM in symptomatic children. Importantly, however, the development of AOM seems to be unlikely in an initially healthy middle ear when there is no difference between the SG-AR levels in two separate measurements.

Panel 7: Otitis Media: Treatment and Complications.

Objective We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention.

Can trained nurses exclude acute otitis media with tympanometry or acoustic reflectometry in symptomatic children?

OBJECTIVE: Since acute otitis media (AOM) is the most prevalent bacterial infection in young children, the reliable exclusion of AOM by nurses might save physicians' time for other duties. The study aim was to determine whether nurses without otoscopic experience can reliably use tympanometry or spectral gradient acoustic reflectometry (SG-AR) to exclude AOM. DESIGN: Three nurses were trained, who performed examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard. SETTING: Study clinic at primary health care level. PATIENTS: 281 children 6-35 months of age. MAIN OUTCOME MEASURES: Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child. RESULTS: At 459 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) was 94% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude AOM at 94/459 (20%) of visits. The negative predictive value of SG-AR level 1 result (>95°) was 94% (89-97%). Based on the SG-AR level 1 result, the nurse could exclude AOM at 36/459 (8%) of visits. CONCLUSION: Type A and C1 tympanograms and SG-AR level 1 results obtained by nurses are reliable test results in excluding AOM. However, the clinical usefulness of these test results is limited by their rarity. Type A and C1 tympanograms were obtained by nurses from both ears of the child only at one-fifth of the symptomatic visits. Key Points Acute otitis media (AOM) is the most prevalent bacterial infection in young children. Nurses' role in excluding AOM is unknown. Type A and C1 tympanograms (tympanometric peak pressure >-200 daPa) obtained by nurses are reliable test results in excluding AOM. With type A and C1 tympanograms, nurses could exclude AOM only at one-fifth of the symptomatic visits. The clinical usefulness of the exclusion of AOM performed by nurses seems to be limited.

Parental role in the diagnostics of otitis media: can layman parents use spectral gradient acoustic reflectometry reliably?

OBJECTIVE: Spectral gradient acoustic reflectometry (SG-AR) can be used to detect middle ear effusion (MEE). Since both families and primary health care systems carry the burden of otitis media, our aim was to determine whether layman parents could be taught to use the SG-AR reliably. METHODS: We enrolled 359 children (age 6-35 months) whose parents were willing to use SG-AR at home. The parents were asked to perform bilateral SG-AR daily on their child. In this study, we included children who had undergone successful parental home SG-AR examination performed on the same day that a physician had also performed successful SG-AR examination and pneumatic otoscopy at the study clinic. We compared the parental and study physician SG-AR examination results to the study physicians' pneumatic otoscopy, which served as the diagnostic standard. RESULTS: We analyzed 571 successful parental home SG-AR examinations performed on the same day that a study physician had performed a successful SG-AR examination and pneumatic otoscopy at the study clinic. None of the evaluated SG-AR level combinations resulted in both high sensitivity and specificity. For symptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 64%. For parental SG-AR levels 4-5, the positive predictive value to detect MEE was 88%. However, for asymptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 83%. CONCLUSION: This study showed that layman parents are able to use the SG-AR technically successfully. In symptomatic children, parentally obtained SG-AR level 1 examination is not adequate to exclude MEE. However, parentally obtained SG-AR levels 4-5 do indicate the presence of MEE. At the same time, in asymptomatic children, parentally obtained SG-AR level 1 examination seems to indicate a healthy middle ear. From the perspective of primary care, the implementation of parental SG-AR examinations in the diagnostic chain of otitis media would be intriguing. This study showed that the possibilities lie in the follow up of the resolution of MEE after an episode of OM in asymptomatic children. However, it seems that currently, the SG-AR technique is an obstacle for wider clinical implementation.

Role of Nasopharyngeal Bacteria and Respiratory Viruses in Acute Symptoms of Young Children.

BACKGROUND: The spectrum of acute symptoms in young outpatient children with respiratory tract infection (RTI) is variable, and it cannot be explained by the diagnosis of acute otitis media (AOM) versus uncomplicated RTI. We studied that the variation of symptoms is explained by the nasopharyngeal bacteria and/or respiratory viruses. METHODS: Children aged 6-35 months with acute symptoms with AOM (n = 201) or without AOM (n = 225) were eligible in this cross-sectional study. We analyzed their nasopharyngeal samples for pathogenic bacteria by culture and for respiratory viruses by polymerase chain reaction. We surveyed 17 symptoms (fever, respiratory, ear related, nonspecific, gastrointestinal) with a structured questionnaire. RESULTS: Fever had a positive association with influenza viruses [odds ratio (OR): 6.61; 95% confidence interval (CI): 1.66-26.27], human metapneumovirus (OR: 3.84; 95% CI: 1.25-11.77), coronaviruses (OR: 3.45; 95% CI: 1.53-7.75) and parainfluenza viruses (OR: 2.18; 95% CI: 1.07-4.47). Rhinitis (OR: 5.07; 95% CI: 1.93-13.36), nasal congestion (OR: 2.03; 95% CI: 1.25-3.31) and cough (OR: 1.91; 95% CI: 1.15-3.17) had positive associations with Moraxella catarrhalis. Furthermore, cough had a positive association with respiratory syncytial virus (OR: 7.20; 95% CI: 1.59-32.71) and parainfluenza viruses (OR: 2.79; 95% CI: 1.02-7.69). CONCLUSIONS: The variation of acute symptoms in young children may be influenced by both nasopharyngeal bacteria and respiratory viruses. Our results showed a strong association between fever and respiratory viruses; rhinitis, nasal congestion and cough were associated with M. catarrhalis in the presence of viruses. Further studies are required to determine the possible synergistic role of M. catarrhalis in symptoms of RTI.

Can nurses exclude middle-ear effusion without otoscopy in young asymptomatic children in primary care?

OBJECTIVE: Scandinavian guidelines recommend controlling middle-ear effusion (MEE) after acute otitis media. The study aim was to determine whether nurses without otoscopic experience can reliably exclude MEE with tympanometry or spectral gradient acoustic reflectometry (SG-AR) at asymptomatic visits. DESIGN: Three nurses were taught to perform examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard. SETTING: Study clinic at primary health care level. PATIENTS: A total of 156 children aged 6-35 months. MAIN OUTCOME MEASURES: Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child. RESULTS: At 196 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure > -200 daPa) was 95% (91-97%). Based on type A and C1 tympanograms, the nurse could exclude MEE at 81/196 (41%) of visits. The negative predictive value of SG-AR level 1 result was 86% (79-91%). Based on SG-AR level 1 results, the nurse could exclude MEE at 29/196 (15%) of visits. CONCLUSION: Tympanograms with tympanometric peak pressure > -200 daPa (types A and C1) obtained by nurses are reliable test results in excluding MEE. However, these test results were obtained at less than half of the asymptomatic visits and, thus, the usefulness of excluding MEE by nurses depends on the clinical setting.

Parental role in the diagnostics of otitis media: can parents be taught to use tympanometry reliably?

OBJECTIVE: Tympanometry can be used to detect middle ear effusion (MEE). As the need for rearrangement of clinical resources at the primary care level increases, it is important to determine whether layman parents could be taught to use the tympanometer reliably, aiming to reduce unnecessary physician visits during respiratory tract infections. METHODS: From our AOM treatment trial we enrolled 78 children (age 6-35 months) who had persistent MEE, parents were voluntary and willing to use a tympanometer at home, the child was sufficiently co-operative, and parents learned technically the use of the tympanometer. At home, parents were asked to perform daily bilateral tympanometry on their child. We included those parental tympanometric examinations, to which the corresponding tympanometric examination, within one day by a study physician was available. Parental tympanometric examinations were compared to the pneumatic otoscopy by a study physician which served as the diagnostic standard. RESULTS: This study involved 78 children and a total of 432 parental tympanometric examinations. From these 432 examinations, parents obtained an interpretable tympanogram in 83% (359/432) and physicians in 91% (393/432) (absolute rate difference 8%, 95% CI 3-12%). Both obtained an interpretable tympanogram from the same ear in 75% (326/432) of the tympanometric examinations. Of these 326 interpretable examinations, parents and physicians were in accordance with either a peaked or a flat tympanogram in 88% of examinations (288/326) (kappa-value 0.77). When the tympanogram was peaked, pneumatic otoscopy indicated healthy middle ear in 72% (122/169) of parental and in 69% (149/217) of study physicians' tympanometric examinations (absolute rate difference 4%, 95% CI -6% to 13%). When the tympanogram was flat, pneumatic otoscopy indicated any MEE in 92% of parental (174/190) and in 96% (169/176) of study physicians' tympanometric examinations (absolute rate difference 4%, 95% CI -9% to 1%). CONCLUSION: This study showed that layman parents are able to use tympanometry technically successfully, and that the parental tympanometric examinations are as reliable as those obtained by study physicians.

Panel 7: Treatment and comparative effectiveness research.

BACKGROUND AND OBJECTIVES: Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas. DATA SOURCES: PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing). REVIEW METHODS: All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized. RESULTS: New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Symptoms and otoscopic signs in bilateral and unilateral acute otitis media.

OBJECTIVE: Bilateral acute otitis media (AOM) is considered more severe than unilateral AOM, and several guidelines recommend more active treatment and/or follow-up of bilateral AOM. We studied whether bilateral AOM is a clinically more severe illness than unilateral AOM by comparing symptoms and otoscopic signs between bilateral and unilateral AOM. METHODS: Two hundred thirty-two children aged 6 to 35 months diagnosed with AOM were eligible. We surveyed the symptoms with a structured questionnaire and recorded the otoscopic signs systematically. RESULTS: Ninety-eight children had bilateral and 134 children unilateral AOM. Children with bilateral AOM were more often <24 months than children with unilateral AOM (87% vs 75%; P = .032). Fever (≥38°C) occurred in 54% and 36% (P = .006) and severe conjunctivitis in 16% and 44% (P = .047) of children with bilateral and unilateral AOM, respectively. In 15 other symptoms, we found no overall differences even when adjusted with age. We observed the following severe otoscopic signs in the bilateral and unilateral AOM group, respectively: moderate/marked bulging of tympanic membrane (63% and 40%; P = .001), purulent effusion (89% and 71%; P = .001), bulla formation (11% and 10%; P = .707), and hemorrhagic redness of tympanic membrane (7% and 10%; P = .386). CONCLUSIONS: Bilateral AOM seems to be a clinically only slightly more severe illness than unilateral AOM. Therefore, when assessing AOM severity, bilaterality should not be used as a determining criterion; instead, the child's symptomatic condition together with otoscopic signs should also be taken into consideration.