Using systems thinking and the Intervention Level Framework to analyse public health planning for complex problems: Otitis media in Aboriginal and Torres Strait Islander children.

BACKGROUND: Middle ear disease (otitis media) is endemic among Aboriginal and Torres Strait Islander children in Australia and represents an important cause of hearing loss. The disease is the result of a mix of biological, environmental and host risk factors that interact in complex, non-linear ways along a dynamic continuum. As such, it is generally recognised that a holistic, systems approach is required to reverse the high rates of otitis media in Aboriginal and Torres Strait Islander children. The objective of this paper is to examine the alignment between efforts designed to address otitis media in Aboriginal and Torres Strait Islander children in Queensland, Australia and core concepts of systems thinking. This paper's overall purpose is to identify which combination of activities, and at which level, hold the potential to facilitate systems changes to better support ear health among Aboriginal and Torres Strait Islander children. METHODS: We began with a review of documents identified in consultation with stakeholders and an online search. In addition, key informants were invited to participate in an online survey and a face-to-face or phone interview. Qualitative interviews using a semi-structured interview guide were used to explore survey responses in more depth. We also undertook interviews at the community level to elicit a diverse range of views. Ideas, statements or activities reported in the documents and interviews as being performed under the Intervention Level Framework were identified using qualitative thematic and content analysis. A quantitative descriptive analysis was also undertaken, whereby data was extracted into an Excel spreadsheet and coded under the relevant strategic directions and performance indicators of the Framework. Subsequently, we coded activities against the five-level intervention framework developed by Malhi and colleagues, that is: 1) paradigm; 2) goals; 3) system structure; 4) feedback and delays; and 5) structural elements. RESULTS: Overall, twenty documents were reviewed. We examined surveys and interviews with six key informants. Twenty-four individual and 3 group interviews were conducted across central and community level informants. One hundred and four items were coded from the 20 documents and 156 items from interview data. For both data sets, the majority of activities were coded at the structural elements level. The results suggested three key areas where further work is needed to drive sustained improvements: 1) build the governance structures needed for paradigm shift to achieve a multi-sectoral approach; 2) develop shared system level goals; 3) develop system-wide feedback processes. CONCLUSIONS: Sustained progress in improving ear health within Aboriginal and Torres Strait Islander children requires a holistic, system-wide approach. To advance such work, governance structures for multi-sectoral collaboration including the development of joint goals and monitoring and feedback are required. Intervening at these higher leverage points could have a profound effect on persistent public health issues.

Etiology of Acute Otitis Media and Characterization of Pneumococcal Isolates After Introduction of 13-Valent Pneumococcal Conjugate Vaccine in Japanese Children.

BACKGROUND: Acute otitis media is a leading cause of childhood morbidity and antibiotic prescriptions. We examined etiologic changes in acute otitis media after introduction of 13-valent pneumococcal conjugate vaccine as routine immunization for Japanese children in 2014. Serotypes, resistance genotypes, antibiotic susceptibilities and multilocus sequence typing of pneumococcal isolates were also characterized. METHODS: Otolaryngologists prospectively collected middle ear fluid from 582 children by tympanocentesis or sampling through a spontaneously ruptured tympanic membrane between June 2016 and January 2017. Causative pathogens were identified by bacterial culture and real-time polymerase chain reaction for bacteria. Serotypes, resistance genotypes, sequence types and susceptibilities to 14 antimicrobial agents were determined for pneumococcal isolates. RESULTS: At least 1 bacterial pathogen was identified in 473 of the samples (81.3%). Nontypeable Haemophilus influenzae (54.8%) was detected most frequently, followed by Streptococcus pneumoniae (25.4%), Streptococcus pyogenes (2.9%) and others. Pneumococci of current vaccine serotypes have decreased dramatically from 82.1% in 2006 to 18.5% (P < 0.001). Commonest serotypes were 15A (14.8%), 3 (13.9%) and 35B (11.1%). Serotype 3 was significantly less frequent among children receiving 13-valent pneumococcal conjugate vaccine compared with 7-valent pneumococcal conjugate vaccine (P = 0.002). Genotypic penicillin-resistant S. pneumoniae accounted for 28.7%, slightly less than in 2006 (34.2%; P = 0.393); the penicillin-resistant serotypes 15A and 35B had increased. Serotypes 15A, 3 and 35B most often belonged to sequence types 63, 180 and 558. CONCLUSIONS: Our findings are expected to assist in development of future vaccines, and they underscore the need for appropriate clinical choice of oral agents based on testing of causative pathogens.

Skin flap complications after cochlear implantations.

The objective of the study was to analyse and present the surgical management strategy for major skin flap complications (MSFC) after cochlear implantations. Patients fitted with a titanium-silicone-coated implant of the same kind, operated on between 1994 and 2013 with a standardised procedure (1076 medical charts) were analysed. Analysis aimed to identify and study individuals with skin problems related to the cochlear implant treatment, i.e. requiring surgical treatment in hospital defined as MSFC and focused on incidence, risk factors and treatment of MSFC. MSFC were diagnosed in 1.76 % of patients: 2.06 % of children and 1.35 % of adults, 2.43 % after implantation with a long "C"-shaped incision and 1.28 % after short retroauricular incision. Registered risk factors included head trauma, acute otitis media, poor hygiene in children, and general comorbidities in adults. The primary intervention was dependent on skin complication severity and included revision surgery with wound closure over an implant (52.6 %) and revision surgery with explantation (47.4 %). Revision surgery without explantation was successful in 40 % and the most effective approach was debridement with a two-layer rotational flap. Explantation led to ultimate wound healing in all cases. Major skin flap complications after cochlear implantation are rare, but their treatment is complex and difficult. Revision surgery with resection of infected tissue, formation of a rotational two-layer flap preceded and supplemented by intensive targeted antibiotic therapy can be effective and should be the first treatment option. Spontaneous implant explantation, abscess formation or unsuccessful primary treatment necessitate implant removal as the ultimate solution.

Occurrence of otitis media in children and assessment of treatment options.

BACKGROUND: Otitis media is a more frequent occurrence in children, and the disease may progress from an acute to chronic state if appropriate and timely intervention is not initiated. METHODS: A total of 212 children aged 6 months to 10 years were examined and treated for otitis media, in a 13-month hospital-based study. RESULTS: Acute otitis media was diagnosed in 130 (61.3 per cent) of the patients. There were 82 (38.7 per cent) chronic suppurative otitis media cases. The incidence of acute otitis media and chronic suppurative otitis media in the first year of life was 54.6 per cent and 45.1 per cent respectively. Chronic suppurative otitis media patients were assigned to one of three treatment groups. Recovery occurred in 70.4 per cent of amoxicillin-treated patients, in 88.9 per cent of amoxicillin-clavulanic acid treated patients and in 96.4 per cent of culture and antibiotic sensitivity test patients. Relapses were seen only in the amoxicillin (five cases) and amoxicillin-clavulanic acid (two cases) groups. CONCLUSION: The success rate in patients treated with antibiotics makes this option mandatory for an established diagnosis.

In vitro Activity of Cefditoren against Middle Ear Fluid Isolates from Costa Rican Children with Otitis Media.

Otitis media (OM) is one of the most common infections in children, Streptococcus pneumoniae and nontypable Haemophilus influenzae being the two most common pathogens isolated in the middle ear fluid (MEF) of children with OM. Cefditoren is a third-generation cephalosporin with broad-spectrum antibacterial activity, including activity against those pathogens commonly causing OM, with enhanced stability against common ß-lactamases. The main objective of this study was to evaluate the in vitro activity of cefditoren against pathogens collected from the MEF of Costa Rican children with OM between 2006 and 2011. A total of 715 samples were analyzed. Among the 89 S. pneumoniae strains that were penicillin-nonsusceptible, only 7% were cefditoren-resistant according to Spanish Regulatory Agency criteria; among the H. influenza and M. catarrhalis isolates obtained, 100 and 90% of the isolates, respectively, were cefditoren-susceptible. MIC50/90 against the 207 PCV-13 S. pneumoniae serotyped strains and the 79 serotypes not covered by PCV-13 for cefditoren were 0.03/1 and 0.03/0.12 mg/l, respectively. For both amoxicillin-susceptible and resistant H. influenzae strains, the MIC range against cefditoren was from ≤0.015 to 0.06 mg/l as well. In conclusion, the confirmation of the wide spectrum of activity of cefditoren and its intrinsic strength against resistant strains allows us to suggest that cefditoren might be included as one of the best choices among antibiotics that are widely used in empiric therapy for OM in pediatric patients.

Awareness regarding otitis media in patients belonging to rural population of Raichur district, Karnataka.

The objective of this study was to assess awareness regarding otitis media in patients of rural parts of Raichur district, Karnataka. Patients of otitis media attending village health check-up camps conducted by our department were given questionnaire to assess the awareness regarding otitis media. Association between sociodemographic parameters and awareness were studied using Chi-square test. Age group of 10-30 years was the most affected. More than half of the patients had ear discharge of 5 to 15 years duration. Over 50% of the population showed ignorance with regard to the risk factors for otitis media. Earache was either disregarded (32%) or treated with home remedies by most, (63%) while a doctor's opinion was often sought for ear discharge (60%). Lack of awareness about otitis media contributes to its' high prevalence in this South Indian district. Health education is essential to reduce the disease burden.

Use of complementary and alternative medicine in children with recurrent acute otitis media in Italy.

Controlling environmental factors, chemoprophylaxis, immunoprophylaxis and surgery are considered possible means of preventing recurrent acute otitis media (RAOM), but there are no available data concerning the paediatric use of complementary and alternative medicine (CAM). We evaluated the uses of CAM (homeopathy and/or herbal medicine) as means of preventing AOM in children with a history of RAOM. Eight hundred and forty Italian children with RAOM (≥3 episodes in six months) aged 1-7 years were surveyed in 2009 using a face-to-face questionnaire, filled by parents or caregivers, that explored the prevalence, determinants, reasons, cost, and perceived safety and efficacy of CAM. About one-half (46%) of the children used CAM, significantly more than the number who used immunoprophylaxis (influenza vaccine 15%; p<0.05), PCV-7 34%; p<0.05) or chemoprophylaxis (2%; p<0.001). Use of CAM in the family was the only important factor positively associated with the use of CAM in children (adjusted OR 7.94; 95% CI: 5.26-11.99). The main reasons for using CAM were a fear of the adverse effects of conventional medicine (40%) and to increase host defences (20%). CAM was widely seen as safe (95%) and highly effective (68%). CAM prescribers were paediatricians in 50.7% of cases; self-initiation was reported by 23% of respondents. CAM expenditure was between Euro 25 and Euro 50/month in 27.6% of cases and ≥ Euro 50/month in 16%. Children with RAOM should be considered among the categories of subjects likely to be using CAM. Together with the fact that paediatricians are the main prescribers, this is worrying because of the current lack of evidence regarding the efficacy, safety and cost-effectiveness of CAM in the prevention of RAOM.

National survey of pediatricians' opinions about and practices for acute otitis media and xylitol use.

BACKGROUND: Acute otitis media (AOM) is the main reason for physician visits and antibiotic prescriptions in children. Pediatricians (Peds) are gatekeepers for services and sources of information for families. The 2004 American Academy of Pediatrics/American Academy of Family Physicians (AAP/AAFP) Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media recommended preventative and management measures for Peds' practice. Treatments for AOM (antimicrobial therapy and surgery) sometimes have questionable effectiveness, risks, and high costs. Thus, Peds should consider using prophylactics for AOM that are easy to administer, cost-effective, and have minimal side effects. Xylitol, a naturally occurring sugar alcohol, is widely used to prevent AOM and for other health conditions in Europe, and as a dental caries prophylaxis in the United States. It would be helpful to know Peds' attitudes and practices to identify barriers to xylitol's use as a prophylaxis for AOM in the United States. PURPOSE: To conduct a national survey of Peds in the United States to evaluate how closely they adhered to the AAP/AAFP guideline, and their knowledge and opinions about xylitol use. RESEARCH DESIGN: A randomized, national postal survey. METHOD: A 48-item questionnaire developed for this study was mailed to a random sample of 506 Peds within the United States during spring 2009. It assessed Peds' demographics, adherence to the guideline, and knowledge and opinions about and use of xylitol as a prophylaxis for AOM in children. RESULTS: The questionnaire response rate was 22% (98 useable/506 mailed - 63 returned undeliverable). Participants were about equal for gender, and almost all were in private practice for over 10 yr. Most had pediatric patients with at least one bout of AOM annually. The majority adhered to the guideline (e.g., almost all routinely assessed and managed patients' pain for AOM and encouraged prevention by recommending that families reduce risk factors). Most used and were comfortable with otoscopy for diagnosing AOM, but not tympanometry. Almost all believed that conductive hearing loss could hinder speech-language and academic development, and AOM could reduce quality of life of children. They also believed that those under 6 mo of age with AOM should receive antibacterial therapy beginning with amoxicillin but did not use complementary and alternative medicine (CAM). Only about half knew about medical uses for xylitol, but of those, most were aware of its use in chewing gum to prevent AOM but had not used it with patients. They were not sure of xylitol's effectiveness or appropriate dosages but cited stomach cramping and diarrhea as possible side effects. Most would use xylitol if evidence supported it and wanted information about it via reprints or electronically. Few agreed that audiologists are important in diagnosing/managing AOM. CONCLUSIONS: Most of these Peds adhered to the AAP/AAFP guideline. They were not using CAMs like xylitol for preventing AOM in children. Future research should focus on prevention and the use of xylitol as a possible prophylaxis regimen for AOM in patients.

Knowledge, attitudes and practices with respect to risk factors for otitis media in a rural South Indian community.

OBJECTIVES: (a) To study knowledge, attitudes and practices with respect to risk factors of otitis media in a rural South Indian Community where the prevalence of otitis media is high. (b) To discover the association between parental education, socioeconomic status (SES) and family type (nuclear or joint) with knowledge, attitudes and practices regarding risk factors for otitis media. METHODS: Using a cluster sampling design, the caregivers of 150 children attending daycare were interviewed to note knowledge, attitudes and practices with respect to risk factors for otitis media. Data on level of education of the caregiver, house type (an indicator of SES) and type of family structure were noted. A questionnaire was administered to collect all the relevant data. Statistical analysis of the data obtained was performed to note frequencies. Correlations between sociodemographic parameters and knowledge, attitudes and practices were studied using Chi-square test of proportions. RESULTS: Over 50% of the population showed knowledge deficits with regard to the various risk factors for otitis media. Caregivers from nuclear families were slightly less knowledgeable regarding lack of immunization and household smoke as risk factors for the disease. There was no correlation between any of the sociodemographic factors and attitudes. However, educated mothers were more likely than illiterate mothers to clean their children's ears of wax on a regular basis with the belief that it would prevent ear disease (p=0.05). Treatment practices in the community were more or less uniform in that earache was either disregarded (26.4%) or treated with home remedies (67.2%) by most caregivers, while a doctor's opinion was often sought for ear discharge (50%). Parents of higher SES were more likely to use home remedies than those of lower SES (p=0.008). CONCLUSIONS: Sociodemographic factors as well as poor knowledge and attitudes and unhealthy practices with respect to risk factors of otitis media contribute to the high prevalence of otitis media in this rural South Indian community. Health education regarding risk factors and provision of accessible health care is essential to reduce the disease burden.

Factors associated with acute otitis media in children due to penicillin intermediately resistant Streptococcus pneumoniae.

OBJECTIVES: This study was conducted to analyze the association between recent antimicrobial use and acute otitis media (AOM) due to Streptococcus pneumoniae intermediately resistant to penicillin (PISP). The influence of drug resistance on the clinical course of AOM was also assessed. METHODS: A retrospective cohort study was conducted in infants at Japanese Red Cross Medical Center, Tokyo. Children included in the study were under 24 months of age and diagnosed with AOM due to infection with S. pneumoniae between April 2002 and March 2007. Crude risk ratios (cRR) of PISP infection in cases with recent antibiotic use and other factors were obtained. The Mantel-Haenszel estimate was applied for the adjustment of cRR. RESULTS: Of 35 children, 13 had AOM due to penicillin-susceptible S. pneumoniae (PSSP) and 22 had AOM due to PISP. The adjusted risk ratio (aRR) of penicillin antibiotic use within 1 month was 1.99 (95% confidence interval (CI): 1.36-2.92), and the aRR of penicillin antibiotic use within 1 week was 1.93 (95% CI: 1.33-2.67). Recent use of penicillin antibiotics was an associated factor for AOM due to PISP. The clinical course was not clearly different between cases infected with PSSP and those with PISP. CONCLUSION: Recent use of penicillin antibiotics might be a selective pressure for PISP.

The cost-burden of paediatric pneumococcal disease in Sweden and the potential cost-effectiveness of prevention using 7-valent pneumococcal vaccine.

AIMS: A cost-effectiveness model was used to estimate the change in disease burden that might be expected if PCV7 was included as part of the routine 3-dose vaccination schedule in Sweden. METHODS: An economic model was populated with data from the main clinical PCV7 efficacy trials, demographic data from government sources, surveillance and epidemiologic data from the US and Nordic region, and average treatment costs, considering the impact of disease on the whole national population. RESULTS: The model estimated that PCV7 would prevent 18,856 cases of AOM, 684 of pneumonia, 86 of pneumococcal bacteraemia and 21 cases of pneumococcal meningitis in children <10 years, further 221 cases of IPD would be avoided in older children and adults and 397 cases of pneumonia in adults aged 18-39 years. Annually, 4 childhood (<10 years) deaths and 39 deaths in older children and adults would be prevented, resulting in an annual saving of 632 life years. The reduction of cost for the society was estimated to 27.9 (-205, +160) million SEK. The sensitivity analysis showed that it was most sensitive to the efficacy of the vaccine against AOM, the cost of managing infections and the incidence of all disease. CONCLUSION: This model demonstrates that implementing a universal vaccine programme in Sweden with PCV7 would be cost-effective with an estimated net reduction of costs for the society.

La otitis media aguda en la era de la vacunación antineumocócica / Acute otitis media in the era of pneumococcal vaccination

La otitis media aguda (OMA) es una de las enfermedades más frecuentes en el niño y la principal causa de prescripción de antibióticos en países desarrollados. El tratamiento indiscriminado de niños con un diagnóstico dudoso ha favorecido el desarrollo de resistencias, lo que ha conducido a la creación de guías clínicas para el uso racional de antibióticos. La OMA tiene un elevado índice de resolución espontánea y el beneficio antibiótico es mínimo, por lo que en muchos pacientes está justificado un período de observación durante 48-72 h antes de iniciarla antibioterapia. En los últimos años el interés se ha dirigido a la utilización de vacunas frente a los principales patógenos, Streptococcus pneumoniae y Haemophilus influenzae. La vacuna conjugada frente a H. influenzae tipo b tiene muy poco impacto en la OMA, ya que la mayor parte de las cepas son no tipificables. La vacuna neumocócica conjugada heptavalente muestra una eficacia del 55%en la prevención de OMA por serotipos vacunales, perosu reemplazamiento por serotipos no vacunales y H. influenzae no tipificables disminuyen la eficacia globalal 6-8%. Se ha evidenciado una disminución global de la resistencia a penicilina en neumococo en niños vacunados, pero existe una tendencia al incremento de la resistencia antibiótica en los serotipos no vacunales. Aunque el tratamiento de elección de la OMA es amoxicilina en dosis altas, el aumento de H. influenzae en niños vacunados podría modificar esta recomendación en el futuro (AU)

Acute otitis media (AOM) is one of the most common childhood diseases and the main reason for prescribing antibiotics in developed countries. Indiscriminate treatment of children with an inconclusive diagnosis has favored the development of resistance, and this has led to the creation of clinical guidelines to promote judicious antibiotic use. AOM has shown high rates of spontaneous resolution and minimal benefits from antibiotics; hence apolicy of observation for 48-72 hours before initiating treatment is justified in many children. In recent years, attention has been focused on developing effective vaccines against the most common causative pathogens, Streptococcus pneumoniae and Haemophilus influenzae. The H. influenzae type b conjugate vaccine has little impact on AOM since most strains are nontypable. The 7-valent pneumococcal conjugate vaccine has an efficacy of 55% in AOM caused by vaccine serotypes, but replacement with nonvaccine serotypes and nontypable H. influenzae reduce the overall efficacy of the vaccine to6-8%. An overall decrease of pneumococcal resistance to penicillin has been seen in vaccinated children, but there is a trend to an increase in antibiotic resistance in non-vaccine serotypes. High-dose amoxicillin is the treatment of choice for AOM, but the increase of H. influenzae in pneumococcal-vaccinated children may require reconsideration of this recommendation in forthcoming guidelines (AU)

Trends in otitis media treatment failure and relapse.

OBJECTIVES: The goals were to describe trends in acute otitis media, treatment failure, and relapse and in high-dose amoxicillin use and to determine whether treatment of acute otitis media with high-dose amoxicillin was associated with treatment failure or relapse. METHODS: We conducted a retrospective study of acute otitis media visits made between 1996 and 2004 by children 2 months to 12 years of age in a large group practice, using computerized data. We defined acute otitis media as an otitis media visit with antibiotics dispensed (preceded by 30 days without otitis media visits), treatment failure as initiation of treatment with a second antibiotic before the first prescription was finished, and relapse as initiation of antibiotic treatment after the first prescription was finished but within 30 days after the index acute otitis media episode. The primary independent measure was high-dose amoxicillin (>70 mg/kg per day). We evaluated changes over time and determined whether high-dose amoxicillin use was associated with otitis media treatment failure or relapse. RESULTS: We identified 111,335 acute otitis media visits over a 9-year period. The incidence of acute otitis media decreased from 385.1 visits per 1000 enrollees in 1996 to 188.8 visits per 1000 enrollees in 2004. The proportion of acute otitis media visits treated with high-dose amoxicillin increased from 1.7% in 1996 to 41.9% in 2004. Both otitis media treatment failure and relapse rates decreased from 1996 to 2004 (from 3.9% to 2.6% and from 9.2% to 8.9%, respectively). The odds of treatment failure or relapse did not differ between acute otitis media episodes treated with high-dose and low-dose amoxicillin. CONCLUSIONS: During the past decade, acute otitis media, treatment failure, and relapse became less common and high-dose amoxicillin use increased. However, high-dose amoxicillin treatment did not reduce the risk of individual infections resulting in adverse outcomes.

Treating common ear problems in pregnancy: what is safe?

In everyday practise, more than 80% of pregnant women receive one at least medication, often for ENT causes. The aim of the present paper is to review the literature on safety and administration of medical treatment for ear diseases, in pregnant women. The literature review includes Medline and database sources. Electronic links, related books and written guidelines were also included. The study selection was as follows: controlled clinical trials, prospective trials, case-control studies, laboratory studies, clinical reviews, systematic reviews, metanalyses, and case reports. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), and acyclovir. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, first generation antihistamines, or cetirizine (third trimester) and loratadine (second and third trimester) from the second generation, H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole), can be used to relieve patients from the related symptoms. Meclizine and dimenhydrinate, as antiemetics in vertigo attacks; metoclopramide, vitamin B6 and ginger rhizome, alternatively. Low-dose diazepam and diuretics in severe cases of Meniere's disease (with caution). Systemic administration of prednisone and prednisolone can be considered in selected cases. By contrast, selective COX-2 inhibitors, betahistine and vasodilating agents are contraindicated in pregnancy. Since otologic and neurotologic manifestations during pregnancy tend to seriously affect the quality of life of the expectant mothers, ENT surgeons should familiarise themselves with the basic guidelines and safety precautions for any related medication, in order to provide appropriate treatment.

Osteopathic evaluation and manipulative treatment in reducing the morbidity of otitis media: a pilot study.

OBJECTIVE: To study the effects of osteopathic manipulative treatment in routine pediatric care for children with recurrent acute otitis media. STUDY DESIGN: Pilot cohort study with 1-year posttreatment follow-up. At follow-up, subjects' parents or legal guardians and their referring and/or family physicians were contacted to determine recurrence of otitis media since intervention. SUBJECTS: A referred and volunteer sample of pediatric patients ranging in age from 7 months to 35 months with a history of recurrent otitis media (N=8). INTERVENTION: For 3 weeks, all subjects received weekly osteopathic structural examinations and osteopathic manipulative treatment. This intervention was performed concurrently with traditional medical management. RESULTS: Five (62.5%) subjects had no recurrence of symptoms. Of the three remaining subjects in this cohort, one had a bulging tympanic membrane, another had four episodes of otitis media, and the last underwent surgery after recurrence at 6 weeks posttreatment. Closer analysis of the posttreatment course of the last two subjects indicates that there may have been a clinically significant decrease in morbidity for a period of time after intervention. CONCLUSION: The present study indicates that osteopathic manipulative treatment may change the progression of recurrent otitis media, a finding that supports the need for additional research in this area.

Otitis media: re-evaluation of diagnosis and treatment in the era of antimicrobial resistance, pneumococcal conjugate vaccine, and evolving morbidity.

The changing susceptibility of bacterial otopathogens is only one aspect of the evolving concepts regarding pathogenesis, immunoprophylaxis, pharmacodynamics, and sequelae of acute otitis media that mandates new insights for achieving a successful outcome. 2004 guidelines by the American Academy of Pediatrics for the treatment of acute otitis media provide one perspective that proposes a rethinking of the routine use of antimicrobial therapy with the hope of preventing further increases in bacterial resistance among otopathogens. The goals of this article are to incorporate the advances in diagnosis, treatment, prevention, and management of sequelae into strategies that optimize the outcome of acute otitis media and limit further emergence of resistant otopathogens.

[Naturopathic therapy for acute otitis media. An alternative to the primary use of antibiotics]. / Naturheilkundliche Therapie der akuten Otitis media. Eine Alternative zum primären Antibiotikaeinsatz.

BACKGROUND: First line antibiotic treatment of uncomplicated acute otitis media has been questioned. PATIENTS AND METHODS: In an prospective, open, controlled study, 390 children aged 1-10 years were treated either conventionally (free combinations of decongestant nose drops, mucolytics, analgesics and antibiotics) or alternatively with Otovowen, supplemented by conventional medications when considered necessary. RESULTS: Patients treated conventionally took more antibiotics (80.5% vs 14.4%) and analgesics (66.8% vs 53.2%). The time to recovery (5.3 vs 5.1 days) and absence from school or pre-school nursery (both 1.7 days) were not significantly different between groups. Pain resolution was slightly better with conventional treatment (-5.8 vs -5.2 score points). The alternative treatment was judged both by doctors, and parents, to be significantly better tolerated. CONCLUSION: In uncomplicated acute otitis media of childhood, an alternative treatment strategy with the natural medicine Otovowen may substantially reduce the use of antibiotics without disadvantage to the clinical outcome.

Otitis media in dairy calves: a retrospective study of 15 cases (1987 to 2002).

Epidemiological data, clinical signs, complementary examination findings, antimicrobial treatments, and outcome were reviewed in 15 calves diagnosed with otitis media at the Centre hospitalier universitaire vétérinaire de l'Université de Montréal between 1987 and 2002. Age at presentation ranged from 2 to 18 weeks. A purulent ear discharge and epiphora were seen in 8/12 and 6/15 cases, respectively. Neurological signs observed were head tilt (13), eyelid ptosis (7), paresis/paralysis of the pinna (8), ataxia (2), strabismus (2), and convulsions (1). Concurrent pneumonia was frequently diagnosed (n = 11). A Mycoplasma sp. was the principal pathogen isolated from ear discharge; 6 out of 6 samples submitted were positive for mycoplasma. Tympanic bullae radiographs were considered abnormal in 12 out of 13 cases. Cerebrospinal fluid analysis was considered abnormal in 2 out of 5 cases. The antibiotic most commonly used was enrofloxacin (n = 7). Average treatment duration was 19.6 days. Four out of 8 treated animals for which follow-up information was available completely recovered. These results suggest that M. bovis is a major pathogen of otitis media in dairy calves and effective antimicrobial therapy should be of long duration.