Commentary

A vexing problem with otitis media research is the lack of agreement over the diagnostic definition of acute otitis media.¹ No widely accepted gold standard for the diagnosis of this condition exists, which means there is no way to determine which combination of clinical findings provides the most accurate diagnosis.

The most practical definition of acute otitis media may be the combination of clinical findings that best identifies children who will benefit most from antibiotics. Little et al have taken an important first step towards finding such a definition. They identified several symptoms and signs at presentation that were associated with more severe morbidity during follow up. They then assessed the benefit of immediate antibiotic treatment in subgroups of children with these predictive clinical findings.

In their initial study, the authors found a modest benefit of immediate antibiotic treatment similar to those found in other studies.² However, in this secondary analysis, they show that children with acute otitis media accompanied by fever or vomiting had a more substantial improvement from antibiotics, whereas children with neither vomiting nor fever did not benefit from antibiotics.

Because this is a secondary analysis and multiple symptoms and signs were evaluated, it is possible that the findings were because of chance, despite the statistical significance. On the other hand, the authors used very low antibiotic doses, and perhaps using high dose amoxicillin would result in a greater treatment benefit. Either way, other studies are needed to confirm the present findings. Such studies should also evaluate individual otoscopic findings to establish diagnostic criteria that best identify children who will benefit from antibiotic treatment. Such research could lead to substantial improvement in our ability to decrease unnecessary antibiotic use while maintaining maximum benefit to children with acute otitis media.