Pediatric Press Newsletter

Publication date: 2004-01-06

Acute Otitis Media and Acute Bacterial Rhinosinusitis: Understanding the Similarities Results in Appropriate Treatment

This report was reviewed for medical and scientific accuracy by Amisha Malhotra, MD, Associate Professor of Pediatrics, University of Medicine & Dentistry of New Jersey—Robert Wood Johnson Medical School, New Brunswick, New Jersey

Expert Commentary

Jack B. Anon, MD, FACS, Clinical Associate Professor, Department of Otolaryngology University of Pittsburgh School of Medicine, Erie, Pennsylvania; Chairman, American Academy of Otolaryngology—Head and Neck Surgery’s Rhinology and Paranasal Sinus Disease Committee

Acute otitis media and acute bacterial rhinosinusitis are remarkably similar diseases.¹ Both are infections that share common pathogens, are usually diagnosed on the basis of the patient's history and physical examination, and in the majority of cases, are treated empirically due to the invasive nature of culturing the infection. Although not identical, knowledge of the basic pathophysiology of middle ear disease often assists a clinician in understanding sinus disease. Recognizing these similarities provides a better understanding of their pathophysiology and appropriate treatment.

Acute otitis media and acute bacterial rhinosinusitis are the two primary diagnoses that result in antibacterial therapy.² However, a significant proportion of this antibacterial therapy is medically unjustified due to misdiagnosis. For example, millions of courses of antibiotics are prescribed every year for otitis media with effusion,³ even though antibiotics are of little clinical use in this condition. Similarly, antibiotics are often prescribed for viral rhinosinusitis, which is 20 to 200 times more common than bacterial sinusitis.⁴

The need to understand and appropriately treat these diseases is made more dramatic in an environment of increasing antibiotic resistance, particularly with their common bacterial etiology. Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), and Moraxella catarrhalis (M. catarrhalis) colonizing the nasopharynx are responsible for acute otitis media in children,⁵ and are the most common bacterial isolates from the maxillary sinuses of patients with acute bacterial rhinosinusitis.⁶ An understanding of factors associated with antibiotic resistance is key to limiting the spread of drug resistance.

This Pediatric Press Newsletter is very timely. As treatment guidelines for acute otitis media and acute bacterial rhinosinusitis are being revised, a review of the similarities and differences between these conditions is clinically prudent and provides a foundation upon which to accept and incorporate the new treatment guidelines into clinical practice.

Common Bacterial Pathogens

Treatment for acute otitis media and acute bacterial rhino-sinusitis must take into account the pathogens most commonly implicated in these conditions (ie, S. pneumoniae, H. influenzae, and M. catarrhalis) (Table 1). The most predominant bacterial pathogen in each of these conditions is S. pneumoniae, followed by H. influenzae (non-typeable strains represent the majority of cases in each condition), with M. catarrhalis generally less frequently involved in acute bacterial rhinosinusitis compared to acute otitis media.

Inappropriate use of antibiotics has contributed to the development of drug resistance among S. pneumoniae, H. influenzae, and M. catarrhalis. The U.S. component of the 1998–2000 Alexander Project demonstrated that 12.0% and 25.0% of the S. pneumoniae isolates were penicillin-intermediate and penicillin-resistant, respectively.⁸ Resistance of H. influenzae strains to β-lactam antibiotics by production of β-lactamase has become more prevalent in the U.S. with contemporary percentages of β-lactamase-producing H. influenzae ranging from