Medicine

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SYSTEMATIC REVIEW AND META-ANALYSIS

Complementary and Alternative Medicine Treatment
Options for Otitis Media
A Systematic Review
Tal Marom, MD, Paola Marchisio, MD, Sharon Ovnat Tamir, MD, Sara Torretta, MD,
Haim Gavriel, MD, and Susanna Esposito, MD

Abstract: Otitis media (OM) has numerous presentations in children. Abbreviations: AHS = a-hemolytic Streptococcus, AOM = acute
Together with conventional medical therapies aimed to prevent and/or otitis media, CAM = complementary and alternative medicine, CI =
treat OM, a rising number of complementary and alternative medicine confidence interval, ET = Eustachian tube, 25(OH)D = 25-
(CAM) treatment options can be offered. Since OM is common in hydroxyvitamin D, OM = otitis media, OMT = osteopathic
children, parents may ask healthcare professionals about possible CAM manipulative treatment, RAOM = recurrent AOM, RCT =
therapies. Many physicians feel that their knowledge is limited regard- randomized controlled trial, SMT = spinal manipulation therapy,
ing these therapies, and that they desire some information. Therefore, URTI = upper respiratory tract infection.
we conducted a literature review of CAM therapies for OM, taking into
account that many of these treatments, their validity and efficacy and
have not been scientifically demonstrated. INTRODUCTION
We performed a search in MEDLINE (accessed via PubMed) using
the following terms: ‘‘CAM’’ in conjunction with ‘‘OM’’ and ‘‘chil- A lternative medicine is any practice claiming to possess the
healing effects of conventional medicine, but does not
originate from evidence-based scientific methods.1 It consists
dren. Retrieved publications regarding treatment of OM in children
which included these terms included randomized controlled trials, of a range of healthcare practices, products, and therapies,
prospective/retrospective studies, and case studies. ranging from being biologically plausible but not scientifically
The following CAM options for OM treatment in children were tested, to being directly contradicted by evidence, or even
considered: acupuncture, homeopathy, herbal medicine/phytotherapy, harmful or toxic. Complementary medicine is an alternative
osteopathy, chiropractic, xylitol, ear candling, vitamin D supplement, medicine used in conjunction with conventional medicine, in a
and systemic and topical probiotics. We reviewed each treatment and belief that it may be synergistic.2
described the level of scientific evidence of the relevant publications. Complementary and alternative medicine (CAM) is pop-
The therapeutic approaches commonly associated with CAM are ular worldwide. Expenditure on CAM experts visits and thera-
usually conservative, and do not include drugs or surgery. Currently, pies in children is constantly growing.3 The main reasons for
CAM is not considered by physicians a potential treatment of OM, as choosing CAM therapies are that CAM attempts to provide a
there is limited supporting evidence. Further studies are warranted in personalized approach to the sick child, parents’ disappointment
order to evaluate the potential value of CAM therapies for OM. with conventional medicine, personal or professional recom-
mendations, and parents’ previous experience. Despite signifi-
(Medicine 95(6):e2695) cant expenditures on testing CAM, including $124 million spent
by the U.S. Government in 2014,4 <5% of therapies were tested
in children. Only few have shown effectiveness, leading phys-
icians to question their efficacy.
Editor: Wen-Hung Wang. Otitis media (OM) includes a spectrum of diseases, which
Received: October 17, 2015; revised: December 23, 2015; accepted:
January 13, 2016. range from middle ear fluid collection (OM with effusion,
From the Department of Otolaryngology-Head and Neck Surgery, Assaf OME), to purulent fluid behind the tympanic membrane (acute
Harofeh Medical Center, Tel Aviv University Sackler Faculty of Medicine, otitis media, AOM) and recurrent AOM (RAOM). Many
Zerifin, Israel (TM, HG); Pediatric Highly Intensive Care Unit, Department countries published different guidelines for OM treatment.
of Pathophysiology and Transplantation, Università degli Studi di Milano,
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Currently, CAM therapies are either ignored or discouraged
Italy (PM, SE); Department of Otolaryngology-Head and Neck Surgery, those guidelines, even in countries where CAM is popular.5,6
Edith Wolfson Medical Center, Tel Aviv University Sackler Faculty of Due to OM high prevalence, physicians may be asked their
Medicine, Holon, Israel (SOT); and Otolaryngology Unit, Fondazione opinion regarding CAM therapies for pediatric OM, but they may
IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Clinical
Sciences and Community Health, University of Milan, Milan, Italy (ST). often feel uncomfortable advising parents due to lack of knowledge.
Correspondence: Susanna Esposito, Pediatric Highly Intensive Care Unit, In order to fill the knowledge gap, we sought to review scientifically
Department of Pathophysiology and Transplantation, Università degli the knowledge gained regarding CAM therapies for pediatric OM.
Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Via Commenda 9, I-20122 Milan, Italy
(e-mail: susanna.esposito@unimi.it). METHODS
The authors have no funding and conflicts of interest to disclose. We used the terms ‘‘complementary medicine’’ and/or
Copyright # 2016 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons ‘‘alternative medicine’’ in conjunction with ‘‘otitis media’’ and
Attribution-NoDerivatives License 4.0, which allows for redistribution, ‘‘children’’ in our MEDLINE search (accessed via PubMed), and
commercial and non-commercial, as long as it is passed along unchanged The Cochrane Library, from January 1980 to September 2015.
and in whole, with credit to the author. Randomized controlled trials (RCTs), prospective/retrospective
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000002695 studies, and case reports in the English language reporting on any

Medicine  Volume 95, Number 6, February 2016 www.md-journal.com | 1

The first prospective cohort study comparing the use of homeopathy for RAOM with conventional treatment was reported in 1997: 71% children from the homeopathic group had fewer OM episodes. specific locations around the external canal are believed to be Most remedies combine an extract of a natural substance. Problematic daily dosing Ear candling þ Potentially hazardous Vitamin D þ Questionable. Mainly for prevention Probiotics (systemic/intranasal) þ þ þ Encouraging results AOM ¼ acute otitis media. OM ¼ otitis media. whereas 57% of the conventional group received treatment for OM. majority of the dogs in the acupuncture group RESULTS were otitis-free. chi (qi). 2 weeks.8 –10 as it appeared in the search engine. February 2016 TABLE 1. children experiencing ‘‘cure’’ suggested that early homeopathic 2 | www. acupuncture was evaluated for the interest. compared to none in the homeopathy group. and the Israeli and Italian laws.1 Homeopaths generally prescribe remedies into a healthy state. Number 6. these conclusions may not be attributable to humans. The number of helix. and they are combined with a synthetic compound. and its quality is limited. Key locations for relieving ear pain in otitis media (OM) dren in the conventional group eventually required antibiotics. India.14 and the absence of randomization con- siderably weakened the study’s validity. the primary gatekeepers of the ear’s energy. and 6 weeks. All rights reserved. CAM treatment in the context of pediatric OM were included. (2) base of the triangular fossa.2 According to acupuncture. 4 closely equates to the constellation of the patient’s symptoms.15 In another study from Jaipur. and given that otitis externa usually affects canines. has immunomodulatory properties that may play a role in Research into the effects of homeopathic treatment for OM clearance of middle ear fluid. 81 young children with AOM were randomly assigned to conventional (antipyretics. Nearly all chil- FIGURE 1. differentiates a corpse from a live human toms of a disease in healthy people would cure similar symp- being. but not in English. Inc. animals with is not needed for systematic reviews of the literature according to otitis were randomized to receive conventional therapy. Yet. OME ¼ otitis media with effusion.11 The same authors reported that acupuncture may enhance the effect of antibiotic treatment for otitis in Table 1 summarizes the evidence gathered regarding the dogs. There is little understanding therapeutic effect. The auricle harbors numerous locations that have a ‘‘symptom picture. RAOM ¼ recurrent otitis media. but it is suggested that it treatment is shown in Table 2. No authors declared conflict of In 2 studies in canines. According to OM Type Treatment AOM RAOM OME Overall Efficacy Acupuncture þ Effective with concomitant antibiotic therapy Homeopathy þ þ þ Mild Herbal medicine/phytotherapy þ Mild to moderate Osteopathy þ þ þ Very few benefits Chiropractic medicine þ Very few benefits Xylitol þ þ Conflicting results. If Few studies concerning acupuncture for the treatment of the article was not published in English. analgesics) and homeopathy treatment groups.com Copyright # 2016 Wolters Kluwer Health. Ethics committee approval was not requested because it treatment of recurrent otitis episodes. Reported CAM Treatment Options for OM. we relied on the abstract OM in humans have only been published. A significant decrease in symptoms at 24 and 64 hours after treatment were observed in the homeopathy group. the body’s similibus curentur) doctrine: a substance that causes the symp- energy force.13 The unequal numbers between the homeopathic (103) and conventional group. and (4) antitragus.’’ which they consider most which are punctured for the treatment of many diseases. and there were fewer treatment failures in this group after 5 days. efficacy of different CAM treatment options for OM in children. The 1st compared homeopathic and placebo for AOM in 75 children from Seattle who presented with otalgia and tympanic membrane bulging of 36 hours duration. ACUPUNCTURE Acupuncture (needle puncturing) derives from traditional HOMEOPATHY Chinese medicine and involves inserting thin needles into the Homeopathy is based on the ‘‘like cures like’’ (similia body at specific points. but they were not statistically significant. . which enhances the punctured in OM cases (Figure 1). in an ear model: (1) tragus.7 is scant.Marom et al Medicine  Volume 95. A list of homeopathic remedies for OM why acupuncture may be beneficial.12 However. Over the subsequent year. (3) mid. since the reported type of otitis is unclear. At first.md-journal. Two subsequent RCTs also showed promising results. CAM ¼ complementary and alternative medicine. Acupuncture balances and enhances chi to bring the body toms in sick people. either sham acupuncture or ‘‘directed’’ acupuncture.

OM ¼ otitis media. February 2016 Complementary and Alternative Therapies for Otitis Media TABLE 2. craves affection and physical contact 2. Earache with by thick rhinorrhea or otorrhea 3. Mild disposition. Increased salivation. www. All rights reserved. chilliness. desire for warmth 5. with few prior symptoms of URTI (eg. smothering them 3. Earache worse from warmth and worse at night 3. desire for warm covering 2. symptoms similar to Belladonna. Pain behind the ear in the region of the mastoid 3. inhibiting enzyme production and. URTI ¼ upper respiratory tract infection. worse at night Pulsatilla 1. Sweating about the head or on the hands or feet Colloidal silver 1. Early stages of earaches before pus has formed. If the silver particles are small enough. wants fresh air 5. Inc. Signs of uncomplicated AOM: bright red outer ear.md-journal. if Belladonna did not improve symptoms Fe3(PO4)2 Hepar sulfate 1. Apply when otorrhea is present 2.com | 3 . but not as sudden or severe 2. even in a warm room 4. bad-smelling perspiration. in effect. Earache beginning suddenly with intense pain. Common Homeopathic Remedies for Otitis Media Agent Common Indications Figure Belladonna 1. Earache worse in cold or open air or from cold applications better from warmth. watery rhinorrhea) 2. Later stages of an earache: physical weakness and tiredness. severe otalgia 2. Number 6. Symptoms are worse when stooping or bending over and improved by warmth or being wrapped in warm covers 4. Worse in general from warmth. head sweats 4. Ear pain worse at night. Chilliness and aversion to the cold or uncovering. Severe ear pain 3. Watery rhinorrhea Soluble mercurius 1. and disrupt their ability to replicate AOM ¼ acute otitis media. Little or no thirst Chamomilla 1. or accompanied with sore throat Ferrum phosphate 1. Submicroscopic particles of mineral silver in colloidal silver adhere to the cell walls of harmful microorganisms. Mild-moderate cases of OM 2. they can even adhere to the DNA of viruses. or eardrum without pus formation. Profuse.Medicine  Volume 95. Copyright # 2016 Wolters Kluwer Health. puffiness of the tongue Silica 1. Sharp. Ear pain extending down into the neck. Purulent rhinorrhea/otorrhea 3. Alternatively. sudden high fever 3. Irritability 4. ear canal. Extreme irritability 2.

and fewer required tympanostomy tubes placebo. increasing both lymphatic drainage and ET opening.18 Nevertheless.26 faster. standard pharmacology isolates an active compound from a given plant. phytotherapy has been heavily criticized by opractic is thought to prevent recurrent infections by correcting others. mediates changes in the sympathetic and parasympathetic row. antiinflammatory.19. Other studies have shown that OMTs admi- practiced together and sometimes confused. vous system. Number 6. and that OMTs may effects may vary. which contains extract of mullein flowers. 75% in the loskeletal framework. Osteopathy is a noninvasive manual medicine that focuses In an RCT which compared homeopathic and conventional on total body health by treating and strengthening the muscu- treatment in 33 children diagnosed with OME. Israel). joints. and essentially dismissed the need for further RCTs. and good penetration through the tympanic mem. portion of children receiving homeopathic treatment had a Osteopathic manipulative treatments (OMTs) are hearing loss <20 dB at follow-up. Although small with high drop-out rates and lacked a control group. Inc. In the largest study so far. via the ner- (Healthy-On. there were no differences in the overall anti- biotic use.1 Herbal products are resulted in faster resolution of middle ear effusion following generally considered as safe. other authors who published in esteemed received weekly treatments had fewer episodes of AOM journals considered homeopathy to be no more effective than (P ¼ 0.2 The main techniques involve manipulations of mullein flower. a movement of the mandible aimed to indirectly generate a AOM. .24 ear (illustrating maneuvers are shown in Figure 2). change the progression of recurrent OM cases. when homeopathy should be integrated into the treatment strategy for compared to antibiotics without OMTs. which contains extracts of garlic bulb. and hearing results between both groups.20 (P ¼ 0. Otic solutions. these conclusions Herbal medicine and homeopathy are interchangeable are questionable. there is an ‘‘effectiveness gap’’ antibiotics decreased the frequency of AOM episodes and the in the conventional approach for OM.28 –30 The Phytotherapy is the study of the use of extracts of natural methodology of these studies is lacking. John’s wort herb in the spine. Chiropractic medicine believes that disorders of the management of ear pain in OM. circulatory. Another hypothesis suggests that presumed antimicrobial.1 Its aim is to positively affect the body’s homeopathic group had a normal tympanogram after 12 months. mechanical disorders of the musculoskeletal system. behavioral parameters. though the difference was occasionally used for acute and recurrent cases of OM.23. OH.md-journal. since the alleged antiinflammatory properties could not ‘‘misalignments. and in further 33% of patients after 12 hours. Herbal medicine nistered adjunctively with standard care for children with AOM is the use of plants for medicinal purposes. olive oil. such as Otikon musculoskeletal system affect the general health. and soft tissues. Phytotherapy avoids mixing Chiropractic focuses on the diagnosis and treatment of plant ingredients with synthetic substances. ance’’ and providing overall good health and well-being.03).27 Children who OM. garlic. The not statistically significant. 4 | www.22 Yet. or Mullein Garlic (Equinox Botanicals. there are no serious adverse effects. effects. FIGURE 2. In another prospective observational 2 most common OMTs for OM include: ‘‘Galbreath’’ maneu- study of 230 children receiving homeopathic treatment for ver. the study groups were origin as medicines or health-promoting agents.16 The results of these trials are promising. A higher pro. yar.25 and ‘‘Muncie’’ 6 hours. especially Phytotherapy has been reported to be effective in the the spine. and lymphatic systems. calendula flowers.21. though efficacy is unclear and side AOM.04). phytotherapy aims to preserve the complexity of Chiropratic substances from a given plant. tympanometry measurements. and vitamin E. pain control was achieved in 40% of patients after pumping action on the Eustachian tube (ET). February 2016 treatment could have advantages beyond a ‘‘watch and wait’’ OSTEOPATHY policy. the placement of a fin- of AOM resolution in the homeopathic group was 2. Common chiropractic maneuvers for otitis media (OM).14. without complications. were shown to be as neural activity via the biomechanical changes produced in effective as oral amoxicillin and topical anesthetics due to their the spine during treatment. combinations of OMTs with According to homeopathy. nervous. Thus. All rights reserved. immunostimulating cervical SMT reduces tension within hypertonic muscles.Marom et al Medicine  Volume 95.17 The rate and ‘‘modified Muncie’’ techniques.31 Chir- brane.com Copyright # 2016 Wolters Kluwer Health.4 times gertip on the Rosenmuller’s fossa to open the ET. it is argued that insertion of tympanostomy tubes in otitis-prone children.’’ and allowing fluid drainage from the middle be tested or confirmed in vitro. It is hypothesized that spinal manipulation therapy (SMT) USA). Rutland. When Herbal Medicine/Phytotherapy considering the large drop-out rate (25%). Yet. calendula flower and St. leading to ‘‘’bal- compared to 31% in the conventional group.

03). consists of placing a hollow candle in the ear tract infection (URTI). and fewer children receiving most children. the use of xylitol was not opted by many RCTs in which different xylitol remedies were used yielded less national guidelines as a means to prevent OM. but xylitol was effective in AOM prevention among daycare tod. Decrease biofilm production by S.37 to support using SMT. lactoferrin. control chewing gum.’’ Little research has been performed on ear candling. only 29% of the examined if viscous xylitol solution at a dose of 5 g 3-times- children who received xylitol had AOM episode(s) (30% per-day could reduce the occurrence of clinically diagnosed decrease. acts as an immunomodulator of both innate and adaptive immune systems. it demonstrated a statistically significant reduction (25%) in the risk of occurrence of OM among healthy children Xylitol in the xylitol group. Chewing gum and lozenges containing xylitol appeared etables.32 dence decreased by 40% compared with control subjects in the Unfortunately. Uhari first published an RCT. however. In group. Ear Candling control mixture. Inc. Ear candling.75.31 Although there were evidence gathered for the use of xylitol in preventing recurrent no serious adverse effects of SMT.88. Fair evidence found that xylitol reduced the incidence to be more effective than syrup. Protective Characteristics of Xylitol 1. convincing results.12 to found in low concentrations in the fibers of fruits and veg. T-helper cell pool toward Th2 status. Overall. and Ear candling. When xylitol mixture. Xylitol was shown to be ineffective in chil- dren with indwelling tympanostomy tubes. the authors stated that this therapy may be harmful. 95% CI: 0. Seely reported that ear candling is implausible and demonstrably wrong.38–43 In particular. AOM among otitis-prone children 6 months through 5 years.com | 5 . expression. and cathelicidin12 4. there was no clear evidence OM. www.6–55. the same group showed that reduced the number of xylitol doses to 3-times-per-day. Most studies report a In 1996. and found 4 RCT studies that met the criteria for analysis. February 2016 Complementary and Alternative Therapies for Otitis Media TABLE 3. occlusions of the ear canal. causing ear injuries (burns.1 The alleged properties of children <2 years who are at the greatest risk of developing OM xylitol to prevent OM are summarized in Table 3. Ear candling claims to ‘‘purify the blood’’ and heal children with OM through ‘‘’cleaning’’ of the middle ear cleft by creating a ‘‘negative pressure. Egypt. inducing antimicrobial Copyright # 2016 Wolters Kluwer Health. pneumoniae and Haemophilus influenzae to nasopharyngeal cells11 3. Increases the efficacy of the innate immune system13 Exposure to xylitol lowered cpsB (pneumococcal capsular locus) gene. also known as ear coning or thermal-auri- xylitol lozenges were given during an active upper respiratory cular therapy. Concomitant increase of quantity in each dose xylitol required antibiotics. leading to deposit of candle residue in the ear canal with no therapeutic effect on extraction of cerumen or the middle ear. antibiotic use between the xylitol group versus the placebo These encouraging results initiated additional studies. compared with the control placebo group Xylitol is a 5-carbon sugar alcohol. Inhibition of the attachment of S.34 Later. which is naturally (relative risk [RR] 0. which changes the ultrastructure of the pneumococcal capsule14 6.35 Although 1 AOM episode(s) was observed in 41% of A recent National Institute of Health-funded study the children who received control syrup. Number 6. AOM inci.4). cannot safely use lozenges or chewing gum. Ear coning has its roots in the traditional healing practices of China. the isoform that reflects the individual’s vitamin D status.Medicine  Volume 95. and North America. dlers. 95% CI: 0. vitamin D plays a role in immunity and infec- tion. Greece. human b-defensins. xylitol chewing gum. and by 20% in the significant differences in the occurrence of AOM and total lozenges group. All rights reserved. by shifting the FIGURE 3. it emphasized that of AOM episodes in healthy children. Vitamin D Supplement In addition to its role in bone metabolism and calcium homeostasis. as well as otitis externa.65–0. the results were discouraging.36 Recent Cochrane review examined the dence for SMT use in children with OM. there was no preventive effect for any of canal and lighting the other end33 (Figure 3). pneumoniae32. in which xylitol 5 times-per-day dosing schedule. 0. including lysozyme. it has been postulated that 25-hydro- xyvitamin D [25(OH)D]. the xylitol mixtures.md-journal. Decreases the salt concentration of human airway surface that contains antimicrobial substances. 95% confidence interval [CI] 4.33 A systematic report found only a limited quality of evi. which lowers the compliance in reduced AOM occurrence by 41%. Tibet.33 Furthermore. and tympanic membrane perforation). Therefore. Inhibition of Streptococcus pneumoniae growth11 2. resulted in various side effects. as there were no children who received xylitol chewing gum.

2). the treatment and serum 25(OH) D levels 30 ng/mL. which were a causative effect of vitamin D deficiency on the etiology and mainly prescribed for AOM (82%). in whom it was demon. randomized them to receive a nasal cacy of probiotics against infections have been obtained in spray containing 5 AHS strains (selected among those coloniz- patients with gastrointestinal diseases. P ¼ 0. Streptococcus pneumoniae or Haemophilus influenzae. children who were 6 | www. vitamin D is involved in the modu. These data are in children with RAOM who also had vitamin D deficiency. respiratory tract infections. All rights reserved.48 frequently associated with AOM development.Marom et al Medicine  Volume 95.7–1.8  10. . did not reduce the occurrence (probiotic vs placebo 72% vs sis. He found significantly URTIs ¼ 0. aged 10 months to 6 Therefore. A total of AOM episodes (P ¼ 0. Both the risk of development of antibiotic-associated diarrhea. and antibiotics were significantly They studied the possible effect of vitamin D supplementation less prescribed (treated: 31% vs placebo: 60%. February 2016 peptide synthesis. the study. 1.4  9. experiencing at least 1 AOM episode was significantly lower in In a double-blind. data were confirmed by the same group.9 ng/mL. P ¼ 0.6  10.01). cathelicidin and b-defensins. The most largely studied benefits by modulating the microbial community and enhancing microorganism has been a-hemolytic Streptococcus (AHS). During the first 7 months of life. and to suggest a protective effect of composition did not differ in the 2 groups at any time during the vitamin D supplementation in children with RAOM. inhibiting the production of pro-inflammatory cyto. ing the ETs opening. and an increased percentage of children with serum increased the carriage of Moraxella catarrhalis (OR ¼ 1. The likelihood of and prebiotics (Raftilose/Raftiline). The probiotic treatment previous clinical studies performed in patients with tuberculo.40–43 Moreover. and interfere with survival and multiplication of pathogens more enhancement of both mucosal and systemic immunity.3 ng/mL. These presence of pathogenic bacteria or viruses. and (incidence rate ratio. case–control study significantly feeding. 95% CI: 0. but P < 0. when considering the whole 1st year of life.44. host immunity. when compared to the control group. or number of antibiotic Despite these data. During the 3-months follow-up.2 vs and Bifidobacterium lactis Bb-12 or placebo until the age of 12 23.49 streptococcal and placebo solutions were sprayed for a first 10- Data regarding the use of probiotics on OM have gathered day period and then resumed for 10 days starting from day 60 of in the last few years.9.79). and that the mean number of global biotics and prebiotics could reduce the risk of AOM. because of their superior inhibitory strated that administration of probiotics can significantly reduce activities against otopathogens) or a placebo solution.md-journal. further follow-up. The nasopharyngeal flora pathogenesis of AOM.05). P ¼ 0. in reducing the number of AOM episodes in 116 otitis-prone However. 95% CI: 0. taking into account that the presence in the nasopharynx could bition of pathogen colonization.05).2).com Copyright # 2016 Wolters Kluwer Health. placebo-controlled trial.38. and in nasopharyngeal carriage of otopathogens in otitis-prone chil- regulation of toll-like receptor mediated events in neutrophils.03).2  13. incidence (IRR 0.50–52 In general. the proportion of Marchisio et al45 evaluated the relationship between AOM episodes was significantly lower (treated: 22% vs decreased vitamin D levels and the increased risk of RAOM. production of bacteriocins. 10-day antibiotic course.47 which has recently Rautava et al55 enrolled 81 infants requiring formula reported in a single-blind. after a multiple bacteria. who were randomized to receive either infant formula reduced serum 25(OH)D levels in 88 children with AOM supplemented with the probiotics Lactobacillus rhamnosus GG compared to 81 healthy controls (20. as indicated by probiotic daily or a placebo capsule. that is.56. The administration of reduced mean serum 25(OH)D levels in children with RAOM probiotics did not modify the nasopharyngeal carriage of compared to controls (11. the 1-year follow-up period.8–1. or follow-up formula AOM occurrence was significantly reduced in patients with alone. In the authors’ opinion. PROBIOTICS Topical Probiotics Topical administration of probiotics has been considered Oral Probiotics as a method to reduce the risk of recurrent AOM in children Probiotics are live microorganisms that offer health when administered by nasal spray. while a reduction in the occurrence of conducted in 84 children aged 1 to 5 years with RAOM and in recurrent URTIs was noticed in the probiotic group (OR for 4 108 comparable healthy controls. controlled clinical trials are needed to solve these questions. vitamin D but that its presence is not associated with a reduction in the quantities may play a role in the susceptibility to OM.8 vs 29. The study involved 309 children.57 Commercial probiotics preparations are based on single or Roos et al58 enrolled 108 otitis-prone children and. the agreement with the work of Tapiovaara et al.001) occurring in the vitamin D group was significantly assigned to follow-up formula supplemented with probiotics lower.2 These effects can be obtained through inhi.39. months. showing variable efficacy. Number 6.54 who demon- occurrence of AOM and RAOM significantly dropped during strated that Lactobacillus GG is able to penetrate the middle ear. Most of the data regarding preventive effi. dren. the children (58 receiving vitamin D supplementation and 58 prevalence of AOM was not statistically different (treated: receiving placebo). reduce the occurrence and duration of AOM episodes or the lation of macrophages and dendritic cells activities. P < 0.03) and uncomplicated AOM episodes 224 healthy infants aged 7 to 13 months were randomly (P < 0.05). They found that the number of children 13% vs 25%). OR for 6 URTIs ¼ 0. Hatakka et al53 evaluated the possibility that probiotics could kines. This study concluded that the control groups did not differ in the incidence of AOM vitamin D deficiency is frequent in otitis-prone children. P < 0. During the 12 months study period.0. 25(OH)D levels <20 ng/mL in the study group compared to confirming from a microbiological point of view the basis for controls (69% vs 30%.2). Inc. When vitamin D was given to the negative results in prevention of AOM. placebo: 50%. lower URIs that blood 25(OH)D concentrations 30 ng/mL are protective.59). 95% CI: 0. vitamin D status may influence the incidence and years.01). who were randomised to consume for 24 weeks a severity of some bacterial and viral infections. and AOM.0. there is not enough evidence to support treatment courses (RR 1.45 65%) or the recurrence (3 episodes) of AOM (probiotic vs Cayir et al46 published a longitudinal cross-sectional study placebo 18% vs 17%). and the reduction in OM incidence in treated children was limited. when compared with the placebo group assessed whether follow-up formula supplemented with pro- (26/58 vs 38/58.8–1. Cohen et al56 the treatment group.

9%. It against others fed with standard formula. was intranasally admi. strated for the use of probiotics and xylitol. Gabbasova NG.md-journal. Similar results were observed ingol.8% vs 95. Tian ZM. Tano59 randomized 43 children to receive medical community. J Tradit Chin higher among the children treated with the S.gov. 2. Int J Pediatr children aged 3 to 12 years with a recent history of recurrent oral Otorhinolaryngol.27:835– 848.2%) and/or of reported AOM (40%) during [Accesssed September 12.62 Di otitis media. The negative results. Copyright # 2016 Wolters Kluwer Health. Levi JR. salivarius K12 in pre. 2015]. P ¼ 0. Bikbaeva AI. The proportion of children with recur. Acupunct Med. Zhongguo Zhen Jiu. For milk with 0. we pharyngeal colonization of otopathogens was detected. Visits to complementary tered an oral slow-release tablet containing 5 billion colony. Sánchez-Araujo M. infections (92. Yussman SM. Sánchez-Araujo M. Clinical practice guidelines after the treatment. Acupuncture treatment for aerotitis media. Complementary and venting recurrent streptococcal pharyngitis and AOM in 82 alternative medicine for pediatric otitis media. Otolaryngol Clin North Am. P ¼ 0. a mild-moderate benefit was demon- placebo group: 40%) and no significant changes in the naso. has received attention. rhamnosus treatment infants fed with probiotic-enriched formulas will be evaluated group. 2013. 2011. sanguinis compared to 1/17 patients We further suggest that trials should be conducted in which in the placebo group (P ¼ 0.5:259–260. National Center for Complementary and had significantly fewer episodes of streptococcal pharyngeal Alternative Medicine Web site. cant activity against AOM pathogens. Inc. Puchi A. RAOM history were randomized 1:1 to receive an intranasal S. It is a potential nasopharyngeal probiotic. 1997. currently not considered a treatment option for OM in the Subsequently.029). salivarius 24SMB Med. further clinical evaluation is needed in antibiotics treatment for canine otitis crises. pharyngeal and middle ear infections by 65.4:429–435. streptococcal pathology. and treatment of AOM. www. P ¼ 0.6%. Wang ZM.Medicine  Volume 95. Acupuncture prevents relapses of analyzed (67. in terms of age of 1st should be taken into consideration that the study population AOM episode and RAOM prevalence. J Korean Med Sci.9% was also registered in the treatment group in the 6 months follow-up 6. et al.46:309–327. rhamnosus. in association with the potential risk ACKNOWLEDGEMENTS of infections directly due to the bacteria used for topical treatment. Ryan SA. no significant difference in cure rates was detected. sanguinis.33:988. 2013. so the tested tubes. Auris Nasus Larynx. 2012. the pharynx of healthy subjects. J Laryngol Otol. 2015. L. was small. 106. for More recently. RAOM. et al. et al. A reduction in the reported incidence of guidelines: otitis media in children. At this time. Karkos PD.77:926–931. or placebo in children We propose RCTs in pediatric mild-moderate AOM cases. 7. et al. and vitamin D.0% vs 10.61.5%. Streptococcus salivarius. 2013. Acupunct Electrother order to assess their true potential. Ambul Pediatr. Korean clinical practice the time period). we have noticed scant benefit for the use of probiotics rences was similar in the 2 groups (treatment group: 44%. containing S. the 90-day probiotic intake compared to the previous 12 months (but the difference was not significant for AOM if adjusted for 5. because of the contrasting results 12. have led to halting of research with these strains. All rights reserved. vitamin D. who were randomized to be adminis- 3. 1985.8% vs 13. PhD. hemodynamics after complex therapy. vention of AOM and URI but. February 2016 Complementary and Alternative Therapies for Otitis Media given AHS-supplemented spray experienced significantly more CONCLUSIONS cure from AOM (42% vs 22%.9% NaCl. Children aged 1 to 5 years with systematic review of commonly used supplements. salivarius 24SMB or placebo twice daily for 5 days each month 8. For OME. National Institutes of Health. P ¼ 0. 19 patients treated with S. ‘Complementary ENT’: a nistered in otitis-prone children.nih. [Cerebral and peripheral 14. Tsyglin AA.05). an AHS isolated from reviewing this paper and his helpful comments. In our opinion. The 41 children who completed the 90-days treatment 4. number of children who did not experience any AOM was 9.57. O’Reilly R. The author’s conclusions favored the pies for OM. there may be some milk and 0.076) and among children colonized by S. Leong SC. very good in vitro inhibitory activity on otopathogens. 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