Acute otitis media (AOM) refers to inflammation of the middle ear with effusion and clinical features of a middle ear infection.
Normally AOM is a self-limiting condition, commonly affecting children, though adults may also suffer. In general symptoms settle after 3 days, but can remain for a week. Bacteria or viruses are normally implicated - differentiating the two is challenging.
The majority of cases do not require antibiotic therapy and will settle with time. Though rare, serious complications such as mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis may occur.
NICE define the persistent and recurrent AOM as follows:
AOM occurs primarily in children but may also affect adults.
Children aged 0 to 4 years are most affected, with a peak in the incidence at around 9-15 months. It is more commonly seen in winter and is often associated with an upper respiratory tract infection.
AOM is commonly caused by viruses, bacteria or both.
Commonly identified bacteria include:
Streptococcus pneumoniae is thought to be the most common bacterial cause followed by Haemophilus influenzae.
Commonly identified viruses include:
Infective organisms reach the middle ear via the eustachian tube.
AOM is often associated with a preceding upper respiratory tract infection. Pathogen transmission via the eustachian tube to the middle ear may result in AOM.
It is thought that in young children the less acute angle of the eustachian tube with the wall of the pharynx results in increased transmission of pathogens, particularly when coughing or sneezing.
Otoscopy is key to identify signs of AOM.
Signs and symptoms depend somewhat on the age-group of the presenting patient. Remember features of an upper respiratory tract infection may be present. Otoscopy is key to identify signs of AOM.
AOM has a spectrum of severity from a self-limiting illness to severe systemic upset requiring hospital admission.
Explain the condition to patients, as well as the fact that it is generally self limiting. Normally the illness lasts 3 days but it may last up to a week.
Analgesia and antipyretics are advised. Paracetamol and ibuprofen (in absence of contra-indications) at appropriate doses can be used.
NICE guidelines NG91: Otitis media (acute): antimicrobial prescribing, offers guidance to GPs on which children and young people may require antibiotics.
Three main options exist; no antibiotics, delayed prescription and immediate antibiotics. In all cases give safety netting advice to return if symptoms worsen, do not improve after 3 days or the patient becomes systemically unwell.
When giving a delayed or back-up prescription advise using if symptoms don’t improve after 3 days or if they worsen (rapidly or significantly).
When used amoxicillin tends to be preferred first-line (in absence of penicillin allergies) with alternatives including clarithromycin, erythromycin. Co-amoxiclav is used second line (again in the absence of penicillin allergies) in treatment resistant cases.
In ‘Children and young people who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are symptoms and signs of a more serious illness or condition, or are at high-risk of complications at high-risk of complications.’ immediate antibiotic therapy is advised. The need for urgent hospital admission should be considered (see below).
In ‘Children and young people who may be more likely to benefit from antibiotics (those of any age with otorrhoea or those under 2 years with infection in both ears).’ consider either no antibiotics, a back-up script for antibiotics or immediate antibiotics.
In ‘Children and young people who may be less likely to benefit from antibiotics.’ consider either no antibiotics or a back-up script.
As always clinical judgement should be used when making decisions on the best place of care. Clinicians must consider the severity of the presentation (and any complications that may be present), home dynamics and any co-morbidities.
NICE advise the following patients should be admitted for treatment:
In addition NICE advise admitting:
Patients with persisting (or worsening) symptoms should be reviewed. Repeat a complete history and re-examine. Consider other potential causes of similar symptoms such as otitis media with effusion (‘glue ear’). In general management follows the outline described above.
Some patients may develop chronic suppurative otitis media (CSOM) as a complication of their AOM. Those with persistent symptoms of AOM should be referred to ENT, particularly if lasting longer than 6 weeks or there is persistent hearing loss.
See the section in the above for guidance on who to admit.
ENT referral for specialist management should be considered for those with recurrent AOM. This is especially important if there is a craniofacial abnormality, an adult patient, or debilitating / complicated AOM.
If nasopharyngeal cancer is suspected an urgent referral to ENT is required. In particular NICE advise high suspicion if:
Though most AOM resolves without sequelae, some may develop complications.
Frequent complications include:
Rarely very serious complications like mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve paralysis may occur.
Mastoiditis is perhaps the most commonly occurring serious complication. It is a potentially life-threatening infection of the mastoid air cells causing pain, swelling and erythema behind the ear and systemic upset. It tends to affect younger patients, normally under the age of 5. Blood tests, fluid cultures and CT scanning forms the core of the work-up. It requires prompt recognition, early antibiotics and management that may include myringotomy and mastoidectomy.
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