Acute otitis media

Definition and microbiology

Acute otitis media is acute inflammation of the middle ear due to viral or bacterial infection. It is very common in children under 3 years and uncommon in adults.

Important bacterial causes include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and, in older children, Streptococcus pyogenes.

Upper respiratory symptoms, vomiting, or diarrhoea may coexist and confuse the diagnosis, so examination of the tympanic membranes is central.

Clinical features and diagnosis

• Rapid onset ear pain is typical. Infants may present with crying, irritability, sleeplessness, or reluctance to nurse.
• Fever and otorrhoea can occur. Associated rhinorrhoea, cough, diarrhoea, or vomiting are common.
• Otoscopy confirms the diagnosis when ear pain or fever is combined with a bright red tympanic membrane, yellow tympanic membrane suggesting imminent rupture, pus draining through a perforation, or an opaque or bulging tympanic membrane.
• A red tympanic membrane alone is not enough; it may occur with viral upper respiratory infection, prolonged crying, or high fever.
• Air bubbles or fluid behind an intact tympanic membrane without acute infection signs suggests otitis media with effusion rather than acute otitis media.

Treatment in all cases

• Treat fever and pain with paracetamol, and consider ibuprofen where age and contraindications allow.
• Do not irrigate the ear if the tympanic membrane is ruptured or cannot be fully visualised.
• Ear drops are not indicated for uncomplicated acute otitis media.
• Explain return signs: persistent fever or pain after 48 hours of antibiotics, worsening illness, mastoid swelling, neurological signs, persistent discharge, or hearing concerns.

When to use antibiotics

• Prescribe antibiotics for children under 2 years, children with severe infection features such as vomiting, fever above 39 C or severe pain, and children at higher risk of unfavourable outcome such as malnutrition, immunodeficiency, or ear malformation.
• For other children, delay antibiotics if reliable re-examination within 48 to 72 hours is possible. Treat fever and pain and start antibiotics only if symptoms fail to improve or worsen.
• If reassessment is not possible, prescribe antibiotics at the first visit.
• For patients started on antibiotics, advise review if fever or ear pain persists after 48 hours.

Failure and persistent discharge

• Treatment failure is persistence of fever and/or ear pain after 48 hours of antibiotic treatment.
• Persistent ear drainage alone does not necessarily mean antibiotic failure when fever, pain, systemic symptoms, and local inflammation are improving.
• For persistent drainage in an otherwise improving child, clean the ear canal gently by dry mopping until no more drainage is obtained.
• Reassess diagnosis, adherence, dose, complications, and risk factors before changing antibiotics.

Complications and prevention

• High-risk children include those with malnutrition, immunodeficiency, or ear malformation. Complications include chronic suppurative otitis media, mastoiditis, brain abscess, meningitis, persistent perforation, and hearing loss.
• Refer urgently for tender swelling behind the ear, protruding ear, high fever with severe ear pain, severe systemic illness, impaired consciousness, neck stiffness, focal neurological signs, facial nerve palsy, or suspected meningitis.
• Prevention includes vaccination according to local schedule, breastfeeding support, reduced smoke exposure, prompt treatment of severe upper respiratory infections, and follow-up of recurrent infections or hearing concerns.
• Handover should include age, fever, pain severity, otoscopy findings, perforation or otorrhoea, antibiotic indication, medicine/dose/duration, risk factors, previous antibiotics, complications sought, and planned reassessment.