QuestionSBA
QuestionChoice
This child has acute otitis media, which would be managed with reassurance and analgesia in the well child. As they are on immunosuppressants, they should be prescribed oral antibiotics unless unwell, where it can be escalated to intravenous antibiotics and admission
33150
c
Analgesia and reassurance
QuestionChoice
Back-up antibiotics can be given to children whose signs of infection do not resolve within 3 days or worsen significantly or rapidly at any time. As this child is on immunosuppressants, they should receive antibiotics immediately
33151
d
Prescribe a back-up antibiotics prescription to take if not improving after three days
QuestionChoice
This child has presented with acute otitis media. It is very common in children and is often managed conservatively without antibiotics. Antibiotics should be prescribed if the symptoms last >4 days, they are systemically unwell, are immunocompromised, or have evidence of tympanic perforation. This child is well but on immunosuppression and so oral antibiotics should suffice with good safety netting
33148
a
Oral antibiotics
QuestionChoice
While this patient is on immunosuppressants, they are systemically well with acute otitis media. This will require oral antibiotics at present, but should have a low threshold for admission and intravenous antibiotics if not resolving in the community
33149
b
Admit for intravenous antibiotics
QuestionChoice
This child is on immunosuppressants but is systemically well at present with only one previous episode of acute otitis media. A child should be referred to the local emergency department if unwell or have systemic complications of acute otitis media such as meningitis, mastoiditis, intracranial abscess sinus thrombosis, or facial nerve paralysis. A child can be referred to ENT if they have recurrent unexplained episodes or they have a craniofacial abnormality. In this case, she can be managed with oral antibiotics alone
33152
e
Refer to ENT
QuestionComment
Also because the child is 2 years old right?
29047
User
subscriber
Lateral Kinase
QuestionComment
I thought this was malignant otitis externa 
37784
QuestionComment
Bulging of the tympanic membrane is better explained by otitis media. Typical signs of otitis external are not present eg. swollen eczematous canal etc 
43118
User
subscriber
Ale
User
subscriber
Imran
Concept
Chapter
# Summary
 

Acute otitis media is a common infection resulting in inflammation of the middle ear. It typically presents with rapid onset of symptoms such as ear pain, fever, irritability, and vomiting. Key investigations include physical examination of the tympanic membrane and assessing systemic illness. Management primarily consists of pain and fever relief, with antibiotics reserved for severe cases or those at high risk of complications. Possible complications can be intracranial or extracranial and may be life-threatening.
 

# Definition
 

Acute otitis media (AOM) is inflammation of the middle ear with an associated effusion. It can be due to bacterial or viral infections. 
 

# Epidemiology
 

Acute otitis media is a common condition, particularly among young children, often occurring after a viral upper respiratory tract infection. It affects 70% of children before the age of 2 years, peaking between ages 6-15 months before reducing as the child grows older. It affects boys slightly more than girls. 
 

# Aetiology

Acute otitis media is common in children because the less acute angle between the Eustachian tube and the wall of the pharynx enables organisms in the nasopharynx to enter the ear. 

The primary cause of otitis media is bacterial infection, especially prevalent in young children. The most common causative pathogens include: 

- Streptococcus pneumoniae 
- Haemophilus influenzae
- Moraxella catarrhalis 

Viral causes are less common but normally precede AOM (i.e. respiratory syncytial virus, adenovirus, enterovirus)

Risk factors include:

- Age below 2 years
- Male sex
- Parental smoking
- Immunodeficiency 
- Formula feeding 
- Attendance at nursery or daycare
- Structural abnormalities (i.e. associated with Down's syndrome, presence of cochlear implants) 

Recurrence is more common in children with GORD or those who use dummies. 
 

# Signs and Symptoms
 

Acute otitis media typically presents with a rapid onset of symptoms such as:
 

 - Earache 
 - Ear tugging in younger children
 - Pain
 - Fever
 - Irritability
 - Anorexia
 - Vomiting
 
Otoscopy may reveal:

- Erythema of tympanic membrane 
- Presence of an effusion in the middle ear: air-fluid levels, bulging tympanic membrane
- Evidence of perforation: tear in tympanic membrane or discharge 
 

 [lightgallery]
 
Red Flag symptoms to screen for (which may indicate intracranial spread):
 
- Changes to vision 
- Photophobia or headache
- Nystagmus 
- Post auricular swelling 
- Facial paralysis 
 

# Differential Diagnosis
 

The key signs and symptoms of the differential diagnoses of otitis media include:
 
 - **Chronic Benign Otitis Media**: Characterised by a dry tympanic membrane perforation without chronic infection.
 - **Otitis media with effusion (Glue Ear)**: Persistent presence of middle ear effusion without acute infective symptoms. 
 - **Chronic Suppurative Otitis Media**: Persistent purulent drainage through the perforated tympanic membrane.
 - **Upper respiratory tract infection**: Symptoms include a runny nose, cough, and sore throat.
 - **Mastoiditis**: Symptoms include postauricular swelling, ear pain, fever, and irritability.
 - **Otitis externa**: Presents with ear pain, itching, discharge, and hearing loss. Associated with sloughy discharge within the ear canal.
 

# Investigations
 

Investigations for otitis media primarily involve a physical examination of the tympanic membrane, assessing the presence of systemic illness, and evaluating the patient's symptoms.

Further investigations may include:

- Culture of discharge in chronic or recurrent AOM
- CT or MRI if concerns of mastoiditis or intracranial spread
- Audiometry, following resolution of infection if chronic hearing loss secondary to AOM is suspected
 

# Management
 
Admission should be considered for:
 
 - Children under 3 months with a temperature of 38 or more.
 - Children with suspected acute complications of otitis media such as meningitis, mastoiditis, or facial nerve palsy.
 - Children who are severely systemically unwell.

Immediate antibiotics should be given if the child is systemically unwell, or at high risk of complications (e.g. immunocompromised patients). It may be considered if the child has otorrhoea or is aged < 2 years and has bilateral AOM.


- Amoxicillin for 5-7 days is typically given as first line. 
     - Clarithromycin is used if penicillin allergic. 
- If symptoms do not improve after 2-3 days of antibiotic, then co-amoxiclav may be considered.AOM


If immediate antibiotics are not required:
 
 - Maximise pain relief using paracetamol or ibuprofen.
     - A warm compress over the ear may help to relieve pain.
 - Eardrops containing an anaesthetic and analgesic (phenazone 40 mg/g with lidocaine 10 mg/g) may also be used if antibiotics are not given and there are no signs of eardrum perforation. 
 - Parental/caregiver education:
       - Antibiotics make little difference to the duration of symptoms or complication rates associated with AOM.
     - Most children will not require antibiotics. 
         - Antibiotics may also cause side effects of diarrhoea and nausea. 
- Consider a delayed antibiotic prescription to be taken if symptoms don't improve within 3 days.
     - Can be considered if the child has otorrhoea or is age <2 years and bilateral AOM.
 
Children can return to school once no longer febrile. 
 

# Complications of Otitis Media 
 

Whilst the majority of children recover without any acute or chronic complications, otitis media can lead to a wide range of complications, many of which are potentially life-threatening. These can be divided into intracranial and extra-cranial complications.
 

**Extra-cranial Complications of Otitis Media**:
 
 - **Facial nerve palsy**: Acute otitis media can lead to a lower motor neuron lesion of the VII cranial nerve. Patients usually recover well with treatment of the otitis media.
 - **Mastoiditis**: Infection can spread from the middle ear to form an abscess in the mastoid air spaces of the temporal bone, leading to postauricular swelling and mastoid tenderness.
 - **Petrositis**: Infection spreading to the apex of the petrous temporal bone, leading to Gradenigo syndrome: otorrhoea, deep ear and eye pain, and ipsilateral VI nerve palsy.
 - **Labyrinthitis**: Inflammation of the middle ear can lead to inflammation of the semi-circular canals, leading to symptoms of vertigo, nausea, vomiting, and imbalance.
 

**Intra-cranial Complications of Otitis Media**:
 
 - **Meningitis**: An important and life-threatening complication presenting with sepsis, headache, vomiting, photophobia, and phonophobia.
 - **Sigmoid sinus thrombosis**: Patients present with sepsis, swinging pyrexia, and meningitis.
 - **Brain abscess**: A patient will present with sepsis and neurological signs due to compression of cranial nerves.

**Chronic complications may include**:

- Hearing loss 
- Otitis media with effusions ("glue ear"):
        - If children are under the age of 3, a "watch and wait" approach can be taken initially.
        - If children are over the age of 3, or have developed associated language or behavioural problems, then referral to ENT for consideration of grommets would be appropriate. 
- Chronic suppurative otitis media
        - A persistent tympanic membrane perforation results in re-infection and chronic inflammation. It is often associated with conductive hearing loss. It is not commonly seen in the UK and is more common in the developing world.

# Prognosis
 
The majority of children will not have severe complications from acute otitis media. 60% of children will have symptom resolution within 24 hours, with most symptom-free by 1 week. 

## Recurrent Acute Otitis Media

Children are considered to have recurrent otitis media if they have had more than 3 episodes of AOM in 6 months or more than 4 episodes in one year. This should prompt consideration of reducing risk factors (i.e. parental smoking, avoiding supine feeding and reducing use of dummies). These children may be referred to ENT for consideration of grommets or prophylactic antibiotics. 

# NICE Guidelines
 
[NICE CKS on otitis media - acute](https://cks.nice.org.uk/topics/otitis-media-acute/)
 
#  References 
 
[NHS Inform Middle Ear Infections](https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/middle-ear-infection-otitis-media/) 
 
[Microbial Etiologies of Acute Otitis Media](https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)64948-X/fulltext)

[Patient Info Acute Otitis Media in Children](https://patient.info/doctor/acute-otitis-media-in-children) 

[Patient Info Otitis Media with Effusion](https://patient.info/doctor/otitis-media-with-effusion)
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An example appearance of otitis media.
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Acute otitis media (paediatrics)
Topic
29
Paediatrics
6630
In immunocompromised children, acute otitis media requires prompt antibiotic treatment, especially if accompanied by tympanic membrane bulging and erythema.
A 2-year-old child presents with 2 days of right-sided otalgia and pyrexia. She is otherwise well and had a similar problem two weeks ago which initially self-resolved. She is currently taking immunosuppressants for a liver transplant she had as a neonate for extrahepatic biliary atresia. On otoscopy there is bulging of the tympanic membrane with surrounding erythema.

Which of the following is the best next step in the management of this patient?
a